風冊

風濕過敏免疫科住院醫師手冊
目錄
序言
• 介紹
o 1-1 工作須知
o 1-2 工作規範
o 1-3 門診、會診及科內常用資源
o 1-4 如何報告病例
• 常見症狀，檢驗及鑑別診斷
o 2-1 簡介
o 2-2 Arthralgia
o 2-3 Low back pain
o 2-4 Myalgia
o 2-5 Arthrocentasis & Interpretation of synovial fluid analysis
o 2-6 Serum analysis
o 2-7 X-rays
• 常見疾病之診斷標準
• 常用藥物
o 3-1 NSAIDs
o 3-2 Steroids
o 3-3 DMARDs，biologic agents/IVIG/miscellaneous
1
序言
由於人體的奧妙與複雜，使得內科學成為醫學生好奇又傾慕的一門學科。在這當中，風濕病
學及免疫學之廣泛發展不過是近七十年的事情。免疫系統遍佈全身，肉眼並不可見，致衍生
的疾病往往屬於全身多系統侵犯的問題。又因病患族群較為少數，因之成為醫學生雖有興趣
但不熟悉的領域。
面對知識瀚海與原文書籍，我們都深知孤獨與陌生的困難。想到風濕疾病，眾人的直覺便是
許多的診斷要件與條文，還有許多的可能、疑似與機率。很希望能有這麼一個媒介，用朋友
談心一般的語言，將前輩所傳承的智識紀錄下來，成為我們可以隨身攜帶並熟讀的利器。因
此在前輩醫師群的指導下而能有這本手冊的誕生。希望這本手冊能對內科學子有所幫助，也
期待眾位先進能夠不吝指教，以期更臻圓滿。
編著群
2
1-1 工作須知 98.10.20 修訂
1. 教學部分：
a. 本科辦公室、檢查室與實驗室位於研究大樓 2J，每日都有偏光顯微鏡檢查，每周
一上午在 3D 檢查室進行甲摺鏡以及超音波檢查，每週三在醫學大樓二樓腎臟超音
波室有肌肉軟組織及關節超音波檢查歡迎前往實習。
b. 所有輪訓至本科的見實習及住院醫師請準時參加各學術會議，包括每日 8:00 AM 在
7D 的晨會，星期四上午 11:00-12:00 之 Journal meeting，與每週安排的 Chart round
以及 teaching round。
2. 病房工作：
a. 病患病危或病況變化，請務必通知病房 CR 與主治醫師，下班前確實交班給值班醫
師並記錄於交班本上。
b. 病況穩定可出院者，儘量今辦明出。病人出院後，請於二十四小時內完成出入院病
歷，POMR，並請主治醫師簽名。
c. 病患對用藥有不良反應（ADR）時，請提報 ADR（由住院醫囑中點選）。藥物過敏請
記錄於病歷首頁。
d. 本科白班病人換藥、NG、Foley、ABG 與 EKG 由實習醫師執行。
e. 實習醫師應主動填寫 problem oriented sheet 及 laboratory examination follow
sheet，將重要用藥和檢查記載於 T.P.R. sheet 上。並由病房 CR 或住院醫師指派
2~5 個病人 primary care。
f. Progress note，on/off service note 須記錄 diagnostic criteria & X-ray
staging/finding。有 Special procedure 包括 CVP，Endotracheal tube，Lumbar
puncture，Arthrocentasis 請記錄 indication，finding，complication 於 Progress
note 中。每週要寫一次 Weekly summary。
g. 醫囑單每星期至少 renew 一次。
3. 醫護人員之間關係密切，偶有磨擦，請互相包容，維持良好的工作氣氛。有任何意見，
可向病房 CR 或護理長反映，並請「就事論事，對事不對人」，避免將負面情緒帶給旁人，
正向溝通才能解決問題。
4. 希望各位在本科工作愉快。
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1-2 工作規範 98.10.20 修訂
Fresh Autoimmune Disease Case

1. 懷疑 SLE ，請將 criteria 中的項目完成，包含 antiDsDNA ， antiSm/RNP ，
anti-cardiolipin IgG & IgM，lupus anticoagulant，若有懷疑 Sicca complex，
應加測 anti-SSA/SSB，有中樞神經症狀，加測 anti-Ribosomal P。
2. 懷疑MCTD請check Anti-ENA（RNP）（M25-212）。
3. SLE及Sjogren＇s syndrome，請check Anti-Sm & RNP（M25-212）及Anti-SSA &
Anti-SSB（M25-213）。
懷疑systemic sclerosis（SS）則check Anti-Scl 70（M25-214）。
懷疑Polymyositis/dermatomyositis則check Anti-Jo-1（M25-221）。
4. 懷疑Vasculitis syndrome，請check ANCA（M25-223）。再主治醫師同一下，可測
antiPR3/MPO antibody。
5. 懷疑 antiphospholipid antibody syndrome，應測 anti-Cardiolipin IgG & IgM
以及 lupus anticoagulant，或是 anti- ß2-glycoprotein 1。若均陰性但仍高度懷
疑，可測 anti-Phosphotidylserine。
再依鑑別診斷完成所有該有的檢查項目，參考後面的說明。
本科還提供的 auto-antibodies 及相關檢驗項目：（檢查→風溼過敏免疫科→再點選各項目）
代號項目 Indication
M25-211 Anti-ENA Screening test
M25-212 Anti-RNP & Sm MCTD & SLE
M25-213 Anti-SSA & SSB Sicca syndrome 及 SLE
M25-214 Anti-Scl-70 Scleroderma
M25-221 Anti-Jo-1 Inflammatory myositis
M25-156 Myositis panel (anti-Jo1, anti-SSA/SSB, Ki, Ku) Inflammatory myositis
M25-223 ANCA（Antineutrophil cytoplasmic antibody） Vasculitis
Anti-PR3 & MPO （自費 880 元） Vasculitis
Anti-Histone
M25-140 Anti-centromere Ab （自費 600 元）
M25-137 Anti-ß2-glycoprotein-1 APS & SLE
M25-216 Anti-Cardiolipin IgG APS & SLE
M25-216A Anti-Cardiolipin IgM
Anti-phosphotidylserine antibody
M25-139 anti-citrullinated filaggrin Abs（自費 1250 元）RA
M25-142 Anti-LKM-1 antibodies（自費 820 元） Autoimmune hepatitis
M25-155 Autoimmune hepatitis profile (M2, LKM-1, LC-1, Autoimmune hepatitis
SLA)（自費 1000 元）
M25-143 anti-ribosomal P Abs NPSLE
M25-129 Procalcitonin Infection
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Fresh arthritis
1. 若是有關節炎，請註明那些關節受影響，是否有紅腫熱痛，活動（ROM）是否有
limitation。再與 VS 討論是否要照關節的 image（plain film 或是其他 x 光檢查，
用那個 view）。若關節腫大．是否要做 synovial fluid aspiration，且要送那些檢
查。
2. 常用的有：X光片最都做stress或standing view，才能正確的評估cartilage damage
的程度。Hand的A-P & Oblique view。Wrist的A-P view。Shoulder的A-P view或是
照CXR時註明包括bilateral shoulder。Hip照Pelvic或Hip A-P view。Knee & ankle
請註明standing A-P & lateral view。Foot照A-P & Lat view。Cervical spine open
mouth A-P & lateral flexion view X-ray films。
3. 抽 Synovial fluid 送檢要開兩種單（a+b）
a. Synovial fluid aspiration（M25-063）
b. Crystal and Routine Analysis（檢查→風溼過敏免疫科→M36-001）
c. 若有懷疑CPPD crystal需加開Alizarin red staining
d. 懷疑 septic arthritis，請開 Gram stain（檢驗Æ風溼免疫科ÆL72-621-5 Gram
stain）及送 aerobic culture。最好是下午三點半前能送出檢體，急做五點才
會有結果。隔夜的檢體 cell 會 clotting，無法 counting。再依病人臨床判斷
是否要送 AFB stain，TB & fungus culture 還是 cytology。
4. Routine & Gram stain 當天就可打分機 2410 問結果。
5. 肌肉關節超音波（Musculoskeletal echo M36-031）於檢驗單上註明要檢查的部位
或關節，臨床資料和是否需要 intervention（aspiration or drainage）。若需超
音波導引抽吸，改開 Echo-guided aspiration (M23-041-D)。
6. Intraarticular injection 請開立過敏試驗檢查單之 M25-064。
A. 若是有雷諾氏現象、digital ischemia 或是 periungual erythema。
1. Nailfold Capillary microscopy請開M25-219。
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SLE
A. 診斷：
1. 若有皮膚病變，不典型要切片確定。
2. 要有 CXR 來排除 serositis。
3. 有週邊關節炎，需要照 plain film 看是否有 joint erosion。
4. 至少兩次 CBC/DC 。若有貧血，則需進一步檢查是否有 hemolysis （血液科
peripheral blood smear，reticulocyte count，bilirubin D/T，haptoglobulin,
direct & indirect Coombs＇ test）。
5. ANA，其他 Immunologic marker(C3, C4)，anti-phospholipid antibodies 是否
陽性。
6. Baseline U/A。若 urine protein 是 positive，則需進一步留 24hr Total protein
加上 CCr。
7. SLE 病人住院，可由範本 Assessment 中點選診斷之 classification criteria 或
SLEDAI 並計分。
B. Organ involvement：
1. SLE with fever除了做culture，找infection focus外，請check CRP。若需分辨
發燒是否為細菌感染，可測Procalcitonin。
2. SLE with thrombo-embolism or abortion history。請check Anti-cardiolipin
antibody IgG & IgM（M25-216, M25-216A），Lupus Anticoagulant（檢驗→血液
科 → M26-094 ）。 Anti-B2-glycoprotein 1 （ B2-GP1 ）（ M25-137 ），也是
anti-phospholipid Abs 之一，不可與 anti-cardiolipin Ab 同時開立。（ VS
order）：Anti-thrombin III（檢驗→血液科→M26-089），Protein C（檢驗→血
液科 → L72-069 ）， Protein S （檢驗 → 血液科 → L72-067 ）， Homocysteine ，
antiphosphotydylserine。
3. SLE with Neuropsychiatric 症狀時。 CT or MRI 排除 CVA （ ischemic or
hemorrhage）；MRI 在 white matter & brain stem lesion 上較 sensitive；考慮
做 lumbar puncture 排除 CNS infection；若都 negative，依 VS 意見看是否做核
醫 99mTc HMPAO brain SPECT（brain perfusion scan）
、CT-gated brain perfusion
scan、MRI/MRS 或 anti-ribosomal P Abs（M25-143）。
4. Thrombocytopenia，GI bleeding，Cr increase 的病人應儘量避免使用 NSAID。
5. 若 PLT<2 萬，請患者臥床休息，避免頭部碰撞產生 CNS bleeding，禁 IM injection
或 supp 給藥。若需要 multiple transfusion，請 prepare leukocyte-poor
platelet（single donor）and pRBC。Neutropenia 須衛教勿吃生食及礦泉水，
注意 occult infection。
C. Treatment protocol：
1. Methylprednisolone Pulse Therapy：1000 mg in D5W 100c.c. IVF QD x 3 days
or 500 mg IVF Q12hr x 3 days。每次注射時間應大於一小時。
2. Cyclophosphamide Pulse Therapy：請事先詢問主治醫師要用哪種 protocol
2
z NIH protocol: Endoxan initial 500mg/m in D5W 100c.c. IVF 1hr
z Eurolupus protocol: Endoxan 500mg (不用算 body surface) in D5W 100c.c.
6
IVF 1hr
z 在 endoxan 之前用 D5W 100 cc/hr x 2 hrs，之後用 D5W 100 cc/hr x 3 hrs。
請病人不要憋尿。
z 可以給病人止吐藥。
7
RA
1. 診斷：需 check rheumatoid factor，至少要有一次 Hand x-ray films（A-P & Oblique
view）。主治醫師同意可自費驗 anti-CCP = anti-citrullinated filaggrin Abs
（M25-139, 自費 1250 元）。
2. 需記載受影響的關節。
3. 需測 ESR 以及 CRP。
4. 有 peripheral arthritis 且有 bone erosion 者的 RA 及 seronegative

spondyloarthropathy病人，須照cervical spine open mouth A-P & lateral flexion
view X-ray。
5. 做 cervical collar，brace 可直接連絡電話：2666 復健科。
6. 並注意病人 DMARD 的使用劑量，特別是 MTX = methotrexate (2.5 mg/tab)（起始劑
量 7.5-10 mg/week）。
Seronegative spondyloarthropathy
1. 診斷：KUB 或 pelvic A-P view 看 SI joint 的變化。
2. MRI或Bone scan for early detection of sacroiliitis，在Bone scan項次（N73-060）
後請註明加做SI/S ratio。
3. Check 血液 IgA，IgG，IgM 及 HLA-B27。
4. 若病人有 Low back pain 可 order wooden bed。
Sjögren syndrome
1. 懷疑 Sjögren syndrome，需抽血驗 ANA，RF，Anti-SSA/SSB。
2. Exocrine function 可照會眼科安排 Schirmer test。Salivary gland function 可做
Saliva Production Test（M25-012），或安排核醫的 saliva production scan。也可
consult 口腔外科做 lip mucosa 的 minor salivary gland biospy。
Scleroderma
1. SS associated with dysphagia須做esophagogram（放射診斷科→ GI special exam
→S1001）時，請在X光片單註明UGI series + esophagogram，並請註明esophageal
motility evaluation；安排Nuclear Scan；Esophageal Transit Time（N73-038）。
2. 若做Pulmonary function test：作Standard Bronchodilator Test（檢查→風溼過
敏免疫科→M25-021B）（聯絡電話：2410）。Screening spirometry & DLCO（檢查→
胸腔科→M21-037 & M21-028 之diffusion velocity rate［非DLCO的名稱］）。
3. 若需要 Prostaglandine E1（Alprostadil 20ug/vial, Promostan®）2-3 vial in NS
500c.c. Run 4 hours x 7 days，（小心不要開到 500 ug 的藥物）。
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Myositis
1. 診斷：會診神內科做 muscle biopsy。並安排 EMG，依情況安排 NCV。check CPK。
2. 若懷疑病人有呼吸肌肉的問題可請 RT 測量 TV & Pi max（weaning profile）。
3. 若懷疑病人有 Interstitial pneumonitis 或 Chest PA 有異常時需安排 Screening
spirometry & DLCO（檢查→胸腔科→M21-037 & M21-028 之 diffusion velocity rate
［非 DLCO 的名稱］），並考慮做 High resolution CT scan (HRCT).
4. IVIG（intravenous immunoglobulin）在PM/DM使用一定要開立自費項目，並簽自費
同意書。本院的Gamimune N 5% 50ml/vial（2.5gm/vial）（~3690 元/vial）dosage：
inflammatory myositis 2 g/kg in divided doses for 3 to 5 days. Infusion rate：
0.01~0.02 ml/kg/min x 30 min and gradually increase up to 0.08ml/kg/min，
以 60kg的人為例，就需要 48 vial（60 x 2 / 2.5），若分為三天打完，則一天需打
16 vial。
甲、給法：initial 36 ml/hr for 30 min then 100~140 ml/hr for total 16 vial/day。
乙、或是：1st vial run 1.5 hr，then 2nd vial~16th vial run 100ml/hr，第 2 & 3
天就 run 100ml/hr。
5. 使用 IVIG 要注意病人是否為 isolated IgA deficiency，可能會產生 anaphylaxis。
Infusion rate 不要太快，否則可能產生 acute renal failure。
Gouty arthritis
1. 請 check 24 hrs urine uric acid 及 Ccr。
2. 若U/A有血尿或蛋白尿或結石病史或renal function abnormal請排renal echo。
3. 給予低普林飲食衛教單張或痛風衛教手冊。
Vasculitis
1. 若皮膚有 lesions，問主治醫師要不要會皮膚科做 skin biopsy。
2. 抽血檢驗：ANCA（M25-223），ANA，RF，C3，C4，CIC，Cryofibrinogen （檢驗→血
清→L72-241）；Cryoglobulin（檢驗→血清→L72-239）。若沒驗過，還要測 hepatitis
B & C 的 marker（HBsAg，anti-HCV Ab）。主治醫師同意可測 anti-PR3 & MPO。
Bronchial asthma 或過敏症：

