CASO CLÍNICO

SERVICIO: ARO II

Interna:
Lizeth Yandira Huamancayo Apacclla
Filiació
n
Nombres y Apellidos Cortez Lázaro Katherine
Edad 28 Años
Fecha de Nacimiento 17/10/1992
Lugar de Nacimiento Huancavelica
Lugar de Procedencia El Tambo – Huancayo
Estado civil Casada
Religión Católica
Grado de instrucción Secundaria complete
Ocupación Ama de Casa
Fecha de Ingreso 27/09/21
Modalidad de Ingreso Emergencia
 Antecedentes fisiológicos
G4 P1 1 1 2
FUR 05-02-21
FPP 14-11-21
EG 33 2/7 HTA Niega VHB Niega
CPN 06 DM Niega VHC Niega

1RS 18 años ASMA Niega VIH Niega

N°PS 1
TIROIDES Niega TBC Niega
MENARQUÍA 15 años
CARDIOPATÍA Niega COVID Niega
PAP 2015-Negativo
MAC Ampolla trimestral EPILEPSIA Niega ANEMIA Niega
ITS Niega
ANTECEDENTES PATOLÓGICOS PERSONALES

2011 2014 2018

CESÁREA CESÁREA
Trabajo de Presentación LU por aborto
parto podálica incompleto
detenido Pretérmino

ANTECEDENTES FAMILIARES
• MAMÁ: 54a Aparentemente sana
• PAPÁ: 56 a Hipertensión arterial hace 5 años (en
tratamiento)
INGRESO POR EMERGENCIA

TE 1 Enfermedad Actual:
5 días

SIGNOS Y
-Epigastralgia
SÍNTOMA 2 -Náuseas
S -Contracciones
uterinas

RELATO 3
RELATO

Paciente refiere que cuadro

clínico inició hace 5 días
aproximadamente caracterizado
por epigastralgia de intensidad
6/10 asociado a sensación de
náuseas sin llegar al vómito.
Hace 1 día se añaden
contracciones uterinas de regular
intensidad y frecuencia además
de dolor a nivel de heridas
anteriores de cesáreas.
 FUNCIONES VITALES
PA: 110/70 mmhg
EXAMEN FÍSICO FC: 82 lpm
FR: 18 rpm
Paciente con fascie dolorosa, buen estado general, T°: 36,6 ºc
LOTEP, Glasgow 15/15, AREH, AREN para su edad, P: 75 kg
coloreado, perfundico. T: 1.55 cm
IMC: 31

ABDOME EXTREMI
APAR CV GINECOL
N D

No sangrado vaginal,
Ocupado por útero grávido.
no pérdida de líquido.
AU: 31 cm No edemas
Rítmico con buena D: 0 cm
frecuencia, sin SPP: LDP
I: 50%
soplos. LCF: 136-146 Tono y fuerza
AP: -3 muscular
DU: Espontáneo conservado
MO: Íntegras
MF: ++/+++
Pelvis ginecoide
 DIAGNÓSTICO PRESUNTIVO

Sindrómico Nosológico Etiológico

• Sindrome doloroso • Multigesta de 33ss 2/7 x • Antecedente de parto

abdominal. FUR pretérmino
• Cesareada anterior 2
veces
• Amenaza de parto
pretérmino
 PLAN DE TRABAJO
DIAGNÓSTICO

EXAMENES DE EXAMENES DE EXAMENES

LABORATORIO IMAGEN ESPECIALES

 Hemograma completo • Ecografía - NST

 Examen Bioquímico: Doppler
Glucosa, creatinina,
Urea.
 Examen completo de
orina
 Plan de trabajo
Diagnóstico
EXAMENES DE LABORATORIO EXAMENES DE IMAGEN
 Hemograma completo • Ecografía TV
 Exam. Bioquímico:
Glucosa, urea, creatinina.
 Examen completo de orina
 HEMOGRAMA:
1. Hemoglobina → 17.1 g/dl
2. Hematocrito → 40%
3. Lleucocitos: 7.520
4. Recuento de plaquetas: 336.000 / ml

