CASOS CLNICOS EN INGLS

A 45-yr-old woman with a history of mild hypertension underwent a lumpectomy and

1 mo later, a left radical mastectomy for breast cancer. Histopathology revealed an
infiltrating ductal carcinoma with local lymphatic spread. During these surgeries, the
patient was noted to be mildly hypertensive, with systolic blood pressures varying
from 140160 mmHg and diastolic blood pressures ranging from 80100 mmHg.
After surgery, her blood pressure was controlled by doubling her dose of enalapril
(the only medication she was taking) from 5 to 10 mg/day. Following these surgeries,
as a part of the staging evaluation of her cancer, she had a CT scan of her abdomen
and pelvis, which revealed a 4.8 3.7 cm nonhomogeneous left suprarenal mass,
suspicious for a metastatic lesion (see Fig. 1). Because of the concern for metastatic
disease, an ultrasound-guided fine needle aspiration biopsy (FNAB) of the
suprarenal mass was performed. After the first pass of the needle, the patient
developed severe pounding occipital headaches and palpitations. Her blood
pressure rapidly increased from 120/80 mmHg to 185/90 mmHg and her heart rate
rose from 72 to 90 beats/min. She vomited twice.

CONTESTA LAS SIGUIENTES PREGUNTAS:

1. CON BASE EN LOS CUADROS DE HIPERTENSIN PAROXISTICA Y LA

CRISIS QUE PRESENTO POSTERIOR A LA BIOPSIA LA CAUSA MAS
PROBABLE DEL TUMOR SUPRARENAL SERIA:
a. ADENOMA NO FUNCIONANTE
b. ALDOSTERONOMA
c. FEOCROMOCITOMA
d. ADENOMA PRODUCTOR DE CORTISOL
e. TUMOR PRODUCTOR DE ANDROGENOS
LA RESPUESTA CORRECTA ES LA C, YA QUE SE HA REPORTADO QUE
CUALQUIER CONTACTO CON EL TUMOR (FEOCROMOCITOMA) SIN DAR UN
TRATAMEINTO PREVIO PUEDE DESENCADENAR UNA CRISIS (
URGENCIA/EMERGENCIA HIPERTENSIVA)

2. PARA CONFRMAR TU DIAGNOSTICO SOLICITARIAS:

a. RENINA Y ALDOSTERONA
b. RMN CON GADOLINEO
c. GAMAGRAMA SUPRARRENAL
d. METANEFRINAS SERICAS Y/O URINARIAS
e. CORTISOL SERICO

LA RESPUESTA CORRECTA ES LA D, YA QUE ES EL ESTUDIO CON MS

ATA SENSIBILIDAD Y ESPECIFIDAD DURANTE UNA CRISIS.

3. UNA VEZ CONFIRMADO EL DIAGNOSTICO QUE MEDICAMENTO

DARIAS PARA EVITAR UNA NUEVA CRISIS:
a. ESPIRNONOLACTONA
b. ENALAPRIL
c. LOSARTAN
d. NITROPRUSIATO
e. FENAZOBENZAMINA

LA RESPUESTA CORRECTA ES LA E, YA QUE ES EL FRMACO DE

ELECCIN EN UNA CRISS POR FEOCROMOCITOMA POR SER UN
BLOQUEADOR PREDOMINANTEMENTE ALFA.

4. EL TRATAMIENTO DEFINITIVO EN ESTE CASO SERIA

a. QUIRURGICO
b. ESPIRONOLACTONA
c. QUIMIOTERAPIA
d. RADIOTERAPIA
e. PRAZOCIN

LA RESPUESTA CORRECTA ES LA A, YA QUE ES EL TRATAMIENTO

DEFINITIVO PARA ESTE TIPO DE TUMORES SUPRARRENALES.
A 38-yr-old woman was referred because of a 75-lb weight gain over the past 7 yr.
She has noticed some increasing facial fullness and has had some problems with
climbing stairs. She has had insomnia and nocturia for the past 3 yr and complains
of some easy bruisability. She recently suffered a stress fracture in her right foot.
She has maintained normal menstrual periods, but has had a decreased libido. She
complains of emotional lability over the past 2 yr. She has recently been receiving
some counseling for depression. There is a family history of thyroid disease in her
mother and diabetes in both maternal grandparents. Examination showed a slightly
cushingoid woman with a BP of 130/90, pulse 88, height 63'', weight 222 lbs. She
had some mild facial rounding with very slight plethora. and generalized obesity with
increases in supraclavicular fullness. The thyroid examination was normal.
Laboratory studies a 24-h urine free cortisol (UFC) was 205 g/d (normal <130 g/d)
and morning serum cortisol 29 g/dL decreased only to 22 g/dL following overnight
1-mg dexamethasone suppression test. Computed tomography (CT) of the
abdomen showed both enlarged adrenal glands. CT scan of the pituitary gland
showed a convexity of the pituitary gland and discrete pituitary lesion was identified.

