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风湿病学诊所
风湿病转诊指南
范围:
- To focus on inflammatory and autoimmune conditions that require management with immunosuppressive 地中海ications
- 避免重复或不必要的诊断测试
适合转诊的病人包括:
1)炎性关节炎
-
- 定义:关节肿胀, 温暖, 积液, and/or tenderness on exam; significant stiffness in affected joints that generally improves with activity, 没有恶化.
- 条件
- 炎性关节炎NOS
- 类风湿性关节炎
- 血清反应阴性的spondyloarthropathy
- 银屑病关节炎
- 反应性关节炎
- IBD-associated关节炎
- 强直性脊柱炎
- 水晶关节病
- 痛风 – tophaceous gout, or repetitive flares DESPITE urate lowering therapy
- DO NOT REFER patients without complicated gout as above – see below re tips for management
- 焦磷酸钙沉积病
- 痛风 – tophaceous gout, or repetitive flares DESPITE urate lowering therapy
- Juvenile idiopathic arthritis (juvenile rheumatoid arthritis) – if age >18yo
- 在转诊前进行有益的研究
- CBC / diff, CMP, ESR, CRP
- RF, anti-CCP, 安娜
- 丙肝病毒和乙肝病毒/艾滋病筛查
- 尿酸水平(用于痛风)
- X-rays of involved joints; if rheumatoid arthritis, please get bilat hand AND feet xrays (needed for baseline)
2)红斑狼疮
- 条件
- 系统性红斑狼疮
- 皮肤性狼疮. discoid lupus, subacute cutaneous lupus erythematosus)
- 药物引起的红斑狼疮
- 混合性结缔组织病
- 未分化结缔组织病
- 在转诊前进行有益的研究
- CBC / diff, CMP
- 安娜, dsDNA, Sm / RNP, Ro /洛杉矶, C3, C4, 狼疮抗凝剂, anti-beta2-glycoprotein IgA / IgM /免疫球蛋白, anti-cardiolipin IgA / IgM /免疫球蛋白
- UA, random 尿蛋白:Cr比值 (note – this is different than microalbumin)
- If already done: renal bx and skin bx pathology reports
3)系统性硬化症(硬皮病)
- 条件
- Diffuse/limited cutaneous systemic sclerosis (scleroderma)
- 硬皮病模仿
- Scleredema
- Scleromyxedema
- 嗜酸性筋膜炎
- 局部硬皮病(morphea)
- 在转诊前进行有益的研究
- CBC / diff, CMP
- 安娜, dsDNA, sci - 70, Sm / RNP, Ro /洛杉矶, C3, C4, CK, 狼疮抗凝剂, anti-beta2-glycoprotein IgA / IgM /免疫球蛋白, anti-cardiolipin IgA / IgM /免疫球蛋白
- UA, random 尿蛋白:Cr比值 (note – this is different than microalbumin)
- 如果已经做过:胸部CT无对比,pft, TTE
4)炎性肌病(肌炎)
- 条件
- 多肌炎
- 皮肌炎
- 自身免疫性坏死性肌病
- 包涵体肌炎
- 在转诊前进行有益的研究
- CBC / diff, CMP
- CK
- 安娜, Sm / RNP, Ro /洛杉矶, anti-Jo-1
- If already done: EMG/NCS studies, MRI deltoid/thigh, CT chest w/o contrast, PFTs, TTE
5)血管炎
- 条件
- 巨细胞动脉炎
- Takayasu指出的
- 结节性多动脉炎
- Cryoglobulinemic血管炎
- IgA血管炎(Henoch-Schönlein紫癜)
- 血栓闭塞性脉管炎(伯格氏病)
- ANCA-associated血管炎
- 肉芽肿病伴多血管炎(韦格纳氏)
- Eosinophilic granulomatosis with polyangiitis (Churg Strauss)
- 微观polyangiitis
- Leukocytoclastic血管炎
- 荨麻疹的血管炎
- 摘要贝氏病
- 在转诊前进行有益的研究
- CBC / diff, CMP, ESR, CRP
- UA, random 尿蛋白:Cr比值 (note – this is different than microalbumin)
- C3/C4
- C-ANCA and p-ANCA with proteinase 3 and myeloperoxidase
- 丙肝病毒和乙肝病毒/艾滋病筛查
- 如果已经做过:CT血管造影, MR血管造影, 肾或皮肤病理报告, CT窦部或胸部无对比
6)其他风湿病学
- 条件
- Polymyalgia rheumatica à CBC / diff, CMP, ESR, CRP, RF/anti-CCP
- IgG4-related疾病
- 成人发病斯蒂尔氏病
- 复发polychondritis
- 雷诺氏现象
- Sjögren’s Syndrome, dsDNA, Sm / RNP, Ro /洛杉矶, c3/c4, UA, 尿蛋白:Cr比值, 定量免疫球蛋白, 带IFE的SPEP, upp与IFE, 自由轻链(kappa/lambda)比
- Antiphospholipid antibody syndrome – positive serology (+lupus anti-coagulant, +anti-cardiolipin ab and/OR +anti-beta2-glycoprotein ab…WITH arterial/venous clots and/OR obstetric complications)
请不要转诊以下病人:
- 骨关节炎 → orthopedic surgery if end-stage; see PCP 地中海ical mgmt tips below otherwise
