風濕免疫科標準病歷範本
Case 一: 【Allopurinol allergy】
Chief Complaints:
Rash, fever, and malaise for two days.
Present illness:
This 52-year-old man suffered from acute painful swelling in his big toe 5 weeks
earlier, for which he was treated with ibuprofen followed by allopurinol 200 mg daily.
Then his serum urate concentration was 8.5 mg/dl and serum creatinine concentration
2.5 mg/dl. He noted a widespread rash, oral and genital ulceration, fever, malaise,
diarrhoea, and diminished urine output 5 days before this entry. Then he was sent to
out ER.
On examination he was feverish and unwell. His face was red and edematous, and he
had blistering on his hands and feet, superficial ulceration in the mouth and
conjunctiva, and balanitis. He had a morbilliform rash over his trunk and limbs. The
white cell count was 17 × 109/l with 70% neutrophils and 12% eosinophils. Alanine
aminotransferase concentration was 143 U/l (normal <31), and the creatinine
concentration had risen to 5.5 mg/dl. Under the impression of allopurinol related
Stevens-Johnson syndrome, he was admitted for further management.
Impression:
1. Steven-Johnson syndrome, allopurinol related, with hepatitis and acute on chronic
renal failure.
2. Gout
Plans:
1. Diagnostic plan
Check IgE, ANA, septic workup
2. Therapeutic plan
Systemic steroid, close monitor skin, renal, liver function
Adequate Hydration and nutrition
Consult Oph
IVIG if necessary
3. Education plan
Skin care, stop allopurinol
Case 二: 【Stevens-Johnson syndrome (SJS)/TEN overlap induced by
carbamazepine】
Chief Complaints:
Generalized skin rash for 1 day.
Present illness:
This 28-year-old woman had history of childhood epilepsy and was on antiepileptic
medication previously until the age of nine years. She was unable to provide the name
of the medication. She was started on carbamazepine 15 days before this entry for
recurrence of seizures. She developed a macular rash, fever and mouth ulcers 2 days
before this entry. The rash started on the face and progressed rapidly to her trunk and
limbs over the next day. The facial rash subsequently evolved into pustules, which
also erupted over her neck and chest within 24 hours. She was sent to our ER for
further management.
Clinical examination of the skin revealed a generalized erythematous macular rash,
confluent over the trunk and back. Nikolsky’s sign was positive. Targetoid lesions
were noted over the thighs and upper limbs, including palms and soles, some of which
had central clear bullae. The total extent of the erythematous rash was 55% body
surface area (BSA) and bullae accounted for 1% BSA. Of note, there were confluent
lakes of pustules over the face. Non-follicular pustules were also noted over the neck
and the chest. There were multiple erosions over the mouth and vulva, and her
conjunctiva was inflamed. She was febrile. There was no hepatosplenomegaly or
lymphadenopathy. Her total white blood cell count was 4 × 109/L. No atypical
lymphocytosis or eosinophilia was noted. She had mild transaminitis, alkaline
phosphatase (ALP) 181 U/L, alanine aminotransferase (ALT) 176 U/L, aspartate
aminotransferase (AST) 140 U/L. The clinical impression was Stevens-Johnson
syndrome (SJS)/TEN overlap induced by carbamazepine. Then she was admitted.
Imp:
1. Stevens-Johnson syndrome (SJS)/TEN overlap induced by carbamazepine
2. Seizure disorder
Plans:
1. Diagnostic plan
Check IgE, ANA, septic workup
2. Therapeutic plan
Systemic steroid, close monitor skin, renal, liver function
Adequate Hydration and nutrition
Consult Oph; Neurologist (alternative anti-seizure medication)
IVIG if necessary
3. Education plan
Skin care, stop carbamazepine
Case 三: 【Septic arthritis in a Rheumatoid arthritis patient receiving
anti-Tumor Necrosis Factor agent】
Chief Complaints:
Painful swelling, redness in right ankle for 2 days
Present Illness:
A 65-year-old man had a 6-year history of rheumatoid arthritis with medications
included daily administration of 7.5 mg prednisolone, 1000 mg salazosulfapyridine,
300 mg sulindac, and weekly 15 mg methotrexate. Eighteen weeks earlier he had
started a twice-weekly subcutaneous administration of 25 mg etanercept due to severe
RA activity. This was well tolerated and offered sufficient control of disease activity.
