Wounds of various locations. Wounds of various locations ICD code 10 incised wound of the forearm
Head - Caput
The victim was hit in the head with a heavy blunt object. In the area of the bruise, in the frontoparietal region, there is a wound with uneven edges, 4 cm long, bleeding. There is crushed non-viable tissue around the wound. The bones of the skull are intact to the touch.
D.S. Contused wound of the frontoparietal region on the right.
Vulnus contusum regionis frontoparietalis dextrae.
Pain in the cheek area, aggravated by chewing. According to the victim, three days ago there was a large abrasion on his cheek. No initial treatment of the wound was performed. Redness with unclear contours and measuring 3 by 4 cm on the right cheek. The cheek is swollen, swollen, and hot to the touch. In the center of the purplish-red infiltrate there is a small wound under a crust, scanty discharge of a purulent nature.
D.S. Infected wound of the right cheek.
Vulnus infectum regionis buccalis dextrae.
Complaints of pain in the left earlobe. The victim's earring was torn out of her left ear. On the left earlobe there is a through laceration wound about 1 cm long with jagged edges, directed vertically downwards. There is some bleeding.
D.S. Lacerated wound of the left earlobe.
Vulnus laceratum lobuli auris sinistri.
Male 23 years old.
Complaints of pain, swelling, burning sensation in the left ear.
According to the patient, while sleeping, a playing dog bit his ear. The dog is homemade, well-groomed, all vaccinations were completed on time, documents for the dog and vaccinations are available. Before the arrival of the EMS team, he independently treated the wound with 3% hydrogen peroxide.
Upon examination, there is a bite wound on the inner surface of the left auricle, the edges are smooth, d = 0.2 x 0.5 cm, does not bleed; The ear wound is swollen and hyperemic. Painful on palpation. Hearing acuity is not impaired.
Ds. Bite wound on the left ear.
Vulnus morsum auriculae sinistrae.
Treatment of the wound with 3% hydrogen peroxide. Treating the edges of the wound with tincture of iodine. Adhesive bandage.
The victim fell while ice skating. In the fall I injured my lower lip. Upon external examination, the red border of the lower lip is cut in the middle of its length. The wound has a vertical direction with uneven edges, about 1 cm long, and bleeds moderately.
D.S. Bruised wound of the lower lip.
Vulnus contusum labii inferioris.
The victim was chopping a metal plate with a chisel. The left eyebrow was cut by a shrapnel. The wound has an oblique direction and is located closer to the bridge of the nose and bleeds moderately. The length of the wound is about 1.5 cm, the edges are uneven. The bone is intact to the touch.
D.S. Bruised wound on the left eyebrow.
Vulnus contusum supercilii sinistri .
The victim was chopping wood; a large sliver broke off and hit him in the forehead. I didn’t lose consciousness. There is a moderately bleeding wound on the forehead, about 3 cm long, with uneven edges. There is a zone of necrosis around the wound. The frontal bone is intact to the touch. The general condition of the patient is satisfactory.
D.S. Bruised wound of the frontal area.
Vulnus contusum regionis frontalis.
While working on the machine, the victim's hair was twisted onto the rotating shaft of the machine, and the skin was torn off from the parietal-occipital region of the head. In the left parieto-occipital region, a detached skin flap measuring 5 by 8 cm, oval in shape with uneven edges, is retained only in the forehead area. The wound surface bleeds profusely. The victim is agitated and crying.
D.S. Scalped head wound.
Vulnus panniculatum capitis.
Male 47 years old. Complaints of headache, dizziness, chest pain when breathing and moving. Denies chronic diseases. According to the man, about an hour ago, he opened the front door when the bell rang and was beaten in his home by two unknown men. He can’t say for sure whether he lost consciousness or not. I have been drinking alcohol for the last three days. Urination and stool - b/o.
Consciousness is clear. 130/80 mm. Heart rate = 80 per minute. RR = 18 per minute. Skin of normal color. Breathing is vesicular, weakened. It spares the chest when breathing. Visually – swelling of the face, numerous hematomas, hematoma of the right paraorbital region. Deformation and swelling in the bridge of the nose, bridge of the nose, pain on palpation. Sharp pain on palpation of the 5th and 6th ribs on the left along the anterior axillary line. No crepitus is detected. Signs of alcohol intoxication: smell of alcohol on the breath, unsteadiness of gait.
Ds.CCI. Concussion? Bruises of the soft tissues of the head. Closed fracture of the nasal bones? Closed fracture of the left 5th-6th rib?
Trauma craniocerebrale clausum. Commotio cerebri? Contusiones textuum mollium capitis. Fractura ossium nasi clausa. Fractura costarum V-VI (quintae et sextae) sinistrarum?
Sol. Dolaci 3% - 1 ml i/v
Sol.Natrii chloridi 0.9% - 10 ml
Transportation to a trauma center.
Reported to local police department.
