器官移植临床案例二.doc

CaseNum214PtNameAmy FarrahAddress10 SW Merlin CourtAge68Height5 11Weight125 lbSexFRaceWhiteAllergiesCodeineSectionNameOrgan TransplantationCaseNameCardiac TransplantationChiefComplaintTransfer from St. Andrew MedicalCenter in cardiogenic shockHxPresIllnessAF is a 68-year-old woman with coronary artery disease admitted 10 days ago with chest pain for about 3 hours, diaphoresis, and shortness of breath, which was preceded by about 3 days of shortness of breath, dyspnea on exertion, wheezing, and orthopnea. On presentation, she was tachycardic and normotensive, and EKG revealed loss of R waves across the anterior precordium with no acute ST or T wave changes. Chest x-ray revealed pulmonary edema. Initial CK was 505. She was found to have normal renal function and normal hematocrit. An echocardiogram revealed anteroseptal akinesis, a laminar clot, posterior and inferior right ventricular hypokinesis, severe tricuspid regurg, and mild mitral regurg. She had a cardiac index of 1.4. The patient is on 100% nonrebreather mask while plans are underway for heart transplantation.PastMedicalHxCHF; going for HHTx todayParkinsons disease which is felt to be mild, managed only with Artane which controls a mild tremorHiatal herniaEndometrial cancerGERDSevere kyphosis and scoliosisSocialHxShe lives independently. She is married with very supportive family, church, and husband. She is active and drives. She is a retired secretary.FamilyHxIncludes a history of coronary artery diseaseReviewOfSystemsVS: Temperature 37.5C, blood pressure initially 155/85 mmHg, decreasing to 110-120/40-60, heart rate 85-90, respirations 10/10 on a ventilator She came with an intraaortic balloon pump 1:1. Initial Swan numbers revealed a cardiac index of 1.49, a cardiac output of 2.55, a CVP of 10, a pulmonary artery wedge pressure of 22, systemic venous resistance of 1474, anda pulmonary vascular resistance of 188 at the time of transfer to transplantation.PhysicalExamGEN: In general, she is sedated and quickly became more awake and alert as propofol was decreased. She was intubated and ventilated.HEENT: PERRLACARDIOVASCULAR: S1, S2. Balloon pump made heart sounds difficult to assess further.LUNGS: Bilateral crackles to bilateral bases but bilateral exchange throughout.ABDOMEN: Bowel sounds were active. Abdomen was soft. There was no obvious hepatosplenomegaly. EXTREMITIES: Cool but pink. Distal pulses were palpable. There was no edema.LabsAndDxTestsSodium 137 mEq/LPotassium 3.6 mEq/LChloride 94 mEq/LHCO330 mEq/LBUN 28 mg/LCreatinine 1.1 mg/LMg 2 mg/dLWBC 7500/mm3Hematocrit 32.7%Platelets 158 x 109/LDiagnosisCardiogenic shock and heart transplantationRxRecordDate4/34/38/113/113/114/34/34/34/2Rx NoD246631D456863D245702D256822D248926D240031D340983D320423D429824Physician Drug and StrengthSirolimus 1 mgTacrolimus 1 mgPrednisone 5 mgPrevacid 30 mgDilantin 100 mgAtenolol 50 mgAmlodipine 5 mg po qdMVI MycelexQuantity200300500601001003060140Sig2 mg po bid1 mg po bid2 po q am1 po bid300 mg po q hsUd1 po q am2 po qd10 mg po Refills33336633RPhNotesNew admit for heart transplantCaseNum214QuestNum2131QuestionWhen monitoring serum concentration of tacrolimus, the recommended range for a trough level is:AnswerChoiceA2-3 ng/mL.AnswerChoiceB5-15 ng/mL.AnswerChoiceC150-250 ng/mL.AnswerChoiceD250-500 ng/mL.AnswerChoiceEgreater than 500 ng/mL.CorrectAnswerBExplanationFollowing oral administration, approximately 20% of the dose is absorbed in the GI tract. Tacrolimus concentration can be measured in both plasma and blood. Whole blood is the preferred method for measuring tacrolimus blood concentration. Tacrolimus levels should be maintained in a range of 5-15 ng/mL. Levels greater than 20 ng/mL have been associated with nephrotoxicity, neurotoxicity, and