BIOQUÍMICO:
LABORATORIO 1. Úrea → 11.2 mg/dl
AL INGRESO 2. Creatinina → 0,72 mg/dl
3. Glicemia → 102,8 mg/dl

EXAMEN DE ORINA
1. Células epiteliales → Escasos
2. Leucocitos → 0-1 x campo
3. Hematies → 0-1 x campo
 ECOGRAFÍA
GINECOLOGICO

• CONCLUSIONES:
Miomatosis uterina múltiple
Miomatosis uterina gigante:
91x91mm
 Diagnóstico
Definitivo
Sindrómico Nosológico Etiológico

• Sindrome doloroso • Hemorragia uterina • Nuliparidad

abdominal. anormal
• Miomatosis uterina
 Plan
terapéutic
1. NPO
o
2. 1 vía periférica calibre #20 → ClNa 0,9%
3. Opioides → Tramadol 100mg IV c/4h
4. Antibiótico → 1gr x/6h
5. Tratamiento definitivo → Histerectomía
6. CFV
7. Sonda Foley
8. Examen de riesgo quirúrgico
 HISTERECTOMÍA ABDOMINAL
TOTAL
SOP +
SALPINGOOFORECTOMÍA
BILATERAL

HALLAZGOS:
• ÚTERO: 14 cm
• ANEXO DERECHO: Ovario y
trompa sin alteraciones
• ANEXO IZQUIERDO: Ovario y
trompa sin alteraciones
• Sangrado: 200 cc
 HEMOGRAMA:
1. Hemoglobina → 15.2 g/dl
2. Hematocrito → 35.6%
3. Lleucocitos: 14. 430
4. Recuento de plaquetas: 316.000 / ml

LABORATORIO
POST-OPERATORIO

BIOQUÍMICO:
1. Úrea → 10.2 mg/dl
2. Creatinina → 0,82 mg/dl
3. Glicemia → 96,8 mg/dl
PA: 90/50 mmhg
FC: 88 lpm <EVOLUCIÓN
FR: 20 rpm
T°: 37,2 ºC Paciente en su 5to día enDIURNA>
el servicio, refiere haber amanecido
SatO2: 92%
S tranquila, con leve dolor a nivel de herida operatoria, no náuseas,,
no vómitos,
Paciente diuresis espontáneamente
ventilando (+), deposiciones (+)
en AREG, AREN, AREH, al
examen físico:
Piel: T/H/E llenado capilar <2 segundos
Aparato CV: Ruidos cardiacos rítmicos de buen tono e intensidad, no
soplos
O Aparato Resp: Murmullo vesicular pasa bien en ambos hemitórax, no
ruidos agregados
Abdomen: Blando depresible RHA (++/+++) leve dolor a la palpación
profunda en hemiabdomen inf HO: Afrontada, sin signos
de flogosis,
Paciente no eritematoso, sin estable,
hemodinamicamente salida deafebril,
secreción
con purulenta
los
siguientes diagnósticos:
A 1.- PO3 + HAT + Salpingooforectomía bilateral por
miomatosis uterina gigante

• Antibioticoterapia
• Tratamiento analgésico
P • Continuar deambulación
• Posibilidad de alta
 Plan
terapéutic
o
1. DC + LAV
2. 1 vía periférica calibre #20 → ClNa 0,9%
3. Opioides → Tramadol 100mg IV c/8h
4. Antipirético → Metamizol 2gr PRN T° >38,5
5. Antibióticos → Clindamicina 900mg c/8h
Gentamicina 240mg c/24h
6. Iniciar ambulación
7. CFV
FECHA DE ALT
INGRESO A
SOP 24-27 27/09
22/09
POS
HOSPITALIZAC 24/09
T
IÓN -
GINECOLOGÍA PO3
 Alta con
indicaciones
1. Paracetamol 500mg c/8h x 3 días
2. Clindamicina 300mg c/8h x 5 días
3. Control en su Centro de salud en 5 días
Retiro de puntos en el mismo centro en 7 días
4. Control por telemedicina de Ginecología en 7
días
GRACIAS
 Creativity Infographics

