Find information on left upper arm pain diagnosis, including differential diagnoses, clinical documentation tips, and relevant medical codes (ICD-10, CPT). Explore causes of left upper arm pain such as rotator cuff tear, bicep tendonitis, brachial plexus injury, or cervical radiculopathy. Learn about symptoms, examinations, and treatment options for left upper arm pain to improve your healthcare documentation and medical coding accuracy.
Also known as
Pain in left upper arm
Pain localized to the left upper arm.
Myalgia
Muscle pain, which could include the left upper arm.
Pain in left shoulder joint
Shoulder pain, which may radiate to the left upper arm.
Injury of upper arm
Injury to the upper arm that may cause pain.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the pain due to trauma/injury?
When to use each related code
| Description |
|---|
| Left upper arm pain |
| Left biceps tendinitis |
| Left brachial plexus neuropathy |
Patient presents with left upper arm pain. Onset of pain was [duration] ago and is described as [quality of pain; e.g., sharp, dull, aching, burning] and [frequency; e.g., constant, intermittent]. Pain severity is rated [scale; e.g., 0-10] with exacerbating factors including [list exacerbating factors; e.g., lifting, reaching overhead] and alleviating factors including [list alleviating factors; e.g., rest, ice]. Location of pain is specified as [specific location; e.g., anterior, posterior, medial, lateral aspect of upper arm] and radiates [radiation pattern; e.g., to the elbow, shoulder, neck, fingers; or, no radiation]. Associated symptoms include [list associated symptoms; e.g., numbness, tingling, weakness, swelling, redness, warmth]. Patient denies [list pertinent negatives; e.g., fever, chills, trauma, recent infection]. Medical history includes [list relevant medical history; e.g., hypertension, diabetes, prior shoulder injury]. Surgical history includes [list relevant surgical history]. Medications include [list current medications]. Allergies include [list allergies]. Physical examination reveals [objective findings; e.g., tenderness to palpation over the [specific muscle or area], limited range of motion in the shoulder, normal pulses, intact sensation]. Differential diagnosis includes [list potential diagnoses; e.g., rotator cuff tear, biceps tendinitis, brachial plexus neuropathy, cervical radiculopathy]. Assessment: Left upper arm pain, likely due to [most likely diagnosis]. Plan: [Outline plan; e.g., Recommend conservative management including rest, ice, and over-the-counter pain relievers such as ibuprofen. Prescribed [medication, if any]. Referred to physical therapy. Follow-up appointment scheduled in [timeframe]. Return sooner if symptoms worsen or new symptoms develop].