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PIISA 12

The patient has no significant past medical history related to gastrointestinal conditions. The patient, a 35-year-old male, presented with a one-month history of non-bilious postprandial vomiting, progressive non-tender abdominal distension, and visible peristalsis. Abdominal ultrasound revealed a thickened hypertrophic pylorus with a length of 18 mm and a channel length of 3 mm. Adult hypertrophic pyloric stenosis (K311): The patient presents with a one-month history of non-bilious postprandial vomiting, visible peristalsis, and an ultrasound showing a thickened hypertrophic pylorus. The patient's physical examination was remarkable for a palpable olive-shaped mass in the right upper quadrant. No signs of peritonitis were noted. The patient underwent a pyloromyotomy procedure to relieve the pyloric stenosis. Postoperatively, the patient tolerated a clear liquid diet and was discharged home on postoperative day two. The patient was discharged home in good condition with instructions for a gradual return to a normal diet and to follow up with the surgical team in two weeks for a wound check. 35 years old Male Not specified ICD Code: K311

The patient has a history of chronic gastritis and recurrent episodes of abdominal pain. The patient presents with intermittent upper abdominal discomfort, bloating, and occasional nausea. Upper gastrointestinal endoscopy revealed a small outpouching in the gastric wall consistent with a diverticulum. Gastric diverticulum (K31.4) - A gastric diverticulum is a rare condition characterized by an outpouching in the gastric wall. Verbatim EHR quote justifying the code: 'Upper gastrointestinal endoscopy revealed a small outpouching in the gastric wall consistent with a diverticulum.' The patient's symptoms correlate with the presence of a gastric diverticulum. No signs of bleeding or inflammation were noted during the endoscopy. The patient was advised on dietary modifications and prescribed proton pump inhibitors for symptom management. The patient's symptoms improved with treatment, and they were discharged with recommendations for follow-up endoscopy in six months. 56 Female Caucasian ICD Code: K31.4

The patient has no history of gastrointestinal disorders or surgeries. The patient presents with severe abdominal pain, distention, vomiting, and inability to pass stools or gas. Abdominal X-ray shows dilated loops of the proximal duodenum with air-fluid levels, suggestive of duodenal obstruction. Obstruction of the duodenum (K31.5) - The duodenal obstruction is evidenced by the patient's symptoms of severe abdominal pain, distention, vomiting, and the diagnostic findings on abdominal X-ray. The patient's symptoms and diagnostic tests are consistent with acute duodenal obstruction. Immediate intervention is necessary to relieve the obstruction and prevent complications. The patient was taken for emergency surgery and a laparotomy was performed to relieve the duodenal obstruction. Postoperatively, the patient was kept nil by mouth and received intravenous fluids and antibiotics. The patient showed improvement postoperatively, with resolution of symptoms. The patient was discharged with instructions for a restricted diet and follow-up with the surgical team in two weeks. 58 Male Caucasian ICD Code: K31.5

The patient has a history of peptic ulcer disease. The patient presents with persistent upper abdominal pain, vomiting blood, and signs of gastrointestinal bleeding. Imaging studies revealed a fistula between the stomach and duodenum. Fistula of stomach and duodenum (K316) The patient shows classic symptoms of a fistula between the stomach and duodenum, including abdominal pain, vomiting blood, and imaging evidence confirming the diagnosis. The patient is being prepared for surgical intervention to repair the fistula and manage the complications of gastrointestinal bleeding. The patient underwent successful surgical repair of the fistula and is recovering well without any postoperative complications. 58 Female Caucasian ICD Code: K316

The patient has a history of recurrent upper abdominal discomfort and occasional episodes of dyspepsia. The patient presents with intermittent epigastric pain, postprandial fullness, and mild anemia. Upper endoscopy revealed vascular malformations consistent with angiodysplasia in the stomach and duodenum. Hemoglobin level is slightly decreased. Angiodysplasia of stomach and duodenum without bleeding (K31.819): Angiodysplasia in the stomach and duodenum without evidence of active bleeding. The patient's symptoms and endoscopic findings are indicative of angiodysplasia in the stomach and duodenum. No active bleeding or other significant abnormalities were noted. The patient was started on iron supplementation for the mild anemia and advised on dietary modifications. Follow-up endoscopy in six months is recommended. The patient responded well to treatment and was discharged in stable condition with instructions for follow-up. 55 Female Caucasian ICD Code: K31.819

The patient has a history of gastroesophageal reflux disease (GERD) and occasional episodes of gastritis. The patient presents with intermittent upper abdominal pain, bloating, and occasional nausea. Upper endoscopy revealed mild gastritis with no evidence of ulcers or masses. Biopsies were taken and showed chronic inflammation. Other diseases of stomach and duodenum (K31.89) - The patient presents with intermittent upper abdominal pain, bloating, and mild gastritis on endoscopy. The patient's symptoms and endoscopy findings are consistent with a diagnosis of Other diseases of stomach and duodenum (K31.89). No other significant abnormalities were noted. Prescribed proton pump inhibitor (PPI) for gastritis and advised dietary modifications to manage symptoms. The patient responded well to treatment and was discharged with instructions for follow-up in two weeks. 45 Female Caucasian ICD Code: K31.89

The patient has a history of intermittent epigastric pain and occasional bloating over the past six months. The patient presents with recurrent epigastric pain, worsened after meals, and occasional nausea without vomiting. No signs of gastrointestinal bleeding. Upper endoscopy revealed mild gastritis without any ulcers or masses. Disease of stomach and duodenum, unspecified (K319) - The patient presents with recurrent epigastric pain and mild gastritis on upper endoscopy, without specific findings to classify into a more precise diagnosis. The patient denies any unintentional weight loss, dysphagia, or melena. Physical examination shows epigastric tenderness without rebound tenderness. No palpable masses or signs of peritonitis. Prescribed proton pump inhibitor for gastritis symptom management. Advised dietary modifications and follow-up in four weeks. 48 Female Caucasian ICD Code: K319

The patient has no previous history of abdominal surgeries or gastrointestinal disorders. The patient presented with severe abdominal pain that started around the umbilicus and migrated to the right lower quadrant. The pain was associated with nausea, vomiting, and fever. Laboratory tests showed leukocytosis with a left shift. Abdominal ultrasound revealed an inflamed appendix with surrounding fluid collection. Acute appendicitis with generalized peritonitis. Verbatim EHR quote justifying the code: 'The patient presents with classic symptoms of acute appendicitis, including migrating abdominal pain to the right lower quadrant, rebound tenderness, guarding, fever, leukocytosis, and imaging findings consistent with appendicitis.' On examination, the patient had rebound tenderness and guarding in the right lower quadrant. The clinical presentation and imaging findings are highly suggestive of acute appendicitis with generalized peritonitis. The patient was started on intravenous antibiotics and underwent an emergency laparoscopic appendectomy. The patient recovered well post-surgery and was discharged home with appropriate post-operative care instructions. 32 Female Caucasian ICD Code: K352

The patient has no prior history of gastrointestinal issues or abdominal surgeries. The patient presented with severe abdominal pain starting centrally and shifting to the right lower quadrant, associated with nausea, vomiting, and low-grade fever. CT scan of the abdomen revealed findings consistent with acute appendicitis, including appendiceal perforation, localized peritonitis, gangrene, and the presence of an abscess. Acute appendicitis with perforation, localized peritonitis, and gangrene, with abscess. The patient shows classic signs of acute appendicitis with complications, including rebound tenderness and guarding upon abdominal examination. Surgical consultation was immediately requested. The patient underwent an emergency laparoscopic appendectomy with drainage of the abscess. Intravenous antibiotics were administered postoperatively to manage the infection. The patient recovered well post-surgery and was discharged with a course of oral antibiotics. Follow-up appointment scheduled in two weeks for wound check and overall recovery assessment. 32 Female Caucasian ICD Code: K3533

The patient has no previous history of gastrointestinal disorders or surgeries. The patient presented with sudden-onset abdominal pain starting around the umbilical area and migrating to the right lower quadrant. The pain is sharp, constant, and worsens with movement. The patient also reported nausea and anorexia. Physical examination revealed tenderness in the right lower quadrant with rebound tenderness. Laboratory tests showed elevated white blood cell count and neutrophils. Abdominal ultrasound demonstrated an inflamed appendix without signs of perforation or abscess. Other acute appendicitis without perforation or peritonitis. Verbatim EHR quote justifying the code: 'Patient presents with classic symptoms of acute appendicitis including migration of pain to the right lower quadrant, tenderness with rebound tenderness on physical examination, elevated white blood cell count, and imaging findings of an inflamed appendix without perforation.' The patient's presentation is consistent with acute appendicitis without complications. Surgical consultation was obtained, and the patient was scheduled for an appendectomy. The patient was started on intravenous antibiotics and underwent laparoscopic appendectomy without complications. Postoperatively, the patient recovered well and was discharged home with instructions for wound care and follow-up. The patient had an uneventful recovery post-appendectomy and was discharged in stable condition with no signs of infection or other complications. 32 Female Caucasian ICD Code: K3589

The patient has no previous history of appendicitis or abdominal surgeries. The patient presented with acute abdominal pain localized in the right lower quadrant, rebound tenderness, and guarding. CT scan revealed an inflamed appendix with evidence of gangrene but no signs of perforation. Other acute appendicitis without perforation, with gangrene (ICD-10-CM code K35.891): The appendix shows evidence of gangrene without perforation. The patient's symptoms and diagnostic imaging are consistent with acute appendicitis without perforation but with gangrene. Surgical consultation was obtained promptly. The patient underwent an emergency laparoscopic appendectomy. Intravenous antibiotics were administered postoperatively to prevent infection. The patient recovered well post-surgery without any complications and was discharged home in stable condition. 32 Female Caucasian ICD Code: K35.891

The patient has no history of gastrointestinal disorders or previous abdominal surgeries. The patient presented with a 2-day history of right lower quadrant abdominal pain, anorexia, nausea, and low-grade fever. Physical examination revealed tenderness in the right iliac fossa with localized rebound tenderness. Laboratory tests showed elevated white blood cell count and neutrophil count. Abdominal ultrasound demonstrated an enlarged, non-compressible appendix with no evidence of perforation or abscess. Other appendicitis without mention of peritonitis (K36) The patient's presentation of classic symptoms of appendicitis along with physical exam findings and imaging results confirm the diagnosis of appendicitis without complications. The patient underwent an appendectomy, and postoperative recovery was uneventful. Intravenous antibiotics were administered perioperatively. The patient was discharged in stable condition with instructions for wound care and a follow-up appointment in two weeks. 32 Female Caucasian ICD Code: K36