Earth
Mercury
It’s the biggest
planet of them all

Neptune is the
farthest planet Saturn is a gas
from the Sun giant and has
It’s now several rings
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cold place a dwarf
planet
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Mars Neptune
It’s actually a Neptune is
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Jupiter Earth Saturn
Jupiter is the Earth is the A gas giant
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rings
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Mars
Despite being red,
it’s actually a cold
Saturn place
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has several rings
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It’s the farthest
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biggest planet of
them all
1 2 3 4
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Jupiter is the biggest planet Mercury is the closest planet
in the Solar System to the Sun

Saturn Earth
Saturn is a gas giant and has Earth is the third planet from
several rings the Sun
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Jupiter Mars Saturn Neptune Mercury Earth

Jupiter is the Saturn is a Neptune is Mercury is
Despite being Earth is the
biggest gas giant and the farthest the closest
red, Mars is a third planet
planet of has several planet from planet to the
cold place from the Sun
them all rings the Sun Sun
 Creativity Infographics
Mars Mercury Earth
Despite being red, it’s Mercury is the closest Earth is the third
actually a cold place planet to the Sun planet from the Sun

Jupiter Saturn Neptune

Jupiter is the biggest It’s a gas giant and has It’s the farthest planet
planet of them all several rings from the Sun
 Creativity Infographics

Jupiter
Jupiter is the biggest
planet of them all
4
Neptune
It’s the farthest
planet from the Sun 3

Mercury
2 Mercury is the
closest planet to the
Sun

Earth
1 Earth is the third
planet from the Sun
 Creativity Infographics

Jupiter Mars Saturn Neptune Mercury Earth

Jupiter is the Saturn is a Neptune is Mercury is
Despite being Earth is the
biggest gas giant and the farthest the closest
red, Mars is a third planet
planet of has several planet from planet to the
cold place from the Sun
them all rings the Sun Sun
 Creativity Infographics

1 Jupiter 3 Mars
Despite being red,
Jupiter is the biggest it’s actually a cold
planet of them all place

2 Saturn 4 Neptune
Saturn is a gas giant Neptune is the
and has several farthest planet from
rings the Sun
 Creativity Infographics

Mars Mercury Earth

Despite being red, it’s Mercury is the closest Earth is the third
actually a cold place planet to the Sun planet from the Sun

Jupiter Saturn Neptune

Jupiter is the biggest It’s a gas giant and has It’s the farthest planet
planet of them all several rings from the Sun
 Creativity Infographics

Jupiter Mercury
Jupiter is the biggest It’s the closest planet
planet of them all to the Sun

Neptune Earth
It’s the farthest It’s the third planet
planet from the Sun from the Sun

Saturn Mars
Despite being red,
It’s a gas giant and
it’s actually a cold
has several rings
place
 Creativity Infographics
1

Jupiter 2
Jupiter is the
biggest
planet of
them all

Mars 3
Despite
being red,
Mars is a
cold place

Saturn 4 Neptune
Saturn is a Neptune is
gas giant the farthest
and has planet from
several rings the Sun
 Creativity Infographics
It’s the fifth planet
from the Sun and the
largest in the Solar
Jupiter
System
It’s the eighth and
Neptune farthest-known solar
planet from the Sun
It’s the fourth planet
from the Sun and it’s Mars
a cold place
It’s a gas giant with
an average radius of
Saturn about nine times that
on Earth
Venus is the second
planet from the Sun
and has a beautiful
Venus
name
 Creativity Infographics

Jupiter Mercury
Jupiter is the biggest It’s the closest planet
planet of them all to the Sun

