Male, 17 years old, 10 hours after left quarter rib trauma, thirsty, palpitations, irritability 2 hours. The patient suffered a bruise on the ribs of the left upper abdomen in a car accident. At that time, the pain was severe and he went to the hospital. The X-rays showed it confirmed that he had a rib fracture. He felt better after bed rest and local fixation, but still had left upper abdominal pain and nausea. When waking up in the afternoon, he felt entire abdomen pain and abdominal distention, accompanied by dizziness, palpitations, and thirsty and irritability in 2 hours. Physical examination: T37.6°C, P110 beats/min, Bp 90/60mmHg. Conscious, obvious pale conjunctiva, cardiopulmonary (-), ecchymosis and tenderness under the skin of on the ribs of the left upper abdomen. The abdomen is slightly swollen, and the whole abdomen has obvious tenderness, focusing on the left upper abdomen. The muscle tension is not obvious, but there is obvious rebound pain, shifting dullness (+), and bowel sounds are audible and weak. Blood routine: Hb 82g/L, WBC 9.0x10⁹/L. Please briefly describe the diagnosis and basis of diagnosis, differential diagnosis, further examination, and treatment principles.
Male, 17 years old, 10 hours after left quarter rib trauma, thirsty, palpitations, irritability 2 hours. The patient suffered a bruise on the ribs of the left upper abdomen in a car accident. At that time, the pain was severe and he went to the hospital. The X-rays showed it confirmed that he had a rib fracture. He felt better after bed rest and local fixation, but still had left upper abdominal pain and nausea. When waking up in the afternoon, he felt entire abdomen pain and abdominal distention, accompanied by dizziness, palpitations, and thirsty and irritability in 2 hours. Physical examination: T37.6°C, P110 beats/min, Bp 90/60mmHg. Conscious, obvious pale conjunctiva, cardiopulmonary (-), ecchymosis and tenderness under the skin of on the ribs of the left upper abdomen. The abdomen is slightly swollen, and the whole abdomen has obvious tenderness, focusing on the left upper abdomen. The muscle tension is not obvious, but there is obvious rebound pain, shifting dullness (+), and bowel sounds are audible and weak. Blood routine: Hb 82g/L, WBC 9.0x10⁹/L. Please briefly describe the diagnosis and basis of diagnosis, differential diagnosis, further examination, and treatment principles.
Understanding Health Insurance: A Guide to Billing and Reimbursement
14th Edition
ISBN:9781337679480
Author:GREEN
Publisher:GREEN
Chapter6: Icd-10-cm Coding
Section: Chapter Questions
Problem 105R
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Transcribed Image Text:Male, 17 years old, 10 hours after left quarter rib trauma, thirsty, palpitations, irritability 2
hours.
The patient suffered a bruise on the ribs of the left upper abdomen in a car accident. At that
time, the pain was severe and he went to the hospital. The X-rays showed it confirmed that he
had a rib fracture. He felt better after bed rest and local fixation, but still had left upper
abdominal pain and nausea. When waking up in the afternoon, he felt entire abdomen pain
and abdominal distention, accompanied by dizziness, palpitations, and thirsty and irritability
in 2 hours.
Physical examination: T37.6°C, P110 beats/min, Bp 90/60mmHg. Conscious, obvious pale
conjunctiva, cardiopulmonary (-), ecchymosis and tenderness under the skin of on the ribs of
the left upper abdomen. The abdomen is slightly swollen, and the whole abdomen has obvious
tenderness, focusing on the left upper abdomen. The muscle tension is not obvious, but there
is obvious rebound pain, shifting dullness (+), and bowel sounds are audible and weak.
Blood routine: Hb 82g/L, WBC 9.0x10⁹/L.
Please briefly describe the diagnosis and basis of diagnosis, differential diagnosis, further
examination, and treatment principles.
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