器官移植临床案例二.docx

器官移植临床案例二.docx

《器官移植临床案例二.docx》由会员分享，可在线阅读，更多相关《器官移植临床案例二.docx（18页珍藏版）》请在冰豆网上搜索。

器官移植临床案例二

CaseNum214

PtNameAmyFarrah

Address10SWMerlinCourt

Age68

Height5'11"

Weight125lb

SexF

RaceWhite

AllergiesCodeine

SectionNameOrganTransplantation

CaseNameCardiacTransplantation

ChiefComplaintTransferfromSt.AndrewMedical Centerincardiogenicshock

HxPresIllnessAFisa68-year-oldwomanwithcoronaryarterydiseaseadmitted10daysagowithchestpainforabout3hours,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

SocialHxShelivesindependently.Sheismarriedwithverysupportivefamily,church,andhusband.Sheisactiveanddrives.Sheisaretiredsecretary.

FamilyHxIncludesahistoryofcoronaryarterydisease

ReviewOfSystemsVS:

Temperature37.5°C,bloodpressureinitially155/85mmHg,decreasingto110-120/40-60,heartrate85-90,respirations10/10onaventilator

Shecamewithanintraaorticballoonpump1:

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

PhysicalExamGEN:

Ingeneral,sheissedatedandquicklybecamemoreawakeandalertaspropofolwasdecreased.Shewasintubatedandventilated.

HEENT:

PERRLA

CARDIOVASCULAR:

S1,S2.Balloonpumpmadeheartsoundsdifficulttoassessfurther.

LUNGS:

Bilateralcracklestobilateralbasesbutbilateralexchangethroughout.

ABDOMEN:

Bowelsoundswereactive.Abdomenwassoft.Therewasnoobvioushepatosplenomegaly.

EXTREMITIES:

Coolbutpink.Distalpulseswerepalpable.Therewasnoedema.

LabsAndDxTestsSodium137mEq/L

Potassium3.6mEq/L

Chloride94mEq/L

HCO330mEq/L

BUN28mg/L

Creatinine1.1mg/L

Mg2mg/dL

WBC7500/mm3

Hematocrit32.7%

Platelets158x109/L

DiagnosisCardiogenicshockandhearttransplantation

RxRecord

Date

4/3

4/3

8/11

3/11

3/11

4/3

4/3

4/3

4/2

RxNo

D246631

D456863

D245702

D256822

D248926

D240031

D340983

D320423

D429824

Physician

DrugandStrength

Sirolimus1mg

Tacrolimus1mg

Prednisone5mg

Prevacid30mg

Dilantin100mg

Atenolol50mg

Amlodipine5mgpoqd

MVI

Mycelex

Quantity

200

300

500

60

100

100

30

60

140

Sig

2mgpobid

1mgpobid

2poqam

1pobid

300mgpoqhs

Ud

1poqam

2poqd

10mgpo

Refills

3

3

3

3

6

6

3

3

RPhNotesNewadmitforhearttransplant

CaseNum214

QuestNum2131

QuestionWhenmonitoringserumconcentrationoftacrolimus,therecommendedrangeforatroughlevelis:

AnswerChoiceA2-3ng/mL.

AnswerChoiceB5-15ng/mL.

AnswerChoiceC150-250ng/mL.

AnswerChoiceD250-500ng/mL.

AnswerChoiceEgreaterthan500ng/mL.

CorrectAnswerB

ExplanationFollowingoraladministration,approximately20%ofthedoseisabsorbedintheGItract.Tacrolimusconcentrationcanbemeasuredinbothplasmaandblood.Wholebloodisthepreferredmethodformeasuringtacrolimusbloodconcentration.Tacrolimuslevelsshouldbemaintainedinarangeof5-15ng/mL.Levelsgreaterthan20ng/mLhavebeenassociatedwithnephrotoxicity,neurotoxicity,anddiabetogenicity.

CompetencyStmt1.2.6

K-Type

CaseNum214

QuestNum2132

QuestionWhichofthefollowingmedicationsrequirecloseplasmatherapeuticmonitoring?

I.áAzathioprine
II.áSteroids
III.Tacrolimus

AnswerChoiceAIonly

AnswerChoiceBIIIonly

AnswerChoiceCIandIIonly

AnswerChoiceDIIandIIIonly

AnswerChoiceEI,II,andIII

CorrectAnswerB

ExplanationTacrolimustroughlevelsshouldbemaintainedinarangeof5-15ng/mL.Clinicalpharmacokineticstudiesdonotsuggestastrongcorrelationbetweenplasmaconcentrationandpharmacodynamicpropertiesofsteroidsandazathioprine.Becauseofhighinterindividualvariabilityandwidertherapeuticindicesinazathioprineandsteroidplasmalevels,therapeuticdrugmonitoringisnotrequiredintheseagents.

CompetencyStmt1.2.6

K-TypeK

CaseNum214qid
3
4/11
D429828
@
Fluconazole
12
100mgpodaily
0

QuestNum2133

QuestionWhichofthefollowingisthedose-limitingtoxicityoftacrolimus?

I.Nephrotoxicity
II.Alopecia
III.Diarrhea

AnswerChoiceAIonly

AnswerChoiceBIIIonly

AnswerChoiceCIandIIonly

AnswerChoiceDIIandIIIonly

AnswerChoiceEI,II,andIII

CorrectAnswerA

ExplanationAvarietyofadversedrugreactionshavebeenreportedwiththeuseoftacrolimus.Evidencesuggeststhattacrolimus-inducedadversedrugreactionsaretypicallyassociatedwithahighbloodconcentration.Alopeciaanddiarrheahavebeenreportedinpatientswithlowtroughátacrolimuslevels.

