Puncture wound of abdominal wall without foreign body, right lower quadrant without penetration into peritoneal cavity
ICD-10 S31.133 is a billable code used to indicate a diagnosis of puncture wound of abdominal wall without foreign body, right lower quadrant without penetration into peritoneal cavity.
A puncture wound of the abdominal wall in the right lower quadrant is characterized by a breach in the skin and underlying tissues without the introduction of a foreign body and without penetration into the peritoneal cavity. This type of injury may occur due to various mechanisms, including accidental trauma from sharp objects or intentional injuries. Clinically, patients may present with localized pain, swelling, and tenderness in the right lower quadrant, but without signs of peritoneal irritation such as rebound tenderness or guarding. Diagnostic imaging may be warranted to rule out deeper organ injury, particularly to the appendix or other structures in the right lower quadrant. Management typically involves wound care, monitoring for infection, and ensuring that no underlying organ injury has occurred. Surgical intervention is rarely required unless complications arise, such as abscess formation or if there is a concern for deeper tissue involvement.
Detailed account of the injury mechanism, examination findings, and treatment provided.
Patients presenting with stab wounds, accidental punctures, or sports-related injuries.
Ensure that all relevant imaging and consultations are documented to support the diagnosis.
Operative notes if surgical intervention is performed, including findings and procedures.
Management of abdominal wall injuries with potential for deeper organ involvement.
Document any intraoperative findings that may affect coding.
Used when the puncture wound requires suturing or closure.
Document the size of the wound and the method of closure.
Emergency medicine may require additional documentation for trauma cases.
S31.133 refers to a puncture wound without penetration into the peritoneal cavity, while S31.134 indicates a puncture wound that does penetrate the peritoneal cavity, which may require different management and coding.
