器官移植临床案例分析一.docx
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器官移植临床案例分析一.docx
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器官移植临床案例分析一
器官移植临床案例分析一
CaseNum213
PtNameHeidiMaryam
Address2202SWSamJackson
Age59
Height6'0"
Weight198lb
SexF
RaceWhite
AllergiesNKDA
SectionNameOrganTransplantation
CaseNameCardiacTransplantation
ChiefComplaintOrthotopichearttransplantation
HxPresIllnessHMisa59-year-oldCaucasianfemalewithahistoryofviralcardiomyopathydiagnosedapproximatelyin1999.Shehashadprogressiveheartfailureoverthepast2yearswithshortnessofbreath,edema,andseverelimitationofactivityandiscurrentlymaintainedondobutamineandnitroprusside.Attemptstoweanoffofherinotropicsupportwereunsuccessful.Patientwaslistedandconsideredforhearttransplantation3weeksago.Pastmedicalhistoryissignificantforseveredepression,gout,andherpeszoster.Afterfindingasuitabledonor,patientunderwenthearttransplantationforviralcardiomyopathy.
PastMedicalHx
Unstableangina
Statuspostcerebrovascularaccident
Anemia
Depression
Ingrownrightfirsttoenail
Gout
Herpeszoster
Ventriculararrhythmia
SocialHxSmokingfor20years
Noillicitdruguse
Marriedwith fivechildren
FamilyHxHermotherandfatherarealive,andshehasnofamilyhistoryofviralcardiomyopathyorMI.
ReviewOfSystemsThepatientdeniesanyfever,chills,backpain,dizziness,weakness,chestpain,shortnessofbreath,orrash.Shedoeshavefatigue.Nosymptomsofgastroesophagealreflux,dysphagia,odynophagia,lowerextremityedema,orgastrointestinalbleeding.Shedoeshaveoccasionallowerextremityparesthesias.Noabdominalbloatingorcramping.Theremainderofherreviewofsystemsisnoncontributory.
PhysicalExamA59-year-oldfemaleinnoacutedistress.Vitalsignsarestable.Bloodpressure158/79mmHg,heartrate93,respiratoryrate20,temperature37.1.Oxygensaturationatroomairis98%.
Postoperativehearttransplantday2
CHEST:
Respirationsareevenandunlabored
LUNGS:
Cleartoauscultation.Noaccessorymuscleusenoted.Noretractionsnoted.
CARDIAC:
S1,S2,irregularrateandrhythmirregular,rubsandsignificantgallops
GI:
Bowelsoundsarepresent.Nomassesororganomegalynoted.
EXTREMITIES:
Thereisnotedlowerextremitypittingedemabilaterally,whichthepatientstatesishernorm.Dorsalispedispulses2+bilaterally.
NEUROLOGIC:
Withoutasterixis.Shehasnofocalneurologicaldeficits.
LabsAndDxTests
Sodium141mEq/L
Potassium4.1mEq/L
Chloride102mEq/L
CO224mEq/L
Glucose99mg/L
Albumin3.7g/L
HCT41%
Hemoglobin10.6g/dL
DiagnosisHearttransplantation
RxRecord
Date
6/1
6/1
6/1
8/10
5/2
5/2
6/1
10/1
10/1
RxNo
D245536
D455537
D244538
D246539
D246555
D246555
D346876
D368654
D468762
Physician
@
@
@
@
@
@
@
@
@
DrugandStrength
Cellcept
Cyclosporine100mg
Prednisone5mg
Prevacid30mg
Zocor40mg
Capoten12.5mg
Zenapax1mg/kg
Tacrolimus1mg
Mycelex
Quantity
100
300
500
60
30
100
@
400
140
Sig
1gpobid
2pobid
2poqam
1pobid
1poqd
1pobid
q14daysforatotalof5doses
2mgpobid
10mgpoqid
Refills
3
2
3
1
6
6
0
6
3
RPhNotesNoneavailable
CaseNum213
QuestNum2121
QuestionWhichtwoagentsactbyinhibitingtheenzymecalcineurin,whichisneededforT-cellactivation?
AnswerChoiceADaclizumabandbasiliximab
AnswerChoiceBTacrolimusandmycophenolatemofetil
AnswerChoiceCCyclosporineandmycophenolatemofetil
AnswerChoiceDTacrolimusandcyclosporine
AnswerChoiceECyclosporineandazathioprine
CorrectAnswerD
ExplanationBothcyclosporineandtacrolimusinhibitTlymphocyteproliferationbyinhibitingcalcineurin.CyclosporineinhibitscalcineurinbybindingtocyclophilinreceptorswhiletacrolimusinhibitscalcineurinbybindingtoFKPB-12.