Before administration of etanercept, C-reactive protein (CRP) levels were 83 mg/l,
erythrocyte sedimentation rate (ESR) was 100 mm/h, and DAS284 was 5.17.
Hepatitis B and C serology were negative, and tuberculin skin testing was positive.
Inflammatory signs decreased after administration of etanercept, the levels of CRP
were 3.4 mg/l, ESR was 17 mm/h, and DAS28 was 3.31.
The patient experienced a 2-day history of swelling, redness, and worsening pain in
his right ankle. He was afebrile. And he denied trauma history. He was sent to our ER.
On initial examination, the patient’s temperature was 36.9°C and pulse and blood
pressure were normal. There was tenderness, swelling, and redness of the right ankle
joint with a decreased range of motion.
Laboratory data revealed a white blood cell count of 12 000/mm3 (segmented
neutrophils 84%), a hemoglobin level of 12.0 g/dl, and elevated inflammatory
markers (ESR 40 mm/h, CRP 248 mg/l). X-ray films of the right ankle joint revealed
spreading of the talotibial joint space and erosive destruction of the subtalar joint. Ten
milliliter yellow turbid synovial fluid was aspirated from the ankle for laboratory
analysis. He was admitted for further management under the impression of septic
arthritis.
Impression: Septic arthritis; right ankle; probably related to anti-TNF agent
(etanercept)
Plans:
1. Diagnostic plan
Septic workup; pursue culture report
2. Therapeutic plan
Arthrocentesis and joint irrigation if necessary
Oxacillin
Consult Orthopedics for surgical drainage
Stop etanercept
3. Education plan
Bed rest; leg elevation; local ice packing.
Case四: 【Systemic lupus erythematosus #1】
Chief complaint:
Severe pain over small joints of fingers, wrists, knees, hips and ankles for one month
Present Illness:
A 48-year-old woman with systemic lupus erythematosus (SLE) diagnosed more
than 20 years ago presented to our clinic with a history of generalized pain, profound
fatigue, oral ulcers, dry eyes and mouth, and hair loss. She complained of severe pain
in her fingers, wrists, knees, hips and ankles. She also reported significant morning
stiffness and muscle soreness. In the past, she had had immune thrombocytopenic
purpura, several deep venous thromboses and an episode of pulmonary embolism. She
was taking warfarin (2.5 mg daily), hydroxychloroquine (200 mg twice daily),
acetaminophen as required for pain, and prednisone (5 mg/d).
The patient was afebrile. There was no overt synovitis, but there was tenderness
over her wrists, elbows, knees and ankles. Radiographs of her long bones showed
evidence of multiple bone infarcts and avascular necroses. A technetium-99m
radionuclide bone scan showed evidence of a healed infarct of the right lunate and
lateral femoral condyles.
The patient had a prolonged prothrombin time of 18.6 (normal 9.9–13) seconds, an
international normalized ratio (INR) of 1.7 (normal 0.9–1.2) and an activated partial
thromboplastin time (aPTT) of 56.1 (normal 24.6–34) seconds. The prolonged
prothrombin time was consistent with her history of warfarin therapy. The patient was
positive for IgG anticardiolipin antibodies (16 [normal < 12] MPL units). She was
admitted to the hospital, and diagnostic procedures were performed.
Impression:
SLE with antiphospholipid syndrome causing multiple avascular necrosis bone
infarction
Plans
1. Diagnostic plan:
Evaluation of SLE disease activity (anti-dsDNA antibody, C3, C4)
Check anti-beta2 microglobulin-I antibody
2. Therapeutic plan:
Raise dose of warfarin to achieve a therapeutic INR 2-3
3. Educational plan:
Avoid sports and activities that may cause injury
Report any abnormal bleeding and measure INR regularly
Case五: 【Systemic lupus erythematosus #2】
Chief complaint:
Dry cough for 2 months
Present Illness:
A previously healthy 43-year-old woman presented with a 2-month history of dry
cough. She denied constitutional symptoms such as fever, malaise, poor appetite, or
body weight loss. Physical examination revealed no abnormalities. A chest radiograph
showed blunting of the left costophrenic angle, suggesting the presence of pleural
effusion. Thoracocentesis yielded 30 ml of odorless milky fluid containing
4,608/mm3 white blood cells with a differential of 59% lymphocytes, 6% neutrophils,
2% eosinophils, and 33% tissue cells. Biochemical analysis of the pleural fluid
demonstrated the following: total protein, 7.8 g/dl; lactate dehydrogenase, 228 U/l;
glucose, 86 mg/dl; amylase, 29 U/l; cholesterol, 89 mg/dl; and triglyceride, 857 g/dl,
supporting the diagnosis of chylothorax. Gram’s stain, acid-fast stain, and culture of
bacteria and mycobacteria all gave negative results. Cytology of the pleural fluid was
negative for malignant cells. The computed tomographic (CT) scan of chest
demonstrated small amounts of left-sided pleural effusion without evidence of
pulmonary parenchyma lesion or mediastinal lymphadenopathy. There was no history
of antecedent chest trauma or thoracic surgery.