1. Asthma 可 order 本科的 Standard Bronchodilator Test（檢查→風溼過敏免疫科→
M25-021B）與 PEFR（peak expiratory flow rate）qid，並記錄於 special sheet。
2. 過敏症相關的檢驗如下：
3. 過敏性鼻炎可做 Nasal smear（M25-011）：對鼻黏膜抹片做特殊染色，看是否有 eosinophil
infiltration。
4. 可先測定血清 IgE 濃度，看是否有過敏體質：
i. IgE 過敏測試法（代號 M25-108）。而 Phadiatop（M25-134）也是測血清 IgE，
只不過以 inhaled antigen（未指定任一種）為主。
5. 之後可進行「多種特異性抗體過敏篩檢試驗」（multiple antigen simultaneous test，
MAST，M25-130）。包含了 36 種 Ag。CAP（M25-131）可以對特定過敏原進行定量分析，
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目前有分成四大類：A1，A2，B1，B2。E.C.P（EOSINOPHIL CATIONIC PROTEIN）M25-133，
可測知過敏發炎嚴重度。
6. 減敏治療：目前只針對 Mite Allergen 的 Immunotherapy，有需要的，請約至風濕科門
診。
其他事項
1. 懷疑 adrenal insufficiency 請 check 10pm，8am，cortisol level 或作 CRH stimulating
test（檢驗→核醫 RIA→N73-192）。
2. T-cell subset analysis（檢驗→血清→L72-267）。
3. 不明熱可測 procalcitonin。
重大傷病（需終身治療之全身性自體免疫症候群。）
ICD9 診斷名稱
710.0 紅斑性狼瘡
710.1 全身性硬化症
714.0 類風溼關節炎
（符合 1987 年美國風溼病學院修訂之診斷標準，含幼年型類風溼關節炎）
710.4 多發性肌炎
710.3 皮肌炎
446.0 血管炎（全身壞死性血管炎）
446.2 血管炎（過敏性血管炎）
446.4 血管炎（韋格納氏肉芽腫）
446.5 血管炎（巨細胞動脈炎）
443.1 血管炎（血栓閉鎖性血管炎）
446.7 血管炎（閉鎖式動動脈炎）
446.1 血管炎（川崎病）
136.1 血管炎（貝塞特氏病）
710.2 乾燥症
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1-3 門診、會診及科內常用資源 96.12.15 修訂
門診、會診及工作表分配表，請參考每月更新之工作表。
科內常用資源
1. 常用電話：
9 7D 病房：2912
9 2J辦公室：8812，8813（祕書：黃佳琪小姐）；FAX：8813
9 2J檢查室：2410（醫檢師：載寶蓮小姐及謝寶鳳小姐）
9 醫學大樓二樓腎超：2688
9 醫學大樓 3D 檢查室:5122
9 醫學大樓 7D 協談室
2. 常用網站
9 本科網站 http://www.cgmh.org.tw/intr/intr2/c3180/homepage-1.htm
9 內科部網頁 http://www.cgmh.org.tw/intr/intr2/c3100/IM.htm
9 中華民國風濕病醫學會 http://www.rheumatology.org.tw/
9 中華民國免疫學會 http://www.immunology.org.tw/
9 美國風濕病醫學會 http://www.rheumatology.org/
9 林口長庚實證醫學中心 http://lnkwww.cgmh.org.tw/intr/intr2/ebmlink/html/website.htm
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1-4 如何報告病例
為何要報告？To show that you：

1. Know（well）the patient's medical problem and his emotional reaction to the
illness. How is his daily life and work affected? How does he cope?
How much support from the family? What is his compliant? Co-operative?
Motivated? His understanding of the illness and the treatment options?
2. Collected adequate data（both positive and negative）for diagnosis and treatment
3. Analyze and synthesize the data thoroughly and now presenting it
4. Good communication and speaking skills
5. Sufficient knowledge of the disease and diseases process and the prognosis
6. Read up-to-date literature about the disease and differential diagnosis
7. Logic and reason in your decision making（how you reach conclusion?）
8. Learn by presenting the case（errors in omission/commission, DM, reasoning,
etc.）
如何報告？
1. Know your case well（never read from chart）
2. Read the textbook about the disease（relevance of the data）（omissions）
3. Read the up-to-day literature of the disease and it's treatment
4. Think it through and arrange date chronologically
5. Anticipating the questions and prepare for the answers
祕訣？（Willis Hurst, Notes from a Chairman, 1987 Year Book Med. Pub）
1. Deliver from memory（never read）（use notes）
2. Average listener's attention span is 5 minutes
3. Don't see patient prior to presentation
4. Use blackboard is distracting（read the board and not listening）
5. Complicated teaching aid can be confusing
6. At the end: never state why case was presented and ask if there is any question
（usually, many irrelevant questions are asked）
7. Give only positive and relevant negative information in your presentation
8. Don't disparage physician or hospital
9. No jargon（e.g. crab, bump, etc.）and limited abbreviation
10.Be descriptive of symptoms and findings
11.Use correct grammar
12.Singular（Datum, diverticulum, phenomenon, criterion, medium, serum, etc.）
13.Plurals（data, diverticula, adnexa, phenomena, criteria, media, sera, etc.）
14."Many data or few data", not "much data or little data"
15.Say man, woman, boy, girl, not male, female, not gentleman or lady.
12
16.Say normal, not essentially or basically normal
17.Say before, not prior to.
18.Avoid "there is " to begin a sentence, just say "the liver and spleen are not
enlarged" not "There is not liver and spleen enlargement"
13
New case presentation should include the following
（Evidence-based Medicine by Sacket DL. p34）
1. Surname
2. Age
3. Gender
4. Occupation
5. When admitted
6. The chief complaint that led to admission
7. Where in the body its located
8. Quality
9. Quantity, intensity, and degree of impairment
10.Chronology：when it began, constant/episodic, progressive
11.Setting：under what circumstances did it occur
12.Any aggravating or alleviating factors
13.Any associated symptoms
14.Whether a similar complaint had happened previously, if so：
15.How it was investigated
16.What the patient was told about its cause
17.How the patient has been treated for it
18.Pertinent past history of other conditions that are either of prognostic
significance or would affect the evaluation of treatment of the chief
complaints
19.And how those other conditions have been treated
20.Family history, if pertinent to chief complaint or hospital care
21.Social history if pertinent to chief complaint or hospital care
22.Their：
ideas（what they think is wrong with them）
concerns（about their illness, and other issues）
expectations（of what's going to happen to and for them）
23.Their condition on admission：
Acutely and/or chronically ill
Severity
Requesting what sort of help.
24.The pertinent physical findings on admission.
25.The pertinent diagnostic test results.
26.Your concise, one-sentence problem synthesis.
27.What you think the most likely diagnosis is
28.And the other items in your differential diagnosis
29.Any further diagnostic studies you plan to carry out.
30.Your estimate of the patient's prognosis
14
31.Your treatment plans
32.How you will monitor the treatment.
33.And what you will do if the patient doesn't respond to treatment
34.The educational prescription you would like to write for yourself in order to
better understand the patient's pathophysiology, clinical findings,
differential diagnosis, diagnosis, prognosis, therapy, prevention or other
issue in order to become a better clinician
Presentation of an "old" case for "follow-up" rounds

（20 items in 2 minutes）（Sackett DL p.87）
1. The patient's surname
2. The age
3. Gender
4. Occupation/social role
5. When admitted
6. Chief complaint that led directly to admission
7. The number of active problems at the present time. For each active problem
（which may be a symptom, sign, event, diagnosis, injury, psychological state,
or social predicament, etc.）
8. The most important symptom, if any
9. The most important sign, if any
10.The result of diagnosis or other investigations
11.The explanation for the problem（diagnosis or state）
12.The treatment plan instituted for the problem
13.The response to the treatment
14.The future plans for managing this problem.
15.Repeat 8 to 14 for each active problem
16.Your plans for discharge, post-hospital care and follow-up
17.Whether you've filled the educational prescription that you requested when this
patient was admitted （ in order to better understand the patient's
pathophysiology, clinical findings, diagnosis, prognosis, therapy, prevention
of recurrence, quality of care or other important issue in order to become a
better clinician）. If so：
18.How you found the relevant evidence
19.What you found. The clinical bottom line derived from that evidence.
20.Your critical appraisal of that evidence for its validity and applicability
21.How that critically appraised evidence will alter your care of that（or the
next similar）patient. If not, when you are going to fill it?
15
Example of "follow-up" case presentation
Mr./Mrs./Dr. 1111, is a 2222 year-old 3333, 4444 who was admitted on 5555 with the
chief complaint of 6666.
The patient has 7777 active problems.
The first active problem is . It is characterized by 8888 and 9999 and we
performed a , which revealed 101010. We decided that the cause for this problem
was 11, 11, 11 and we started 12, 12, 12 to which he/she responded with 13, 13, 13.
We plan to 14, 14, 14.
The second/third/fourth active problem is .（Repeat 8-14）
At the time of his/her admission, I didn't understand as well as I'd like to
and I requested an education Rx to answer the question:
I found the relevant evidence by 17, 17, 17, and its clinical bottom line is 18, 18,
18. I believe that this bottom line is not valid because 19a, 19a, 19a and believe
that it is/is not applicable because 19b, 19b, 19b. I therefore plan to manage this
and future, similar patient by 20, 20, 20.
16
常見症狀，檢驗及鑑別診斷
2-1 風濕病史與理學檢查簡介
When a patient presents with joint complaints
1. What do you think at first?
2. Is it real arthritis?
3. Definition:
• Arthralgia: subjective, may not be real joint inflammation
• Arthritis: real joint inflammation
4. Arthralgia may involve the joint itself or periarticular tissues, such as
ligament, tendon, bone, muscle …etc. pain
5. Arthritis indicates joint swelling or two or more of the following：1.
erythema, 2. local heat, 3. tenderness, 4. limited range of motion（ROM）.
When arthritis is defined

1. How many joints involve?
i. 1 joint: monoarthritis
ii. 2-4 joints：oligoarthritis
iii. 5 or above：polyarthritis
2. Where?
i. Symmetric? If yes：RA is likely（occasionaly, psoriatic arthritis）
ii. Peripheral or axial joints, small or large joints
1. Involve wrist, MCP and PIP：RA is likely（occasiongly, psoriatic
arthritis）
2. Involve DIP, knee etc.：OA is likely.
3. Involve ankle, MTP （ monoarthritis or oligoarthritis,
asymmetric）：Gout or seronegative spondyloarthropathy is likely
3. Timing?
(1) How long?
i. About less than 1 month：acute：septic or gout
ii. About more than 1 month：chronic：OA or RA
(2) Intermittent：Gout. Persistent：OA or RA
(3) First attack or recurrence?
(4) Frequency?
(5) Duration? Less than 7 days：Gout
(6) Onset? Less than 1 day：Gout
4. Aggravating factors：Beer, wine, seafood, posture（sitting up）, cold and
wet air, exercise（walking longer）etc.
5. Associated symptoms：involving other organ systems.
17
Physical Examination of Musculoskeletal System
I. Joints
1. Observe：
(1) Erythema：Gout or septic arthritis, if spreading across over joint area：
cellulitis
(2) Swelling：Only or not only joint area
2. Touch：
(1) Local heat：warmer or not
(2) Swelling：bulge or balloon sign
3. Compress：
(1)Tenderness：only joint or periarticular tissue, grade I, II, III, IV
4. Move：
(1)ROM（range of motion）：compared with the physician＇s or the contralateral
side
(2)Listen to the crepitus or click
5. Examination in order of：
Upper to lower, Right to left, Proximal to distal
TM joint ÆShoulder ÆElbow ÆWrist ÆMCP ÆPIP ÆDIP
L-spine ÆHip ÆKnee ÆAnkle ÆMTP
II. Muscle
1. Muscle power：Upper：proximal, distal; Lower：proximal, distal
2. Muscle tenderness
3. Muscle atrophy
If symmetric proximal limbs weakness（especial in lower limbs）, polymyositis
should be considered.
III.Skin rash, nail changes, hair loss.

1. distribution：trunk & extremities, symmetric
2. pattern of changes：macular, papular, nodule, mass, vesicles, bulla, ulceration.
clubbing fingers, nail deformities, telangiectasia, nail bed changes, pitting
scar.
18
2-2 Arthralgia
前面稍為提到 musculoskeletal complaints 的簡單問診及身體檢查的重點，接下來我們來看

關節痛。討論關節痛時，第一個也是最重要的問題就是：這是關節炎嗎？由 anatomy 來看，
關節痛可能是關節炎也有可能是關節週邊的問題。關節炎和非關節炎的診斷及處置完全不同。
1. Anatomic localization of complaint（articular vs. non-articular in origin）
1. Articular
1. Synovium
2. Articular cartilage
3. Juxta-articular bone
4. Other--meniscus, capsule
2. Periarticular
1. Ligaments
2. Tendons
3. Bursae
3. Extraarticular
1. Muscle
2. Fascia
3. Bone
4. Skin and subcutaneous tissue
那要如何區分是關節炎所造成的疼痛呢？在病史和理學檢查上的特點如下：
Articular disorders
1. deep or diffuse joint pain, limited range of motion on active and passive
movement
2. swelling and/or erythema caused by synovial proliferation, effusion,
bony enlargement, crepitation, instability, locking, or deformity.
Deep seated articulations, such as the shoulder, hip, and sacroiliac
joints may not exhibit the latter two findings.
3. If joint motion is preserved but tenderness can be elicited by palpation
over one of the regional bursae, tendons, or ligaments, it is unlikely
that the joint pain is due to arthritis.
Nonarticular disorders
1. be painful on active but not passive range of motion
2. demonstrate point or focal tenderness in regions distinct from articular
structures
3. having physical findings remote from the joint capsule.
4. non-articular disorders seldom demonstrate crepitus, instability,
deformity, or swelling.
19
確定是關節炎後，我們的鑑別診斷只要是根據疾病的不同病理機轉來區分：發炎和非發炎性。
造成發炎的常見原因有下面五個：
1. infectious（infection with Neisseria gonorrhoea or tuberculosis）,
2. crystal-induced（gout, pseudogout）,
3. immune-related（RA, SLE）,
4. reactive（rheumatic fever, Reiter's syndrome）
5. idiopathic.
而發炎的徵兆可從下面三個方向來觀察：
1. local：4 TESH (tenderness, erythema, swelling, heat)
2. systemic：prolonged morning stiffness, fatigue, fever, weight loss
3. lab ： elevated ESR/CRP, thrombocytosis, anemia of chronic disease, or
hypoalbuminemia
再對關節痛做為清楚的澄清後，就要考慮病程的時間關係（chronology）
1. onset：abrupt, indolently
2. evolution：acute, chronic（常以 6~8 週為界）intermittent, migratory, additive
3. duration：acute/chronic, 6 weeks or 2 months
4. frequency
侵犯的範圍如何（monarticular, polyarticular, focal, widespread）

1. localized or widespread（systemic）in distribution; symmetric or asymmetric;
small or large joints; peripheral or axial joints.
2. Number：monoarthritis：1; oligoarthritis：2-4; polyarthritis：> 4.
參考圖一的方式，我們就可以根據以上的資料做詳細的鑑斷。風濕病雖然有許多奇奇怪怪的
檢驗，不過大家仔細想想這些疾病的診斷標準中，病史和病程特徵往往占了十之八九，Lab
檢驗多在確認我們的診斷。以 rheumatoid arthritis 為例，病史就占四項，Lab 只有
rheumatoid factor 一項，另外兩項，一項是 X-ray 變化，一項是 physical finding。診斷
RA 在七項中只要四項，且超過六週即可，因此沒有 RF 或 X-ray 變化仍可診斷為 RA，這就是
風濕科最特別的地方。所以 history 一定要好好問，chart 要好好寫，不然一定診斷的亂七
八糟。
20
圖一、肌肉骨骼症狀的鑑別診斷流程圖。
（ ESR, erythrocyte sedimentation rate; CRP, C-reactive protein; DIP, distal

interphalangeal; CMC, carpometacarpal; PIP, proximal interphalangeal; MCP,
metacarpophalangeal; MTP, metatarsophalangeal; PMR, polymyalgia rheumatica; SLE,
systemic lupus erythematosus; JA, juvenile arthritis.）
接著我們來看看這些不同的發病模式有那些鑑別診斷。
I. Acute monarthritis
A. Infectious arthritis
B. Crystal-induced disease ［ Gout, Calcium pyrophosphate dihydrate （ CPPD ）
deposition disease（pseudogout）］
1. Hemarthrosis（trauma, internal derangement or nontraumatic hemarthrosis
- anticoagulation, after dialysis, or with benign neoplasms such as
pigmented villonodular synovitis, synovial osteochondromatosis, or
hemangioma of the synovium.）
C. Periarticular syndromes.
21
tendinitis, bursitis, overuse syndromes, and surrounding cellulitis. Erythema
nodosum. Osteomyelitis or neoplasia
D. Noninfectious inflammatory conditions
1. Seronegative spondyloarthropathies.
2. Juvenile rheumatoid arthritis（JRA）.
E. Monarticular presentation of a polyarticular disease.
rheumatoid arthritis（RA）
"palindromic rheumatism" resembles gout.
Differential diagnosis of monarthritis by presentation
II. Chronic monarthritis.

