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1 : , (tennis elbow), (trigger finger) (systemic lupus erythematosus, SLE).. (pain), (physical disability),.,. 40% 1)., SLE,,..,.. 1. (Preconsultation intuitive observation). Table 1. Preconsultation intuitive observations Clinical problem Painful foot, elderly lady on diuretics Young, sexually active; hot sw ollen joint Headache w ith diffuse aches and pains in an elderly person Antinuclear antibody- positive, but no symptoms On allopurinol w ith a high uric acid, but no arthritis Postpubertal male w ith low back pain Woman, 6 w eeks postpartum; small joint arthritis Pos s ible diag nos is Gout Gonococcal arthritis Polymyalgia rheumatica Refering physician' s dilemma, not the patient' s Not gout Ankylosing spondylitis Rubella vaccination; Rheumatoid arthritis - 3 -

2 Korean Journal of Medicine : Vol. 58, No. 1, 2000 Figure 1. Aspects of different diagnosis in rheumatology. (T able 1)2). 2..,,,. 2. (History taking),,,.,....,,,, (Raynaud s phenomenon),. (Figure 1).,,,,, red flag (T able 2)3).. (pain) (stiffness).,,. (quality), (intensity), (duration), (type of onset), (diurnal variation)

3 Seong Yoon Kim : Rheumatologic consultation Table 2. Red flags sugg esting the need for urgent evaluation and management of the patient with musculoskeletal symptoms Feature History of significant trauma Hot, swollen joint Constitutional signs and symptoms (e.g., fever, weight loss, malaise) Weakness Focal Diffuse Neurogenic pain (burning, numbness, paresthesia) Asymmetric Symmetric Claudication pain pattern Differential Diag nosis Soft tissue injury, internal derangement, or fracture Infection, systemic rheumatic disease, gout, pseudogout Infection, sepsis, systemic rheumatic disease Focal nerve lesion (compartmetn syndrome, entrapment neuropathy, mononeuritis multiplex, motor neuron disease, radiculopathy) Myositis, metabolic myopathy, paraneoplastic syndrome, degenerative neuromuscular disorder, toxin, myelopathy, transverse myelitis Radiculopathy, reflex sympathetic dystrophy, entrapment neuropathy Myelopathy, peripheral neuropathy Peripheral vascular disease, giant cell arteritis.,. 3. (Physical Examination) 4). (synovium)., (bursa), (tendon), (ligament).. (,, )... (redness), (local heat).. (firm or nodular)..,,,.,,,,.,,, SLE,.. 1-4)(Figure 2).,. SLE (facial rash), (scaling skin lesion).,, SLE,,,

4 : Fig ure 2. Initial approach to the patient with polyarticular joint symptoms X- ray. (rheumatoid factor, RF) (antinuclear antibody, ANA) 5,6).. RF. ANA SLE 97% 99% 7). ANA SLE (,,, ). ANA (anti- dsdna, anti- Ro, anti- Lam anti- Scl 70, anti- RNP, anti- Sm, anti- Jo 1) 8) 9, 10). monosodium urate. CK(creatine phophokinase), LDH(lactate dehy

5 : drogenase). ANCA(anti- neutrophil cytoplasmic antibody)11), HLA- B2712), (antiphospholipid antibody) (Wegener s granulomatosis),,..,,,,. 2,000/mm3, 75%. 5. (Rheumatology consultation criteria) 6. 1%, 13).,,.. RF 70% 2.. (mononeuritis multiplex) 6,, Figure 3. Management of rheumatoid arthritis

6 Korean Journal of Medicine : Vol. 58, No. 1, ). Figure 3. (,, ), (functional status), (, ESR, CRP ),,, 15)...,,..,, ESR, 20,..,. (nonsteroidal antiinflammatory drugs, NSAIDs), (disease- modifying antirheumatic drugs, DMARDs), (glucocorticoids). DMARDs NSAID. DMARD hydroxychloroquine(hcq), sulfasalazine(ssz), methotrexate (MT X), gold salts, D- penicillamine, azathioprine,. HCQ SSZ. MT X 16-19). Cyclosporin A 20, 21).. DMARD. 22). DMARD. 10mg/. 7. (SLE) SLE SLE 10 80%, 20 65% ,24). SLE 25).. SLE (flare).. SLE 4 26)., SLE, SLE,,, SLE. SLE SLE 4 27). SLE (T able 4, Figure 4)

