Datasets:

PIISA

/

Healthcare

like 0

Follow

PIISA 12

The patient has a history of Crohn's disease, a chronic inflammatory bowel condition. The patient presented with severe abdominal pain, fever, and elevated white blood cell count. CT scan revealed a fluid-filled abscess in the intestine. Abscess of intestine (K630): The CT scan confirmed the presence of a fluid-filled abscess in the intestine, consistent with the diagnosis of an intestinal abscess. The patient's symptoms and diagnostic imaging are indicative of an intestinal abscess. No signs of rectal polyps, perforation, ulcers, or other conditions were observed. The patient was started on intravenous antibiotics and scheduled for a drainage procedure to treat the abscess. The patient responded well to treatment, and the abscess was successfully drained. Discharged with a prescription for oral antibiotics and a follow-up appointment in two weeks. 47 Female Caucasian ICD Code: K630

The patient has a history of Crohn's disease, which is a known risk factor for developing Fistula of intestine. The patient presents with chronic abdominal pain, recurrent fever, and foul-smelling discharge from the rectum. Colonoscopy revealed an abnormal connection between the intestine and another organ, confirming the presence of a fistula. Fistula of intestine (K632): A fistula involving the intestine, confirmed by colonoscopy showing an abnormal connection. The patient reports worsening symptoms over the past few months, consistent with a fistula complication. Started the patient on antibiotics and scheduled for surgical intervention to repair the fistula. The patient responded well to treatment and was discharged with a follow-up appointment scheduled in two weeks. 45 Female Caucasian ICD Code: K632

The patient has a history of irritable bowel syndrome but no previous history of ulcerative conditions in the intestine. The patient presents with abdominal pain localized in the lower abdomen, especially after meals, along with unexplained weight loss. There is no rectal bleeding, anal pain, or discomfort. Colonoscopy revealed a shallow ulcer in the small intestine with no other abnormalities detected. Ulcer of intestine (K633): Ulceration of the intestine is confirmed by colonoscopy, presenting as a shallow ulcer in the small intestine without involvement of the anus, rectum, or other parts of the intestine. The patient reports persistent abdominal pain that is not relieved by over-the-counter medications. There is no family history of gastrointestinal disorders or malignancies. Physical examination shows tenderness in the lower abdomen. The patient is prescribed a proton pump inhibitor to reduce stomach acid production and advised to follow a bland diet. Follow-up colonoscopies are scheduled to monitor the healing of the intestinal ulcer. The patient responded well to treatment and reported a decrease in abdominal pain. Discharged with instructions to continue medication and attend scheduled follow-up appointments. 52 Female Caucasian ICD Code: K633

The patient has a history of recurrent abdominal pain and bloating over the past six months, with no prior surgeries or significant gastrointestinal issues. The patient presents with intermittent crampy abdominal pain, diarrhea, and unintentional weight loss. Colonoscopy revealed nonspecific inflammation in the large intestine. Blood tests showed mild anemia and elevated inflammatory markers. Disease of intestine, unspecified. The patient's symptoms, medical history, and diagnostic test results are consistent with an unspecified disease of the intestine. The patient reports no rectal bleeding, changes in bowel habits, or family history of gastrointestinal conditions. Physical examination shows mild tenderness in the lower abdomen. The patient was started on a course of mesalamine for suspected inflammatory bowel disease and advised to follow up for further evaluation. The patient responded well to treatment and was discharged with a plan for outpatient follow-up in two weeks. 47 Male Caucasian ICD Code: K639

The patient has a history of constipation and sedentary lifestyle. The patient presents with severe perianal pain, swelling, and tenderness. Physical examination reveals thrombosed veins in the perianal area. Perianal venous thrombosis (K645): Thrombosed hemorrhoidal veins causing severe perianal pain (verbatim_EHR_quote_justifying_the_code) On examination, perianal inspection shows significant edema and bluish discoloration consistent with thrombosed veins. The patient is in significant discomfort. Treatment includes sitz baths, topical analgesics, and dietary recommendations to manage constipation. The patient's symptoms improved with conservative management, and they were discharged with advice for follow-up if symptoms recur. 42 Male Caucasian ICD Code: K645

