: 58 1 2000 100, (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 -
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).. 60.. 15. - 4 -
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,,,. - 5 -
: 58 1 473 2000 Fig ure 2. Initial approach to the patient with polyarticular joint symptoms. 4... 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- - 6 -
: 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. - 7 -
Korean Journal of Medicine : Vol. 58, No. 1, 2000 14). 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 1000 1. SLE 10 80%, 20 65% 40 3 23,24). SLE 25).. SLE (flare).. SLE 4 26)., SLE, SLE,,, SLE. SLE SLE 4 27). SLE (T able 4, Figure 4). - 8 -
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),,. - 9 -
: 58 1 473 2000 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 37:1215-1219, 1998 2) 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, 1998 3) 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, 1996 4) Liang MH, Sturrock. Evaluation of m usculoskeletal symptoms. In K lippel J H, Dieppe PA, eds. Practical Rheum atology. 3-20, London, M osby, 1995 5) Shmerling RH, Delbanco T L. H ow useful is the - 10 -
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