Neck - Collum
The victim was wounded with a knife in the right side of the neck. Pale skin, lying on the ground, lethargic. In the area of the sternocleidomastoid muscle on the right (approximately in the middle of its length) there is a deep wound about 1.5 cm long, from which scarlet blood is rhythmically ejected. Pulse is frequent and weak. Breathing is shallow and frequent.
D.S. A stab wound on the side of the neck with injury to the carotid artery and bleeding.
Vulnus punctoincisivum faciei lateralis colli et laesio traumatica arteriae carotis cum haemorrhagia.
Complaints of pain in the upper half of the neck, difficulty swallowing and breathing. The victim (a young girl) made an unsuccessful suicide attempt. I tried to hang myself.
Upon external examination of the neck, a purplish-bluish bruise is visible - a mark from the rope. The neck is swollen, edematous, palpation of the injury site is painful. The patient is conscious. The pulse is frequent and weak, breathing is shallow and frequent.
D.S. Closed injury to the soft tissues of the neck. Suicide attempt.
Laesio traumatica textuum mollium colli clausa. Tentamen suicidii.
Complaints of pain when swallowing. The victim was hit in the neck with a sharp object (a wide screwdriver) in the fight. Upon external examination, on the front surface of the neck on the left behind the thyroid cartilage, there is an oval-shaped wound about 1 cm long with uneven edges. The wound bleeds moderately. When swallowing, saliva and food are released from the wound. Breathing is normal, through the nose. There is no subcutaneous emphysema.
D.S. Stab and laceration of the neck with damage to the esophagus.
Vulnus punctolaceratum colli cum laesione traumatica oesophagi.
Upper limb. Brush. Forearm. Shoulder. - Extremitas superior. Manus. Antebrachium. Brachium.
The victim complains of pain in the right hand. The injury occurred at work: a metal part fell on the back of the hand.
On the back surface of the right hand there is a subcutaneous purplish-bluish hematoma of a round shape measuring 4 by 5 cm. Due to swelling, he cannot completely clench his fingers into a fist. The skin in the area of injury is not damaged. Fluctuation is determined.
D.S. Contusion of the dorsum of the right hand.
Contusio faciei dorsalis manus dextrae.
The victim complains of pain in the left hand. The patient was hit hard on the palm with a heavy blunt object. Upon examination, the palmar surface of the left hand is swollen, painful when palpated, the fingers are in a bent position, and movements are limited. Cannot fully clench fingers into a fist. The skin of the hand is not damaged.
D.S. Contusion of the palmar surface of the left hand.
Contusio faciei anterioris manus sinistrae.
The victim complained of a feeling of pressure and pain in the fourth finger of the left hand. He asks to remove the ring from his finger, which causes great inconvenience.
A metal ring is tightly placed on the main phalanx of the fourth finger of the left hand. Below the ring, the finger is swollen and somewhat bluish. Due to swelling, movement is limited. Sensitivity is fully preserved.
D.S. Compression of the 4th finger of the left hand by a foreign object (ring).
Compressio digiti quarti manus sinistrae per corporem alienum (per anulum).
The victim was hammering a nail into the wall and hitting the nail phalanx of the second finger of his left hand with a hammer.
The nail phalanx of the second finger is swollen, painful when palpated. In the center of the nail plate there is a subungual hematoma of a purplish-bluish color, oval in shape, about 1 cm in size. The nail does not peel off.
D.S. Subungual hematoma of the second finger of the left hand.
Haematoma subunguinalis digiti secundi manus sinistrae.
A teenager hit a sports equipment with his right hand during a physical education class at school. There is a subcutaneous hematoma on the dorsal surface of the middle phalanx of the 3rd finger of the right hand. The finger is swollen and painful when touched. Flexion is limited. The skin is not damaged. The load along the axis of the finger is painless.
D.S.. Contusion of the middle phalanx IIIfinger of the right hand.
Contusio phalangis medialis digiti tertii manus dextrae.
The mechanic was tidying up the workplace. Damaged my right hand with technical debris (shavings, small glass fragments). The skin of the right hand is stained with fuel oil and oil paint. There are many small abrasions and wounds on the palmar surface. Bleeding from them is insignificant.
D.S.. Multiple wounds and abrasions on the right hand.
Vulnera multiplices et excoriationes manus dextrae.
The victim was cut by a piece of broken window glass. On the dorsum of the right hand there is a shallow wound about 4 cm long with smooth edges, bleeding moderately. Sensitivity and motor function of the fingers of the injured hand are preserved.
D.S.. Incised wound on the dorsum of the right hand.
Vulnus incisivum faciei dorsalis manus dextrae.
The victim was stabbed in the fight. The dorsum of the left hand is damaged. Upon external examination, the dorsum of the hand in the area II On the metacarpal bone there is an incised wound about 1.5 cm long. In the depth of the wound, the peripheral end of the transected tendon is visible. The wound bleeds moderately. II the finger is bent. The patient cannot straighten it on his own.