The patient has a history of occasional lower abdominal discomfort but no prior abdominal surgeries or hernia repairs. The patient reports bilateral bulging in the groin area that becomes more prominent when standing or coughing. There is no associated pain, tenderness, redness, or symptoms of bowel obstruction. Physical examination reveals reducible bilateral inguinal hernias without signs of strangulation or obstruction. Ultrasound confirms the presence of bilateral inguinal hernias without any complications. Bilateral inguinal hernia, without obstruction or gangrene, not specified as recurrent. Verbatim EHR quote justifying the code: 'Patient presents with bilateral inguinal hernias without signs of obstruction, gangrene, or recurrence.' The patient's physical exam findings are consistent with bilateral inguinal hernias. There are no signs of complications requiring urgent surgical intervention. The patient is scheduled for elective bilateral inguinal hernia repair surgery. Preoperative counseling and consent were obtained. Postoperative care and follow-up instructions were provided. 56 Male Caucasian ICD Code: K4020

The patient has a history of occasional lower abdominal discomfort but no prior hernia repair surgeries or known abdominal pathologies. The patient presented with a bulge in the right inguinal area that becomes more prominent with straining and occasional mild abdominal pain. No signs of inflammation or skin changes were noted. Physical examination revealed a reducible bulge in the right inguinal region without signs of strangulation. Ultrasound confirmed the presence of a unilateral inguinal hernia with evidence of obstruction but no signs of gangrene. Unilateral inguinal hernia, with obstruction, without gangrene, not specified as recurrent. Verbatim_EHR_quote_justifying_the_code: The patient presented with a reducible bulge in the right inguinal area, consistent with a unilateral inguinal hernia. Diagnostic tests confirmed the presence of obstruction without any signs of gangrene, supporting the assignment of the ICD-10-CM code K4030. The patient's physical exam findings and imaging results are consistent with a diagnosis of unilateral inguinal hernia with obstruction. The patient was counseled on the condition, treatment options, and the importance of monitoring for any changes in symptoms. The patient was advised on lifestyle modifications and referred to a surgeon for a hernia repair procedure. The patient underwent successful hernia repair surgery without complications and was discharged in stable condition with appropriate post-operative instructions. 45 Male Caucasian ICD Code: K4030

The patient has no history of abdominal surgeries or hernias. The patient complains of a bulge in the right inguinal region that appears during straining or lifting heavy objects and disappears when lying down. The bulge is reducible. Physical examination reveals a reducible bulge in the right inguinal area without signs of obstruction or strangulation. Unilateral inguinal hernia without obstruction or gangrene, not specified as recurrent. The patient presents with a reducible bulge in the right inguinal region. The patient's physical exam findings are consistent with a diagnosis of unilateral inguinal hernia without signs of obstruction or gangrene. No evidence of bowel obstruction or compromised blood flow is noted. The patient is scheduled for an elective hernia repair surgery. The patient underwent successful hernia repair surgery without complications and is recovering well postoperatively. 45 Male Caucasian ICD Code: K4090

The patient underwent abdominal surgery 2 years ago due to a perforated appendix and has been in good health since then. The patient complains of a visible bulge at the site of the previous surgical incision, associated with severe abdominal pain and vomiting. Abdominal CT scan shows a protrusion of abdominal contents through the surgical incision with signs of bowel obstruction but no evidence of gangrene. Incisional hernia with obstruction, without gangrene (K430). On examination, a palpable mass is noted at the surgical scar consistent with an incisional hernia. The patient's bowel sounds are hyperactive, indicating an obstruction. There are no signs of infection or gangrene. The patient was admitted for observation and kept nil per os. Intravenous fluids were initiated, and a surgical consult was obtained for possible hernia repair. Following conservative management and symptom resolution, the patient was discharged with a surgical follow-up appointment scheduled for hernia repair in two weeks. 58 Female Caucasian ICD Code: K430

The patient has a history of incisional hernia repair surgery. The patient presents with severe abdominal pain, tenderness, redness, and skin discoloration around the incision site. CT scan shows signs of bowel strangulation and gangrene at the site of the incisional hernia. Incisional hernia with gangrene (K431): The presence of gangrene in the incisional hernia site is confirmed by imaging studies, indicating the need for urgent intervention. The patient's condition is critical due to the gangrene complicating the incisional hernia. Surgery consultation is urgently requested for immediate intervention. Emergency surgical repair of the incisional hernia with gangrene, broad-spectrum antibiotics, and close monitoring of the patient's postoperative recovery. 55 Female Caucasian ICD Code: K431

The patient has a history of a permanent colostomy due to colon cancer surgery performed two years ago. The patient complains of a bulge and occasional mild discomfort near the stoma site for the past two weeks. No signs of bowel obstruction or strangulation. Abdominal ultrasound confirms the presence of a parastomal hernia without any signs of obstruction or gangrene. Parastomal hernia without obstruction or gangrene (K435): The patient presents with a parastomal hernia without any signs of obstruction or gangrene. The hernia is causing discomfort but no alarming symptoms. The patient's physical examination revealed a small bulge near the stoma, consistent with a parastomal hernia. No signs of bowel obstruction or strangulation were noted. Surgical consultation recommended conservative management. Prescribed supportive garments and advised on lifestyle modifications to reduce symptoms. Follow-up in two weeks to monitor hernia progression. 65 Female Caucasian ICD Code: K435

The patient has a history of obesity and multiple abdominal surgeries in the past. The patient presents with abdominal pain, nausea, vomiting, and a visible bulge on the abdominal wall. Abdominal ultrasound shows a hernia sac protruding through the abdominal wall with signs of obstruction but no evidence of gangrene. Other and unspecified ventral hernia with obstruction, without gangrene. The patient presents with a visible bulge on the abdominal wall, abdominal pain, and nausea. Abdominal ultrasound confirms the presence of a hernia sac with signs of obstruction but no gangrene. The patient's symptoms and diagnostic tests are consistent with a ventral hernia with obstruction. Surgery consult scheduled for further evaluation and management. The patient was started on IV fluids, kept nil per os, and scheduled for surgical repair of the ventral hernia. The patient underwent successful surgical repair of the ventral hernia and was discharged in stable condition with instructions for post-operative care. 58 Female Caucasian ICD Code: K436

The patient has a history of obesity and multiple pregnancies. The patient presents with a visible bulge in the abdominal area that becomes more prominent when standing or straining, along with occasional mild discomfort at the site of the bulge. Physical examination reveals a reducible midline abdominal mass without signs of obstruction or tenderness. Imaging studies confirm the presence of a ventral hernia without complications. Ventral hernia without obstruction or gangrene. Verbatim EHR quote justifying the code: 'Physical examination and imaging studies confirm the presence of a ventral hernia without signs of obstruction or gangrene.' The patient's hernia is reducible and not incarcerated. No signs of bowel obstruction or vascular compromise are noted. Surgical consultation scheduled for repair. The patient was advised on weight management and provided with a support belt for comfort. Surgical repair of the hernia is planned. 45 Female Caucasian ICD Code: K439

The patient has a history of gastroesophageal reflux disease (GERD) and obesity. The patient presents with severe abdominal pain, chest discomfort, and shortness of breath. CT scan revealed a diaphragmatic hernia with herniation of abdominal contents into the thoracic cavity causing mediastinal shift. Diaphragmatic hernia with obstruction, without gangrene. The diaphragmatic hernia is obstructing the passage without any signs of gangrene. Upon examination, there were no signs of gangrene present. The patient's symptoms correlate with a diaphragmatic hernia with obstruction. The patient was started on nasogastric decompression, and surgical repair of the diaphragmatic hernia is planned. The patient underwent successful surgical repair of the diaphragmatic hernia and was discharged in stable condition with appropriate follow-up instructions. 58 Male Caucasian ICD Code: K440

The patient has a history of obesity and multiple pregnancies, which are known risk factors for abdominal hernias. The patient presents with a noticeable bulge in the abdominal area that is more prominent when standing or coughing. The bulge is reducible and does not cause any pain or discomfort. Physical examination reveals a reducible abdominal mass without signs of obstruction or strangulation. Imaging studies confirm the presence of an abdominal hernia without any complications. Other specified abdominal hernia without obstruction or gangrene. Verbatim EHR quote justifying the code: 'Patient presents with a reducible abdominal mass without signs of obstruction or strangulation.' The patient's physical exam findings and imaging results are consistent with a diagnosis of Other specified abdominal hernia without complications. No signs of obstruction or gangrene are noted. The patient is advised on hernia management strategies, including watchful waiting and lifestyle modifications. Surgical intervention is discussed if symptoms worsen or if the hernia becomes incarcerated. The patient is discharged with instructions for follow-up appointments to monitor the hernia and assess for any changes in symptoms or size. 56 Female Caucasian ICD Code: K458

The patient has a history of obesity and a sedentary lifestyle. The patient complains of a bulge in the abdomen that is more prominent when standing or straining. Physical examination reveals a reducible bulge in the umbilical region without signs of obstruction or strangulation. Unspecified abdominal hernia without obstruction or gangrene. The patient presents with a reducible bulge in the umbilical region, consistent with an unspecified abdominal hernia without complications. The patient's physical exam findings are indicative of an uncomplicated abdominal hernia. No signs of obstruction or strangulation are noted. The patient is advised on lifestyle modifications, including weight loss and avoiding heavy lifting. Surgical repair is discussed if symptoms worsen. The patient was discharged in stable condition with instructions for follow-up if symptoms persist or worsen. 52 Female Caucasian ICD Code: K469

The patient has a history of recurrent abdominal pain, diarrhea, and weight loss over the past year, prompting further evaluation. The patient presents with abdominal pain, cramping, diarrhea, fatigue, and occasional low-grade fevers. Laboratory tests show mild anemia and elevated inflammatory markers. Imaging studies reveal segmental wall thickening and skip lesions in the small intestine consistent with Crohn's disease. Crohn's disease of the small intestine without complications. Verbatim_EHR_quote_justifying_the_code: 'Patient presents with typical symptoms of Crohn's disease, including abdominal pain, diarrhea, and weight loss. Diagnostic workup confirms segmental wall thickening and skip lesions in the small intestine, consistent with Crohn's disease.' The gastroenterologist notes the presence of aphthous ulcers and cobblestoning in the small intestine during colonoscopy, further supporting the diagnosis of Crohn's disease. The patient is started on a course of corticosteroids and mesalamine to induce remission of Crohn's disease. Nutritional counseling is initiated to address weight loss. The patient responded well to treatment and is scheduled for follow-up colonoscopy in six months to assess disease activity and response to therapy. 34 Female Caucasian ICD Code: K5000