Neptune Earth
It’s the farthest It’s the third planet
planet from the Sun from the Sun

Saturn Mars
Despite being red,
It’s a gas giant and
it’s actually a cold
has several rings
place
 Creativity Infographics

Jupiter Mars

Jupiter is the biggest Despite being red,

planet of them all Mars is a cold place

Neptune Saturn
Neptune is the
Saturn is a gas giant
farthest planet from
and has several rings
the Sun
 Creativity Infographics

Mercury
Mercury is the
closest planet to the
1
Sun
Earth
2 Earth is the third
planet from the Sun
Mars
Despite being red,
it’s actually a cold
3
place
Neptune
4 It’s the farthest
planet from the Sun
Jupiter
Jupiter is the biggest 5
planet of them all
Saturn
6 It’s a gas giant and
has several rings
 Creativity Infographics

Jupiter is the Despite Saturn is a

biggest being red, gas giant and
planet of Mars is has several
them all actually cold rings

Neptune is Mercury is
Earth is the
the farthest the closest
third planet
planet from planet to the
to the Sun
the Sun Sun
 Creativity Infographics

Jupiter Mars Saturn Neptune Mercury

Jupiter is the Saturn is a Neptune is Mercury is
Despite being
biggest gas giant and the farthest the closest
red, Mars is a
planet of has several planet from planet to the
cold place
them all rings the Sun Sun
Creativity Infographics

Mercury
Mercury is the closest
planet to the Sun
Earth
Earth is the third
planet from the Sun
Mars
Despite being red, it’s
actually a cold place

Neptune
It’s the farthest planet
from the Sun

Jupiter
Jupiter is the biggest
planet of them all
 Creativity Infographics
Jupiter Mercury
Jupiter is the biggest It’s the closest planet
planet of them all to the Sun

Neptune Earth
Earth is the third
It’s the farthest
planet
planet from the Sun
from the Sun

Saturn Mars
Despite being red,
It’s a gas giant and
it’s actually a cold
has several rings
place
 Creativity Infographics
Jupiter Mercury
Jupiter is the
It’s the closest
biggest planet of
planet to the Sun
them all

Neptune Earth
It’s the farthest
It’s the third planet
planet from the
from the Sun
Sun

Saturn Mars
It’s a gas giant and Despite being red,
has several rings it’s a cold place
 Creativity Infographics

Mars Saturn

01 Despite being
red, Mars is a
03 Saturn is a
gas giant and
05
has several
cold place
rings

Jupiter Venus Neptune

Jupiter is the Neptune is
biggest
planet of
02 Venus is the
closest planet
to the Sun
04 the farthest
planet from
them all the Sun
 Creativity Infographics
Saturn
Saturn is a
Mars gas giant and Neptune
has several Neptune is
Despite being
rings the farthest
red, Mars is a
planet from
cold place
Jupiter the Sun Mercury
Jupiter is the Mercury is
biggest the closest
planet of planet to the
them all Sun
Creativity Infographics

Jupiter
Jupiter is the
biggest planet of
them all
Mercury
It’s the closest
planet to the Sun
Neptune
It’s the farthest
planet from the
Sun
Earth
It’s the third planet
from the Sun

Saturn
It’s a gas giant and
has several rings
 Creativity Infographics

Mars Neptune
Neptune is
Despite being
the farthest
red, Mars is a
planet from
cold place
the Sun

1
Jupiter
2 3
Saturn
4 5
Mercury
Jupiter is the Saturn is a Mercury is
biggest gas giant and the closest
planet of has several planet to the
them all rings Sun
 Creativity Infographics

Jupiter Saturn Mercury

Jupiter is the Saturn is a Mercury is
biggest gas giant and the closest
planet of has several planet to the
them all rings Sun

Mars Neptune
Neptune is
Despite being
the farthest
red, Mars is a
planet from
cold place
the Sun
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