D.S.. Extensor tendon injury IIfinger of the left hand.
Laesio tendinis musculi extensoris digiti secundi manus sinistrae.
The victim received a sharp blow from the opening door on the straightened, tense fingers of her left hand. As a result, the nail phalanx III the finger sharply bent and seemed to “hang”. On the back surface III finger of the left hand in the distal interphalangeal joint there is slight swelling, which is moderately painful on palpation. The nail phalanx is bent and does not straighten on its own. Passive movements are preserved.
D.S.. Extensor tendon rupture IIIfinger of the left hand.
Ruptura tendinis musculi extensoris digiti tertii manus sinistrae.
The young victim was working with a shovel without gloves in the garden. As a result of prolonged friction of the shovel handle on the palm surface, a callus formed on the right hand. On the palm, the surface layer of skin peeled off and underneath it formed a tense red bubble, about 2 cm in size, filled with liquid. The bladder is not opened, palpation is painful.
D.S.. Callus on the palmar surface of the right hand.
Clavus faciei palmaris manus dextrae.
The victim, defending himself from a knife attack, grabbed the knife with his right hand by the blade. The attacker forcibly pulled it out of the victim’s hand. As a result, a deep wound formed on the palmar surface of the right hand.
On the palmar surface there is a deep transverse wound 4 cm long with smooth edges and severe bleeding. In the depths of the wound, in the area III finger, the peripheral end of the tendon is visible, the central end is not in the wound. III the finger is extended and there is no active flexion of the terminal and middle phalanges. With passive flexion, the finger straightens again on its own. Sensitivity is preserved.
D.S.. Dissection of the superficial and deep flexor tendon IIIfinger of the right hand.
Dissecatio tendinum superficialis et profundae flexoris digiti tertii manus dextrae.
According to the mother, the child fell on his outstretched arm, while the hand turned inward. I am worried about pain in the left wrist joint. On external examination, swelling of the dorsal surface of the wrist joint and severe pain when flexing the wrist are noted. Loading along the axis of the forearm is painless. When palpating the wrist, the child feels pain.
D.S.. Sprain of the left wrist joint.
Distorsio articulationis radiocarpalis sinistrae.
The victim injured the back of his forearm with a piece of broken glass while removing the window frame.
On the dorsal surface of the lower third of the left forearm there is a wound with smooth edges and moderate bleeding, 5 cm long. Sensitivity and motor function of the fingers are fully preserved.
D.S.. Incised wound on the dorsum of the left forearm.
Vulnus incisivum faciei dorsalis antebrachii sinistri.
An 18-year-old victim, for the purpose of suicide, inflicted a wound on herself with a blade on the flexor surface of her left forearm.
The condition is satisfactory, consciousness is clear. The skin is pale. Heart rate 85 per minute. The pulse is weak. Blood pressure 90/50 mm Hg. In the lower third of the left forearm there is a cut wound located transversely, about 4 cm long with smooth edges. The wound gapes wide, dark red blood slowly flows out of it in a continuous stream. There are several parallel shallow skin abrasions near the wound.
D.S.. Incised wound of the left forearm with venous bleeding, signs of acute anemia.
Vulnus incisivum antebrachii sinistri cum haemorrhagia venosa, signa anaemiae acutae.
While chopping wood, the victim's ax fell off its handle and wounded his left forearm with the tip. Upon external examination, on the front surface of the left forearm in the middle third there is a deep chopped wound directed across the forearm, about 4 cm long, with smooth edges. The wound gapes wide and bleeds profusely. The hand is in an extended position, there are no active flexion movements. In the depth of the wound, the ends of the dissected muscle are determined - the flexor carpi radialis.
D.S.. A chopped wound of the left forearm with damage to the carpi flexor muscle.
Vulnus scissum antebrachii sinistri cum laesione traumatica musculi flexoris carpi radialis.
The teenager, while roller skating behind a truck, fell on the asphalt with his left arm extended forward. The blow fell on the forearm. There is a large wound with jagged edges in the middle third of the left forearm. The skin on the palmar surface of the forearm is torn off. In some places, the skin flaps are separated from the underlying tissue and hang down, part of the skin is lost.
D.S.. Flap wound of the middle third of the left forearm.
Vulnus panniculatum tertiae medialis antebrachii sinistri.
A 14-year-old schoolboy tried to pet a stray dog, it bit him and ran away. When examining the right forearm, there are several deep, irregularly shaped wounds with teeth marks on the dorsal surface in the lower third. The wounds are contaminated with the animal's saliva and bleed moderately.
D.S.. Bite wound on the right forearm.
Vulnus morsum antebrachii dextri.
