Right upper quadrant abdominal rigidity
ICD-10 R19.31 is a billable code used to indicate a diagnosis of right upper quadrant abdominal rigidity.
Right upper quadrant abdominal rigidity refers to a clinical finding characterized by increased tension and resistance in the abdominal muscles located in the right upper quadrant (RUQ) of the abdomen. This rigidity can be a sign of underlying pathology, often indicating irritation or inflammation of the abdominal organs, such as the liver, gallbladder, or pancreas. It may present as a protective mechanism in response to pain or inflammation, leading to involuntary muscle contraction. Common causes include acute cholecystitis, liver disease, pancreatitis, or perforated viscus. The presence of rigidity may be accompanied by other symptoms such as tenderness, guarding, or rebound tenderness, which can help clinicians assess the severity of the underlying condition. Laboratory findings may include elevated liver enzymes, bilirubin levels, or inflammatory markers, depending on the etiology. Accurate identification and documentation of RUQ rigidity are crucial for appropriate diagnosis and management, as it can significantly influence treatment decisions and patient outcomes.
Detailed documentation of the patient's history, physical examination findings, and any diagnostic tests performed.
Patients presenting with RUQ pain, jaundice, or elevated liver enzymes.
Ensure that the documentation clearly indicates the presence of rigidity and any associated symptoms to support the diagnosis.
Acute care documentation must include a thorough assessment of abdominal findings, vital signs, and any immediate interventions.
Patients with acute abdominal pain, suspected gallbladder disease, or pancreatitis.
Rapid assessment and documentation are critical; ensure that the presence of rigidity is noted in the context of acute presentations.
Used when a patient presents with RUQ rigidity and requires moderate complexity evaluation.
Document the patient's history, physical exam findings, and any diagnostic tests performed.
Emergency medicine providers should ensure that the evaluation reflects the complexity of the case.
Documenting RUQ rigidity is crucial as it can indicate serious underlying conditions that require immediate attention. Accurate documentation supports appropriate coding and ensures that the clinical picture is clear for treatment decisions.