The patient has a history of Crohn's disease of the small intestine. The patient presents with abdominal pain, diarrhea, weight loss, and fatigue. MRI of the abdomen shows a fistulous tract in the small intestine. Crohn's disease of the small intestine with fistula (K50013): The presence of a fistula in the small intestine is pathognomonic for this code. Upon physical examination, a fistulous opening was observed in the lower abdomen consistent with a small intestine fistula. The patient was started on a course of antibiotics and scheduled for a surgical consultation to address the fistula. The patient responded well to treatment and was discharged in stable condition. 42 Female Caucasian ICD Code: K50013

The patient has a history of Crohn's disease affecting the large intestine. The patient presents with abdominal pain, diarrhea, weight loss, and rectal bleeding. Colonoscopy showed inflammation and ulceration in the large intestine consistent with Crohn's disease. Crohn's disease of the large intestine with rectal bleeding (K50.111). The patient reports increased frequency of bowel movements and abdominal cramping. Physical examination reveals tenderness in the lower abdomen. Started the patient on a course of corticosteroids to reduce inflammation and manage symptoms. Advised dietary modifications and follow-up colonoscopy in six months. Patient responded well to treatment, with decreased rectal bleeding and improved abdominal pain. Discharged home with a follow-up plan. 42 Female Caucasian ICD Code: K50.111

The patient has a history of Crohn's disease affecting the large intestine. The patient presents with abdominal pain, bloating, constipation, and vomiting. Colonoscopy showed severe inflammation and narrowing in the large intestine. Crohn's disease of the large intestine with intestinal obstruction (K50.112) The patient's symptoms and diagnostic tests are consistent with Crohn's disease of the large intestine with evidence of obstruction. Started on corticosteroids and scheduled for surgical consult for possible bowel resection. Patient discharged in stable condition with close follow-up for ongoing management of Crohn's disease. 38 Female Caucasian ICD Code: K50.112

The patient has a history of Crohn's disease affecting the large intestine. The patient presents with chronic abdominal pain, diarrhea, weight loss, and fatigue. Colonoscopy revealed deep ulcers and inflammation in the large intestine. MRI confirmed the presence of a fistula. Crohn's disease of the large intestine with fistula (K50.113) The patient's symptoms and diagnostic tests are consistent with Crohn's disease of the large intestine with a fistula. No signs of rectal bleeding, intestinal obstruction, or abscess were noted. Started the patient on a course of corticosteroids and antibiotics to manage inflammation and prevent infection. The patient responded well to treatment and was discharged with a follow-up appointment in two weeks. 42 Female Caucasian ICD Code: K50.113

The patient has a history of Crohn's disease affecting the large intestine. The patient presents with abdominal pain localized to the lower left quadrant, fever, and tenderness upon palpation. CT scan shows a well-defined abscess in the large intestine. Crohn's disease of large intestine with abscess (K50.114) The patient reports worsening abdominal pain over the past week. Physical examination reveals localized tenderness and guarding in the lower left quadrant. CT scan confirms the presence of an abscess in the large intestine. The patient is started on intravenous antibiotics and scheduled for a drainage procedure. The patient responded well to treatment, and the abscess was successfully drained. Discharged with oral antibiotics and follow-up appointment in two weeks. 42 Female Caucasian ICD Code: K50.114

The patient has a known history of Crohn's disease affecting the large intestine. The patient presents with abdominal pain, diarrhea, weight loss, and fatigue. Colonoscopy revealed deep ulcers and inflammation in the large intestine. Crohn's disease of the large intestine with other complications. Verbatim_EHR_quote_justifying_the_code: 'Colonoscopy revealed deep ulcers and inflammation in the large intestine, consistent with Crohn's disease of the large intestine with other complications.' The patient has a history of recurrent Crohn's disease flares despite previous treatments. Started the patient on a course of corticosteroids and scheduled for a biologic therapy consultation. Patient responded well to treatment and was discharged with a follow-up appointment in two weeks. 42 Female Caucasian ICD Code: K50.118

The patient has a history of intermittent abdominal pain, diarrhea, and weight loss over the past six months. The patient presents with abdominal cramping, frequent loose stools with blood, fatigue, and occasional low-grade fevers. Colonoscopy revealed skip lesions in both the small and large intestines with no signs of strictures, fistulas, or abscesses. Crohn's disease of both small and large intestine without complications. Verbatim EHR quote justifying the code: 'Colonoscopy findings indicate skip lesions in both small and large intestines without complications.' The gastroenterologist confirmed the diagnosis of Crohn's disease involving both the small and large intestines based on the colonoscopy results. The patient was started on a regimen of mesalamine to manage the Crohn's disease symptoms. The patient responded well to treatment and was discharged with instructions to follow up with the gastroenterologist in one month. 38 Female Caucasian ICD Code: K5080

The patient has a history of recurrent abdominal pain, diarrhea, and weight loss over the past year. The patient presents with abdominal cramping, frequent diarrhea with blood in stool, fatigue, and decreased appetite. Colonoscopy revealed cobblestoning, deep ulcers, and skip lesions in both small and large intestines. Blood tests showed elevated inflammatory markers. Crohn's disease of both small and large intestine with rectal bleeding (K50811). The patient reports a 10-pound weight loss over the last three months. Physical examination shows tenderness in the lower abdomen. Colonoscopy findings are consistent with Crohn's disease involving both small and large intestines. Started the patient on a course of corticosteroids and mesalamine for induction of remission. The patient responded well to treatment and was discharged with a follow-up appointment in three weeks. 38 Female Caucasian ICD Code: K50811

The patient has a history of Crohn's disease affecting both the small and large intestines. The patient presents with abdominal pain, cramping, bloating, and vomiting. There is no evidence of rectal bleeding, fistula, or abscess. Colonoscopy and imaging studies reveal inflammation and strictures in both the small and large intestines consistent with Crohn's disease. There is evidence of intestinal obstruction. Crohn's disease of both small and large intestine with intestinal obstruction (K50812): "Crohn's disease of both small and large intestine with intestinal obstruction." The patient reports chronic abdominal pain and distension. Physical examination shows tenderness in the abdomen with no signs of perianal disease. Imaging studies confirm the presence of strictures and obstruction in both the small and large intestines. The patient is started on corticosteroids and bowel rest. Symptomatic management is initiated to alleviate pain and vomiting. The patient responded well to treatment and is scheduled for follow-up colonoscopy in six weeks to assess treatment response and disease progression. 42 Female Caucasian ICD Code: K50812

The patient has a history of Crohn's disease involving both the small and large intestine with a fistula. The patient presents with abdominal pain, diarrhea, weight loss, and fatigue. Colonoscopy showed active inflammation in both the small and large intestine with evidence of a fistula. Crohn's disease of both small and large intestine with fistula (K50813): The patient has Crohn's disease involving both the small and large intestine with a fistula. The patient reports chronic abdominal pain and recurrent diarrhea. Physical examination reveals tenderness in the lower abdomen. Diagnostic tests confirm active inflammation in both the small and large intestine with a fistula. The patient was started on a course of corticosteroids and antibiotics to manage the inflammation and prevent infection. The patient responded well to treatment and was discharged with a follow-up appointment scheduled in two weeks. 42 Female Caucasian ICD Code: K50813

The patient has a history of recurrent abdominal pain, diarrhea, weight loss, and fatigue consistent with Crohn's disease. Previous colonoscopy showed inflammation in both the small and large intestines. The patient presents with severe abdominal pain, fever, and localized tenderness in the lower abdomen. There is no rectal bleeding, no signs of intestinal obstruction, and no fistula formation. CT scan reveals the presence of an abscess in the terminal ileum involving the cecum and ascending colon, confirming the diagnosis of Crohn's disease with an abscess. Crohn's disease of both small and large intestine with abscess (K50814): The CT scan shows the presence of an abscess in the terminal ileum involving the cecum and ascending colon, confirming the diagnosis. The patient's symptoms and imaging findings are consistent with Crohn's disease complicated by the formation of an abscess. The absence of rectal bleeding, fistula, or signs of obstruction indicates a localized complication. The patient was started on intravenous antibiotics, and a surgical consult was obtained for drainage of the abscess. Pain management and nutritional support were initiated. The patient responded well to treatment, and the abscess was drained successfully. Discharged home with a course of oral antibiotics and follow-up with gastroenterology in two weeks. 34 Female Caucasian ICD Code: K50814

The patient has a history of intermittent abdominal pain, diarrhea, and weight loss over the past year. No history of rectal bleeding, intestinal obstruction, fistula, or abscess. The patient presents with abdominal pain, diarrhea, fatigue, and occasional low-grade fevers. No symptoms of rectal bleeding, severe cramping, or obstructive symptoms. Colonoscopy showed patchy areas of inflammation in the terminal ileum and colon. Biopsies confirmed non-caseating granulomas. No signs of strictures, fistulas, or abscesses. Crohn's disease, unspecified, without complications. The absence of rectal bleeding, intestinal obstruction, fistula, and abscess supports the diagnosis of uncomplicated Crohn's disease. The patient's symptoms and diagnostic tests are consistent with a diagnosis of Crohn's disease without any complicating factors. Plan to start the patient on a course of mesalamine for induction of remission. Prescribed mesalamine 800mg three times daily. Advised the patient on dietary modifications and scheduled a follow-up in six weeks. 34 Female Caucasian ICD Code: K50.90

