caso clinico sx felty
TRANSCRIPT
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Samuel Yucumá Gutiérrez
Residente Medicina Interna
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NOMBRE: B. G. D. L.
EDAD: 62 AÑOS
NATURAL : NEIVA
PROCEDENTE: NEIVA (RURAL)
PROFESIÓN: AMA DE CASA
INGRESO: 17-05-2011 15:30
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“ME HA DADO FIEBRE, DOLOR EN ABDOMEN Y NO HAGO DEL CUERPO”
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Paciente con cuadro clínico de mas o menos 3
meses de evolución consistente en fiebre
subjetiva, asociado a mialgias generalizadas,
además hábito intestinal cada 15 días, flatos (+),
dolor abdominal tipo cólico de leve intensidad,
sin emesis.
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Pérdida de peso
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PATOLÓGICOS: Artritis reumatoide hace 13 años tratamiento empírico. Desde hace 4 años postrada en cama.
QX: (-)
TA: Cocinó con leña durante 40 años.
FAMILIARES: Madre AR.
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TA 100/70 FC 90x FR 18 X T: 36.5
Aceptable estado general, postrada en cama
CC: normal
CP: ruidos cardíacos rítmicos, no soplos, no agregados pulmonares
Abdomen: blando depresible, no doloroso, no masas, no megalias, no irritación peritoneal
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SNC: consciente, alerta, colabora con el examen físico, no signos meníngeos.
Extremidades: no edemas, llenado capilar menos de 2 segundos, deformidad manos y pies secundaria artritis.
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1 SINDROME FEBRIL
2 ARTRITIS REUMATOIDEA SEVERA
3 DOLOR ABDOMINAL
4 CONSTIPACION
5 PANCITOPENIA
NEUTROPENIA FEBRIL A DESCARTAR
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1. HOSPITALIZAR EN OBSERVACION AISLAMIENTO PROTECTOR
2. TAPON HEPARINIZADO
3. CABECERA 30 GRADOS
4. DIETA LIBRE DE CRUDOS
5. OMEPRAZOL 20 MG C/ DIA
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6. RESERVAR 3 UGRE
7. SE SOLICITA GLUCOMETRIA, EKG
8. SE SOLICITA CUADRO HEMÁTICO, FSP, TP, TPT, PCR, VDRL, BUN, CREATININA, LDH, TGO, TGP, ELETROLITOS, TSH, VSG.
9. SE SOLICITA HEMOCULTIVOS NO. 3
10. SE SOLICITA RX TÓRAX PA Y LATERAL
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11. SE SOLICITA ELISA VIH, AGS HB
12. CURVA TÉRMICA C/ 4 HORAS
13. CONTROL SIGNOS VITALES
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18/ 05/ 2011
Se solicita aspirado de médula ósea.
Se solicita Ecografía abdominal total.
Se inicia bisacodilo 5 mg c/ día,
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19/05/2011
Paciente presenta taquicardia (FC 120x), PCR (+), neutropenia, se considera cubrimiento empírico antibiótico.
Cefepime 1 g IV c/ 8 horas.
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20/05/2011
Examen físico se encuentra esplenomegalia, sin hepatomegalia.
Pendiente Ecografia abdominal total
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21/05/2011
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22/05/ 2011
Ecografía abdominal Total:
Colelitiasis
Esplenomegalia moderada homogénea
Imágenes quísticas a nivel de mesogastrio(psedoquistes pancreáticos?).
Se solicita TAC abdomen Simple y contrastado
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22/05/2011
TAC Abdomen Simple y contrastado:
Aumento volumen esplénico
Vesícula biliar distendida, contenido heterogéneo, imágenes indican lesiones líticas en su interior, no dilatación de la vía biliar
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23/05/2011
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23/05/2011
Valoración por Reumatología
24/05/2011
Hemocultivos Número 2 y 3 Negativo.
Valoración por Infectología
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24/05/2011
Biopsia médula ósea
Representación de las 3 líneas hematopoyéticas.
Médula hipercelularidad para la edad.
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25 05 2011
Valoración Infectología:
Síndrome febril resuelto ( no fiebre documentada intrahospitalaria) .
No evidencia de foco séptico claro.
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25 05 2011 Infectología
1. Manifestación sistémica por enfermedad de base.
2. Patología Oncohematológica.
3. Menos probable patología Infecciosa.
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25 05 2011 Infectología
Plan:
1 Observación sin tratamiento antimicrobiano
2 Se sugiere Realizar TAC Tórax
3 Reporte aspirado biopsia de médula ósea
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25/05/2011
Estudio de Tórax límites Normales
Esplenomegalia
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29/05/2011
FACTOR REUMATOIDEO POSITIVO 256.
PENDIENTE VALORACION POR REUMATOLOGIA.
PENDIENTE HOSPITALIZAR.