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"note_text": "Se trata de un varón de 48 años, con antecedentes de obesidad, diabetes mellitus tipo 2 controlada con dieta y tabaquismo, que fue diagnosticado de insuficiencia renal secundaria a glomerulonefritis rápidamente progresiva, con anticuerpos antimembrana basal glomerular. Por este motivo, recibió tratamiento inmunosupresor con esteroides, ciclofosfamida y también plasmaféresis, todo ello, sin resultado satisfactorio para su función renal.\n Inicialmente recibió tratamiento renal sustitutivo mediante HD y posteriormente pasó a DP. Durante los 5 años en esta técnica, el paciente desarrolló 10 episodios de peritonitis, 9 de ellos por Staphilococcus (8 epidermidis y 1 capitis). El último de ellos por Candida albicans, que motivó la retirada del catéter de DP y su transferencia a HD. Durante el tratamiento con DP se transformó en un \"alto transportador\".\n Seis meses después del cambio de modalidad terapéutica, el paciente sufre cuadro de dolor abdominal con vómitos, pérdida de peso, distensión abdominal y efecto masa en hipogastrio. Se realizó ecografía abdominal, apreciándose marcada dilatación del estómago y asa proximal del intestino delgado, que presenta pared moderadamente engrosada; colección de líquido con múltiples septos en hipogastrio.\n También se realizó una tomografía axial computorizada (TAC) abdominal, donde se constató la existencia de una pequeña cantidad de líquido perihepático además de periesplénico, con engrosamiento peritoneal, asociada a colección líquida pélvica con septos en su interior que engloba asas de intestino delgado, condicionando gran dilatación gástrica, duodenal y de yeyuno, con niveles hidroaéreos, lo cual condujo al diagnóstico de esclerosis peritoneal.\n \n Por otra parte, al paciente se le propuso tratamiento quirúrgico, que desestimó.\n La evolución fue tórpida, con varios ingresos por cuadros de oclusión intestinal, precisando alimentación parenteral, administración sin éxito de esteroides y progresivo deterioro de su estado, con ascitis y desnutrición que motivaron su fallecimiento a los 6 meses del diagnóstico.\n \n Resultados y descripción\n \n Tenemos una serie de marcadores predictivos de esta entidad, como son el tiempo en DP, el que sea alto transportador, y factores predisponentes como son, el hiperparatiroidismo grave (primer caso) o los episodios de peritonitis de repetición (en el segundo). Hay que tener en cuenta, que más de la mitad de los casos, se producen tras el abandono de la técnica de DP.\n El diagnóstico se efectúa mediante pruebas de imagen: Rx simple, ecografía o TAC abdominal, aunque el diagnóstico definitivo se puede obtener mediante biopsia peritoneal, donde se puede apreciar, un aumento del tamaño de los fibroblastos, depósito de fibrina, angiogénesis capilar, sangrado perivascular e infiltración de mononucleares.\n El tratamiento de este grave cuadro, dependerá del grado de afectación peritoneal. En los estadios iniciales podría ser suficiente el reposo peritoneal; con lavados peritoneales y esteroides. En casos más avanzados se necesitará tratamiento inmunosupresor (ciclofosfamida, azatioprina, ciclosporina) e incluso tamoxifeno. En casos extremos con compromiso visceral, puede ser necesario recurrir a la cirugía, realizando enterolisis, técnica que tiene una mortalidad entre 40-80%.\n Entre las medidas de prevención del desarrollo de la peritonitis esclerosante, cabe destacar la importancia del papel de enfermería en el entrenamiento del paciente para reducir al máximo los episodios de peritonitis y tratarlos adecuadamente de forma precoz; además debemos utilizar soluciones lo más biocompatibles posible, evitando de ese modo altas concentraciones de glucosa. Así mismo, es muy importante el control del hiperparatiroidismo secundario en los pacientes urémicos.\n Finalmente, debemos estar alerta en aquellos pacientes que se convierten en altos transportadores con el paso del tiempo en DP. Por tanto, es conveniente realizar un PET (test de equilibrio peritoneal), al menos una vez al año y tras episodios de peritonitis.\n \n",
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"note_text": "Paciente de 13 años, sin antecedentes patológicos de interés, que viene a la consulta para una revisión odontológica. A los 10 años tuvo que acudir por no exfoliarse el segundo molar temporal izquierdo. Le realizaron una ortopantomografía y observaron que presentaba agenesia del segundo premolar inferior izquierdo y un mesiodens en la arcada superior. Le recomendaron realizarse controles periódicos. En la exploración bucodental de los 13 años se observa la persistencia del molar temporal. El sector anterior está erupcionado correctamente. El mesiodens no ha provocado ninguna anomalía en la posición de los incisivos superiores. En la ortopantomografía se aprecia el mesiodens incluido en una ligera distoversión, con la cúspide localizada entre las raíces del incisivo central y el incisivo lateral superior izquierdo, a nivel del 1/3 medio radicular, y el ápice en la línea media. A los 16 años el paciente acude por presentar una caries en el molar temporal. Solicitamos una nueva radiografía para valorar si se puede obturar el molar, controlar el supernumerario y valorar los cordales. En la ortopantomografía observamos el mesiodens en la línea media, ligeramente más verticalizado, pero sin cambios significativos en su posición respecto a las radiografías anteriores. Decidimos seguir realizando controles periódicos del supernumerario y lo remitimos a cirugía maxilofacial para la exodoncia de los cordales inferiores por presentar falta de espacio para su erupción. Recomendamos la obturación del molar temporal.\n \n",
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"note_text": "Niño de 12 años que acude a su pediatra para una revisión rutinaria. El paciente es un niño sano sin ningún antecedente personal de interés.\n Durante la exploración física, el pediatra detecta un soplo cardiaco sistólico vibratorio 2/6 en borde esternal izquierdo bajo, no irradiado y que se modifica con la postura, con un segundo tono normal y tonos arrítmicos sin relación con la fase respiratoria. Los pulsos periféricos son palpables y simétricos. El resto del examen físico es normal. La tensión arterial se encuentra dentro de los percentiles para su edad y talla.\n El paciente está asintomático; no refiere haber presentado palpitaciones, precordalgia ni síncopes y tiene una buena tolerancia al ejercicio físico.\n En la familia no refieren enfermedades cardiovasculares ni hay antecedente de muerte súbita.\n Ante la presencia de tonos arrítmicos a la auscultación, el pediatra realiza un electrocardiograma (ECG) en la consulta que se muestra en la Fig. 1.\n \n ¿Cuál es la lectura e interpretación del electrocardiograma?1\n Aunque lo primero que nos llama la atención es la irregularidad en el ritmo, empezamos nuestra lectura sistemática comprobando que es un ritmo sinusal (onda P positiva en I y aVF) a una frecuencia de 55 lpm.\n Seguidamente analizamos el eje del QRS siguiendo tres pasos: 1) localizar el cuadrante utilizando las derivaciones I y aVF; 2) encontrar la derivación con complejo QRS equifásico (altura de la onda R similar a la de la onda S) entre las derivaciones de los miembros (I, II, III, aVR, aVL, aVF), y 3) el eje QRS será perpendicular a esta derivación dentro del cuadrante localizado en el paso 1. En nuestro caso: 1) el QRS es positivo en ambas derivaciones por lo que el eje se encontrará entre 0 y 90o; 2) la derivación con complejo más equifásico sería la derivación I, cuya perpendicular es 90o, por tanto el eje QRS está a 90o.\n El eje de la onda T es normal también pues está entre 0 y 90o.\n La duración del complejo QRS es normal (0,04 seg). No observamos morfología de QRS que sugiera alteración en la conducción intraventricular (por ejemplo, ausencia de rR´ en V1) ni hallazgos sugestivos de hipertrofia ventricular.\n La onda T y el segmento ST son normales; no hay alteraciones en la repolarización.\n A continuación analizamos los intervalos PR2: llama la atención que el intervalo PR (desde el inicio de la onda P hasta el inicio del QRS) va variando a lo largo del registro, no es constante. En la Fig. 2 se muestra el trazado en DII a partir del quinto latido del ECG basal: el intervalo PR del primer latido mide 4,5 cuadritos o milímetros (0,04 x 4,5=0,18 seg), que está en el límite superior de la normalidad para la edad, el segundo latido tiene un intervalo PR de 5,5 mm (0,22 seg), el tercero de 6 mm (0,24 seg), el cuarto de 8 mm (0,32 seg), todos ellos por encima del límite superior de la normalidad. Vemos también que después del cuarto latido hay una onda P (marcada con una flecha) que no va seguida de complejo QRS. Este registro electrocardiográfico (intervalo PR que se alarga progresivamente hasta que una onda P no conduce) refleja un bloqueo auriculoventricular (BAV) de segundo grado tipo Mobitz I. El intervalo QTc es normal (0,38 seg).\n \n Ante los hallazgos electrocardiográficos, el pediatra decide remitir al paciente al hospital, a la consulta de Cardiología Pediátrica, para valoración de esta arritmia.\n En la consulta de Cardiología se realizó un ecocardiograma que fue normal, descartando patología estructural. En el nuevo electrocardiograma se observó ritmo sinusal a 60 lpm con un PR alargado (BAV de primer grado), siendo el resto de la lectura sistemática normal. Tras realizar ejercicio leve, con la finalidad de aumentar la frecuencia cardiaca, se repitió el ECG, con normalización (acortamiento) del intervalo PR.\n En resumen, estamos ante un paciente asintomático desde el punto de vista cardiovascular, con un soplo cardiaco de características funcionales, una ecocardiografía normal y un hallazgo casual de BAV de primer grado y de segundo grado en el ECG.\n Para ampliar el estudio se solicitó un Holter-ECG de 24 horas que constató un BAV de primer grado con dos episodios de BAV de segundo grado tipo Mobitz I durante el descanso nocturno.\n \n",
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"note_text": "Paciente varón de 11 años que acude por una contusión en la parte lateral del pie derecho. Durante la exploración, presenta cierta tumefacción sin hematoma y escaso dolor en la cara lateral del pie, siendo el tobillo normal. Al no sospechar fractura, se recomienda inmovilización y reposo físico relativo, además de tratamiento analgésico, indicando control en una semana según la evolución clínica. Transcurrido el periodo de inmovilización, acude a consulta, se retira la inmovilización y, ante la ausencia de sintomatología, se da de alta, retomando su actividad física habitual como portero de waterpolo.\n Al cabo de dos semanas, acude a Urgencias del centro de salud por persistencia de dolor en la cara lateral del pie derecho. Ha estado practicando waterpolo y niega antecedente traumático en este periodo de tiempo. En la exploración destaca la presencia de dolor y tumefacción a nivel proximal del quinto metatarsiano del pie derecho, por lo que se realizan una radiología frontal y otra lateral de dicho pie, informándose como posible fractura de Jones. Posteriormente, es valorado por su pediatra, que observa tumefacción no dolorosa también en el pie izquierdo; al tratarse de un preadolescente que realiza deporte de forma habitual, sin un antecedente traumático conocido, y ante la sospecha de posible apofisitis, decide realizar una radiología bilateral oblicua, que presenta una imagen de fragmentación en la base del quinto metatarsiano de ambos pies. Se diagnostica de apofisitis del quinto metatarsiano, también conocida como enfermedad de Iselin, recibiendo tratamiento analgésico y antiinflamatorio, junto con reposo deportivo hasta la desaparición del dolor.\n \n El paciente ha vuelto a la práctica de su actividad deportiva sin presentar molestias de nuevo.\n \n",
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"note_text": "Paciente de siete años que es llevada a Urgencias por un cuadro de cefalea frontal, fiebre máxima de 40 °C y vómitos de tres días de evolución, asociado a dolor cervical y tumefacción en el ojo derecho en las últimas 24 horas. Presentaba el antecedente de corrección quirúrgica endoscópica de trigonocefalia a los cuatro meses.\n Al ingreso, presentaba frecuencia cardiaca de 137 lpm, frecuencia respiratoria de 25 rpm, tensión arterial de 102/60 mm Hg y temperatura de 36,8 °C. Neurológicamente estaba consciente, orientada y colaboradora, con Glasgow 15/15. Rigidez de nuca con signos de Kernig y Brudzinski positivos. En la región periorbitaria derecha presentaba tumefacción con eritema, calor local y movimientos oculares conservados. Se realizó analítica con leucocitosis 14 500/mm3, neutrofilia 13 900/mm3, linfopenia 390/mm3 y aumento de reactantes de fase aguda: fibrinógeno 881 mg/dl y proteína C reactiva 241 mg/l. Se realizó punción lumbar, tras confirmar normalidad de fondo de ojo, obteniéndose líquido cefalorraquídeo de aspecto turbio, que en el análisis citoquímico mostraba 380 leucocitos/mm3 con un 38% de polimorfonucleares, hipoglucorraquia 41 mg/dl e hiperproteinorraquia 240 mg/dl; en la tinción de Gram no mostró bacterias. En el hemocultivo se aisló S. pyogenes. La tomografía computarizada craneal evidenciaba ocupación parcial de celdillas etmoidales izquierdas y frontales asociada a tumefacción de partes blandas periorbitaria derecha.\n Se inició tratamiento empírico con cefotaxima y vancomicina, suspendiendo este último al aislarse S. pyogenes, y se asoció clindamicina por presentar exantema escarlatiniforme.\n Al séptimo día de ingreso tuvo un episodio convulsivo tónico-clónico focalizado en el hemicuerpo izquierdo que posteriormente se generalizó. Se realizó una resonancia magnética craneal, encontrando una imagen sugestiva de trombosis de vena oftálmica derecha y ocupación parcial del seno cavernoso derecho, así como persistencia de realce meníngeo. Fue tratada con ácido valpróico y dexametasona, y se inició anticoagulación. Posteriormente, la paciente evolucionó satisfactoriamente manteniéndose 21 días de tratamiento antibiótico intravenoso, con controles clínicos, neurológico, electrocardiográfico y mediante resonancia magnética normales y sin secuelas neurológicas.\n \n",
