Luokat: Kaikki - dolor - cirugía - leucocitos - ansiedad

jonka Delia Badilla 4 vuotta sitten

224

Mujer, PFC

Una mujer de 45 años con antecedentes de hernioplastia y uso de anestesia general se presenta con varios resultados de exámenes de laboratorio que indican hiperglicemia y un recuento elevado de leucocitos.

Mujer, PFC

Mujer, PFC

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Exámenes de laboratorio

Proteína C reactiva
5 mgr./dl

Subtopic

ECG
Glicemia
En ayunas

115 mg/dl

Hiperglicemica

VHS o sedimentación globular
13 mm/hora
Tiempo de protombina
13 segundos
Recuento de leucocitos
14.000 x mm3

Aumentado

Hemoglobina
12%
Hematocrito
38%

Normal

Signos vitales

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Escala ENA de dolor
4/10

Palpación profunda

2/10

Reposo

36.4°C Axilar

Afebril

FR
18 Rpm

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Simétrico regular

Eupneica

FC
70 Lpm

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Pulso regular, simétrico, blando

Normocárdica

PA
120/60

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Normotensa

Procedimientos pre operatorios

Sonda folley vesical
Medias anti tromboticas
Suero
Profilácticos

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Examen fisico segmentario

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Extremidades inferiores
Normales
Abdomen
Ruidos intestinales presentes
Doloroso a la palpación en región periumbulical
Depresible
Blando
Globuloso
Auscultación cardiaca
Murmullo vesicular positivo
Ruidos cardíacos en 2T
Tórax Simétrico
Cuello movil
No se palpan ganglios
Prótesis dentaria superior
Mucosa oral
Húmeda
Pupilas

Normoreactivas a la luz
Isocoricas

Examen Fisico General

Deambula sin problemas
Higiene corporal
Mantenida
Piel y mucosas
Integra, tibia al tacto
Hidratadas
Obesa
IMC de 30
Posición
Decubito activa
Fascie
Ansiosa
Intranquila
Coloración normal
Consciente

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Orientada temporoespacialmente
Lucida

Antecedentes hospitalarios

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Servicio de cirugia mujeres
Uso de anestesia general
Hernioplastia

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Por hernia humbilical gigante recidivada

Antecedentes personales

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Refiere preocupación por desconocimiento del procedimiento
Dueña de casa
Casada
4 hijos
45 años

Author

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GRUPO 2