CompetencyStmt1.2.2
K-Type
CaseNum213
QuestNum2122
QuestionCyclosporinetroughconcentrationsshouldbemonitoredfor:
I.efficacy.
II.toxicity.
III.compliance.
AnswerChoiceAIonly
AnswerChoiceBIIIonly
AnswerChoiceCIandIIonly
AnswerChoiceDIIandIIIonly
AnswerChoiceEI,II,andIII
CorrectAnswerD
ExplanationTherapeuticmonitoringisusedtoavoidtoxicityandtoassessácompliance.Patientswiththerapeuticbloodconcentrationsareatalowerriskofacuterejection.
CompetencyStmt1.1.4
K-TypeK
CaseNum213
QuestNum2123
QuestionToavoidcosmeticsideeffectssuchashirsutism,coarseningoffacialfeaturesandgingivalhyperplasia,cyclosporinecanbereplacedwithwhichofthefollowingagentsinthesameclass?
AnswerChoiceAMycophenolatemofetil
AnswerChoiceBTacrolimus
AnswerChoiceCSirolimus
AnswerChoiceDAzathioprine
AnswerChoiceESimulect
CorrectAnswerB
ExplanationTheadversedrugreactionprofileoftacrolimusissimilartocyclosporine.However,hirsutismandgingivalhyperplasiahavenotbeenreportedwiththeuseoftacrolimus.
CompetencyStmt1.2.4
K-Type
CaseNum213
QuestNum2124
QuestionComparedtocyclosporine,whichofthefollowingstatementsisáNOTtrueregardingtacrolimus?
AnswerChoiceATacrolimusisassociatedwithimprovementin1-yeargraftsurvivalandmortalityrate.
AnswerChoiceBTacrolimushasfewerrejectionepisodes.
AnswerChoiceCRejectionepisodesassociatedwithtacrolimusaremilderandmoreresponsivetocorticosteroids.
AnswerChoiceDTacrolimusisbetteratreversingrefractoryrejection.
AnswerChoiceETacrolimusisextensivelymetabolizedthroughhepaticenzymes.
CorrectAnswerA
ExplanationPatientandallograftsurvivalofkidney,heart,andlivertransplantundertacrolimusprotocolsaresimilartothoseofcyclosporine.
CompetencyStmt1.3.1
K-Type
CaseNum213
QuestNum2125
QuestionWhichofthefollowingtransplantrecipientsappeartobeatgreaterriskfornephrotoxicity?
AnswerChoiceALivertransplant
AnswerChoiceBKidneytransplant
AnswerChoiceCHearttransplant
AnswerChoiceDBonemarrowtransplant
AnswerChoiceELiverandhearttransplant
CorrectAnswerB
ExplanationKidneytransplantpatientsareatagreaterriskofnephrotoxicitycomparedtoothertransplantrecipients.Acutetubularnecrosis(ATN)isacommonproblem(30%)followingtransplantationcausedbyischemicinjury.Olderdonorsandcoldischemictimegreater24hourshavebeenknownasariskfactorforATN.Therefore,dosageadjustmentisrequiredifnephrotoxicitydevelopsinkidneytransplantpatients.
CompetencyStmt1.3.1
K-Type
CaseNum213
QuestNum2126
QuestionWhichofthefollowingagentsisamonoclonalantibodythatinhibitsIL-2receptors?
AnswerChoiceACyclosporine
AnswerChoiceBTacrolimus
AnswerChoiceCDaclizumab
AnswerChoiceDSirolimus
AnswerChoiceEAzathioprine
CorrectAnswerC
ExplanationDaclizumabisahumanizedIL-2receptorantagonistthatcanbeusedtoreduceacuterejectionfollowingtransplantation.
CompetencyStmt1.2.1
K-Type
CaseNum213
QuestNum2127
QuestionWhichofthefollowingagentsconsistsof90%humanand10%murineaminoacidsequences?
AnswerChoiceABasiliximab
AnswerChoiceBDaclizumab
AnswerChoiceCMycophenolate
AnswerChoiceDTacrolimus
AnswerChoiceECyclosporine
CorrectAnswerB
ExplanationDaclizumabisahumanized(90%humanand10%murine)IL-2receptorantagonistthatcanbeusedtoreduceacuterejection.