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"note_text": "Adolescente de 16 años que acude por dolor abdominal constante en la fosa iliaca derecha, de 30 horas de evolución, junto con un vómito aislado. En los días previos refiere haber tenido molestias inespecíficas en la pierna derecha sin apreciar edema o calor. La fecha de la última regla fue diez días antes de su visita a Urgencias. La paciente presenta acné, en tratamiento desde hace dos meses con ciproterona 50 mg y asociación de acetato de ciproterona, 2 mg, con etinilestradiol, 35 µg. Sin otros antecedentes de interés.\n En el examen físico únicamente destaca dolor a la palpación profunda en la fosa iliaca derecha, sin signos de irritación peritoneal. Ante la sospecha diagnóstica de patología apendicular, se realiza, una analítica, que resulta normal excepto por el dímero D de alta sensibilidad, con un valor de 9958 ng/ml, y una ecografía abdominal, en la que se observa un aumento de la ecogenicidad del contenido de la vena iliaca común derecha compatible con un trombo de unos 10 cm sin ocupación completa de la luz y que se extiende desde la porción distal de la vena cava inferior hasta la vena iliaca superficial ipsilateral, estando la vena femoral común permeable.\n \n Con el diagnóstico de trombosis de vena cava inferior, se completa el estudio de imagen con una tomografía computarizada (TC) helicoidal de tórax, cuyos hallazgos son compatibles con defectos de repleción en las arterias pulmonares lobares de ambos lóbulos inferiores y en ambas arterias pulmonares principales, sin signos de dilatación del tronco de la arteria pulmonar ni evidencia de dilatación del ventrículo derecho. Los hallazgos radiológicos resultan compatibles con un tromboembolismo pulmonar (TEP) masivo. En la TC abdominal se aprecia la extensión caudal del trombo a la vena cava inferior.\n \n La paciente recibe tratamiento con heparina de bajo peso molecular subcutánea y presenta una evolución clínica favorable. Se realiza un estudio de trombofilia encontrando como única alteración un nivel de proteína S libre antigénica del 19% (valor de referencia normal por encima del 54%).\n \n",
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"note_text": "Niña de diez años que acude a Urgencias por un cuadro de fiebre alta, cefalea y odinofagia de dos días de evolución en tratamiento con azitromicina y en las últimas 24 horas aparición de lesiones genitales muy dolorosas. Ausencia de menarquia, contacto sexual o traumatismos genitales previos.\n A la exploración genital presenta eritema y edema de ambos labios mayores, con úlceras profundas, simétricas, negruzcas, la mayor de ellas de 3 cm de diámetro longitudinal en ambos labios menores y varias lesiones satélites menores perivulvares, recubiertas algunas de material fibrinoide y muy dolorosa a la manipulación. Resto de la exploración sin hallazgos relevantes.\n \n En las pruebas complementarias destaca leucocitosis de 22,38/µl y proteína C reactiva de 138,9 mg/l, con función renal, hepática y sedimento urinario normales.\n Ante una úlcera genital aguda, planteamos el diagnóstico diferencial entre el origen infeccioso, ya sea venéreo (sífilis, virus herpes simple, linfogranuloma venéreo, chancroide) o no venéreo (virus de Epstein-Barr [VEB], citomegalovirus [CMV], Brucella), y el origen no infeccioso (enfermedad de Crohn, síndrome de Behçet, pénfigo vulgar, liquen escleroso, aftosis idiopática, eritema fijo medicamentoso, eritema multiforme)1-3.\n Se ingresa a la paciente con analgesia, lubricante cicratizante y fomentos con suero fisiológico. Ante la evolución tórpida, se añaden al tratamiento antibióticos de amplio espectro, aciclovir IV y corticoterapia oral, en espera de los resultados de los cultivos. El urocultivo, el hemocultivo y el cultivo de exudado vaginal y cervical (para C. trachomatis), así como los frotis de las úlceras genitales, fueron negativos. Las serologías para VEB, CMV, Brucella, Rosa de Bengala, virus de la inmunodeficiencia humana y lúes fueron negativas. Se solicita determinación de ADN del virus herpes simple tipos I y II, mediante reacción en cadena de la polimerasa de la muestra de la úlcera genital, que resultó finalmente negativa.\n Se establece el diagnóstico, por exclusión, de úlcera de Lipschütz en su forma gangrenosa y se decide el alta a los siete días de ingreso, persistiendo las ulceraciones múltiples con pérdida de tejido, sin aspecto inflamatorio y con inicio de cicatrización, en las más externas, sin apreciarse retracción de las mucosas genitales ni secreciones vaginales.\n \n El cuadro estaba casi totalmente resuelto a las siete semanas del diagnóstico.\n \n",
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"note_text": "Presentamos el caso de una niña de diez días de vida, de origen chino, con fiebre de 38 °C de tres horas de evolución, sin otra sintomatología. Alimentada con lactancia artificial. Sin ambiente epidémico familiar.\n Como antecedentes personales, la gestación había mantenido controles normales; fue un parto eutócico sin factores de riesgo infeccioso, no precisó reanimación al nacimiento y las pruebas metabólicas estaban pendientes en ese momento.\n A la exploración física presentaba buen estado general, sin aspecto séptico, siendo normal por aparatos.\n En Urgencias se inicia protocolo de fiebre sin foco en paciente neonatal (analítica sanguínea, urinaria y de líquido cefalorraquídeo normales) y se pauta antibioterapia empírica.\n Permanece afebril desde las 24 horas de ingreso y hasta el alta, sin incidencias salvo por aparición de exantema maculopapular al segundo día de ingreso, que remite de forma espontánea en las siguientes 24-48 horas. Ante la sospecha de viriasis, y una vez que se confirman los resultados definitivos de los cultivos (negativos), se suspende la antibioterapia. Se decide el alta a los 15 días de vida.\n Dos días después, acude al Servicio de Urgencias por un exantema de un día de evolución, generalizado, a expensas de elementos “en diana” con aclaramiento central, sobreelevados y confluyentes. Leve coloración amoratada, más intensa en miembros inferiores, que se borra parcialmente a la presión, sin petequias. Como única clínica acompañante, presentaba deposiciones líquidas escasas.\n \n Se mantuvo en observación durante 24 horas y, ante la no progresión de las lesiones y el buen estado general, se decidió el alta.\n Tras dos días en domicilio, acude nuevamente por shock hipovolémico secundario a un cuadro de diarrea abundante desde 18 horas antes, sin vómitos ni rechazo de tomas. Las lesiones cutáneas habían desaparecido. En el coprocultivo no se aisló germen y la virología fecal fue negativa. Recibió reposición con fluidoterapia intravenosa, que fue retirándose según mejoraba la tolerancia oral con leche hidrolizada y tras descartar afectación intestinal. Las deposiciones mejoraron progresivamente y se dio de alta asintomática.\n En controles sucesivos en consulta ha presentado adecuada ganancia ponderoestatural, con deposiciones de consistencia normal. Mantuvo la alimentación con fórmula hidrolizada durante unas semanas, con posterior tolerancia de fórmula artificial, sin aparición de nuevas lesiones cutáneas.\n \n",
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"note_text": "Niña de tres años de edad que se diagnostica de neumonía con condensación parenquimatosa en lóbulo inferior derecho.\n En los antecedentes personales no hay datos de interés. Embarazo controlado sin incidencias, nacida a las 38 semanas de edad gestacional, cesárea por falta de progresión. Peso al nacimiento de 2870 g. Vacunas y desarrollo psicomotor normal. Refieren desde el primer año de vida que bebe bastantes líquidos, con diuresis abundante. Peso y talla en el percentil 50. Refieren avidez por la sal (se bebe el agua de la playa con avidez y prefiere alimentos salados) y calambres musculares en ocasiones. No hay antecedentes familiares a destacar.\n Peso 12,4 kg (p10-25), talla 95 cm (p50), tensión arterial 100/60 mmHg, frecuencia cardiaca 90 lpm, frecuencia respiratoria 28 rpm, temperatura 38,3 oC. Regular aspecto general por facies febril, decaída y discreta sequedad de mucosas. Cráneo normal. Signos meníngeos negativos. No presenta exantemas ni petequias. Otoscopia y orofaringe normal. A la auscultación se observa una disminución de la entrada de aire en base derecha. Abdomen blando y depresible, no se palpan masas, ni visceromegalias. Genitales normales de niña. Región lumbosacra normal. Resto de la exploración normal.\n En los análisis realizados para valorar parámetros de infección se objetivó leucocitosis de 22 000 con neutrofilia (neutrófilos 87%) y proteína C reactiva (PCR) de 200 mg/l, pero destacaba la hipopotasemia de 2,2 mmol/l con Na 129 mmol/l, Cl 92,2 mmol/l, Ca 9,5 mg/dl, Mg 1,7 mg/dl, Cr 0,5 mg/dl y alcalosis metabólica (pH 7,50 y bicarbonato 24,1 mmol/l). Renina y aldosterona elevadas.\n Se solicitó estudio de orina: densidad 1005, PH 8, sedimento normal. Iones en orina: K 17,5 mEq/l, Cl 10 mEq/l, Na 7 mEq/l; Na orina/K orina 0,4. Excreciones fraccionadas de K elevadas (8,32%), de Na (0,06%) y de Cl (0,11%) en valores de normalidad. Ca/Cr 0,56 mg/mg. Aclaramiento de creatinina normal, filtrado glomerular 104,50 ml/min/1,73m2,\n La ecografía renal fue normal y en el electrocardiograma (ECG) se confirmó la hipopotasemia por prolongación del PR en el ECG.\n Ante el diagnóstico de neumonía basal derecha, se inició tratamiento antibiótico con cefuroxima intravenosa y de modo progresivo fue mejorando clínica, radiológica y analíticamente.\n Ante la sospecha de tubulopatía, dada la hipopotasemia y la pérdida urinaria elevada de este electrolito, se inició tratamiento con suplementos intravenosos de potasio y se corrigieron poco a poco las cifras, siendo al alta el K de 3,9 mmol/l.\n Se controló en consultas de Nefrología Pediátrica, confirmándose la tubulopatía genéticamente (síndrome de Gitelman) y manteniendo adecuados niveles de K sérico con suplementos orales y dieta rica en este electrolito.\n La paciente es portadora de las variaciones p.Gly741Arg y p.Cys994Tyr, ambas en heterocigosis, en el gen SLC12A3, localizado en el brazo largo del cromosoma 16. Transmisión autosómica recesiva.\n Nuestra paciente, desde su diagnóstico, recibe una dieta rica en potasio y magnesio y suplementos orales de potasio. Tras varios años de tratamiento, dada las altas dosis de suplementos orales de K (4,3 mEq/kg/día) para mantener niveles séricos de K 3,1-3,5 mmol/l, se decide asociar al tratamiento diuréticos ahorradores de potasio.\n En ocasiones, coincidiendo con episodios de diarrea y vómitos, presenta hipopotasemia sintomática, que precisa suplementos intravenosos de potasio.\n No hay datos de hipomagnesemia en ningún momento, por lo que no recibe suplementos de magnesio orales, solo una dieta rica en magnesio.\n Se trata de una enfermedad de carácter permanente con evolución y pronóstico favorables si se cumple el tratamiento.\n \n",
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"note_text": "Se trata de una niña de nueve años que acude a la consulta de su centro de salud por una tumoración cervical izquierda de dos días de evolución, sin fiebre. Como antecedente, destaca un traumatismo directo en la misma región una semana antes con el manillar de un patinete. En la exploración presenta una tumoración de 4 cm, blanda y móvil, sin signos inflamatorios adyacentes y dolorosa a la palpación. Es diagnosticada de adenitis laterocervical, iniciando tratamiento con amoxicilina-clavulánico oral.\n Tras una semana es revisada en consulta, persistiendo el dolor y la tumoración, esta vez indurada, sin otros síntomas acompañantes, por lo que es derivada a Urgencias de su hospital de referencia, donde se le realiza una ecografía en la que se visualiza una lesión abscesificada subyacente al músculo esternocleidomastoideo (ECM), decidiéndose su ingreso para administrar tratamiento antibiótico intravenoso. Reexplorando a la paciente, se palpa el músculo ECM izquierdo engrosado en toda su extensión, por lo que se decide repetir la ecografía cervical de forma bilateral. El informe indica la presencia de un engrosamiento del músculo ECM izquierdo con respecto al derecho, con alteración de la ecogenicidad, visualizándose dos focos hipoecoicos intramusculares compatibles con piomiositis, así como la presencia de un absceso subyacente de 1,6 × 2,7 cm.\n \n La paciente permanece en tratamiento intravenoso con cloxacilina y clindamicina durante siete días, presentando una mejoría progresiva de la clínica, y se da de alta en tratamiento con clindamicina oral.\n La paciente es nuevamente revisada en consulta 15 días después, presentando a la exploración la persistencia de la tumoración cervical izquierda, aunque de menor tamaño. Se le realiza una nueva ecografía cervical bilateral donde ya no se observan datos sugestivos de piomiositis, pero sí la persistencia del absceso subyacente al músculo, aunque con una reducción significativa de su tamaño. Se mantiene el tratamiento durante cuatro semanas, presentando buena evolución hasta la total resolución del cuadro.\n",
