APRENDIZAJE BASADO EN UN CASO CLINICO

CASE HISTORY

Medical History
In August 2002, an 8-year-old Asian female developed fatigue, fevers, and joint pain with swelling of her wrists and knees. Her family practice physician diagnosed acute rheumatic fever and started her on a course of aspirin and penicillin for four weeks. Her fevers improved, but she continued to have marked fatigue and developed swelling of her eyelids and feet.

Laboratory tests were obtained that showed a sedimentation rate of 120, and urinalysis with 2+ protein and 10-20 red blood cells/hpf. She was referred to a nephrologist who obtained an ANA titer of 1:1260. She was then referred to a pediatric rheumatologist.

Physical Examination

Vital Signs: temperature: 37.8 C (100.04 F), pulse 110, blood pressure 122/82
Skin: no malar rash or other rash noted
Eyes: periorbital edema
Nose: normal
Mouth: no lesions
Nodes: increased cervical and axillary adenopathy
Chest: clear to auscultation, no respiratory distress
Heart: mild tachycardia, no murmurs, gallops, or rubs; pulses all full and equal
Abdomen: non-tender, liver slightly enlarged
Musculoskeletal: joint swelling and tenderness of wrists, left knee and right ankle; pitting edema of lower legs
Neurological: normal reflexes, cranial nerves, and mental status
Laboratory Test Results

White blood count 3.2 (normal >4)
Hematocrit 25% (normal for age >36%)
Platelets 250,000 (normal >150,000)
Erythrocyte sedimentation rate 120 mm/hr (normal <20)
Albumin 2.1 gm/dl (normal 3.5-4/3)
Creatinine 0.9 mg/dl (age-matched normals 0.5-0.8)
ANA 1:1260
Anti-ds DNA 1:640
C3 low at 25 ml/dl (normal 86-130)
C4 low at 3.5mg/dl (normal 15-25)
Urinalysis 2+ protein, 5-10 WBC/hpf, 10-20 RBC/hpf, 5-10 hyaline casts
Urine protein-to-creatinine ratio 2.1 (normal <0.1)


Diagnostico?
Manejo y curso clinico?
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