The patient has no significant past medical history related to gastrointestinal conditions or surgeries. The patient presents with rectal bleeding, itching, and discomfort during bowel movements. No symptoms of intestinal fistula, ulcer, polyps, or other intestinal diseases are reported. Physical examination reveals external hemorrhoids without signs of thrombosis or other complications. No abnormalities are detected in the colonoscopy results. Other hemorrhoids (K648): The patient presents with rectal bleeding, itching, and discomfort during bowel movements, consistent with the diagnosis of Other hemorrhoids (K648). The patient's physical examination shows external hemorrhoids without any signs of complications or thrombosis. Colonoscopy results are unremarkable. The patient is advised to increase fiber intake, use topical treatments for symptom relief, and follow up if symptoms persist. The patient's symptoms have improved with conservative management. Discharge instructions include continuing fiber-rich diet and topical treatments for hemorrhoid relief. 54 Male Caucasian ICD Code: K648

The patient has no history of gastrointestinal diseases or peritoneal conditions. The patient complains of painless rectal bleeding during bowel movements, anal itching, and a soft lump protruding near the anus. Physical examination reveals swollen blood vessels around the anus. Unspecified hemorrhoids The patient's symptoms and physical examination findings are consistent with internal hemorrhoids. No signs of peritoneal or intestinal disorders are noted. Prescribed topical creams for symptomatic relief and suggested dietary modifications to prevent constipation. The patient was discharged in stable condition with instructions to follow up if symptoms persist. 45 Female Caucasian ICD Code: K649

The patient has a history of recurrent abdominal pain and previous episodes of intra-abdominal infections. The patient presents with severe abdominal pain localized to the lower abdomen, fever, chills, and rebound tenderness. CT scan of the abdomen shows a fluid collection with air-fluid levels consistent with a peritoneal abscess. Peritoneal abscess (K651): The CT scan of the abdomen revealed a fluid collection with air-fluid levels in the peritoneal cavity, confirming the diagnosis of a peritoneal abscess. The patient is stable hemodynamically but shows signs of localized peritonitis. Urgent surgical consultation is recommended for drainage of the abscess. The patient was started on broad-spectrum antibiotics and scheduled for image-guided percutaneous drainage of the peritoneal abscess. The patient responded well to treatment, and the peritoneal abscess was successfully drained. Discharge instructions include completing the course of antibiotics and follow-up with the surgical team in two weeks. 56 Female Caucasian ICD Code: K651

The patient has a history of liver cirrhosis due to chronic hepatitis C infection. The patient presents with increasing abdominal pain, worsening ascites, and fever for the past three days. Ascitic fluid analysis shows a high absolute neutrophil count (>250 cells/mm3) and a positive culture for Escherichia coli. Spontaneous bacterial peritonitis (ICD-10-CM code K652): The presence of ascites, abdominal pain, fever, and positive ascitic fluid culture results supporting the diagnosis of spontaneous bacterial peritonitis. On examination, the patient has marked abdominal tenderness with shifting dullness. Vital signs show a low-grade fever of 100.8°F. Ascitic tap was performed, and analysis revealed purulent fluid with elevated neutrophil count and positive bacterial culture. The patient was started on intravenous ceftriaxone and albumin infusion. Close monitoring of vitals and response to treatment is ongoing. The patient responded well to treatment with resolution of fever and improvement in abdominal pain. Discharged home with a prescription for oral antibiotics and advised to follow up with the gastroenterologist in one week. 58 Male Caucasian ICD Code: K652

The patient has a history of cholelithiasis (gallstones) and recurrent episodes of cholecystitis (inflammation of the gallbladder). No history of liver disease or recent abdominal surgeries. The patient presents with severe right upper quadrant abdominal pain, fever, and rebound tenderness. No signs of hepatic encephalopathy or ascites. Abdominal ultrasound shows distended gallbladder with thickened walls and pericholecystic fluid collection. Blood tests reveal elevated white blood cell count and C-reactive protein levels. Choleperitonitis (K653): Choleperitonitis is an inflammation of the peritoneum caused by perforation of the gallbladder. The verbatim EHR quote justifying the code: 'The patient presents with severe right upper quadrant abdominal pain, fever, and rebound tenderness. Abdominal ultrasound shows distended gallbladder with thickened walls and pericholecystic fluid collection.' Patient is in significant distress due to the abdominal pain. Surgical consult requested for urgent cholecystectomy. Patient started on intravenous antibiotics and kept NPO (nothing by mouth) in preparation for surgery. Pain management with IV analgesics. Patient underwent successful cholecystectomy without complications. Antibiotics continued postoperatively. Patient recovering well and ready for discharge home. 56 Female Caucasian ICD Code: K653