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"note_text": "Se presenta el caso clínico de una niña de siete años de edad, sin antecedentes familiares de interés, salvo un caso de liquen plano cutáneo en el padre años antes. No hay antecedentes personales de interés, salvo estreñimiento funcional y dermatitis atópica leve. Consulta por lesiones ungueales (piqueteado, líneas transversales, descamación y uñas quebradizas) en algunas uñas de manos y pies, de varios meses de evolución. Sin traumatismo referido. No tiene hábito de chupeteado de dedos. No hay otras lesiones cutáneas ni mucosas. No presenta otra clínica asociada. Refiere una dieta variada, aunque algo deficitaria en frutas.\n \n Exploración clínica normal, salvo por las lesiones ungueales descritas; peso y talla en percentil 50-75.\n Se inició tratamiento con un polivitamínico ante la sospecha de déficit vitamínico, pero tras dos meses seguían las lesiones sin cambios.\n El piqueteado ungueal nos hacía sospechar varias enfermedades como diagnóstico diferencial (eccema, psoriasis ungueal, liquen plano ungueal y alopecia areata), por lo que fue remitida a Dermatología para valoración. Fue diagnosticada inicialmente de sospecha de dermatitis de contacto o lesiones secundarias a atopia. Se descartaron alergias, inclusive a metales pesados y níquel.\n Ante la ausencia de contacto con materiales o productos que le pudiesen causar dermatitis localizada en el lecho ungueal, la ausencia de lesiones de atopia en el momento de la consulta y la persistencia de las lesiones, se realizó estudio analítico para completar el estudio. Se analizó el metabolismo férrico, así como otros posibles déficits nutricionales (zinc, 1-25 hidroxi-colecalciferol, vitaminas B12 y B6), tirotropina (TSH) y tiroxina (T4), resultando todos normales. Se solicitaron también parámetros de autoinmunidad ante la posibilidad de psoriasis ungueal, siendo negativos el factor reumatoide y los anticuerpos antinucleares.\n Ante la normalidad de los resultados analíticos y la persistencia de las lesiones, que hacían sospechar como posibilidades diagnósticas la psoriasis ungueal, sin poder descartar un liquen plano ungueal, o lesiones de eccema ungueal, se inició tratamiento con tazaroteno tópico (un derivado de vitamina A) sobre la lámina ungueal durante tres meses. Evolucionó favorablemente, normalizándose las lesiones ungueales.\n",
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"note_text": "Niña de tres años que acude a Urgencias por presentar desde hace 12 días episodios autolimitados de hipotermia asociados a sudoración fría y palidez cutánea. Ocurren de forma diaria, con duración desde 30 minutos hasta varias horas, siendo más frecuentes durante el sueño. No se acompañan de movimientos tónico-clónicos, desconexión del medio, relajación de esfínteres ni periodo poscrítico. Así mismo no asocia tiritona. Entre los episodios la paciente se mantiene asintomática.\n Entre los antecedentes consta un ingreso a los 6 meses de vida por sospecha de crisis comicial no confirmada, con ecografía transfontanelar y electroencefalograma (EEG) normal. No hay antecedentes de epilepsia familiar. Un tío materno está afecto de migraña.\n A su llegada a Urgencias, presenta exploración física y neurológica normal, con constantes normales, salvo una discreta disminución de la frecuencia cardiaca. En el momento de la exploración no se observa hipotermia, aunque la familia aporta un registro exhaustivo de los días previos, con valores de temperatura rectal de entre 34 y 35 °C.\n Todos los estudios realizados fueron normales (analítica general, gasometría, estudio metabólico y endocrinológico, tóxicos en orina, EEG, resonancia magnética [RM], Holter y ecocardiograma). Después de rehistoriar a la familia, refieren que la niña padece desde hace unos meses episodios de dolor abdominal recurrente, autolimitados, por lo que se añade al estudio una ecografía abdominal, con resultado normal.\n Ante la sospecha de HPE y teniendo en cuenta el alto número de episodios, junto con el antecedente familiar migrañoso, se inicia tratamiento con ciproheptadina. Sin embargo, la paciente rechaza su ingesta, a pesar de lo cual los episodios se autolimitan en el tiempo. A los seis meses del debut, se encuentra asintomática.\n",
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"note_id": "S1139-76322017000200012-1",
"note_text": "Presentamos el caso de una paciente de 12 años que consulta por hiperemia conjuntival y lagrimeo en el ojo izquierdo de una semana de evolución. Entre los antecedentes más destacables constan la alergia a ácaros, el asma bronquial y la rinitis alérgica a tratamiento crónico con budesonida inhalada y terbutalina a demanda. No presenta antecedentes familiares de interés. Se inicia tratamiento antibiótico tópico, acudiendo de nuevo al cabo de cuatro semanas por persistencia de la clínica bilateral, sin secreción purulenta. Durante los siete meses posteriores persiste la sintomatología intermitente a pesar de tratamiento con antihistáminicos orales y oftálmicos, asociando además en los últimos días tumefacción palpebral con fotofobia e hiperemia conjuntival bilateral matutina, sin prurito, estornudos, cuadro catarral ni fiebre. Ante la escasa respuesta a tratamientos habituales, se decide derivar al Servicio de Oftalmología.\n En la exploración oftalmológica se aprecia queratitis bilateral de posible etiología herpética, pautándose terapia antiviral, ciclopléjico y antibiótico tópicos, sin apreciar mejoría. Dada la persistencia del cuadro, se sospecha una queratitis por exposición nocturna secundaria a exoftalmos y se deriva al servicio de endocrinología pediátrica para estudio de función tiroidea, alcanzando el diagnóstico final de hipertiroidismo de causa autoinmune o enfermedad de Graves (EG).\n",
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"note_text": "Niña de 15 meses, de origen africano, a la que se le detecta un genu varo simétrico bilateral llamativo en la revisión de puericultura. No tiene antecedentes médicos ni familiares de interés. Presenta un desarrollo psicomotor normal. Es derivada al Servicio de Traumatología, donde se realiza estudio radiológico confirmándose la alteración en el ángulo metafisodiafisario, con un componente de torsión tibial interna marcado y una alteración del cartílago de crecimiento proximal de la tibia. Se completa el estudio con análisis del metabolismo óseo, siendo los resultados normales. Se inicia tratamiento ortésico inicial sin observarse mejoría tras diez meses de seguimiento, por lo que se decide realizar tratamiento quirúrgico corrector (osteotomía desrotatoria tibial distal y posteriormente osteotomía valguizante proximal) con muy buena evolución. Los controles posteriores son favorables, manteniendo un alineamiento correcto de ambas extremidades.\n \n",
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"note_text": "Paciente de 12 años de edad que acude a consulta por presentar lesiones en el tórax de 0,5 × 0,5 cm, eritematosas, ligeramente descamativas, no pruriginosas. En el brazo presenta otra lesión de características similares, de mayor tamaño, también asintomática. Ante la sospecha de pitiriasis rosada, no se pauta tratamiento y se espera para ver la evolución del cuadro.\n \n A la semana acude de nuevo a consulta, presentando un aumento del número de lesiones, distribuidas por el tronco, el abdomen, el dorso y la región cervical, y respetando la cara, el cuero cabelludo y las extremidades inferiores. Al igual que la semana anterior, las lesiones son asintomáticas.\n Dado la cantidad de lesiones, se decide consultar vía telemática a Dermatología, quienes emiten como diagnóstico más probable una pitiriasis rosada, debido a la probable lesión heraldo del brazo, la descamación periférica en algunas lesiones y la distribución.\n Aconsejan no tratar y nos recuerdan que el cuadro puede durar un total de 6-8 semanas.\n",
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"note_id": "S1575-06202013000200004-1",
"note_text": "Presentamos el caso de un varón español de 28 años de edad, institucionalizado en prisión desde diciembre del 2009 y sin antecedentes de interés salvo asma bronquial en tratamiento con broncodilatadores inhalados. Previo a su ingreso en prisión, residió en el nordeste de Brasil, estado de Ceará, desde marzo del 2008 hasta agosto del 2009, en áreas suburbanas (\"favelas\"). Durante su estancia en Brasil refiere haber consumido agua del grifo y ensaladas frescas y haber caminado descalzo por barro. También refiere haber sufrido un cuadro diarreico autolimitado de origen no aclarado. Doce meses después de su ingreso en prisión inicia un síndrome general marcado con astenia progresiva y adelgazamiento de 10 Kgs de peso, acompañado de mareos, cefaleas ocasionales y sensación dispépsica. Presentó dos episodios de diarrea líquida, acompañados de dolor abdominal y sin presencia de productos patológicos. A la exploración únicamente destacaba una palidez marcada de piel y mucosas. En la analítica, el hemograma mostraba una hemoglobina de 9,4 gr/ dL, un hematocrito de 29,3%, un volumen corpuscular medio de 65fL, leucocitos de 10.900/mm3 (eosinófilos 2.800/mm3), plaquetas 431.000/mm3. Las serologías de VIH, hepatitis B y C fueron negativas. Se derivó para ingreso en su hospital de referencia, donde la bioquímica completa, incluidas pruebas de función hepática y la radiología de tórax, no mostraron alteraciones. Se realizaron estudios de parásitos en heces en 3 muestras consecutivas por la técnica de concentración con éterformol, observándose la presencia de huevos de uncinarias. La serología para Strongyloides stercoralis fue positiva mediante técnica de ELISA con una titulación de 0.6 unidades de densidad óptica. Se pautó tratamiento con albendazol 400 mg/12 horas (d.u) e ivermectina 200 microgramos/Kg/día dos días consecutivos junto con sulfato férrico oral durante 3 meses.\n A los 3 meses del tratamiento se observó una recuperación de todos los parámetros hematológicos y negativización tanto del análisis coproparasitológico de los parásitos intestinales como de la serología para Strongiloydes stercoralis.\n \n",
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"note_text": "Mujer de 67 años de edad portadora de prótesis de rodilla y con antecedentes de colecistectomía y herniorrafia umbilical, que acude a consulta por presentar tumoración en región geniana izquierda de unos 2 años de evolución, que ha ido disminuyendo de tamaño muy lentamente. La única sintomatología referida es la derivada del tamaño del tumor.\n En la exploración se aprecian dos tumoraciones, aparentemente independientes entre sí y de la parótida, de unos 2 ó 3 cm, móviles, bien definidas y de consistencia elástica.\n Se realiza PAAF preoperatoria que muestra un frotis con cuadro citológico sugestivo de tumor mixto de glándula salival. Dado que en la exploración la tumoración se localiza, en principio, independiente de la parótida y en una localización poco frecuente para un adenoma pleomorfo, se decide realizar RNM. Esta evidencia una lesión ocupante de espacio en partes blandas de la mejilla izquierda, de señal homogénea, hipointensa en T1 y marcadamente hiperintensa en T2. Esta imagen es compatible con linfangioma, que en su parte craneal se extiende hasta la altura del límite superior de la órbita y desciende en contacto con el borde externo del masetero hasta la altura de la cavidad bucal donde lo bordea anteriormente y se introduce medialmente contactando con el maxilar superior y la pared externa del seno maxilar.\n \n Tras realizar preoperatorio, se practica la intervención mediante un abordaje intraoral. Al incidir la mucosa se observa una formación que se hernia, y que resulta fácil de separar de los tejidos circundantes mediante disección roma. El resultado final nos muestra una tumoración de 2 x 7 cm, de aspecto quístico y forma tubular arrosariada.\n \n El estudio anatomopatológico de la pieza extirpada muestra macroscópicamente una formación elongada, cilíndrica, de unos 11 x 1,7 cm cubierta por una cápsula con vasos prominentes en superficie y estructuras cilíndricas adheridas a la formación principal. Al corte presenta áreas de aspecto fibroso denso, hialinizado, alternando con zonas de aspecto más laxo. El estudio microscópico reveló una proliferación de células con citoplasma eosinófilo, de bordes mal definidos, con núcleos fusiformes con sus extremos elongados, que se disponen en haces adquiriendo a veces un aspecto serpenteante de las células. No se observan figuras de mitosis. La tumoración presenta zonas más densas que alternan con otras mucho más laxas, contiene vasos de paredes a veces hialinizadas, en general finas y algunas dilatadas quísticamente. La tumoración aparece bien delimitada y en la cápsula se observan fascículos nerviosos, algunos con comienzo de proliferación. El diagnóstico anatomopatológico definitivo fue el de neurofibroma plexiforme.\n En nuestro caso no encontramos ningún hallazgo clínico ni antecedente personal ó familiar sugestivo de neurofibromatosis tipo I ó de síndrome poliglandular MEN III (MEN IIb) y parece confirmar que las lesiones aisladas son independientes de estos síndromes.\n En la actualidad, dos años después de la intervención, la paciente no ha presentado ningún signo de recidiva tumoral en las sucesivas revisiones.\n",