During a suicide attempt, a young woman stuck one blade of scissors into her left cubital fossa and closed the second blade. Thus, she cut the vessels in the ulnar fossa. Soon, a neighbor in a communal apartment provided assistance to the victim: she placed a thick roller in the elbow fossa and bent her arm as much as possible, and called an ambulance. In the left ulnar fossa there is a stab wound about 2 cm long, with smooth edges. Blood flows from the wound in a pulsating stream of bright red color. The patient is pale, covered in cold sweat, indifferent to her surroundings, complains of dizziness and dry mouth. The pulse is frequent, weak filling, blood pressure is below normal.
D.S.. Stab wound of the left ulnar fossa with arterial bleeding and acute anemia.
Vulnus punctoincisum fossae cubitalis cum haemorrhagia arteriale et anemia acuta.
An 18-year-old victim was bitten on the right forearm by a tick during field work. Objectively: on the anterior surface of the middle third of the right forearm, the head and thorax of the tick are tightly embedded in the skin, and the abdomen, filled with blood, protrudes outward. The skin around the tick is slightly hyperemic and the wound is slightly painful.
D.S.. Tick bite on right forearm.
Punctum acari antebrachii dextri.
The man was shot from a pistol from a distance of about 20 meters. The right hand is damaged. Delivered to the hospital's trauma department. When examining the right hand, there is a through gunshot wound on the palmar surface. The entrance wound is funnel-shaped and concave and is located in the area of the hypothenar; the exit wound is in the area of the base of 1 finger, the edges are everted, uneven, and bleed moderately. The motor and sensory function of the 1st and 5th fingers is impaired. The bones are not damaged.
D.S.. A perforating gunshot wound to the soft tissues of the palmar surface of the right hand.
Vulnus sclopetarium bifore textuum mollium faciei palmaris manus dextrae.
The young man hit his left shoulder on a hard object during an accident. 1 hour after the injury, the victim went to the emergency room. Objectively: in the area of the left deltoid muscle there is a wound with uneven, crushed edges, about 5 cm long. Moderate bleeding. Around the wound there is non-viable tissue - a zone of necrosis of a purplish-bluish color. The motor and sensory functions of the shoulder joint are fully preserved. The wound is heavily contaminated with soil and scraps of clothing.
D.S.. Bruised wound in the left shoulder joint.
Vulnus contusum regionis articulationis humeri sinistrae.
Thorax - Thorax
The teenager was hit in the chest with a heavy blunt object. I went to the emergency room. Upon external examination on the chest on the right in the area V, VI and VII of the ribs along the midclavicular line, swelling and a small subcutaneous hematoma are detected. Palpation of this area is painful, there is no crepitus. Raising the right arm and lateral bending of the torso are not painful. Taking a deep breath is painful, but possible.
D.S.. Contusion of the right side of the chest.
Contusio dimidii dextri thoracis.
The victim was sitting on the windowsill and was injured by a large piece of broken window glass. Objectively: on the back below the left shoulder blade there is a shallow wound about 5 cm long with smooth edges, bleeding moderately. The bottom of the wound is subcutaneous fat.
D.S.. Incised wound of the left subscapular region.
Vulnus incisivum regionis subscapularis sinistri.
A young man was taken to the hospital's trauma department with a gunshot wound to the right side of his chest. Objectively: on the anterior wall of the chest in the area of 6-7 ribs on the right along the midclavicular line there is an entrance hole of a gunshot wound with funnel-shaped retracted edges. On the back, slightly below the lower corner of the right shoulder blade, there is a second much larger wound (exit hole). The condition is serious. The wounded man is restless, pale, cyanotic. Complains of cough, chest pain. Breathing is frequent and shallow. Blood pressure is reduced, pulse is frequent. Bloody blisters are released through the wounds (entrance and exit). When you inhale, air passes through them with a characteristic whistling sound. Breathing on the injured side is not detected. The victim has severe respiratory failure.
D.S.. A through gunshot wound to the right half of the chest. Open pneumothorax.
Vulnus sclopetarium bifore dimidii dextri thoracis. Pneumothorax apertus.
The young man was stabbed in the chest. When examining the chest on the left, along the anterior axillary line between the 5th and 6th ribs, there is a small stab wound about 1.5 cm long. Thanks to the retraction of the pectoral muscles, the external wound is closed. There is no further entry of air through the wound into the pleural cavity. The patient has shortness of breath and slight cyanosis. During auscultation, respiratory sounds on the left are significantly weakened; a tympanic sound is detected here by percussion.
D.S.. Penetrating wound to the left half of the chest. Closed pneumothorax.
Vulnus penetrans dimidii sinistri thoracis. Pneumothorax clausus.
While unloading scrap metal, he was hit in the side by a heavy metal blank. Complaints of pain at the site of injury, thirst, vomiting. Subcutaneous hemorrhages are visible in the area of the right hypochondrium. Muscle defence in the upper abdomen on the right. The skin is pale, blood pressure is low. Breathing is frequent, shallow, tachycardia. The abdomen is distended, Shchetkin's sign is positive in the right hypochondrium. Percussion reveals an enlarged liver.