Further immunological studies of serum showed positive for antinuclear antibodies
(ANA) at a titer of 1:1,280 with diffuse chromatin and fine and large speckled pattern.
She was referred to our IMRH OPD, and tests for anti-dsDNA, anti-SSA/Ro,
anti-SSB/La, anti-Sm, and anti-RNP antibodies all gave positive results. Under the
impression of systemic lupus erythematosus with chylothorax, she was admitted for
further evaluation and treatment.
Impression:
SLE with chylothorax
Plans
1. Diagnostic plan:
Systemic evaluation of major organ involvement in SLE (CNS, Heart,
Gastrointestinal, Kidney, etc)
2. Therapeutic plan:
Solumedrol 20mg IV QD and hydroxychloroquine 200mg PO BID
3. Educational plan:
Avoid ultraviolet light exposure
Case六: 【Systemic lupus erythematosus #3】
Chief complaint:
Abdominal pain, nausea and vomiting for 5 days
Present Illness:
A previously healthy 19-year-old woman presented with a 5-day history of
abdominal pain. She described the discomfort as persistent, dull, and diffuse pain that
was aggravated by food intake. The associated symptoms included nausea, vomiting,
constipation, and abdominal distention. She denied fever, chills, diarrhea, tarry stool
passage, or urinary symptoms. There was no history of previous abdominal surgery or
gynecologic disorders. On physical examination, she had no skin lesions or
lymphadenopathy. Her abdomen was soft with diffuse tenderness and rebounding pain,
especially in the right lower quadrant (RLQ) area. There was no guarding or a
palpable mass, and bowel sounds were hypoactive. Laboratory work on admission
was significant for a low platelet count of 110 × 109/L and a low serum albumin level
of 25 g/L. Serum amylase and lipase levels were normal. Urinalysis revealed
proteinuria (3+), and urine pregnancy test was negative.
Abdominal ultrasonography showed diffuse intestinal wall thickening, moderate
ascites, and a target-like lesion in RLQ area, suggesting intussusception. Computed
tomography (CT) revealed multi-segmental wall thickening and intestinal dilatation
involving gastric antrum, jejunum, ileum, cecum, proximal ascending colon and
rectum, and moderate ascites. An ileocecal intussusception was identified without a
definite mass or any enlarged lymph nodes. The CT findings suggested the presence
of mesenteric vasculitis with ileocecal intussusception. Immunological studies of
serum showed positive antinuclear antibodies (ANA) at a titer of 1:640 with
homogenous and speckled pattern. Tests for anti-dsDNA, anti-SSA/Ro, and
anti-SSB/La antibodies all gave positive results Under the impression of SLE with
mesenteric vasculitis causing ileocecal intussusception, she was admitted for further
evaluation and treatment.
Impression:
SLE with mesenteric vasculitis causing ileocecal intussusception
Plans
1. Diagnostic plan:
Systemic evaluation of major organ involvement in SLE (CNS, Heart, Kidney,
etc)
2. Therapeutic plan:
Complete bowel rest (NPO, IV fluid supplement)
Solumedrol 40mg IV Q6H
Closely monitor therapeutic response and abdominal condition
3. Educational plan:
Inform the patient and her family about the possible complications of mesenteric
vasculitis (bowel necrosis, perforation and peritonitis)
Case七: 【Rheumatoid arthritis】
Chief complaint:
Painful swelling of left ankle for days.
Present Illness:
This 25 year-old woman has a past history of rheumatoid arthritis since 2006. She
had received disease modifying anti-rheumatic drug therapy including methotrexate
and sulphasalazine. She suffered from right hip joint pain and left ankle pain for days.
