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レジデントノート

米国にて内科修行中。何ができるか模索している過程を記録していく

Rheumatology (memo from NEJM knowledge plus and MKSAP)

・DDx of patient with rheumatoid arthritis on methotrexate and etanercept who develop fever, arthralgia, pleuritic chest pain, nonblanching purpuric rash, pancytopenia, proteinuria

drug-induced lupus erythematosus (TNF alfa inhibitor)

 

・management of patient with h/o gout who develop acute knee arthritis, joint fluid shows WBC 110,000, positive for crystal, gram stain negative

empiric ABX for possible concomitant infection until Cx come back negative if WBC in joint fluid > 50,000

 

・Tx for chronic reactive arthritis

sulfasalazine, usually self-limited, 25% develep chronic persistent arthritis

 

・initial Tx for gout attack prophylaxis

urate-lowering agent (allopurinol) + colchicine

 

・first-line treatment of uncomplicated dermatomyositis

high-dose corticosteroid

 

・diagnosis of ankylosing spondylitis

MRI of sacroiliac joint

 

・medical Tx for patient with fibromyalgia not tolerate pregabalin

serotonin and norepinephrine reuptake inhibitor (duloxetine, milnacipran)

 

・shoulder pain, large noninflammatory joint effusion, subsequent to trauma, periarticular  diffuse calcification 

basic calcium phosphate diposition disease (Milwaukee shoulder)

 

・diagnostic test for patient with uveitis, erythema nodosum, oligoarthritis

CXR to evaluate hilar lymphadenopathy, sarcoidosis, known as Lofgren syndrome (diagnosis without tissue biopsy)

 

・Tx for musculoskeletal feature of systemic sclerosis

methotrexate

 

・heliotrope and Gottron's papules with normal CPK

amyopathic dermatomyositis

 

・patient with rheumatoid arthritis refractory to methotorexate

add TNF alfa inhibitor

 

・rheumatoid arthritis

diagnosed with > 10 synovitis more than 6 weeks even if RF/anti-CCP Ab/ESR/CRP all negative (20% RA negative with RF and anti-CCP Ab)

 

・erosive hand osteoarthritis

involve proximal and distal interphalangeal joints that are associated with erythema, swelling, and severe pain, ESR mildly elevated

 

・management of active SLE disease with proteinuria

kidney biopsy, followed by aggresive Tx

 

・osteoarthritis-like arthritis in atypical joints

calcium pyrophosphate arthropathy (calcium diposition)

 

・osteoarthritis-like arthritis in metacarpophalangeal joints, wrist, hip

hemochromatosis

 

・Tx for rheumatoid arthritis during pregnancy

discontinue DMARDs (methotrexate), 75% spontaneous remission, if persistent -> prednisone, hydroxychloroquine, sulfasalazine

 

・diagnosis of patient with 3 months h/o rash worsened by sun exposure and fatigue, no other symptoms, ANA negative, anti-Ro/SSA Ab positive

subacute cutaneous lupus erythematosus

 

・pain management of osteoarthritis refractory to medications and physical therapy

try tramadol

 

・mangement of patient with acute gout polyarthritis with CKD

prednisone 0.5mg/kg of ideal body weight

 

・suspected giant cell arteritis with negative temporal artery biopsy

contralateral temporal artery biopsy

 

・anti-U1-ribonucleoprotein (RNP) antibody

mixed connective tissue disease

 

・cutaneous sclerosis that involves only skin without other systematic symptoms

morphea

 

・adverse effect of tocilizumab for RA

hyperlipidemia

 

・diagnostic test for patient with pulmonary nodular infiltrate, boggy nasal turbinate, positive p-ANCA

lung nodule biopsy, instead of nasal sinus mucosa biopsy, which infrequently yield sufficient tissue to evaluate

 

・follow-up management of stable patient with rheumatoid arthritis diagnosed 1 year ago when x-ray showed early sign of erosion 

repeat hand and wrist x-ray

 

・evaluation of patient with thickened ears, saddle nose deformity, polyarthritis

pulmonary function test to evaluate large upper airway involvement in suspected relapsing polychondritis

 

 ・cutaneous palpable papura, low complement, Sjogren syndrome

Type 1 cryoglobuminemic vasculitis 

 

・neck and low back pain with limited mobility throughout spine in obese male h/o DM

diffuse idiopathic skeletal hyperostosis

 

・elbow pain due to repetitive movement

lateral epicondylitis

 

・Tx for urticarial vasculitis

hydroxychloroquine

 

・lateral hip pain, tenderness to palpation on bursa

trochanteric bursitis

 

・lateral hip pain, tenderness to palpation along the band down to knee, young athlete

iliotibial band syndrome

 

・woody induration in extremities, no Raynaud phenomenon

eosinophilic fasciitis (scleroderma spectrum disoder, spare fingers, even normal pheripheral eosinophil count)

 

・diagnostic test for patient with DM, who present with 5 month h/o knee pain, frequently scraping knee in the soil while working, warm and swollen knee, T 38.0, WBC 11000, joint aspiration: WBC 6500, negative crystal and gram stain, negative bacterial Cx, RF, ANA, Lyme titer, TB skin test

synovial biopsy (fungal arthritis: Sporothrix schenckii)

 

 ・diagnosis of patient with thrombocytopenia, livedo reticularis, valvular disease, microangiopathic kidney insufficiency, pregnancy loss

antiphospholipid syndrome