The patient has a history of recurrent abdominal pain, diarrhea, weight loss, and fatigue consistent with Crohn's disease. No history of abscesses, rectal bleeding, or intestinal obstructions. The patient presents with chronic abdominal pain, diarrhea, and intermittent fever. Additionally, the patient reports drainage of pus near the anus and discomfort during bowel movements. Colonoscopy revealed skip lesions, cobblestoning, and a fistula between the small intestine and the skin surrounding the anus. MRI confirmed the presence of a fistula without abscess or intestinal obstruction. Crohn's disease, unspecified, with fistula. Verbatim EHR quote justifying the code: 'Colonoscopy and MRI confirmed the presence of a fistula between the small intestine and the skin surrounding the anus, consistent with Crohn's disease, unspecified, with fistula.' The patient's symptoms and diagnostic test results are indicative of Crohn's disease with a fistula as the primary complication. No signs of abscesses, rectal bleeding, or intestinal obstructions are noted. The patient was started on a course of antibiotics to manage the fistula and prevent infection. Additionally, a biologic therapy was initiated to induce and maintain remission of Crohn's disease. The patient responded well to treatment with resolution of fever and decreased drainage from the fistula. The patient was discharged with a follow-up appointment in two weeks. 34 Female Caucasian ICD Code: K50913

The patient has a history of Crohn's disease diagnosed five years ago, managed with intermittent courses of corticosteroids and mesalamine. The patient presents with abdominal pain in the lower right quadrant, fever, and localized tenderness. No rectal bleeding reported. MRI of the abdomen shows a well-defined abscess in the terminal ileum. Crohn's disease, unspecified, with abscess. Patient's symptoms and imaging findings are consistent with Crohn's disease with an abscess. No signs of rectal bleeding or complications like fistula or intestinal obstruction. The patient was started on intravenous antibiotics and scheduled for percutaneous drainage of the abscess. The patient responded well to treatment, with resolution of fever and decreased tenderness. Discharged with oral antibiotics and follow-up imaging in two weeks. 38 Female Caucasian ICD Code: K50914

The patient has a history of Crohn's disease with unspecified complications. The patient presents with chronic abdominal pain, diarrhea, fatigue, and weight loss. Colonoscopy showed skip lesions, cobblestone appearance, and deep ulcers in the terminal ileum consistent with Crohn's disease. Crohn's disease, unspecified, with other complication (K50.918) The patient's symptoms and diagnostic test results are consistent with Crohn's disease with unspecified complications. No evidence of rectal bleeding, intestinal obstruction, fistula, or abscess. Started the patient on a course of corticosteroids and mesalamine for induction of remission. The patient responded well to treatment and was discharged with a follow-up appointment in two weeks. 42 Female Caucasian ICD Code: K50.918

The patient has a history of chronic abdominal pain, diarrhea, and weight loss over the past six months. The patient presents with bloody diarrhea, urgency, and tenesmus. Colonoscopy revealed continuous inflammation from the rectum to the cecum with a loss of vascular pattern and pseudopolyps consistent with ulcerative pancolitis. Ulcerative (chronic) pancolitis without complications. The colonoscopy findings are consistent with continuous inflammation from the rectum to the cecum, supporting the diagnosis of ulcerative pancolitis. The patient's symptoms and colonoscopy results are indicative of ulcerative pancolitis involving the entire colon without complications. No evidence of fistulas, abscesses, or other complications noted. Started the patient on mesalamine therapy to induce and maintain remission. The patient responded well to treatment and was discharged with a follow-up appointment in six weeks. 42 Female Caucasian ICD Code: K5100

The patient has a history of chronic abdominal pain, diarrhea, and weight loss for the past six months. The patient presents with bloody diarrhea, abdominal cramps, and fatigue. Colonoscopy showed continuous inflammation from the rectum to the cecum with friability and loss of vascular pattern. Ulcerative (chronic) pancolitis with rectal bleeding. The colonoscopy revealed continuous inflammation from the rectum to the cecum with friability and loss of vascular pattern. The patient reports increased frequency of bowel movements up to 10 times a day, with visible blood in the stool. Physical examination shows tenderness in the lower abdomen. Started the patient on mesalamine to induce remission and recommended a follow-up colonoscopy in three months. The patient responded well to treatment and was discharged with a prescription for mesalamine. Advised to follow-up with the gastroenterologist in three months. 42 Female Caucasian ICD Code: K51011

The patient has a history of chronic constipation managed with dietary modifications. The patient presents with rectal pain, tenesmus, and intermittent rectal bleeding. Flexible sigmoidoscopy revealed diffuse inflammation limited to the rectum. Ulcerative (chronic) proctitis without complications Patient reports symptoms consistent with chronic proctitis without evidence of complications. Physical exam findings and diagnostic tests support the diagnosis of localized rectal inflammation. Prescribed mesalamine suppositories for local anti-inflammatory treatment. Advised on dietary fiber intake to improve bowel habits. Patient's symptoms improved with treatment. Scheduled for a follow-up colonoscopy in six months. 45 Female Caucasian ICD Code: K5120

The patient has a history of intermittent abdominal pain and diarrhea over the past six months, with recent worsening of symptoms. No prior history of Crohn's disease or other inflammatory bowel conditions. The patient presents with chronic lower abdominal pain, bloody diarrhea, and tenesmus. There is no history of weight loss, fever, or extraintestinal manifestations. Colonoscopy revealed continuous inflammation starting from the rectum and extending up to the sigmoid colon. Biopsy results showed crypt distortion, chronic inflammatory infiltrate, and absence of granulomas. Ulcerative (chronic) rectosigmoiditis with rectal bleeding. The diagnosis is supported by colonoscopy findings showing continuous inflammation from the rectum to the sigmoid colon, along with biopsy results demonstrating crypt distortion and chronic inflammatory changes. The patient reports increased urgency and frequency of bowel movements, with visible blood in the stool. Physical examination revealed mild tenderness in the lower abdomen. No signs of perianal disease or fistulas were noted. Started the patient on mesalamine suppositories for local treatment of inflammation and symptoms control. Advised to follow a low-residue diet and monitor for any worsening of symptoms. The patient responded well to treatment during hospitalization, with a decrease in the frequency of bloody stools and abdominal pain. Discharged home with a follow-up appointment in two weeks for reassessment. 42 Female Caucasian ICD Code: K51311

The patient has a history of recurrent abdominal pain and diarrhea over the past two years. The patient presents with left lower quadrant abdominal pain, bloody stools, tenesmus, and urgency. Colonoscopy revealed inflammation and ulceration in the sigmoid colon and rectum. Left sided colitis with rectal bleeding. The patient has ulcerative colitis limited to the left side involving the rectum (K51511). Patient reports increased frequency of bloody stools in the past week. Physical examination shows mild tenderness on palpation in the left lower quadrant. Colonoscopy findings are consistent with left sided colitis. Started the patient on mesalamine suppositories for local treatment. Advised to follow a low-residue diet. The patient responded well to treatment. Symptoms of rectal bleeding have improved, and the patient is advised to continue the medication and follow-up with a gastroenterologist in three weeks. 38 Female Caucasian ICD Code: K51511

The patient has a history of intermittent abdominal pain, diarrhea, and weight loss over the past six months. The patient presents with abdominal pain, loose stools with blood, urgency, and tenesmus. Colonoscopy shows continuous inflammation from the rectum extending proximally into the colon. Biopsy results confirm chronic inflammatory changes consistent with ulcerative colitis. Ulcerative colitis, unspecified, without complications. Verbatim_EHR_quote_justifying_the_code: 'Colonoscopy revealed continuous inflammation from the rectum extending proximally into the colon, with biopsy results confirming chronic inflammatory changes consistent with ulcerative colitis.' The gastroenterologist noted the typical appearance of ulcerative colitis during colonoscopy with continuous mucosal inflammation and confirmed the diagnosis based on biopsy results. The patient was started on mesalamine therapy for induction of remission and scheduled for regular follow-up visits. The patient responded well to treatment, with improvement in symptoms and no evidence of complications. Discharged home with a plan for outpatient management. 42 Female Caucasian ICD Code: K5190

The patient has a history of recent antibiotic use for a respiratory infection. The patient presents with severe abdominal pain, diarrhea, and bloody stools. Stool culture showed the presence of Clostridium difficile toxin. Toxic gastroenteritis and colitis (ICD-10-CM code K521): The patient presents with severe abdominal pain, diarrhea, and bloody stools. Stool culture confirmed the presence of Clostridium difficile toxin. The patient is experiencing symptoms consistent with toxic gastroenteritis and colitis. Given the recent antibiotic use and the positive Clostridium difficile toxin result, the diagnosis of toxic gastroenteritis and colitis is clear. The patient was started on oral vancomycin for the treatment of Clostridium difficile infection. Supportive care including hydration and electrolyte replacement was initiated. The patient responded well to treatment and was discharged home with a prescription for a tapering dose of oral vancomycin. Follow-up with the primary care physician in one week is recommended. 55 Female Caucasian ICD Code: K521

The patient has a known history of food allergies, particularly to shellfish and peanuts. No history of chronic inflammatory bowel diseases or radiation exposure. The patient presents with abdominal pain, bloating, diarrhea, and occasional vomiting. The symptoms started shortly after consuming a meal containing shellfish. Laboratory tests show elevated eosinophil levels and IgE antibodies specific to shellfish and peanuts. Stool studies are negative for infectious pathogens. Other allergic and dietetic gastroenteritis and colitis The patient's symptoms and test results are consistent with an allergic reaction leading to gastroenteritis and colitis. There is no evidence of chronic inflammatory changes or radiation-related damage. The patient was treated with intravenous fluids, antihistamines, and corticosteroids to manage the allergic reaction and reduce inflammation. A dietitian was consulted to provide guidance on allergen-free nutrition. The patient's symptoms improved with treatment, and they were discharged with instructions to avoid shellfish and peanuts. Follow-up with an allergist and gastroenterologist was recommended for further management. 42 Female Caucasian ICD Code: K5229

The patient has a history of seasonal allergies and occasional episodes of abdominal discomfort. The patient presents with chronic abdominal pain, nausea, vomiting, and diarrhea. Endoscopy revealed diffuse eosinophilic infiltration in the stomach and duodenum. Eosinophilic gastritis or gastroenteritis Patient's symptoms and endoscopic findings are consistent with eosinophilic gastritis or gastroenteritis. Prescribed proton pump inhibitors and corticosteroids for symptom management. Patient responded well to treatment and was discharged with instructions for follow-up endoscopy in six weeks. 42 Female Caucasian ICD Code: K5281