The patient has a history of chronic abdominal pain, weight loss, and anorexia over the past several months. No history of hemorrhoids, peritonitis, liver diseases, or alcohol abuse. The patient presents with chronic abdominal pain, bloating, diarrhea, and fatigue. Physical examination reveals a palpable abdominal mass and mild tenderness. CT scan shows a thickened mesentery with a 'misty mesentery' appearance and a mass effect on adjacent structures. Biopsy results indicate fibrosis and chronic inflammation of the mesentery. Sclerosing mesenteritis is a rare idiopathic disorder characterized by chronic non-specific inflammation and fibrosis of the mesentery. The CT scan findings of a 'misty mesentery' appearance and biopsy results confirming fibrosis and chronic inflammation support the diagnosis of Sclerosing mesenteritis (K654). The patient's symptoms and imaging findings are consistent with Sclerosing mesenteritis. No signs of hemorrhoids, peritonitis, liver diseases, or alcohol-related conditions are observed. The patient is started on corticosteroids to manage the inflammation and symptoms. Close monitoring of symptoms and periodic imaging follow-ups are planned. The patient responded well to the corticosteroid treatment with a reduction in abdominal pain and improvement in appetite. Discharged home with a follow-up appointment in two weeks. 55 Female Caucasian ICD Code: K654

The patient has a history of recurrent abdominal pain and previous episodes of peritonitis. The patient presents with severe abdominal pain, tenderness, guarding, and rebound tenderness. There are signs of systemic inflammation such as fever and tachycardia. Abdominal CT scan shows diffuse inflammation of the peritoneum without evidence of perforation or abscess. Other peritonitis (K658): The patient presents with diffuse peritonitis without a specified cause. The peritoneal inflammation is not related to hemorrhoids, peritoneal abscess, bacterial peritonitis, choleperitonitis, or other specified disorders of the peritoneum. The patient's symptoms and diagnostic imaging are consistent with a diagnosis of Other peritonitis. There are no findings to suggest hemorrhoids, peritoneal abscess, or other specific peritoneal disorders. The patient was started on broad-spectrum antibiotics and closely monitored for signs of improvement. Pain management and supportive care were also provided. The patient responded well to treatment, with resolution of symptoms and signs of peritoneal inflammation. Discharged home with a course of antibiotics and advised to follow up with the primary care physician for further evaluation. 56 Female Caucasian ICD Code: K658

The patient has a history of recurrent abdominal pain and bloating. The patient presents with severe generalized abdominal pain, tenderness, and guarding. Laboratory findings show elevated white blood cell count. Abdominal ultrasound reveals diffuse peritoneal inflammation. Peritonitis, unspecified (K659): The patient presents with severe generalized abdominal pain, tenderness, and guarding. Laboratory findings show elevated white blood cell count. Abdominal ultrasound reveals diffuse peritoneal inflammation. The patient reports worsening abdominal pain over the last 24 hours. Physical examination indicates rebound tenderness and guarding. No signs of localized peritonitis or abscess. The patient is started on intravenous antibiotics and kept NPO (nothing by mouth) for observation. Pain management is provided. The patient responded well to treatment with resolution of symptoms. Discharged home with a course of oral antibiotics and advised to follow up with the primary care physician in one week. 45 Female Caucasian ICD Code: K659

The patient underwent laparoscopic surgery for appendicitis two years ago and had a recent history of abdominal infection treated with antibiotics. The patient presents with chronic abdominal pain, bloating, and occasional constipation. Abdominal ultrasound shows thickened and fibrotic peritoneal layers suggestive of adhesions. Peritoneal adhesions (postprocedural) (postinfection) (K660): Adhesions in the peritoneum following a procedure or infection. The patient reports persistent abdominal discomfort, likely due to the presence of peritoneal adhesions. Imaging reveals fibrotic bands consistent with adhesions. Prescribed pain management, advised dietary modifications to alleviate symptoms, and recommended follow-up with a gastroenterologist for further evaluation. The patient was discharged in stable condition with instructions to monitor symptoms and seek medical attention if pain worsens or bowel habits change. 42 Female Caucasian ICD Code: K660