diabetogenicity.CompetencyStmt1.2.6K-TypeCaseNum214QuestNum2132QuestionWhich of the following medications require close plasma therapeutic monitoring?I.AzathioprineII.SteroidsIII. TacrolimusAnswerChoiceAI onlyAnswerChoiceBIII onlyAnswerChoiceCI and II onlyAnswerChoiceDII and III onlyAnswerChoiceEI, II, and IIICorrectAnswerBExplanationTacrolimus trough levels should be maintained in a range of 5-15 ng/mL. Clinical pharmacokinetic studies do not suggest a strong correlation between plasma concentration and pharmacodynamic properties of steroids and azathioprine. Because of high interindividual variability and wider therapeutic indices in azathioprine and steroid plasma levels, therapeutic drug monitoring is not required in these agents.CompetencyStmt1.2.6K-TypeKCaseNum214qid34/11D429828Fluconazole12100 mg po daily0QuestNum2133QuestionWhich of the following is the dose-limiting toxicity of tacrolimus? I. NephrotoxicityII. AlopeciaIII. DiarrheaAnswerChoiceAI onlyAnswerChoiceBIII onlyAnswerChoiceCI and II onlyAnswerChoiceDII and III onlyAnswerChoiceEI, II, and IIICorrectAnswerAExplanationA variety of adverse drug reactions have been reported with the use of tacrolimus. Evidence suggests that tacrolimus-induced adverse drug reactions are typically associated with a highblood concentration. Alopecia and diarrhea have been reported in patients with low troughtacrolimus levels.CompetencyStmt1.2.4K-TypeKCaseNum214QuestNum2134QuestionHow would you monitor a patient taking tacrolimus? I. Serum creatinine, cardiac function testsII. Blood pressure, diabetesIII. Plasma therapeutic concentrationAnswerChoiceAI onlyAnswerChoiceBIII onlyAnswerChoiceCI and II onlyAnswerChoiceDII and III onlyAnswerChoiceEI, II, and IIICorrectAnswerEExplanationClinical pharmacokinetic studies do suggest a strong correlation between plasma concentration and toxicity of tacrolimus. Plasma concentration of tacrolimus should be monitored very closely to avoid toxicity. However, some patients may experience adverse drug reactions despite normal tacrolimus level. Therefore, it is essential to monitor for blood pressure and diabetes following transplantation.CompetencyStmt1.2.3K-TypeKCaseNum214QuestNum2135QuestionThe primary criteria for selecting an immunosuppressive drug is: I. patients risk factors for acute rejection and infection.II. efficacy and safety. III. cost.AnswerChoiceAI onlyAnswerChoiceBIII onlyAnswerChoiceCI and II onlyAnswerChoiceDII and III onlyAnswerChoiceEI, II, and IIICorrectAnswerCExplanationRisk factors of acute rejection, efficacy, and safety of immunosuppressive therapy should all be considered before formulating an immunosuppressive protocol for each individual patient. The focus of an immunosuppressive protocol should be on decreasing the risk of acute rejection and limiting adverse drug reactions. Although the cost is important, cost of immunosuppressive drugs are only 5% of the total cost of transplantation.CompetencyStmt1.1.3K-TypeKCaseNum214QuestNum2136QuestionThe most likely cause of hypertension in this patient is: I. sirolimus.II. tacrolimus. III. prednisone.AnswerChoiceAI onlyAnswerChoiceBIII onlyAnswerChoiceCI and II onlyAnswerChoiceDII and III onlyAnswerChoiceEI, II, and IIICorrectAnswerDExplanationSeveral studies have shown that prednisone and tacrolimus can elevate blood pressure. The long-term effect of sirolimus on blood pressure remains unknown, but recent data indicate that sirolimus has a limited effect on blood pressure. Therefore, only II and III are correct.CompetencyStmt1.2.3K-TypeKeCaseNum214QuestNum2137QuestionWhich of the following clinical tests are used for monitoring sirolimus therapy? I. WBC (white blood counts)II. Sirolimus levelIII. NephrotoxicityAnswerChoiceAI onlyAnswerChoiceBIII onlyAnswerChoiceCI and II onlyAnswerChoiceDII and III onlyAnswerChoiceEI, II, and