D.S. Blunt chest trauma with liver damage.
Trauma obtusum thoracis cum laesione traumatica hepatis.
A man was covered in sand in a quarry. I was under the rubble for about 30 minutes. The chest was compressed. Delivered to the thoracic surgery department. The patient is inhibited. Complains of chest pain, tinnitus, weakened vision and hearing. The skin of the upper half of the chest, head and neck is bright red with multiple pinpoint hemorrhages. Auscultation reveals a large number of moist rales in the lungs.
D.S.. Chest compression. Traumatic asphyxia.
Compressio thoracis. Asphyxia traumatica.
The 20-year-old victim was stabbed in the back in a street fight.
Upon external examination, there is a stab wound in the area of the IV thoracic vertebra, from which cerebrospinal fluid flows along with blood. There is spastic paralysis of the right lower limb with loss of deep and partly tactile sensitivity. On the left side, severe pain and temperature anesthesia developed below the level of the wound.
D.S. Stab wound of the thoracic spine with damage to the spinal cord.
Vulnus punctoincisivum partis thoracalis columnae vertebralis cum laesione medullae spinalis.
An elderly man was dismantling an old house when the ceiling collapsed on him. Large pieces of boards, bars, and earth fell onto the victim’s back and crushed him.
Upon external examination of the back, there is a subcutaneous hematoma located along the spinous processes of the 4th, 5th, 6th, 7th, 8th thoracic vertebrae. Palpation of the injury area is painful. There are no obvious signs of a spinal fracture. There are no neurological symptoms. The patient was hospitalized for observation. By the end of the first day, my health gradually began to deteriorate. Girdle radicular pain appeared. Then conduction disorders began to develop (paresis turning into paralysis, hypoesthesia, anesthesia, urinary retention). Later, bedsores and ascending cystopyelonephritis and congestive pneumonia appeared.
D.S. Compression of the spinal cord by an epidural hematoma in the thoracic spine.
Compressio medullae spinalis haematomate epidurale in partem thoracicam columnae vertebralis.
Belly - Abdomen
The patient was brought to the clinic with an abdominal injury. Complaints of pain in the area of injury and vomiting of blood. Upon external examination, a large wound gapes in the epigastric region with prolapse of a loop of the small intestine, part of the omentum and part of the damaged stomach wall.
D.S. Penetrating wound of the anterior abdominal wall with eventeration and injury to the stomach.
Vulnus parietis anterioris abdominis penetrans cum eventeratione et vulneratione traumatica ventriculi.
A 60-year-old man was brought to the abdominal surgery clinic, who, according to passers-by, fell from a third-floor balcony. The patient is unconscious, the skin is pale. The pulse is frequent, thread-like, blood pressure is 70/50 mm Hg. Art. Breathing is shallow and frequent. The number of red blood cells and the amount of hemoglobin are significantly reduced. In the operating room, the patient was transfused with 1000 ml of single-type blood. Blood pressure increased to 90/60 mm Hg. Art. The patient regained consciousness and began to complain of severe abdominal pain. After 20 minutes, blood pressure dropped again and the victim lost consciousness. The volume of the abdomen has noticeably increased. Fluctuation is determined between the palms placed on the lateral surfaces of the abdomen.
D.S.. Rupture of the spleen, rupture of the mesenteric vessels. Traumatic shock.
Raptura lienis, ruptura vasorum mesentericorum. Afflictus traumaticus.
Delivered to the abdominal surgery clinic after an accident. I have severe pain throughout my abdomen. Upon examination, a bruised wound was discovered on the anterior abdominal wall to the right of the navel. The patient lies motionless on his side with his knees pulled up to his stomach and does not allow him to touch the abdominal wall. Touch increases the pain, and light pressure causes a sharp tension in the abdominal muscles. On palpation, the abdomen is board-shaped tense. The Shchetkin-Blumberg symptom is positive. Peristalsis is not detected by auscultation. There is no stool, no gases are passed, little urine is produced. The patient suffers from frequent vomiting. He periodically loses consciousness, does not react to others, and is reluctant to answer questions. Breathing is frequent and shallow. The pulse is small and frequent. The tongue is dry, covered with a white coating. Body temperature 38.5 C.
D.S.. Penetrating abdominal wound. Rupture of the small intestine. Spilled peritonitis.
Vulnus abdominis penetrans.Ruptura intestini tenuae. Peritonitis diffusa.
The patient was taken to the clinic with a gunshot wound to the right hypochondrium. On the anterior wall of the abdomen in the area of the right hypochondrium there is a gunshot wound with uneven funnel-shaped retracted edges. Blood and bile are released profusely from the wound. Defence in the right hypochondrium and a positive Shchetkin-Blumberg sign are determined. The stomach is swollen. Blood pressure is low, the pulse is thready and frequent. Pale skin
D.S. Gunshot wound to the abdomen with damage to the liver and bile ducts.