A. Infectious conditions
1. Pyogenic bacterial infections.
2. Bacterial osteomyelitis.
3. Fungal infection, Lyme arthritis, Tuberculous arthritis
B. Noninfectious inflammatory disorders
1. Seronegative spondyloarthropathies
2. Rheumatoid arthritis
3. Pauciarticular JRA, Sarcoid arthropathy
C. Noninflammatory conditions
1. Osteoarthritis.
2. Internal derangement of the knee
3. Avascular necrosis of bone.
4. Neoplasia.
22
Differential diagnosis of polyarthritis by presentation
III. Acute polyarthritis

A. Infectious conditions. migratory polyarthritis.
1. Bacterial infection ： disseminated neisserial infection （ Neisseria
gonorrhoeae, Neisseria meningitidis.）Polyarticular bacterial arthritis
is unusual except in the immunocompromised host.
2. Reactive（or postinfectious）arthritis
a. Acute rheumatic fever.
b. Reiter's syndrome. triad of Reiter's：arthritis, urethritis, and
conjunctivitis.
3. Spirochetal infection. Borrelia burgdorferi（Lyme disease）
4. Viral infection. HBV, rubella virus（including after vaccination）, mumps
virus, Epstein-Barr virus（infectious mononucleosis）, and parvovirus
B19.
5. Miscellaneous infections. Rickettsia, fungi, or parasites
B. Noninfectious inflammatory conditions
1. Rheumatoid arthritis.
2. Polyarticular JRA
3. Systemic lupus erythematosus（SLE）
4. Other connective tissue diseases
5. Seronegative spondyloarthropathies.
6. Crystal-induced disease
a. Gout 通常是在痛風多年後才會這樣，且常常會看到 tophi。
b. Calcium pyrophosphate dihydrate deposition disease. Pseudogout
可以有下面四種表現方式（a）acute monarticular pseudogout,（b）
23
atypical osteoarthritis,（c）Charcot-like knee disease, and（d）
polyarticular disease in the hands and wrists that can mimic RA.
7. Serum sickness
8. Sarcoidosis or Vasculitis
a. Small-vessel involvement.
b. Medium-sized vessel involvement.
9. Hematologic disorders.
IV. Chronic polyarthritis

A. Rheumatoid arthritis.
B. Systemic lupus erythematosus.
C. Other connective tissue diseases and overlap syndromes
1. Scleroderma, Polymyositis
2. Overlap syndrome RA, SLE, scleroderma, and polymyositis
D. Seronegative spondyloarthropathies
E. Crystalline disease
F. Osteoarthritis.
所以，綜合上述，再做下列的摘要：
Chronic Monoarthritis
1. OA
2. TB arthritis
3. Seronegative spondyloarthritis
4. Osteochondromatosis
5. Avascular necrosis
6. Hemoarthrosis
7. Tumor
8. RA（probable）
9. JRA
Acute Monoarthritis
Common
Crystal Arthritis
Septic Arthritis
Less Common
RA
Seronegative Spondyloarthropathy
SLE
24
Adult Onset Still＇s Disease
Rheumatic Fever
Chronic Polyarthritis
Osteoarthritis
Rheumatoid Arthritis
Chronic Tophaceous Gout
Polymyalgia Rheumatica
SLE
Seronegative Spondyloarthropathy
Adult Onset Still｀s Disease
Infectious Arthritis
Acute Polyarthritis
1. Infectious arthritis
2. Rheumatic fever
3. Seronegative spondyloarthritis
4. Crystal arthritis
5. JRA
6. RA
7. Systemic connective tissue diseases
8. Polymyalgia Rheumatica
Polyarticular Diseases with Frequent Monoarticular Component

Reiter｀s syndrome
Juvenile rheumatoid arthritis（including ankylosing spondylitis）
Psoriatic arthritis
Colitic arthritis, Whipple｀s arthritis
Sarcoid arthritis
Pseudogout
Hemophilic arthritis, scurvy
Hemochromatosis
Septic arthritis（especially due to N. gonorrhoeae and meningitidis）
*
25
*Onset is frequently polyarticular before monarticular localization. Other
syndromes usually have monoarticular presentation initially.
V. Further examinations.
了解上面這些最重要的基本觀念後，才根據可能的鑑別診斷安排進一步的檢查，如，關節液
的抽取和化驗，血清學的檢驗或是 X 光檢查。
Reference
1. SA Paget, et al. Manual of Rheumatology and Outpatient Orthopedic Disorders：
diagnosis and therapy. 5th ed.：Little Brown & Co, 2006
2. E Braunwald, et al. Harrison's Principles of Internal Medicine. 15th ed.：
McGraw-Hill Professional Publishing, 2001：Ch 22, 320
3. 內科工作規範 Update edition
26
2-3 Low back pain
Low back pain 在門診病患當中是僅次於 common cold 第二多的疾病。大部分 acute low back
pain 會 resolve spontaneously，但約有 5% to 10%會 progress to chronic low back pain。
I. Etiology 主要是 lumbosacral process 的問題。The history, physical examination,

and diagnostic studies will allow the formation of a differential diagnosis from
the list below.
A. Vertebral body（e.g., metastatic disease, metabolic bone disease, fracture）.
B. Intervertebral disk（e.g., infection）.
C. Joints（e.g., ankylosing spondylitis, osteoarthritis）
1. Apophyseal joints.
2. Sacroiliac joints.
D. Ligaments
1. Anterior and posterior longitudinal ligaments.
2. Interspinous and supraspinous ligaments.
3. Iliolumbar ligaments.
4. Apophyseal ligaments.
E. Nerve roots（e.g., herniated nucleus pulposus, spinal stenosis）.
F. Paraspinous musculature（e.g., fibromyalgia, myofascial pain）.
G. Pain from adjacent structures or referred pain
1. Kidney（e.g., pyelonephritis, perinephric abscess, nephrolithiasis）.
2. Pelvic structures （ e.g., pelvic inflammatory disease, ectopic
pregnancy, endometriosis, prostatic disease）.
3. Vascular（e.g., aortic aneurysm, mesenteric thrombosis）.
4. Intestinal（e.g., diverticulitis）.
H. Malignancy（involving any of the above structures）.
I. Miscellaneous conditions（e.g., sickle cell disease）.
II. History. The history is of the utmost importance to obtain associated symptoms
and establish a pattern of pain.
A. Associated symptoms 分辨是否非 mechanical cause of low back pain.
1. Fevers or chills would raise the possibility of an infectious process.
2. Weight loss, chronic cough, change in bowel habits, night pain, or other
constitutional symptoms may suggest an underlying malignancy.
3. Similar pain or morning stiffness in other areas of the body would
increase the suspicion that this represents a more generalized
rheumatologic condition （ e.g., ankylosing spondylitis, psoriatic
27
arthritis, or endocrine disorder, such as hypothyroidism,
hyperthyroidism, or hyperparathyroidism）.
4. If fatigue or a sleep disturbance is present, the diagnosis of
fibromyalgia should be considered.
5. Morning stiffness or back pain that improves with exercise should prompt
consideration of a seronegative spondyloarthropathy.
B. Pain. The quality of pain, its distribution, and modulating factors are helpful
in determining etiology.
a. Onset of pain：sudden, indolent, or episodic
2. Localization of pain
a. Localized.
b. Radicular, suggesting nerve root impingement.
3. Modulating factors
a. Exercise.會惡化或改善 pain character
b. Valsalva maneuvers. Radicular pain worsened by coughing or
sneezing suggests nerve root impingement.
C. Neurological symptoms. The presence of neurological symptoms should be
specifically sought in patients with low back pain. Their presence not only
can help delineate the site of the abnormality but also may prompt more rapid
intervention.
1. Weakness, numbness, or paresthesias in a dermatomal distribution suggest
nerve root impingement（如下表）.
Signs and symptoms of common disk lesions
a. The most common cause of nerve root impingement in persons between

ages 20 and 50 is a herniated nucleus pulposus
b. Radicular symptoms in persons over age 60 are more likely to be
secondary to spinal stenosis resulting from degenerative
arthritis.
c. Be aware that neoplasm or infection that causes expansion or
dislocation of any of the elements of the spinal cord can likewise
lead to radiculopathy.
2. Bowel or bladder dysfunction suggests the presence of cauda equina
syndrome and should prompt emergent investigation.
28
III. Physical examination.
A. Patient standing
1. Note alignment of the spine, looking for a pelvic tilt that may indicate
paravertebral spasm, for loss of normal lumbar lordosis that could
indicate either spasm or ankylosis, and for evidence of structural
scoliosis.
2. Evaluate gait, station, and posture.
3. Evaluate the patient＇s ability to flex, hyperextend, rotate, and tilt
the spine.
B. Patient supine
1. Straight leg raising test（SLRT）.
a. A true positive SLRT, defined as radicular pain radiating below
the knee, is a sensitive indicator of nerve root impingement and
should be confirmed by extending the knee while the patient is
sitting to eliminate malingering.
b. A crossed SLRT（radicular pain contralateral to the leg being
raised）is highly predictive of nerve root compromise.
2. Evaluate hip and knee range of motion to eliminate these areas as a source
of pain.
3. Carry out thorough neurological and vascular examinations.
C. Patient prone
1. Look for evidence of sciatic notch tenderness, sometimes seen in
sciatica.
2. Results of the femoral stretch test（extending the hip）may be positive
in L-4 radiculopathy.
3. Palpate bony structures，especially vertebral bodies，for localized
tenderness，and examine for presence of trigger points，除了 spine 連
身體其他部位也要檢查。
IV. Diagnostic studies

A. Imaging studies. 除非 conservative therapy 無效或有 neurological or
constitutional symptom 出現，history and physical examination 才是重點。
1. Plain films 第一個要作的檢查
a. Anteroposterior, lateral, and cone-down views of the lower two
interspaces are standard; oblique views will identify subtle
spondylolysis but are not routinely necessary.
b. Flexion and extension views may be obtained to document
instability.
29
2. Bone scintigraphy （ bone scan ） is useful as a screening study when
malignancy（other than multiple myeloma）or infection is suspected.
3. Diskography is performed by injecting dye into the disk space。容易有
false-positive results。
4. Computed tomography（CT）. When used without intradural contrast, CT is
the study of choice for delineating the bony structures of the spine
5. Myelography outlines the dural theca and its contents after injection
of a contrast medium into the dural sac.在 delineate neural compression
有幫忙，但 side effect 較大。
6. Magnetic resonance imaging（MRI） is the newest diagnostic modality for
the spine.可同時看 bony and soft-tissue structures，但 false-postive rate
高。
7. Electrodiagnostic testing. Help to eliminate false-positive results.
B. Radiologic signs
1. Degenerative disk disease. Radiographic abnormalities correlate poorly
with symptoms.
a. Narrowing of the intervertebral disk.
b. “Vacuum phenomenon.＂ Radiolucency in the disk space.
c. Traction osteophytes.
2. Osteoarthritis
a. Osteophyte formation.
b. Facet joint destruction.
c. Spinal stenosis.
d. Acquired spondylolisthesis（see section 3.b）.
3. Congenital and developmental defects. Many are asymptomatic and are
incidental findings detected on plain radiographs.
a. Spondylolysis.
b. Spondylolisthesis.
c. Transitional vertebrae, with lumbarization of S-1 or
sacralization of L-5.
d. Schmorl＇s nodes are defects in the vertebral end plates that allow
vertical disk herniation.
e. Scoliosis or kyphosis.
4. Seronegative spondyloarthropathies（ankylosing spondylitis, Reiter＇s
syndrome, psoriatic arthritis, inflammatory bowel disease）.
a. Erosions or sclerosis of the sacroiliac joints.
b. Syndesmophytes. Calcification of ligamentous structures leads to
bridging of adjacent vertebral bodies.
5. Neoplasm
30
a. Destruction of vertebral body.
b. Loss of outline of pedicle on anteroposterior films.
c. Pathologic fracture.
6. Infection should be suspected when destruction of adjacent vertebral end
plates is present or bony destruction is accompanied by constitutional
symptoms.
7. Miscellaneous
a. Osteoporosis.
b. Metabolic bone disease.
c. Sickle cell disease.
C. Laboratory studies should be performed as indicated by the history and physical
examination, age of patient, and chronicity of symptoms.
1. ESR, CRP elevated in infection, inflammatory joint disease, and
metastatic malignancies.
2. Ca, P, Alk-P screen for metabolic bone diseases.
3. Serum and urine protein immunoelectrophoreses should be performed if
multiple myeloma is suspected.
V. Treatment.
A. Acute treatment
1. Bed rest.約 2 to 3 days may be adequate for most patients，但不可超過
一週，以免 muscle weakness quickly develops.
2. Spinal traction. Although still used frequently, its only therapeutic
value is to enforce bed rest.
3. Pharmacologic treatment
a. Pain control. NSAID or acetaminophen，但 Narcotics 應避免
b. Muscle relaxants.在部分 acute low back pain 病患有幫助。
4. Physical measures
a. Moist heat.
b. Massage, ultrasound.
c. The use of bracing for any extended period is ill-advised, as it
may lead to muscle weakness.
B. Failure of conservative therapy 應考慮進行一系列的檢查甚至 surgical
intervention
C. Other treatment modalities
1. Injection of trigger points.在有“trigger points＂時可考慮
2. Facet block.
3. Transcutaneous electrical nerve stimulator（TENS）therapy is helpful in
some cases.
4. Physical therapy.
31
D. Invasive intervention should be contemplated when there is a failure of
conservative therapy for 2 months and there is a radiographically demonstrable
anatomic defect that could explain the pain, or when malignancy or infection
cannot be excluded with noninvasive techniques.而超過 6 months 或許會變成
chronic LBP. Types of surgical intervention include the following：
1. Laminectomy or hemilaminectomy.
2. Laminotomy or hemilaminotomy.
3. Diskectomy：
a. Standard surgical approach.
b. Fiberoptic scope.
4. Spinal fusion. instability is present
E. Chronic pain arises from a failure of standard therapy 多肇因於 fibromyalgia，
特徵會 poor sleep，fatigue，and widespread pain and tender points 可考慮以
TCA（如：amitriptyline）或 psychosocial therapy。
VI. Rehabilitation and exercise.

