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Formule su propia pregunta a Pablo Rodríguez

Pablo Rodríguez
Pablo Rodríguez, Licenciatura
Categoría: Medicina
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Experiencia:  Médico adjunto de Servicio de Urgencias Hospitalarias. Consulta de Medicina Familiar y Comunitaria
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Qu cuidados debe tenerse con un paciente , joven adulto de

Pregunta del cliente

¿Qué cuidados debe tenerse con un paciente , joven adulto de 26 años, 1que hace una semana fue dado de alta luego de estar internado por ocho dias en UTI y UCI con diagnóstico inicial de Neumonía Adquidida en Comunidad , o NAC, y dado de alta con diagnóstico de COP, o Neumonia Obliterante Bilateral Criptogénica?

¿Dónde puedo encontrar información sobre casos recientes, de pacientes jóvenes y sin enfermedades previas?

Atentamente,
juvart
Enviada: hace 5 año.
Categoría: Medicina
Experto:  Enrique Artozqui escribió hace 5 año.
Hola. En el siguiente enlace puede ver una explicación de este trastorno y algunos casos: http://www.unav.es/revistamedicina/52_3/pdf/casoclinico.pdf Como se expone en este artículo, el tratamiento que está tomando con prednisona (un corticoide) es el indicado y suele dar resultados excelentes. El adjetivo de "criptogenética" indica que la causa que hace aparecer la enfermedad es desconocida.
Un saludo. Si la respuesta le ha resultado útil pulse Aceptar y puede seguir preguntando cualquier duda.
Experto:  Dr. Maldonado escribió hace 5 año.
Hola, el artioculo que el dr. Artozqui ha puesto tambien lo conozco yo y explica muy bien el problema del paciente. En cuanto a los cuidados que hay que tener con él son los mismos que para un paciente con neumonia: La valoración respiratoria, pudiendo observarse taquipnea (respiracon acelerada), hipoventilación (respiracoin debil), respiración trabajosa, tambíen puede observarse fiebre y taquicardia (frecuencia cardiaca acelerada). Tener una ingesta adecuada de líquidos y nutrientes. Evitar el tabaco y los humos que puedan irritar los bronquios. Y es muy importante el reposo y el sueño. Saludos
Cliente: escribió hace 5 año.
Esta informacíon ya la conocía, por eso precisé requerir antecedentes de casos recientes de pacientes jovenes y sin enfermedasdes previas como es el caso de mi hijo. En consecuencia, reitero que se responda a ese requerimiento.
Experto:  Dr. Jorge Gamboa escribió hace 5 año.
Saludos, espero ayudarla con su pregunta:

Existen bases de datos importantes de acceso libre por ejemplo la de la Biblioteca Nacional de los Estados Unidos, donde ud puede accesar a publicaciones de muchos temas en general, y encontrar también información acerca de pacientes y casos que han presentado enfermedades como la de su hijo.

Siga esta liga y en el buscador ingrese los diagnósticos de su hijo y se dará cuenta de la gran variedad de estudios que existen en esa plataforma.

www.pubmed.gov

saludos, espero que mi respuesta le sea útil. sigo a sus ordenes.
Cliente: escribió hace 5 año.
Tengo conocimiento de esta base de datos pero, dada mi ignorancia en temas de medicina, me fue imposible encontrar BOO en alguna de las categorias presentadas como llaves de acceso a la Base.
Experto:  Dr. Jorge Gamboa escribió hace 5 año.
Intente buscando tópicos como "community acquired pneumonia".

Existen múltiples artículos completos gratuitos.

Existen otras plataformas en español también con mucha información como www.fisterra.com en la cual buscando Neumonía encontrara las Guías de manejo ademas de rehabilitación para esta enfermedad.

Si tiene alguna otra duda pregunte con confianza de está o nuevas dudas que salgan sobre la búsqueda.
Cliente: escribió hace 5 año.

Mi consulta está referida a neumonía organizada criptogenética (COP), o BOOP, es decir,
enfermedad afectando al Sistema Inmunmológico. El diagnóstico inicial, de ingreso a la UTI fue NAC.
Experto:  Dr. Jorge Gamboa escribió hace 5 año.
Sigo atendiendola:

Si claro igual puede encontrar este diagnostico en las bases de datos que le menciono.

