Síndrome Antifosfolipídico en adulto joven

Abstract

Male patient 39 years old. He born in Mother Earth in the province of Pastaza and resident in the Jatari community, mestizo, cohabiting marital status, complete secondary education, occupation agriculture, personal medical history of deep vein thrombosis 4 years ago. Patient comes upon referral Health Center to present about 24 hours ago abdominal pain, continuous type, 6/10, located in epigastric left upper quadrant radiating to further relates that fail nausea vomiting. Physical examination: blood pressure 105 / 78mmHg, heart rate 74 beats per minute, respiratory rate 22 breaths per minute, temperature 36.8ºC, BMI 26.6 m / kg. Abdomen presence of collateral venous network, tenderness epigastric and left upper quadrant, hepatomegaly two traverses palpated below the costal margin. Tips presence of violet plate 10 x 4 cm located in the left wing. According to the clinical and laboratory results, is suspected antiphospholipid syndrome, so tests that are processed through social work, they performed in a private laboratory, confirming the diagnosis so it is processed are prompted for an interconsultation to hematology in a third level institution also hepatosplenomegaly thought of the presence of portal vein thrombosis and Boud Chiari syndrome, which are discarded, continuing his study is studied. The patient is assessed by hematology treatment (enoxaparin 60 subcutaneous milligrams every 12 hours, warfarin 5 mg via daily oral), which evolves satisfactorily, therefore is discharged and continuous controls outpatient service is established, interconsultation also requested to hepatology.