CONTESTE LAS SIGUIENTES PREGUNTAS:

1. CON BASE EN LOS ANTERIOR LA CAUSA DE LOS SINTOMAS DE ESTA

PACIENTE SERIA:
a. SINDROME DE OVARIO POLIQUISTICO
b. OBESIDAD
c. HIPERCORTISOLISMO
d. HIPOCORTISOLISMO
e. HIPERANDROGENISMO

LA RESPUESTA CORRECTA ES LA C, YA QUE TIENE DATOS CLINICOS Y

BIOQUIMICOS DE EXCESO DE GLUCOCORTICOIDES

2. CON LOS HALLAZGOS DE LABORATORIO Y GABINETE LA ETIOLOGIA

PROBABLE PODRA SER:
a. SX DE CUSHING EXOGENO
b. ENFERMEDAD DE CUSHING
c. ADENOMA SUPRARRENAL PRODUCTOR DE CORTISOL
d. TUMOR ECTOPICO PRODUCTOR DE ACTH
e. PSEUDOCUSHING

LA RESPUESTA CORRECTA ES LA B, YA QUE ES LA ETIOLOGIA MS

FRECUENTE Y SE ASOCIA A UN HALLAZGO TOMOGRAFICO DE TUMOR
HIPOFISARIO.

3. PARA CONFIRMAR LA ETIOLOGIA QUE ESTUDIO SOLICITARIAS

a. RITMO DEL CORTISOL
 b. REPETIR TAC DE CRANEO
c. GAMAGRAMA DE SUPRARRENALES
d. PRUEBA CON 8MG DE DEXAMETASONA
e. REPETIR CORTISOL URINARIO
LA RESPUESTA CORRECTA ES LA D, YA QUE ESTA PRUEBA TIENE UNA
ALTA SENSIBILIDAD Y ESPECIFICIDAD PARA LA LOCALIZAR AL TUMOR
PRODUCTOR DE GLUCOCORTICOIDES.

4. CUAL SERIA EL TRATAMIENTO DE PRIMERA LINEA EN CASO DE

CONFIRMARSE EL DIAGNOSTICO
a. FARMACOLOGICO
b. EXPECTANTE
c. RADIOTERPIA
d. QUIMIOTERAPIA
e. QUIRURGICO

LA RESPUESTA CORRECTA ES LA E, YA QUE ES EL QUE OFREE UNA MAYOR

TASA DE CURACIN DE ESTE PADECIMIENTO.
At age 35, this woman was admitted to the hospital with an episode of substernal
chest pain associated with ST depression in the lateral precordial leads. At that time,
she gave a family history of cardiac disease; her mother died at age 42 after several
years of chest pain on exertion and an older sister had a sudden death at age 37.
She was rapidly evaluated during this first hospitalization and underwent bypass
surgery for LAD and right coronary lesions of >70%. Postoperatively, she had a total
cholesterol of 350 mg/dL, HDL 32 mg/dL, triglyceride 140 mg/dL, and LDL 290
mg/dL. She related that her cholesterol had been as high as 450 mg/dL in the past.
Her examination was significant for large xanthomas on both Achilles tendons. At
this visit she was seen by her cardiologist and complained at that time of fatigue and
nonexercise related substernal aching. An exercise tolerance test was normal and a
cardiac catheterization done because of her high-risk status showed full patency of
her grafts and no critical lesions. The chest syndrome subsequently has subsided,
but did not entirely leave. It is an aching in the substernal region that is not related
to either food or exercise

CONTESTE LAS SIGUIENTES PREGUNTAS:

1. LA CAUSA DE LA ATEROESCLEROSIS TEMPRANA EN ESTE CASO FUE:

a. DISLIPIDEMIA
b. ALIMENTACIN
c. HERENCIA
d. DIABETES MELLITUS
e. DEFCIIENCIA ESTROGENICA

LA RESPUESTA CORRECTA ES LA A, YA QUE ES UN CAUSA FRECUENTE

DE ATEROESCLEROSIS EN PACIENTES JOVENES.

2. LA ETIOLOGIA DE ESTE PADECIMIENTO SERIA:

a. CONGENITA
b. HEREDITARIA
c. AUTOINMUNE
d. SECUNDARIA
e. FARMACOLOGICA

LA RESPUESTA CORRECTA ES LA B, YA QUE LAS DISLIPDIEMIAS

PRIMARIAS SON AUTOSOMICAS DOMINANTES Y SE PRESENTAN DESDE
TEMPRANA EDAD

3. LA FISIOPATOLOGIA DE LA ELEVACIN DE LIPIDOS EN ESTE CASO

SERIA:
 a. MUTACIN DEL RECEPTOR DE LDL
b. MUTACIN DE LA LIPOPROTEINALIPASA
c. MUTACIN DE PROTEINA C
d. MUTACIN DE LIPASA HEPATICA
e. HIPERQUILOMICRONEMIA

LA RESPUESTA CORRECTA ES LA A, YA QUE LAS CAUSAS MS

FRECUENTES DE HIPERCOLESTEROLEMIAS PRIMARIAS SE DEBEN A
MUTACION DE RC DE LDL O DE APO B 100 QUE ES SU LIGANDO.