The patient has a history of abdominal discomfort and distension, with no previous episodes of peritonitis, peritoneal abscess, or hemorrhoids. The patient presents with localized tenderness in the lower abdomen, without signs of generalized peritonitis, peritoneal abscess, or hemorrhoids. Abdominal ultrasound shows thickening of the peritoneum without evidence of free fluid or abscess formation. Other specified disorders of peritoneum (ICD-10-CM code K668): The peritoneum is thickened without signs of generalized peritonitis, peritoneal abscess, or hemorrhoids. The patient's symptoms and imaging findings are consistent with localized peritoneal thickening, ruling out generalized peritonitis, peritoneal abscess, or hemorrhoids. The patient is prescribed nonsteroidal anti-inflammatory drugs (NSAIDs) for pain management and advised on symptom monitoring. The patient's symptoms improved with treatment, and they were discharged with instructions for follow-up if symptoms persist or worsen. 45 Female Caucasian ICD Code: K668

The patient has a history of chronic lower back pain and has been on long-term corticosteroid therapy for rheumatoid arthritis. The patient presents with fever, severe localized lower back pain, and difficulty walking. MRI of the lumbar spine showed a 5cm abscess within the right Psoas muscle with surrounding inflammation. Psoas muscle abscess - The patient presents with fever, severe localized lower back pain, and an MRI showing a 5cm abscess within the right Psoas muscle. The patient's clinical presentation and imaging results are consistent with a Psoas muscle abscess. The abscess is localized within the Psoas muscle without involvement of adjacent structures. The patient was started on intravenous antibiotics and underwent percutaneous drainage of the Psoas abscess. Pain management was optimized, and the patient showed improvement. The patient responded well to treatment, with resolution of fever and significant improvement in lower back pain. Discharge instructions include a course of oral antibiotics and close follow-up with the infectious disease specialist. 58 Female Caucasian ICD Code: K6812

The patient has a history of uncontrolled diabetes mellitus type 2. The patient presents with persistent fever, severe abdominal pain localized to the lower back, and general malaise. CT scan of the abdomen revealed a 7cm retroperitoneal abscess with surrounding inflammation. Other retroperitoneal abscess (ICD-10-CM code K6819): The CT scan of the abdomen showed a 7cm retroperitoneal abscess with surrounding inflammation, consistent with the diagnosis of Other retroperitoneal abscess (K6819). The patient is being started on intravenous antibiotics and is scheduled for image-guided drainage of the abscess. The patient is receiving intravenous antibiotics (Ceftriaxone and Metronidazole) and is planned for percutaneous drainage of the retroperitoneal abscess. The patient responded well to treatment, with resolution of fever and significant reduction in abdominal pain. The patient will be discharged home with a course of oral antibiotics and close follow-up with the infectious disease specialist. 56 years Male Caucasian ICD Code: K6819

The patient has a history of chronic alcohol abuse for the past 10 years. The patient complains of fatigue and mild right upper quadrant discomfort. Physical examination reveals hepatomegaly. Laboratory tests show elevated liver enzymes (AST and ALT) and GGT. Imaging studies (ultrasound) demonstrate hepatic steatosis. Alcoholic fatty liver (K700): The patient presents with a history of chronic alcohol abuse, elevated liver enzymes, hepatomegaly, and imaging findings consistent with hepatic steatosis. Patient counseled on the importance of alcohol cessation and referred to a hepatologist for further management. Treatment includes alcohol cessation counseling, dietary recommendations, and close follow-up with a hepatologist. The patient was discharged in stable condition with instructions to follow up with the hepatologist in two weeks. 45 Male Caucasian ICD Code: K700

The patient has a history of chronic alcohol abuse for several years. The patient presents with jaundice, generalized abdominal pain, and elevated liver enzymes. Liver function tests show elevated AST and ALT levels. Abdominal ultrasound reveals liver inflammation without evidence of ascites. Alcoholic hepatitis without ascites (K7010): The patient presents with jaundice, generalized abdominal pain, and elevated liver enzymes. Abdominal ultrasound shows liver inflammation without ascites. The patient denies any recent abdominal distension or fluid retention. The clinical presentation and test results are consistent with alcoholic hepatitis without ascites. The patient is advised to abstain from alcohol. Supportive care, including hydration and nutritional support, is initiated. Close monitoring of liver function is recommended. The patient responded well to treatment and was discharged with instructions to follow up with a gastroenterologist for further management of alcoholic hepatitis. 45 Male Caucasian ICD Code: K7010