- 椎体骨关节炎=退行性椎间盘疾病, spinal stenosis → orthopedic spine surgery or neurosurgery if focal neurologic deficits (do not refer for pain only)
- 纤维肌痛→见下面的PCP医疗管理提示
- Sports 地中海icine or musculoskeletal overuse injuries → orthopedic surgery and/or PT
- complex regional pain syndrome (reflex sympathetic dystrophy) → chronic pain clinic
- 慢性头痛→神经学
- 结节病→肺内科
- 重症肌无力→神经学
- 多发性硬化→神经学
- 遗传性/遗传性结缔组织疾病(如. Ehlers-Danlos) → genetics, or PT for joint protection teaching if arthralgia
- 原发性免疫缺陷综合征(如. common variable immunodeficiency = CVID) → allergy/immunology
- 慢性疼痛
- 慢性疲劳
- Uncomplicated gout (see above – please do not refer unless failing conventional urate lowering therapy, 或tophi是存在的)__. 请参阅下面的PCP医疗管理提示
- Positive 安娜 without other symptoms of autoimmune disease; fatigue alone is not sufficient
- Positive RF without inflammatory joint pain (see above)
- 孤立ESR/CRP升高
- Elevated CK in the absence of muscle weakness; or in the setting of acute trauma, 饮酒, 或药物滥用(急性横纹肌溶解)
安排预约所需的文件:
- 既往病史和当前用药清单
- Most recent clinic note clearly documenting reason for referral, current complaints
- 如在过去6个月内入院,须填写出院摘要
- Most recent labs, imaging studies, pathology reports, etc. 如果已经可用(见 有用的研究 在转介前取得)
一般PCP管理贴士:
- 痛风
- Diagnosis – monosodium urate crystals in synovial fluid is gold standard; reasonable to treat empirically if clinical hx of podagra with elevated uric acid levels.
- 治疗
- 耀斑
- 秋水仙碱0.6mg bid x5d if 肾小球滤过率(GFR) wnl; use prednisone 40mg x5d if not (colchicine is contra-indicated in CKD)
- DO NOT stop allopurinol/febuxostat during a flare if already on it – will cause further shifts in uric acid concentration and PROLONG the flare!
- 维护人员:耀斑消退后,开始…
- 肾小球滤过率(GFR) wnl
- 别嘌呤醇每日300毫克+秋水仙碱0.6g daily as flare ppx (risk of flares when starting allopurinol due to shifts in uric acid concentration)
- Check uric acid levels every 6 weeks and uptitrate allopurinol by 100mg at a time until uric acid level<6.0. 别嘌呤醇最大剂量为900mg
- CKD -伴任何GFR
- Allopurinol 50mg daily + prednisone 5mg daily as flare ppx
- Check uric acid levels every 6 weeks and uptitrate allopurinol by 50mg at a time until uric acid level<6.0. 别嘌呤醇最大剂量为900mg
- NOTE – allopurinol is NOT nephrotoxic and NOT contraindicated in CKD – just needs to be started low and slow due to slight increased risk of allopurinol hypersensitivity syndrome. 如不能用别嘌呤醇使尿酸达到目标, reasonable to switch to febuxostat 40mg daily → increase to 80mg daily if needed.
- 肾小球滤过率(GFR) wnl
- 耀斑
- 骨关节炎
- 参见美国风湿病学会指南:
- 一般
- Acetaminophen 1000mg TID → NSAIDs (COX2 inhibitor might be preferred – recent data do not suggest increased cardiac risk) → tramadol/narcotics AS LAST RESORT
- 物理治疗和减肥是最重要的
- 如果病情严重,请进行x光检查, obtain orthopedic surgery consult regarding possible joint replacement (if pt interested in surgery)
- 纤维肌痛症
- 患者教育
- 也采用非药物治疗干预措施
- 太极-见里程碑NEJM文章. 王超等。. 太极拳治疗纤维肌痛的随机试验. NEJM. 2010.
- Pharmacologic interventions – only helpful for about 30% of patients
- FDA批准
- Duloxetine – most helpful for co-existing osteoarthritis
- Milnacipran
- 普瑞巴林(或尝试加巴喷丁,如果没有覆盖)
- 委员会的成员不是fda批准
- 低剂量TCAs
- DO NOT USE: steroids, opiates – not effective and can worsen condition.
- FDA批准
Samantha Shapiro,医学博士
最后更新:2018年10月16日