5/NOV/21

FICHA CLINICA
NOMBRE: N. G. J
SEXO:
MASCULINO
EDAD: 36 AÑOS
OCUPACIÓN:
POLICIA VIAL
MOTIVO DE CONSULTA:
TCE
CONTUSIÓN HOMBRO IZQ
PB FX CLAVICULA
SEC A ACCIDENTE EN MOTOCICLETA

APNP ENF:
PADRE FINADO HACE 8 AÑOS POR INSUF.
RESP.
MADRE FINADA POR 3 AÑOS POR CA
CASA CON TODOS LOS SERVICIOS
 5/NOV/21

FICHA CLÍNICA 
Nombre: N. G. J 
Sexo: Masculino
Edad: 36 años
Ocupación: Policía
vial 

MOTIVO DE CONSULTA:
Paciente policontundido secundario a 
accidente en motocicleta

APNP:
No relevantes 
APP:
Traumatismos: TCE en regió frontal, hace
años, sin complicaciones. 

Fracturas: hace 20 años fractura en falange

de mano izquierda
Alergias: Penicilina
Alcoholismo: Ocasional
Tabaquismo: +, Crónico de 20 años de
evolución, 10 cigarros por día
INTERROGATORIO DIRECTO: 

Alrededor de las 19:30 hrs mientras conducía en su

moto (con casco, sin influencia de estupefacientes)
pierde el control al intentar esquivar el tráfico y sale
eyectado alrededor de 10 mts. 

Refiere no recordar lo ocurrido desde la caída hasta

encontrarse en el suelo (desconoce tiempo
especifico).

Acude a hospital particular por contar con seguro de

gastos médicos municipales, se coloca vendaje en 8
para inmovilizar por posible fractura + diclofenaco
c/6 hrs  sin recordar dosis.  

Al llegar a hospital particular refieren no cuenta con

cobertura por lo que decide acudir a esta unidad por
sus propios medios.
 URGENCIAS

AMNESIA ENTROGRADA NEUROLóGICO

GLASGOW 15
HEMATOMA SUPRAORBITRARIO
CABEZA IZQUIERDO
1. DOLOROSO A LA CUELLO
MOVILIZACIÓN
2. EXTREMIDAD SUPERIOR
IZQUIERDA CON LIMITACIÓN
EN ARCOS DE MOVILIDAD A
NIVEL DE HOMBRO Y MANO,
EL PACIENTE REFIERE QUE
SIENTE COMO SE MUEVE EL
HUESO. 

Politraumatismo

DX
1. TCE 
%2. CONTUSIÓN HOMBRO IZQ PB FX CLAVÍCULA
3. CONTUSIÓN DE MANO
4. HEMATOMA SUPRAORBITRARIO IZQUIERDO
 URGENCIAS
(ABCDE)
Px poli-contundido sec accidente automovilístico de alta cinemática
Protocolo de trauma
Exploración física completa
Estudios de imagen, pruebas de laboratorio
Monitoreo continuo

MANEJO
MULTIDISCIPLINARIO

Interconsulta a traumatología por pb fractura de clavícula izquierda

 SERIE DE TRAUMA:

CRÁNEO
TÓRAX
PELVIS

CERVICALES
(LATERALES)
EXTREMIDADE
S AFECTADAS
 Biometria hematica
hB: 16.9 g/dl
LABORATORIALES
Hto: 48.9%
Leucocitos: 17.2 miles
Pqt: 222 mil

Quimica Sanguinea
Glucosa: 107 mg/dl
Urea: 35 mg/dl
Cr: 0.7 mg/dl
Leucocitosis
Glicemia ligeramente
Electrolitos sericos elevada
Cl: 100 mmol
K: 3.8 mmol
Na: 135 mmol
CPK: 196 U/l

Tiempos:
TP: 12.4
INR: 1.09
TPT: 30.5
 ESTUDIOS DE IMAGEN

CLAVICULA
AP DE CLAVICULA IZQUIERDA CON SOLUCION DE CERVICALES
CONTINUIDAD A NIVEL DE TERCIO MEDIO, TRAZO
OBLICUO CON DEZPLAZAMIENTO DE 19 MM CON
CABALGAMIENTO ENTRE FRAGMENTOS. Columna rectificada, sin datos de
listesis o soluciones de continuidad
 TÓRAX LUMBAR
SIN ALTERACIONES Sin datos de listesis, escoliosis ni soluciones de
continuidad
 TAC SIMPLE DE CRANEO
Integridad del parénquima, sin datos de solución de
continuidad , sin deviación de la línea media, sin datos de
hematomas
 TCE