The patient has a history of chronic watery diarrhea for the past 6 months, which has progressively worsened over time. No history of abdominal pain, weight loss, or bloody stools. The patient reports frequent, watery diarrhea without blood, mucus, or pus. No associated abdominal pain, tenesmus, or fecal urgency. Colonoscopy revealed a normal-appearing colon with histopathological findings consistent with Lymphocytic colitis, showing an increased number of lymphocytes in the epithelium. Lymphocytic colitis (K52832): Chronic watery diarrhea without blood, with histopathological evidence of increased intraepithelial lymphocytes. The patient's symptoms and colonoscopy findings are classic for Lymphocytic colitis. No evidence of other forms of colitis such as ulcerative colitis or ischemic colitis. Prescribed budesonide for induction of remission. Advised to follow a low-fat, low-fiber diet to alleviate symptoms. The patient responded well to treatment and was discharged with instructions for follow-up colonoscopies to monitor disease activity. 55 Female Caucasian ICD Code: K52832

The patient has a history of chronic watery diarrhea and abdominal pain for the past few months, which has progressively worsened. The patient presents with chronic watery diarrhea, abdominal pain, weight loss, and fatigue. There is no evidence of rectal bleeding, radiation exposure, allergic reactions, or acute vascular disorders. Colonoscopy revealed characteristic findings of Microscopic colitis, including normal mucosa with subepithelial collagen deposition and an increased number of intraepithelial lymphocytes. Microscopic colitis, unspecified: The colonoscopy findings are consistent with Microscopic colitis, supporting the diagnosis of Microscopic colitis, unspecified (K52839). The patient's symptoms and colonoscopy results are indicative of Microscopic colitis. No other significant findings or alternative diagnoses were noted. The patient was started on budesonide therapy to manage the symptoms of Microscopic colitis. Additionally, dietary modifications and hydration were recommended. The patient responded well to treatment and showed improvement in symptoms. Discharged home with instructions for follow-up colonoscopies as needed. 58 Female Caucasian ICD Code: K52839

The patient has a history of intermittent abdominal pain and irregular bowel habits over the past six months. The patient presents with abdominal cramping, bloating, and frequent loose stools without blood or mucus. Colonoscopy revealed diffuse mild inflammation of the colon without evidence of ulcerations or pseudomembranes. Other specified noninfective gastroenteritis and colitis (K5289): Chronic colitis without ulceration. The patient denies recent travel, antibiotic use, or known food intolerances. Physical examination shows mild tenderness in the lower abdomen without rebound tenderness or guarding. Prescribed a course of mesalamine to manage the chronic inflammation and advised on dietary modifications to reduce symptoms. The patient responded well to treatment and was discharged with instructions for follow-up with a gastroenterologist in four weeks. 42 Female Caucasian ICD Code: K5289

The patient has a history of occasional abdominal discomfort but no prior history of inflammatory bowel disease, radiation therapy, or recent antibiotic use. The patient presents with moderate abdominal pain, watery diarrhea, and no fever. There is no history of recent travel or sick contacts. The patient denies any recent changes in diet or medication. Stool studies are negative for infectious pathogens. Colonoscopy shows diffuse mild inflammation in the colon without features of ulcerative colitis or microscopic colitis. Noninfective gastroenteritis and colitis, unspecified. Verbatim EHR quote justifying the code: 'The patient presents with abdominal pain, watery diarrhea, and colonoscopy findings of diffuse mild inflammation in the colon.' The patient does not have findings suggestive of ulcerative colitis, radiation-induced colitis, toxic ingestions, or allergic reactions. There are no features of eosinophilic gastritis, collagenous colitis, or lymphocytic colitis. The patient is advised to maintain hydration and follow a bland diet. Symptomatic treatment with antidiarrheal medication is initiated. The patient's symptoms improved with treatment, and there were no complications during the hospital stay. The patient is discharged home with instructions for follow-up with the primary care provider. 45 Female Caucasian ICD Code: K529

The patient has a history of hypertension and hyperlipidemia, both well-controlled with medications. No prior history of gastrointestinal disorders. The patient presented with sudden onset severe abdominal pain localized to the lower right quadrant. The pain is constant, sharp, and worsens with movement. Abdominal CT scan showed focal ischemia of the small intestine with no signs of infarction. Blood tests revealed elevated lactate levels. Focal (segmental) acute (reversible) ischemia of small intestine. Verbatim_EHR_quote_justifying_the_code: 'Abdominal CT scan confirmed the presence of focal ischemia in the small intestine without any signs of infarction. Elevated lactate levels further supported the diagnosis of acute reversible ischemia.' Patient is stable and responsive. Monitoring for any signs of progression. Pain management initiated with IV analgesics. NPO status and close observation. IV fluids, pain management with analgesics, close monitoring of vitals and pain levels. Patient responded well to treatment, pain resolved, and lactate levels normalized. Discharged with instructions for a soft diet and follow-up with a gastroenterologist in one week. 58 Female Caucasian ICD Code: K55011

The patient has a history of hypertension and hyperlipidemia but no prior gastrointestinal issues. The patient presented with sudden severe abdominal pain localized to the right lower quadrant, associated with nausea and vomiting. No history of allergic reactions or chronic diarrhea. CT angiography showed focal acute infarction of the small intestine with no evidence of chronic changes or allergic reactions. Focal (segmental) acute infarction of small intestine (ICD-10-CM code K55021) - The patient presents with sudden severe abdominal pain localized to the right lower quadrant and CT angiography confirms focal acute infarction of the small intestine. The patient's symptoms and diagnostic tests are consistent with focal acute infarction of the small intestine. No signs of chronic inflammation or allergic etiology observed. The patient was started on anticoagulant therapy and pain management. Close monitoring for signs of peritonitis or sepsis was initiated. The patient responded well to treatment, and symptoms improved significantly. Discharged with instructions for follow-up imaging to assess resolution of infarction. 58 Female Caucasian ICD Code: K55021

The patient has a history of hypertension and hyperlipidemia. The patient presented with severe abdominal pain, nausea, vomiting, and bloody stools. CT scan showed evidence of acute infarction in the small intestine. Acute infarction of small intestine, extent unspecified. Verbatim EHR quote justifying the code: 'CT scan confirmed the presence of acute infarction in the small intestine.' The patient is hemodynamically stable but requires urgent surgical intervention. The patient underwent emergency laparotomy with resection of the infarcted segment and primary anastomosis. The patient recovered well post-surgery and was discharged with appropriate follow-up instructions. 67 Male Caucasian ICD Code: K55029

The patient has a history of hypertension and hyperlipidemia. The patient presents with sudden onset abdominal pain, cramping, and bloody diarrhea. CT angiography shows focal ischemic changes in the large intestine without evidence of infarction. Acute (reversible) ischemia of large intestine, extent unspecified. Verbatim_EHR_quote_justifying_the_code: 'CT angiography reveals focal ischemic changes in the large intestine without infarction.' Patient stable post fluid resuscitation. Surgical consultation for further evaluation. Started on IV fluids and broad-spectrum antibiotics. Pain management with analgesics. Patient responded well to treatment and was discharged home with close follow-up. 65 Female Caucasian ICD Code: K55039

The patient has a history of hypertension and hyperlipidemia. The patient presented with severe abdominal pain, vomiting, and bloody stools. CT angiography showed evidence of acute infarction of the intestine. Acute infarction of intestine, part and extent unspecified. Verbatim_EHR_quote_justifying_the_code: 'CT angiography revealed findings consistent with acute infarction of the intestine.' Patient is stable post CT angiography, surgery consult requested. Started on heparin drip, pain management, and kept NPO. Patient underwent surgical intervention with bowel resection and is recovering well postoperatively. 65 Female Caucasian ICD Code: K55069

The patient has a history of hypertension and peripheral arterial disease. The patient presents with chronic abdominal pain after meals, unintended weight loss, and episodes of bloody stool over the past six months. CT angiography of the mesenteric arteries shows stenosis and calcifications in the superior mesenteric artery consistent with chronic vascular disease. Chronic vascular disorders of intestine (ICD-10-CM code K551) - Chronic vascular disorders of intestine The patient reports a long-standing history of intermittent abdominal pain and bloody stool episodes, suggestive of chronic mesenteric ischemia. CT angiography findings confirm the presence of chronic vascular disease affecting the intestine. The patient was started on antiplatelet therapy and advised dietary modifications to manage symptoms. A multidisciplinary approach involving cardiology and gastroenterology was initiated. The patient's symptoms improved with medical management, and he was discharged with a follow-up plan for ongoing monitoring and optimization of medical therapy. 68 Male Caucasian ICD Code: K551

The patient has a history of chronic constipation and occasional abdominal discomfort. The patient presented with intermittent episodes of painless rectal bleeding and mild anemia. Colonoscopy revealed angiodysplasia in the colon without any signs of active bleeding. Angiodysplasia of colon without hemorrhage The patient's symptoms and colonoscopy findings are consistent with angiodysplasia of the colon without evidence of active bleeding. The patient was advised to increase dietary fiber intake and referred to a gastroenterologist for further management. The patient was discharged in stable condition with instructions to follow up with the gastroenterologist for ongoing care. 67 Female Caucasian ICD Code: K5520

The patient has a history of chronic anemia requiring intermittent iron supplementation over the past year. The patient presents with a two-day history of bright red blood per rectum, associated with fatigue and weakness. Laboratory studies show a hemoglobin level of 9.8 g/dL, consistent with anemia. Colonoscopy reveals angiodysplastic lesions in the colon with active bleeding. Angiodysplasia of colon with hemorrhage. Verbatim EHR quote justifying the code: 'Colonoscopy demonstrates angiodysplastic lesions in the colon with active bleeding.' The patient's symptoms and diagnostic findings are consistent with angiodysplasia of the colon with hemorrhage. No evidence of acute infarction, ischemia, or other vascular disorders. The patient received endoscopic therapy with argon plasma coagulation to cauterize the bleeding angiodysplastic lesions. Transfusion support was provided to correct the anemia. The patient responded well to treatment and was discharged in stable condition with instructions for close follow-up with gastroenterology for further management of angiodysplasia. 67 Female Caucasian ICD Code: K5521

The patient has a history of hypertension and hyperlipidemia, both well-controlled with medications. No prior history of gastrointestinal vascular disorders. The patient presents with recurrent episodes of abdominal pain after meals, associated with bloating and mild diarrhea. No rectal bleeding, weight loss, or signs of acute abdomen. CT angiography shows evidence of vascular abnormalities in the small intestine without signs of acute infarction or ischemia. Other vascular disorders of intestine (K558): Vascular involvement in the small intestine without acute infarction or ischemia. The patient's symptoms and imaging findings are consistent with vascular disorders of the intestine, specifically showing vascular abnormalities without evidence of acute ischemia or infarction. Started on a vasodilator and advised dietary modifications. Follow-up with a gastroenterologist for further management. The patient responded well to treatment and was discharged with instructions for follow-up care. 65 Female Caucasian ICD Code: K558

