Esclarecimento diagnóstico.

CASO CLÍNICO ENVIADO PARA O BLOG POR NOSSO COLEGA  ÍCARO BARROS, EX-INTERNO DO HSA QUE QUER NOSSA AJUDA E OPINIÕES. PACIENTE AINDA SEM DIAGNÓSTICO. 

Paciente de 16 anos, natural do Rio e procedente de Sao Paulo, com quadro previo de dor articular com edema, febre baixa, linfonodomegalia e taquicardia recorrente, apresentou ha 3 meses com dor em joelho e ombro esquerdos, associado a edema e calor, tambem com febre baixa e linfonodomegalia, evoluindo com hemiparestesia e “falta de firmeza” a esquerda. Apresenta tambem taquicardia persistente, alem de um episodio de amaurose subita, com recuperacao espontanea. Nega lesoes orais, genitais ou em pele. Foi feito pulso com metil em outro hospital, com melhora parcial dos sintomas. Ao exame, a paciente esta em bom estado geral, afebril, eupneica, acianotica, anicterica, mucosas hipocromicas 1+. Mantendo taquicardia continuamente, com FC em torno de 120, sem alteracao pressorica. Linfonodomegalia em cadeias cervicais superficiais. AR sem alteracoes. ACV: bulhas ritmicas e normofoneticas em 2T com sopro sistolico plurifocal 1+. Abdome sem alteracoes. Extremidades perfundidas sem edema, sem Raynaud, sem baqueteamento, sem lesoes ungueais. Nao observei lesoes em pele. Exame neurologico: GCS 15, pupilas isocoricas e fotorreagentes, Lhermitt negativo, hemiataxia a esquerda, com hemi-hipoestesia tatil, vibratoria, proprioceptiva e grafiestesica a esquerda, hiperreflexia 3/4 com cutaneo-plantar em extensao, Hoffman e Tromner presentes nesse lado, associado a discreta paresia 4+/5 ipsilateral. fundo de olho sem alteracoes.
Exames: Hb 10.1, Leuco 15.000 sem desvio, Plaquetas 160.000, AST 70, ALT 50, Bilirrubinas normais, Ureia, Creatinina e eletrolitos sem alteracao, VHS 80, FAN + pontilhado denso fino 1/640, fator reumatoide normal.
LCR normal
Sorologias para HIV, EBV, CMV, hepatites, toxo, brucelose….. todas negativas.
RM encefalo: lesao subcortical predominantemente em lobo parietal D, com componente frontal, mal delimitada, com espectroscopia sugerindo processo inflamatorio inespecifico, podendo corresponder a vasculite/desmielinizacao

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Broncoscopia com LBA

—Presença de secreção hialina em toda a árvore brônquica, mucosa pálida com sinais de bronquite, e calibre aumentado de todos os segmentos brônquicos. Foram realizados lavado, escovado e biópsia endobrônquica. O escovado brônquico mostrou presença de células colunares, grande quantidade de neutrófilos, eosinófilos e numerosos macrófagos. Presença de células gigantes multinucleadas englobando estruturas arredondadas com membrana birrefringente;
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A Clinician’s Pearls & Myths in Rheumatology

Important strides have been made in understanding the pathophysiologic basis of many inflammatory conditions in recent years, but rheumatology remains a discipline in which diagnosis is rooted in the medical history skillfully extracted from the patient, the careful physical examination, and the discriminating use of laboratorytests and imaging. Moreover, selection of the most appropriate therapyfor patients with rheumatic diseases also remains heavily reliant upon clinical experience. Medical disciplines such as rheumatology that depend significantly upon clinical wisdom are prone to the development of systems of ‘Pearls’ and ‘Myths,’ related to the diseases they call their own, a ‘Pearl’ being a nugget of truth about the diagnosis or treatment of a particular disease that has been gained by dint of clinical experience and a ‘Myth’ being a commonly held belief that influences the practice of many clinicians – but is false. This book will pool together the clinical wisdom of seasoned, expert rheumatologists who participate in the care of patients with autoimmune diseases, systemic inflammatory disorders, and all other rheumatic conditions.
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http://filepost.com/files/2d2m99mc/184800933X.pdf/

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Caso clínico da semana.

— 

IDENTIFICAÇÃO:  I.J.A, 52 anos, casado, vaqueiro, pardo, natural e procedente de Itabuna-Ba;

QUEIXA PRINCIPAL:  tosse há 3 meses ;

—HISTÓRIA DA DOENÇA ATUAL: Paciente relata que há 3 meses iniciou quadro de tosse inicialmente seca que passou a produtiva com secreção amarelo-esverdeada em pequena quantidade .Refere que algumas vezes apresentou escarro com presença de sangue; Associado passou a cursar com dispnéia aos grandes esforços como subir ladeiras, chegando a cursar em alguns momentos com quadro de dispnéia em repouso;

INTERROGATÓRIO SISTÊMATICO

  • — Geral: refere perda ponderal de 8Kg em 3 meses.Negou  febre no período; Queixa-se de astenia;
  • —  Pele: negou alterações;
  • —  ACV: negou ortopnéia, DPN, edema MMII;
  • —  Abd.: negou alterações;
  • —  Neurológico: refere que apresentou  dois episódios de convulsões tônico-clônicos generalizadas no período com duração aproximada de um minuto, sem prodrómos ou sintomas pos-ictais.Nega cefáleia,trauma craniano ou sintomas neurológicos focais.

