Epigastric rebound abdominal tenderness
ICD-10 R10.826 is a billable code used to indicate a diagnosis of epigastric rebound abdominal tenderness.
Epigastric rebound abdominal tenderness is a clinical sign indicating potential underlying abdominal pathology, often associated with peritoneal irritation. This tenderness is assessed during a physical examination, where the clinician applies pressure to the epigastric region and then quickly releases it. The presence of rebound tenderness suggests that the abdominal cavity may be inflamed or irritated, commonly seen in conditions such as appendicitis, pancreatitis, or perforated viscus. Patients may present with additional symptoms such as abdominal pain, nausea, vomiting, and changes in bowel habits. The clinical context is crucial, as rebound tenderness can indicate serious conditions requiring immediate intervention. Laboratory findings may include elevated white blood cell counts, indicating infection or inflammation, and imaging studies may reveal abnormalities such as fluid collections or organ enlargement. Accurate identification and documentation of this sign are essential for appropriate diagnosis and treatment planning.
Detailed documentation of the physical examination, including the presence and location of tenderness, associated symptoms, and any relevant history.
Patients presenting with abdominal pain, nausea, and vomiting, requiring evaluation for possible acute abdomen.
Consideration of chronic conditions that may mimic acute presentations.
Acute care documentation must include time of onset, severity of pain, and any immediate interventions performed.
Patients with acute abdominal pain presenting to the emergency department, requiring rapid assessment and potential surgical intervention.
Rapid decision-making is crucial; documentation should reflect urgency and rationale for interventions.
Used when a patient presents with epigastric rebound tenderness and requires moderate complexity evaluation.
Document the level of service, including history, examination, and medical decision-making.
Emergency medicine documentation must reflect the urgency of the situation.
Rebound tenderness is a clinical sign that indicates potential peritoneal irritation, often requiring further evaluation to determine the underlying cause.
