Experiencing right-sided abdominal pain? This guide covers potential diagnoses, including appendicitis, cholecystitis, kidney stones, ovarian cysts, and other causes. Learn about associated symptoms, differential diagnosis considerations, relevant ICD-10 codes (like R10.11, R10.31, N23, K80.0), clinical documentation best practices for accurate medical coding, and when to seek emergency medical attention. Understand the importance of proper healthcare documentation for right lower quadrant pain, right upper quadrant pain, and generalized right abdominal pain for effective patient care.
Also known as
Symptoms and signs involving ab
Covers abdominal and pelvic pain.
Diseases of digestive system
Includes conditions like appendicitis, cholecystitis causing right abdominal pain.
Diseases of female genital orga
Relevant for right-sided pain originating from female reproductive organs.
Coding R10.3 (right lower quadrant pain) without laterality documentation may lead to claim denials or improper reimbursement. Clarify right-sided location.
Coding abdominal pain without a documented, confirmed diagnosis can cause compliance issues. Query physician for root cause.
Ruling out appendicitis (K35.80) is crucial for proper coding. Lack of documentation supporting this can impact payment accuracy.
Patient presents with a chief complaint of right-sided abdominal pain. Onset, duration, character, location, radiation, associated symptoms, and relieving or exacerbating factors were thoroughly explored. Differential diagnosis includes appendicitis, cholecystitis, nephrolithiasis, ovarian cyst, ectopic pregnancy, pelvic inflammatory disease, gastroenteritis, constipation, irritable bowel syndrome, and musculoskeletal pain. Physical examination revealed tenderness (or rebound tenderness, guarding, rigidity, or absence thereof) in the right lower quadrant (or right upper quadrant, or generalized right-sided abdomen). Bowel sounds were noted as present, absent, hyperactive, or hypoactive. Vital signs including temperature, heart rate, blood pressure, and respiratory rate were recorded and within normal limits (or specify abnormalities). Laboratory studies such as a complete blood count (CBC), comprehensive metabolic panel (CMP), urinalysis (UA), pregnancy test (if applicable), and liver function tests (LFTs) were ordered (or results documented if available). Imaging studies such as an abdominal ultrasound, CT scan of the abdomen and pelvis, or abdominal X-ray were considered (or results documented if performed). Assessment suggests possible (differential diagnosis listed and ranked by likelihood). The patient was treated with (pain medication, intravenous fluids, antiemetics, antibiotics, or other appropriate interventions). Patient education regarding diagnosis, treatment plan, and follow-up care was provided. The patient tolerated the interventions well and will follow up for further evaluation (or was referred for specialist consultation or admitted for further observation and management). Plan includes continued monitoring, further diagnostic testing if necessary, and adjustment of treatment as indicated.