诊疗详细经过
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患者为女性,34岁,诊断为T细胞淋巴瘤 骨髓移植后出现排异反应,以下为住院期间部分病历资料 医嘱单, 打印时间:5月11日12:52 床号/名称/数量/剂量/频次 6324异丙托溴铵2ml(自备)1.000tid已带回 6324硝苯地平控释片30mg(自备)1.000qd已带回 6324乙胺丁醇吸入气雾剂10ml(自备)1.000q6h已带回 6324测手指末梢血糖1.000qd皮下 6324(甲)氯化钠注射液/0.9%50ml/袋50.000mlqd (10%)氯化钾注射液/10ml:1.0g/支 6324(甲)氯化钠注射液/0.9%500ml/袋250.000mlqd (甲)氯化钾注射液/1.0g/10ml/瓶1.500g (甲)硫酸镁注射液/10ml:2.5g/10.000ml 6324(甲)氯化钠注射液/0.9%250ml/袋250.000mlqd (甲)氯化钾注射液/1.0g/10ml/瓶0.500g 632420%中/长链脂肪乳注射液/0.4g:250ml/瓶(0.200gqd) 6324(甲)氯化钠注射液/0.9%250ml/袋250.000mlqd (甲)注射用对氨基水杨酸钠/2g/瓶6.000g (甲)氯化钾注射液/1.0g/10ml/瓶0.500g 6324(甲)葡萄糖注射液/5%250ml/袋250.000mlqd (甲)注射用两性霉素B/25mg/支20.000mg (甲)灭菌注射用水/10ml50/支5.000ml 6324(甲)氯化钠注射液/0.9%100ml/袋100.000mlqd 10%注射用奥美拉唑钠/20mg/盒(10.00%)40.000mg 6324(甲)葡萄糖注射液/5%100ml/袋100.000mlqd 6324(甲)氯化钠注射液/0.9%100ml/袋100.000mlqd (甲)地塞米松磷酸钠注射液/5mg/1ml10/支10.000mg 632410%脂肪乳氨基酸葡萄糖注射液/1000ml/袋(1000.000mlqd) (甲)注射用多种维生素(12)/5ml/支(5.000ml) (甲)氯化钾注射液/1.0g/10ml/瓶3.000g 普通胰岛素10u1.000 伊曲康唑200mgivgqdNS100ml 替加环素50mgivgq12h 6324(甲)氯化钠注射液/0.9%50ml/袋20.000mlq8h (甲)尼可刹米注射液/0.375g1/支5ml/h0.375g
血常规报告 WBC7.50 (3.5-9.5 * 10⁹/L) RBC3.28 (3.8-5.1 * 10¹²/L) HGB109 (115-150g/L) HCT32.10 (35-45%) MCV97.90 (82-100fL) MCH33.20 (27-34pg) MCHC340.00 (316-354g/L) PLT146.00 (125-350 * 10⁹/L) RDW-SD48.60 (37-54fL) RDW-CV14.30 (11.5-14.5%) NEUT#7.09 (1.8-6.3 * 10⁹/L) LYMPH#0.11 (1.1-3.2 * 10⁹/L) MONO#0.30 (0.1-0.6 * 10⁹/L) EO#0 (0.02-0.52 * 10⁹/L) BASO#0 (0-0.06 * 10⁹/L) NEUT%94.50 (40-75%) LYMPH%1.50 (20-50%) MONO%4.00 (3-10%) EO%0 (0.4-8%) BASO%0 (0-1%) RET#44.9 (30-111 * 10⁹/L) RET%1.37 (0.5-2.5%) LFR98.7 (85-98%) MFR1.3 (2-12%) HFR0 (0-2%) IRF1.3 (2-14%) 血常规报告 WBC5.37 (3.5-9.5 * 10⁹/L) RBC2.79 (3.8-5.1 * 10¹²/L) HGB93 (115-150g/L) HCT26.30 (35-45%) MCV94.30 (82-100fL) MCH33.30 (27-34pg) MCHC354.00 (316-354g/L) PLT170.00 (125-350 * 10⁹/L) RDW-SD40.20 (37-54fL) RDW-CV12.50 (11.5-14.5%) NEUT#5.09 (1.8-6.3 * 10⁹/L) LYMPH#0.13 (1.1-3.2 * 10⁹/L) MONO#0.15 (0.1-0.6 * 10⁹/L) EO#0 (0.02-0.52 * 10⁹/L) BASO#0 (0-0.06 * 10⁹/L) NEUT%94.80 (40-75%) LYMPH%2.40 (20-50%) MONO%2.80 (3-10%) EO%0 (0.4-8%) BASO%0 (0-1%) RET#39.9 (30-111 * 10⁹/L) RET%1.43 (0.5-2.5%) LFR94.7 (85-98%) MFR4.3 (2-12%) HFR1.0 (0-2%) IRF5.3 (2-14%) 血常规报告 WBC7.69 (3.5-9.5 * 10⁹/L) RBC3.11 (3.8-5.1 * 10¹²/L) HGB103 (115-150g/L) HCT29.60 (35-45%) MCV95.20 (82-100fL) MCH33.10 (27-34pg) MCHC348.00 (316-354g/L) PLT165.00 (125-350 * 10⁹/L) RDW-SD41.80 (37-54fL) RDW-CV12.70 (11.5-14.5%) NEUT#7.03 (1.8-6.3 * 10⁹/L) LYMPH#0.27 (1.1-3.2 * 10⁹/L) MONO#0.39 (0.1-0.6 * 10⁹/L) EO#0 (0.02-0.52 * 10⁹/L) BASO#0 (0-0.06 * 10⁹/L) NEUT%91.40 (40-75%) LYMPH%3.50 (20-50%) MONO%5.10 (3-10%) EO%0 (0.4-8%) BASO%0 (0-1%) RET#56.3 (30-111 * 10⁹/L) RET%1.81 (0.5-2.5%) LFR94.5 (85-98%) MFR5.5 (2-12%) HFR0 (0-2%) IRF5.5 (2-14%) 血常规报告 WBC10.10 (3.5-9.5 * 10⁹/L) RBC2.86 (3.8-5.1 * 10¹²/L) HGB96 (115-150g/L) HCT26.80 (35-45%) MCV93.70 (82-100fL) MCH33.60 (27-34pg) MCHC358.00 (316-354g/L) PLT157.00 (125-350 * 10⁹/L) RDW-SD40.40 (37-54fL) RDW-CV12.50 (11.5-14.5%) NEUT#9.44 (1.8-6.3 * 10⁹/L) LYMPH#0.32 (1.1-3.2 * 10⁹/L) MONO#0.34 (0.1-0.6 * 10⁹/L) EO#0 (0.02-0.52 * 10⁹/L) BASO#0 (0-0.06 * 10⁹/L) NEUT%93.40 (40-75%) LYMPH%3.20 (20-50%) MONO%3.40 (3-10%) EO%0 (0.4-8%) BASO%0 (0-1%) RET#67.5 (30-111 * 10⁹/L) RET%2.36 (0.5-2.5%) LFR96.8 (85-98%) MFR3.0 (2-12%) HFR0.2 (0-2%) IRF3.2 (2-14%) 血常规报告 WBC9.59 (3.5-9.5 * 10⁹/L) RBC3.25 (3.8-5.1 * 10¹²/L) HGB107 (115-150g/L) HCT32.00 (35-45%) MCV98.50 (82-100fL) MCH32.90 (27-34pg) MCHC334.00 (316-354g/L) PLT73.00 (125-350 * 10⁹/L) RDW-SD52.60 (37-54fL) RDW-CV15.50 (11.5-14.5%) NEUT#8.80 (1.8-6.3 * 10⁹/L) LYMPH#0.45 (1.1-3.2 * 10⁹/L) MONO#0.34 (0.1-0.6 * 10⁹/L) EO#0 (0.02-0.52 * 10⁹/L) BASO#0 (0-0.06 * 10⁹/L) NEUT%91.80 (40-75%) LYMPH%4.70 (20-50%) MONO%3.50 (3-10%) EO%0 (0.4-8%) BASO%0 (0-1%) RET#46.5 (30-111 * 10⁹/L) RET%1.43 (0.5-2.5%) LFR90.8 (85-98%) MFR8.6 (2-12%) HFR0.6 (0-2%) IRF9.2 (2-14%) ******* 患者曾接受异基因骨髓移植,供者为其弟弟。移植完成后一度出院,但随后因严重排斥反应再次入院。 患者处于持续吸氧状态 几天之后患者死亡