FRACTURA DE CLAVICULA IZQUIERDA

DIAGNOSTICOS
 DIAGNOSTICO
TRAUMATOLOGIA Y ORTOPEDIA
• TCE
• CONTUSIÓN EN MANO DERECHA
EXP. FISICA: • FRACTURA DE CLAVICULA IZQUIERDA AO 15 A2 ALLMAN 1
• CUELLO SIN DOLOR A LA • HEMATOMA SUPRAORBITRARIO IZQUIERDO
PALPACIÓN DE APOFISIS ESPINOZAS Y • ESGUINCE CERVICAL GRADO 1
MOVILIZACIÓN
• NO DOLOR NI CONTRACTURA DE
TRAPECIO
• DOLOR A LA PALPACIÓN DE CLAVICULA
IZQUIERDA SIN EMINENCIA DE
EXPOSICIÓN, SIN EQUIMOSIS
• EXCORACIONES EN AMBAS MANOS Y
RODILLAS, MANO DERECHA CON EDEMA
Y DOLOR A LA PALPACIÓN , SIN
ALTERACIONES DE LA MOVILIDAD DE LA
MUÑECA Y FALANGES
 MANEJO
INMOVILIZADO
EN
R DE HOMBRO
MIEMBRO AFECTADO
UNIVERSAL

PROTOCOLO
PRE
QUIRURGICO

QX MERITATORIA DE
MANEJO QUIRURGICO
SE MANEJA DE MANERA
EXTERNA POR PARTE DE URGENCIAS
TYO
DATOS DE ALARMA EVITAR ACT FISICA HASTA NUEVO AVISO
EXTENUANTE

HIELO MEDIOS FISICOS

15 MIN 3 VECES AL DIA
EN MANO DERECHA
 17/11/21

RAFI DE CLAVICULA BUENA EVOLUCIÓN

1 IZQUIERDA CLINICA 1
DONAT
E
CX SIN ALTA
2 COMPLICACIONES BLOOD 2

HERIDA QUIRURGICA DE 7 CM DE SEGUIMIENTO POR

3 LONGITUD CON BORDES NITIDOS,
BIEN AFRONTADOS SIN CONSULTA EXTERNA 3
DESHICIENCIA, SIN DOLOR A LA DE TRAUMATOLOGIA
PALPACIÓN

WHO CAN
REASONS TO BE
DONATE
A DONOR
BLOOD?
 ALTA
CIPROFLOXACINO 250
MG C/12 HRS X 14 DIAS
CELECOXIB 200 MG
TABLETAS VIA ORAL
C/12 HRS POR 10 DÍAS
INMOVILIZADOR (CABESTRILLO X
4 SEMANAS)
LIMPIEZA DIARIA DE HERIDA
EXTREMIDAD ELEVADA
EVITAR EL APOYO Y CARGAR
PESO k

3
RETIRO DE PUNTOS 01/12/21
 RESUMEN DEL INTERROGATORIO
INTERROGATORIO DIRECTO:
ALREDEDOR DE LAS 19:30 HRS MIENTRAS CIRCULABA EN SU
MOTOCICLETA (CON CASCO, SIN INFLUENCIA DE
ESTUPEFACIENTES). PIERDE EL CONTROL AL INTENTAR
ESQUIVAR EL TRAFICO, SALE EYECTADO ALREDEDOR DE 10 MTS.
REFIERE NO RECORDAR LO OCURRIDO DESDE LA CAÍDA HASTA
ENCONTRARSE EN EL SUELO (DESCONOCE TIEMPO ESPECIFICO).
ACUDE A HOSPITAL PARTICULAR POR CONTAR CON SEGURO DE
GASTOS MEDICOS MUNICIPALES QUIENES COLOCAN VENDAJE EN
8 PARA INMOVILIZAR POR POSIBLE FRACTURA. ACUDE A HOSP
PARTICULAR POR CONTAR CON SEGURO DE GASTOS MEDICOS
MAYORES PERO AL INGRESAR REFIEREN NO CUENTA CON
COBERTURA POR LO QUE DECIDE ACUDIR A ESTA UNIDAD POR
SUS PROPIOS MEDIOS.
 Patient Care Infographics

Diagnostico:
TCE LEVE POR GASGLOW DE RIESGO MODERADO
FX DE CLAVICULA IZQUIERDA DESPLAZADA
ESGUINCE CERVICAL

HEADACHE
5
SYMPTO
MS OF Yes, this is the ringed one. It’s composed of hydrogen and helium
STROKE TROUBLE
SPEAKING
Mercury is the closest planet to the Sun and the smallest of them all