A. Postsurgical patients
1. Ambulation is encouraged early, and prolonged sitting is avoided.
2. Lifting should be avoided.
B. Exercises for low back pain should not be initiated until the acute phase of
recovery
C. Pelvic tilt. Buttocks are tightened, and the lumbar spine is flattened
isometrically.
1. Modified sit-ups. With the patient supine, knees bent and arms at the
side, the head and shoulders are lifted off the ground and held for 5
seconds.
2. Knee-chest stretch. Both knees are brought to the chest and held with
the arms for 5 seconds; then, one at a time, the knees are extended and
the legs are slowly brought to the ground.
3. Back extension. While lying prone with the arms at the sides, lift the
chin and shoulders upward and hold for 5 seconds. Then, in the same
position, lift one leg at a time upward and hold for 5 seconds.
D. Other recommendations
1. Weight reduction for obese patients.
2. Aerobic fitness should be increased, whenever possible, with walking,
swimming, or other low-impact activities. Before one of these activities
is performed, the patient should do stretching exercises to warm up
properly.
3. Life-style modifications
32
a. Proper lifting techniques. While lifting, the knees should be
flexed and the back straight. Twisting while lifting should be
avoided.
b. A firm mattress should be used.
c. Vocational training may be helpful.
33
2-4 Myalgia
在考慮這個問題時，我們應先從這個問題的 anatomical etiology 來看。也就是 neurological

causes、myopathic causes。介由 history 與 PE 來做個基本的判斷後，再利用一些檢查來確
定。
Neurological Causes
由於我們不是神經內科的專家，在這方面只要有個清楚簡單的了解即可。它們可由五個區域
來考慮。
I. Upper motor neuron disease。包括 brain, brainstem, spinal cord（motor neuron
以上的病兆）。病人的肢端會有 spasticity, increased deep tendon reflexes,
pathologic reflexes, sensory abnormalities,及 impaired cerebral functions。
II. Lower motor neuron disease。指的是包括 motor neuron 和他以下路徑的問題。包括
Brainstem lesions 產生的 bulbar palsy 和 poliomyelitis、anterior horn cell
lesions。病人的受影響的肌肉通常只有某一個區段（segmental involvement），且呈
現 flaccid, fasciculations 和 loss of deep tendon reflexes。可能沒有感覺異常。
通常在早期就會有 muscle atrophy。
III.Nerve root disease（ventral root）。可見 loss of deep tendon reflexes 及 muscle
atrophy。肌肉會呈現低張（hypotonic）。肌肉萎縮的程度沒有 anterior horn cell
lesions 明顯。若有 dorsal root dysfunction 則會伴隨 pain 和 sensory loss。
IV. Peripheral nerve disease。病人的 deep tendon reflexes 會消失且合併 hypotonia。
可能有感覺異常。它的特點是同時影響到許多週邊神經。通常由遠端開始。常常要與肌
肉病變區分，特別是肌肉病變晚期近端和遠端都會出現 weakness，muscle atrophy 和
loss of deep tendon reflexes。
V. Myoneural junction disease。Myasthenic syndromes 較像肌肉病變而非神經病變。肌
無力的程度近端也較遠端嚴重，且在疾病早期，也不會有 DTR 和感覺異常的變化。這類
疾病以 Myasthenia gravis 和 Eaton-Lambert syndrome 為典型。特點是症狀有晨昏之別，
且 EMG 上有特別的變化。
Myopathic Causes
重要的原因有可用 systemic approach 的鑑別診斷方式，也就是 VINDICATES（Vascular，
Infection/Inflammation ， Neoplasm ， Degenerative ， Intoxication ， Congenital ，
Autoimmune，Trauma，Endocrine，Psychiatric）。在此我們應列入考慮的有 infections,
toxins/ drugs, metabolic disturbances/endocrinopathies, inflammatory syndromes 和
congenital（muscle dystrophies）。
I. Infectious myositis and myopathy.這類疾病的特徵是通常是 diffuse，且以 proximal

為主。這類的問題需和只侵犯單一塊肌肉的感染區分，如 streptococcal myositis, and
clostridial myonecrosis 等。
A. Trichinosis（Trichinella spiralis，旋毛蟲）.
34
1. Uncooked or poorly cooked pork or bear meat.
2. 檢驗. Biopsy of the deltoid or gastrocnemius muscle should be performed
during the third or fourth week of illness. By the end of the second week,
a 15% to 50% eosinophilia is present. Serologic tests become positive
by the end of the third week.
B. Toxoplasmosis.（Toxoplasma gondii）. Muscle biopsy showed chronic interstitial
myositis, fiber necrosis, and encysted T. gondii. Serologic evidence of
Toxoplasma infection.
C. Viral myositis.有關的病毒有 hepatitis B and C virus, echovirus, coxsackie virus,
herpes simplex virus, and influenza virus. HIV and zidovudine（AZT）所產生
的 severe myopathy 在臨床上無法與 polymyositis 區分。
D. Miscellaneous infections causing myopathy. 其他可能的病菌，有的只發生在
immunocompromised patients.包括了 Candida tropicalis, Mycoplasma pneumoniae,
Trypanosoma cruzi, and Echinococcus alveolaris.
II. Toxin and drug-induced myopathy

A. Steroid myopathy.
1. insidious onset of proximal muscle weakness
2. dose：on low or high doses of steroids, frequently after a recent increase
in dose.
3. The duration of steroid treatment does not correlate with the time of
onset.
4. frequently have at least two other steroid side effects, such as
osteoporosis, cushingoid facies, hyperglycemia, hypertension, or
psychiatric disorders.
5. Laboratory studies. Serum muscle enzymes—creatine kinase（CK）, aldolase,
and aspartate aminotransferase（AST, previously known as SGOT）- are not
increased; urinary creatinine excretion, however, is increased.
6. Treatment is to reduce the steroid dose as much as possible or to
discontinue the drug.
B. Hypokalemic myopathy. Any drug or pathologic condition causing hypokalemia.
C. Alcoholic myopathy. Alcohol has been shown to be a direct hepatotoxin.
D. Drug-induced rhabdomyolysis and myoglobinuria.
1. cocaine, illicit heroin mixtures, amphetamines, alcohol
2. some antimalarial drugs, anesthetics, and other drugs that cause
hypokalemia.
3. Lipid-lowering agents （ e.g., lovastatin and other “statins,＂
gemfibrozil）
4. Leucotriene receptor antagonist
5. Antithyroid druds
35
6. Antibiotics (azithromycin, minocycline)
7. D-Penicillamine
III.Congenital（Metabolic myopathies & Muscular dystrophy）

A. Inborn errors of glycogen metabolism.可能是 energy production 的 pathway 上任
何的問題都可能。如一些 glycolytic pathway 上的 enzyme deficiency，lipid
metabolism 或是 mitochondrial 有問題
B. Disorders associated with abnormal serum potassium.
C. Muscular dystrophy（如：Duchenne＇s pseudohypertrophic muscular dystrophy）.
IV. Endocrine myopathies

A. Hypothyroid myopathy. 最常看到與 endocrine 有關的肌肉病變。可能在
hypothyroidism 出現前數個月就開始有症狀。
B. Thyrotoxic myopathy.症狀可能從 diffuse weakness, easy fatigability, and mild
atrophy 到 severe proximal muscle weakness with pronounced atrophy 都有可能。
並不會影響 laryngeal 和 pharyngeal muscles. Serum muscle enzymes are not
elevated, even in the severe form; creatinuria, however, is present.
C. Acromegalic myopathy. Proximal muscle weakness and easy fatigability occur in
up to 50% of patients with acromegaly. Serum CK are usually normal but may be
slightly elevated.
V. Inflammatory myopathies.
A. 包括了 idiopathic polymyositis, dermatomyositis, myositis of other rheumatic
diseases, and myositis associated with carcinoma，詳細的內容看後面的章節。
B. Sarcoid myopathy. Muscle pain and tenderness are most often seen in acute
sarcoidosis with erythema nodosum. Symmetric proximal muscle weakness can be
seen in chronic sarcoid.
VI. 其他會全身到處都痛的還有 Fibromyalgia 和 Polymyalgia rheumatica（PMR），後者在

台灣不多見，主要是在 50 歲以上的男人，以近端痠痛和僵硬為主。可能合併 temporal
arteritis，PMR 病人的 ESR 通常會超過 50 mm/h。此外還要列入考慮的少見情況有 Primary
amyloidosis，Cervical and lumbar spondylosis 及 Parkinson＇s disease。
檢查
I. Serum chemistries. 電解質（ hypokalemia, hyperkalemia, hypocalcemia,
hypercalcemia, hypomagnesemia, and hypophosphatemia 等都會產生肌無力，抽筋等
症狀。我們所說的 muscle enzymes 包括 CPK, aldolase, myoglobin, LDH, and AST。
其中 CPK 大概是最能代表肌肉情況的指標。但是其他器官 heart, brain, and smooth
muscle 也都有 CPK，在判斷上要小心。
36
II. Plasma cortisol, growth hormone, TSH, and thyroxine 在區分 endocrine myopathies
時也要檢測。
III.Hematological studies. CBC/DC（eosinophil count）和 ESR 都有幫忙。
IV. Electromyography and electroneurography
A. Nerve conduction velocities 可區分 peripheral neuropathies.
B. EMG 在 polymyositis, myasthenia gravis, myotonic dystrophy, Eaton-Lambert
syndrome 等都有特定的變化，可以區分。但仍有許多情況的 EMG 變化與多發性肌炎相
近，如：trichinosis 和 several muscular dystrophies。在 myasthenia gravis，
repetitive stimulation（RST）可發現隨著刺激的次數增加，肌肉的 response 遞減，
而 Eaton-Lambert syndrome 會有相反的結果。
V. Muscle biopsy 是診斷 inflammatory muscle disease, steroid myopathy, muscular
dystrophy 和 infectious myositis 的最重要工具。最好的切片位置在 deltoid 或
quadriceps，不過還是以病人的症狀為主，下肢嚴重就切下肢。也可先以 EMG 定位找出
有問題的地方再切。決對不要切萎縮或非常沒力的地方，因為這些地方的變化可能都是
chronic changes.
其他的影相檢查，如 MRI 和 ultrasound 都有在使用。
Differential Diagnosis of Muscle Weakness

♦ Denervating conditions ： spinal muscular atrophies*, amyotrophic lateral
sclerosis*
♦ Neuromuscular junction disorders：Eaton-Lambert syndrome*, myasthenia gravis*
♦ The genetic muscular dystrophies ： Duchenne＇s facioscapulohumeral, limb
girdle*, Becker＇s Emery-Dreifuss type*, distal ocular
♦ Myotonic diseases：dystrophia myotonica*, myotonia congenital
♦ Congenital myopathies：nemaline, mitochondrial, centronuclear, central core
♦ Glycogen storage diseases：adult onset acid maltase deficiency*, McArdle＇s
disease
♦ Lipid storage myopathies ： carnitine deficiency*, carnitine
palmityltransferased deficiency*
♦ The periodic paralyses
♦ Myositis ossificans*：generalized and local
♦ Endocrine myopathies* ： hypothyroidism, hyperthyroidism, acromegaly,
Cushing＇s disease, Addison＇s disease, hyperparathyroidism,
hypoparathyroidism, vitamin D deficiency myopathy, hypocalcemia
♦ Metabolic myopathies*：uremia, hepatic failure
♦ Toxic myopathies* ： acute and chronic alcoholism, drugs including
penicillamine*, clofibrate*, chloroquine, emetine
♦ Nutritional myopathies：vitamin E deficiency*, malabsorption*
♦ Carcinomatous neuromyopathy*：carcinomatous cachexia
♦ Acute rhabdomyolysis*
♦ Proximal neuropathies：Guillain-Barr＇e syndrome*, acute intermittent
porphyria*, diabetic lower limb chronic plexopathies*, chronic autoimmune
37
polyneuropathy
♦ Microembolization by atheroma or carcinoma
♦ Polymyalgia rheumatica*
♦ Other collagen vascular diseases：rheumatoid arthritis, scleroderma, systemic
lupus erythematosus, polyarteritis nodosa
♦ Infections ： acute viral, including influenza, mononucleosis, rickettsia,
coxsackievirus, rubella and rubella vaccination, acute bacterial including
typhoid
♦ Parasites ： including Toxoplasma, Trichinella, Schistosoma, Cysticercus,
Sarcosporidia
♦ Septic myositis ： including staphylococcal, streptococcal, Clostridium
perfringens（welchii）and leprosy
* Indicates the conditions that are most commonly confused with muscle weakness.
※Differential diagnosis of muscle weakness.
2-5 Arthrocentesis
有那些情況要考慮 Arthrocentesis，可分成 diagnostic 和 therapeutic 兩大方面。
A. Diagnostic indications
1. As part of an initial evaluation.
2. To rule out superimposed infection
in an already diseased joint.
B. Therapeutic indications
1. Drainage of an effusion to relieve
pain.
2. Instillation of medication.
3. Drainage of a septic joint.
4. Drainage of hemarthrosis（correct
any coagulation disorder first）.
C. Contraindications
1. Infection in overlying skin or soft
tissue.
2. Severe coagulation disorder.
準備事項
A. Materials for aseptic skin preparation
1. Sterile gloves & gauze pads.
2. Iodine & Alcohol solution.
B. Sterile 18- to 25-gauge needles, 根據關節的大小選擇針頭。一般而言 knee 這一
類的關節需要 18G 的大針才行，特別是那些發炎的關節。因為關節液通常很黏稠，若
38
有 tophi 還常常會把 18G 的針頭塞住。Ankle, wrist, elbow 這一類的關節可選擇
20~22G 的針頭。至於 MCT/MTP, PIP, DIP 等小關節可以要 23G 或以上的小針才有可能
將針深入 joint space，如果該關節的發炎不是那麼厲害，effusion 不多，這些小關
節是很難抽的。
C. Syringes, 3 to 50 mL in size, depending on the joint and amount of effusion.
D. Tubes for synovial fluid analysis
1. Bacterial Study: Gram Stain（on slide）; Culture（sterile tube）
*Culture for Gonococcus ： Done on bed-side and send to bacteriology
department immediately, chocolate Agar or Thayer-Martin Agar
2. Cell count and crystal examination：檢體置綠頭試管送風濕科檢查室
3. Lactate：Heparin tube kept in ice and send to biochemical department
immediately.
4. Other biochemical study: as indicated（sugar, protein etc.）3 和 4 因
在鑑別診斷上的幫助不大，目前很少檢送。
5. Cytology bottle（if neoplasm is suspected）.
E. Arthrocentesis
這兒只介紹臨床上最常抽也是最如易上手的關節－knee，其他各關節，有機會到 rheuma
OPD 或病房再研習即可。
Knee 的 aspiration 有兩個 approach 方式，
一個是 medial approach（如圖），另一個是
lateral approach。讓病人平躺，使膝關節
能很放鬆的伸直或稍微彎曲，使 quadriceps
放鬆。若我們能輕易的將 patella 向內側或
外側移動，表示病人已足夠放鬆了。輕輕抓
住 patella 中線的內緣和外緣，並在中線或
稍微偏上的 patella 下緣做記號。在完成消
毒和準備工作後，直接將針頭水平插入 patella 的下緣（我們之前在皮膚上做記號的地
方）。抽的時後，可以用另一手壓膝蓋上緣的 suprapatellar pouch 可加速 synovial
fluid 的 drainage。如果 knee effusions 的量多時，可直接由 quadriceps muscle 內
側或外側的 suprapatellar pouch 抽吸。
F. Synovial biopsy: may be very helpful diagnosis of chronic monarthrits of
unknown etiology, infiltrative diseases of synovium, benign or malignant tumor
of synovium/joints 。如： PVS （ pigmented villonodular synovitis ），
Chondromatosis，Sarcoma；TB or fungal Infection；Amyloidosis，Hemochromatosis。
Synovial fluid studies

A. Gross examination
1. Color & Clarity. straw-colored.
Inflammatory fluids range from yellow to greenish yellow.
Hemarthrosis occurs in patients with coagulation disorders, trauma,
39
neoplasms, and tuberculous arthritis and in patients receiving
anticoagulant therapy.
2. Viscosity. Because viscosity is decreased in inflammatory synovial
fluids, no string sign.
3. Mucin clot. If 1 mL synovial fluid + 3 mL 2% acetic acid> firm mucin clot.
When acetic acid is added to an inflammatory fluid, a poor clot results.
B. Cell count. The ratio of RBCs/WBCs is ~750/1.
C. Polarizing microscopy（crystal examination.）
urate crystals：
（平黃垂藍）parallel to the polarizer axis appear yellow, & urate
crystals perpendicular to the polarizer axis appear blue.（needle-shaped）
calcium pyrophosphate is the opposite is true for the calcium pyrophosphate
crystals of pseudogout.（rhomboid）.
The finding of crystals does not rule out the possibility of an infection.
D. Morphologic Features of some Synovial Fluid Crystals Associated with Joint Dx
Crystals Size(μm) Morphology Birefringence Diseases
MSU 2-10 Needles, rods Intensely acute and chronic

negative gout
CPPD 2-10 Rhomboids, rods Weakly positive CPPD crystal

deposition disease
Apatite-like 5-20 Round, irregular None osteoarthritis,

clumps clumps periarthritis, acute
or chronic arthritis
Calcium oxalate 2-10 Polymorphic, Intensely or osteoarthritis,
dipyramidal weakly positive renal failure
shapes
Cholesterol 10-80 Rectangles, Negative or chronic rheumatoid or

often with positive osteoarthritic
missing corners, effusions
needles
Depot 4-15 Irregular rods, Intensely Iatrogenic

glucocorticoids rhomboids positive or postinjection flare
negative
Lipid liquid Intensely acute arthritis,