The patient has a history of chronic alcohol abuse. The patient presents with abdominal pain, jaundice, and swelling in the abdomen. Laboratory tests show elevated liver enzymes, bilirubin levels, and presence of ascites on imaging studies. Alcoholic hepatitis with ascites (K7011): The presence of ascites and elevated liver enzymes in a patient with a history of chronic alcohol abuse supports the diagnosis of Alcoholic hepatitis with ascites. The patient's symptoms and test results are consistent with a diagnosis of Alcoholic hepatitis with ascites. No evidence of peritonitis, peritoneal adhesions, hemoperitoneum, or other liver diseases like fatty liver or cirrhosis. The patient was started on supportive care, including diuretics for management of ascites and advised to abstain from alcohol. The patient responded well to treatment and was discharged with instructions for outpatient follow-up and continued abstinence from alcohol. 52 Male Caucasian ICD Code: K7011

The patient has a history of chronic alcohol abuse for the past 15 years. Complaining of fatigue, abdominal pain, and unintentional weight loss. Liver function tests show elevated liver enzymes. Ultrasound of the liver reveals liver fibrosis and sclerosis. Alcoholic fibrosis and sclerosis of liver (K702) Patient shows signs of advanced liver damage due to chronic alcohol consumption. Liver biopsy confirmed the presence of fibrosis and sclerosis without evidence of cirrhosis or hepatitis. Initiated treatment with vitamin supplements, dietary changes, and referral to addiction counseling. The patient was discharged in stable condition with recommendations for continued abstinence from alcohol and follow-up with a gastroenterologist for further management. 45 Male Caucasian ICD Code: K702

The patient has a history of chronic alcohol abuse spanning over a decade, with no known history of liver disease or ascites. The patient presents with fatigue, jaundice, weight loss, and lower extremity edema. Laboratory tests show elevated liver enzymes, prolonged prothrombin time, and imaging studies reveal a nodular liver consistent with cirrhosis. Alcoholic cirrhosis of liver without ascites. The patient's liver biopsy confirms the presence of micronodular cirrhosis with no evidence of ascites. The clinical presentation aligns with advanced liver disease due to chronic alcohol abuse. The patient is advised to abstain from alcohol completely and is started on a diuretic regimen to manage edema. Nutritional support and close monitoring of liver function are initiated. The patient responded well to treatment, with improvement in symptoms. Discharge instructions include strict abstinence from alcohol, adherence to the prescribed medications, and follow-up appointments for monitoring liver function. 54 Male Caucasian ICD Code: K7030

The patient has a history of chronic alcohol abuse for several years. The patient presents with jaundice, abdominal pain, and fatigue. Liver function tests show elevated liver enzymes and bilirubin levels consistent with liver dysfunction. Imaging studies reveal hepatomegaly. Alcoholic liver disease, unspecified (K709): 'Alcoholic liver disease, unspecified, is a chronic liver disease resulting from the harmful effects of alcohol on the liver.' The patient has a history of chronic alcohol abuse and presents with typical symptoms of alcoholic liver disease. Diagnostic tests confirm liver dysfunction and imaging studies show hepatomegaly. The patient is diagnosed with Alcoholic liver disease, unspecified (K709) based on the clinical presentation and test results. The patient is advised to abstain from alcohol. Symptomatic treatment for pain and fatigue is initiated. Referral to a hepatologist for further management is recommended. The patient responded well to treatment and is stable for discharge. Close follow-up with a hepatologist is advised to monitor liver function and provide ongoing care. 45 Male Caucasian ICD Code: K709

