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CASO CLINICO

RESIDENCIA DE EMERGENTOLOGIA. CASO CLINICO. DRA GABRIELA DIAZ DR EDGAR ORTEGA 19_10_12. CASO CLINICO. EDAD: 68 años Sexo: Masculino MOTIVO DE CONSULTA; sx febril prolongado + sx icterico

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CASO CLINICO

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  1. RESIDENCIA DE EMERGENTOLOGIA CASO CLINICO DRA GABRIELA DIAZ DR EDGAR ORTEGA 19_10_12

  2. CASO CLINICO • EDAD: 68años • Sexo: Masculino • MOTIVO DE CONSULTA; sx febril prolongado + sxicterico • AEA: Paciente refiere sensacion febril de 1 mes de evolucion que no cede con medicacion habitual, tambien refiere perdida de peso de 15 kg aproximadamente. • APP:Tabaquismo • Consumo de alcohol • HTA •  PA: 110/80 FC: 76/min FR18/min T°:38.5°

  3. EXAMEN FISICO • ACV: R1 R2 hipofoneticos, RR, soplo sistolico FM • A RESP:torax normal, simetrico, MV conservado, no rales • ABDOM; plano, depresible, se palpa hepatomegalia a 3cm por debajo del RCD y en Epigastrio, levemente doloroso a la palpacion profunda, RHA + • Piel: presenta ictericia de piel y mucosas ++

  4. LABORATORIO • Hemoglobina 11 • Recuento plaquetario 645.000 • Hematocrito 33.4 % • L: 22 % • N:78 • Electrolitos. Sodio: 137 Potasio: 3.75 • Calcio 8.20 • TP 44 %

  5. LABORATORIO • glucemia, 262 mg/dl • GOT, 48 U/l • GPT, 25 U/l • GGT, 326 U/l • FA, 234 U/l

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