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"note_text": "Mujer de raza blanca, 80 años de edad, sin antecedentes personales de interés, que acudió a nuestra consulta por presentar disfagia progresiva de un mes de evolución. A la exploración se objetivó la existencia de una induración eritematosa, parcialmente ulcerada, en el dorso de la lengua dolorosa al tacto. No se objetivó, a la palpación, la presencia de adenomegalias, ni de otras masas cervicales. Se efectuó una biopsia incisional cuyo estudio histopatológico evidenció la existencia de una proliferación uniforme de células linfoides compatible con un linfoma. La analítica preoperatoria (hemograma, bioquímica) y radiografía de tórax, no mostraron alteraciones significativas. Bajo anestesia local se procedió a la exéresis de la tumoración con amplios márgenes de seguridad.\n Microscópicamente, el infiltrado linfoide ulceraba la superficie epitelial infiltrando, en profundidad, la musculatura lingual. Alrededor de este infiltrado se podían reconocer múltiples folículos linfoides; algunos mostraban centros germinales reactivos con histiocitos tipo cielo estrellado (starry-sky); otros mostraron cambios regresivos en los centros germinales con depósitos de sustancia eosinófila homogénea. Todos estaban rodeados por un importante infiltrado perifolicular compuesto por pequeñas células linfoides con núcleos ligeramente irregulares y acúmulos de cromatina moderadamente densos similares a los centrocitos de la zona marginal. También se pudo reconocer la existencia de numerosos histiocitos y eosinófilos. Ocasionalmente algunas células de gran tamaño, con varios nucleolos prominentes, se entremezclaban con las células pequeñas formando columnas de centroblastos e inmunoblastos. También podía reconocerse la existencia de una importante diferenciación plasmocitoide, predominante en la zona paraseptal y subepitelial. En los bordes de la tumoración, se observaba la existencia de lóbulos, parcialmente conservados, de glándulas salivales menores de tipo mucoso, mostrando una destacada infiltración linfoidea. Los conductos salivales estaban dilatados e infiltrados por células B con formación ocasional de islas epimioepiteliales. También se podían reconocer, abundantes células plasmáticas alrededor de los conductos glandulares. El estudio inmunohistoquímico se efectuó sobre secciones congeladas y fijadas en formalina y parafina, utilizando el método estreptavidina-biotina. Se emplearon los siguientes anticuerpos: CD20, CD3, CD5, CD10, CD23, CD43, DBA44, CD68, inmunoglobulinas α, γ, µ de cadena pesada y κ, λ de cadena ligera. Las células centrocíticas, mostraron un fenotipo B, con positividad para CD20, CD5 y CD43. CD10, CD23 y DBA44 fueron negativos. También se evidenció la presencia de una pequeña proporción de células T, con positividad para el CD3. Las células plasmáticas en las bandas paraseptales y subepiteliales y también las de los conductos de las glándulas mucosas, mostraron producción de inmunoglobulina IgG/κ. El diagnóstico definitivo fue de linfoma MALT. Las alteraciones morfológicas de las glándulas salivales menores próximas al tumor, se interpretaron como sialoadenitis mioepitelial.\n La paciente no sufrió otras manifestaciones de enfermedad como síndrome de Sjögren, artritis reumatoide diseminada, lupus eritematoso, o tiroiditis de Hashimoto. El linfoma se consideró por lo tanto en un estadio IE. La paciente no ha recibido ningún tratamiento salvo el quirúrgico, sin presentar signos de enfermedad al año del diagnóstico.\n",
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"note_text": "Mujer de 52 años con sintomatología otica y craneofacial referida con otalgia izquierda, tinitus bilateral, vértigo, sensación de oído tapado bilateral y dolor bilateral a nivel de cuello y cuero cabelludo en zona izquierda. Al examen otorrinolaringologico no se encuentra patología localizada en oído, nariz o garganta. La paciente presenta compromiso músculo-esquelético con resentimiento muscular local en zonas de: pterigoideo externo bilateral, temporal bilateral, digastrico vientre posterior, esternocleidomastoideo bilateral, esplenio bilateral, occipitofrontal en zona izquierda. Se encuentran puntos gatillo en músculo trapecio bilateralmente. La paciente reporta dolor al masticar y dolor al tragar alimentos duros. También relata odontalgias fantasmas en zona de molares mandibulares izquierdos sin patología dental evidente al examen, igualmente describe dolor tipo hiperalgesia secundaria en cuero cabelludo lo que hace pensar en un posible componente neuropatico de su queja. Reporta sabores agrio-amargos periódicamente con sensación de quemadura en paladar. Se palpan los procesos hamulares, encontrando dolor intenso local del lado izquierdo y referido a oído y zona mandibular izquierda a la palpación. Se programa la infiltración de la zona hamular izquierda con corticoide sintético (Betametasona - suspensión de 4 mg) previa anestesia local. La paciente también fue manejada con dispositivo intraoral para la supresión de la actividad muscular como tratamiento del DTM y la sintomatología otica referida 1 mes posterior a la sintomatología de la Bursitis Hamular. Se ha controlado la paciente durante 18 meses sin recurrencia de la sintomatología. La presentacion clinica del compromiso músculo-esqueletico y otico, adicional al dolor en zona del proceso hamular y posible relacion concomitante pueden tener la misma base fisiopatologica del caso clínico anterior.\n \n",
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"note_id": "S1698-69462006000400014-1",
"note_text": "Paciente varón de 20 años que acude a consulta solicitando una solución estética para su frente anterior. Durante sus 5 primeros años de vida fue sometido a 3 intervenciones quirúrgicas para conseguir el cierre de tejidos blandos de labio y paladar.\n A la exploración extraoral se podía observar una asimetría del labio superior debido a las diversas operaciones a las que fue sometido en la infancia.\n En la exploración intraoral se pone de manifiesto una evidente malposición y maloclusión dentaria así como distintas agenesias dentales (15,12,11,25,34,33 y 44) y discrepancia maxilo-mandibular. Apreciándose también una gingivitis moderada por falta de control de placa.\n \n Vemos que el paciente presenta una grave dismorfosis maxilo-mandibular que aconsejaba la realización de un tratamiento ortodóncico previo a cualquier toma de decisión de tipo prostodóncico. El caso fue consultado al especialista en ortodoncia y este planteo la necesidad de una cirugía ortognática previa al tratamiento protético. Se le explicó al paciente y este se opuso a someterse al tratamiento quirúrgico.\n Analizado los hábitos higiénicos del paciente y observando una clara deficiencia en su control de placa, se opta por realizar una prótesis fija sobre coronas telescópicas, facultativamente removible, lo cual, por un lado mejorará el control de placa por parte del paciente, cuestión fundamental para el pronóstico del tratamiento, y por otro lado se cumple la necesidad de ferulización de la arcada a ambos lados de la fisura palatina.\n Las coronas telescópicas como sistema prostodóncico de doble corona permite realizar una ferulización cruzada de la arcada dentaria (en nuestro paciente se limita a la zona anterior del maxilar), lo cual va a permitir una estabilización de los dientes a largo plazo. El concepto de doble corona y el diseño intrínseco de las mismas hace que la transmisión de las fuerzas masticatorias sean lo más favorable al diente ya que estas se van a producir siempre en sentido axial al eje del diente. La posibilidad de que el paciente pueda retirar la estructura secundaria hace más fácil la higiene de los dientes pilares sobre todo si se compara con la dificultad de limpieza de un puente fijo convencional, esta circunstancia fue uno de los principales motivos por el que optamos en nuestro paciente para realizar el tratamiento con coronas telescópicas, ya que la higiene del paciente no era del todo satisfactoria, tal y como hemos mencionado anteriormente.\n Desde el primer momento se informa al paciente que el resultado estético y funcional no va a ser el idóneo, cuestión que en todo momento entiende y acepta. Previo al tratamiento prostodóncico se realizó la exodoncia del resto radicular del diente 13 y una vez cicatrizada la herida se procedió a realizar el tratamiento definitivo. Este consistió en la preparación de los dientes pilares 15, 21,22,23 y 24, realizando tallados convencionales para coronas telescópicas. Cabe resaltar el importante tallado que hubo que realizar a la corona del diente 21, para poder conseguir el paralelismo entre pilares, cuestión ésta que es de crucial importancia en todos los trabajos con coronas telescópicas.\n Posteriormente se procedió a la toma de impresiones y registros intermaxilares para que con los modelos obtenidos se confeccionen en el laboratorio las cofias primarias. Estas son probadas en la boca del paciente en donde se verifica su correcto ajuste para a continuación tomar una segunda impresión \"de arrastre\" que nos posiciona las cofias primarias con respecto al resto de estructuras de la boca del paciente. Obteniéndose un nuevo modelo donde van a ser confeccionadas las coronas secundarias que conforman la prótesis fija facultativamente removible. Esta estructura secundaria es probada en la boca del paciente en donde se comprueba tanto el ajuste como la relación oclusal.\n \n Una vez seleccionado el color se procede a su terminación y colocación. El resultado final, que se aprecia en la imagen, podemos ver un resultado que desde nuestro punto de vista es simplemente aceptable, pero que el paciente valoró como muy satisfactorio, quizás debido a, lógicamente, al estado inicial que presentaba el paciente y que el creía imposible de mejorar, y a la predisposición favorable que el paciente presentó en todo momento.\n \n El caso ha sido revisado a lo largo de cinco años consecutivos y a pesar del mal control de placa por parte del paciente, que no hemos conseguido que adquiera unos hábitos adecuados de higiene, los pilares de la prótesis están en perfecto estado y tanto el confort y la estética para el paciente siguen siendo satisfactorias. De esta manera se pone de manifiesto el correcto funcionamiento de los tratamientos con coronas telescópicas a medio y largo plazo siendo una posibilidad que siempre debemos tener en cuenta a la hora de planificar nuestros tratamientos, sobre todo en pacientes con un mal pronóstico de sus dientes ya que el comportamiento biomecánico de las coronas telescópicas hace que la supervivencia a largo plazo de estos dientes sea prolongada.\n \n",
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"note_text": "Mujer de 56 años que acude a consulta para extracción de un resto radicular. Durante la exploración clínica se descubren múltiples lesiones papulares en encías, con tendencia a confluir, que adquieren aspecto de empedrado. La mucosa labial inferior tiene una disposición coarrugada y en la lengua aparecen gran número de pápulas que confieren a ésta, aspecto moriforme. En la mucosa yugal aparece una lesión polipoide que extirpamos a la vez que realizamos una biopsia de la encía cuyo resultado es hiperplasia inflamatoria y la lesión de la mucosa yugal, pólipo fibroepitelial.\n \n En la anamnesis la paciente refiere haber sido operada de bocio en dos ocasiones, así como de quistes mamarios bilaterales. Padece ulcera gástrica, esofagitis y pólipos en el colon.\n En varias ocasiones le han extirpado lesiones cutáneas en brazos y en la plantas de los pies.\n Ante esta patología tan florida solicitamos la historia clínica al archivo central de nuestro hospital de referencia y realizando un resumen de ésta, a la enferma se le han extirpado nódulos coloides en tiroides, se ha operado en dos ocasiones de enfermedad fibroquística de la mama, presenta ulcus gástrico y en varias ocasiones se le han extirpado por vía endoscópica pólipos gástricos y de colon.\n Las lesiones extirpadas del brazo resultaron ser hiperplasias reactivas inflamatorias de Ackerman, y la de los pies verrugas plantares.\n Ante estos hallazgos realizamos el diagnóstico de afectación oral de Síndrome de Cowden.\n \n",
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"note_text": "Presentamos el caso de un varón de 33 años con antecedentes personales de ansiedad, por lo que sigue tratamiento con escitalopram 10 mg y alprazolam 0,5 mg. Exfumador desde hace 6 meses.\n Acude a urgencias de Atención Primaria refiriendo \"asfixia\", sensación de falta de aire y de cuerpo extraño faríngeo. A la exploración presenta buen murmullo vesicular sin ruidos sobreañadidos, saturación de oxígeno 98 %. A la inspección de la faringe presenta una úvula con prolongación filiforme y en su base una lesión papilomatosa engrosada.\n \n Se tranquiliza al paciente y se le explica la patología. Se aconseja valoración por su médico de familia, quien deriva al otorrinolaringólogo (ORL). Se le realizó cribado de otras patologías de transmisión sexual con resultados negativos para infección por sífilis, virus de inmunodeficiencia humana, herpes y hepatitis.\n El ORL le diagnostica de poliposis senonasal izquierda con remodelación ósea, desviación del tabique nasal, ensanchamiento del infundíbulo del seno maxilar y úvula con formación papilomatosa en su base y engrosamiento de la misma. Se interviene y desde Anatomía Patológica informan de un papiloma invertido en el seno nasal y la lesión en úvula como papiloma escamoso.\n Actualmente el paciente ha mejorado notablemente tanto por la sintomatología nasal a la que no hizo referencia hasta llegar al ORL como por la sensación de cuerpo extraño.\n En este caso en particular sería interesante poner en conocimiento que el paciente no mantiene buena relación con su médico de familia porque en su opinión no le trata bien su clínica ansioso-depresiva. El paciente suele acudir a consulta cuando su médico esta saliente de guardia o de vacaciones; de hecho el tratamiento antidepresivo y ansiolítico no fue instaurado por su médico, haciendo complicado el seguimiento de su patología. El paciente no comentó nada sobre la congestión que le provocaba la poliposis nasal por el mismo motivo. La relación que tiene con su médico de familia también ayuda a explicar por qué acude a urgencias por una consulta que realmente no es aguda. Tampoco podemos descartar que sus síntomas hayan pasado desapercibidos por los facultativos relacionándolos con la ansiedad.\n \n",
