器官移植临床案例二.docx
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器官移植临床案例二.docx
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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
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