2-8 Maltese crosses
crystals positive bursitis
Positive and eosinophilic

Charcot-Leyden 17-25 Spindles
negative synovitis
40
Polymorphic, Positive and multiple myeloma,
Immunoglobulins 3-60
rods negative cryoglobulinemia
E. Microbiologic studies
1. Stains should include both Gram and acid-fast methods.
2. Cultures should include routine bacterial studies. Fungal and
mycobacterial cultures are ordered as clinically necessary.
F. Biochemical studies（Glucose, Protein, Complement）
41
II. Diagnosis by fluid group（下表）. 3 groups based on the degree of inflammation.
Gross Exam Normal Noninflammatory Inflammatory Septic
Volume（knee） < 4 ml Often> 4 ml Often> 4 ml Often> 4 ml
Viscosity High High Low Variable
Colorless to
Color Straw to yellow Yellow Variable
straw
Clarity Transparent Transparent Translucent Opaque
Often> 100,000
WBCs/mm3＊ < 200 200-2000 2000-75000 ＊
PMN＊ < 25% < 25% Often> 50% > 85%
Culture Negative Negative Negative Often positive
Mucin clot Firm Firm Friable Friable
> 50 mg/dl
Glucose （ A.M. Nearly equal to Nearly equal to <50 mg/dl lower
lower than
fasting） blood blood than blood
blood
＊
WBC count and PMN percentage are less if organism is less virulent or partially
treated.
A. Group 1 fluids （ WBC <2k ）： clear & transparent. They include normal,
osteoarthritic, & SLE.
B. Group 2 fluids（WBC 2k~50k）：translucent. This group includes fluids from most
noninfectious, inflammatory arthritic conditions such as gout, pseudogout,
42
psoriatic arthritis, Reiter's syndrome, and RA. Leukemia or lymphoma
occasionally presents in this category, but the differential count reveals >90%
mononuclear cells.
C. Group 3 fluids（WBC >50k）：opalescent or purulent. Bacterial infections &
tuberculosis（gonococcal arthritis can be either group 2 or group 3）. Group
3 fluids typically have 50k to 300k WBC/cmm; these are mostly neutrophils.
Occasionally, the synovial fluid from a patient with an inflammatory arthritic
condition such as RA may have as many as 50k to 75k WBC/cmm and appears
opalescent or even purulent.
2-6 血清分析 Serum Analysis
z Acute-phase reactants
1. Erythrocyte Sedimentation Rate（ESR）（紅血球沉降速率）：（發炎指數）
• Rate of fall in millimeters per hour of RBC
• Falsely low---sickle cell disease, anisocytosis, spherocytosis,
polycythemia, heart failure.
• Falsely high --- rouleaux formation （ multiple myeloma, inflammatory
disorder）
• Increased with increased fibrinogen, prolong storage of blood, tilting
of the calibrated tube, severe anemia
• Normal 0~15 mm/h --- male; 0~20 mm/h --- female
• Active inflammatory disorder（acute rheumatic fever, SLE, RA, temporal
arteritis-polymyalgia rheumatica）
• For follow the course of chronic inflammatory disorder
2. C-Reactive Protein（CRP）（C- 反應蛋白）：（急性發炎指數）
♦ Acute-phase reactant serum protein
♦ Precipitin reaction with pneumococcal C polysaccharide
♦ Rise rapidly when acute inflammation and fall when inflammation subside
♦ SLE and scleroderma, CRP usually low and only elevated when infection
♦ Increased：In infections（especially in bacterial infection）, tissue
injury or necrosis, and inflammatory disorders（ex：SLE, RA, vasculitis
etc.）
♦ Normal：<5 mg/L
z Anti-double stranded DNA antibodies（Anti-ds-DNA Ab）（抗雙股 DNA 抗體）：

1. They are associated with SLE disease activity and lupus nephritis. If the
activity is high, they should be checked every month to follow up the effect
of treatment.
2. Anti-ds DNA 的值和 SLE 疾病活動度相關；而 ANA 則否。
43
z Anti-Extractable Nuclear Antibodies（Anti-ENA Ab）)（抗可萃取核抗體）：
1. Other intracellular constituents; soluble components derived from cells as
extractable antigens（ENAs）
2. molecular clone fusion protein , recombinant antigen
3. speckled ANA pattern【Sm, nRNP, Ro（SSA）, La（SSB）, RANA】
4. If ANA is positive and the patient is suspected as SLE, we may order them.
5. They includes：
♦ anti-dsDNA, anti-Sm specific to SLE
♦ Anti-U1 RNP Ab：MCTD or SLE
♦ Anti- Ro Ab（SS-A）：SLE or Sjogren＇s syndrome
♦ Anti-La Ab（SS-B）：SLE or Sjogren＇s syndrome
♦ Anti-Scl. 70：SLE or sclerosis
♦ RANA specific to RA, only in human B lymphocytes lines
z Antiphospholipid Antibodies（抗磷脂質抗體）：
They are associated with recurrent arterial or venous thrombosis, young stroke,
or spontaneous abortion. There are two antibodies:
1. Anticardiolipin antibody（抗心脂質抗體）：
(1) IgG：（-）：<12 GPL unit/ ml;
（+-）：12-18
（+）：>18
(2) IgM：立即短暫出現之免疫球蛋白，判讀單位同 IgG.
2. Lupus Anticoagulant（LA）（狼瘡抗凝血時間）：
Normal：31-44 sec.（>44 sec：may have antiphospholipid syndrome）
Complement
---at least 18 different plasma
proteins, major effector of the
human immune system
---classic pathway
（antigen-antibody）C1 C2 C4
---alternative pathway （ complex
polysaccharides or aggregated IgA）
properdin, factor D, factor B, C3b
---cleave C3 C5b~C9 lysis of target
cells and generate multiple
mediators of inflammation and
anaphylaxis
---heat-labile, sera kept
44
frozen –20c and assayed within 2 weeks and even –70c and assayed within 2
years
FIG. 1. Complement pathways
Complement deficiency states

1. C1~C4（most C2 and C4）---SLE-like syndromes and increased incidence of
infection
2. C5~C9 --- rheumatic syndrome and increased incidence of infection（especially
Neisseria）
3. inhibitor of C1 esterase ---hereditary angioedema
4. C3b inactivator ---increased incidence of infection
Lupus anticoagulant
---lupus antibody that inhibit the activation of thrombin
---aPTT prolong, TT normal or slightly prolong
---antibodies inactivate factor VII, XI , XII
---seen with vascular thrombosis !!
VDRL false positive if patient with lupus anticoagulant
About 1/4 SLE p＇t with false VDRL positive
Anti-phospholipid antigens antibody responsible to it
---high titers of IgG Anti-cardiolipin antibodies in SLE---associated with
thrombosis
HBsAg---30% PAN, 30% mixed cryoglobulinemia, MPGN
HCV---mixed cryoglobulinemia
Parvovirus --- PAN, WG
HIV---PAN
*Complement（C3, C4）（補體）：
和免疫有關的蛋白質，SLE 活動度高時會下降。
(1) C3：Normal：73-134 mg/dl
(2) C4：Normal：18.2- 45.5 mg/dl
*Cortisol（可體松）：
懷疑病人服用過量類固醇（如：黑藥丸等）有滿月臉、水牛肩等症狀時測。
Normal（serum）：8am：5.0-23.0 ug/dl；4pm：3.0-15.0 ug/dl
*Creatine phosphokinase（CPK）（肌酸磷酸激酵素）：
It may increase in AMI, rhabdomyolysis, and polymyositis（多發性肌炎）etc.
Normal：25-150 U/L
45
*Cryoglobulins（冷凝球蛋白）（cryoglobulinemia）：
z Immune complex syndrome ex：SLE
z Normal：negative
z simplest test for immune complex, based on diminished solubility in the
cold--- cryoprecipitation of sera at 0~5c
z immune complex syndrome---mixed or essential cryoglobulinemia
z common feature of SLE & hepatitis C
z blood should kept in 37c and clotting, examine pricipitation after 2 days
at 0~5c
*Human Leukocyte Antigen（HLA）（人類白血球抗原）：

在第六對染色體上，許多自體免疫疾病與之有關如：僵直性脊椎炎常有 HLA B27（+）; RA：
HLA DR4 etc.
*Protein C：
Associated with vascular thrombosis or CVA（level decreased）
Normal：73-107%
*Protein S：
Associated with vascular thrombosis or CVA（level decreased）
Normal：90-130%
*Urid Acid （尿酸）：

Gout acute attack 不一定尿酸高，反之亦然，需靠臨床症狀，尤其關節液檢查來判斷。
Normal：2.7-8.2 mg/dl
24 hours urinary uric acid: Overproducer, >800 mg/day; Underexcretor, < 800 mg/day
*VDRL and RPR：

Some SLE patients may have false-positive serologic tests for syphilis.
Normal：negative
46
2-7 Radiology in rheumatology
要評估各別關節和肌腱、韌帶在骨頭的附著處（entheses），一般的 plain film 我們會需

要兩個相互垂直的 view 來看他們間的彼此關係。下面是各關節我們常用的 X-ray 射影方位。
Regional Views for Arthritis Survey
Hands: AP & Oblique
Feet: AP & lateral
Shoulders: AP & Axillary
Elbows: AP & Lateral
Pelvis AP
Hips: AP & Frog leg
Knees: AP & lateral（In standing）
Ankles: AP & lateral
Spines: AP & lateral, oblique if necessary
* C1-C2: Lateral view, lateral flexion view, Open mouth view
如何看片子
如同看 CXR，看骨骼關節 X-ray 也應有一個 systemic apporach 的方法。有時我們會稱為
Anatomic-Radiologic Correlations（ABCs），就是 Alignment，Bone，Cartilage 和 Soft
tissue。也可以由外而內（soft tissue to bone）或是由內而外（bone to soft tissue）
的方式來檢查。
Alignment
評估骨頭間與關節的位置關係，可能會發現一些典型的輕微錯位（misalignments）或變型
（deformities）。另外，如果可能的話，利能一些骨科學上的測量或線條對我們的判斷也
會有幫助。
Bone
評估關節問題，最重要的就是 subchondral bone plate。這個結構由 articular cortex
和它下面的 cancellous bone 組成。關節部分的 cortex 明顯會比其他部位 bone 的 cortex
來的薄。它的表面應該很平滑且與關節面平行。Cortical bone 下面的 cancellous bone
則會組成支撐的 trabeculae 來平均分擔關節的受力。在 X 光檢查下，epiphysis 的
subarticular region 也通常是最透明的地方（radiolucent）。之後再看 metaphysis 和
diaphysis 部分的 density，periosteal response 和 bone-ligament 或 bone-tendon
junction 處是否有變化。
Cartilage
在 X 光下，我們是看不到正常的軟骨。然而，兩個關節面間的距離約等於軟骨的厚度（關
節面間除了軟骨外，中間只有一點潤滑用的關節液）。因為，不同關節疾病侵犯軟骨的方式
不同，觀察關節間距的變化就很重要。
47
Soft tissue
關節與周圍的軟組織關係密切。我們需要看看這些軟組織是否有腫脹，是否有不正常的鈣
化。一般來說，我們是看不到 joint capsule 和 synovium，然而，在發炎的情況，肌肉或
韌帶等軟組織可能因發炎而腫脹，兩者間的脂肪就可能因此而突顯出來。
一般常見疾病的變化
Basic characteristics：
• Inflammatory arthritis：uniform joint space narrowing, “rat-bite＂ erosion
of articular bone.
• Osteoarthritis：Irregular joint space narrowing, osteophyte, eburnation of
articular bone.
• Metabolic arthritis：Normal joint space, soft tissue mass, sharply marginated
erosions.
Imaging of degenerative joint disease

• Asymmetric joint space narrowing
• Osteophytes-bony spurs
• Degenerative cysts
• Sclerosis of subchondral bone
Imaging in RA
• Osteopenia - a demineralization of the bone - is the result of increased blood
flow, due to inflammation, which washes out the calcium.
♦ Early on in the inflammatory process, only the periarticular portions
of the bone are affected.
♦ Over time, the inflammatory pain causes disuse of affected joints leading
to generalize osteopenia of whole bones.
• Uniform joint space narrowing - a feature which helps differentiate RA from
OA.
• Marginal erosions at bare areas where synovium lies on bone
• Subluxation due to ligamentous or capsular laxity
48
常見疾病之診斷標準
1997 REVISED CRITERIA FOR CLASSIFICATION OF SYSTEMIC LUPUS ERYTHEMATOSUS*
Criterion Definition
1、Malar rash Fixed erythema, flat or raised, over the malar eminences,
tending to spare the nasolabial folds.
2、Discoid rash Erythematous raised patches with adherent keratotic
scaling and follicular plugging; atrophic scarring may occur
in older lesions.
3、Photosensitivity Skin rash as a result of unusual reaction to sunlight, by
patient history or physician observation.
4、Oral ulcers Oral or nasopharyngeal ulceration, usually painless,
observed by a physician.
5、Arthritis Nonerosive arthritis involving two or more peripheral
joints, characterized by tenderness, swelling, or effusion.
6、Serositis (a) Pleuritis--convincing history of pleuritic pain or rub
heard by a physician or evidence of pleural effusion OR
(b) Pericarditis--documented by ECG or rub or evidence of
pericardial effusion.
7、Renal disorder (a) Persistent proteinuria greater than 0.5gm per day or
greater than 3+ if quantitation not performed OR
Cellular casts-may be red cell, hemoglobulin, granular,
tubular, or mixed.
8、Neurologic disorder (a) Seizures--in the absence of offending drugs or known
metabolic derangements, e.g., uremia, ketoacidosis, or
electrolyte imbalance OR
(b) Psychosis--in the absence of offending drugs or known
metabolic derangements, e.g., uremia, ketoacidosis, or
electrolyte imbalance.
9、Hematologic disorder (a) Hemolytic anemia--with reticulocytosis OR
3
(b) Leukopenia-less than 4000/mm total on two or more
occasions
3
(c) Lymphopenia--less than 1500/mm on two or more
occasions
3
(d) Thrombocytopenia--less than 100,000/mm in the absence
of offending drugs.
10、Immunologic disorder (a) Anti–DNA: antibody to native DNA in abnormal titre; or
♦ Modified 1997 (b) Anti–Sm: presence of antibody to Sm antigen; or
(c) Positive finding of antiphospholipid antibodies based
on: （ 1 ） an abnormal serum level of IgG or IgM
anticardiolipin antibodies;（2）a positive test result
for lupus anticoagulant using a standard method; or
（3）a false-positive serological test for syphilis
known to be positive for at least 6 months and confirmed
by Treponema pallidum immobilization or fluorescent
treponemal antibody absorption test
49
11、Antinuclear antibody An abnormal titer of antinuclear antibody by
immunofluorescence or an equivalent assay at any point in
time and in the absence of drugs known to be associated with
“drug-induced lupus syndrome.＂
*The proposed classification is based on 11 criteria. For the purpose of identifying
patients in clinical studies, a person shall be said to have systemic lupus
erythematosus if any 4 or more of the 11 criteria are present, serially or
simultaneously, during any interval of observation.（Arthritis and Rheumatism 25：
1271, 1982. The American Rheumatism Association.）Hochberg MC for the Diagnostic and
Therapeutic Criteria Committee for the American College of Rheumatology. Updating
the American College of Rheumatology revised criteria for systemic lupus
erythematosus［Letter］. Arthritis Rheum 1997；40：1725.
REVISED ARA CRITERIA FOR CLASSIFICATION OF RHEUMATOID ARTHRITIS

Criteria Definition
1、Morning stiffness Morning stiffness in and around the joints lasting
at least 1 hour before maximal improvement
2、Arthritis of three or more At least three joint areas have simultaneously had
joint areas soft tissue swelling or fluid（not bony overgrowth
alone）observed by a physician. The 14 possible joint
areas are （right or left）: PIP, MCP, wrist, elbow,
knee, ankle, and MTP joints
3、Arthritis of hand joints At least one joint area swollen as above in wrist,
MCP, or PIP joint
4、Symmetric arthritis Simultaneous involvement of the same joint areas
（as in 2）on both sides of the body（bilateral
involvement of PIP, MCP, or MTP joints is acceptable
without absolute symmetry）
5、Rheumatoid nodules Subcutaneous nodules, over bony prominences, or
extensor surfaces, or in juxta-articular regions,
observed by a physician
6、Serum rheumatoid factor Demonstration of abnormal amounts of serum
“rheumatoid factor＂ by any method that has been
positive in less than 5 percent of normal control
subjects
7、Radiographic changes Radiographic changes typical of RA on PA hand and
wrist x-rays, which must include erosions or
unequivocal bony decalcification localized to or
most marked adjacent to the involved joints
（osteoarthritis changes alone do not quality）
50
For classification purposes, a patient is said to have RA if he or she has satisfied
at least 4 of the above 7 criteria. Criteria 1 through 4 must be present for at least
6 weeks. Patients with two clinical diagnoses are not excluded. Designation as classic,
definite, or probable rheumatoid arthritis is not to be made.
Classification of Functional Capacity in Rheumatoid Arthritis