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"note_text": "El 23 de agosto de 2011 el médico de Role 1 informa al Medical Advisor de la Operación European Union Training Mission (EUTM) Somalia que la prueba de \"quick test\" realizada a una de las enfermeras del Role 2 ha resultado positiva. Por lo que se va a proceder a su traslado de forma urgente al Hospital Nakasero en Kampala situado a 400 km aproximadamente por carreteras en muy malas condiciones. La decisión de cómo realizar el traslado no depende de EUTM-Somalia, el Role 2 puede decidir de forma independiente al estar éste contratado por EUTM-Somalia. El personal del Role-2 tiene su propio seguro sanitario. Quiere decir que, pueden gestionarse sus propias evacuaciones e ingresos en hospitales. Al igual que cuentan siempre con la ayuda y colaboración del Cuartel General EUTM-Somalia.\n Los síntomas alarmantes que llevan a sus compañeros a realizar el Quik test es un síndrome agudo pseudo-confusional, asociado a cansancio, cefalea, y fiebre de más de 38oC. Al parecer, en las horas posteriores a la confirmación del diagnóstico se suman antecedentes que la paciente no había revelado hasta ese momento: astenia en los últimos quince días, cefaleas, diarrea y un cuadro aparentemente infeccioso que la paciente había comenzado a automedicarse con antibiótico del tipo amoxicilina y ácido clavulánico. Como antecedentes médicos la paciente sufría de migrañas.\n El personal de este Role 2 permanecía en zona por periodos largos de más de un año (con un mes de descanso cada seis meses de estancia aproximadamente), lo que ha llevado en muchos casos al abandono de forma voluntaria de la quimioprofilaxis (Lariam®, Malarone® o Doxiciclina).\n Se decide realizar el traslado de la paciente por carretera con ambulancia procedente de Kampala y se informa al Medical Advisor que el ingreso será en el hospital Nakasero de Kampala. A las 12 horas aproximadamente del diagnóstico la paciente ingresa en el citado Hospital y pocas horas más tarde entra en coma. Ya entonces se estaba gestionando la aeroevacuación a Italia. Dado el estado avanzado de la enfermedad la paciente es aeroevacuada por la compañía de \"Flying Doctors\" a Nairobi dos días más tarde. Tras su ingreso en el hospital de Nairobi su evolución persiste muy desfavorablemente falleciendo pocas horas después al cuarto día de su diagnóstico inicial.\n Se puede pensar que una de las causas de la rápida y mala evolución de la enfermedad de nuestra compañera fue debido a un diagnóstico e inicio del tratamiento tardíos, la falta de inmunidad adquirida de la paciente y el abandono de la quimioprofilaxis que pudo ayudar al plasmodium a una reproducción e invasión rápida.\n \n El Medical Advisor\n Durante todo este proceso y como es habitual, el Medical Advisor informa en cada momento al Jefe de Estado Mayor y éste mantiene informado al Jefe de la Mision, quien a su vez transmite todo lo que acontece en nuestra Misión en Uganda al Cuartel General en Bruselas. La preocupación de Bruselas se hace evidente. Asimismo el Medical Advisor informa al Mando de Operaciones (CMOPS) y al Instituto de Medicina Preventiva de la Defensa (IMPDEF) para que se informe a la mayor brevedad posible a la Inspección General de Sanidad.\n Tras esta amarga experiencia, cobra mayor relieve la figura del Medical Advisor en Uganda, una de cuyas funciones es la de recordar a todo el contingente desplegado en la misión las enfermedades de riesgo en la zona, les aconseja e instruye sobre la prevención de dichas enfermedades y sobre las medidas higiénico-sanitarias a tomar para prevenirlas. En relación a la Malaria se remarca lo importante que es tomar la quimioprofilaxis, además de llevar a cabo medidas defensivas que todos conocemos para evitar la picadura del mosquito como:\n 1. Utilizar repelente de insectos de tipo dietiltoluamida, de aplicación en zonas expuestas sobre todo desde las 18 p.m. a las 05 a.m.\n 2. En el exterior utilizar ropa de manga larga y pantalón largo. Incluso impregnar el uniforme con permetrina.\n 3. Disponer de mosquiteras en las ventanas de las habitaciones. Malla mosquitera impregnada en permetrina en la cama, que se mantenga bien tensada y metida por debajo del colchón, y que nunca se apoye en el suelo.\n 4. En el interior de la habitación utilizar insecticidas para el cuarto.\n Se les informa y recuerda continuamente que para evitar un desenlace fatal con la malaria es fundamental el tratamiento precoz y, para ello es fundamental que adviertan al médico del Role 1 (en Bihanga o Kampala) de cualquier síntoma que se presente, en general \"cuando uno se encuentre mal\". Se dice que cuando aparece fiebre en zona endémica de malaria \"hay que pensar como primera opción en esta enfermedad\". Es muy importante tener en cuenta este principio pero, no hay que olvidar además, todos los síntomas que pueden aparecer en la malaria: cefalea, dolor de garganta, astenia intensa, escalofríos, sudoración, náuseas, diarrea y vómitos. Estos, son síntomas comunes a otras afecciones frecuentes en la zona como es el caso de la gastroenteritis, por lo que el paciente puede no darles importancia. Se debe insistir en la necesidad de consultar con el médico de la presencia de cualquiera de ellos.\n Durante la misión, el Medical Advisor viaja a la capital de Kenya para informarse de las prestaciones y servicios de los hospitales que allí se encuentran. Así mismo se informa sobre el protocolo que siguen para el diagnóstico y tratamiento de la malaria. Todos ellos coinciden en el tratamiento precoz de la enfermedad, siendo suficiente la presencia de síntomas clínicos aunque el diagnóstico microscópico sea negativo. En la mayoría de los casos se utiliza Artemether 20mg/Lumefantrine 120mg cuatro unidades cada 12 horas durante 3 días. En el Cuartel General de Kampala, se trataron dos casos sospechosos de malaria, sin diagnóstico evidente al microscopio. La evolución fue muy buena.\n Otra medida de prevención que se tuvo en cuenta, fue luchar contra el vector. Se visitaron varias compañías expertas en la lucha contra el vector de la malaria y se pidió estudio para la desinfección del Campamento de Bihanga. En el Cuartel General de Kampala se desinfecta una vez al mes dentro de las habitaciones y en el exterior más próximo, incluyendo toda la vegetación que allí se encuentra.\n La desinfección completa del Campamento de Bihanga es más complicada, al estar rodeado de zonas verdes muy extensas y de una zona de vida de los militares de Uganda y sus familias que no reúnen las condiciones higiénico sanitarias suficientes para la lucha contra el vector, y el plan de desinfección implicarían medidas que precisaría de la autorización de los militares Ugandeses.\n \n Se realizó un estudio por parte de la compañía experta para la desinfección dentro de las viviendas, medidas para evitar que entren mosquitos en el interior, drenaje de charcas y desecación de colecciones de agua estancada, además de eliminación de vegetación que pueda favorecer el desarrollo de larvas. Todo ello en un radio mínimo de un kilómetro.\n \n La misión del Medical Advisor en Uganda terminó sin haberse decidido sobre muchas de las medidas anteriores. Al no poner ningún país Europeo un Medical Advisor que reemplace al anterior, todos estos temas quedan abiertos y pendientes de que se tome una decisión por el nuevo Jefe de la Mision, asesorado por el Jefe de Estado Mayor y los estudios realizados.\n En las Figuras 1 y 2 se observan las condiciones de las viviendas de las familias de militares Ugandeses muy próximas a la zona de vida de los europeos. Debieran tratarse y cerrar ventanas y puertas con mosquiteras para una correcta desinfección y eliminación del vector.\n La Figura 3, nos da clara idea de la cercanía de las viviendas de militares europeos (con tejados azules) y las viviendas de militares ugandeses (construcciones propias de la zona).\n \n",
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"segment": "Por lo que se va a proceder a su traslado de forma urgente al Hospital Nakasero en Kampala situado a 400 km aproximadamente por carreteras en muy malas condiciones. La decisión de cómo realizar el traslado no depende de EUTM-Somalia, el Role 2 puede decidir de forma independiente al estar éste contratado por EUTM-Somalia. El personal del Role-2 tiene su propio seguro sanitario. Quiere decir que, pueden gestionarse sus propias evacuaciones e ingresos en hospitales. Al igual que cuentan siempre con la ayuda y colaboración del Cuartel General EUTM-Somalia.\n ",
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"note_text": "Un oficial afgano de 30 años de edad fue evacuado al ROLE 2 de Herat desde el ROLE 1 de Farah por una herida por arma de fuego en la región inguinal derecha. Entre los antecedentes personales destacaba una estenosis traqueal por un disparo por arma de fuego sufrido años atrás. En el ROLE 1 se realizó una exploración de la herida y se colocó un shunt de Argyle de 10F en la arteria femoral, tras constatar una pérdida de substancia que afectaba al 80 % de su circunferencia, 10 centímetros por debajo del pliegue inguinal, con lo que se consiguió revascularizar el miembro y cohibir la hemorragia. Durante su ingreso requirió 8 concentrados de hematíes, 9 de plaquetas y 1 de factores de coagulación. A su llegada a ROLE 2 estaba intubado. Los valores de presión arterial fueron 13/7, la frecuencia cardíaca era de 74 latidos por minuto y no se constató fiebre. En la analítica destacaron una plaquetopenia de 67.000 y un INR de 1´4, aunque no existía acidosis y el lactato era normal. La extremidad estaba caliente y sin palidez ni cianosis, pero no se palpaban pulsos distales. El estudio radiológico no demostró la existencia de fracturas. Por ello, y dada la dificultad para trasladar al paciente a un centro de referencia, se decidió realizar una exploración de la herida. El orificio de entrada, de 1 cm de diámetro, se hallaba en el tercio medio de la cara externa del muslo, y el de salida, en la cara interna, cerca del canal de los aductores. El lecho de la herida estaba exangüe y no había compromiso venoso. La arteria femoral se hallaba seccionada en un 80% de su circunferencia. Seguidamente, se realizó una incisión en la cara interna del muslo contralateral hasta disecar la vena safena mediante disección roma y electrocoagulación. Tras la ligadura de las colaterales y de ambos extremos se obtuvo un injerto de 4 cm, el cual fue irrigado con una solución de suero salino heparinizado para evidenciar la ausencia de fugas. Tras ello, se procedió a la disección y exposición del tramo arterial afectado y se inició la anticoagulación sistémica con 3.000 UI de heparina, teniendo en cuenta el valor elevado del INR y la plaquetopenia. Se liberó de forma controlada el clampaje de los cabos arteriales para evacuar los posibles trombos neoformados y se aplicó suero heparinizado. Se colocó el injerto venoso de modo invertido y se suturó de forma continua con Prolene de 5/0. Se comprobó la presencia de pulso distal pedio y tibial posterior con ultrasonidos y se lavó copiosamente la herida con suero salino. El tejido subcutáneo se cerró con Vicryl de 3/0 recubriendo la arteria reconstruida. Durante su estancia en la Unidad de Cuidados Intensivos se comprobó cada hora la presencia de pulsos distales con ultrasonidos, así como temperatura y aspecto del miembro, sin observarse ninguna anomalía hasta el traslado del paciente a las 24 horas de su ingreso. La analgesia se controló con fentanilo y dipirona. Se administró cefazolina 1 gr cada 8 horas y se mantuvo la anticoagulación con 25.000 UI de heparina en 500 cc de suero a 500 unidades por hora.\n \n",
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"note_text": "Paciente varón de 42 años sin alergias conocidas y con antecedentes personales de desprendimiento de retina bilateral y paladar hendido. Valorado en consultas de Traumatología por traumatismo casual sobre dorso de mano derecha. En la exploración se observa eritema y tumefacción en dorso de mano a nivel de cabeza de 4o metacarpiano, dolor leve a la palpación de estructuras óseas y una marcada limitación para la flexión completa de la articulación metacarpofalángica de 3o y 4o dedos. El paciente manifiesta que dicha limitación es anterior al traumatismo en varios años. Presenta similar limitación en la mano contralateral que afecta a los mismos dedos, 3o y 4o.\n \n Se solicita una radiografía simple de ambas manos, donde se objetiva la ausencia de lesión traumática ósea en zona de contusión, y como hallazgo radiológico, la presencia de aplanamiento de las cabezas metacarpianas 3a y 4a en ambas manos, con lesión espejo en la base de sus falanges correspondientes, lo que da un aspecto «cuadrado» a la articulación.\n \n Se pauta tratamiento para la contusión (reposo, crioterapia y toma de AINEs) y se le cita en dos semanas para una exploración funcional no alterada por el dolor.\n A las dos semanas, el paciente refiere mejoría completa de su proceso traumático. Se observa disminución del arco de movilidad metacarpofalángico en ambas manos (valores normales: extensión 0-20o y flexión 0-90o) consistente en pérdida en la mano derecha de los últimos 30o de flexión en el 3o dedo y de los últimos 25o en el 4o. En la mano izquierda tan solo se aprecia la pérdida de los últimos 20o en la flexión del 3o y 4o dedos (coincidente con una menor afectación radiológica en esa mano). Pese a la afectación radiológica de más articulaciones, no objetivamos déficit de movilidad en ninguna otra.\n No tiene dolor actualmente, ni lo ha sufrido en el pasado, siendo su queja principal la limitación que presenta en actividades que requieren formar un puño con la mano.\n \n Diagnóstico: enfermedad de dieterich\n",