LOSS STRENGTH
Neptune is the fourth-largest planet by diameter in the Solar System

LOSS BALANCE
Despite being red, Mars is a cold place full of iron oxide dust
 Patient Care Infographics

STEPS TO FEEL BETTER

STEP 1 STEP 2 STEP 3 STEP 4 STEP 5

Mercury is the Earth is the Venus has a Mars is a cold Jupiter is a

smallest third planet nice name place gas giant
 Patient Care Infographics

Jupiter is a gas Neptune is the Despite being

giant and the furthest planet red, Mars is a
biggest planet TWO from the Sun FOUR cold place

ONE Saturn is a gas THREE Mercury is the FIVE

giant and has closest planet to
several rings the Sun
 Patient Care Infographics

HEART ATTACK SYMPTOMS

MARS NEPTUNE URANUS SATURN EARTH

JUPITER THE SUN MARS VENUS MERCURY

 Patient Care Infographics

Mercury is the smallest

PREVENTION planet in the entire Solar
System
COVID-19
Jupiter is a gas giant and It’s full of iron oxide dust,
the biggest planet in the which gives the planet its
Solar System reddish cast

Yes, this is the ringed one. Neptune is the fourth-

It’s composed mostly of largest planet in the Solar
hydrogen and helium System
 Patient Care Infographics

It’s now a JUPITE Jupiter is a

dwarf planet PLUTO gas giant
R
Neptune is
Mercury is MERCU NEPTU the farthest
the smallest RY NE

Venus has a Earth is the

nice name VENUS EARTH third planet

SATUR Saturn is the

Mars is a
MARS ringed one
cold place N
 Patient Care Infographics

MERCURY
Mercury is the closest planet
to the Sun and the smallest
SATURN
one in the Solar System
This is the ringed one. It’s a
gas giant, composed mostly of MARS
hydrogen and helium
Despite being red, Mars is a
VENUS cold place. The planet is full
of iron oxide dust
Venus has a beautiful name,
but it’s terribly hot, even hotter
than Mercury
 Patient Care Infographics

Mercury is the closest planet to

MERCU the Sun and the smallest one in
WHAT TO DO IN RY the Solar System

CASE OF AN
ACCIDENT
Venus has a beautiful name Despite being red, Mars is a cold
and is the second planet from SATURN place. The planet is full of iron
the Sun. It’s terribly hot and oxide dust
its atmosphere is extremely
poisonous. It’s the second-
brightest natural object in the
night sky NEPTUN Neptune is the farthest planet
from the Sun and the fourth-
E largest by diameter
 Patient Care Infographics

Venus has a beautiful name and

39°C FEVER is the second planet from the Sun.
It’s hotter than Mercury and its
atmosphere is poisonous

Mercury is the closest planet to

36.6° NORMAL BODY the Sun and the smallest one in
C TEMPERATURE the Solar System—it’s only a bit
larger than our Moon
 Patient Care Infographics

PREVENTION OF BREAST
CANCER
20 30 40
YEARS YEARS YEARS
SELF- CLINICAL MAMMOGRAPH
EXAMINATION EXAMINATION Y DETECTION
Despite being red, Mars Jupiter is a gas giant and Saturn is the ringed one.
is a cold place. It’s full the biggest planet in our It’s a gas giant, composed
of iron oxide dust, which Solar System. It’s the mostly of hydrogen and
gives the reddish cast fourth-brightest object helium
 Patient Care Infographics

JUPITER
Jupiter is a gas giant
and the biggest planet
in the Solar System VENUS
Venus has a beautiful
name, but it is a
terribly hot planet

SATURN
Saturn is composed
mostly of hydrogen FIRST AID KIT MARS
and helium
Despite being red,
Mars is a cold place
full of iron oxide dust
 Patient Care Infographics

SYMPTOMS TREATMENT
Despite being red, Mars is a cold place. Mercury is the closest planet to the
It’s full of iron oxide dust, which gives Sun and the smallest planet in the
the planet its reddish cast Solar System

It’s a gas giant and the biggest planet Jupiter is a gas giant and the biggest
in our Solar System. Jupiter is the planet in our Solar System. It’s the
fourth-brightest object in the sky fourth-brightest Solar System

Saturn has multiple rings, it’s the This is the ringed one. Saturn is a gas
ringed one. It’s a gas giant, composed giant planet, composed mostly of
mostly of hydrogen and helium hydrogen and helium
 Patient Care Infographics