The patient has a history of exposure to industrial toxins and medications known to cause liver damage. The patient presents with jaundice, itching, and dark urine, classic symptoms of cholestasis. Liver function tests show elevated bilirubin levels, alkaline phosphatase, and gamma-glutamyl transferase (GGT) levels. Imaging studies reveal intrahepatic bile duct dilatation. Toxic liver disease with cholestasis. Verbatim ICD-10-CM quote: 'Toxic liver disease with cholestasis.' The patient's symptoms and test results are consistent with toxic liver disease with cholestasis. No history of alcohol abuse or findings suggestive of other liver diseases. The patient is started on cholestyramine for symptomatic relief and Ursodeoxycholic acid to improve bile flow. Close monitoring of liver function tests is initiated. The patient responded well to treatment and was discharged with instructions for follow-up liver function tests in two weeks. 54 Male Caucasian ICD Code: K710

The patient has a history of moderate alcohol consumption and occasional acetaminophen use for headaches. The patient presents with jaundice, fatigue, and mild upper abdominal discomfort. Liver function tests show elevated ALT and AST levels, along with increased total bilirubin. Hepatitis panel is positive for hepatitis B and C. Toxic liver disease with acute hepatitis, not elsewhere classified. The patient denies any history of intravenous drug use or recent travel. Physical examination reveals hepatomegaly without signs of cirrhosis. The patient is alert and oriented with no signs of hepatic encephalopathy. The patient is advised to abstain from alcohol and is started on antiviral therapy for hepatitis B and C. Symptomatic treatment for fatigue and regular monitoring of liver function tests are recommended. The patient responded well to treatment and showed improvement in symptoms. Discharge instructions include follow-up appointments for monitoring liver function tests and compliance with antiviral therapy. 45 Male Caucasian ICD Code: K716

The patient has a history of chronic exposure to industrial toxins in a manufacturing plant over the past 10 years. The patient presents with fatigue, jaundice, abdominal swelling, and weight loss. Liver function tests show elevated liver enzymes, imaging studies reveal liver fibrosis and cirrhosis. Toxic liver disease with fibrosis and cirrhosis of liver (K717): "Toxic liver disease with fibrosis and cirrhosis of liver" The patient's symptoms and diagnostic tests are consistent with toxic liver disease due to industrial toxin exposure, leading to fibrosis and cirrhosis of the liver. The patient was started on Ursodeoxycholic acid to manage liver function and referred to a hepatologist for further evaluation. The patient was discharged in stable condition with instructions to avoid further exposure to toxins and follow up with the hepatologist in two weeks. 55 Male Caucasian ICD Code: K717

The patient has a history of alcohol abuse and non-compliance with medical treatment for liver disease. The patient presents with fatigue, jaundice, abdominal swelling, and confusion. Liver function tests show elevated bilirubin, prolonged prothrombin time, and low albumin levels. Chronic hepatic failure without coma (K7210): Chronic hepatic failure without coma The patient has a history of chronic liver disease with evidence of hepatic decompensation. There is no evidence of hepatic necrosis, acute hepatitis, active hepatitis, ascites, fibrosis, cirrhosis, acute/subacute hepatic failure, or coma. The patient is started on lactulose for hepatic encephalopathy, spironolactone for ascites, and advised to abstain from alcohol. The patient's condition improved with treatment, and arrangements are made for close outpatient follow-up. 55 Male Caucasian ICD Code: K7210

The patient has a history of mild intermittent right upper quadrant abdominal pain and elevated liver enzymes on routine blood work for the past six months. The patient complains of occasional fatigue but denies any jaundice, pruritus, fever, or significant weight loss. Liver function tests show elevated ALT and AST levels. Hepatitis B and C serologies are negative. Abdominal ultrasound demonstrates a normal liver size and echotexture without evidence of cirrhosis or focal lesions. Chronic hepatitis, unspecified. The patient has a history of mild intermittent right upper quadrant abdominal pain and elevated liver enzymes on routine blood work for the past six months. The patient has a history of alcohol use within recommended limits and denies any recent medication changes or use of hepatotoxic drugs. No stigmata of chronic liver disease are appreciated on physical examination. The patient is advised to abstain from alcohol completely. Follow-up liver function tests are scheduled in three months to monitor enzyme levels. 42 Female Caucasian ICD Code: K739

