Solitary pulmonary nodule
ICD-10 R91.1 is a billable code used to indicate a diagnosis of solitary pulmonary nodule.
A solitary pulmonary nodule (SPN) is defined as a single, well-defined round opacity in the lung that is 3 cm or less in diameter, surrounded by normal lung tissue. These nodules can be detected incidentally on chest X-rays or CT scans and may represent a variety of conditions, including benign lesions such as hamartomas or granulomas, as well as malignant tumors like lung cancer. Symptoms associated with SPNs are often absent, but patients may present with cough, hemoptysis, or unexplained weight loss if the nodule is malignant. The clinical significance of an SPN is determined by its size, shape, and growth rate, as well as the patient's risk factors, including smoking history and exposure to carcinogens. A thorough diagnostic approach typically involves imaging studies, such as CT scans, and may include biopsy or PET scans to assess for malignancy. The management of SPNs is guided by the likelihood of cancer, with options ranging from surveillance to surgical intervention.
Detailed documentation of patient history, imaging findings, and any follow-up plans is essential.
Patients presenting with incidental findings on imaging during routine check-ups or evaluations for other conditions.
Consideration of patient risk factors and the need for multidisciplinary discussions regarding management.
Acute care documentation should include the reason for imaging, findings, and any immediate management decisions.
Patients presenting with respiratory symptoms who undergo imaging that reveals a solitary pulmonary nodule.
Rapid assessment of the nodule's potential malignancy and coordination with specialists for further evaluation.
Used for further evaluation of a solitary pulmonary nodule after initial imaging.
Document the indication for the CT scan and findings related to the nodule.
Pulmonologists may require additional imaging to assess nodule characteristics.
A solitary pulmonary nodule can represent a range of conditions from benign to malignant. Its significance is determined by factors such as size, growth rate, and patient risk factors.
Monitoring typically involves follow-up imaging at intervals determined by the nodule's characteristics and the patient's risk factors, often guided by established protocols.