Vulnus abdominis sclopetarium cum laesione hepatis et ductuum choledochorum.
A policeman was stabbed in the stomach while arresting a criminal. Upon examination, the abdomen participates in the act of breathing. On the anterior wall of the abdomen there is a stab wound about 2 cm long, 3 cm to the left of the umbilical ring. There is a slight swelling in the area of the wound; palpation of the abdomen is painful only at the site of injury. Tension of the abdominal muscles is determined only within the wound. There were no peritoneal symptoms, vomiting, flatulence, or increased heart rate. Body temperature is normal.
D.S.. Stab wound of the anterior abdominal wall.
Vulnus punctoincisivum parietis anterioris abdominis.
Lumbar - Regio lumbalis
The young man was taken to the urology department. According to the victim, he was kicked in the lumbar region. The injury resulted in severe pain in the lower back. Upon examination, there is swelling and subcutaneous bruising in the lumbar region on the right. Urine is intensely stained with blood (hematuria). Pulse and blood pressure are within normal limits. The patient underwent a survey radiography of the kidneys and excretory urography with intravenous administration of a radiocontrast agent.
D.S. Closed subcapsular rupture of the right kidney.
Ruptura renis dextri clausa subcapsularis.
The victim was stabbed in the lower back with a knife during the fight. I am worried about pain at the site of injury. In the lumbar region to the left of the spine, 5 cm below the 12th rib, there is a stab wound about 2 cm long. There is intense bleeding from the wound. Macrohematuria. There is no urine in the bloody discharge from the wound. General condition is satisfactory.
D.S. A stab wound in the lumbar region with damage to the left kidney.
Vulnus punctoincisivum regionis lumbalis cum laesione traumatica renis sinistri.
Genital organs - Organa genitalia
A 35-year-old woman was kicked in the pubic area by her husband. The victim went to the emergency room 2 days after the injury. Complains of pain at the site of the injury. Objectively: the pubic area and the right labia majora are swollen. A subcutaneous hematoma of a purplish-bluish color is detected. Blood fluctuates in the thickness of the bruised tissue. The pelvic bones are intact to the touch. Urination is normal, there is no blood in the urine. The function of the lower extremities is fully preserved.
D.S. Contusion of the external genitalia.
Contusio organorum genitaliorum externorum.
Hip- Femur
The young man received a stab wound to his right thigh. The victim lies on his right side, with a pool of blood underneath him. The face is pale, the pulse is frequent, weak filling. Consciousness is preserved. On the front surface of the right thigh, just below the inguinal fold, there is a stab wound, from which scarlet blood is ejected in pulsating impulses.
D.S. Stab wound of the right thigh with arterial bleeding.
Vulnus punctoincisivum femoris dextri cum haemorrhagia arteriale.
Male 47 years old. Complaints of pain in the wound area, heat in the body.
According to the patient, about a day ago he injured his leg on a wooden chair leg. I did not treat the wound. Today there was pain in the wound area and fever in the body. According to him, he drinks alcohol almost every day (except today). Suffers from epilepsy. He is not receiving treatment for epilepsy. The working blood pressure does not know. I have not been vaccinated against tetanus for 10 years. Vulnus infectiosum tertiae inferioris femoris sinistri. Knee, shin - Genu, crus
An elderly woman suffered a knee injury in a fall. I am worried about pain in the knee joint. The right knee joint is increased in volume, its contours are smoothed. On palpation, fluid is detected; the patella ballasts when pressed. Movement of the right knee joint is somewhat limited and painful. The leg is in a half-bent position.
D.S. Bruise, hemarthrosis of the right knee joint.
Contusio, haemarthrosis articulationis genus dextrae.
A 20-year-old man was injured during freestyle wrestling training. The partner pressed his leg, straightened at the right knee joint, with his body. The blow hit the inner side of the joint. The victim went to the emergency room a day later with complaints of pain in the area of injury and instability in the knee joint when walking.
Objectively. The right knee joint is swollen, its contours are smoothed, a bruise is visible on the inside, palpation of the inner femoral condyle is painful. When straightening the leg at the knee joint, there is an excessive outward deviation of the tibia and the volume of its external rotation is significantly increased. Flexion and extension of the knee joint is not limited.
D.S. Rupture of the medial collateral ligament of the right knee joint.
Ruptura ligamenti collateralis tibialis articulationis genus dextrae.
At a wrestling competition, a young man experienced a sharp “hyperextension” of his knee joint. As a result, something crunched in the knee joint, and severe pain appeared. The victim did not seek help; he bandaged his knee with an elastic bandage. After 5 days he went to the trauma department. I am concerned about instability in the left knee joint when walking. Difficulty climbing stairs. The patient cannot squat on his left leg. Examination of the left knee joint revealed excessive mobility of the tibia when it moves anteriorly relative to the thigh (anterior drawer symptom). The leg was bent at a right angle at the knee joint and relaxed. The fracture is not visible on the x-ray.
