ICD 10 CM S36.029S | Description & Clinical Information

ICD 10 S36.029S describes a medical condition characterized by an unspecified contusion of the spleen, which occurs as a result of a blunt injury that breaks small blood vessels in the highly vascular organ, leading to immediate pain in the left side of the abdomen, typically caused by blunt trauma such as a heavy object falling on the abdomen, a motor vehicle accident, or a sports injury, and resulting in the leakage of capillaries in the splenic region without any overt tear or laceration, while the provider does not document the nature of the injury at this encounter for the sequela, which is a condition resulting from the injury.

Official Description Of S36.029S

The ICD 10 CM book defines ICD 10 code S36.029S as:

When To Use S36.029S

The diagnosis describes by the ICD 10 CM S36.029S code pertains to a contusion of the spleen. A contusion refers to a bruise that occurs due to an injury, although in some cases it may also arise spontaneously. The spleen lies in the upper left portion of the abdomen, and a contusion of this organ can cause a range of symptoms.

One of the most common symptoms of spleen contusion is pain and tenderness in the upper left portion of the abdomen, which may radiate towards the left shoulder. Patients may also experience nausea and vomiting, sudden low blood pressure, swelling, difficulty in breathing, discolored skin, and bruising in and around the spleen.

To diagnose spleen contusion, healthcare providers initially perform a physical examination to look for external signs of injury, such as discoloration or swelling. They also obtain a complete personal history of the patient’s trauma and inquire about any recent accidents, falls or blunt force injuries that may have provoked the injury.

Healthcare providers may also make use of diagnostic imaging techniques such as X-ray, ultrasound, and computed tomography to better visualize the extent of the injury. In certain cases, laboratory evaluations, such as blood tests, may also be necessary to assess the patient’s condition and rule out other underlying medical problems.

Treatment options for spleen contusion aim to manage the symptoms effectively, restore the spleen to its normal functions, and minimize the risk of complications. Patients may be prescribed pain-relieving medications to alleviate the discomfort, and additional intravenous fluids to rehydrate the body if necessary.

Moreover, healthcare providers may recommend bed rest and observation to allow the spleen contusion to heal naturally. In some instances, surgical interventions may be required to repair the spleen or opt for splenectomy if the organ has suffered extensive damage that cannot be salvaged.

In summary, the ICD 10 CM S36.029S diagnosis code refers to an unspecified contusion of the spleen. It can cause a range of symptoms, including pain and tenderness in the upper left portion of the abdomen, nausea and vomiting, low blood pressure, and difficulties in breathing. To diagnose the condition, healthcare providers rely on a combination of physical examinations, medical history, imaging techniques, and laboratory tests. Treatment options range from pain relief and rest to possible surgical intervention for spleen repair or removal. With prompt diagnosis and appropriate treatment, most patients recover fully from spleen contusion with minimal complications.