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"segment": "Presenta similar limitación en la mano contralateral que afecta a los mismos dedos, 3o y 4o.\n \n Se solicita una radiografía simple de ambas manos, donde se objetiva la ausencia de lesión traumática ósea en zona de contusión, y como hallazgo radiológico, la presencia de aplanamiento de las cabezas metacarpianas 3a y 4a en ambas manos, con lesión espejo en la base de sus falanges correspondientes, lo que da un aspecto «cuadrado» a la articulación.\n \n ",
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"segment": "A las dos semanas, el paciente refiere mejoría completa de su proceso traumático. Se observa disminución del arco de movilidad metacarpofalángico en ambas manos (valores normales: extensión 0-20o y flexión 0-90o) consistente en pérdida en la mano derecha de los últimos 30o de flexión en el 3o dedo y de los últimos 25o en el 4o. En la mano izquierda tan solo se aprecia la pérdida de los últimos 20o en la flexión del 3o y 4o dedos (coincidente con una menor afectación radiológica en esa mano). Pese a la afectación radiológica de más articulaciones, no objetivamos déficit de movilidad en ninguna otra.\n No tiene dolor actualmente, ni lo ha sufrido en el pasado, siendo su queja principal la limitación que presenta en actividades que requieren formar un puño con la mano.\n \n Diagnóstico: enfermedad de dieterich\n",
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"note_text": "Exponemos los efectos de un programa de ejercicio en una paciente (55 años, 58 kg, 158 cm y 22,83 kg/m2), jubilada por incapacidad física, con MG grado III de 2 años de evolución, con marcada debilidad muscular, especialmente cervical (necesitaba sujetar con las manos su cabeza cuando comía o cuando se iba a tumbar) y que, a nivel dorsal, le causaba una actitud cifótica. Había recibido tratamiento con plasmaféresis, Prograf® e Inmurel® y durante el programa de ejercicio tomaba Ciclosporina® (500 mg/15días), Dacortin® (5 mg/24 h), Escitalopram® (10 mg/24 h), Mestinon® (60 mg/8 h), Lanzoprazol® (30 mg/24 h), Lexatin® (1,5 mg/24 h) y Calcium Sandoz D® (1.000 mg/880 UI/24 h). No se le había practicado timectomía aunque su situación era de eutiroidismo con presencia de nódulos tiroideos y además padecía osteoporosis. Tras ser informada dio su consentimiento por escrito para su participación en el estudio. El diseño y realización de esta investigación respetaron las recomendaciones éticas de la Asociación Médica Mundial y la Declaración de Helsinki y fue aprobado por el comité de Ética de Asociación Miastenia de España (AMES).\n Programa de ejercicio y valoraciones efectuadas\n El programa de ejercicio se inició el 20 de junio de 2012 y concluyó el 17 de julio de 2012 y consistió en la realización de 2 sesiones matinales semanales. Los componentes de cada sesión consistían en ejercicios de Pilates suelo, ejercicios de fuerza para los grupos musculares de bíceps, tríceps, pectoral y dorsal ancho, mediante contracciones auxotónicas, con banda elástica de dureza baja (Domyos® Villeneuve D'Ascq. Francia), ejercicios de propiocepción de tobillo con pelota 100% de FOAM de 16 cm (Gui-an S.L. Servicios Deportivos®, San Sebastián de los Reyes, Madrid), ejercicios de flexibilidad (ejercicios pasivos asistidos de cuádriceps, isquiotibiliales, sóleo, cuadrado lumbar, dorsal ancho, trapecios, esternocleidomastoideo, tríceps, deltoides y pectoral) y ejercicios de facilitación neuromuscular propioceptiva (PNF) asistidos por un fisioterapeuta profesional (isquiotibiales, cuádriceps, cuadrado lumbar, dorsal y trapecios). Durante las sesiones de ejercicio se monitorizó la frecuencia cardíaca (FC) para evitar que esta aumentase más de 30 pulsaciones por minuto (ppm).\n \n Al inicio y al final del estudio se midieron: peso (kg), talla (cm) mediante báscula con tallímetro (modelo PS10®DINA, Derio, España), FC en reposo, en ejercicio y a 1 y 3 minutos de recuperación mediante pulsímetro (modelo M22 Polar®, Helsinki, Finlandia) y presión arterial (PA, en mmHg) mediante tensiómetro (modelo M2 BASIC OMRON HEALTHCARE®, Hoofddorp, Holanda). En cada sesión de ejercicio se determinaron la temperatura y la humedad ambientales mediante un termómetro-higrómetro-barómetro-altímetro-cronómetro digital modelo AT701-H® (Atech Navigator, Hirschau, Alemania). Para valorar el ejercicio realizado se midió el tiempo de ejercicio completado.\n A la paciente se le practicaron, al inicio y al final del programa, los siguientes test:\n -Caminata de 6 minutos (Six-minute Walk Test, 6MWT)11, la distancia recorrida se midió mediante un podómetro modelo Dista Newfeel 100® (Oxylane, Madrid, España)\n -Dinamometría manual: se midió la fuerza máxima ejercida por la paciente al instante y la fuerza resistencia (aquella que aplica el sujeto durante 10\" con cada mano, manteniendo el brazo estirado y presionando la perilla del dinamómetro tanto como se pueda) en ambos miembros superiores12,13. Para evitar que la fatiga alterase los resultados, se instruyó a la paciente un día y se realizó la prueba al siguiente. Ambas variables se midieron en kg mediante un dinamómetro de precisión 100 g (modelo SH50008 Squeeze Saehan Corporation®, North Lincolnshire, Inglaterra).\n -Flexibilidad de tronco, extremidades superiores e inferiores14: la paciente se sentó al borde de una silla de 44 cm de altura. Una pierna permanecía flexionada con la planta del pie apoyada en el suelo. La otra estirada lo máximo posible, con el talón en contacto con el suelo y el pie en flexión de 90o. Espalda y cabeza erectas. La mano derecha colocada encima de la izquierda, con los terceros dedos superpuestos. Se invitó a la paciente a alcanzar la punta del pie con las manos mientras se expulsa el aire. Se realizó un intento con cada pierna. Se permitió una familiarización previa al test. El resultado es la máxima distancia alcanzada (cm), mantenida durante 2\", medida con cinta antropométrica (Clase I modelo CM040 Gisibérica®, Cáceres, España).\n -Flexibilidad de extremidades superiores14: la participante se colocó en bipedestación, con una de las manos por encima del hombro, con el codo apuntando hacia arriba, los dedos extendidos con la palma de la mano hacia la escápula e intentando deslizar esta lo máximo posible a lo largo de la espalda. Al mismo tiempo, se colocaba la otra mano detrás de la espalda, con el dorso hacia la zona dorsal, intentando alcanzar o sobrepasar la otra mano. Se realizó un intento con cada brazo. Hubo una familiarización previa al test. El resultado es la mínima distancia (cm) alcanzada entre los terceros dedos de ambas manos, mantenida durante 2\", medida mediante cinta antropométrica (Clase I modelo CM040 Gisibérica®, Cáceres, España).\n -Fuerza de las extremidades inferiores: se midió el número de sentadillas realizadas en 30\" con las manos cruzadas sobre el pecho14. Se ha utilizado una silla de 44 cm de altura y un cronómetro (modelo AT701-H® Atech, Hirschau, Alemania).\n Para valorar la percepción del estado de salud se le aplicó el cuestionario de Percepción del Estado de Salud y Calidad de Vida SF-36 validada para español por Alonso et al.15.\n Los resultados de los test funcionales y del test de Percepción del Estado de Salud, SF-36, obtenidos al inicio y tras realizar el programa de ejercicios, se muestran en las tablas 2 y 3 respectivamente.\n \n",
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"note_text": "Mujer de 47 años, sin hábitos tóxicos ni alergias conocidas a fármacos, ni enfermedades médicas relevantes. Acudió al hospital en enero de 2010 por presentar dolor en tobillo derecho de un año de evolución, que aumentaba con la carga y se acompañaba de signos flogóticos. Se realizó una gammagrafía ósea y una RMN que objetivó un intenso edema óseo con severa pérdida de densidad mineral, sugestivo de osteonecrosis del astrágalo con derrame articular asociado. Se inició tratamiento con pamidronato intravenoso, pero la paciente presentó fiebre alta tras la infusión por lo que se suspendió su administración. Se pautó tramadol, diclofenaco y tratamiento rehabilitador, sin evidente mejoría del dolor. En septiembre de 2010 refiere dolor intenso en región inguinal derecha, que aumentaba con la deambulación. Se realizó una RMN de ambas caderas observándose una necrosis avascular de la cabeza femoral derecha, estadío I-II de la clasificación de FICAT. Se inició tratamiento con gabapentina oral (600 mg/8 horas), y se remitió a la unidad de metabolismo óseo. En la exploración física en nuestra consulta llamaba la atención la presencia de escleras azuladas. Reinterrogada la paciente, señalaba que su madre había presentado múltiples fracturas desde los 49 años, que la mantenían inmovilizada. Un hermano y dos tías maternas también habían padecido fracturas de cadera precoces. La densitometría mostró una osteoporosis grave en las tres localizaciones habituales (columna lumbar: T-score=-3, Z-score=-1,8; cuello femoral: T-score=-3,1, Z-score=-2,3 y cadera total: T-score=-2,7, Z-score= -2,0). La calciuria era de 336 mg/dl, los niveles de 25(OH) vitamina D de 11 ng/ml y la PTH intacta, de 49 pg/ml. Los marcadores de remodelado óseo estaban elevados de forma franca (CTX: 1,036 ng/ml). Dados los hallazgos clínicos y los antecedentes familiares, se estableció el diagnóstico de osteogénesis imperfecta tipo I. La audiometría mostró una mínima caída en los tonos agudos. Se inició tratamiento con calcio (1.000 mg/día), vitamina D (800 UI/día) y risedronato (35 mg/semana), en enero de 2011. En marzo de ese año, se cambió el risedronato por teriparatida subcutánea (20 mcg/día) debido a intolerancia digestiva. En mayo de 2011, una RMN de control mostró una franca disminución del edema óseo y del derrame articular del tobillo así como del edema medular en la cadera derecha. La paciente cumplió 24 meses de teriparatida sin complicaciones y con progresiva mejoría clínica. Los marcadores de formación se mantuvieron elevados durante el tratamiento (propéptido aminoterminal del procolágeno tipo 1 -PINP-: 45 ng/ml; osteocalcina: >100 ng/ml), así como los niveles de 25(OH) vitamina D. En marzo de 2013 se inició tratamiento con denosumab (60 mg/6 meses), presentando la paciente una evolución clínica y radiológica satisfactoria. En la última consulta, en enero de 2015, los marcadores de remodelado estaban suprimidos (PINP: 5,8 ng/ml; telopéptido carboxiterminal del colágeno tipo 1 -CTX-: <0,030 ng/ml) y los niveles de 25(OH) vitamina D son de 31 ng/ml. La densidad mineral ósea (DMO) de control no se redujo significativamente respecto a la basal (columna lumbar: T-score=-3,1 y Z-score=-1,5; cuello femoral: T-score=-3,2 y Z-score=-2; cadera total: T-score=-3 y Z-score=-2), pero la paciente no había sufrido ninguna fractura ni osteonecrosis en el seguimiento.\n \n",
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"note_text": "Paciente mujer, de 68 años de edad, sin antecedentes patológicos de interés, que consultó por episodios repetidos de dolor e inflamación en ambas rodillas, atribuido hasta entonces a un proceso degenerativo, y que mejoraban con antiinflamatorios no esteroideos. Durante los últimos dos años también había presentado dolor en ambas muñecas y raquis cervical, de características mecánicas. No refería haber padecido episodios de diarrea ni vómitos, no consumía diuréticos ni ningún otro tipo de fármacos.\n La exploración mostraba a una paciente con buen estado general, normohidratada, con una presión arterial de 120/80 mmHg. Del resto de la exploración destacaba el dolor y la limitación a flexo-extensión de la rodilla derecha con maniobras meniscales positivas, sin signos de derrame articular. En las manos mostraba signos degenerativos en articulaciones interfalángicas distales sugestivas de nódulos de Heberden.\n En la analítica, el hemograma y fórmula fueron normales; los análisis bioquímicos mostraron los siguientes resultados: urea, 37 mg/dl; creatinina, 0,71 mg/dl; filtrado glomerular, >60 mL/min/1,73m2; calcio total, 9,45 mg/dl; fosfato inorgánico, 3,51 mg/dl; fosfatasa alcalina, 56 U/L; sodio (Na), 140 mEq/l; potasio (K), 3,4 mEq/l; TSH, 3,45 mUL; PTH plasma, 2,9 pmol/L (1,6-6,9); 25-hidroxicolecalciferol, 30,9 ng/ml (30-100); fosfatasa alcalina ósea, 9,7 ug/L; magnesio (Mg), 0,54 mmol/L (0,66-0,99). En orina de 24 horas: proteinuria negativa; calciuria, 69,56 mg (100-250); fosfaturia, 588,30 mg; Mg, 1,31 mg/dL (1,7-5,7); fosfato en primera orina de la mañana, 15,9 mg/dL (40-136). Los reactantes de fase aguda, factor reumatoide, anticuerpo anticitrulinado y anticuerpos antinucleares (ANA, anti-ENA) fueron normales o negativos.\n El estudio radiológico mostró calcificaciones de los meniscos de ambas rodillas con signos degenerativos añadidos, de sínfisis púbica, ambos carpos, en cartílago hialino de coxofemorales y también en metatarsofalángicas de primer dedo de ambos pies.\n \n La resonancia magnérico nuclear (RM) de rodilla derecha mostraba severos signos degenerativos de artrosis fémoro-rotuliana, fémoro-tibial interna y externa, con rotura degenerativa de ambos meniscos.\n Se solicitó estudio genético molecular mediante amplificación PCR y secuenciación del gen SCL112A3, detectando homozigosis de la mutación c2576T>C(p.L859P) en el exón del citado gen y que confirmaba el diagnóstico de síndrome de Gitelman.\n El tratamiento fue de suplementos orales de magnesio a dosis variables según resultados analíticos de seguimiento, y colchicina 0,5 mg al día para evitar los episodios de pseudogota que venía padeciendo la paciente.\n \n",
