Accidental puncture and laceration of the spleen during other procedure

D78.12

Clinical Vignette:

Patient Profile:

* Age: 39 years old

* Sex: Male

* Name: Robert

History of Present Illness:

Robert, a 39-year-old computer programmer and part-time nature photographer, was rushed to the emergency department with acute onset of severe left-sided abdominal pain. The pain started abruptly two days following a cholecystectomy performed at a neighboring hospital due to a long-standing battle with gallstones. Robert had been progressing well during the post-operative period, indulging in his favorite graphic novel, when he experienced a sudden, sharp pain in his left upper abdomen.

Physical Examination:

Upon examination, Robert appeared pale and visibly distressed. His blood pressure was recorded at 105/65 mm Hg, pulse rate at 105 beats per minute, and a respiratory rate of 20 breaths per minute. On inspecting his abdomen, tenderness was noted in the left upper quadrant along with some guarding. The rest of his examination did not yield any additional notable findings.

Investigations and Diagnosis:

Given his recent surgical history and the sudden onset of his symptoms, an urgent abdominal CT scan was ordered. The scan revealed a small laceration on the spleen with evidence of active bleeding, suggesting accidental injury to the spleen during his previous surgery. The surgical team was immediately informed and Robert was prepped for possible intervention.

Robert's sudden change in condition was diagnosed as an accidental puncture and laceration of the spleen during a previous procedure. This was an unexpected and rare complication of his cholecystectomy.

Diagnosis and ICD-10-CM Code:

Accidental puncture and laceration of the spleen during other procedure (D78.12).