What is the principal diagnosis code, and additional diagnosis codes for this scneario ? ( what is the ICD-10-CM codes here)
What is the principal procedure code, additional procedure codes for this scenario? ( what is the ICD-10-PCS code here)
Admitting Diagnosis: Abdominal pain
Discharge Diagnosis: Same
Procedures: Intravenous hydration
Consultations: None
Chief Complaint: Abdominal pain for two weeks which has progressively gotten worse.
History of Present Illness: Female with significant past medical history who presented to the ER with abdominal pain that progressed to the upper abdominal area. The pain has been present daily, approximately one week ago the pain progressed to the point where she had pain radiating on either side. Today the pain was sharp, stabbing pain, lasting 5-10 minutes, primarily in the mid-abdominal region. The pain is made worse with standing, deep breaths, and laying on right side. Pain is decreased with laying on back or stomach. The patient states that it hurts into her anus and her abdomen to have bowel movement. She states that her bowel movements are increased to 3 times per day since the pain started approximately 11 days ago. Her BM's have been "hard balls". She denies any blood, mucus, bright red blood per rectum, watery stools. The patient states that her stools have changed slightly in color from dark brown to slight brown. She states that she has had
nausea, chills, and night sweats. She states that she has had some pain with urination. She complains of cloudy, smelly urine. She states that she has had some brownish vaginal discharge which is foul smelling. She also states that she was sexually active approximately four months ago, but used a condom. Last menstrual period was mid- March.
PAST MEDICAL HISTORY: Injuries: The patient reports a sexual assault for which she was seen for 5 months ago. She was forced at that time to perform fellatio and had penile, rectal penetration. She was uncertain at that time whether there was vaginal penetration. The vagina, rectum, and oral cavities were negative for sperm and seminal fluid.
HOSPITALIZATIONS: None.
SURGERIES: None.
BLEEDING AND TRANSFUSIONS: None. Immunizations are up to date.
HABITS: Alcohol occasionally, street drugs none, tobacco one pack per week.
FAMILY HISTORY: Positive for leukemia in maternal uncle. There was also some family history of cardiac disease.
REVIEW OF SYMPTOMS: Negative other than occasional otitis media and Salter II colles fracture.
LABORATORY: UA Negative. Panel II within normal limits. Lactate 1.0. Amylase 39, CBC and differential within normal limits. Wet prep was negative. Stool cultures were negative. Chlamydia was positive.
PHYSICAL EXAMINATION: Temperature 102, blood pressure 108/70, pulse 104, respirations 30, weight 115.
General appearance: Female laying on mat in mild distress.
Head: Atraumatic, normocephalic.
Ears: TMs trans lucent, light reflex present, no erythema.
Eyes: PERLA. Extraocular muscles intact.
Nose: Pink and moist. Mouth and teeth: Pink and moist, no lesions.
Throat: Pink, moist, no exudate, within normal limits.
Neck: Supple, no thyromegaly.
Lungs: Clear to auscultations. Breath sounds equal bilaterally.
Cardiovascular: Normal Sl, SZ, no murmurs.
Abdomen: Soft, non-distended, normal bowel sounds, diffusely tender. No rebound. No organomegaly. No guarding. Negative Murphys. +/- Peritoneal signs. Positive left heel strike, positive, right CVA tenderness.
Genitalia: Within normal limits.
Speculum: Cervix, without lesions or erythema. Clear discharge present.
Vaginal walls: Pink. Bimanual: Negative Chandelier, negative cervical motion tenderness. Positive right adnexal pain, positive left adnexal pain with hard stool palpated.
Uterus; Difficult to assess, but slightly retroflexed.
Rectal; Normal tone, no masses.
Skeletal: Supple, full range of motion.
Lymphatics: Negative cervical, axillary, supraclavicular or inguinal lymphadenopathy.
Skin: Warm and dry, no lesions.
Neurologic: Alert, oriented x 3. Speech normal. Grip strength equal, strong bilaterally, intact light touch. Deep tendon reflex 2/4 upper and lower extremities. General muscle strength 5/5 lower extremities. Cranial nerves II-XII grossly intact. Chest x-ray was unremarkable.
Flat plate: Moderate amount of stool, otherwise negative.
HOSPITAL COURSE: The patient was admitted to the Pediatric Floor and given three Fleets enemas. The patient had good results with the enemas and her abdominal pain was greatly reduced. By the end of the first day the patient was able to sit without any discomfort and the abdominal pain was basically only noticed when standing and walking to go to the bathroom. By the morning of discharge,
the abdominal pain was primarily gone and only slightly aggravated with ambulation.
On the night of her discharge the patient was essentially pain free. Her heart rate and temperature were unremarkable. Blood pressure within normal limits.Respiratory rate 20. The patient was discharged with Metamucil, 1 tsp in liquid po bid and Doxycycline, 100 mg p.o. x 7 days. She is to be followed up in one week in the Peds Clinic. She was instructed to return to the ER should she have increase in fever, abdominal pain, nausea, or any other problems.