APRENDIZAJE BASADO EN UN CASO

A Case of Metabolic Syndrome and Elevated High-Sensitivity C-Reactive Protein: Approach to Management
Autor: Madhuri M. Vasudevan, MD, MPH
CASE
A 60-year-old postmenopausal mexican woman comes to the clinic for evaluation of her medical conditions. She has a 3-year history of hypertension and impaired fasting glucose and reports a gradual 40-pound weight gain after her second pregnancy. Although she has tried multiple diets, she has not had consistent, long-term success with weight loss
Past Medical History: Gestational diabetes during 2 pregnancies, impaired fasting glucose for 3 years and hypertenstion for 3 years
Medications: None
Past Surgical History: None
Family History: Mother diagnosed with diabetes at 45 years of age, father diagnosed with coronary artery disease and diabetes at 54 years of age
Her 26-year-old son and her 24-year-old daughter are both overweight and have never had their cholesterol checked

Diet: Eats fried foods twice weekly. does not restrict meal portions
Drinks at least 24 ounces of sweetened sodas daily. Believes her dietary habits are not that bad when compared to others in her family
Exercise: No regular exercise regimen
Limited by her 8-hr work day and 2-hr daily commute
Social History: Nonsmoker. Occasional alcohol intake (~4 glasses of wine per week)

Vital Signs: Blood pressure = 144/88 mmHg Heart rate = 78
Resting respiratory rate = 12 Temperature = 98.8 °F
Height = 5’6” Weight = 188 lbs
Waist circumference = 36” Body mass index = 30.3 kg/m2
General Appearance: overweight, no apparent distress. Neck: no thyromegaly; no carotid bruits. Cardiovascular: regular rate and rhythm; no murmurs. Extremities: no edema; pulses normal

LAB
Total cholesterol = 226 mg/dL
Triglycerides = 285 mg/dL
High-density lipoprotein cholesterol = 38 mg/dL
Low-density lipoprotein cholesterol = 117 mg/dL
Aspartate aminotransferase = 38 U/L (range 10–35 U/L)
Alanine aminotransferase = 62 U/L (range 6–40 U/L)
Glucose = 116 mg/dL
Non–high-density lipoprotein cholesterol = 174 mg/dL
High-sensitivity C-reactive protein = 6 mg/L (normal limit <2>ANSWER THE QUESTIONS:
According to AHA/NHLBI criteria, how many components of the metabolic syndrome does this patient have?
According to the Framingham 10-year coronary heart disease (CHD)-risk assessment, what is the patient’s risk for developing cardiovascular disease in the next 10 years?
Based on the patient’s risk for coronary heart disease, what is the recommended goal for low-density lipoprotein cholesterol?
What secondary target should be met in a person classified as being at moderate risk for coronary heart disease?
Does the Framingham risk score assessment for coronary heart disease include family history?
Comments about treatment

MARCADORES TUMORALES 1

PANCREATITIS AGUDA

ENSAYO FIBROTEST

Enayo realizado por el Dr. Christian Eduardo Gonzalez Orduña, alumno de la rotación de patologia clinica, modulo Medicina Interna. Departamento de Medicina y Nutrición. Universidad de Guanajuato

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APREDIZAJE BASADO EN PROBLEMAS (CASO CLINICO)

Mujer de 49 años. Desde 2 meses antes del ingreso, nota cansancio progresivo, anorexia y febrícula vespertina ocasional. En las últimas semanas, edema en miembros inferiores hasta rodillas, sensación de tumefacción en ambas manos, disnea de pequeños esfuerzos y aparición de lesiones cutáneas eritematovioláceas en cara anterior de tórax y regiones malares. Acude a su médico quien tras detectar anemia severa remite a la enferma al Servicio de Urgencias.
En la exploración física TA 175/100, Tª 37.6 ºC. Consciente y orientada, palidez de piel y mucosas. Lesiones maculares con componente descamativo en ambas regiones malares. Numerosas adenopatías pequeñas, no dolorosas en regiones laterocervicales, submandibulares y occipitales. Auscultación cardiaca con soplo sistólico multifocal grado II/IV, auscultación pulmonar, abolición de murmullo vesicular en base derecha. Abdomen normal. Extremidades, edema con fóvea (+++) hasta rodillas.

Exploraciones complementarias realizadas en Urgencias:
Hemograma: Htº 24%, Hgb 7.9 g/dl; plaquetas 64.000/mm3; leucocitos 1.450/mm3 (neutrófilos 65%, linfocitos 28%, monocitos 5%, eosinófilos 1%, basófilos 1%).
Frotis de sangre periférica: abundantes esquistocitos, sin otras anomalías relevantes.
Estudio de coagulación: actividad de protrombina 100%, cefalina 25, fibrinógeno 425 mg/dl.
Sodio 142 mEq/l, K 4 mEq/l, glucosa 79 mg/dl, calcio 8.3 mg/dl, proteínas totales 4.3 g/24 h, albúmina 2.2 g/dl, bilirrubina y transaminasas normales. LDH 555 UI/l. Creatinina 1.2 mg/dl.
Sedimento urinario: incontables hematíes con algún cilindro hemático y cilindros granulosos; 8-10 leucocitos por campo. Proteinuria ++++.
En la diuresis de 24 horas recogida en el primer día de ingreso: Proteinuria 5.2 g/24 h. Aclaramiento de creatinina 61 ml/min.
Rx Tórax: Derrame pleural derecho moderado.
Ecografía abdominal : Normal

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