El termino para encontrar información de este tipo de alteraciones lo puede buscar como "Neumonías Intersticiales Idiopáticas" bajo este titulo se describe todas las alteraciones similares a la que padece su hijo.

sigo a sus ordenes.
Cliente: escribió hace 5 año.
Estimado Doctor

En relación a mi pregunta debo comentar que ninguna de las respuestas recibidas parecen provenir de un experto en el tema. En efecto, en vez de responder derechamente a mis planteamientos se me ha remitido a Bases de Datos, las cuales una vez revisadas, por ello mi demora en contestar, no dan respuesta a mis requerimientos en cuanto a " Información reciente de pacientes jóvenes y sin enfermedades previas".

Dado lo anterior, no considero satisfactorias las respuestas recibidas.

Atentamente
JUVAR
















Experto:  Pablo Rodríguez escribió hace 5 año.
Le dejo información actualizada a Marzo de 2011 sobre el problema que usted comenta. Tenga en cuenta que la información está en inglés porque las bases de datos más potentes y mejor actualizadas están así, si tiene una duda en particular de la información tan sólo hágamelo saber, además tiene múltiples referencias para ampliar la información:

INTRODUCTION — Cryptogenic organizing pneumonia (COP), the idiopathic form of organizing pneumonia (formerly called idiopathic bronchiolitis obliterans organizing pneumonia or BOOP), is a distinct clinical entity with predominant features of pneumonia, rather than a primary airway disorder [1-7]. Organizing pneumonia can also be seen in association with connective tissue diseases, a variety of drugs, malignancy, and other interstitial pneumonias [2,8].

Cryptogenic organizing pneumonia will be discussed here. An overview of the idiopathic interstitial pneumonias is presented separately. (See "Idiopathic interstitial pneumonias: Clinical manifestations and pathology".)

The American Thoracic Society (ATS) and European Respiratory Society (ERS) statement on the classification of idiopathic interstitial pneumonias, as well as other ATS guidelines, can be accessed through the ATS web site at www.thoracic.org/statements.

PATHOLOGICAL CHANGES — The histopathologic lesions characteristic of COP include excessive proliferation of granulation tissue within small airways (proliferative bronchiolitis) and alveolar ducts, associated with chronic inflammation in the surrounding alveoli. This organizing pneumonia is the most important process underlying the clinical and radiographic manifestations of COP. There are, in addition, several other key features (table 1) [9]:

  • A uniform, temporally recent appearance to the changes, without severe disruption of the lung architecture
  • A patchy and peribronchiolar distribution
  • Localization of lesions within the airspaces (figure 1)
  • Foamy macrophages are commonly seen in the alveolar spaces, presumably secondary to the bronchiolar occlusion
  • Intraluminal buds of granulation tissue consist of loose collagen-embedding fibroblasts and myofibroblasts that extend from one alveolus to the adjacent one through the pores of Kohn, giving rise to the characteristic "butterfly" pattern (picture 1 and figure 2) [9].
  • Bronchiolar lesions are secondary to intraluminal plugs of granulation tissue always in association with plugs in the alveolar ducts and alveolar spaces.
  • Severe fibrotic changes, such as honeycombing, are unusual at the time of diagnosis.
  • Giant cells are rare or absent, and no granulomas or vasculitic lesions are present.

The pathogenesis of these changes remains unknown. Abnormal vascular endothelial growth factor and matrix metalloproteinase regulation has been reported in association with COP [10,11]. However, dysregulation of these proteins has been observed in a large number of other pulmonary diseases, and their precise role in the pathogenesis of COP remains speculative [12]. Regulation of angiogenesis appears to influence the reversibility of the fibrotic lesions in COP, compared to the irreversible lesions in usual interstitial pneumonia [10,11].

CLINICAL PRESENTATION — The incidence and prevalence of COP are unknown, though a cumulative incidence of six to seven per 100,000 hospital admissions was found at a major teaching hospital [13]. The disease onset is typically in the fifth or sixth decades of life, with men and women affected equally [14]. Almost three-fourths of the patients are symptomatic for less than two months before presentation (figure 3). Cigarette smoking is not a precipitating factor [15].