The patient has a history of non-alcoholic fatty liver disease (NAFLD) and obesity. The patient complains of persistent right upper quadrant abdominal pain, unintentional weight loss, and yellowing of the skin. Liver function tests show elevated levels of ALT and AST. Imaging studies reveal signs of liver fibrosis without cirrhosis. Hepatic fibrosis (K740): The patient presents with abdominal pain, weight loss, and jaundice, along with elevated liver enzymes and imaging evidence of liver fibrosis without cirrhosis. The patient's symptoms and test results are consistent with hepatic fibrosis. No evidence of toxic exposure, hepatic failure, chronic hepatitis, or cirrhosis is noted. The patient is advised to follow a low-fat diet, lose weight, and undergo regular monitoring of liver function tests. The patient responded well to conservative management and was discharged with instructions for lifestyle modifications and follow-up appointments. 52 Female Caucasian ICD Code: K740

The patient has a history of autoimmune conditions and chronic liver abnormalities. The patient presents with fatigue, severe pruritus, jaundice, and hepatomegaly. Laboratory tests show elevated alkaline phosphatase and bilirubin levels. Imaging studies reveal characteristic changes in the liver. Primary biliary cirrhosis (K743): Primary biliary cirrhosis is a chronic autoimmune liver disease characterized by the destruction of intrahepatic bile ducts, leading to cholestasis, fibrosis, and eventually cirrhosis. The presence of antimitochondrial antibodies (AMA) is a hallmark of this condition. The patient's symptoms, along with the diagnostic test results and medical history, strongly support the diagnosis of Primary biliary cirrhosis. Further evaluation confirmed the characteristic histological features of the disease. The patient has been started on ursodeoxycholic acid to manage cholestasis and slow disease progression. Close monitoring of liver function tests and symptom management is advised. The patient responded well to treatment and is stable for discharge. Close follow-up with a hepatologist is recommended for ongoing management of Primary biliary cirrhosis. 56 Female Caucasian ICD Code: K743

The patient has a history of chronic liver disease, including long-standing liver enzyme abnormalities and recurrent episodes of jaundice. The patient presents with fatigue, pruritus, jaundice, and hepatomegaly. Liver function tests show elevated bilirubin levels, prolonged prothrombin time, and decreased albumin levels. Imaging studies reveal signs of cirrhosis such as liver nodularity and splenomegaly. Biliary cirrhosis, unspecified. Verbatim EHR quote justifying the code: 'The patient presents with a history of chronic liver disease, elevated bilirubin levels, prolonged prothrombin time, and imaging findings consistent with cirrhosis.' The patient's symptoms and test results are indicative of advanced liver disease with features of cirrhosis. There is no evidence of toxic liver disease, acute hepatic failure, chronic hepatitis, hepatic fibrosis, primary biliary cirrhosis, or other inflammatory liver diseases. The patient is started on ursodeoxycholic acid to manage cholestasis, advised on dietary modifications, and scheduled for regular follow-ups with a hepatologist. The patient responded well to treatment, with symptomatic improvement noted. Discharge instructions include medication adherence, monitoring for disease progression, and lifestyle recommendations to support liver health. 58 Female Caucasian ICD Code: K745

The patient has a history of alcohol abuse for several years, with no known history of viral hepatitis or autoimmune liver diseases. The patient presents with fatigue, jaundice, abdominal swelling, and easy bruising. Liver function tests show elevated liver enzymes, prolonged prothrombin time, and low albumin levels. Imaging studies reveal liver nodularity consistent with cirrhosis. Unspecified cirrhosis of liver (ICD-10-CM code K7460): "Cirrhosis of liver, unspecified, without mention of alcohol (K7460)" The patient's symptoms, along with the liver function tests and imaging findings, are consistent with the diagnosis of cirrhosis. The patient denies any recent toxic exposures or use of hepatotoxic medications. The patient is advised to abstain from alcohol. Supportive care and monitoring for complications of cirrhosis are initiated. The patient's condition improved with treatment, and arrangements are made for outpatient follow-up for continued management of cirrhosis. 56 Male Caucasian ICD Code: K7460

