高考申論題
109年
[藥事] 調劑學與臨床藥學
第 一 題
📖 題組：
請閱讀下述案例報告病程描述並回答下列問題： A 71-year-old woman with paroxysmal atrial fibrillation being treated with warfarin 3.75 mg/day presented at the hospital with a 5-day history of increasing swelling in her neck, sialorrhoea, and difficulty swallowing. One week earlier, she had been started on fluconazole 200 mg once a day because of oral candidiasis. She was afebrile. Physical examination showed a large, soft, dark-red swelling on the floor of her mouth: her tongue was displaced superiorly. She had a sublingual haematoma. Laboratory testing showed a C-reactive protein level of 65 mg/L (reference value <5.0 mg/L), a white cell count of 12.510^9 per L with 83.3% neutrophils, and an international normalised ratio of more than 9.0 (reference range 3.0). Coagulation was rapidly corrected with prothrombin complex concentrate and intravenous vitamin K, leading to spontaneous resolution of haematoma over the course of one week while the patient was under close surveillance.
請閱讀下述案例報告病程描述並回答下列問題： A 71-year-old woman with paroxysmal atrial fibrillation being treated with warfarin 3.75 mg/day presented at the hospital with a 5-day history of increasing swelling in her neck, sialorrhoea, and difficulty swallowing. One week earlier, she had been started on fluconazole 200 mg once a day because of oral candidiasis. She was afebrile. Physical examination showed a large, soft, dark-red swelling on the floor of her mouth: her tongue was displaced superiorly. She had a sublingual haematoma. Laboratory testing showed a C-reactive protein level of 65 mg/L (reference value <5.0 mg/L), a white cell count of 12.510^9 per L with 83.3% neutrophils, and an international normalised ratio of more than 9.0 (reference range 3.0). Coagulation was rapidly corrected with prothrombin complex concentrate and intravenous vitamin K, leading to spontaneous resolution of haematoma over the course of one week while the patient was under close surveillance.
📝 此題為申論題，共 3 小題
小題 (一)
列出文中所述及藥品與其用途。（3分）
思路引導 VIP
- 快速掃讀案例內容，圈選出所有出現的藥物名稱，包含長期用藥、近期新增用藥以及急診處置用藥。2. 對照上下文，精準抓出各藥品在該名病患身上對應的適應症或臨床治療目的。3. 條列式清楚呈現「藥品名稱」與「用途」即可穩拿分數。
小題 (二)
說明該年長女士之病程概要與可能原因。（7分）
思路引導 VIP
看到此題應先抓取個案的核心特徵：「高齡」、「Warfarin用藥史」以及「新加入的Fluconazole」。接著運用藥物動力學知識，點出Fluconazole對CYP2C9的抑制作用，推導出Warfarin代謝受阻、INR異常升高，最終導致嚴重自發性出血（舌下血腫）的臨床因果關係。
小題 (三)
分析如何解決與監測此案例之臨床狀況，並闡述藥師角色。（10分）
思路引導 VIP
看到本題，應首要辨識出核心藥物交互作用：Fluconazole 是強效 CYP2C9 抑制劑，導致 Warfarin 代謝受阻，進而引發 INR 爆表 (>9.0) 與嚴重舌下血腫。解題結構應分為三部分：(1) 依據抗凝血指引（如 CHEST）說明急性出血的反轉處置；(2) 列出需監測的實驗室與臨床指標；(3) 凸顯藥師在處方審核、DDI 預防、急救藥物建議及長期替代療法（如 DOACs 轉換）的專業角色。