D.S. Rupture of the anterior cruciate ligament of the left knee joint.
Ruptura ligamenti cruciati anterii articulationis genus sinistrae.
The man, scrubbing the floor with a brush worn on his right leg, sharply turned his body with his shin fixed. After this, I felt a sharp pain in my right knee joint. I am worried about pain in the knee joint, which intensifies when going down the stairs. On examination, the right knee joint is swollen and hemarthrosis. Full extension of the knee joint is impossible, as pain appears in its depths. When palpating the joint, local pain is noted at the level of the joint space between the patellar ligaments and the medial lateral ligament of the knee joint. During flexion-extension movements, a clicking sound is heard in the damaged joint. An X-ray of the knee joint shows no bone damage. History of psoriasis for many years. Habitual blood pressure 130/80 mm
Objectively: The condition is satisfactory. Consciousness is clear. Blood pressure 140/80 mm. RT Art.
Heart rate = 90 per minute. On the left shin in the lower third there is a bandage soaked in blood, above the bandage there is a rubber tourniquet. The skin of the foot is bluish. On the skin of the limbs and torso there are psoriatic plaques from 0.5 to 1.5 cm, merging in places. After removing the tourniquet and bandage, dark blood flows out in a thin stream from a small wound on the inner surface of the leg.
Ds.Venous bleeding from the left leg.
Haemorrhagia venosa ex crure sinistro.
Help. An aseptic pressure bandage was applied. Transport to the surgical department.
Ankle joint, foot - Articulatio talocruralis, pes
While walking, the victim twisted her leg (a high heel got caught in a crevice, and her right foot turned inward). Pain appeared in the area of the outer ankle. The victim went to the emergency room. When examining the right ankle joint, swelling is noted along the outer surface of the foot and below the outer malleolus. There is also pain on palpation. Movements in the ankle joint are preserved in full and are painful. Palpation of the outer ankle is painless.
D.S. Sprain of the lateral ligament of the right ankle joint.
Distorsio ligamenti talofibularis anterii dextri.
RCHR (Republican Center for Health Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Archive - Clinical protocols of the Ministry of Health of the Republic of Kazakhstan - 2007 (Order No. 764)
Open wounds involving multiple areas of the body (T01)
General information
Brief description
Wound- damage to body tissues due to mechanical impact, accompanied by a violation of the integrity of the skin and mucous membranes.
Protocol code: H-S-026 "Wounds of various locations"
Profile: surgical
Stage: hospital
ICD-10 code(s):
T01 Open wounds involving multiple areas of the body
S21 Open chest wound
S31 Open wound of the abdomen, lower back and pelvis
S41 Open wound of the shoulder girdle and shoulder
S51 Open wound of the forearm
S61 Open wound of wrist and hand
S71 Open wound of the hip joint and thigh
S81 Open wound of the leg
S91 Open wound of the ankle and foot area
S16 Injury to muscles and tendons at the neck level
S19 Other and unspecified neck injuries
S19.7 Multiple neck injuries
S19.8 Other specified neck injuries
S19.9 Neck injury, unspecified
T01.0 Open wounds of the head and neck
T01.1 Open wounds of the chest, abdomen, lower back and pelvis
T01.2 Open wounds of several areas of the upper limb(s)
T01.3 Open wounds of several areas of the lower limb(s)
T01.6 Open wounds of several areas of the upper and lower extremities
T01.8 Other combinations of open wounds involving multiple areas of the body
T01.9 Multiple open wounds, unspecified
Classification
1. Stabbed - as a result of exposure to a sharp object.
2. Cut - as a result of exposure to a sharp long object, no less than 0.5 cm in size.
3. Bruised - as a result of exposure to an object of large mass or high speed.
4. Bitten - as a result of the bite of an animal, less often a person.
5. Scalped - detachment of the skin and subcutaneous tissue from the underlying tissue occurs.
6. Firearms - as a result of the action of a firearm.
Diagnostics
Diagnostic criteria:
Pain syndrome in the injured limb;
Forced position of the injured limb;
Limited or absent limb mobility;
Changes in soft tissue over the fracture site (swelling, hematoma, deformation, etc.);
Crepitation upon palpation of the suspected injured area of the leg;
Associated neurological symptoms (lack of sensitivity, coldness, etc.);
Damage to the skin according to the above classification;
X-ray signs of injury to underlying tissues.
List of main diagnostic measures:
1. Determination of the type of injury in accordance with the given classification.
2. Determination of the degree of dysfunction of the injured organ (range of motion).
3. Clinical examination of the patient (see diagnostic criteria).
4. X-ray examination of the injured lower leg in 2 projections.
5. General blood test.
6. General urine analysis.
7. Coagulogram.
8. Biochemistry.
9. HIV, HbsAg, Anti-HCV.
List of additional diagnostic measures:
1. Determination of blood group and Rh factor.
2. Determination of sensitivity to antibiotics.
3. Determination of blood sugar.
Treatment
Treatment tactics
Treatment goals: timely diagnosis of wounds taking into account their location, determination of therapeutic tactics (conservative, surgical), prevention of possible complications.
