Comunicaciones y Congresos semFYC

XXXIX Congreso de la semFYC - Málaga

del 9 al 11 de mayo de 2019

Comunicaciones: Casos clínicos

A propósito de un caso: edema en extremidad inferior y disnea. (Póster)

Ámbito del caso

Servicio de urgencias.

Caso multidisciplinar

Motivos de consulta

Edema en pierna derecha y disnea.

Historia clínica

Enfoque individual

AP: HTA. DLP. Hernia de hiato. IQx: amigdalectomía, apendicectomía, cataratas AO.

Anamnesis: mujer de 81 años que consulta por disnea de esfuerzo de inicio súbito hace 24 horas asociando dolor e inflamación de extremidad inferior derecha de 5 días de evolución. Afebril. No clínica respiratoria infecciosa.

EF: Buen estado general. TA 110/70 mmHg, SO2 96%. AC: rítmico a 100 lpm. AP: buena ventilación global. EEII: edema generalizado de extremidad inferior derecho con aumento de diámetro respecto a pierna contralateral con eritema generalizado. Homans positivo. Pulsos distales presentes y simétricos.

PPCC:

- ECG: ritmo sinusal a 100 lpm, eje a 60º, onda T negativa en D3.

- Analítica: leucocitosis de 13.000 sin desviación izquierda, dímero D 6980, resto sin interés.

- Ecografía Doppler venoso EEII: vena femoral y safena interna dilatadas, no compresibles, con presencia de material isoecogénico en su interior, con ausencia de flujo. Territorio arterial permeable.

- Angio TAC pulmonar: se evidencia tromboembolismo pulmonar en rama principal derecha, lobares superior, media e inferior bilateral y segmentarias para lóbulo inferior.

Enfoque familiar y comunitario

Vive en domicilio con su marido. Tiene 3 hijas independizadas. Funciones superiores conservadas. Independiente para ABVD.

Juicio clínico, diagnóstico diferencial, identificación de problemas

Tromboembolismo pulmonar bilateral secundario a trombosis venosa profunda.

Tratamiento y planes de actuación

Se inicia anticoagulación con heparina de bajo peso molecular (HBPM) a dosis terapéutica (1 mg/Kg/12h) y se ingresa a la paciente para tratamiento y control evolutivo.

Evolución

Durante el ingreso se cambia anticoagulación a acenocumarol según pauta de laboratorio, y tras permanecer estable hemodinámicamente, se decide alta domiciliaria.

Conclusiones (y aplicabilidad para la Medicina de Familia)

Destacar la elevada sensibilidad (98-100%) y baja especificidad (35-40%) del Dímero-D, que combinado a una baja probabilidad clínica pre-test presenta un valor predictivo negativo (VPN) cercano al 99,5%, útil para descartar enfermedad tromboembólica venosa (ETEV) y evitar realización de más pruebas diagnósticas. Sin embargo, un resultado positivo, dada su baja especificidad, no tiene valor diagnóstico.

Comunicaciones y ponencias semFYC: 2025; Comunicaciones: Casos clínicos. ISSN: 2339-9333

Autores

Amesti Gallastegui, Jone
Las Arenas. Getxo

Goicoechea Zenon, Ander
Kueto. SESTAO

Rodríguez Marco, Nerea
Hospital San Eloy. BARAKALDO

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