She visited the rheumatology clinic and biologic therapy was suggested for her
current disease condition. CXR showed minimal increased lung markings in the
bilateral lower lung fields. The inflammatory parameters such as ESR (49 mm/hr) and
CRP (25.3 mg/L) were still high. The rheumatoid factor was positive and the chest
X-ray showed no active infection. There were no infection symptoms and signs such
as fever and chills. Under the impression of rheumatoid arthritis with active disease,
she was admitted for biologic therapy.
Throughout the disease course, there were no respiratory symptoms or abdominal
symptoms and she denied having a drug allergy history.
Impression:
Rheumatoid arthritis
Plans
1. Diagnostic plan:
Immunoglobulin G/A/M and rheumatoid factor
2. Therapeutic plan:
Mabthera 1000 mg injection
3. Educational plan:
Observation of allergic reaction to the drug
Case八: 【Ankylosing spondylitis】
Chief complaint:
Arthritis exacerbation of right knee and ankle pain for days.
Present Illness:
This 41 year-old man has a history of ankylosing spondylitis for 5 years. He was
followed up at Chi Mei Hospital. He had suffered from painful swelling of right knee
and right ankle since September 2007. Despite sulphasalazine therapy, recurrent
arthritis was still noticed over the right knee and right ankle. Thus, the patient started
to receive Enbrel (etanercept) therapy every two weeks. However, intermittent joint
pain was still noticed with such dosage. The pain increased in intensity and the joint
stiffness aggravated in recent days.
The sonography performed last week showed active proliferative synovitis at right
ankle and right 3rd-5th toe joints. It also showed bone erosion at right 4th toe joint.
Under the impression of ankylosing spondylitis with exacerbation, he was admitted
for biologic therapy.
Throughout the disease course, there were no infection symptoms/signs,
respiratory symptoms or abdominal symptoms and he denied having a drug allergy
history.
Impression:
Ankylosing spondylitis
Plans
1. Diagnostic plan:
Inflammatory index including C reactive protein and ESR
2. Therapeutic plan:
Enbrel (etanercept) 25 mg subcutaneous injection twice per week.
3. Educational plan:
Observation of allergic reaction to the drug
Case九: 【Primary Sjögren’s syndrome】
Chief complaint:
Respiratory distress, progressive oligouria and leg edema for a period of two weeks.
Present Illness:
This 57-year-old woman was admitted to our hospital because of chest pain,
respiratory distress, progressive oligouria and leg edema for a period of two weeks.
The patient had no prodromal fever, rash, sore throat, or diarrhea. Two months prior to
this admission, laboratory investigations including blood cell count, serum
biochemistry, and urinalysis were all normal.
At the emergency room, she was afebrile, hypertensive (blood pressure 170/90
mmHg), having fainter heart sounds, and bilateral leg pitting edema. Local
examination revealed eye redness and buccal mucosa dryness with diminished
salivary pool at the floor of the mouth. Schirmer’s test was positive (0 mm in 5 min)
in both eyes confirming xerophthalmia. Tracing the medical history, she had a daily
feeling of dry mouth and a foreign-body sensation in the eye. These symptoms
persisted for several years but were so mild that she did not have any medical help.
The initial laboratory evaluations disclosed leukocyte count 5,900/mm3 with normal
differential, hemoglobulin 9.7g/dl, platelet count 111,000/mm3, BUN 32 mg/dl,
creatine 2.1 mg/dl, and C-reactive protein 2.6 mg/dl. The chest radiogram showed
marked enlargement of the cardiac silhouette. The presence of moderate to large
pericardial fluid was confirmed by echocardiography. The pericardial fluid obtained
from pericardiocentesis had the physical characteristics of an exudate (lactic
dehydrogenase level 630 IU/ml and leukocyte 87/mm3). The patients reported less
symptoms of dyspnea and chest discomfort. Under the impression of primary
Sjögren’s syndrome and pericarditis, she was admitted for further evaluation and
treatment.
Impression:
1. Primary Sjögren’s syndrome
2. Pericarditis
3. Renal insufficiency
Plans
1. Diagnostic plan:
The cause of pericarditis: cultures of the pericaial fluid for tuberculosis and other
microorganisms, cytology of aspirated specimens.
The urinalysis and renal biopsy if heavy proteinuria.
Coombs tests, coagulation studies, antinuclear antibodies, anti-Ro antibody,
anti-double-strand DNA, Smith antigen, Ro/La antigen, and cardiolipin to exclude
systemic lupus erythematosus
2. Therapeutic plan:
Initial corticosteroid at a dosage of methylprednisolone 240 mg/day
3. Educational plan:
Bed rest