The patient has no history of gastrointestinal disorders or surgeries. The patient presented with severe abdominal pain, vomiting, and bloody stools. Ultrasound revealed the classic target sign indicative of intussusception. Intussusception is a medical emergency where one segment of the bowel telescopes into another, causing severe abdominal pain, vomiting, and bloody stools. On physical examination, a palpable abdominal mass was detected, further supporting the diagnosis of intussusception. The patient was taken for an emergency air enema, which successfully reduced the intussusception. Intravenous fluids and bowel rest were initiated post-procedure. The patient responded well to treatment, and symptoms resolved. Discharge instructions included monitoring for recurrence and follow-up with the pediatric gastroenterologist in two weeks. 3 years old Male Caucasian ICD Code: K561

The patient has a history of intermittent abdominal pain and constipation over the past few months. The patient presents with severe abdominal pain, distension, nausea, and vomiting. There is a notable absence of rectal bleeding or hematochezia. Abdominal X-ray shows a 'coffee bean sign,' indicative of a sigmoid volvulus. CT scan confirms the presence of a twisted loop of the sigmoid colon. Volvulus of the sigmoid colon The patient is stable but requires urgent surgical intervention to untwist the bowel and prevent ischemia. Immediate surgical detorsion followed by elective sigmoid colectomy. The patient underwent successful surgical intervention and is recovering well postoperatively. 58 Male Caucasian ICD Code: K562

The patient has a history of chronic constipation and irregular bowel movements. The patient presents with severe abdominal pain, bloating, and the inability to pass stool or gas. Digital rectal examination reveals a palpable hard mass in the rectum. Fecal impaction without evidence of bowel obstruction. Upon examination, the patient shows signs of fecal impaction with no signs of bowel perforation or obstruction. The patient was treated with manual disimpaction, laxatives, and advised on dietary modifications and increased fluid intake. The patient's symptoms improved post-treatment, and they were discharged with instructions for follow-up with a gastroenterologist if symptoms reoccur. 68 Female Caucasian ICD Code: K5641

The patient has a history of abdominal surgeries. The patient presents with abdominal pain, bloating, constipation, and vomiting. Abdominal X-ray shows dilated loops of the small intestine with air-fluid levels, suggestive of obstruction. Intestinal adhesions [bands] with obstruction (postprocedural) (postinfection) (ICD-10-CM code K565) Upon examination, the patient has localized tenderness in the lower abdomen with audible bowel sounds. No signs of peritonitis. The patient was kept NPO, received IV fluids, and was monitored closely. Nasogastric tube inserted for decompression. The patient responded well to treatment, symptoms resolved, tolerating diet, and discharged in stable condition. 58 Female Caucasian ICD Code: K565

The patient has a history of abdominal surgeries, including appendectomy and cholecystectomy. The patient presents with recurrent episodes of crampy abdominal pain, bloating, and constipation. Abdominal X-ray shows dilated loops of the small bowel with air-fluid levels, suggestive of a mechanical obstruction. Intestinal adhesions [bands], unspecified as to partial versus complete obstruction (ICD-10-CM code K5650) Upon physical examination, the patient has localized tenderness in the lower abdomen with audible bowel sounds. No signs of peritonitis. The patient was kept NPO, received IV fluids, and underwent exploratory laparoscopy to release the adhesions. The patient recovered well postoperatively and was discharged with instructions for a gradual return to a normal diet. 56 Female Caucasian ICD Code: K5650

The patient has a history of multiple abdominal surgeries due to conditions like appendicitis and ovarian cysts. The patient presents with intermittent crampy abdominal pain, bloating, and constipation for the past week. Abdominal X-ray shows signs of partial intestinal blockage. Intestinal adhesions [bands] with partial obstruction (ICD-10-CM code K5651): The patient presents with symptoms of partial intestinal obstruction, including crampy abdominal pain, bloating, and constipation, along with a history of multiple abdominal surgeries leading to the formation of adhesions. Diagnostic imaging confirms partial blockage. The patient's symptoms and history are consistent with partial intestinal obstruction due to adhesions. Plan for conservative management with close monitoring. The patient was started on bowel rest, intravenous fluids, and pain management. Surgical intervention is not immediately warranted. The patient's symptoms improved with conservative management. Discharged home with instructions for a low-residue diet and follow-up with the gastroenterologist in one week. 45 Female Caucasian ICD Code: K5651

The patient has a history of abdominal surgeries, including appendectomy and cholecystectomy. The patient presents with severe abdominal pain, bloating, constipation, and vomiting. Abdominal X-ray shows dilated loops of the small intestine with air-fluid levels consistent with bowel obstruction. Intestinal adhesions [bands] with complete obstruction. Physical examination reveals a distended abdomen with high-pitched bowel sounds. The patient has a history of multiple abdominal surgeries predisposing to the development of adhesions. The patient was kept nil by mouth, received intravenous fluids, and underwent emergent exploratory laparotomy with adhesiolysis. The patient recovered well postoperatively and was discharged home with instructions for a gradual return to normal diet and close follow-up. 58 Female Caucasian ICD Code: K5652

The patient has a history of intermittent abdominal discomfort and bloating over the past few months, which have worsened recently. The patient presents with severe abdominal pain, distention, nausea, and vomiting. Abdominal tenderness and absence of bowel sounds are noted upon examination. Abdominal X-ray shows dilated loops of the small bowel with air-fluid levels, indicative of an obstruction. Blood tests reveal elevated white blood cell count and metabolic acidosis. Unspecified intestinal obstruction, unspecified as to partial versus complete obstruction (ICD-10-CM code K56.609) - The patient presents with severe abdominal pain, distention, nausea, vomiting, and abdominal tenderness. Diagnostic tests show dilated loops of the small bowel with air-fluid levels on X-ray and abnormal blood test results. The patient is hemodynamically stable but in significant distress due to the pain. Surgery consult has been requested for further evaluation and management. The patient is kept nil per os (NPO), receives intravenous fluids, and is started on broad-spectrum antibiotics. Pain management is provided, and close monitoring for signs of peritonitis is initiated. 58 Female Caucasian ICD Code: K56.609

The patient has a history of irritable bowel syndrome (IBS) and recurrent episodes of constipation. The patient presents with severe abdominal pain, bloating, and inability to pass stool or gas for the past two days. Abdominal X-ray shows multiple air-fluid levels indicative of bowel obstruction. Other intestinal obstruction (K56.69) - The patient presents with symptoms of intestinal obstruction including abdominal pain, distension, and constipation. Diagnostic imaging reveals multiple air-fluid levels consistent with bowel obstruction. Patient appears uncomfortable due to abdominal pain. Bowel sounds are hypoactive. No signs of peritonitis. Surgical consult requested for further management. Nasogastric tube insertion for decompression, intravenous fluids, and bowel rest. Pain management with analgesics. Monitoring for signs of bowel perforation or ischemia. The patient responded well to conservative management and was able to pass stool and flatus. Discharged with instructions for dietary modifications and follow-up with a gastroenterologist in one week. 45 Female Caucasian ICD Code: K56.69

The patient has a history of recurrent abdominal pain and bloating. The patient presents with crampy abdominal pain, distension, constipation, and vomiting. Abdominal X-ray shows dilated loops of the small intestine with air-fluid levels, suggestive of partial obstruction. Other partial intestinal obstruction (ICD-10-CM code K56.690): The patient presents with crampy abdominal pain, distension, constipation, and vomiting. Abdominal X-ray shows dilated loops of the small intestine with air-fluid levels, indicative of partial obstruction. The patient's symptoms and imaging findings are consistent with a diagnosis of Other partial intestinal obstruction. There are no signs of volvulus, fecal impaction, or complete obstruction. The patient was kept nil per os (NPO), received intravenous fluids, and was closely monitored. A nasogastric tube was placed for decompression. The patient responded well to conservative management and was discharged with instructions for a low-residue diet and follow-up with a gastroenterologist. 55 Female Caucasian ICD Code: K56.690

The patient has a history of chronic constipation and has previously undergone abdominal surgery for appendicitis. The patient presents with severe abdominal pain, bloating, and inability to pass gas or stool. Abdominal X-ray shows dilated loops of the small intestine with air-fluid levels. Other intestinal obstruction unspecified as to partial versus complete obstruction. Verbatim EHR quote justifying the code: 'Patient presents with symptoms of severe abdominal pain, bloating, and imaging studies reveal dilated loops of the small intestine with air-fluid levels, indicative of intestinal obstruction. There is no evidence of fecal impaction or specific adhesions causing the obstruction.' The patient's abdomen is distended and tympanic to percussion. Bowel sounds are hypoactive. The patient is being closely monitored for signs of bowel ischemia. The patient is kept nil per os (NPO), receives intravenous fluids, and is prepared for possible surgical intervention if the obstruction does not resolve. The patient showed improvement with conservative management and was discharged with dietary instructions to prevent constipation. 56 Female Caucasian ICD Code: K56.699

The patient has a history of abdominal surgeries, including appendectomy and cholecystectomy. No history of inflammatory bowel disease or diverticular disease. The patient presents with abdominal distension, crampy abdominal pain, absence of bowel sounds, and vomiting. No signs of peritonitis or rectal bleeding. Abdominal X-ray shows multiple air-fluid levels and dilated loops of the small bowel, consistent with a mechanical obstruction. Blood tests indicate leukocytosis with no electrolyte abnormalities. Ileus, unspecified: The patient presents with abdominal distension, crampy abdominal pain, absence of bowel sounds, and vomiting. Abdominal X-ray shows multiple air-fluid levels and dilated loops of the small bowel, consistent with a mechanical obstruction. The patient's symptoms and diagnostic tests are consistent with a diagnosis of Ileus. No signs of peritonitis or other specific causes of obstruction are noted. The patient will be closely monitored for any signs of complications. The patient is kept NPO (nothing by mouth) and receives intravenous fluids. A nasogastric tube is placed for decompression. Close monitoring of vital signs and bowel function is initiated. The patient responded well to conservative management and showed gradual improvement in bowel function. Discharged with instructions for a low-residue diet and to follow up if symptoms recur. 58 Female Caucasian ICD Code: K567