Symptoms and signs — The clinical presentation of COP often mimics that of community-acquired pneumonia. In one-half of cases, the onset is heralded by a flu-like illness with fever, malaise, fatigue, and cough. The most common features at presentation are:

  • Persistent nonproductive cough
  • Dyspnea with exertion
  • Weight loss of greater than 10 pounds (57 percent of subjects).

Physical examination often reveals inspiratory crackles (74 percent). Wheezing is rare and is usually present with rales, while clubbing is seen in less than 5 percent of cases [16]. A normal pulmonary examination is found in one-fourth of subjects [6].

Laboratory findings — Routine laboratory studies are nonspecific [5,17,18]. Leukocytosis is present in about 50 percent of patients, while an elevated initial ESR (frequently reaching or exceeding 100 mm) and a positive C-reactive protein are each observed in 70 to 80 percent [9,16]. Autoantibodies are usually negative or present in very low titer [9].

Chest imaging studies

Chest radiograph — The chest radiograph manifestations of COP are quite distinctive, with bilateral, diffuse opacities in the presence of normal lung volumes occurring in most patients (picture 2 and picture 3) [15]. Other changes include:

  • A peripheral distribution of the opacities, similar to that seen in chronic eosinophilic pneumonia, may also be found in COP [5,19].
  • The consolidative and ground-glass opacities are rarely unilateral [20].
  • Recurrent or migratory pulmonary opacities are common (up to 50 percent of subjects in some series) [21].
  • Irregular linear or nodular opacities are rarely present as the only radiographic manifestation (picture 4).
  • Honeycombing is rarely seen at presentation in patients with COP and occurs as a late manifestation in the few patients with progressive disease.
  • Other rare radiographic abnormalities include pleural effusion, pleural thickening, hyperinflation, and cavities.

The severity of the radiographic abnormalities correlates with the extent of histologic involvement of the respiratory bronchioles and alveolar ducts, but not the larger terminal bronchioles.

Computed tomographic scanning — Computed tomographic (CT) lung scans from patients with COP often reveal more extensive disease than expected from review of the plain chest radiograph. Radiographic patterns include patchy air-space consolidation, ground-glass opacities, small nodular opacities, and bronchial wall thickening with dilation (picture 5) [22-25]. Patchy opacities occur more frequently in the periphery of the lung and are often in the lower lung zone.

Confident radiographic differentiation of COP from chronic eosinophilic pneumonia is frequently not possible, as both diseases have a predilection for the peripheral lung fields (picture 6 and picture 7) [26]. Rarely, a single nodule is the only manifestation of organizing pneumonia; this is termed focal organizing pneumonia [27].

Pulmonary function tests — A mild to moderate restrictive ventilatory defect is most common. In contrast, an obstructive defect (FEV1/FVC ratio less than 70 percent) was found in only 20 percent of patients in one report, all of whom were current or former smokers. Lung function is occasionally normal.

The pressure-volume curve is shifted downward and to the right, consistent with a stiff, noncompliant lung. The maximal transpulmonary pressure and the coefficient of elastic recoil (maximum transpulmonary pressure/total lung capacity) are increased.

Gas exchange abnormalities are extremely common. The diffusing capacity (DLCO) is reduced in the majority of patients. Resting and/or exercise arterial hypoxemia (each defined by an alveolar-arterial oxygen gradient greater than 20 mmHg) are present in more than 80 percent of subjects [28].

Bronchoalveolar lavage — The percentage of the volume of bronchoalveolar lavage (BAL) fluid recovered from patients with COP is less than that recovered from healthy volunteers, but the total number of cells recovered is greater from patients with COP [28]. In general, the BAL findings are most similar to those in hypersensitivity pneumonitis. The proportion of macrophages is lower in COP than in normals, whereas the proportions of lymphocytes, neutrophils, and eosinophils are higher [28]. Patients with COP tend to have higher lymphocyte counts than do those with idiopathic pulmonary fibrosis, with expansion of CD8 cells and increased levels of Th1 related cytokines, including IFN-y, IL-12 and IL-18 [29,30].

Other BAL abnormalities found in COP patients include [20,31]:

  • Foamy macrophages
  • Occasionally, mast cells and plasma cells
  • Decreased CD4/CD8 cell ratio, while the percentage of CD57+ cells is normal
  • An increase in activated T-cells, in terms of HLA-DR expression and occasionally interleukin-2 receptor (CD25) expression

The "mixed pattern" of increased cellularity is thought to be characteristic of COP, especially in the proper clinical setting, eg, when associated with multiple alveolar opacities on chest radiograph [9].