IIICorrectAnswerCExplanationClinical pharmacokinetic studies suggest a strong correlation between plasma concentration of sirolimus and toxicity. Plasma sirolimus concentrations should be monitored very closely to avoid toxicity. However, some patients may develop hyperlipidemia and neutropenia despite normal sirolimus levels. Nephrotoxicity is not a common complication of sirolimus therapy.CompetencyStmt1.2.3K-TypeKCaseNum214QuestNum2138QuestionWhen monitoring serum concentrations of sirolimus, the recommended range for a trough level is:AnswerChoiceA1-2 ng/mL.AnswerChoiceB10-20 ng/mL.AnswerChoiceC40-50 ng/mL.AnswerChoiceD150-250 ng/mL.AnswerChoiceEgreater than 250 ng/mL.CorrectAnswerBExplanationLike other agents with narrow therapeutic windows, sirolimus levels should be monitored very closely to avoid acute rejection or toxicities. Sirolimus levels should be maintained in a range of 10-20 ng/mL.CompetencyStmt1.2.6K-TypeCaseNum214QuestNum2139QuestionThe most common cause(s) of post-transplant hyperlipidemia is: I. mycophenolate.II. sirolimus.III. prednisone.AnswerChoiceAI onlyAnswerChoiceBIII onlyAnswerChoiceCI and II onlyAnswerChoiceDII and III onlyAnswerChoiceEI, II, and IIICorrectAnswerDExplanationHyperlipidemia developing after heart transplantation is nearly universal, occurring in 70-80% of patients. Although the exact pathogenesis of hyperlipidemia following transplantation is still being determined, several studies have shown that both prednisone and sirolimus are independent risk factors for the development of hyperlipidemia.CompetencyStmt1.3.1K-TypeKCaseNum214QuestNum2140QuestionWhich of the following immunosuppressive drugs is associated with causing gingival hyperplasia?AnswerChoiceACyclosporineAnswerChoiceBTacrolimusAnswerChoiceCMycophenolateAnswerChoiceDBoth cyclosporine and mycophenolateAnswerChoiceECyclosporine and tacrolimusCorrectAnswerAExplanationGingival hyperplasia has been attributed to the use of cyclosporine only. Other commonly used drugs in transplant that might increase the risk of this cosmetic adverse reaction are Nifedipine and Dilantin.CompetencyStmt1.2.2K-Type214 器官移植病人姓名：艾米法拉地址：莫林院西南10号年龄：68 身高：156cm性别：女性 种族：白人体重：57Kg过敏史：可待因主诉转移来自安德鲁医疗中心心源性休克。现病史艾米法拉，68岁，女性，10天前胸痛3小时，出汗，呼吸急促持续3天，运动性呼吸困难，哮喘，端坐呼吸，被诊断患有冠状动脉疾病。检查结果显示，患者心动过速，血压正常，心电图显示R波缺失，心前区无窦性心动过速或T波改变。胸部X线显示肺水肿。最初的CK是505。患者肾功能正常，红细胞比容正常。心脏超声回波图显示房室隔前的暂时性肌麻痹，薄片状凝血。右心室机能减退，严重三尖瓣返流和轻度二尖瓣返流。心脏指数1.4。当心脏移植手术计划时患者已100%非反复呼吸。既往史充血性心力衰竭头颈部牵引轻度帕金森，目前仅用苯海索控制震颤。疝气子宫内膜癌胃食管返流疾病脊柱后凸与侧凸社会史患者独立生活，她嫁入有支持性的家庭。患者活跃，是一位退休秘书。家族史冠状动脉疾病史。整体评价生命体征：体温37.5C，血压最初155/85 mmHg，而后降为110-120/40-60，心率85-90，呼吸音10/10。主动脉内球囊泵1：1，最初患者心脏指数为1.49，注射强心剂后为2.55，心室起搏10，肺动脉楔压22，全身静脉阻力1474，肺循环血管阻力188。体格检查一般情况，随着异丙酚的代谢，患者镇静后很快清醒警觉。插管治疗。头眼耳鼻喉：瞳孔等大心血管：S1S2，球囊泵使心脏音很难评估。肺：两侧基底湿罗音，两侧始终交换。腹部：肠鸣音活跃。腹部柔软。无明显肝脾大。四肢：凉，粉红色。可明显触及到末梢脉搏。无水肿。实验室和诊断检查钠 137 mEq/L 钾 3.6 mEq/L氯 94 mEq/L HCO3 30 mEq/L血尿素氮 28 mg/L肌酸酐 1.1 mg/L镁 2 mg/dL白细胞 7500/mm3血细胞比容 32.7%血小板 158*109/L 诊断心源性休克心脏移植用药记录日期4/34/38/113/113/114/34/34/34/2处方号D246631D456863D245702D256822D248926D240031D340983D320423D429824医师 药物规格西罗莫司 1 mg他克莫司 1 mg泼尼松 5 mg兰索拉唑缓释胶囊 30 mg苯妥英100 mg阿替洛尔 50 mg氨氯地平 5 mg 多维生素注射剂菌丝体数量200300500601001003060140用法2 mg po bid1 mg po bid2 po q am1 po bid300 mg po q hsUd1 po q am2 po qd10 mg po Refills33336633药师记录和其他病人信息新入院心脏移植病人问题1若进行他克莫司的血药浓度监测，推荐的范围是：A：2-3 ng/mL.B：5-15 ng/mL.C：150-250 ng/mL.D：250-500 ng/mL.E：greater than 500 ng/mL.正确答案：B解释：口腔给药约20%由胃肠吸收，他克莫司的血药浓度在血浆和全血中均可以检测到，全血是首选的检测他克莫司浓度的方法。他克莫司的浓度范围是5-15 ng/mL。若高于20ng/mL，会出现肾毒性，神经毒性和糖尿病倾向。2下列哪些药物需要进行血药浓度监测？依木兰类固醇 他克莫司A：，B：，C：I and II，D：II and III，E：I, II, and III正确答案：B解释：他克莫司的浓度范围是5-15 ng/mL。临床药代动力学研究显示，依木兰和类固醇血药浓度与疗效没有直接的相关性。由于依木兰和类固醇具有个体差异性和广泛的治疗指数，所以这两种药物无须进行血药浓度监测。3下列哪些是他克莫司的剂量限制性毒性？肾毒性脱发症 腹泻A：，B：，C：I and II，D：II and III，E：I, II, and III正确答案：A解释：他克莫司药物不良反应的报道有很多。研究显示他克莫司引起药物不良反应与较高的血药浓度有关系。在较低的他