Right upper quadrant pain
ICD-10 R10.11 is a billable code used to indicate a diagnosis of right upper quadrant pain.
Right upper quadrant (RUQ) pain is a clinical symptom that can arise from various underlying conditions affecting the organs located in this area, including the liver, gallbladder, pancreas, and parts of the intestines. Patients may present with acute or chronic pain, which can be sharp, dull, or cramping in nature. Associated symptoms may include nausea, vomiting, jaundice, and changes in bowel habits. Clinical evaluation often involves a thorough history and physical examination, focusing on the quality, duration, and intensity of the pain, as well as any accompanying symptoms. Laboratory tests such as liver function tests, complete blood count, and imaging studies like ultrasound or CT scans are commonly employed to identify the underlying cause. Common causes of RUQ pain include gallstones, hepatitis, liver abscess, pancreatitis, and peptic ulcer disease. Accurate diagnosis is crucial as it guides appropriate management and treatment strategies.
Detailed history of present illness, including onset, duration, and character of pain, along with associated symptoms and relevant past medical history.
Patients presenting with RUQ pain due to gallbladder disease or liver dysfunction.
Ensure that all relevant lab results and imaging studies are documented to support the diagnosis.
Acute care documentation must include a rapid assessment of pain, vital signs, and any immediate interventions performed.
Acute presentations of RUQ pain due to conditions like acute cholecystitis or pancreatitis.
Document the urgency of the situation and any immediate treatments provided, as this may affect coding.
Used to evaluate RUQ pain in suspected gallbladder disease.
Document the reason for the ultrasound and findings.
Ensure that the ultrasound report is included in the patient's medical record.
Use R10.11 when a patient presents with right upper quadrant pain without a specific underlying diagnosis. Ensure that the documentation supports the symptom and any related clinical findings.