DIAGNOSIS — The diagnosis of COP depends on finding the characteristic pathological features of the disease in the proper clinical setting, and the absence of features suggestive of another process (table 2) [9]. The differential diagnosis often includes:

  • Bacterial pneumonia
  • Diffuse alveolar damage (acute respiratory distress syndrome)
  • Hypersensitivity pneumonitis
  • Chronic eosinophilic pneumonia
  • Pulmonary drug reaction
  • Pulmonary disease associated with a connective tissue disorder

Lung biopsy — An open or thoracoscopic lung biopsy is suggested to confirm the diagnosis. Ample lung tissue must be obtained and carefully reviewed to rule out other diseases. Step sectioning of transbronchial biopsies may be useful in identifying the lesions of COP [32], but transbronchial biopsies generally do not provide an adequate sample to definitively confirm COP and rule out other disorders. Because the histologic features of bronchiolitis obliterans associated with areas of organizing pneumonia can be seen in a number of settings, reliance on small transbronchial biopsies increases the chance of missing the central diagnosis.

It is important that the pathologist be given adequate clinical information to guide the search for the specific lesions and patterns that support the diagnosis. Once the characteristic histologic lesions of proliferative bronchiolitis are confirmed, the clinician must ensure that a thorough search has been performed to rule out the many possible processes that induce similar pathological findings (table 2). (See 'Pathological changes' above.)

The clinicopathological syndrome of COP is a diagnosis of exclusion. (See "Role of lung biopsy in the diagnosis of interstitial lung disease".)

TREATMENT — In cryptogenic organizing pneumonia, spontaneous improvement is rare; most patients will need therapy with glucocorticoids, although resection may be adequate initial therapy for focal organizing pneumonia [6,14,17].

Glucocorticoids — Therapy is usually initiated with prednisone at 1.0 to 1.5 mg/kg per day (using ideal body weight) to a maximum of 100 mg/day given as a single oral dose in the morning.

We recommend maintaining this dose for four to eight weeks. If the patient is stable or improved, the prednisone dose is gradually tapered to 0.5 to 1.0 mg/kg per day (using ideal body weight) for the ensuing four to six weeks. High-dose parenteral glucocorticoid therapy (methylprednisolone 125 to 250 mg every six hours intravenously for three to five days) has been recommended as the initial treatment in patients with rapidly progressive severe disease.

Prednisone is gradually tapered to zero if the patient remains stable or improved after three to six months. The patient should be routinely followed with plain chest radiograph and pulmonary function testing every six to eight weeks during the first year, and therapy should be reinstituted aggressively at the sign of any recurrence. Importantly, the chest radiograph may change before the patient develops significant symptoms.

Other immunosuppressive drugs — If the patient has deteriorated despite, or cannot tolerate adequate glucocorticoid therapy, a cytotoxic agent should be started while generally maintaining low-dose (0.25 mg/kg per day) oral prednisone, if tolerated. We most often use cyclophosphamide in this setting. The recommended dose is one to two mg/kg per day (given as a single daily dose), although the optimal dose in COP is unknown. We usually start at 50 mg daily and slowly increase the dose over two to four weeks. We do not recommend exceeding 150 mg/day. A trial of at least three to six months is needed to ensure an adequate opportunity for clinical response.

Hematologic alterations are common side effects of cyclophosphamide therapy and frequently necessitate dose adjustment — the total white blood cell count should be maintained above 4000/mm3. Leukopenia is the most common manifestation of hematologic toxicity, with anemia and thrombocytopenia occurring less often. (See "General toxicity of cyclophosphamide and chlorambucil in inflammatory diseases".)

Macrolide antibiotics — A few case reports have described responses to a macrolide antibiotic (eg, clarithromycin 250-500 mg twice a day) in patients with mild symptoms [6,33,34]. In these cases, a prolonged course of three to six months was needed; tapering of the macrolide to a once daily dose was successful in some patients, but early discontinuation led to recurrent disease. It is thought that the benefit of the macrolide was related to anti-inflammatory rather than antimicrobial effects [33]. More commonly, the diagnosis of COP is made after a patient has failed one or more courses of antibiotics. Macrolides are not indicated for the vast majority of patients, but may be a second line option for patients with mild disease who are intolerant of glucocorticoids.

