基本資料：
Dx: ____________ ___________
Disease status: □CR □PR □Refractory
MRD: □ (+) □ (-)
Conditioning regimen: _______________________
移植種類 : □autologous □allogeneic □syngeneic
異體移植 : □sibling □unrelated □family donor □identical twin
幹細胞來源 : □PBSC □BMSC □cord blood
照會
Neurology
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Psychiatry
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Ophthalmology
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ENT (請先照好para-nasal sinus X-ray) 已涵蓋於BMT醫令套餐內
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Dentist (如須進一步處理，如拔牙，請先通知VS)
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Gynecology (女性病患適用)
請加做 FSH, LH, E2, P4，如須保存卵子請告知婦產科
(排卵藥需在月經開始時就給,需入手術室全麻取卵) (自費)
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Urology (男性病患適用)
如需保留精子請聯絡泌尿科門診for sperm analysis and collection (分機: 67590, 67591) (自費)
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Dermatology
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營養師
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[Optional] Radio-oncology:
請詢問VS是否會用Total Body Irradiation (TBI) conditioning
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ENT and Chest exams
Para-nasal sinus X-ray
(如過去有鼻竇炎病史, 或para-nasal x-ray有異常, 請加做sinus CT)
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CXR (PA view)
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Chest HRCT (如病人為lymphoma, 或有liver abscess等病史,
請詢問主治醫師是否改為neck/chest/abd/pelvis CT with/without contrast)
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Lung volume with FRC (standard spirometry) + DLCO
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Cardiac functions
EKG
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Cardiac echo
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[optional] RNA study for LVEF evaluation (如有心臟功能不佳病史,或曾使用多次Anthracycline-based chemotherapy, 請安排)
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GI tract exams
Stool OB
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Abdominal echo
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請確認有無hemorrhoid/ peri-anal pain/ abscess history/fistula
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Transfusion/Immunology
Ferritin, iron TIBC
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ABO and Rh typing (在檢驗項目transfusion/blood type內)
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Anti-A (IgM), Anti-B (IgM) titer
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IgG, IgA, IgM 及 Serum protein electrophoresis (SPEP)
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Hematology
確認病患與捐贈者的HLA ABC/DR/DQ high resolution DNA結果相符
並請單獨記錄成BMT-donor note (含donor姓名、病歷號及HLA data)
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Pre-BMT STR (Auto免做)
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Infections
HBV profile (含HBsAg, anti-HBs, IgG anti-HBc)
若為下列兩種情況1 HBsAg(-)且anti-HBc(-) 2 HBsAg(+)
請加做HBV viral load. Anti-HBe及HbeAg。
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Anti-HCV (如果抗體陽性, 加做HCV RNA viral load)
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HIV (anti-HIV 1/2 screening)
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HTLV 1/2 (Anti-HTLV1/2 Ab qualitative)
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CMV (IgM anti-CMV, IgG anti-CMV, CMV viral load)
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EBV (IgM anti-VCA, IgG anti-VCA, IgA anti-VCA, IgG anti-EA, IgA anti-EA,EBNA Ab, EBV viral load)
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VZV (IgG anti-VZV)
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Serum Aspergillus Ag
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VDRL test (在檢驗項目Immunology/Bacteria內)
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Pan-cultures
Nasal swab culture for bacteria/ fungus
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Throat swab culture for bacteria/ virus/ fungus
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Sputum culture+ Gram stain; Sputum AFS+TB ; Sputum fungus culture
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Urine culture
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Anal swab culture & anal swab VRE
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Stool culture & Clostridium
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Blood culture & Blood fungus culture
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如有wound/水泡,加做wound swab culture for bacteria.fungus/ virus
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Endocrine
TSH. Free T4
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其他重要事項
請詢問病患、家屬，及整理歷次住院病歷後，更新藥物過敏病史。
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移植前衛教: 請通知5PW/ 3D1 護理長安排移植前衛教
(5PW分機: 70533 / 3D1分機: 62415)
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確認病人一周內是否有 CBC / BCS data,若無請加做檢驗。
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與VS討論後，決定是否做disease status evaluation，例如:
(1) Leukemia: BM study, cytogenetics, FISH, flowcytometric MRD,ph(+)->Bcr-Abl,NPM1/FLT3 etc follow up.
(2) Lymphoma: BM study, X-ray, CT, MRI, PET etc
(3) Myeloma: serum IFE, β 2-microglobulin, spot urine EP + IFE, 24-hrs urine κ /λ 定量,serum free κ /λ ratio
如需做Bone marrow study, 請通知BMT or 12D CR (分機: 63629)
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若病患診斷非AML / ALL / CML / AA ,且需作Allo-HSCT,請聯絡主治醫師事前申請移植。
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藥物申請:請詢問VS conditioning regimen是否會用到須事先申請用藥 (ex. Fludarabine,Anti-CD52, BCNU) ,如果是請通知BMT or 12D CR填事前申請書或確認庫存(分機: 63629)
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預備接受sibling-allo-PBSCT, 請聯絡血庫VS羅仕錡確認day0/day1已排程 (分機:65398, GSM 51637)，並請捐贈者確認血管。
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如預計接受自捐血 (during auto-BM-harvest backup in OR) 或尋找HLA-matched PLT, 請通知血庫VS羅仕錡 (分機: 65398, GSM 51637) or 盧先生 (分機: 62151)
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