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"note_text": "Mujer de 26 años con ERC secundaria a glomerulonefritis proliferativa extracapilar tipo I. Fumadora activa, Hipertensa aunque no precisa tratamiento farmacológico actualmente. Presenta enfermedad de Darier cutánea.\n Recibió 14 sesiones de plasmaféresis tras su diagnóstico en 2006. Posteriormente abandonó las revisiones en consulta y finalmente acudió por urgencias 3 años después en situación de uremia terminal iniciando diálisis.\n La paciente da consentimiento expreso para la exposición de su caso.\n Historia del acceso vascular\n • Varios intentos de Fístula Arteriovenosa (FAV), todos ellos infructuosos: FAV radio-cefálica izquierda en 01-2009, húmero-cefálica izquierda en 03-09, radio-cefálica derecha en 04-09 y húmero-cefálica derecha en 05-11. Se le realizó un mapa vascular en el que no se evidenció ninguna vena apta en MMSS.\n • Catéter venoso permanente yugular derecho, implantado el 14/01/09 y retirado el 05/11/09 por Endocarditis Tricuspídea secundaria a MARS.\n • Varios catéteres temporales en ambas venas femorales retirados por trombosis o disfunción.\n • Catéter permanente yugular izquierdo colocado el 16/11/09 y retirado el 21/06/10 por trombosis de la vena yugular izquierda.\n • Catéter permanente femoral derecho colocado el 21/06/10 y retirado 4 días después por disfunción persistente.\n • Tras ello se le realizó un estudio endovascular que mostraba oclusión completa de vena iliaca izquierda y de cava inferior, lo que inhabilitaba los accesos femorales. En lo que respecta a los troncos superiores la situación no es mejor pues existe oclusión de venas subclavias, yugular derecha, tronco braquio-cefálico izquierdo y cava superior. Ante esta situación se colocó catéter permanente por abordaje transhepático a través de vena suprahepática derecha, con extremo en aurícula derecha9. Se recambió el 03/07/2012 por disfunción. Desde entonces ha sufrido continuas infecciones que han obligado a instaurar tratamiento antibiótico casi de manera continua.\n • En 12/2012 sufre extrusión espontánea colocándose catéter femoral provisional izquierdo.\n • Se le realizó nuevo estudio de troncos venosos encontrando oclusión de vena iliaca con desviación del flujo por rama hipogástrica hasta iliaca común, de modo que no es subsidiaria de catéter de diálisis permanente por este acceso. La vena femoral común derecha se encontró permeable pero no se detectó flujo doppler en vena iliaca, probablemente por trombosis. Se realizaron flebografías de ambos brazos encontrando que el flujo va por colaterales a intercostales hasta acigos-hemiacigos de forma bilateral debido a la oclusión de las venas subclavias. Se descartó colocar un catéter por subclavia. Se realizó ecografía doppler de ambas yugulares visualizando la vena yugular izquierda permeable aunque es muy probable estenosis central del tronco braquiocefálico venoso izquierdo dada la flebografía de ese miembro y la vena yugular derecha ocluida crónica (no visible en la ecografía).\n • El 17/01/2013 se le implantó nuevo catéter transhepático que fue recambiado el 20/03/2013 por disfunción. Este es su acceso actual y probablemente el único posible.\n A todos estos problemas vasculares que ponen en riesgo su supervivencia se suma la situación social complicadísima que vive la paciente, ya que no recibe ningún apoyo familiar y se encuentra totalmente desmotivada presentando en la mayoría de ocasiones un comportamiento rebelde y de rechazo a cualquier cambio en sus opciones de tratamiento, hecho que dificulta enormemente la labor de enfermería en el ámbito de educación para la salud.\n Cabe reseñar que la paciente rechaza iniciar cualquier tipo de tratamiento anticoagulante (se le ha propuesto tomar sintrom® en muchas ocasiones).\n Por otra parte se descartó su inclusión en la lista de trasplante al no acudir a las reiteradas citas, autoexcluyéndose además como candidata a diálisis peritoneal dada su negativa a cumplir con las pautas de tratamiento propuestas por el personal médico y de enfermería.\n En las figuras 1 y 2 se muestra el acceso actual de la paciente: el catéter transhepático.\n \n Cuidados de enfermería\n En cada sesión se informa a la paciente de los cuidados que debe tener para cuidar al máximo su AV haciendo especial hincapié en la importancia de mantener el apósito seco y limpio y de informar al personal de enfermería acerca de cualquier incidencia que note, especialmente si aparece dolor o calor en la zona de inserción y fiebre.\n Todo el equipo de enfermería cumple con los protocolos de cura del orificio de salida del catéter, conexión y desconexión según los criterios aceptados en nuestra unidad de diálisis:\n • La cura del orificio de salida del catéter (OSC) se realiza de forma aséptica con cloruro sódico al 20%, clorhexidina alcohólica al 2% y gasas estériles, observando de forma exhaustiva la zona para detectar precozmente la aparición de eritema, secreción, etc. Después se cubre el orificio con un apósito estéril.\n • El sellado de las ramas del catéter se realiza con Taurolock® y tapones tipo luer-lock. Desde el último recambio del catéter transhepático en la primera sesión de diálisis semanal se sella con Urokinasa 50.000 UI/rama como terapia fibrinolítica intraluminal según protocolo de nuestra unidad.\n Se valora el funcionamiento adecuado del catéter en cada sesión de hemodiálisis alcanzando flujos sanguíneos adecuados superiores a 300 ml/min y Kt mayor de 45 L.\n En la figura 3 se muestran los datos obtenidos de las sesiones de diálisis desde enero de 2013.\n \n",
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"note_id": "S2254-28842015000400011-1",
"note_text": "Varón de 41 años con ERC estadio V de perfil intersticial que tras recibir educación en opciones de tratamiento elige DPCA. En septiembre de 2014 se procedió a la implantación de catéter de silicona Swan-neck con doble cuff y reparación de dos hernias, inguinal y umbilical. Su superficie corporal era 2.06 m2 y su Indice de Masa Corporal 26.1. Se realizó la educación para el aprendizaje de la técnica y en Noviembre de 2014 comenzó tratamiento en domicilio con 4 intercambios de Bicavera al 1,5% de glucosa y 2000 ml de volumen, sin complicaciones. Los volúmenes de UF eran de 500-700 ml/ 24 horas y la diuresis residual de 1700 ml. En diciembre de 2014 se realizó Prueba de función peritoneal catalogándose como alto transportador con un volumen residual de 411,39 ml y Presión Intraperitoneal (PIP) de 16,05 cm H2O. El 2 de febrero de 2015 acudió a urgencias por dificultad para el drenaje, su patrón intestinal era normal sin estreñimiento ni diarrea y la radiografía de abdomen mostró migración del catéter, tratado con laxantes mejoraron los drenajes pero presentó una ganancia de 4 kg de peso. Se cambió pauta de tratamiento a 2 intercambios de 2,3 % y 2 de 1,5% de glucosa bajando 800 gr de peso. Al día siguiente en consulta telefónica se percibió disnea al hablar y tos, por lo que se le indicó acudir urgentemente a la consulta del hospital. La radiografía de tórax, mostró gran derrame pleural derecho que no existía en radiografías de tórax posteriores al comienzo de la DP.\n \n Se realizó toracentesis, mostrando la bioquímica del líquido una concentración de glucosa en líquido pleural mayor de la presentada en plasma y compatible con líquido de diálisis. Ante la sospecha de fuga de líquido hacia la cavidad pleural, se suspendió la diálisis peritoneal.\n Se realizó gammagrafía administrando 117 MBq de Nanocoloide de albumina TC 99 m.\n La administración del radio fármaco requirió la colaboración de la enfermería de DP y la de Medicina Nuclear (MN). La enfermera de DP realizó el intercambio manual y la de MN dosificó e inyectó el radiofármaco en la solución de diálisis, según protocolo de administración de medicación en líquido de diálisis, antes de infundirlo en la cavidad peritoneal.\n A los 10-15 minutos se hizo la primera lectura y tras 3-4 horas las imágenes tardías. Al finalizar, se realizó un nuevo intercambio manual para drenar completamente el abdomen, desechando el líquido drenado en el contenedor específico según protocolo de MN. El estudio fue indicativo de comunicación peritoneopleural, por lo que se suspendió definitivamente la DP. Se transfirió a hemodialisis (HD), resolviendose el hidrotórax. Actualmente el paciente esta trasplantado.\n \n",
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"note_text": "Mujer de 83 años con insuficiencia renal crónica terminal de etiología no filiada en programa de hemodiálisis crónica en centro periférico de diálisis desde Octubre de 2004.\n Antecedentes personales:\n Hipertensión arterial, no dislipemia, no diabetes mellitus, artritis reumatoide de larga evolución sin tratamiento actual, osteoporosis severa con fractura vertebral, e insuficiencia cardíaca con disfunción diastólica moderada/leve.\n Desde su inicio en programa de hemodiálisis se le han realizado dos fístulas arteriovenosas internas con pérdida de función posterior, y actualmente porta un catéter venoso central tunelizado en yugular interna derecha como acceso vascular.\n Durante el último año la paciente no ha presentado complicaciones ni ingresos hospitalarios. Durante este tiempo no se ha modificado su pauta de diálisis, la cual ha sido de sesiones de 240 minutos tres días/semana, con dializador de alta permeabilidad y 2m2 de superficie, y Qb de 350 ml/min, con lo que se ha conseguido mantener a la paciente estable con sesiones confortables y asintomáticas, y con cifras adecuadas de tensión arterial, peso seco entre 42-43 Kg, e índice de diálisis adecuada Kt/v >1.8.\n Situación actual:\n Aproximadamente desde el inicio del verano, la paciente presenta mala tolerancia a la ultrafiltración con episodios severos de hipotensión arterial prácticamente en todas las sesiones de diálisis, que requirieron infusión de fluidos para su estabilización, y reprogramación de las sesiones renunciando a lograr el peso seco al final de las sesiones.\n Por ello el día 8/08/16, es trasladada a la unidad hospitalaria de diálisis para mejor control de la paciente durante la hemodiálisis.\n A su llegada a la unidad, la paciente presenta signos evidentes de sobrecarga hídrica, con hipertensión arterial pre hemodiálisis, peso prediálisis de 47.5 Kg que indica un sobrepeso de 4.2 Kg sobre su peso seco anterior, ortopnea, y edemas muy intensos en MMII.\n En la anamnesis la paciente refiere que desde que empezó el calor del verano, prácticamente no comía nada, y destaca en la analítica albuminemia 2.6 g/dl y proteínas totales en suero 5.5 g/dl, motivo por el cual se le prescribió hace 10 días suplementación oral con Renilón7.5©, 1 frasco al día.\n Durante las dos primeras semanas de su estancia en la unidad hospitalaria, se intenta sin éxito conseguir el peso seco de la paciente al persistir los episodios de hipotensión intradiálisis. Incluso ganó 1 Kg en este periodo, a pesar de poner en práctica diferentes estrategias como limitar la ultrafiltración horaria a 300- 400 ml/h, haciendo diálisis secuencial prolongando las sesiones con tiempos de ultrafiltración aislada pre o post hemodiálisis, bajando la temperatura del baño a 35oC, y fijando la concentración de Na en el baño en 140 meq/l.\n Durante este tiempo, se revisa el tratamiento de la paciente retirándole toda la medicación hipotensora, se realiza ecocardiograma descartando agravamiento de su insuficiencia cardíaca, y al persistir los intensos edemas en MMII, aparecen heridas ulcerosas que requieren curas diarias según pauta descrita por cirugía plástica, y tratamiento antibiótico IV (Vancomicina) por cultivo + a staphylococo epidermidis.\n En la cuarta semana de tratamiento en la unidad, ante la intolerancia a la ultrafiltración, y para limitar en lo posible un sobrepeso excesivo entre sesiones, se pasa a la paciente a hemodiálisis diaria, prescribiéndose 6 sesiones semanales de 2.5 h, haciendo ultrafiltración aislada pre diálisis, y se cursa interconsulta a Endocrinología- Nutrición, para valorar la indicación de nutrición parenteral intradiálisis (NPID), ya que con los suplementos orales las cifras de albuminemia y proteínas totales en suero han bajado situándose en 2.4 g/dl y 5.3 g/dl respectivamente.\n Aunque en principio Endocrinología descartó la prescripción de nutrición parenteral, al considerar que la paciente tenía posibilidad de alimentación por vía oral, y propuso su seguimiento en consulta de dietética manteniendo los suplementos que tenía prescritos, en la sexta semana tras valorar de nuevo a la paciente prescribieron NPID con bajo volumen (900 ml/sesión), al considerar que la paciente estaba en riesgo nutricional alto/intermedio, con mala respuesta al suplemento oral.\n A partir del inicio de la NPID, la cual es bien tolerada por la paciente sin requerimientos de insulina adicionales por hiperglucemias, la paciente presenta buena tolerancia a la ultrafiltración que nos permite aumentar el tiempo de las sesiones a 3 horas manteniendo las seis semanales, y se consigue bajar el peso seco (44.5 Kg), hasta niveles próximos al peso seco que la paciente tenía antes del traslado a la unidad hospitalaria (43.3 Kg).\n En la octava semana se revisa la prescripción de la NPID, bajando el volumen a infundir en cada sesión a 700 ml, los edemas en MMII persisten aunque son casi inapreciables post diálisis, las heridas ulcerosas están prácticamente cicatrizadas, y las sesiones transcurren sin episodios de hipotensión. Por tanto se decide reducir el número de sesiones semanales a cinco, y seguir bajando el peso seco paulatinamente hasta alcanzar los 42 Kg, lo cual se consigue en la semana décima.\n A partir de esta semana, la paciente ha permanecido estable hemodinámicamente durante las sesiones de hemodiálisis, sin presentar dificultades para la ultrafiltración ni para alcanzar el peso seco al final de las sesiones, y se decide mantener la NPID hasta recuperación total de las cifras analíticas y hasta la cicatrización completa de las úlceras en MMII, y cuando la dieta de la paciente se corrija para que tenga todos los aportes necesarios asegurados, e ir reduciendo paulatinamente los días de diálisis prescritos hasta llegar a su esquema original de tres días en semana.\n \n",