The patient has a history of recurrent abdominal pain, bloating, and changes in bowel habits over the last few months. No history of previous abdominal surgeries or known adhesions. The patient presents with severe lower abdominal pain, tenderness on palpation, fever, and signs of localized infection like redness and warmth over the abdomen. CT scan of the abdomen shows evidence of small intestine diverticula, along with perforation and abscess formation without any signs of active bleeding. Diverticulitis of small intestine with perforation and abscess without bleeding. The presence of diverticula in the small intestine, along with perforation and abscess formation, supports this diagnosis. Patient likely developed diverticulitis due to inflammation and infection of the small intestine diverticula. No signs of complete obstruction or large intestine involvement noted. The patient was started on intravenous antibiotics to treat the infection, along with bowel rest and supportive care. Close monitoring for signs of sepsis initiated. The patient responded well to treatment, with resolution of fever and improvement in abdominal pain. Discharged with oral antibiotics and advised to follow up for a repeat CT scan in two weeks. 58 Female Caucasian ICD Code: K5700

The patient has a history of recurrent abdominal discomfort and irregular bowel habits. The patient presents with crampy lower abdominal pain, bloating, and changes in bowel habits. Colonoscopy revealed multiple small diverticula in the small intestine without any signs of perforation or bleeding. Diverticulosis of small intestine without perforation or abscess without bleeding (K5710) Patient's symptoms and diagnostic tests confirm the diagnosis of diverticulosis of the small intestine without any complications. Prescribed a high-fiber diet, increased fluid intake, and scheduled a follow-up appointment in three months. The patient was discharged in stable condition with instructions to follow the dietary and lifestyle recommendations provided. 58 Female Caucasian ICD Code: K5710

The patient has a history of recurrent abdominal pain, constipation, and bloating. The patient presents with severe abdominal pain localized in the lower left quadrant, fever, chills, and signs of peritonitis. CT scan shows evidence of diverticulitis with perforation and abscess formation in the large intestine without signs of active bleeding. Diverticulitis of large intestine with perforation and abscess without bleeding (K5720): The diverticulitis of the large intestine with perforation and abscess without bleeding is confirmed by CT scan findings showing perforation and abscess formation without active bleeding. The patient's condition is stable post-CT scan, and urgent surgical consultation is requested for further management. The patient is started on intravenous antibiotics, kept nil per os, and closely monitored for signs of sepsis. 65 Female Caucasian ICD Code: K5720

The patient has a history of recurrent episodes of abdominal pain and changes in bowel habits. The patient presents with severe abdominal pain, fever, and rectal bleeding. CT scan revealed perforation and abscess in the large intestine. Diverticulitis of large intestine with perforation and abscess with bleeding (K5721): The patient is diagnosed with diverticulitis of the large intestine with perforation and abscess with bleeding. Patient is in stable condition post-CT scan. Started on IV antibiotics and scheduled for a surgical consult. Treatment includes IV antibiotics, bowel rest, and pain management. Surgery may be required depending on the surgical consult. 65 Female Caucasian ICD Code: K5721

The patient has a history of recurrent abdominal pain, bloating, and irregular bowel habits. The patient presents with left lower quadrant abdominal pain, tenderness, and mild fever. CT scan shows colonic diverticula without signs of perforation, abscess, or bleeding. Diverticulitis of large intestine without perforation or abscess without bleeding (K5732). The patient's symptoms and CT findings are consistent with uncomplicated diverticulitis of the large intestine. No signs of complications such as perforation or abscess are noted. Prescribed a course of antibiotics, advised on a low-fiber diet, and recommended follow-up with a gastroenterologist. The patient responded well to treatment, with resolution of symptoms. Discharged home with instructions for symptom monitoring and dietary modifications. 58 Female Caucasian ICD Code: K5732

The patient has a history of intermittent abdominal pain and irregular bowel habits. The patient presents with abdominal pain, bloating, and rectal bleeding. Colonoscopy revealed multiple diverticula in the intestine with active bleeding but no signs of perforation. Diverticulosis of intestine, part unspecified, without perforation or abscess with bleeding. (K5791) Patient reports recurrent episodes of bright red blood in stools without any signs of infection or inflammation. Prescribed high-fiber diet, increased fluid intake, and monitoring for anemia. The patient responded well to conservative management and was discharged with instructions for follow-up colonoscopy in six months. 64 Female Caucasian ICD Code: K5791

The patient has a history of recurrent abdominal pain, bloating, and frequent loose stools over the past six months. The patient presents with chronic abdominal pain relieved by defecation, increased frequency of bowel movements, and loose stools with mucus. Colonoscopy revealed normal colonic mucosa with no signs of inflammation, infection, or structural abnormalities. Stool studies were negative for infectious pathogens. Irritable bowel syndrome with diarrhea (K580): The patient presents with chronic abdominal pain relieved by defecation, increased frequency of bowel movements, and loose stools with mucus. The patient reports that symptoms worsen during periods of stress and anxiety. Physical examination shows no signs of alarm features such as weight loss, rectal bleeding, or anemia. Prescribed a low-FODMAP diet, fiber supplements, and stress management techniques. Follow-up in four weeks to assess symptom improvement. 38 Female Caucasian ICD Code: K580

The patient has a history of chronic constipation and abdominal discomfort. The patient presents with infrequent bowel movements, abdominal pain, bloating, and a sensation of incomplete evacuation. Colonoscopy revealed no structural abnormalities or signs of inflammation. Irritable bowel syndrome with constipation (K581): The patient meets the Rome IV criteria for irritable bowel syndrome with predominant constipation. Symptoms include recurrent abdominal pain on average at least 1 day per week in the last 3 months associated with two or more of the following: related to defecation, a change in frequency of stool, or a change in form (appearance) of stool. The patient reports that symptoms have been ongoing for the last six months and have significantly impacted daily activities. Prescribed dietary modifications, increased water intake, and fiber supplements. Advised on stress management techniques. The patient responded well to conservative management and was discharged with instructions for follow-up in the outpatient clinic in two weeks. 42 Female Caucasian ICD Code: K581

The patient has a history of chronic abdominal pain, bloating, and alternating diarrhea and constipation for the past two years. The patient presents with abdominal pain, bloating, and irregular bowel habits without any alarming features such as weight loss, rectal bleeding, or anemia. Colonoscopy showed normal colonic mucosa without any signs of diverticulosis or inflammatory bowel disease. Mixed irritable bowel syndrome (IBS-M) is characterized by abdominal pain and altered bowel habits, including both diarrhea and constipation, in the absence of specific alarm features. The patient reports recurrent episodes of abdominal discomfort associated with changes in bowel habits, meeting the diagnostic criteria for Mixed irritable bowel syndrome. No red flag symptoms suggestive of organic gastrointestinal diseases are present. Prescribed dietary modifications, stress management techniques, and antispasmodic medication to alleviate symptoms. 42 Female Caucasian ICD Code: K582

The patient has a history of chronic abdominal discomfort and irregular bowel habits. The patient presents with recurrent abdominal pain, bloating, and alternating constipation and diarrhea. Colonoscopy revealed normal colonic mucosa without any signs of diverticular disease. Other irritable bowel syndrome (K588): The patient presents with recurrent abdominal pain, bloating, and changes in bowel habits, consistent with the diagnosis of Other irritable bowel syndrome. The patient reports that the abdominal pain is relieved after passing stool. No signs of diverticular disease were noted on colonoscopy. Prescribed dietary modifications, increased fluid intake, and stress management techniques. Follow-up in 4 weeks. The patient was discharged in stable condition with instructions to follow up with a gastroenterologist for further management if symptoms persist. 45 Female Caucasian ICD Code: K588

The patient has a history of occasional constipation but has not required medical intervention for it previously. The patient presents with infrequent bowel movements, hard stools, and a sensation of incomplete evacuation for the past two weeks. Abdominal X-ray shows fecal loading in the colon without any signs of obstruction. Constipation, unspecified. Verbatim EHR quote justifying the code: 'Patient presents with infrequent bowel movements, hard stools, and a sensation of incomplete evacuation for the past two weeks.' Upon examination, the patient does not exhibit any signs of gastrointestinal bleeding, perforation, or abscess. No other concerning symptoms or findings are noted. The patient was advised to increase fiber intake, hydrate adequately, and engage in regular physical activity. A laxative was prescribed for symptomatic relief. The patient's symptoms improved with the prescribed treatment, and they were discharged with instructions for follow-up if needed. 45 Female Caucasian ICD Code: K5900

The patient has a past medical history of chronic constipation and recurrent episodes of abdominal distension and discomfort. The patient presents with severe abdominal pain, bloating, and infrequent passage of large stools. There is a palpable mass in the lower abdomen upon physical examination. Abdominal X-ray reveals marked dilation of the colon, confirming the diagnosis of megacolon. Other megacolon (K5939): The patient presents with severe abdominal pain, bloating, and infrequent passage of large stools. Abdominal X-ray reveals marked dilation of the colon, consistent with megacolon. The patient's symptoms and diagnostic tests are consistent with a diagnosis of megacolon. Immediate intervention is necessary to relieve the obstruction and prevent complications. Immediate decompression of the colon was performed followed by dietary modifications, laxatives, and close monitoring of bowel movements. The patient responded well to treatment and was discharged with instructions for follow-up care and dietary management to prevent future episodes of megacolon. 56 Male Caucasian ICD Code: K5939

The patient has no history of chronic constipation or inflammatory bowel disease. The patient presents with rectal pain, bright red blood in stool, and pain during bowel movements. Physical examination shows a tear in the anal lining consistent with an anal fissure. Anal fissure, unspecified. Verbatim ICD-10-CM quote: 'An anal fissure is a small tear in the thin, moist tissue that lines the anus, typically causing pain during bowel movements.' Upon examination, the patient displayed tenderness in the anal region with a visible tear, confirming the diagnosis of an anal fissure. Prescribed topical analgesic ointment and advised on dietary modifications to promote healing and prevent constipation. The patient was discharged with instructions for follow-up in two weeks to assess treatment response and discuss further management if needed. 45 Female Caucasian ICD Code: K602

The patient has a history of recurrent perianal abscesses and drainage procedures. The patient complains of persistent pain, swelling, and discharge near the anal opening. Fistulography reveals a tract extending from the anal canal to the perianal skin, confirming the presence of an anal fistula. Anal fistula (K603): An anal fistula is an abnormal tunnel-like connection between the anal canal and the skin near the anus. The verbatim quote justifying the code is: 'Fistulography reveals a tract extending from the anal canal to the perianal skin, confirming the presence of an anal fistula.' On examination, a small opening with pus discharge is noted near the anal verge. The patient has tenderness on palpation in the perianal region. The patient underwent a fistulotomy procedure to open and drain the fistula tract. Post-operative care includes analgesics and sitz baths. The patient is discharged in stable condition with instructions for wound care and follow-up in the outpatient clinic. 42 Male Caucasian ICD Code: K603

