Left upper quadrant abdominal swelling, mass and lump
ICD-10 R19.02 is a billable code used to indicate a diagnosis of left upper quadrant abdominal swelling, mass and lump.
R19.02 refers to the clinical presentation of swelling, mass, or lump specifically located in the left upper quadrant (LUQ) of the abdomen. This symptom can arise from various underlying conditions, including organ enlargement (such as splenomegaly), tumors, cysts, or inflammatory processes. Patients may present with associated symptoms such as pain, discomfort, or changes in bowel habits. Physical examination may reveal a palpable mass, tenderness, or signs of peritoneal irritation. Diagnostic imaging, such as ultrasound or CT scans, is often employed to characterize the mass and determine its etiology. Laboratory tests may include complete blood counts, liver function tests, and tumor markers, depending on the suspected underlying condition. Accurate documentation of the mass's characteristics, associated symptoms, and any relevant imaging or lab findings is crucial for appropriate coding and management.
Detailed history and physical examination notes, including mass characteristics and associated symptoms.
Patients presenting with LUQ pain and palpable mass during routine examinations.
Consideration of chronic conditions that may contribute to mass formation, such as liver disease.
Acute care documentation must include immediate assessment findings, imaging results, and treatment plans.
Patients presenting with acute LUQ pain and signs of possible splenic rupture or other urgent conditions.
Rapid assessment and documentation are critical due to the potential for life-threatening conditions.
Used to evaluate the LUQ mass found during examination.
Document the indication for the ultrasound and findings.
Ensure that the ultrasound report is included in the patient's medical record.
Documentation should include the characteristics of the mass, associated symptoms, results of any imaging studies, and the clinical rationale for the diagnosis.
