Rheumatology
Efim Benenson Rheumatology Clinical Scenarios Syndrome or disease?
Author Efim Benenson, MD Professor of Medicine Department of Internal Medicine University of Cologne Cologne Germany The work was first published as a part of a work published in 2009 by Shaker Media in German language with the following title: Rheumatologie: Syndrome und Algorithmen Translation: Beverley Taylor ISBN 978-0-85729-239-1 DOI 10.1007/978-0-85729-240-7 e-isbn 978-0-85729-240-7 Springer London Dordrecht Heidelberg New York A catalogue record for this book is available from the British Library Mathematics Subject Classification (2000): insert codes if applicable Springer-Verlag London Limited 2011 Apart from any fair dealing for the purposes of research or private study, or criticism or review, as permitted under the Copyright, Designs and Patents Act 1988, this publication may only be reproduced, stored or transmitted, in any form or by any means, with the prior permission in writing of the publishers, or in the case of reprographic reproduction in accordance with the terms of licenses issued by the Copyright Licensing Agency. Enquiries concerning reproduction outside those terms should be sent to the publishers. The use of registered names, trademarks, etc., in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant laws and regulations and therefore free for general use. Product liability: The publisher can give no guarantee for information about drug dosage and application thereof contained in this book. In every individual case the respective user must check its accuracy by consulting other pharmaceutical literature. Cover design: estudiocalamar, Figueres/Berlin Printed on acid-free paper Springer is part of Springer Science+Business Media (www.springer.com)
I dedicate this book to my wife, Irina, for her patience and support, our children, Anna and Vladimir, and to our grandchildren, Patrick, Paulina, and Wlada.
Preface Clinical Scenarios is directed toward trainees of rheumatology. Active learning by case studies on the way toward an established diagnosis based on a structured clinical knowledge and thinking such is the concept of this training. It has arisen from the experience of practical clinical teaching. How can I find a diagnosis for the pictures on the front matter page? Which two commonly confused diseases do the two hands represent? Which syndromes can be seen here: arthritis, osteoarthritis, or both? How can I find the correct diagnosis for diseases I am seeing for the very first time? How to get the ability to apply my knowledge about diseases from the basic books to a real patient? The 73 clinical situations and 156 illustrations provide a realistic simulation of everyday medical practice not as an illustration of the topic, but as a problem to be solved when seeking a diagnosis. Furthermore the case reports and pictures complete most part of the specific area of rheumatology and present the important basis of what every doctor should be able to identify and interpret correctly. Syndrome or disease? This lately important of questions is the key both to diagnosis and clinical training. During the training with this book you can reach a diagnosis for the first time on your own, using the morphological structured signs or syndromes (terminated as a stable combination of symptoms from the Greek syn. together, dromos passage) which, unlike the symptoms, clearly depict the similarities and distinctions of the individual diseases. The solutions to the images and associated clinical situations are offered not as a process of perception or visual diagnosis, but rather as a flow of thoughts (the Greek term for flow, rheuma, happens to fit perfectly here) and respectively the outcome of integrated morphological and pathophysiological reasoning. The clinical situations and figures enclose the relatively comprehensive collection of rheumatologic leading symptoms and syndromes (Chap. 1). Certain clinical situations also emergencies are presented as typical, unusual, or memorable. They are labeled with the combinations of symptoms and syndromes, documented in the images by means of various radiological and morphological methods; also included are the traditional and new therapeutic options (immunosuppressive, biologics, laser therapy, surgeries) partly with therapy outcomes in figures. The syndromes, especially on the images, should be recognized by the reader in the context of the clinical situation and then linked with the correct diagnosis. The exemplary solutions are presented, even in the case when comparing the classical nosological and here favorite syndromes principle (Chap. 1.2). vii
viii Preface The reader is encouraged to enter his/her preliminary diagnosis of all figures and clinical situations in Chap. 3 as self-check and then compare his/her opinion with the diagnosis given in the Appendix. This table also serves as an index for all figures and clinical situations for a quick diagnosis. A critical review of each figure and clinical situation is presented and discussed in terms of specifics of the cases and its boundaries in the overall context with the individual treatment options (Chap. 2). In Clinical Scenarios with the images and clinical cases is also presented the deductive key for their clearing. The standardized diagnostic program (diagnostic skills) achieves a solid structuring of the findings based on morphology and pathophysiology as well as the causal investigation and wide-ranging clinical examination. The Rheumatology Trees 1 and 2 (Tables 1 and 2) offer compact information as basics at a glance and as shortcut for the already experienced colleagues who want to fresh up their proficiency. All images were structured as syndrome-specific, non-disease-specific, or disease specific. Rheumatology: Symptoms and Syndromes, E. Benenson, Springer 2011, is a reference work for this book. Thus the clinical routine from patient to information and back is in the active learning completely modulated. The idea, how to get a diagnosis, can be applied to other areas of clinical medicine. Training in rheumatology with these clinical cases could vary according to the individual objectives: as self-assessment (quiz) or study program (case-based learning) with the book as a well-structured guide to differential diagnosis (diagnostic Index of all syndromes and diseases in the Appendix), or package of individual therapeutic options with clear outcomes. I wish my readers both enjoyment and success and to myself a broad discussion in the future about clinical training (efim@benenson-rheumatologie.de). Cologne, Germany Efim Benenson, MD
Acknowledgements Sincere thanks to my colleagues Professor of Medicine Michael Hallek, Director of Department I of Internal Medicine, University of Cologne for his advice and support, and my former boss, Professor of Medicine Volker Diehl, for welcoming me kindly to this Clinic in 1994, and especially Ursula Voigt-Pfeil for her active support in realizing this project. ix
Contents 1 2 Diagnostic Training and Rheumatology Trees... 1.1 The Pictures and Clinical Cases That Every Doctor Should Correctly Identify and Interpret... 1.1.1 Pictures of the Major Syndromes in Rheumatology (Fig. 1 132, page onwards).... 1.1.2 Clinical Situations (CS) Marked by Syndromes... 1.2 Solutions to the Clinical Situations... 1.2.1 Arthrology... 1.2.2 Connective Tissue Disease (CTD)... 1.2.3 Vasculitis... 1.3 Rheumatology Tree 1: Articular and Musculoskeletal Disorders (Table of the Major Syndromes)... 1.4 Rheumatology Tree 2: Connective Tissue Diseases and Vascilitides (Table of Syndromes of the Major Systemic Diseases)... 1 1 2 2 27 27 30 32 34 35 xplanations of Figures and Case Reports with Individual E Therapeutic Options... 39 3 Index of Figures (Fig.) and CS with Syndromes (for Self-assessment)... 81 Appendix: Index of the Solutions to the Syndromes and Diagnostics (for Rapid Diagnosis)... 89 References... 99 Abbreviations... 101 Pictures With Major Syndromes of Rheumatology... 105 Index 127 xi