CLINICAL CASE #5

Juan Ramón Chaparro Gasca

29 de septiembre de 2023

Licenciatura: Médico Cirujano

Octavo semestre
Ingles de la Práctica Clínica
Docente titular: Ávila González Ana Catalina del Pilar

Notas del Autor.

Facultad de Ciencias de Medicina, Universidad del Valle de México
La correspondencia relacionada con esta investigación debe ser dirigida a Juan
Ramón Chaparro Gasca, Universidad del Valle de México, Naranjos Punta
Juriquilla 1000 Santa Rosa Jáuregui, 76230 Santiago de Querétaro, Qro.

Contacto:
Juan Ramón Chaparro Gasca
Correo: A110173032@my.uvm.edu.mx
Clinical case
A 45-year-old, male, called Rodrigo de la Villa del Villar, Mexican, married, farmer
with no studies. He reports a gradual onset of fever, joint pain, and fatigue over the
past three weeks. He describes the fever as intermittent, with temperatures ranging
from 37.8°C to 38.9°C. The joint pain primarily affects his knees, wrists, and
shoulders, making it difficult for him to perform his daily farm duties. He also
complains of night sweats, generalized weakness, and a significant loss of appetite.
John reports no recent travel history or exposure to sick animals but mentions
consuming raw unpasteurized milk from his farm.
Patient
45 years old male, called Rodrigo de la Villa del Villar, Mexican, married, farmer with
no studies.
Subjective
He reports a gradual onset of fever, joint pain, and fatigue over the past three weeks.
He describes the fever as intermittent, with temperatures ranging from 100°F to
102°F (37.8°C to 38.9°C). The joint pain primarily affects his knees, wrists, and
shoulders, making it difficult for him to perform his daily farm duties. He also
complains of night sweats, generalized weakness, and a significant loss of appetite.
John reports no recent travel history or exposure to sick animals but mentions
consuming raw unpasteurized milk from his farm.
Objective
Alerted, oriented, cooperative, well hydrated, fatigued, pale, normal cardiovascular
examination, normal respiratory examination. Vital Signs: temperature: 38.4°C,
blood pressure: 120/80 mm Hg, heart rate: 82 bpm, respiratory rate: 18 bpm.
Analysis
Male in his 4th decade diagnosed with probable diagnosis of brucellosis.
Plan
Studies:

• Blood Cultures: Obtain blood cultures to isolate the Brucella species.

• Serological Tests: Perform serological tests, such as the Rose Bengal Test
or serum agglutination test, to detect Brucella antibodies.
• Complete Blood Count (CBC): Evaluate for leukocytosis or anemia.
Nonpharmacologic
 • Avoidance of smoking and excess alcohol intake
• Antipyretics (paracetamol, ibuprofen, naproxen)
Pharmacologic Therapies

• Antibiotics:
o Doxycycline 200mg per/24h for 6 weeks
o Rifampicin 600mg per/24h for 6 weeks
o Streptomycin 1gr per/ 24h for 2 weeks
Prevention:

• Educate the patient about proper hygiene practices when dealing with
animals and animal products.
• Encourage vaccination of livestock on the patient's farm to prevent the
spread of Brucella.

References:
S. Malaquin. 2015. Síndromes Oclusivos. Recuperado de:
https://www.sciencedirect.com/science/article/abs/pii/S1280470315738764

Elizabeth Hernández Moore. 2021. Guía de Práctica Clínica de invaginación intestinal en niños.
Recuperado de: http://scielo.sld.cu/scielo.php?script=sci_arttext&pid=S0034-
75312021000200016