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Edad:51 años
Natural/Procedente: Bogota
Ocupacion: Educadora
Estudios: Universitarios
Lateralidad: Diestra
Religion: Catolica
Acompañante: Tio
Vive con madre
MC: "Me ahogo y tengo diarrea"
EA: Paciente femenina de 51 años de edad con cuadro clinico de 2 dias de evolucion consistente en disnea asociado a dolor toracico no tipico tipo opresivo, subito de intesidad 7/10, que irradia a miembro superior izquierdo, que empeora con el ejercicio, constante asociado a parestesias bilaterales en manos y disnea anteriormente NYHA II, actualmente NYHA IV, ademas refiere dos semanas de aumento de gasto fecal por ileostomia.
Revision por sistemas
Paciente refiere dolor de oidos, niega cefalea, nauseas o vomito.
Dolor abdominal
Antecedentes
Patologicos: HTA, epilepsia focal, fibromalgia, espondilitis alquilosante, anemia cronica, TBC latente (hace 5 años), diverticulitis
Farmacologicos: verapamilo 120/8h, fenitoina 300mg/24h, loperamida 2mg/24h, argotamina, acetaminofen 1g/6h, b12, hidroclorotiazida
Alergia: dipirona y metoclorpramida
Cirugias: hernia discal, remplazo l2-l4, hemicolectomia izquierda, bridas, dedos en gatillo,
Toxicologicos: niega
Familiares: tio cancer de colon, madre cancer de esofago, padre diabetes tipo 2,
Trasfusionales: 7 unidades en febrero 2023, 3 unidades cirugia columna 2007
Examen fisico
Normocefalo, mucosa oral semiseca y rosada, cuello movil sin adenopatias ni masas, torax simetrico, ruidos respiratorios presentes, sin agregados, ruidos cardiacos ritmicos sin soplos, abdomen con herida quirurgica, doloroso a la palpacion con ileostomia, extremidadea eutroficas sin edema, neurologico sin deficit aparente.
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