Focal organizing pneumonia — Resection is adequate initial therapy for most patients with focal organizing pneumonia. In two retrospective studies of a combined total of 43 patients, focal organizing pneumonia was found in resected solitary pulmonary nodules [27,35]. No further therapy was given and there was no recurrence in 41 patients; the two patients with local recurrences were treated successfully with glucocorticoids.

PROGNOSIS — Recovery, usually with complete clinical and physiologic improvement and normalization of the chest film, occurs in two-thirds of patients treated with glucocorticoids (figure 4) [1]. Approximately one-third of patients demonstrate persistent disease. Improvement is occasionally quite dramatic, occurring in one to two weeks. Serial HRCT scans may reveal persistent abnormalities despite clinical improvement [25]. However, most patients improve within several weeks to three months.

Relapses are common and may occur when the glucocorticoids are withdrawn after one to three months of treatment. In some series, over one-half of patients experience at least one clinical relapse during the course of their disease [8,25,36]. Most of these patients will improve when retreated with glucocorticoids, and the occurrence of relapses generally does not appear to affect the overall long-term prognosis.

Those patients with persistent or frequently recurrent (>3 episodes) may require continuous treatment with prednisone, cyclophosphamide, or both. Patients with airspace opacities on chest radiograph have a much better outcome than those with interstitial opacities [18,37].

The overall prognosis of COP is much better than that of other interstitial lung disease, such as idiopathic pulmonary fibrosis. Rapidly fatal COP is uncommon [38].

SUMMARY AND RECOMMENDATIONS

  • Cryptogenic organizing pneumonia (COP) is a distinct clinical entity with predominant features of pneumonia, rather than those of a primary airway disorder. (See 'Introduction' above.)
  • Disease onset is typically in the fifth or sixth decades of life, with men and women affected equally. Most patients are symptomatic for less than two months, with a clinical presentation that mimics community-acquired pneumonia (eg, cough, dyspnea with exertion, weight loss). Approximately half of cases are heralded by a flu-like illness. (See 'Clinical presentation' above.)
  • Multiple ground-glass or consolidative opacities are the most frequent and typical features of COP identified by chest imaging. (See 'Chest imaging studies' above.)
  • Histopathologic lesions characteristic of COP include excessive proliferation of granulation tissue within small airways (proliferative bronchiolitis) and alveolar ducts, associated with chronic inflammation in the surrounding alveoli. (See 'Pathological changes' above.)
  • The diagnosis of COP requires histopathologic identification of organizing pneumonia and the exclusion of any possible cause, which may be relatively evident or may require a laborious search. (See 'Diagnosis' above.)
  • An open or thoracoscopic lung biopsy is recommended to confirm the diagnosis. (See 'Diagnosis' above.)
  • Glucocorticoid therapy induces rapid clinical improvement and clearing of the opacities on chest imaging, usually without significant sequelae. Relapses are common upon stopping or reduction of glucocorticoids, often leading to prolonged treatment. (See 'Treatment' above.)
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  11. Lappi-Blanco E, Soini Y, Kinnula V, Pääkkö P. VEGF and bFGF are highly expressed in intraluminal fibromyxoid lesions in bronchiolitis obliterans organizing pneumonia. J Pathol 2002; 196:220.
  12. Suga M, Iyonaga K, Okamoto T, et al. Characteristic elevation of matrix metalloproteinase activity in idiopathic interstitial pneumonias. Am J Respir Crit Care Med 2000; 162:1949.
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  14. Oymak FS, Demirbaş HM, Mavili E, et al. Bronchiolitis obliterans organizing pneumonia. Clinical and roentgenological features in 26 cases. Respiration 2005; 72:254.
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  17. Müller NL, Guerry-Force ML, Staples CA, et al. Differential diagnosis of bronchiolitis obliterans with organizing pneumonia and usual interstitial pneumonia: clinical, functional, and radiologic findings. Radiology 1987; 162:151.
  18. Bartter T, Irwin RS, Nash G, et al. Idiopathic bronchiolitis obliterans organizing pneumonia with peripheral infiltrates on chest roentgenogram. Arch Intern Med 1989; 149:273.
  19. Izumi T, Kitaichi M, Nishimura K, Nagai S. Bronchiolitis obliterans organizing pneumonia. Clinical features and differential diagnosis. Chest 1992; 102:715.
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  23. Costabel U, Teschler H, Guzman J. Bronchiolitis obliterans organizing pneumonia (BOOP): the cytological and immunocytological profile of bronchoalveolar lavage. Eur Respir J 1992; 5:791.
  24. Kim SJ, Lee KS, Ryu YH, et al. Reversed halo sign on high-resolution CT of cryptogenic organizing pneumonia: diagnostic implications. AJR Am J Roentgenol 2003; 180:1251.
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  26. Arakawa H, Kurihara Y, Niimi H, et al. Bronchiolitis obliterans with organizing pneumonia versus chronic eosinophilic pneumonia: high-resolution CT findings in 81 patients. AJR Am J Roentgenol 2001; 176:1053.
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  30. Forlani S, Ratta L, Bulgheroni A, et al. Cytokine profile of broncho-alveolar lavage in BOOP and UIP. Sarcoidosis Vasc Diffuse Lung Dis 2002; 19:47.
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  36. Lazor R, Vandevenne A, Pelletier A, et al. Cryptogenic organizing pneumonia. Characteristics of relapses in a series of 48 patients. The Groupe d'Etudes et de Recherche sur les Maladles "Orphelines" Pulmonaires (GERM"O"P). Am J Respir Crit Care Med 2000; 162:571.
  37. Chandler PW, Shin MS, Friedman SE, et al. Radiographic manifestations of bronchiolitis obliterans with organizing pneumonia vs usual interstitial pneumonia. AJR Am J Roentgenol 1986; 147:899.
  38. Cohen AJ, King TE Jr, Downey GP. Rapidly progressive bronchiolitis obliterans with organizing pneumonia. Am J Respir Crit Care Med 1994; 149:1670.
Espero que mi respuesta le resulte útil, si ha sido así le agradecería que la aceptase y siguiese preguntando sus dudas.