Class I： Complete functional capacity with ability to carry on all usual duties
Class II： without handicaps
Functional capacity adequate to conduct normal activities despite
Class III： handicap of discomfort or limited mobility of 1 or more joints
Functional capacity adequate to perform only few or none of the duties
Class IV： of usual occupation or of self care
Largely or wholly incapacitated with patient bedridden or confined to
wheelchair, permitting little or no self care
Steinbrocker O, Traeger CH, Batterman RC. Therapeutic criteria in rheumatoid
arthritis. JAMA 140:659-662,1949
Classification of Progression of Rheumatoid Arthritis

Stage I, Early Stage III, Severe
1. *No destructive changes on 1. *Roentgenologic evidence of
roentgenographic examination cartilage and bone destruction, in
2. Roentgenologic evidence of addition to osteoporosis
osteoporosis, may be present. 2. *Joint deformity, such as
Stage II, Moderate subluxation, ulnar deviation, or
1. *Roentgenologic evidence of hyperextension, without fibrous or
osteoporosis, with or without bony ankylosis.
slight subchondral bone 3. Extensive muscle atrophy
destruction; slight cartilage 4. Extraarticular soft tissue lesions,
destruction may be present. such as nodules and tenosynovitis
2. *No joint deformities, although may be present.
limitation of joint mobility may be Stage IV, Terminal
present. 1. *Fibrous or bony ankylosis
3. Adjacent muscle atrophy 2. Criteria of stage III
4. Extraarticular soft tissue
lesions, such as nodules and
tenosynovitis may be present.
* The criteria prefaced by an asterisk are those that must be present to permit
classification of a patient in any particular stage or grade.
51
Criteria for the Diagnosis of Adult Still＇s Disease
A diagnosis of adult Still＇s disease requires the presence of all of the
following：
Fever ≥39℃
Arthralgia or arthritis
Rheumatoid factor＜1：80
Antinuclear antibody＜1：100
in addition to any two of the following：
White blood cell count > 15,000 cells/mm3
Still＇s rash
Pleuritis or pericarditis
Hepatomegaly, splenomegaly, or
Generalized lymphadenopathy
※ Criteria for the diagnosis of adult Still＇s disease.（Adapted
from Cush JJ, Medsger Jr TA, Christy WC, Herbert DC, Cooperstein
LA. Adult-onset Still＇s disease：clinical course and outcome.
Arthritis Rheum. 1987；30：186-94.）
Preliminary Criteria for Classification of Progressive Systemic Sclerosis

A 、 Major criteriaProximal scleroderma: For the purposes of classifying
Symmetric thicken-ing, tightening, and patients in clinical trials,
induratioon of the skin of the fingers and population surveys, and other
the skin proximal to the studies, a person shall be said to
metacarpo-phalangeal or have progressive systemic sclerosis
metatarsophalangeal joints. The changes may （scleroderma）, if the one major or
affect the entire extremity, face, neck, and 2 or more minor criteria listed baove
trunk（thorax and abdomen）. are present. Localized forms of
B、Minor criteria1. scleroderma, eosinophilic fasciitis,
1. Sclerodactyly: Above-indicated skin and the various forms of
changes limited to the fingers pseudoscleroderma are excluded from
2. Digital pitting scars or loss of these criteria.
substance from the finger pad: Depressed Masi AT. Rodnan GP. Medsger TA Jr.
areas at tips of fingers or loss of digital Altman RD, D＇ Angelo WA. Fries JF.
pad tissue as a result of ischemia LeRoy EC. Kirsner AB. Mackenzie AH.
3. Bibasilar pulmonary fibrosis: Bilateral McShane DJ. Myers AR. Sharp GC:
reticular pattern of linear or Preliminary criteria for the
lineonodular densities most pronounced in classification of systemic sclerosis
basilar portions of the lungs on standard （scleroderma）. Arthritis Rheum 23：
chest roentgenogram; may assume 581-590, 1980
appearance of diffuse mottling or
“honeycomb lung.＂ These changes should
not be attributable to primary lung
disease.
52
Diagnostic Criteria for Polymyositis-Dermatomyositis
1. Typical skin rash of dermatomyositis
2. Symmetrical proximal muscle weakness by history and physical examination
3. Elevation of one or more serum muscle enzymes
4. Myopathic changes on electromyogram
5. Typical polymyositis on muscle biopsy
Bohan and Peter Criteria
Dermatomyositis Polymyositis
Definite：(1) + any 3 of (2),(3),(4) or (5) All 4 of (2),(3),(4) and (5)
Probable：(1) + any 2 of (2),(3),(4) or (5) Any 3 of (2),(3),(4) or (5)
Possible：(1) + any 1 of (2),(3),(4) or (5) Any 2 of (2),(3),(4) or (5)
Crystal Deposition Diseases of Joints

Crystal Distribution of Acute inflammatory Chronic destructive
deposits disorder disease
Monosodium urate Peripheral Acute gout Chronic tophaceous
monohydrate （ feet, hands ） Pseudogout gout
Calcium Intermediate Acute calcific Chronic destructive
pyrophosphate （knees, wrists, periarthritis ｀pyrophosphate
dihydrate elbows, hips, arthropathy＇Some
Hydroxyapatite shoulders, hands） forms of
Central（shoulders, osteoarthritis
hips, spine, knees）
53
Criteria for the Classification of Sjögren＇s Syndrome*
1、Ocular symptoms
Definition. A positive response to at least one of the following three questions;
(a) Have you had daily, persistent, troublesome dry eyes for more than 3 months?
(b) Do you have a recurrent sensation of sand or gravel in the eyes?
(c) Do you use tear substitutes more than three times a day?
2、Oral symptoms
Definition. A positive response to at least one of the following three questions:
(a) Have you had a daily feeling of dry mouth for more than 3 months?
(b) Have you had recurrent or persistently swollen salivary glands as an adult?
(c) Do you frequently drink liquids to aid in swallowing dry foods?
3、Ocular signs
Definition. Objective evidence of ocular involvement, determined on the basis of
a positive result on at least one of the following two tests:
(a) Schirmer-I test（≦5 mm in 5 minutes）
(b) Rose bengal score（≧4, according to the van Bijsterveld scoring system）
4、Histopathologic features
Definition. Focus score ≧1 on minor salivary gland biopsy（focus defined as an
agglomeration of at least 50 mononuclear cells; focus score defined as the number
of foci per 4 min2 of glandular tissue）
5、Salivary gland involvement
Definition. Objective evidence of salivary gland involvement, determined on the
basis of a positive result on at least one of the following three tests:
(a) Salivary scintigraphy
(b) Parotid sialography
(c) Unstimulated salivary flow（≦1.5 ml in 15 minutes）
6、Autoantibodies
Definition. Presence of at least one of the following serum autoantibodies:
(a) Antibodies to Ro/SS-A or La/SS-B antigens
(b) Antinuclear antibodies
(c) Rheumatoid factor
Exclusion criteria: preexisting lymphoma, acquired immunodeficiency syndrome,

sarcoidosis, or graft-versus-host disease
* For primary Sjögren＇s syndrome, the presence of three of six items showed a very
high sensitivity （ 99.1% ） , but insufficient specificity （ 57.8% ） . Thus, this
combination could be accepted as the basis for a diagnosis of probable primary
Sjögren＇s syndrome. However, the presence of four of six items （ accepting as
serologic parameters only positive anti-Ro/SS-A and anti La/SS-B antibodies）had a
good sensitivity（93.5%）and specificity （94.0%）, and therefore may be used to
establish a definitive diagnosis of primary Sjögren＇s syndrome.
Vitali C, Bombardieri S, Moutsopoulos HM, et al：Preliminary criteria for the
classification of Sjögren＇s syndrome. Arthritis Rheum 36：340-347, 1993
54
Criteria for Behçet＇s Disease
Recurrent oral ulceration Minor aphthous, major aphthous, or herpetiform
Plus 2 of： ulceration observed by physician or patient, which
Recurrent genital recurred at least 3 times in one 12-month period
ulceration Aphthous ulceration or scarring, observed by
Eye lesions physician or patient
Anterior uveitits, posterior uveitis, or cells in
vitreous on slit lamp examination; or Retinal vasculitis
Skin lesions observed by ophthalmologist
Positive pathergy test Erytherma nodosum observed by physician or patient,
pseudofolliculitis, or papulopustular lesions; or
acneiform nodules observed by physician in
postadolescent patients not on corticosteroid treament
Read by physician at 24-48h.
（Findings applicable only in absence of other clinical explanations.）International
Study Group for Behcet＇sDisease Lancet：1990；335：1078-80
Criteria for the Classification of Wegener＇s Granulomatosis*

CRITERION DEFINITION
1、Nasal or oral inflammation Development of painful or painless oral ulcers or
purulent or bloody nasal discharge
2、Abnormal chest radiograph Chest radiograph showing the presence of nodules,
fixed infiltrates, or cavities
3、Urinary sediment Microhematuria（> 5 red blood cells per high power
field）or red cell casts in urine sediment
4、Granulomatous inflammation Histologic changes showing granulomatous
on biopsy inflammation within the wall of an artery or in the
perivascular or extravascular area （ artery or
arteriole）
*For purposes of classification, a patient shall be said to have Wegener＇s

granulomatosis if at least two of these four criteria are present. The presence of
any two or more criteria yields a sensitivity of 88.2% and a specificity of 92.0%.
Leavitt RY, Fauci AS, Bloch DA, et al: The American College of Rheumatology 1990
criteria for the classification of Wegener＇s granulomatosis. Arthritis Rheum 33：
1101-1107, 1990
55
Criteria for the Classification of Giant Cell Arteritis*
1、Age at disease onset ≧50 years Development of symptoms or findings beginning
at age 50 or older
2、New headache New onset of or new type of localized pain in
the head
3、Temporal artery abnormality Temporal artery tenderness to palpation or
decreased pulsation, unrelated to
arteriosclerosis of cervical arteries
4、Elevated ESR Erythrocyte sedimentation rate ≧50 mm/hour by
the Westergren method
5、Abnormal artery biopsy Biopsy specimen with artery showing vasculitis
characterized by a predominance of mononuclear
cell infiltration or granulomatous inflammation,
usually with multinucleated giant cells.
* For purposes of classification, a patient shall be said to have giant cell（temporal）
arteritis if at least three of these five criteria are present. The presence of any
three or more criteria yields sensitivity of 93.5% and a specificity of 91.2%. Hunder
GG, Bloch DA, Michel BA, et al: the American College of Rheumatology 1990 criteria
for the classification of giant cell arteritis. Arthritis Rheum 33：1122-1128, 1990
Criteria for the Classification of Churg-Strauss Syndrome*
Asthma History of wheezing or diffuse high-pitched rales
on expiration
Eosinophilia Eosinophilia >10% on white blood cell differential
count
Mononeuropathy or Development of mononeuropathy, multiple
polyneuropathy mononeuropathies, or polyneuropathy（ie,
glove/stocking distribution）attributable to a
systemic vasculitis
Pulmonary infiltrates, Migratory or transitory pulmonary infiltrates on
non-fixed radiographs（not including fixed infiltrates）,
attributable to a systemic vasculitis
History of acute or chronic paranasal sinus pain or
Paranasal sinus abnormality tenderness or radiographic opacification of the
paranasal sinuses
Biopsy including artery, arteriole, or venule,
Extravascular eosinophils showing accumulations of eosinophils in
extravascular areas
*For purposes of classification, a patient shall be said to have Churg-Strauss
syndrome if at least four of these six criteria are present. The presence of any four
or more of the six criteria yields a sensitivity of 85% and a specificity of 99.7%.
Masi AT, Hunder GG, Lie JT, et al: The American College of Rheumatology 1990 criteria
56
for the classification of Churg-Strauss syndrome （ allergic granulomatosis and
angiitis）. Arthritis Rheum 33：1094-1100, 1990
Criteria for the Classification of Takayasu Arteritis*

1、Age at disease onset ≦40 years Development of symptoms or findings related
to Takayasu arteritis at age ≦40 years
2、Claudication of extremities Development and worsening of fatigue and
discomfort in muscles of one or more
extremity while in use, especially the upper
extremities
3、Decreased brachial artery pulse Decreased pulsation of one or both brachial
arteries
4、BP difference > 10 mm Hg Difference of >10 mm Hg in systolic blood
pressure between arms
5、Bruit over subclavian arteries or Bruit audible on auscultation over one or
aorta both subclavian arteries or abdominal aorta
6、Arteriogram abnormality Arteriographic narrowing or occlusion of the
entire aorta, its primary branches, or large
arteries in the proximal upper or lower
extremities, not due to arteriosclerosis,
fibromuscular dysplasia, or similar causes;
changes usually focal or segmental
* For purposes of classification, a patient shall be said to have Takayasu arteritis if at
least three of these six criteria are present. The presence of any three or more criteria
yields a sensitivity of 90.5% and a specificity of 97.8%. BP = blood pressure（systolic;
difference between arms）. Arend WP, Michel BA, Bloch DA, et al：The American College of
Rheumatology 1990 criteria for the classification of Takayasu arteritis. Arthritis Rheum
33：1129-1132, 1990
Criteria for the Classification of Henoch-Schönlein Purpura*
1、Palpable purpura Slightly raised “palpable＂ hemorrhagic skin
lesions, not related to thrombocytopenia
2、Age ≦20 at disease onset Patient 20 years or younger at onset of first
symptoms
3、Bowel angina Diffuse abdominal pain, worse after meals, or the
diagnosis of bowel ischemia, usually including
bloody diarrhea
4、Wall granulocytes on biopsy Histologic changes showing granulocytes in the
walls of arterioles or venules
57
*For purposes of classification, a patient shall be said to have Henoch-Schönlein purpura
if at least two of these four criteria are present. The presence of any two or more criteria
yields a sensitivity of 87.1% and a specificity of 87.7%. Mills JA, Michel BA, Bloch DA,
et al ： The American College of Rheumatology 1990 criteria for the classification of
Henoch-Schönlein purpura. Arthritis Rheum 33：1114-1121, 1990
Criteria for the Classification of Polyarteritis Nodosa*

1、Weight loss ≧4kg Loss of 4 kg or more of body weight since
illness began, not due to dieting or other
factors
2、Livedo reticularis Mottled reticular pattern over the skin of
portions of the extremities or torso
3、Testicular pain or tenderness Pain or tenderness of the testicles, not due
to infection, trauma, or other causes
4、Myalgias, weakness, or leg tenderness Diffuse myalgias（excluding shoulder and hip
girdle）or weakness of muscles or tenderness
of leg muscles
5、Mononeuropathy or polyneuropathy Development of mononeuropathy, multiple
mononeuropathies, or polyneuropathy
6、Diastolic BP >90 mm Hg Development of hypertension with the
diastolic BP higher than 90 mm Hg
7、Elevated BUN or creatinine Elevation of BUN >40 mg/dl or creatinine >1.5
mg/dl, not due to dehydration or obstruction
8、Hepatitis B virus Presence of hepatitis B surface antigen or
antibody in serum
9、Arteriographic abnormality Arteriogram showing aneurysms or occlusions
of the visceral arteries, not due to
arteriosclerosis, fibromuscular dysplasia,
or other noninflammatory causes
10 、 Biopsy of small or medium-sized Histologic changes showing the presence of
artery containing PMN granulocytes or granulocytes and
mononuclear leukocytes in the artery wall
* For classification purposes, a patient shall be said to have polyarteritis nodosa
if at least three of these 10 criteria are present. The presence of any three or
more criteria yields a sensitivity of 82.2% and a specificity of 86.6%. BP = blood
pressure; BUN = blood urea nitrogen; PMN = polymorphonuclear neutrophils.
Lightfoot RW Jr, Michel BA, Bloch DA, et al：The American College of Rheumatology
1990 criteria for the classification of polyarteritis nodosa. Arthritis Rheum 33：
1088-1093, 1990
58
Criteria for the Classification of Hypersensitivity Vasculitis*
Age at disease onset >16 years Development of symptoms after age 16
Medication at disease onset Medication was taken at the onset of symptoms that
may have been a precipitating factor
Palpable purpura Slightly elevated purpuric rash over one or more
areas of the skin; does not blanch with pressure
and is not related to thrombocytopenia
Maculopapular rash Flat and raised lesions of various sizes over one
or more areas of the skin
Biopsy including arteriole and Histologic changes showing granulocytes in a
venule perivascular or extravascular location
*For purposes of classification, a patient shall be said to have Hypersensitivity
Vasculitis if at least two of these five criteria are present. The presence of any
two or more criteria yields a sensitivity of 71.0% and a specificity of 83.9%.
Calabrese LH, Michel BA, Bloch DA, et al：The American College of Rheumatology 1990
criteria for the classification of hypersensitivity vasculitis. Arthritis Rheum
33:1108-1113, 1990
59
CLINICAL CRITERIA FOR ANKYLOSING SPONDYLITIS（NEW YORK, 1966）
Diagnosis
1. Limitation of motion of the lumbar spine in all three planes- anterior flexion,
lateral flexion, and extension
2. History or the presence of pain at the dorsolumbar junction or in the lumbar
spine
3. Limitation of chest expansion to 1 inch (2.5 cm) or less, measured at the level
of the fourth intercostal space
Grading
Definite AS
1. Grade 3-4 bilateral sacroiliitis with at least one clinical criterion
2. Grade 3-4 unilateral or grade 2 bilateral sacroiliitis with clinical criterion
1（limitation of back movement in all three planes）or with both clinical
criteria 2 and 3（back pain and limitation of chest expansion）Probable AS
Grade 3-4 bilateral sacroiliitis with no clinical criteria
Diagnostic Criteria for the Classification of Juvenile Rheumatoid Arthritis*