Treatment: the need for anesthesia depends on the type of wound according to the classification. Taking into account the violation of the integrity of the skin, it is necessary to administer tetanus toxoid.
Conservative treatment:
1. Primary surgical treatment of the wound.
2. If the wound is not infected, antibiotic prophylaxis is not carried out.
Surgical treatment:
1. Application of primary sutures in the absence of signs of wound infection.
2. Antibiotic prophylaxis is carried out for 3-5 days for wounds received more than 8 hours ago with a high risk of infection:
Moderate and severe wounds;
Wounds reaching a bone or joint;
Hand wounds;
Immunodeficiency state;
Wounds of the external genitalia;
Bite wounds.
3. Surgical treatment of wounds is indicated when damage to a nerve or vascular bundle is confirmed.
The results of multicenter studies have established that the use of antibiotic prophylaxis in patients with wounds reduces the risk of developing purulent-inflammatory complications.
Patients can be divided into 3 risk groups:
1. Injuries with damage to the skin and soft tissue less than 1 cm in length, the wound is clean.
2. Injuries with skin damage more than 1 cm in length in the absence of significant damage to the underlying tissues or significant displacements.
3. Any injuries with severe damage to underlying tissues or traumatic amputation.
Patients of risk groups 1-2 require a dose of antibiotics (as early as possible after injury), mainly with an effect on gram-positive microorganisms. For patients at risk group 3, antibiotics that act on gram-negative microorganisms are additionally prescribed.
Antibiotic prophylaxis regimens:
For patients of risk groups 1-2 - amoxicillin 500 thousand after 6 hours, 5-10 days per os;
Patients of the 3rd risk group - amoxicillin 500 thousand after 6 hours, 5-10 days per os + clavulanic acid 1 tablet 2 times.
List of essential medications:
1. *Amoxicillin tablet 500 mg, 1000 mg; capsule 250 mg, 500 mg
2. *Amoxicillin + clavulanic acid film-coated tablets 500 mg/125 mg, 875 mg/125 mg, powder for solution for intravenous administration in vials 500 mg/100 mg, 1000 mg/200 mg
3. *Cefuroxime powder for solution for injection in a bottle 750 mg, 1.5 g
4. Ceftazidime - powder for the preparation of solution for injection in a bottle of 500 mg, 1 g, 2 g
5. Ticarcillin + clavulanic acid, lyophilized powder 3000 mg/200 mg for solution for intravenous infusion
6. *Nitrofural 20 mg tablet.
List of additional medications: no.
Indicators of treatment effectiveness: wound healing, restoration of functions of damaged organs.
* - drugs included in the list of essential (vital) medicines.
Hospitalization
Indications for hospitalization: emergency.
Information
Sources and literature
- Protocols for diagnosis and treatment of diseases of the Ministry of Health of the Republic of Kazakhstan (Order No. 764 of December 28, 2007)
- 1. Evidence-based medicine. CLINICAL GUIDELINES for practicing doctors. - Moscow, Geotar-Med. - 2002. - pp. 523-524 2. Surgery. Guide for doctors and students. - Moscow, Geotar-Med. - 2002. - p. 576-577 3. National Guideline Clearinghouse. Practice Managment for Prophylactic Antibiotic Use in Open Fracture: Eastern Association for the Surgery of Trauma.- 2000.- p.28 4. National Guideline Clearinghouse. Preoperative Test: the Use of Routine Preoperative Tests for Elective Surgery: Evidence, Methods&Guidance. London.-NICE.- 2003. 108p.
Information
List of developers: Ermanov E.Zh. Scientific Center of Surgery of the Ministry of Health of the Republic of Kazakhstan
Attached files
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Traumatic injuries to the body also have their own code in the international classification of diseases. In most cases, an incised wound of the hand according to ICD 10 will relate to one nosology, but there are exceptions, for example, superficial wounds.
Moreover, upon diagnosis it should be taken into account which structures were damaged: vessels, nerves, muscles, tendons or even bones. In the classification of open wounds of the hand, mechanical amputation is excluded.
Encoding Features
This nosology belongs to the class of traumatic injuries to the body, poisoning and some additional consequences of external influences.
According to ICD 10, a bite wound of the hand or any other open wound belongs to the wrist injury block. This is followed by a section of open wounds, which includes the following codes:
- S0 – damage without involving the nail plate;
- S1 – finger injury involving the nail;
- S7 – multiple wounds of the limb up to the level of the forearm;
- S8 – damage to other parts of the hand and wrist;
- S9 – injury to unspecified areas.
If the incised wound involves the forearm, then the coding will change, since several structures are involved in the process. The same applies to purulent complications of mechanical damage.