Un saludo!
Cliente: escribió hace 5 año.

Estimado doctor

En atención a las dificultadfes y tardanza en obtener una respuesta satisfactoria a mis necesidades de información, me he contactado con la Sociedad Chilena de Enfermedades Respiratorias a fin de obtener la información requerida. En consecuencia he dado por satisfechas mis consultas.

Atte.
juvar.
Experto:  Pablo Rodríguez escribió hace 5 año.
Espero que ellos resuelvan de forma adecuada sus dudas, un saludo.

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    Clientes satisfechos:

    300
    Licenciado en Medicina y Cirugía.Especialista en Endocrinología y Nutrición.Especialista en Urología.
  • http://ww2.justanswer.es/uploads/DS/dspalma/2012-10-18_23912_facebook14920836141.64x64.jpg Avatar de Dra. Debora Palma

    Dra. Debora Palma

    Postdoctorado

    Clientes satisfechos:

    201
    doctora en medicina con especialidad en cirugia general
  • http://ww2.justanswer.es/uploads/JU/juancarlosvillanueva/2013-3-7_9363_Dr.JCVillanueva.64x64.JPG Avatar de juancarlosvillanueva

    juancarlosvillanueva

    Médico

    Clientes satisfechos:

    56
    Licenciado en Medicina y Cirugía Universidad de Valencia año 1983
  • http://ww2.justanswer.es/uploads/PA/pablo.rdt/2013-3-14_17142_IMG0614.64x64.JPG Avatar de Pablo Rodríguez

    Pablo Rodríguez

    Licenciatura

    Clientes satisfechos:

    11179
    Médico adjunto de Servicio de Urgencias Hospitalarias. Consulta de Medicina Familiar y Comunitaria
  • http://ww2.justanswer.es/uploads/DR/drgamboa/2015-4-8_1861_foto.64x64.jpg Avatar de Dr. Jorge Gamboa

    Dr. Jorge Gamboa

    Especialidad Medicina Integrada

    Clientes satisfechos:

    1106
    Especialista en Enfermedades Crónicas de los Adultos
 
 
 

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