7 Seong Yoon Kim : Rheumatologic consultation Table 4. Reasons for referral to a rheumatolog ist T o confirm a diagnosis T o assess disease activity and severity T o provide general disease management T o manage uncontrolled disease T o manage organ involvement or life- threatening disease In other specific circumstance, including antiphopholipid syndrome, pregnancy, surgery.,,,. Figure 4. Tasks of the primary care physician in the diagnosis and management of systemic lupus erythematosus(sle). 1), SLE. SLE. 2). 24, 28). 3) 4) SLE.,,,, CPK,,,, (T able 5)., DNA. 5) 29). 6) (intolerance),,,,,,,,. 7),,

8 : Table 5. Examples of org an- or life- threatening manifestations in SLE Cardiac Coronary vasculitis/ vasculopathy Libmann- Sacks endocarditis Myocarditis Pericardial tamponade Malignant hypertension Pulmonary Pulmonary hypertension Pulmonary hemorrhage Pneumonia Emboli/ infarts Shrinking lung Hematologic Hemolytic anemia Neutropenia (w hite blood cells < 1000/mm3) T hrombocytopenia ( < 5000/ mm3) T hrombotic thrombocytopenic Purpura T hrombosis (venous or arterial) Neurologic Seizures Acute confusional state Coma/ Stroke T ransverse myelopathy Mononeuritis, polyneuritis Optic neuritis Demyelinating syndrome Muscle myositis Gastrointestinal Mesenteric vasculitis Pancreatitis Renal Persistent nephritis Rapidly progressive glomerulonephritis Nephrotic syndrome Skin Vasculitis, Diffuse severe rash, w ith ulceration or blistering Constitutional High fever (prostration) in the absence of infection...,. R E F E R E N C E S 1) Gamez- Nava JI, Gonzalez- Lopez L, Davis P, Suarez- Almazor ME. Referral and diagnosis of common rheumatic diseases by primary care physicians. Br J Rheum atol 37: , ) Russel AS, Percy JS. T he adult patient. In: M addison PJ, Isenberg DA, W oo P, Glass DN, eds. Oxford T extbook of Rheumatology. 2nd ed. P.1-9, Oxford, Oxford University Press, ) Amerian College of Rheumatology Ad Hoc Committee on Clinical Guideline. Guidelines for the initial evaluation of the adult patient with acute musculoskeletal symptom. Arthritis Rheum 39:1-8, ) Liang MH, Sturrock. Evaluation of m usculoskeletal symptoms. In K lippel J H, Dieppe PA, eds. Practical Rheum atology. 3-20, London, M osby, ) Shmerling RH, Delbanco T L. H ow useful is the

