Female, 26 years old, married. Abdominal pain, diarrhea, fever, vomiting for 20 hours After 24 hours of eating, the patient developed abdominal discomfort, paroxysmal with nausea, vomiting stomach contents, fever and diarrhea several times, loose stools, no pus and blood, body temperature 37-38.5°C, come to our hospital for emergency, the routine test of stool was negative. She was treated according to "acute gastroenteritis". The abdominal pain worsened in the evening, accompanied by fever of 38.6°C.Then, the abdominal pain moved from the stomach to the right lower abdomen, and there was still diarrhea, she come to see a doctor again at night, check blood routine WBC21×10%/L, and be admitted to the hospital urgently. Previous history: healthy, no history of drug allergy. Physical examination: T38.7°C, P120/min, BP 100/70mmHg, no bleeding spots and rashes on the skin all over the body, no large superficial lymph nodes, no pallor of the conjunctiva, no yellow staining of the sclera, heart rate 120/min, normal cardiac rhythm with no murmurs, clear lungs, no dry and wet rales, flat abdomen, unreachable liver and spleen, no masses, tenderness of the whole abdomen is around McBurney point in the right lower abdomen, no obvious muscle tension, bowel sounds 10- 15/min. Auxiliary examination: Hb 162g/L, WBC 24.6×10%/L, 86% neutrophils, normal liver function. Please briefly describe the diagnosis and basis of diagnosis, differential diagnosis, further examination, and treatment principles.
Female, 26 years old, married. Abdominal pain, diarrhea, fever, vomiting for 20 hours After 24 hours of eating, the patient developed abdominal discomfort, paroxysmal with nausea, vomiting stomach contents, fever and diarrhea several times, loose stools, no pus and blood, body temperature 37-38.5°C, come to our hospital for emergency, the routine test of stool was negative. She was treated according to "acute gastroenteritis". The abdominal pain worsened in the evening, accompanied by fever of 38.6°C.Then, the abdominal pain moved from the stomach to the right lower abdomen, and there was still diarrhea, she come to see a doctor again at night, check blood routine WBC21×10%/L, and be admitted to the hospital urgently. Previous history: healthy, no history of drug allergy. Physical examination: T38.7°C, P120/min, BP 100/70mmHg, no bleeding spots and rashes on the skin all over the body, no large superficial lymph nodes, no pallor of the conjunctiva, no yellow staining of the sclera, heart rate 120/min, normal cardiac rhythm with no murmurs, clear lungs, no dry and wet rales, flat abdomen, unreachable liver and spleen, no masses, tenderness of the whole abdomen is around McBurney point in the right lower abdomen, no obvious muscle tension, bowel sounds 10- 15/min. Auxiliary examination: Hb 162g/L, WBC 24.6×10%/L, 86% neutrophils, normal liver function. 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 208R
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Transcribed Image Text:Female, 26 years old, married. Abdominal pain, diarrhea, fever, vomiting for 20 hours
After 24 hours of eating, the patient developed abdominal discomfort, paroxysmal with
nausea, vomiting stomach contents, fever and diarrhea several times, loose stools, no pus and
blood, body temperature 37-38.5°C, come to our hospital for emergency, the routine test of
stool was negative. She was treated according to "acute gastroenteritis". The abdominal pain
worsened in the evening, accompanied by fever of 38.6°C. Then, the abdominal pain moved
from the stomach to the right lower abdomen, and there was still diarrhea, she come to see a
doctor again at night, check blood routine WBC21×10%/L, and be admitted to the hospital
urgently.
Previous history: healthy, no history of drug allergy.
Physical examination: T38.7°C, P120/min, BP 100/70mmHg, no bleeding spots and rashes on
the skin all over the body, no large superficial lymph nodes, no pallor of the conjunctiva, no
yellow staining of the sclera, heart rate 120/min, normal cardiac rhythm with no murmurs,
clear lungs, no dry and wet rales, flat abdomen, unreachable liver and spleen, no masses,
tenderness of the whole abdomen is around McBurney point in the right lower abdomen, no
obvious muscle tension, bowel sounds 10- 15/min.
Auxiliary examination: Hb 162g/L, WBC 24.6×10%/L, 86% neutrophils, normal liver function.
Please briefly describe the diagnosis and basis of diagnosis, differential diagnosis, further
examination, and treatment principles.
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