The patient has a history of recurrent perianal abscesses and chronic anal pain. The patient presents with persistent discharge from the perianal region and intermittent pain exacerbated by defecation. MRI findings reveal a fistulous tract connecting the anal canal to the perianal skin. Anorectal fistula. The MRI shows a fistulous tract extending from the anal canal to the perianal skin, confirming the diagnosis of an anorectal fistula. On examination, a small external opening was noted at the 6 o'clock position from the anal verge, consistent with an anorectal fistula. No signs of acute infection or abscess were observed. The patient was scheduled for a fistulotomy procedure to treat the anorectal fistula. Antibiotics were prescribed to prevent infection post-surgery. The patient underwent successful fistulotomy without complications and was discharged in stable condition. 42 Male Caucasian ICD Code: K605

The patient has a history of recurrent rectal pain and discomfort. The patient presents with severe rectal pain, swelling, and redness in the perianal area. There is also fever and chills. Physical examination reveals tenderness and fluctuance in the perianal region, consistent with an abscess. No other significant findings on lab tests. Rectal abscess (K611): A rectal abscess is a collection of pus located in the rectal area. It presents with symptoms such as severe rectal pain, swelling, redness, and fever. Physical examination shows tenderness and fluctuance in the perianal region, confirming the presence of an abscess. Upon examination, the patient displayed classic signs of a rectal abscess, including tenderness, swelling, and redness in the perianal area. The patient reported severe pain exacerbated by sitting. No signs of other conditions like anal fissures or fistulas were noted. Incision and drainage of the abscess were performed. The patient was started on a course of antibiotics and advised on proper wound care. The patient responded well to treatment and was discharged with instructions for follow-up care. 45 Male Caucasian ICD Code: K611

The patient has no prior history of anorectal abscess or similar conditions. The patient presents with localized pain, swelling, redness, and fever in the anorectal region. MRI imaging confirmed the presence of an abscess in the anorectal area. Anorectal abscess without mention of fistula (K612) On examination, the patient has tenderness, swelling, and redness in the anorectal region, consistent with an anorectal abscess. Incision and drainage of the abscess were performed, and the patient was started on a course of antibiotics. The patient was discharged in stable condition with instructions for wound care and a follow-up appointment in two weeks. 42 Female Caucasian ICD Code: K612

The patient has a history of recurrent perianal abscesses and has undergone incision and drainage procedures in the past. The patient presents with severe pain in the perianal region, swelling, redness, and localized warmth. There is no history of chronic constipation, neurogenic bowel, megacolon, or other functional intestinal disorders. Physical examination reveals a fluctuant swelling in the ischiorectal region. No signs of rectal prolapse, stenosis, hemorrhage, or ulceration are noted. Ischiorectal abscess (K613): An abscess in the ischiorectal fossa. On examination, there is tenderness and induration in the right ischiorectal region. The patient has a low-grade fever. No evidence of rectal polyps, fistulas, or other abscess types. Incision and drainage of the abscess performed under local anesthesia. The patient was started on oral antibiotics and advised on wound care. The patient was discharged in stable condition with instructions for follow-up care and monitoring for any signs of recurrence. 42 Male Caucasian ICD Code: K613

The patient has no significant past medical history relevant to the current condition. The patient complains of acute pain and swelling in the perianal region, along with fever and difficulty sitting. Physical examination reveals a tender, fluctuant mass in the ischiorectal fossa. Ischiorectal abscess is a collection of pus in the ischiorectal space, typically caused by infection of the anal glands. The hallmark of ischiorectal abscess is a painful, swollen lump in the anal region, often accompanied by systemic symptoms like fever. The diagnosis is confirmed by physical examination, which reveals a tender, fluctuant mass in the ischiorectal fossa. On examination, the patient presented with a swollen, erythematous perianal region and reported severe pain exacerbated by sitting. The digital rectal exam showed tenderness and induration in the right ischiorectal fossa. No other significant findings were noted. The patient was taken to the operating room for incision and drainage of the abscess under local anesthesia. Postoperatively, the patient was started on oral antibiotics and analgesics. The patient tolerated the procedure well and was discharged home with appropriate wound care instructions. Follow-up was scheduled in one week to assess healing and ensure resolution of symptoms. 42 Male Caucasian ICD Code: K6139

The patient has a history of chronic constipation and occasional rectal bleeding. The patient presents with severe anal pain exacerbated by bowel movements, localized swelling and tenderness near the anus, and fever. Physical examination reveals fluctuance near the anal sphincter, and an MRI confirms the presence of an abscess within the internal anal sphincter. Intrasphincteric abscess (K614): An abscess located within the anal sphincter muscles. Verbatim EHR quote justifying the code: 'MRI confirmed the presence of an abscess within the internal anal sphincter.' The patient is in significant discomfort due to the abscess. No signs of rectal fistula or other anorectal conditions were noted upon examination. Incision and drainage of the abscess were performed under local anesthesia. The patient was started on a course of antibiotics and advised on sitz baths for symptomatic relief. The patient was discharged in stable condition with instructions for wound care and a follow-up appointment in one week. 42 Female Caucasian ICD Code: K614

The patient has a history of chronic constipation and a previous vaginal delivery. The patient reports a feeling of a bulge or protrusion from the anus during bowel movements. She describes the bulge as reducing spontaneously after defecation. Physical examination reveals a circumferential protrusion of the rectal mucosa during Valsalva maneuver. Anorectal manometry shows decreased resting anal sphincter pressure. Rectal prolapse (K623): The rectal mucosa protrudes through the anal opening during defecation or straining. On examination, a full-thickness rectal prolapse was noted with no signs of fistulas, abscesses, or other anorectal conditions. Anorectal manometry confirmed decreased anal sphincter pressure. The patient was advised on dietary modifications, pelvic floor exercises, and referred for surgical evaluation. N/A 42 Female Caucasian ICD Code: K623

The patient has a history of chronic constipation and recurrent episodes of rectal pain. The patient presents with difficulty passing stools, feeling of incomplete evacuation, and intermittent rectal bleeding. Colonoscopy revealed narrowing of the rectal lumen consistent with stenosis. Biopsy results are pending. Stenosis of anus and rectum - The rectal lumen is narrowed, causing symptoms of constipation and rectal bleeding. The patient reports worsening symptoms over the past few months, with no relief from dietary changes or laxatives. Started on stool softeners and scheduled for further evaluation pending biopsy results. The patient was discharged in stable condition with close follow-up for biopsy results and treatment planning. 55 Female Caucasian ICD Code: K624

The patient has a history of chronic constipation and recurrent episodes of rectal pain and discomfort. The patient presents with persistent anal pain, rectal bleeding, and mucous discharge. Colonoscopy revealed a single ulcer in the rectal mucosa measuring 1 cm in diameter. Ulcer of anus and rectum (K626): The patient has a single ulcer in the rectal mucosa without evidence of abscess, prolapse, or active bleeding. The patient reports worsening pain during defecation and occasional blood streaks on the stool. Physical examination shows tenderness on palpation around the anus with no palpable masses. The patient was started on a high-fiber diet, sitz baths, and topical analgesics for symptom relief. The patient responded well to conservative management and was discharged with instructions for follow-up with a gastroenterologist in two weeks. 45 Female Caucasian ICD Code: K626

The patient has a history of pelvic cancer and underwent radiation therapy six months ago. The patient presents with complaints of rectal bleeding, diarrhea, and persistent rectal pain. Colonoscopy revealed telangiectasias and mucosal friability in the rectum consistent with radiation-induced changes. Radiation proctitis (K627): Proctitis following radiation therapy (Code K62.7) The patient reports that symptoms started a month after completing radiation therapy. Physical examination shows erythema and friability of the rectal mucosa. Prescribed mesalamine suppositories for local anti-inflammatory effect and advised dietary modifications. The patient was discharged with instructions for follow-up colonoscopy in three months to monitor the rectal mucosal changes. 58 Female Caucasian ICD Code: K627

The patient has a history of chronic constipation and recurrent anal fissures. The patient presents with chronic anal pain, bleeding during bowel movements, and a feeling of a mass protruding from the anus. Colonoscopy revealed dysplastic changes in the lining of the anus. Dysplasia of anus (K62.82): Dysplastic changes in the lining of the anus. Upon examination, there were visible dysplastic lesions in the anal canal. The patient's symptoms and diagnostic test results are consistent with dysplasia of the anus. The patient was scheduled for a surgical excision of the dysplastic lesions followed by regular follow-ups for surveillance. The patient underwent successful surgical removal of the dysplastic lesions and was discharged in stable condition with instructions for post-operative care. 56 Female Caucasian ICD Code: K62.82

The patient has a history of chronic constipation and occasional rectal bleeding. The patient complains of anal pain, itching, and occasional discharge. Colonoscopy revealed multiple small ulcers in the rectum and anus. Other specified diseases of anus and rectum (K6289) Clinical examination shows erythema and tenderness around the anus. Colonoscopy findings confirm the presence of ulcers in the anal canal. Prescribed topical corticosteroids for local application and advised dietary modifications. The patient responded well to treatment, symptoms improved, and was discharged with follow-up in the outpatient clinic in two weeks. 56 Female Caucasian ICD Code: K6289

The patient has a history of occasional rectal discomfort and minor rectal bleeding over the past few months, with no prior diagnosis of specific rectal conditions. The patient presents with mild rectal pain, occasional rectal bleeding, and a feeling of fullness in the rectal area. Colonoscopy and rectal exam showed no specific abnormalities other than mild inflammation in the rectal area. Disease of anus and rectum, unspecified. The patient presents with mild rectal pain, occasional rectal bleeding, and a feeling of fullness in the rectal area. The patient's symptoms are non-specific and do not indicate a clear diagnosis of a specific rectal condition. Plan for symptomatic management and follow-up in two weeks. Prescribed topical analgesic cream for pain relief and advised dietary modifications to increase fiber intake. Follow-up appointment scheduled in two weeks for symptom reassessment. 45 Female Caucasian ICD Code: K629