器官移植临床案例二Word文档格式.docx

器官移植临床案例二Word文档格式.docx

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White

Allergies

Codeine

SectionName

OrganTransplantation

CaseName

CardiacTransplantation

ChiefComplaintHxPresIllness

TransferfromSt.AndrewMedicalCenterincardiogenicshock

AFisa68-year-oldwomanwithcoronaryarterydiseaseadmitted10

daysagowithchestpainforabout3hours,diaphoresis,andshortnessofbreath,whichwasprecededbyabout3daysofshortnessofbreath,dyspneaonexertion,wheezing,andorthopnea・Onpresentation,shewastachycardicandnormotensive,andEKGrevealedlossofRwavesacrosstheanteriorprecordiumwithnoacuteSTorTwavechanges・Chestx-rayrevealedpulmonaryedema・InitialCKwas505・Shewasfoundtohavenormalrenalfunctionandnormalhematocrit・Anechocardiogramrevealedanteroseptalakinesis,alaminarclot,posteriorandinferiorrightventricularhypokinesis,severetricuspidregurg,andmildmitralregurg・Shehadacardiacindexof1・4・Thepatientison100%nonrebreathermaskwhileplansareunderwayforhearttransplantation・

PastMedicalHx

CHF;

goingforHHTxtoday

Parkinson*sdiseasewhichisfelttobemild,managedonlywithArtanewhichcontrolsamildtremor

Hiatalhernia

Endometrialcancer

GERD

Severekyphosisandscoliosis

SocialHx

Shelivesindependent!

y.Sheismarriedwithverysupportivefamily,

church,andhusband・Sheisactiveanddrives・Sheisaretiredsecretary.

FamilyHxIncludesahistoryofcoronaryarterydisease

ReviewOfSystemsVS:

Temperature37.5°

C,bloodpressureinitially155/85mmHg,

decreasingto110-120/40-60,heartrate85-90,respirations10/10onaventilatorShecamewithanintraaorticballoonpump1:

1.InitialSwannumbersrevealedacardiacindexof1・49,acardiacoutputof2・55,aCVPof10,apulmonaryarterywedgepressureof22,systemicvenousresistanceof1474,andapulmonaryvascularresistanceof188atthetimeoftransfertotransplantation・

PhysicalExamGEN:

Ingeneral,sheissedatedandquicklybecamemoreawakeand

alertaspropofolwasdecreased・Shewasintubatedandventilated・

HEENT:

PERRLA

CARDIOVASCULAR:

SI,S2・Balloonpumpmadeheartsoundsdifficulttoassessfurther・

LUNGS:

Bilateralcracklestobilateralbasesbutbilateralexchangethroughout・ABDOMEN:

Bowelsoundswereactive・Abdomenwassoft・Therewasnoobvioushepatosplenomegaly・

EXTREMITIES:

Coolbutpink・Distalpulseswerepalpable・Therewasnoedema・

LabsAndDxTestsSodium137mEq/L

Potassium3・6mEq/L

Chloride94mEq/L

HC0330mEq/L

BUN28mg/L

Creatinine1・1mg/L

Mg2mg/dL

WBC7500/nim3

Hematocrit32.7%

Platelets158x10VL

DiagnosisCardiogenicshockandhearttransplantation

RxRecord

Date

4/3

8/11

3/11

4/S

4/2

RxXo

D2466S1

M56863

D245702

0256822

D248926

D240031

D540983

D32O123

D429S21

Physician

DrusandStrength

Sirolisu:

1N

Tacrolizms1叱

Prednisone5

ns

Prevacid

30ns

Dilantin

100EL*

Atenolol

50ne

Aulodipine5ngpoqS

MVI

Xycelex

^oantity

200

300

500

60

100

30

140

Sie

2sepobid

1S3pobid

2poQAQ

1pobid

300yxqhs

Vd

1POQAS

2poqd

10rx*po

Refills

3

6

RPhNotesNewadmitforhearttransplant

QuestNumQuestionrangefor

2131

Whenmonitoringserumconcentrationoftacrolimus,therecommended

atroughlevelis:

AnswerChoiceA2-3ng/mL.

AnswerChoiceB5-15ng/mL.

AnsweirChoiceC

150-250ng/mL・

AnswerChoiceD

250-500ng/mL・

AnswerChoiceE

greaterthan500ng/mL・

CorrectAnswer

Explanation

B

Followingoraladministration,approximately20%ofthedoseis

absorbedintheGItract・Tacrolimusconcentrationcanbemeasuredinbothplasmaandblood.Wholebloodisthepreferredmethodformeasuringtacrolimusbloodconcentration・Tacrolimuslevelsshouldbemaintainedinarangeof5-15ng/mL・Levelsgreaterthan20ng/mLhavebeenassociatedwithnephrotoxicity,neurotoxicity,anddiabetogenicity・

CompetencyStmt

1.2.6

K-Type

QuestNumQuestion

2132

Whichofthefollowingmedicationsrequirecloseplasmatherapeutic

monitoring?

<

br>

I.aAzathioprine<

II.6Steroids<

III.Tacrolimus

AnswerChoiceA

Ionly

AnswcrChoiceB

IIIonly

AnswerChoiceC

IandIIonly

IIandIIIonly

I,II,andIII

Tacrolimustroughlevelsshouldbemaintainedinarangeof5-15

ng/mL・Clinicalpharmacokineticstudiesdonotsuggestastrongcorrelationbetweenplasmaconcentrationandpharmacodynamicpropertiesofsteroidsandazathioprine・Becauseofhighinterindividualvariabilityandwidertherapeuticindicesinazathioprineandsteroidplasmalevels,therapeuticdrugmonitoringisnotrequiredintheseagents・

K