CompetencyStmt1.2.4

K-TypeK

CaseNum214

QuestNum2134

QuestionHowwouldyoumonitorapatienttakingtacrolimus?

I.Serumcreatinine,cardiacfunctiontests
II.Bloodpressure,diabetes
III.Plasmatherapeuticconcentration

AnswerChoiceAIonly

AnswerChoiceBIIIonly

AnswerChoiceCIandIIonly

AnswerChoiceDIIandIIIonly

AnswerChoiceEI,II,andIII

CorrectAnswerE

ExplanationClinicalpharmacokineticstudiesdosuggestastrongcorrelationbetweenplasmaconcentrationandtoxicityoftacrolimus.Plasmaconcentrationoftacrolimusshouldbemonitoredverycloselytoavoidtoxicity.However,somepatientsmayexperienceadversedrugreactionsdespitenormaltacrolimuslevel.Therefore,itisessentialtomonitorforbloodpressureanddiabetesfollowingtransplantation.

CompetencyStmt1.2.3

K-TypeK

CaseNum214

QuestNum2135

QuestionTheprimarycriteriaforselectinganimmunosuppressivedrugis:

I.patient'sriskfactorsforacuterejectionandinfection.
II.efficacyandsafety.
III.cost.

AnswerChoiceAIonly

AnswerChoiceBIIIonly

AnswerChoiceCIandIIonly

AnswerChoiceDIIandIIIonly

AnswerChoiceEI,II,andIII

CorrectAnswerC

ExplanationRiskfactorsofacuterejection,efficacy,andsafetyofimmunosuppressivetherapyshouldallbeconsideredbeforeformulatinganimmunosuppressiveprotocolforeachindividualpatient.Thefocusofanimmunosuppressiveprotocolshouldbeondecreasingtheriskofacuterejectionandlimitingadversedrugreactions.Althoughthecostisimportant,costofimmunosuppressivedrugsareonly5%ofthetotalcostoftransplantation.

CompetencyStmt1.1.3

K-TypeK

CaseNum214

QuestNum2136

QuestionThemostlikelycauseofhypertensioninthispatientis:

I.sirolimus.
II.tacrolimus.
III.prednisone.

AnswerChoiceAIonly

AnswerChoiceBIIIonly

AnswerChoiceCIandIIonly

AnswerChoiceDIIandIIIonly

AnswerChoiceEI,II,andIII

CorrectAnswerD

ExplanationSeveralstudieshaveshownthatprednisoneandtacrolimuscanelevatebloodpressure.Thelong-termeffectofsirolimusonbloodpressureremainsunknown,butrecentdataindicatethatsirolimushasalimitedeffectonbloodpressure.Therefore,onlyIIandIIIarecorrect.

CompetencyStmt1.2.3

K-TypeK

e

CaseNum214

QuestNum2137

QuestionWhichofthefollowingclinicaltestsareusedformonitoringsirolimustherapy?

I.WBC（whitebloodcounts）
II.Sirolimuslevel
III.Nephrotoxicity

AnswerChoiceAIonly

AnswerChoiceBIIIonly

AnswerChoiceCIandIIonly

AnswerChoiceDIIandIIIonly

AnswerChoiceEI,II,andIII

CorrectAnswerC

ExplanationClinicalpharmacokineticstudiessuggestastrongcorrelationbetweenplasmaconcentrationofsirolimusandtoxicity.Plasmasirolimusconcentrationsshouldbemonitoredverycloselytoavoidtoxicity.However,somepatientsmaydevelophyperlipidemiaandneutropeniadespitenormalsirolimuslevels.Nephrotoxicityisnotacommoncomplicationofsirolimustherapy.

CompetencyStmt1.2.3

K-TypeK

CaseNum214

QuestNum2138

QuestionWhenmonitoringserumconcentrationsofsirolimus,therecommendedrangeforatroughlevelis:

AnswerChoiceA1-2ng/mL.

AnswerChoiceB10-20ng/mL.

AnswerChoiceC40-50ng/mL.

AnswerChoiceD150-250ng/mL.

AnswerChoiceEgreaterthan250ng/mL.

CorrectAnswerB

ExplanationLikeotheragentswithnarrowtherapeuticwindows,sirolimuslevelsshouldbemonitoredverycloselytoavoidacuterejectionortoxicities.Sirolimuslevelsshouldbemaintainedinarangeof10-20ng/mL.

CompetencyStmt1.2.6

K-Type

CaseNum214

QuestNum2139

QuestionThemostcommoncause（s）ofpost-transplanthyperlipidemiais:

I.mycophenolate.
II.sirolimus.
III.prednisone.

AnswerChoiceAIonly

AnswerChoiceBIIIonly

AnswerChoiceCIandIIonly

AnswerChoiceDIIandIIIonly

AnswerChoiceEI,II,andIII

CorrectAnswerD

ExplanationHyperlipidemiadevelopingafterhearttransplantationisnearlyuniversal,occurringin70-80%ofpatients.Althoughtheexactpathogenesisofhyperlipidemiafollowingtransplantationisstillbeingdetermined,severalstudieshaveshownthatbothprednisoneandsirolimusareindependentriskfactorsforthedevelopmentofhyperlipidemia.

CompetencyStmt1.3.1

K-TypeK

CaseNum214

QuestNum2140

QuestionWhichofthefollowingimmuno