CompetencyStmt1.2.1
K-Type
CaseNum213
QuestNum2128
QuestionWhichoffollowingisamajorsideeffectofdaclizumab?
AnswerChoiceAHypertension
AnswerChoiceBFlu-likesyndrome
AnswerChoiceCNephrotoxicity
AnswerChoiceDHyperlipidemia
AnswerChoiceENomajorclinicalsideeffectshavebeenreportedwiththeuseofdaclizumab
CorrectAnswerE
ExplanationNomajordrugtoxicitieshavebeenassociatedwiththeuseofdaclizumab.Theoverallrateofinfectionorcancerissimilartotheplacebogroup.
CompetencyStmt1.1.4
K-Type
CaseNum213
QuestNum2129
QuestionWhichofthefollowingstatementsistrueaboutmycophenolatemofetil(MMF)?
AnswerChoiceAMMFisacalcineurininhibitor.
AnswerChoiceBMMFinhibitspurinesynthesisandthusinhibitsDNAandRNAsynthesisofT-andB-cells.
AnswerChoiceCMMFisanIL-2receptorantagonist.
AnswerChoiceDMMFinhibitsm-TORinduction.
AnswerChoiceEMMFisahumanizedIL-2receptorinhibitor.
CorrectAnswerB
ExplanationMycophenolatemofetilisapro-drugofmycophenolaicacidthatblockstheproliferationofbothB-andT-cells.
CompetencyStmt1.3.2
K-Type
CaseNum213
QuestNum2130
QuestionComparedtoazathioprine,whichofthefollowingstatementsisáNOTtrueaboutámycophenolatemofetil(MMF)?
AnswerChoiceAMMFmayhaveagreaterincidenceofgastrointestinalsideeffectsandlymphoproliferativedisease.
AnswerChoiceBMMF3g/dayisbettertoleratedthanazathioprine.
AnswerChoiceCMMFisassociatedwithlessneutropenia.
AnswerChoiceDMMFisassociatedwithaloweruseofantilymphocytetherapy.
AnswerChoiceEMMFisassociatedwithareducedincidenceofrejection.
CorrectAnswerB
ExplanationClinicalstudieswith3g/dayofmycophenolatearelimited.At3g/day,mycophenolateisassociatedwithasignificantlyhigherriskofGIcomplications.
CompetencyStmt1.3.1
K-Type
213器官移植
病人姓名:
海蒂·麦尔彦
地址:
萨姆杰克森2202
年龄:
59身高:
183cm
性别:
女性种族:
白人
体重:
90Kg
过敏史:
无
主诉
常位心脏移植。
现病史
海蒂·麦尔彦,59岁,女性,白种人。
1999年诊断患有病毒性心肌炎,在过去两年内有心力衰竭的迹象,症状包括呼吸急促,水肿,严重的活动受限,目前主要依靠多巴酚丁胺和硝普盐来维持。
尝试弃去收缩器未能成功。
3周前考虑心脏移植。
既往病史有抑郁,痛风,带状疱疹。
在找到合适的供体后,患者实施心脏移植手术。
既往史
不稳定性心绞痛
脑血管中风后遗症
贫血
抑郁
右侧第一指甲内翻
痛风带状疱疹
室性心律失常
社会史
患者已婚,有5个子女,20年的吸烟史,未服用违禁药品。
家族史
她的父亲母亲健在,无关于病毒性心肌炎或心肌梗塞的家族病史。
整体评价
患者无发热,寒颤,背痛头晕,虚弱,胸痛,呼吸急促或疹。
患者有些疲劳。
无胃食管返流,吞咽困难,吞咽痛,下肢水肿或胃肠出血等症状。
她有临时下肢感觉异常。
无腹部胀气或绞痛。
目前遗留重要的问题是无捐献者。
体格检查
女性,59岁,无急性痛。
生命迹象稳定。
血压:
158/79mmHg,心率:
93bmp,呼吸频率:
20rmp,体温:
37.1℃,室内空气氧饱和98%。
移植手术后两天:
胸:
呼吸平稳
肺:
两侧听诊呼吸音清
无副肌肉使用。
无取消记录。
心血管病与营养对照:
S1S2心率不齐节律不规整。
胃肠:
存在肠鸣音。
无器官巨大症。
四肢:
病人正常状态下下肢凹陷性水肿,足背双侧脉搏2+。
神经系统:
无震颤,无神经系统疾病。
实验室和诊断检查
钠141mEq/L
钾4.1mEq/
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