ANTECENDENTES MÉDICOS: Nega patologias prévias, nega passado de TB pulmonar, nega passado de epilepsia;

HÁBITOS DE VIDA:  Tabagismo importante ( 1 a 2 cart./dia há 25 anos) e alcoolismo  ( 3 a 4 doses de bebida destilada a cada 2/3 dias há 20 anos);

EXAME FÍSICO

  • —  GERAL: paciente em bom estado geral e regular estado nutricional, corado , afebril, eupnéico;
  •     TA= 120/80mmHg  FR= 18 ipm  FC= 72bpm
  • —  PESCOÇO: presença de linfonodo  cervical  a direita, 3cm , duro, indolor;
  • —  PELE: sem alterações;
  • —  ACV: ictus não visível e não palpavél, BRNF em 2T sem sopros;
  • —  AR: MV diminuído difusamente sem RA;
  • —  ABD.: sem alterações;
  • —  NEUROLÓGICO: paciente alerta,força muscular grau V globalmente, reflexos presentes e simétricos, pares cranianos sem alterações, tônus muscular e provas de coordenação motora sem alterações;

Suspeitas e condutas  diagnósticas para este caso.

Próxima quarta  teremos a discussão e colocaremos os resultados dos exames.

 

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The Cleveland Clinic Intensive Review of Internal Medicine

 

Now in its revised, updated Fifth Edition, The Cleveland ClinicIntensive Review of Internal Medicine offers thorough preparation for board certification and recertification exams in internal medicine. It is written by distinguished Cleveland Clinic faculty and serves as the syllabus for the Cleveland Clinic’s esteemed internal medicine board review course.

Clinical vignettes and bulleted lists throughout the book highlight key clinical points. This edition also includes boxed “Points to Remember”. Board simulations appear at the end of each section. An updated mockboard exam containing over 200 multiple-choice questions appears at the end of the book.

A companion Website will offer an interactive question bank with 200 additional questions.
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http://lumfile.com/rxfru7xpkpt3/0781790794.chm.html

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NMS Medicine Casebook (National Medical Series for Independent Study)

Customer Reviews

1.  This book is ROCK SOLID for preparing for Steps 2CK and 3 of the USMLEs.

2. When I first bought this book I didn’t think I would be able to get through it in time, but I really wanted to have a good case book along with the questions that I was doing for my medicine shelf. The book actually went really fast, and I felt like I learned the material better than I would have just by doing questions, or reading a traditional text. I only had 2 months in my medicine block and got through this book twice and made honors on the shelf! The algorithms were key, and although I did think there may have been some mnemonic overkill I remembered a lot of them when I actually took the shelf. Do yourself a favor and buy this book. You will be happy when you get your shelf results. I’ll probably use it when I am a medicine intern too.

3.  The cases have variations that lead you to develop a differential, and clear tables are provided that summarize useful information.

Book Description

Organized by subspecialty, this case-based review covers all the information students are expected to learn during their internal medicine clerkship. Each topic begins with a brief patient history and a question about the most likely diagnosis or next step in management followed by a discussion of alternative diagnoses and management strategies. The user-friendly approach includes numerous algorithms, images, mnemonics, and tables.

A companion Website will offer the fully searchable text.
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http://filepost.com/files/4b15b593/0781784689.chm

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The Washington Manual of Medical Therapeutics, 33rd Edition

Established for over 40 years, as the “bible” of the medical ward, The Washington Manual® of Medical Therapeutics is now in its Thirty-Third Edition and builds upon that proud tradition—with even more of the current information you need, delivered in a timesaving, quick-reference style. Its portability, comprehensiveness, and ease of access makes it a favorite on-call resource for housestaff and faculty around the world. In this edition, color has been added for better navigation, new decision support algorithms have been added, and an improved templated and bulleted format facilitates a quicker answer.

With this edition you now have the capability to upload this content to your handheld device and receive updates to the information throughout the activation period. Plus, you have access to eight medical calculators that include:

GFR – Cockcroft-Gault Method (Adult)

Urea Reduction % (Hemodialysis)

Transtubular Potassium Gradient

Osmolal Gap

Anion Gap

Serum Osmolality

Reticulocyte Index

Body Mass Index (BMI)

The Washington Manual® is a registered mark belonging to Washington University in St. Louis to which international legal protection applies. The mark is used in this publication by LWW under license fromWashington University.
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http://filepost.com/files/8f53126b/1608310035.chm

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Concise Cardiology: An Evidence-Based Handbook

Useful Review

Newly released Concise Cardiology by Daniels is the best cardiology pocket-book I’ve seen. It’s chapters are easy to read and navigate, filled with nice charts and diagrams. Bullet-points make important concepts easy to review. Literature review summary on each subject make this a useful book even at the fellow/attending level. The book dimensions and weight make it easy to carry in you pocket. I am a senior IM resident at a top program and soon-to-be cardiology fellow. I use this book all the time on my cards rotations!

Book Description

Written by residents, fellows in training, and experienced attending physicians, this pocket book presents an evidence-based clinical approach to cardiology in a concise quick-reference format. The book is designed for rapid point-of-care consultation and is ideal for residents, fellows, andpractitioners who operate in a fast-paced environment.

The comprehensive coverage ranges from preventive cardiology, to acute coronary syndromes, to electrophysiology, to cardiology consultation. Current AHA/ACC guidelines are combined with evidence-based findings and reviews of clinical trials. Each clinical problem is analyzed in detail to aid in diagnosis. Appendices cover central vascular access techniques and clinical pharmacology.
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GET IT HERE
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http://extabit.com/file/28df3bno4zsw1

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