4. EL TRATAMIENTO RECOMENDADO EN ESTE CASO

a. FIBRATOS
b. ESTATINAS
c. ACIDO NICOTINICO
d. NIACINA
e. COLESTIRAMINA

LA RESPUESTA CORRECTA ES LA B, YA QUE LAS DOSIS ALTAS DE ESTOS

FRMACOS SON LAS DE MAYOR EFECTIVIDAD PARA PREVENCION
PRIMARIA Y SECUNDARIA DE CARDIOPATIA ISQUEMICA POR QUE A PARTE
DE SU EFECTO HIPOLIPEMIENTE TIENE EFECTO PLEIOTROPICO
(DISMINUYE GROSOR DE LA INTIMA DE LAS ARTERIAS)
A 35-yr woman presented in the outpatient clinic with a serum calcium of 11.6 mg/dL
(normal 8.510 mg/dL) and phosphate of 2.0 mg/dL (normal, 2.54.5 mg/dL). Her
serum total alkaline phosphatase was 300 U/L (normal, 108282 U/L), and serum
creatinine 1.8 mg/dL (normal, 0.60.9 mg/dL). Her whole-molecule parathyroid
hormone (PTH) by immunochemiluminometric assay (ICMA) was increased at 10.5
pmol/L (normal 1.05.2 pmol/L). Her 24-h urine calcium was 420 mg (normal, 20
275 mg). Further evaluation showed that she had vertebral osteoporosis with an L2
L4 lumbar spine BMD (T-score:- ) and left femoral neck osteoporosis with BMD
(T-score:- .9). An X-ray of the kidneys, ureters, and bladder with tomograms
showed no calcium containing kidney stones. She denied any complaint of
abdominal pain, esophageal reflux, heartburn, or history of peptic ulcer disease. She
complained of mild fatigue and difficulty maintaining concentration, and wondered
whether her mild hypercalcemia was contributing to her lack of energy or declining
mental acuity.

CONTESTA LAS SIGUIENTES PREGUNTAS:

1. CON BASE EN LA HISTORIA CLINICA CUAL PODRIA SER LA CAUSA DE

HIPERCALCEMIA EN ESTE CASO:
a. HIPERPARATIROIDISMO 1RIO
b. HIPERPARATIROIDISMO 2RIO
c. HIPERFOSFATEMIA
d. HIPERCALCEMIA MALIGNA
e. HIPERTIROIDISMO

LA RESPUESTA CORRECTA ES LA A, YA QUE LA PRIMERA CAUSA DE

HIPERCALEMIA EN UN PACIENTE NO HOSPITALIZADO ES EL
HIPERPARATIROIDISMO PRIMARIO Y ES GENERALMENET ASINTOMATICO
HASTA CAUSAR DAO SEVERO A RGANOS BLANCOS.

2. DE LOS ESTUDIOS QUE YA LE REALIZARON O QUE SOLICITARIAS

CUALES SERIAN LOS MS ESPECIFICOS PARA CONFIRMAR EL
DIAGNOSTICO
a. PERFIL TIROIDEO
b. CALCIO, FOSFORO Y PTH
c. MAGNESIO
d. PEPTIDO SIMILAR A PTH
e. NIVELES DE VITAMINA D

LA RESPUESTA CORRECTA ES LA B, YA QUE LOS DATOS

CARACTERISTICOS DE ESTE PADECIMEINTO SON HIPERCALCEMIA
ASOCIADA A HIPOFOSFATEMIA CON PTH ELEVADA
 3. CUAL ES EL SIGUIENTE ESTUDIO QUE TE PERMITIRIA LOCALIZAR LA
CAUSA
a. RX DE TORAX
b. TAC DE CRANEO
c. GAMAGRAMA OSEO
d. GAMAGRAMA PARATIROIDEO
e. USG RENAL

LA RESPUESTA CORRECTA ES LA D, YA QUE ES EL ESTUDIO CON MS

ALTA SENSIBILIDAD Y ESPECIFIDAD PARA LOCALIZAR EL SITIO DE
AFECTACIN (ADENOMA O HIPERPLASIA PARATIROIDEA)

4. CON BASE EN LOS DATOS REFERIDOS EL TRATAMIENTO

QUIRURGICO ESTARIA INDICADO POR:
a. TAMAO DEL TUMOR
b. NIVEL DE FOSFATASA ALCALINA
c. CALCIO URINARIO
d. NIVEL DE PTH
e. OSTEOPOROSIS

LA RESPUESTA CORRECTA ES LA E, YA QUE LAS INDICACIONES PARA EL

TRATAMIENTO QUIRURGICO SON EDAD MENOR DE 50 AOS, DAO A
ORGANO BLANCO (FALLA RENAL, LITIASIS RENAL RECURRENTE,
OSTEOPOROSIS, HIPERCALCEMIA MODERADA (>1MG/DL DEL RANGO
SUPERIOR DEL LABORATORIO EMPLEADO)