ICD 10 CM S36.119A | Description & Clinical Information

ICD 10 S36.119A describes an instance of harm to the liver, the largest internal organ in the body situated across the upper abdominal quadrants, resulting from blunt or penetrating trauma caused by various factors such as a motor vehicle accident, sports activity, falls, a puncture or gunshot wound, assault, or surgery, where the healthcare provider does not provide any specific details regarding the nature of the injury during the initial encounter.

Official Description Of S36.119A

The ICD 10 CM book defines ICD 10 code S36.119A as:

When To Use S36.119A

The diagnosis describes by ICD 10 CM S36.119A pertains to an unspecified injury to the liver. This condition can cause severe pain and tenderness in the upper right quadrant of the abdomen, which can spread to the right shoulder. In some cases, it can also lead to hemorrhaging, difficulty breathing, discoloration of the skin, and shock with a rapid heartbeat. Sudden drops in blood pressure due to bleeding may also occur, along with confusion and dizziness. There is also a possibility of complications arising from this condition, including the formation of a fistula – an abnormal connection between the biliary tract and liver tissue.

Providers use a series of methods to diagnose this condition. Firstly, they take into account the patient’s medical history and conduct a thorough physical examination. Following this, laboratory tests to assess blood loss and liver function, imaging techniques such as Xray, ultrasound and computed tomography, as well as a laparoscopy, may be employed to facilitate an accurate diagnosis. Diagnostic peritoneal lavage may also be performed in some instances to determine the extent of the damage.

Once diagnosed, treatment options must be initiated swiftly. To address any breathing difficulties, supplemental oxygen with mechanical ventilation may be necessary. Pain management can also be provided through analgesic medication, while intravenous fluid and blood transfusions may be administered to patients with a loss of blood. Antibiotics may also be given if the patient is at risk of, or is already suffering from, an infection. For less severe cases, rest and observation may be advised.

Lastly, surgery may be required, depending on the nature and severity of the injury. The nature of the surgery will differ from case to case and will be dependent on factors such as the size of the injury, the location of the injury, and the extent of damage it has caused.

In conclusion, the diagnosis code, ICD 10 CM S36.119A is particularly concerning, given the potential for complications and long-term effects. Therefore, it is absolutely vital that doctors, patients, and medical staff remain swift and accurate in their diagnosis, and that the necessary steps are taken to provide the best possible treatment options. By doing so, we can help to mitigate the impact of this diagnosis and secure a smoother, more expeditious recovery process for those who suffer from it.