Left lower quadrant abdominal tenderness
ICD-10 R10.814 is a billable code used to indicate a diagnosis of left lower quadrant abdominal tenderness.
Left lower quadrant abdominal tenderness is a clinical sign that indicates discomfort or pain in the lower left section of the abdomen. This symptom can arise from various underlying conditions affecting the gastrointestinal, urinary, or reproductive systems. Common causes include diverticulitis, appendicitis (in cases where the appendix is located in the left lower quadrant), ovarian cysts, and urinary tract infections. The tenderness may be elicited during a physical examination, where the clinician palpates the abdomen, leading to localized pain. It is essential to assess the tenderness in conjunction with other symptoms such as fever, nausea, vomiting, or changes in bowel habits to determine the underlying cause. Laboratory findings may include elevated white blood cell counts or imaging studies that reveal structural abnormalities. Accurate documentation of the tenderness, associated symptoms, and clinical findings is crucial for proper coding and management of the patient's condition.
Detailed history and physical examination notes, including associated symptoms and lab results.
Patients presenting with abdominal pain, requiring evaluation for gastrointestinal disorders.
Ensure that all relevant clinical findings are documented to support the diagnosis.
Acute care documentation, including vital signs, immediate lab results, and imaging studies.
Patients with acute abdominal pain requiring rapid assessment and intervention.
Document the urgency of the situation and any immediate treatments provided.
Used when a patient presents with left lower quadrant tenderness for evaluation.
Document the history, examination findings, and medical decision-making.
Ensure that the visit level reflects the complexity of the case.
Documenting left lower quadrant tenderness is crucial for identifying potential underlying conditions, guiding treatment, and ensuring accurate coding for reimbursement.