1、Age at onset less than 16 years
2、Arthritis in one or more joints defined as swelling or effusion, or the presence
of two or more of the following signs：limitation of range of motion, tenderness
or pain on motion, and increased heat.
3、Duration of disease of 6 weeks to 3 months
4、Type of onset of disease during the first 4 to 6 months classified as
a.Polyarthritis- 5 joints or more
b.Oligoarthritis- 4 joints or fewer（2-4 joints）
c.Systemic disease
(1)Arthritis
(2)Intermittent fever
(3)Rheumatoid rash
(4)Visceral disease（hepatosplenomegaly, lymphadenopathy, etc.）
5、Exclusion of other diseases
*Modified from Cassidy J.T. et al.：Arthritis Rheum. 29：274, 1986
Criteria for the Diagnosis of Rheumatic Fever*

MAJOR MANIFESTATIONS MINOR MANIFESTATIONS SUPPORTING EVIDENCE OF
PRECEDING STREPTOCOCCAL
INFECTION
Carditis Clinical findings Positive throat culture or
Polyarthritis Arthralgia rapid streptococcal antigen
Chorea Fever test
60
Erythema marginatum Laboratory findings Elevated or rising
Subcutaneous nodules Elevated acute phase reactants streptococcal antibody titer
ESR
C-reactive protein
Prolonged PR interval
If supported by evidence of preceding group A streptococcal infection, the presence
of two major manifestations, or of one major and two minor manifestations indicates
a high probability of acute rheumatic fever.
Special Writing Group of the Committee on Rheumatic Fever, Endocarditis, and Kawasaki
Disease of the Council on Cardiovascular Disease in the Young, American Heart
Association: Guidelines for the diagnosis of rheumatic fever：Jones criteria, updated
1992, JAMA 268：2069-2073, 1992
Diagnostic Guidelines for Kawasaki Syndrome*

Fever lasting >5 days plus four of the following criteria
1、Polymorphous rash
2、Bilateral conjunctival injection
3、One or more of the following mucous membrane changes:
Diffuse injection of oral and pharyngeal mucosa
Erythema or fissuring of the lips
Strawberry tongue
4、Acute, nonpurulent cervical lymphadenopathy（one lymph node must be >1.5 cm）
5、One or more of the following extremity changes:
Erythema of palms and /or soles
Indurative edema of hands and /or feet
Membranous desquamation of the fingertips
* Other illnesses with similar clinical signs must be excluded.
Kawasaki T, Kosaki T, Okawa S, et al：A new infantile acute febrile mucocutaneous
lymph node syndrome（MLNS）prevailing in Japan. Pediatrics 54：271-276, 1974
The 1990 Criteria for the Classification of Fibromyalgia*

1. History of widespread pain
Definition: Pain is considered widespread when all of the following are present:
pain in the left side of the body, pain in the right side of the body, pain above
the waist, and pain below the waist. In addition, axial skeletal pain（cervical
spine or anterior chest or thoracic spine or low back）must be present. In this
definition shoulder and buttock pain is considered as pain for each involved side.
Low back pain is considered lower segment pain.
2. Pain in 11 of 18 tender point sites on digital palpation
Definition: Pain, on digital palpation, must be present in at least 11 of the
61
following 18 tender point sites. Digital palpation should be performed with an
approximate force of 4 kg. For a tender point to be considered “positive＂ the
subject must state that the palpation was painful. “Tender＂ is not to be
considered painful.
Occiput: bilateral, at the suboccipital muscle insertions
Low cervical: bilateral, at the anterior aspects of the inter-transverse spaces
at C5-C7
Trapezius: bilateral, at the midpoint of the upper border
Supraspinatus: bilateral, at origins, above the scapula spine near the medial
border
2nd rib: bilateral, at the second costochondral junctions, just lateral to the
junctions on upper surfaces
Lateral epicondyle: bilateral, 2 cm distal to the epicondyles
Gluteal: bilateral, in upper outer quadrants of buttocks in anterior fold of muscle
Greater trochanter: bilateral, posterior to the trochanteric prominence
Knees: bilateral, at the medial fat pad proximal to the joint line
*For classification purposes patients will be said to have fibromyalgia if both criteria
are satisfied. Widespread pain must have been present for at least 3 months. The presence
of a second clinical disorder does not exclude the diagnosis of fibromyalgia. From Wolfe
F, Smythe HA, Yunus MB, et al：The American College of Rheumatology 1990 criteria for the
classification of fibromyalgia：Report of the Multicenter Criteria Committee. Arthritis
Rheum 33：160-172, 1990.
ANTINUCLEAR ANTIBODIES
Subgroups
1. Anti-DNA Commonly associated pattern of immunofluorescence
Double-strand（native）
Single-strand（denatured）
2. Anti-histone
3. Anti-non histone antigen
eg：SSA, SSB
RA-associated nuclear antigen（RANA）
Sm antigen
Nuclear ribonucleoprotein（nRNP）
4. Anti-nucleolar
62
Antibodies, Antigens, and Diseases*
Antibody Disease Antigen
Anti-ssDNA Nonspecific Purine -and pyrimidine- related
Anti-dsDNA SLE antigens
Antihistone SLE, DRL, rheumatoid Deoxyribose phosphate backbone of DNA
arthritis H1, H2A, H2B, H3, H4, H2A-H2B
Anti-Sm SLE Proteins complexed with U1-U6 RNAs
（splicesome）
Anti-RNP MCTD, SLE Proteins complexed with U1a, U1b
（splicesome）
Anti-Ro/SS-A SLE, Sjogren＇s Proteins complexed with hY, hY3,
hY4, hY5
Anti-La/SS-B SLE, Sjogren＇s Phosphorylated protein complexed with
Anti-Scl-70 Systemic sclerosis small RNA polymerase III transcripts
Anti-centromere CREST DNA Topoisomerase I
Anti-RNA polymerase I Diffuse systemic sclerosis Proteins in kinetochore
Antifibrillarin Systemic sclerosis RNA polymerase I
Anti-PM-Scl Polymyositis, systemic Nucleolar protein with U3-RNP complex
sclerosis, and overlap Not known
Anti-Jo-1 Polymyositis and
dermatomyositis Histidyl-tRNA synthetase
Anti-PL-7 Polymyositis and
dermatomyositis Threonyl-tRNA synthetase
Anti-PL-12 Polymyositis and
dermatomyositis Naked alanyl-tRNA and alanyl-tRNA
Anti-Ku Systemic sclerosis and synthetase
polymyositis, overlap. Proteins binding to DNA
SLE overlap
Anti-Mi-1 Dematomyositis and SLE
Anti-Mi-2 Dermatomyosiis Nucleolar protein
Anti-PCNA SLE Not known
Anti-RANA Rheumatoid arthritis Auxiliary protein of DNA polymerase
Anti-Ma delta
Possibly EBNA-1
Nuclear acidic protein
* ssDNA = single-stranded DNA; dsDNA= double-stranded DNA; DRL= drug-related lupus;
tRNA= transfer RNA; PCNA= proliferating cell nuclear antigen; RANA= rheumatoid
arthritis-associated nuclear antigen; EBNA-1= Epstein-Barr nuclear antigen.
63
SLEDAI：DATA COLLECTION SHEET
Systemic Lupus Erythematosus Disease Activity Index（SLEDAI）form

Chart no.： Date of Visit：
M.D.： Patient＇s Name：
（Enter weight in SLEDAI Score column if descriptor present at the time of the visit
or in the preceding 10 days.）
Weight SLEDAI Descriptor Definition
Score
8 Seizure Recent onset. Exclude metabolic, infectious, or
drug causes.
8 Psychosis Altered ability to function in normal activity
due to severe disturbance in the perception of
reality. Include hallucinations, incoherence,
marked loose associations, impoverished thought
content, marked illogical thinking, bizarre,
disorganized, or catatonic behavior. Exclude
uremia and drug causes.
8 Organic brain Altered mental function with impaired
syndrome orientation, memory, or other intellectual
function, with rapid onset and fluctuating
clinical features. Include clouding of
consciousness with reduced capacity to focus,
and inability to sustain attention to
environment, plus at least 2 of the following:
perceptual disturbance, incoherent speech,
insomnia or daytime drowsiness, or increased or
decreased psychomotor activity. Exclude
metabolic, infectious, or drug causes.
8 Visual Retinal changes of SLE. Include cytoid bodies,
disturbance retinal hemorrhages, serous exudates or
hemorrhages in the choroids, or optic neuritis.
Exclude hypertension, infection, or drug causes.
8 Cranial nerve New onset of sensory or motor neuropathy
disorder involving cranial nerves.
8 Lupus headache Severe, persistent headache; may be migrainous,
but must be nonresponsive to narcotic analgesia.
8 CVA New onset of cerebrovascular accident(s).
Exclude arteriosclerosis.
64
8 Vasculitis Uceration, gangrene, tender finger nodules,
periungual infarction, splinter hemorrhages, or
biopsy or angiogram proof of vasculitis.
4 Arthritis More than 2 joints with pain and signs of
inflammation （ i.e., tenderness, swelling, or
effusion）
4 Myositis Proximal muscle aching/weakness, associated
with elevated creatine phosphokinase/aldolase
or electromyogram changes or a biopsy showing
myositis.
4 Urinary casts Heme-granular or red blood cell casts.
4 Hematuria >5 red blood cells/high power field. Exclude
stone, infection, or other cause.
4 Proteinuria >0.5 gm/24 hours. New onset or recent increase
of more than 0.5 gm/24 hours.
4 Pyuria >5 white blood cells/high power field. Exclude
infection.
2 New rash New onset or recurrence of inflammatory type
rash.
2 Alopecia New onset or recurrence of abnormal, patchy or
diffuse loss of hair.
2 Mucosal ulcers New onset or recurrence of oral or nasal
ulcerations.
2 Pleurisy Pleuritic chest pain with pleural rub or
effusion, or pleural thickening.
2 Pericarditis Pericardial pain with at least 1 of the
following: rub, effusion, or electrocardiogram
or echocardiogram confirmation.
2 Low complement Decrease in CH50, C3 or C4 below the lower limit
of normal for testing laboratory.
2 Increased DNA >25% binding by Farr assay or above normal range
binding for testing laboratory.
1 Fever >38℃. Exclude infectious cause.
1 Thrombocytopenia <100,000 platelets/mm3.
1 Leukopenia <3,000 white blood cells/mm3. Exclude drug
causes.
TOTAL
SLEDAI
SCORE
65
常用藥物
NSAID
Analgesics
Drug Dosage Side effects Cautions and
contraindications
Acetaminophen 1000-4000mg/day in Fasting, drinking A history of alcohol
3-4 doses alcohol, and/or abuse, kidney disease,
taking excessive hepatitis, or other
amounts of liver disease
acetaminophen may
result in liver or
kidney damage
Acetaminophen with 1200-2400mg Constipation, A history of drug or
codeine acetaminophen dizziness or alcohol abuse, asthma;
combined with lightheadedness, head injury; prostate
60-480mg of codeine drowsiness, or gastric problems;
per day in 2-4 doses. nausea, fatigue or liver, kidney or
Take with food weakness, thyroid disease;
vomiting. Chronic sensitivities to
use may cause acetaminophen,
psychologic and codeine or sulfites
physical
dependence
Propoxyphene 65mg every 3-4h as Dizziness or Current or previous
（dextropropoxyphene） needed, no more than lightheadedness, serious depression,
hydrochloride 390mg/day drowsiness, use of tranquilizers
nausea, vomiting or antidepressants
66
Tramadol 50-400mg/day in 2-4 Dizziness, nausea, Liver disease, asthma,
hydrochloride doses constipation, kidney disease,
headache, history of drug or
sleepiness alcohol abuse
CORTICOSTEROID（皮質類固醇）
一、前言：
Corticosteroid 能快速壓制發炎反應，所以常用於治療自體免疫疾病、氣喘、及過敏等。
由於效果快又好，因而俗稱「美國仙丹」，常有密醫不當添加於中藥裏，病人長期服用造
成嚴重的副作用。然而目前資訊發達，民眾多知其害，一聽到醫師開立類固醇，常心生
排斥。其實「水能載舟，亦能覆舟」，當病情必要使用時，在醫師監控下對症適量的投予，
類固醇是治療的利器。
二、機轉：﹝一﹞、減少多形核白血球的移動。抑制中性球附著在血管內皮部位，因此可減
少白血球從血管滲出到發炎的部位。﹝二﹞、抑制巨噬細胞處理抗原。﹝三﹞、抑制
lymphokines 的作用。﹝四﹞、抑制花生酸（arachidonic acid）代謝成前列腺素
(prostaglandin)，prostaglandin 是一種血管擴張劑而且會造成疼痛感。Corticosteroid
抑制 arachidinic acid，即減少 prostaglandin 的產生，因而抑制疼痛。
三、風溼免疫科常用類固醇製劑的介紹：
﹝一﹞、口服：
1. Prednisolone 5mg/tab. 一般先從 5-15mg/day 開始，視病情輕重而定，可用到約
1-2mg/kg/day，等病情改善再漸減劑量（tapering），減量速度沒有一定，原則是“The
lower, the slower.＂
2. Methylprednisolone（Metisone）4mg/tab.
﹝二﹞、針劑：
1. Hydrocortisone（Solu-cortef）100mg/2ml/vial 劑量 1vial QD-qid.
2. Methylprednisolone（Solu-medrol）（2）40mg/vial；
（2）500mg/vial（1）用於抗
發炎、過敏、氣喘，及自體免疫疾病等，（2）SLE 腎炎或 SLE 致中樞神經疾患，一般
Steroid 不足以控制時，可用脈衝療法（Pulse therapy）。劑量：1gm（1000mg）IV/QD
for 3 days, or 500mg IV/q12h for 3 days.
四、副作用：
67
﹝一﹞、皮膚：痤瘡（Acne）、條紋、紫斑、傷口癒合不良。
﹝二﹞、肌肉骨骼：骨質疏鬆、骨骼非敗血性壞死。
﹝三﹞、腸胃：潰瘍、穿孔、胰臟炎。
﹝四﹞、中樞神經：興奮、精神疾患。
﹝五﹞、內分泌：續發性無月經、抑制下視丘─腦下腺─腎上腺軸、血糖升高、肥胖。
﹝六﹞、其他：感染機率增加、白血球升高、青蛙肚、水牛肩、滿月臉、水腫
（Methylprednisolone 較少）。
Corticosteroids
Drug Dosage Side effects Cautions and
contraindications
Cortisone Dosages of Cushing＇s syndrome Active infection（or
Dexamethasone corticosteroids （weight gain, inactive
Hydrocortisone are highly moon-face, thin tuberculosis），
Methylprednisolone variable and skin, muscle hypothroidism，herpes
Prednisolone determined by the weakness）， simplex of the eye，
Prednisolone rheumatic disease osteoporosis, hypertension，
sodium phosphate to be treated. In cataract, osteoporosis，gastric
（liquid only） general, the hypertension， ulcer，diabetes
Prednisone lowest dose that increased
Triamcinolone successfully appetite，elevated
controls the blood sugar，
condition should indigestion，
be used. insomnia，mood
Corticosteroids changes，
should be taken nervousness or
with food or an restlessness＇
antacid. A single cramps，immune
daily dose should suppression/infect
be taken with ion
breakfast. It is
very important
that
corticosteroids,
when used
long-term, not be
stopped abruptly;
dosage must be
tapered gradually
68
免疫調節劑簡介
前言：免疫調節劑（Disease-Modifying Anti-Rheumatic Drugs）