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"note_id": "S2254-28842016000400013-2",
"note_text": "Mujer de 74 años con enfermedad renal crónica (ERC) estadio 5 atribuida a nefroangioes-clerosis, con antecedentes de hipertensión arterial, hiperparatiroidismo secundario, síndrome anémico y leucemia linfática crónica tipo B, que eligió terapia sustitutiva de DP tras el proceso de toma de decisión.\n Tiene 4 hijos pero vive acompañada de dos, cuida de los nietos, no sabe leer ni escribir, pero es independiente para las actividades diarias e instrumentales:\n (Enero 2014)= Barthel 100%, Lawton-Brody 8/8, Calidad de vida (sf-12): PCS 50.6, MCS 59,7\n El 10/04/2013 se colocó catéter peritoneal e inició DPCA en domicilio el 22/5/2013, siendo la propia paciente la cuidadora principal.\n El tratamiento de DPCA inicial fue de: 3 intercambios/ día (2 con Phisioneal 35 1,36% de glucosa y 1 con Extraneal, con volúmenes de 2000 ml). Diariamente ultrafiltraba 500 ml con los intercambios y mantenía un volumen de diuresis de 1500 ml. El resultado del estudio de la membrana peritoneal antes de la ultima peritonitis mostró una membrana peritoneal HA (transportador medio alto).\n En 8 meses presentó 4 episodios de peritonitis, de los cuales 3 fueron recidivante, con cultivo positivo de la misma bacteria (Staphylococcus epidermidis).\n Se administró tratamiento antibiótico protocolizado: Vancomicina 1gr/72h intraperitoneal (IP) durante 15 días y Fluconazol via oral (vo) durante 21 días. Tras la resolución de la ultima infección peritoneal se decidió realizar, además, sellados del catéter con Daptomicina (35 mg en 7,2 ml de ringer/24h después del último intercambio del día) medicación que se preparaba en el hospital, que la paciente recogía semanalmente y se auto administraba después del último intercambio del día en el domicilio.\n Episodio de peritonitis fúngica:\n Durante el periodo de sellado (14/8/2014) la paciente avisa al teléfono de urgencias, por líquido turbio, dolor abdominal y malestar general. Se realizó cultivo de líquido peritoneal protocolizado y quedó ingresada en espera de resultados. Tras el resultado del recuento celular, se inició tratamiento antibiótico empírico con Vancomicina 1gr/72h y Ceftazidima 1gr/24h IP. El cultivo mostró crecimiento de BGN (Klebsiella oxytoca y Acinetobacter sp multisensible), por lo que se mantuvo tratamiento con Ceftazidima 1gr/24h/IP, añadiéndose Gentamicina 40mgr/24h/IP y Ciprofloxacino 500 mg/12h vo.\n Ante la mejoría clínica (efluente claro y sin problemas de drenaje) se decidió alta a domicilio. Se realizó reentrenamiento de la técnica y manejo de la medicación antibiótica domiciliaria (tratamiento IP durante 21 días).\n A los ocho días, acude nuevamente a urgencias por líquido turbio, apareciendo en el cultivo un nuevo patógeno (Cándida parapsilosis) por lo que se añadió al tratamiento Fluconazol 200 mg vo/24h, y quedó nuevamente ingresada.\n Debido a la mala respuesta al tratamiento se decidió retirar el catéter Tenckoff, como recomienda el protocolo, y transferirla a Hemodiálisis definitivamente.\n Se le coloco un catéter venoso bilumen (yugular derecho) provisional, en espera de programar intervención quirúrgica de fístula arterio-venosa interna en codo derecho (5/09/2014).\n Cinco días después, se recambió el catéter venoso por disfunción y se visualizó mediante angio TAC, importante trombo en vena yugular por lo que precisó cirugía, ingreso en cuidados intensivos y colocación de un nuevo catéter (ubicación femoral). Este nuevo catéter, también, presentó trombosis venosa no oclusiva, por lo que precisó anticoagulación y retirada en 2-3 semanas.\n A pesar de la utilización de la fistula arterio-venosa interna al mes de su intervención, se observó mala adaptación al tratamiento de HD por continuas hipotensiones, dificultad en la canalización venosa y dolor de la extremidad por síndrome de \"robo\".\n La calidad de vida de la paciente había empeorado notablemente, tras el ingreso de 74 días y el traspaso a hemodiálisis:\n (Octubre 2014)= Barthel 95%, Lawton-Brody 6/8, Calidad de vida (sf-12): PCS 20,1, MCS 40,3\n Debido a las complicaciones, la mala adaptación a HD y por petición de la paciente, se replanteó volver a DP con el tratamiento de cicladora nocturna.\n Regreso a Dialisis Peritoneal:\n Así pues, el 19/12/14 se colocó catéter Tenckoff (vía laparoscopia para poder valorar las posibles adherencias, que pueden aparecer tras la peritonitis fúngicas) y como no hubieron problemas, en 1 mes la paciente reinició terapia domiciliaria de diálisis peritoneal automática (DPA). Como cuidador principal quedó la hija menor de la paciente, que aunque no vive con ella realizaba el montaje y conexión desplazándose al domicilio diariamente. La desconexión, solución de alarmas nocturnas y desmontaje de la maquina, lo realiza la paciente sin supervisión.\n El tratamiento pautado con cicladora fue de: 8 horas, 4 ciclos de 2000 ml (Phisioneal 35 1,36%), 80 minutos de permanencia y día seco.\n Diariamente tiene una ultrafiltrafiltración con el tratamiento de 400-500 ml y mantiene un volumen de diuresis de 1500 ml. El test de equilibrio peritoneal se mantuvo igual que al inicio.\n Actualmente lleva > de 1 año sin ningún tipo de problema, recuperando prácticamente la autonomía y calidad de vida del inicio:\n (Septiembre 2015)= Barthel 100%, Lawton-Brody 8/8, Calidad de vida (sf-12): PCS 43,6, MCS 51,5\n Las guías SEN recomiendan realizar reentrenamiento después de cada episodio de peritonitis. El objetivo es buscar causas posibles, evaluar la capacitación del responsable y rectificar aquellos procedimientos erróneos. Esta metodología nos ayuda a revelar la posible causa de la infección. En nuestro caso, el resultado indicó que la paciente no había seguido las medidas de asepsia recomendadas en la manipulación del antibiótico para el sellado.\n Con el primer resultado del cultivo del líquido peritoneal se diagnosticó la peritonitis bacteriana, pero acabo añadiendose, también, una peritonitis fúngica. Así pues, la infección fúngica condicionó la retirada del catéter peritoneal y el abandono del programa de diálisis peritoneal. El equipo multidisciplinar tomó la decisión de transferirla a HD definitivamente tras el diagnostico de peritonitis fúngica.\n Muchos autores describen que la supervivencia de la técnica tras una peritonitis fúngica por Candidas no Albicans es muy baja, y además existen pocos pacientes que pueden retornar de nuevo a la terapia de DP tras el suceso, así lo describen García-Martos1,2 y Molina3 en sus estudios.\n Las causas de que nos planteáramos que la paciente volviera a DP, fueron: la mala adaptación a la HD, las complicaciones surgidas durante el traspaso a hemodiálisis y la petición de la propia paciente. También se tuvo en cuenta la recomendación de las guías sobre la posibilidad de reinserción de un nuevo catéter peritoneal a las 4-6 semanas de la resolución del cuadro clínico.\n Una vez tomada la decisión de regresar al programa de DP, estaba claro que era necesario un cambio de estrategia, de manera que se propuso iniciar en forma de cicladora automática, con la finalidad de disminuir el número de manipulaciones del paciente/familia con el catéter. Pero también, era imprescindible evitar nuevos episodios de infección, por eso, se pensó en buscar un nuevo responsable para realizar la técnica y todo ello nos condujo a reiniciar el proceso de entrenamiento con la hija y puesta en marcha de la técnica en casa.\n \n",
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"label": "PRESENT_ILLNESS",
"segment": "Mujer de 74 años con enfermedad renal crónica (ERC) estadio 5 atribuida a nefroangioes-clerosis, ",
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"label": "PAST_MEDICAL_HISTORY",
"segment": "con antecedentes de hipertensión arterial, hiperparatiroidismo secundario, síndrome anémico y leucemia linfática crónica tipo B, que eligió terapia sustitutiva de DP tras el proceso de toma de decisión.\n Tiene 4 hijos pero vive acompañada de dos, cuida de los nietos, no sabe leer ni escribir, pero es independiente para las actividades diarias e instrumentales:\n (Enero 2014)= Barthel 100%, Lawton-Brody 8/8, Calidad de vida (sf-12): PCS 50.6, MCS 59,7\n El ",
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"segment": "10/04/2013 se colocó catéter peritoneal e inició DPCA en domicilio el 22/5/2013, siendo la propia paciente la cuidadora principal.\n El tratamiento de DPCA inicial fue de: 3 intercambios/ día (2 con Phisioneal 35 1,36% de glucosa y 1 con Extraneal, con volúmenes de 2000 ml). Diariamente ultrafiltraba 500 ml con los intercambios y mantenía un volumen de diuresis de 1500 ml. ",
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"segment": "El resultado del estudio de la membrana peritoneal antes de la ultima peritonitis mostró una membrana peritoneal HA (transportador medio alto).\n ",
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"segment": "En 8 meses presentó 4 episodios de peritonitis, de los cuales 3 fueron recidivante, con cultivo positivo de la misma bacteria (Staphylococcus epidermidis).\n ",
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"segment": "Se administró tratamiento antibiótico protocolizado: Vancomicina 1gr/72h intraperitoneal (IP) durante 15 días y Fluconazol via oral (vo) durante 21 días. Tras la resolución de la ultima infección peritoneal se decidió realizar, además, sellados del catéter con Daptomicina (35 mg en 7,2 ml de ringer/24h después del último intercambio del día) medicación que se preparaba en el hospital, que la paciente recogía semanalmente y se auto administraba después del último intercambio del día en el domicilio.\n ",
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"segment": "Episodio de peritonitis fúngica:\n Durante el periodo de sellado (14/8/2014) la paciente avisa al teléfono de urgencias, por líquido turbio, dolor abdominal y malestar general. ",
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"segment": "Se realizó cultivo de líquido peritoneal protocolizado y quedó ingresada en espera de resultados. ",
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"segment": "Tras el resultado del recuento celular, se inició tratamiento antibiótico empírico con Vancomicina 1gr/72h y Ceftazidima 1gr/24h IP. ",
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"end_offset": 2236,
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"segment": "El cultivo mostró crecimiento de BGN (Klebsiella oxytoca y Acinetobacter sp multisensible), ",
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"label": "TREATMENT",
"segment": "por lo que se mantuvo tratamiento con Ceftazidima 1gr/24h/IP, añadiéndose Gentamicina 40mgr/24h/IP y Ciprofloxacino 500 mg/12h vo.\n ",
"start_offset": 2236
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"segment": "Ante la mejoría clínica (efluente claro y sin problemas de drenaje) se decidió alta a domicilio. ",
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"segment": "apareciendo en el cultivo un nuevo patógeno (Cándida parapsilosis) ",
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"segment": "por lo que se añadió al tratamiento Fluconazol 200 mg vo/24h, y quedó nuevamente ingresada.\n ",
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"segment": "Debido a la mala respuesta al tratamiento ",
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"segment": "se decidió retirar el catéter Tenckoff, como recomienda el protocolo, y transferirla a Hemodiálisis definitivamente.\n Se le coloco un catéter venoso bilumen (yugular derecho) provisional, en espera de programar intervención quirúrgica de fístula arterio-venosa interna en codo derecho (5/09/2014).\n ",
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"segment": "Cinco días después, se recambió el catéter venoso por disfunción y se visualizó mediante angio TAC, importante trombo en vena yugular ",
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"segment": "Este nuevo catéter, también, presentó trombosis venosa no oclusiva, ",
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"segment": "por lo que precisó anticoagulación y retirada en 2-3 semanas.\n ",
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"segment": "A pesar de la utilización de la fistula arterio-venosa interna al mes de su intervención, se observó mala adaptación al tratamiento de HD por continuas hipotensiones, dificultad en la canalización venosa y dolor de la extremidad por síndrome de \"robo\".\n La calidad de vida de la paciente había empeorado notablemente, tras el ingreso de 74 días y el traspaso a hemodiálisis:\n (Octubre 2014)= Barthel 95%, Lawton-Brody 6/8, Calidad de vida (sf-12): PCS 20,1, MCS 40,3\n Debido a las complicaciones, la mala adaptación a HD ",
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"segment": "y por petición de la paciente, se replanteó volver a DP con el tratamiento de cicladora nocturna.\n Regreso a Dialisis Peritoneal:\n Así pues, el 19/12/14 se colocó catéter Tenckoff (vía laparoscopia para poder valorar las posibles adherencias, que pueden aparecer tras la peritonitis fúngicas) y como no hubieron problemas, en 1 mes la paciente reinició terapia domiciliaria de diálisis peritoneal automática (DPA). Como cuidador principal quedó la hija menor de la paciente, que aunque no vive con ella realizaba el montaje y conexión desplazándose al domicilio diariamente. La desconexión, solución de alarmas nocturnas y desmontaje de la maquina, lo realiza la paciente sin supervisión.\n El tratamiento pautado con cicladora fue de: 8 horas, 4 ciclos de 2000 ml (Phisioneal 35 1,36%), 80 minutos de permanencia y día seco.\n ",
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