4/12(木)
◆今日の気持ち
(膠原病科 2週目)
・久方ぶり早く帰ってみた。最近、ほんとにぼろぼろになっていた…
・大学病院、雑務は減ったとは聞いているけれど、それでもいろいろ効率悪い…。電子カルテだけでなく…。一日を振り返ってみると、やれたことの量が少ないし。効率よく動きたいな
・IPを分類する意義がよく分からない。何でだ?
・CRP上昇って細菌感染を第一に、けっこう考えるものなのだな…。身体所見が違うと言っていると思うのだけれど…
・Dermliteが届いた!!! 明日からさっそくつかってみないと!!
●今の目標
・大学病院の仕事を覚える
●今までの新患・診断
・成人発症Still病
・ベーチェット病terminal
・副腎クリーゼ
・振戦 ステロイドの副作用?
・ステロイドでのmoon face、にきび、大腿骨骨董壊死
・関節リウマチ
・間質性肺炎
・多発筋炎?
・SLE
・CREST症候群
・足趾壊死
●今日の病院滞在時間
8時〜19時
●今まで行ったこと・見たこと・知ったこと
・IP
BOOP-likeが最も早くsteroidに反応する
・胸ope後、なら横隔神経マヒも鑑別に
・Stillの皮疹
サーモンピンク疹が普通だけれど、蕁麻疹が出ることも
・Still
咽頭痛って特徴的
・AOSDに合併する血球貪食症候群に注意!!
CRP、フェリチン、AST/ALT、LDHが上昇する!
Pltに注意。パルスを早く始める!
・ビスホスホネートは妊娠可能な女性には使えない
長く血中に残るため
・PSL 20mgをこえると感染の確率が跳ね上がる
・AaDO2= PAO2-PaO2…を忘れていた
PAO2=150-PaCO2/0.8
・RAに合併する輪状被裂軟骨関節炎
→上気道閉塞、異物感、嗄声、呼吸苦、喘鳴など
・eternaceptは入院するほどの感染があれば3ヶ月は止めるのが普通
・特にRAは、PSLで易感染性高まる
・痰を除去したい…2%NaCl 10mlネブライザー
・壊死にPGE1 …投与していると悪くなることがある。Steel現象
4週間は保険がきく
・RAの評価にDAS score
疼痛、腫脹、炎症反応、主観の4つで計算。
こわばりはあまり関与しない
・PSL投与の時のisoniazid(INH)予防投与
9ヶ月間
・免疫抑制導入前にTB見つかったら
三週間抗生剤を先行させる
・6分間歩行
どれくらい歩けたか、30秒ごとにSpO2がどれくらい変わったか
・サルコイドーシスのBAL
リンパ球が20%を越える
CD4/CD8が2以上
・MTXの効果
出てくるのは3〜4週。ちょっと遅い
骨髄抑制もそれくらいで出てくる… 注意!!!
アレルギー機序の副作用だと濃度に比例しないことに注意
・meloxicam(モービック)は比較的選択性が高く、胃にやさしい?
・disital pad
SScで低下しているのはきちんと見る
・SSc
脱色素 骨があたるところは色素抜けやすい
・振戦 鑑別
高アドレナリン状態!
lithium, βアドレナリン作動薬、グルココルチコイド、チロキシン、SSRI、バセドウ
・IVC
循環血量をエコーでチェック
心窩部または肝をこえて見る
・免疫抑制剤は、
濃度を保っていたとしても2週間たたないときかない!
説明を忘れない
・CRESTの毛細血管拡張なら唇でよく見える
・膠原病の疾患とは…
・リウマチ性(痛風、OA含む)
・自己免疫疾患(アトピー、溶血性貧血、MG含む)
・結合組織病(血管炎などなど)
の三つの重なったもの
・不明熱
感染
腫瘍(特に、リンパ腫、腎腫瘍)
薬剤
膠原病 を考える
・「痛みを伴わない発疹」 膠原病!!
・レイノー
動脈の収縮・痙攣で起きる →興奮・寒冷を刺激とする
・immunogroblin
軽鎖 κ・λ
重鎖 5種類
・リウマトイド因子
グロブリンのFc部分(Yの根っこのほう)につく抗体
RA …感度高いが特異度低い IgM
RAPA … IgM
RF-IgG
LC、Chronic hepatitisでもなぜか増えることに注意
RAの75%でRFは陽性
LCの80%でRFは陽性
・CRP
炎症性サイトカインが肝臓に届くと作られる
サイトカインは種類多すぎるし半減期が極めて短いから、半減期が手ごろ(3日)に長いCRPは有用
・ESR
肝臓で作られたFbgがRBCの電荷を狂わせ、おきる。半減期はなかなか長い
・ESR↑、CRP(-)
…貧血、ネフローゼ、高γグロブリン など
・抗Sm抗体
SLEの活動性に相関する
・P-ANCA(MPA)、C-ANCA(Wegener)も活動性に相関
・筋炎
握ると痛い、と調べる
・人工関節のひとできちんと歯を磨かないと…菌が飛ぶことあり
・IEも、歯は重要
・女性の痛風は2種類のみ!!
遺伝性代謝異常
ラシックス多用
・OA
DIPが赤く腫れる
→DIPが腫れていたら膠原病はありえない!
・RAの関節…
多発
対称性
移動性
…の関節痛の8割はRA
・RAの尺側変形は…
よくなってからおこる。こんなことにならないように、外回転の仕事は制限させる。蓋を開ける、とか
・RAのactivity
ESR、CRP
・MMP-3
軟骨破壊ででた酵素
RA, SLEで上昇 腎臓が悪くても上昇(排出されない)
・OAのX線
骨硬化像(RAならerosion)、骨棘
・乾癬性皮膚炎
…関節炎起こる! DIPから
・筋肉痛
筋力低下、があったら膠原病を疑う!
甲状腺機能低下やカリウム低下(ラシックスミオパチー)にも注意
・レイノーの特徴
すべての指が白くなる、ことはありえない!
・ミュンヒハウゼン症候群
…病気になりたいから自分を自分で病気にする。便を創に入れる、とか
・動脈しまると白く、静脈がしまると紫になる
・SjSではなく、SSと表記
・PCP
免疫力が低下すると、コロナイズする
普通の免疫力ではコロナイズすらしない
・微細な音が聞こえたら…
DLcoが感度高い!
・MTXはST合剤の排出を抑える…ので同時投与はしないのも、よくやること
・SSc
末梢骨の吸収像
・強直性脊椎炎
診断基準が大切!
・抗CCP抗体
感度特異度ともに、なかなか
・小児の筋炎は膝に硬化見えやすい! 大人とは違う
・リウマトイド結節
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