A.I.R. Orientation

For new staff

Staff Dr. 李修身 Dr. 陳天令 Dr. 黃章喜 (R5)

Allergy, Immunology, Rheumatology

Study:Teaching:1. Morning meeting ( W3 and W5, 7:45 am at 6F MICU meeting room) 2. Radiology-Rheuma combined meeting (once a month,

W4, 4:00 pm at Radiology Department 4F meeting room)

3. 病房主任 teaching (at least 4 times a month, 2 months /year)

4. Clerk teaching (usually W4, W5 & W6, scheduled by 醫教部 )

5.Bed side teaching (any time)

免疫風濕疾病相關症狀• a)   關節症狀 : 觀察病人是否真的關節腫或是軟組織腫？

是否有紅腫熱痛，是否有關節液？ (bulge sign). 是否有晨僵大於一小時情形？是否 symmetric ？受影響之關節區域 (Mono/Oligo/poly) ？發作的情形？持續或陣發性 ? 是周邊或中樞關節？急性或慢性 ( 持續存在六星期 ) ？

• b)   皮膚症狀 : 觀察病人是否有 Malar Rash, Discoid rash, Photosensitivity, Oral ulcer, Skin ulcer, Genital ulcer, Heliotrope’s sign, Shawl’s sign, Pitting nail, Gottron’s papule, Mechanic hands, Raynaud‘s phenomenon, psoriasis.

• c)  掉髮、 眼睛乾燥、 口乾、 血管炎。• d)  持續不明原因的發燒， 肌肉疼痛或乏力。• e) 最近使用之藥物及過敏史 , 相關疾病之家族史。

After admission

# Infection or inflammation? === priority: the one which is life- threatening# If no old chart === 病歷查詢 , 報告查詢 (OPD and Lab) # Rx may as OPD unless contraindication (e.g. drug adverse effects) 1. Hypersensitivity: NSAID’s, DMARD’s, antibiotics, …… (anaphylaxis, urticaria, angioedema, Steven-Johnson syndrome…)

** [dilantin, bactrium, tegretal, allopurinol] 2. Idiosyncratic reaction: antithyroid drugs, immunosuppressants 3. Discomfort: any drug 4. Overdose: hypoglycemic agents, hypnotics, acetaminophen……

Routine Examination

• a) WBC-DC, Hb, Hct, MCV, platelet, ESR, CRP• b) Sugar, BUN, Cr, Na, K, GOT, GPT, Albumin, TG,

Chol, U.A. (MAR)• c) Urine routine , CCr, Daily urine protein • d) STS-RPR, stool OB• e) Chest PA, 12-lead EKG• f) Heart echo: pericardial effusion 時或其它 CV 問

題。• g)  腹部 Echo: ascites, serositis, 肝脾腫大 , 排除

感染。• h)  肺功能 : Vasculitis, Sjogren, RA, DM/PM or SLE

會併發 Interstitial pneumonitis 。• i) X-ray of involved joints 。

AIR 相關之檢驗• a) RF, ANA, C3, C4(CH50), 若入院時，門診已有測過

ANA 且結果為陽性 , 則可測 Anti-ds-DNA, 有分免疫方法 (dilution titer) 及核醫方法 (unit), 並做 ENA screening (Extractable Nuclear Antigen).

• b) ENA screening >> Anti-Sm ( 懷疑為 SLE 病人時 ), Anti-RNP (MCTD), Anti-SSA/SSB ( 乾燥症 ), Anti-Scl 70 (PSS)

• c) PT: normal, PTT: prolonged >> Lupus Anticoagulant (LA), Anti-cardiolipin Ab(IgG/IgM) >> Antiphospholipid syndrome.

• d) Anemia survey: lower MCV: Ferritin, Fe, TIBC, 必要時做 Hb 電泳 .

• e) HLA-B27, IgG/M/A/E, Cryoglobulin, c/p-ANCA• f) Thyroid function test, CPK,

# ENA screen test and Anti-Sm/Anti-RNP# ENA screen test and Anti-SSA/Anti-SSB# Anti-ds-DNA: 63129 ( 核醫單 ) and 66632( 免疫單 )# Before scheduled major operation: DC aspirin 1 week earlier DC NSAID’s for 3- 4 T1/2 and keep using COX-2 specific NSAID’s and nonactylated salicylate# MAST and CAP: allergen detection# Muscle biopsy: special stain available ( 外送萬芳醫院 pathologist), => notify the Surgeon for collecting fresh muscle specimen => notify Pathology Dept. for preparing solution

AIR 相關 procedure

• a) Shirmer’s test: 淚腺功能檢查。• b) Scialoscintigraphy: 檢查唾液腺之功能• c) Whole body bone scan (Tc-99m)• d) Ga-67 inflammation scan• e) Skin biopsy, kidney biopsy, lip biopsy, mus

cle biopsy• f) Joint & soft tissue Echo (W2 pm) • g) NCV, EMG• h) Pathergy test• i) Joint aspiration, intra-articular injection• j) Arthroscopy• k) Angiography

Antinuclear

antibody

(ANA)

Homogenous Peripheral

Speckled Nucleolar

, HCV

(Rheumatoid arthritis)

(Rheumatoid arthritis)

C spine AP view (open mouth)

C spine

lateral view

(flexion)

# NSAID’s in MMH1.Salicylic acids:

a.Acetylated: aspirin (infant tapal, Bokey)b.Nonacetylated: choline magnesium trisalicylate (Trilisate)

2.Acetic acids:a.Indole derivatives: indomethacine (Indocin)b.Phenylacetic acid: diclofenac (Kataflam, Voltaren-S, Vetin Inj.)c.Etodolac (Lonine*)

3.Propionic acids: a.Naproxen (Naposin)b.Ketoprofen (Ketoprofen)c.Tiaprofenic acid (Synotec)d.Ketorolac tromethamine (Keto, & Keto Inj.)…..( < 5 days)

4.Fenamic acids: Mefenamic acid (Ponstan)5.Enolic acids: Oxicam---Meloxicam (Mobic*)6.Nonacidic compounds: Naphthylalkanone---Nebumeton (NO-TON*)7.Cyclooxygenase-2 (COX-2) specific inhibitor:

a.Celecoxib (Celebrex**)b.Rofecoxib (Vioxx**)

Choosing NSAID’s: effective, adverse effect, age, underlying disease and T1/2

# Misoprostol (U-Miso)…(endoscopic proof of PUD)1.“X” class for pregnancy2.Prevention of NSAID-induced PUD3.For RA > 50 y-o, or SLE( 專案 )

Gout with renal impairment

1.Sulindac( 馬偕無 )2.Non-acetylated salicylate (Trilisate)3.COX-2 selective NSAID* (Lonine, Mobic, NO-TON)4.COX-2 specific NSAID** (Celebrex, Vioxx)5.Corticosteroid6.Colchicine7.Lower dose allopurinol

Gout with PUD (UGI bleeding)

1.NSAID(* & **) or corticosteroid prn2.Intra-articular injection3.Colchicine4.H2-antagonist (4 months), PPI (2 months) 5.Misoprostol ( 專案，一年份 )

Thanks!