（DMARDs）are more readily
and promptly utilized for the treatment of systemic rheumatic illness. DMARDs 能
真正調節病人的免疫系統，使自體免疫疾病緩解，是治本之藥物，非只有止痛而已。以 RA 為
例：DMARDs 能有效延緩關節侵蝕變形，而 steroid or NSAIDs 只是消炎止痛。但是 DMARDs 作
用較慢（數週至數月），所以發病時先用 steroid or NSAIDs 加上 DMARDs，等 DMARDs 發揮效
果再漸減 steroid，可減少 steroid 之 side effects.
機制：Some are immunosuppressive or cytotoxic, whereas others may act by reducing

systemic inflammation. Their adverse effects are diverse, and so careful monitoring
for toxicities is crucial. Moreover, there appear to be advantages in using
combinations of DMARDs in lower doses to maximize benefit while minimizing
toxicities.
個論：
1. Azathioprine（Imuran）：
Action：Inhibit of purine synthesis.
Selected Indications：RA, SLE, vasculitis.
Dosage：2 to 3 mg/kg/day（1 tab. =50 mg）
Adverse Reactions：mild leukopenia and thrombocytopenia; drug fever; hepatitis and
pancreatitis; nausea, stomatitis, and increased susceptibility to infections. Thus,
CBC and liver function should be followed weekly initially.
2. Cyclophosphamide（Endoxan）：
Action：Alkylating agent. Interferes with nucleic acids and proteins. It can inhibit
secondary immune responses.
Selected Indications：Severe RA, SLE.
Adverse Reactions：Bone marrow depression, primarily of white cell series, and
predisposition to infection are noted. Infertility（male and female）, hemorrhagic
cystitis（about 25%）, malignancies, and nausea are also noted.
Dosage：（1） Oral：0.5-3 mg/kg QD（1 tab.=50 mg）（2）IV：1000mg/ day in D5W 100
ml IV drip（pulse therapy）;（1vial= 500 mg）
請病人多攝取水份，預防膀胱出血症狀。
3. Cyclosporin A（Neoral）：環孢靈
Action：Inhibit T-cell activation.
Selected Indications：RA, psoriatic arthritis etc.
Adverse Reactions ： Nephrotoxicity, hypertension, GI intolerance, infections,
abnormal liver function, hyperuricemia, and malignancies.
69
Dosage：2.5-5 mg/kg QD or bid（1 tab.=25 and 100 mg）
4. Gamma Globulin（IVIG）：免疫球蛋白
Action：It contains polyvalent antibodies. Action in thrombocytopenia may involve
blockade of macrophage.
Selected Indications：Myositis, immune thrombocytopenia purpura, vasculitis 用
於如 SLE 造成之 refractory thrombocytopenia,但目前需自費，一次療程約十幾萬元。開
始：IVIG
Adverse Reactions ： Flushing, fever, dizziness, and hypotension. （ frequent
monitoring vital signs）.
Dosage：0.4g/kg/day for 5 days or divided into 3 days.
5. Hydroxychloroquine（Plaquenil）：氫氧奎寧
Action：Potential actions include binding of nucleic acids, and stabilization of
lysosomal membranes.
Selected Indications：RA, SLE, etc.（對 SLE 之皮膚症狀效果佳）
Adverse Reactions：Common: allergic eruptions and GI disturbances（吐、拉、腹痛）.
The most serious complication is ocular toxicity（but rare）. Hyperpigmented skin
rash may be seen 本藥副作用較輕，故常用，但每年仍需至眼科門診檢查，皮膚及 GI 也
要注意。
Dosage：Initial：1 tab. QD（1 tab.=200 mg）, if no adverse reactions are seen for
1-2 days, dosage may be increased to 1 tab. bid. Maintain dose is at 200~400mg/day.
6. Methotrexate（MTX）：
Action：Folate antagonist that inhibits dihydrofolate reductase, resulting in
immunosuppressive and antiinflammatory properties.
Selected Indications：RA, psoriatic arthritis, vasculitis, and systemic sclerosis
etc.
Adverse Reactions：Bone marrow suppression（leukopenia, thrombocytopenia, and
pancytopenia）and GI injury（diarrhea, stomatitis, and hepatic dysfunction）此
藥副作用甚大，需常追蹤 CBC, liver and renal function etc.需配合 Folic acid（葉酸），
減少 side effects.
Dosage：7.5-15 mg/week（1 tab. = 2.5 mg）.
7. D- Penicillamine：
Action：It decreases RF titer and circulating immune complexes. 2 to 3 months
才有效果。
Selected Indications：RA, systemic sclerosis.
Adverse Reactions ： Most common: pruritus and skin rash （治 : 減量 or using
antihistamines）. Stomatitis or alteration of taste may also occur. The most common
70
late toxic effect is nephropathy. Proteinuria may be seen in 20 % of patients.
禁忌：懷孕，penicillin allergy, and renal insufficiency 此藥不和其他 DMARDs 併用，
需定期追蹤 CBC, urine routine.
Dosage：Initial：250 mg/day（1 tab. =125 or 250 mg）, then may increase to 750 mg/day
2 to 3 months later.
8. Sulfasalazine（磺氨類）：
Action ： There is evidence for antiinflammatory, immunomodulatory, and
antibacterial actions.
Selected Indications：RA, seronegative arthritis.
Adverse Reactions：Common：GI disturbance, headache. Less common：pruritus, rash,
and hemolytic anemia 需定期追蹤：CBC, liver function, and urine routine 多攝取水
份以防 renal stones.
Dosage：2 to 3gm/day with meals. 1 tab. =500mg（先 1 tab. bid then adds to 2 or
3 bid）.（1 gm =1000mg）.
9. Mycophenolate:
Mycophenolic acid (MPA) or mycophenolate is an immunosuppressant drug used to
prevent rejection in organ transplantation. It was initially marketed as the prodrug
mycophenolate mofetil (MMF) to improve oral bioavailability. More recently, the salt
mycophenolate sodium has also been introduced. Mycophenolic acid is commonly
marketed under the trade names CellCept (mycophenolate mofetil; Roche) and
Myfortic (mycophenolate sodium; Novartis). MPA是一種選擇性、非競爭性且可逆性的
inosine monophosphate dehydrogenase(IMPDH)抑制劑，IMPDH抑制guanosine核甘酸的重
新合成途徑而不用建立於脫氧核醣核酸之上。每日投與 1-3 gm/day (通常使用 2-4 # BID)
10. Anti-TNF: Etanercept (恩博)， (Adalimumab 復邁)

Action：Etanercept is an injectable drug that blocks tumor necrosis factor alpha
(TNF alpha).
Selected Indications：RA, JRA. (in Taiwan)
Adverse Reactions： Injection site reaction, infection (TB, bacterial, fungal et
al) .
Dosage：Etanercept is injected under the skin. Adults usually inject 25mg twice
weekly. Children 4 to 17 years old should receive 0.4mg/kg (maximum 25mg) twice
weekly.
復邁(Adalimumab, HUMIRA)是一種全人的腫瘤壞死因子的單株抗體，皮下注射 40mg，每兩
周一次。Adalimumab was constructed from a fully human monoclonal antibody, while
infliximab is a mouse-human chimeric antibody and etanercept is a TNF receptor-IgG
fusion protein.
71
Disease-modifying antirheumatic drugs used in treatment of rheumatoid arthritis
Disease-Modifying Antirheumatic Drugs

Drug Dosage Side effects Cautions and Monitoring
contraindicatio System review Laboratory
ns
Azathioprine 50-150mg/day in Loss of Kidney or live Symptoms of CBC and platelet
1-3 doses, appetite, nausea disease, myelosuppression count every 1-2
based on body or vomiting, concomitant use weeks with
weight. Take skin rash, bone of allopurinol, changes in
with food. marrow pregnancy dosage, and
suppression, every 1-3 months
infection, thereafter
malignancy,
pancreatitis
72
Cyclophosphamide 50-150mg/day Infertility in Kidney or liver Stmptoms of CBC and platelet
orally in a men and women, disease, any myelosuppression, count every 1-2
single morning loss of active hematuria weeks with
dose. Fluid appetite, bone infection, changes in
intake marrow pregnancy dosage, and
（2-3L/day）and suppression, every 1-3 months
emptying infection, thereafter
bladder before hemorrhagic
bedtime is cystitis,
important. malignancy
Cyclosporin 2.5-5mg/kg/day Bleeding, tender Sensitivity to Edema, blood Creatinine every
in 1-2 doses or enlarged castor oil（if pressure every 2 2 weeks until
gums; fluid receiving drug weeks until dose is stable,
retention, by injection）, dosage stable, then monthly;
hypertension, liver or kidney then monthly periodic CBC,
increase in hair disease, active potassium, and
growth; loss of infection, liver function
renal function; hypertension tests
loss of
appetite;
trembling or
shaking of
hands; tremors
Hydroxychloroquine 200-600mg/day Diarrhea, loss Allergy to any Visual changes,
sulfate in 1-2 doses. of appetite, antimalarial funduscopic and
Take with food nausea, stomach drug, retinal visual fields
cramps or pain, abnormality, every 6-12
skin rash, G6PD deficiency, months
retinopathy, pregnancy
neuromyopathy
Methotrexate 7.5-25mg orally Cough, diarrhea, Bone marrow Symptoms of CBC, platelet
or hair loss, loss suppression, myelosuppressio count, aspartate
intramuscularl of appetite, liver and lung na, shortness of aminotransferas
y per week in a unusual bleeding disease breath, e, albumin,
single dose or bruising, alcoholism, nausea/vomiting creatinine every
fever, immune-system , lymph node 4-8 weeks
pneumonitis, deficiency, swelling
infection, active
stomatitis infection,
pregnancy
73
D-Penicillamine 125-250mg/day Diarrhea, joint Penicillin Symptoms of CBC, urine
in a single dose pain, lessening or allergy, blood myelosuppression* dipstick for
to start, loss of sense of disease, kidney , edema, rash protein every 2
increased to taste, loss of disease weeks until
not more than appetite, fever, dosage stable,
1500mg/day in 3 hives or itching, then every 1-3
doses. Take on mouth sores, months
an empty nausea or
stomach vomiting, skin
rash stomach pain,
lymphadenopathy,
bone marrow
suppression,
unusual bleeding
or bruising,
weakness
Sulfasalazine 2-3g/day in 2-4 Stomach pain, Allergy to sulfa Symptoms of CBC every 2-4
doses achiness, drugs or myelosuppression* weeks for first 3
diarrhea, aspirin, kidney , months, then
dizziness, or liver photosensitiveity every 3 months
headache, light disease, blood , rash
sensitivity, disease,
itching appetite bronchial asthma
loss, liver
abnormalities,
lowered blood
count, nausea or
vomiting, rash
Mycophenolate CellCept Diarrhea, 禁止與 MMF 及
(mycophenola leucopenia, Azathioprine 類
te mofetil) Pure Red 型藥物合併使用
and Myfortic Blood Cell
(mycophenola Aplasia, 可
te sodium) 能增加流產及
先天異常風險
＊Symptoms of myelosuppression include fever，symptoms of infection，easily bruisability and bleeding.
Disease-modifying antirheumatic drugs（DMARDS）.（Primer on the Rheumatic Diseases，
11E，Atlanta，GA: arthritis Foundation，1997，and from the American College of
Rheumatology Ad Hoc Committee on clinical guidelines. Guidelines for monitoring drug
therapy in rheumatoid arthritis. Arthritis Rheum. 1996; 39: 723-31.）…
74
RA guideline reference:
Guidelines for the management of rheumatoid arthritis: Arthritis Rheum 2002 46:328-46. American
College of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines.
Intranet web page: http://lnkwww.cgmh.org.tw/intr/c38e00/EBOOK/CPG/RA%20Guideline.pdf
SLE guideline reference:

Guidelines for referral and management of systemic lupus erythematosus in adults. American
College of Rheumatology Ad Hoc Committee on Systemic Lupus Erythematosus Guidelines.
Arthritis Rheum. 1999;42:1785-96.
Flanc, RS. Roberts, MA. Strippoli, GFM. Chadban, SJ. Kerr, PG. Atkins, RC. Treatment for lupus
nephritis. [Systematic Review] Cochrane Renal Group Cochrane Database of Systematic Reviews.
2, 2004.
Gout guideline reference:

EULAR evidence based recommendations for gout. Part I: Diagnosis. Report of a task force of the
Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT).
Ann Rheum Dis. 2006 Oct;65(10):1301-11. EULAR evidence based recommendations for gout.
Part II: Management. Report of a task force of the EULAR Standing Committee for International
Clinical Studies Including Therapeutics (ESCISIT). Ann Rheum Dis. 2006 Oct;65(10):1312-24.
Modified 2009.10.20
75

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風濕過敏免疫科住院醫師手冊

Fresh Autoimmune Disease Case

4. 有 peripheral arthritis 且 有 bone erosion 者 的 RA 及 seronegative

Bronchial asthma 或過敏症：

為何要報告？To show that you：

Presentation of an "old" case for "follow-up" rounds

When arthritis is defined

III.Skin rash, nail changes, hair loss.

前面稍為提到 musculoskeletal complaints 的簡單問診及身體檢查的重點，接下來我們來看

侵犯的範圍如何（monarticular, polyarticular, focal, widespread）

（ ESR, erythrocyte sedimentation rate; CRP, C-reactive protein; DIP, distal

Differential diagnosis of monarthritis by presentation

II. Chronic monarthritis.

III. Acute polyarthritis

IV. Chronic polyarthritis

Polyarticular Diseases with Frequent Monoarticular Component

I. Etiology 主要是 lumbosacral process 的問題。The history, physical examination,

a. The most common cause of nerve root impingement in persons between

IV. Diagnostic studies

VI. Rehabilitation and exercise.

在考慮這個問題時，我們應先從這個問題的 anatomical etiology 來看。也就是 neurological

I. Infectious myositis and myopathy.這類疾病的特徵是通常是 diffuse，且以 proximal

II. Toxin and drug-induced myopathy

III.Congenital（Metabolic myopathies & Muscular dystrophy）

IV. Endocrine myopathies

VI. 其他會全身到處都痛的還有 Fibromyalgia 和 Polymyalgia rheumatica（PMR），後者在

Differential Diagnosis of Muscle Weakness

有那些情況要考慮 Arthrocentesis，可分成 diagnostic 和 therapeutic 兩大方面。

Synovial fluid studies

Crystals Size(μm) Morphology Birefringence Diseases

MSU 2-10 Needles, rods Intensely acute and chronic

CPPD 2-10 Rhomboids, rods Weakly positive CPPD crystal

Apatite-like 5-20 Round, irregular None osteoarthritis,

Cholesterol 10-80 Rectangles, Negative or chronic rheumatoid or

Depot 4-15 Irregular rods, Intensely Iatrogenic

Lipid liquid Intensely acute arthritis,

Positive and eosinophilic

Volume（knee） < 4 ml Often> 4 ml Often> 4 ml Often> 4 ml

Viscosity High High Low Variable

Clarity Transparent Transparent Translucent Opaque

PMN＊ < 25% < 25% Often> 50% > 85%

Culture Negative Negative Negative Often positive

Mucin clot Firm Firm Friable Friable

2-6 血清分析 Serum Analysis

z Anti-double stranded DNA antibodies（Anti-ds-DNA Ab）（抗雙股 DNA 抗體）：

FIG. 1. Complement pathways

Complement deficiency states

*Human Leukocyte Antigen（HLA）（人類白血球抗原）：

*Urid Acid （尿酸）：

*VDRL and RPR：

要評估各別關節和肌腱、韌帶在骨頭的附著處（entheses），一般的 plain film 我們會需

Imaging of degenerative joint disease

REVISED ARA CRITERIA FOR CLASSIFICATION OF RHEUMATOID ARTHRITIS

Classification of Functional Capacity in Rheumatoid Arthritis

Classification of Progression of Rheumatoid Arthritis

Preliminary Criteria for Classification of Progressive Systemic Sclerosis

Crystal Deposition Diseases of Joints

Exclusion criteria: preexisting lymphoma, acquired immunodeficiency syndrome,

Criteria for the Classification of Wegener＇s Granulomatosis*

*For purposes of classification, a patient shall be said to have Wegener＇s

Criteria for the Classification of Takayasu Arteritis*

Criteria for the Classification of Polyarteritis Nodosa*

Diagnostic Criteria for the Classification of Juvenile Rheumatoid Arthritis*

Criteria for the Diagnosis of Rheumatic Fever*

4. 有 peripheral arthritis 且有 bone erosion 者的 RA 及 seronegative