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A.I.R. Orientation For new staff

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: Morning meeting ( W3 and W5, 7:45 am at 6F MICU meeting room)

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A.I.R. Orientation For new staff

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  1. A.I.R. Orientation For new staff

  2. Staff Dr. 李修身 Dr. 陳天令 Dr. 黃章喜(R5)

  3. Allergy, Immunology, Rheumatology

  4. Study: • Teaching: • 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)

  5. 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。

  6. 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……

  7. 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 。

  8. 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,

  9. # 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

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

  11. Antinuclear antibody (ANA)

  12. Homogenous Peripheral Speckled Nucleolar

  13. , HCV

  14. (Rheumatoid arthritis)

  15. (Rheumatoid arthritis)

  16. C spine AP view (open mouth)

  17. C spine lateral view (flexion)

  18. # NSAID’s in MMH • 1.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**)

  19. Choosing NSAID’s: effective, adverse effect, age, • underlying disease and T1/2 • # Misoprostol (U-Miso)…(endoscopic proof of PUD) • 1.“X” class for pregnancy • 2.Prevention of NSAID-induced PUD • 3.For RA > 50 y-o, or SLE(專案)

  20. 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.Corticosteroid • 6.Colchicine • 7.Lower dose allopurinol

  21. Gout with PUD (UGI bleeding) • 1.NSAID(* & **) or corticosteroid prn • 2.Intra-articular injection • 3.Colchicine • 4.H2-antagonist (4 months), PPI (2 months) • 5.Misoprostol (專案，一年份)

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