TYPE A
CARDIAC 85%
The Sun is the star at the
ARRHYTHMIA center of the Solar System
Mercury is the closest
planet to the Sun and the
smallest one in the Solar
System—it’s only a bit
larger than the Moon. TYPE B 25%
The planet’s name has
nothing to do with the Venus has a beautiful
liquid metal name, but it’s terribly hot

TYPE C 45%
Jupiter is the biggest
planet in the Solar System
 Patient Care Infographics

IMPROVE THE SYMPTOMS OF THE Mercury is the closest

planet to the Sun
IRRITABLE COLON

Mercury is the closest Venus has a beautiful

planet to the Sun and the name, but it’s very hot
smallest one in the Solar
System—it’s only a bit
larger than the Moon.
The planet’s name has Despite being red, Mars
nothing to do with the is a cold place
liquid metal, since it was
named after the Roman
messenger god, Mercury
Yes, this is the ringed
one. It’s a gas giant
 Patient Care Infographics

IMPROVE THE SYMPTOMS OF THE IRRITABLE COLON

Mercury is the closest Despite being red, Mars

planet to the Sun is a cold place

Venus has a beautiful Yes, this is the ringed

name, but it’s very hot one. It’s a gas giant

Neptune is the farthest Jupiter is a gas giant

planet from the Sun and the biggest planet
 Patient Care Infographics

SATURN
Saturn is the ringed one.
It’s composed mostly of
hydrogen and helium

MERCURY
Mercury is the closest
planet to the Sun and the
smallest one EMERGENC
Y MARS
Despite being red, Mars is a
PROTOCOL cold place. The planet is full
of iron oxide dust
VENUS
Venus has a beautiful
name and is the second
planet from the Sun
 Patient Care Infographics

Venus has a really beautiful Despite being red, Mars is A

name, but it’s very hot cold place, is full of iron

Saturn is the one with multiple Venus has a really beautiful

rings. It’s a gas giant name, but it’s very hot

TREATMENT EVALUATION

Neptune is the farthest planet Yes, this is the one with

from the Sun of them all multiple rings. It’s a gas giant

Jupiter is the biggest planet in Mercury is the closest planet to

the Solar System the Sun and the smallest one
 Patient Care Infographics

Mercury is the TIRED VISION Neptune is the

closest planet farthest planet
to the Sun from the Sun

Venus has a It’s the biggest

cute name, but planet in our
it’s very hot Solar System

Despite being Mercury is the closest planet to Yes, this is the

red, Mars is a the Sun and the smallest one in ringed one. It’s
cold place the Solar System a gas giant
 Patient Care Infographics

NURSING MERCURY
Despite being red, Mars is a cold place, not It’s the biggest planet in
hot. It’s full of iron oxide dust, which gives 01. the Solar System
the planet its reddish cast

VENUS MARS
Venus has a beautiful 03. 02. Despite being red, Mars
name, but it’s very hot is a cold place

04.
SATURN
Yes, this is the ringed
one. It’s a gas giant
 Patient Care Infographics

KEEP YOUR MIND IN SHAPE

VENUS MARS
Venus has a beautiful Despite being red,
name, but it’s very hot Mars is a cold place

MERCURY SATURN
Mercury is the closest Yes, this is the ringed
planet to the Sun one. It’s a gas giant
 Patient Care Infographics

DENTAL
CARE

VENUS MERCURY MARS JUPITER

Venus has a Mercury is the Despite being It’s the biggest
beautiful name, closest planet red, Mars is a planet in the
but it’s hot to the Sun cold place Solar System
 Patient Care Infographics

GOOD
HEALTH & THE SUN
GOOD The Sun is the star at the
center of the Solar System
HABITS
MARS VENUS
Despite being red, Mars is Venus has a beautiful name,
a cold place but it’s terribly hot

JUPITER Mercury is the closest

planet to the Sun and the
Jupiter is the biggest planet smallest one in the Solar
in the Solar System System—it’s only a bit
larger than the Moon
 Patient Care Infographics

THE VACCINE
80%
Mercury is the closest planet to the Sun
and the smallest one in the Solar
WOME
System—it’s only a bit larger than the N
Moon

70%

MEN
VACCINATED PEOPLE
The Sun is the star at the center of the
30%
Solar System

KIDS
 Patient Care Infographics

FLU SEASON

HEADACHE GENERAL
Jupiter is a gas giant and DISCOMFORT
Despite being red, Mars is
the biggest planet in the a cold place full of iron
Solar System oxide dust

RHINORRHEA COUGH
Mercury is the smallest Saturn is a gas giant
planet in the Solar composed mostly of
System hydrogen and helium