9 : rheum atoid factor? Analysis of sensitivity, specificity, and predictive value. Arch Intern M ed 152: , ) Richardson B, Epstein WV. Utility of the fluorescent antinuclear antibody test in a single patient. Ann Intern M ed 95: , ) Shiel WC Jr, Jason M. T he diagnostic associations of patients with antinuclear antibodies referred to a community rheumatologist. J Rheum atol 16: , ) Von Niuhlen CA, Tan EM. Autoantibodies in the diagnosis of systemic rheumatic diseases. Semin Arthritis Rheum 24: , ) Homburger HA. Cascade testing for autoantibodies in connective tissue diseases. M ayo Clin Proc 70: , ) Juby A, Johnston C, Davis P. Specificity, sensitivity and diagnostic predictive value of selected laboratory generated autoantibody profiles in patients with connective tissue diseases. J Rheum atol 18: , ) Jennette JC, Falk RJ. A ntineutrophil cytoplasmic autoantibodies associated disease: A review. A m J Kidney Dis 15: , ) Hawkins BR, Dawkins RL, Christiansen FT, Zildo PJ. Use of the B 27 test in the diagnosis of ankylosing spondylitis: A statistical evaluation. Arthritis Rheum 24: , ) Hochberg MC. A dult and juvenile rheumatoid arthritis: Current epidem iologic concepts. Epidemiol Rev 3:27-44, ) Amerian College of Rheumatology Ad Hoc Committee on Clinical Guideline. Guidelines for the management of rheum atoid arthritis. Arthritis Rheum 39: , ) Pinals RS, Masi AT, Larsen RA, and the Subcommittee for Criteria of Remission in Rheumatoid Arthritis of the American Rheumatism Association Diagnostic and Therapeutic Criteria committee. Prelim inary criteria for remission in rheumatoid arthritis. A rthritis Rheum 24: , ) Weinblatt ME, Kaplan H, Germain BF, Block S, Solomon SD, Merriman RC, Wolfe F, Wall B, Anderson L, Gall E, Torretti D, Weissman B. M ethotrexate in rheumatoid arthritis: A five- year prospective multicenter study. Arthritis Rheum 37: , ) Kremer JM, Phelps CT. Long- term prospective study of the use of methotrexate in the treatm ent of rheum atoid arthritis: Update after a mean of 90 months. Arthritis Rheum 35: , ) Alacon GS, Tracy IC, Blackburn WD Jr. M ethotrexate in rheumatoid arthritis: T oxic effects as the major factor in lim iting long- term treatment. Arthritis Rheum 32: , ) Maini RN, Breedveld FC, Kalden JR, Smolen JS, Davis D, Macfarlane JD, Antoni C, Leeb B, Elliott MJ, Woody JN, Schaible TF, and Feldmann M. Therapeutic efficacy of multiple intravenous infusions of anti- T N F monoclonal antibody combined with low- dose weekly methotrexate in rheumatoid arthritis. J Rheumatol 41: , ) Altman RD, Schiff M, Kopp EJ, and The Cyclosporin A Study Group. Cyclosporin A in rheumatoid arthritis: randomized, placebo controlled dose finding study. J Rheumatol 26: , ) Johns KR, Littlejohn GO. T he safty and efficacy of cyclosporin in rheumatoid arthritis. J Rheumatol 26: , ) Kirwan JR and the Arthritis and Rheumatism council Low-Dose Glucocorticoid Study Group. T he effect of glucocorticoids on joint destruction in rheumatoid arthritis. N Engl J M ed 333: , ) Abu- Shaka M, Urowits MB, Glademan DD, Gough J. M ortality studies in systemic lupus erythematosus: results from a single centre. I. Cause of death. J Rheum atol 22: , ) Gladmann DD. Prognosis and treatment of systemic lupus erythematosus. Curr Opin Rheumatol 8: , ) Urowitz MB, Bookman AAM, Koehler BE, Gordon DA, Smythe HA, Ogryzlo MA. The bimodal mortality pattern of systemic lupus erythematosus. Am J Med 60: , ) Amerian College of Rheumatology Ad Hoc Committee on Clinical Guideline: Guidelines for referral and managem ent of systemic lupus erythematosus in adults. A rthritis Rheum 42: , ) Hochberg MC. Updating the American College of Rheum atology revised criteria for the classification of systemic lupus erythematosus letter. A rthritis Rheum 40:1725, ) Kalunian KC. Definition, classification, activity and damage indics. In: W allace DJ, Hahn BH, eds. Dubois lupus erythematosus. 5th ed. p.19-30, Baltimore, W illiams and W ilkins, ) Gladmann D, Ginzler E, Goldsmith C, Fortin P, Liang M, Urowitz M, et al. T he development and initial validation of the Systemic Lupus International Collaborating Clinics/ A merican College of Rheumatology Dam age Index for systemic lupus erythematosus. Arthritis Rheum 39: ,

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A 617 Special Issue Diabetic Retinopathy Won Ki Lee, M.D. Department of Ophthalmology The Catholic University of Korea College of Medicine Kangnam St. Mary s Hospital E mail : wklee@catholic.ac.kr Abstract R