Epigastric swelling, mass or lump
ICD-10 R19.06 is a billable code used to indicate a diagnosis of epigastric swelling, mass or lump.
Epigastric swelling, mass, or lump refers to an abnormal enlargement or protrusion in the epigastric region, which is located between the lower ribs and above the umbilicus. This symptom can arise from various underlying conditions, including gastrointestinal disorders, tumors, or fluid accumulation. Patients may present with associated symptoms such as pain, discomfort, or changes in bowel habits. Clinical evaluation often includes a thorough physical examination, imaging studies (such as ultrasound or CT scans), and laboratory tests to identify the underlying cause. Common causes of epigastric masses include hernias, cysts, tumors (benign or malignant), and organomegaly. Accurate diagnosis is crucial as it guides treatment options and management strategies. The presence of an epigastric mass may indicate serious conditions requiring immediate intervention, thus necessitating prompt and thorough clinical assessment.
Detailed history and physical examination findings, imaging results, and lab tests must be documented to support the diagnosis.
Patients presenting with unexplained abdominal pain and a palpable mass in the epigastric region.
Consideration of chronic conditions such as pancreatitis or liver disease that may contribute to epigastric swelling.
Acute care documentation must include vital signs, immediate assessment findings, and any interventions performed.
Patients with acute abdominal pain and a sudden onset of epigastric swelling, possibly indicating a surgical emergency.
Rapid assessment is critical; documentation should reflect the urgency of the situation and any immediate actions taken.
Used to evaluate the cause of epigastric swelling.
Document the indication for the CT scan and findings.
Ensure imaging is justified based on clinical findings.
Documentation should include a clear description of the mass, associated symptoms, results of any imaging studies, and the clinical rationale for the diagnosis.
