Left upper quadrant abdominal tenderness
ICD-10 R10.812 is a billable code used to indicate a diagnosis of left upper quadrant abdominal tenderness.
Left upper quadrant abdominal tenderness is a clinical sign characterized by discomfort or pain upon palpation of the left upper quadrant of the abdomen. This area encompasses vital organs such as the stomach, spleen, left kidney, and parts of the pancreas and colon. Tenderness in this region can indicate a variety of underlying conditions, ranging from benign to serious. Common causes include splenic enlargement, gastritis, pancreatitis, and renal issues. The presence of tenderness may be accompanied by other symptoms such as nausea, vomiting, or changes in bowel habits, which can aid in diagnosis. Clinicians often assess tenderness through physical examination, and it may prompt further diagnostic testing, including imaging studies or laboratory tests, to identify the underlying cause. Accurate documentation of the tenderness, associated symptoms, and any relevant medical history is crucial for effective diagnosis and treatment planning.
Detailed history of present illness, physical examination findings, and any relevant lab results.
Patients presenting with abdominal pain, nausea, or vomiting, requiring evaluation for gastrointestinal disorders.
Ensure to document any chronic conditions that may contribute to abdominal tenderness.
Acute care documentation including vital signs, immediate assessment findings, and any interventions performed.
Patients with acute abdominal pain requiring rapid assessment and potential imaging.
Document the time of onset of symptoms and any changes in the patient's condition.
Used when a patient presents with left upper quadrant tenderness during a follow-up visit.
Document the history, examination findings, and medical decision-making.
Internal medicine providers should ensure comprehensive documentation of the visit.
Use R10.812 when there is documented tenderness in the left upper quadrant of the abdomen, and it is relevant to the patient's clinical presentation.