The patient has a history of alcohol abuse for the past 10 years. The patient presents with fatigue, jaundice, ascites, and lower extremity edema. Liver function tests show elevated liver enzymes (ALT, AST, ALP, and bilirubin levels). Imaging studies reveal nodular liver surface and splenomegaly. Other cirrhosis of liver: The liver biopsy confirmed the presence of cirrhosis with nodular regeneration and fibrous septa formation, consistent with the diagnosis of Other cirrhosis of liver (ICD-10-CM code K7469). The patient's presentation aligns with advanced liver disease, showing classic signs of cirrhosis with portal hypertension. The etiology of the cirrhosis is likely related to chronic alcohol consumption. The patient has been started on diuretics for management of ascites, vitamin supplementation, and referred for addiction counseling and liver transplant evaluation. The patient is stable post-treatment initiation and education on alcohol cessation and dietary modifications. They are scheduled for regular follow-ups to monitor liver function and disease progression. 56 Male Caucasian ICD Code: K7469

The patient has a history of autoimmune disorders, including rheumatoid arthritis and celiac disease, which are known to be associated with autoimmune hepatitis. The patient complains of fatigue, abdominal discomfort, and jaundice, which are common symptoms of autoimmune hepatitis. Laboratory tests show elevated liver enzymes (AST and ALT), hypergammaglobulinemia, and the presence of autoantibodies (such as anti-smooth muscle antibodies and anti-nuclear antibodies). Liver biopsy reveals interface hepatitis and lymphoplasmacytic infiltrates, consistent with autoimmune hepatitis. Autoimmune hepatitis (K754): The liver biopsy shows interface hepatitis and lymphoplasmacytic infiltrates, along with the presence of autoantibodies, confirming the diagnosis of autoimmune hepatitis. The patient's symptoms, along with the laboratory findings and liver biopsy results, support the diagnosis of autoimmune hepatitis. Treatment with corticosteroids and immunosuppressants has been initiated to manage the condition. The patient is started on prednisone for induction therapy, followed by azathioprine for maintenance therapy to suppress the autoimmune response and reduce liver inflammation. The patient responded well to the treatment and is scheduled for regular follow-up visits to monitor liver function tests and adjust medication dosages as needed. 45 Female Caucasian ICD Code: K754

The patient has a history of obesity, type 2 diabetes, and hyperlipidemia. The patient complains of fatigue, mild right upper quadrant abdominal pain, and unintentional weight loss. Liver function tests show elevated ALT and AST levels. Abdominal ultrasound demonstrates hepatic steatosis. Nonalcoholic steatohepatitis (NASH) (ICD-10-CM code K7581) - The liver biopsy shows steatosis, lobular inflammation, and hepatocyte ballooning without significant fibrosis. The patient presents with classic symptoms of NASH including fatigue, right upper quadrant abdominal pain, and weight loss. Diagnostic tests confirm the presence of hepatic steatosis and elevated liver enzymes. No evidence of other liver diseases is noted. The patient is advised to follow a low-fat diet, increase physical activity, and monitor blood glucose levels regularly. Prescribed vitamin E supplementation and scheduled for a follow-up in three months. The patient responded well to the treatment plan and is stable for discharge. Close monitoring of liver enzymes and weight is recommended post-discharge. 52 Female Caucasian ICD Code: K7581

The patient has a history of occasional alcohol consumption but denies any significant liver disease in the past. No history of autoimmune disorders or chronic viral hepatitis. The patient presents with mild right upper quadrant abdominal pain, fatigue, and unintentional weight loss. No jaundice, pruritus, or signs of chronic liver disease are reported. Liver function tests show mildly elevated transaminases (AST and ALT) with normal bilirubin levels. Imaging studies reveal hepatomegaly with no evidence of cirrhosis or focal lesions. Inflammatory liver disease, unspecified. The patient's presentation of mild right upper quadrant abdominal pain, fatigue, unintentional weight loss, and mildly elevated transaminases without evidence of cirrhosis or specific etiology justifies the assignment of K759. The patient's physical examination is significant for hepatomegaly without stigmata of chronic liver disease. Further workup for viral hepatitis, autoimmune markers, and imaging ruled out specific etiologies, supporting the diagnosis of inflammatory liver disease, unspecified. The patient is advised to abstain from alcohol. Symptomatic management with analgesics is initiated. Close follow-up with repeat liver function tests is recommended. The patient responded well to treatment with resolution of symptoms. Liver function tests trended downwards, indicating improvement. The patient is discharged with instructions for outpatient follow-up. 48 Female Caucasian ICD Code: K759

The patient has a history of obesity and type 2 diabetes, both known risk factors for fatty liver disease. The patient complains of mild right upper quadrant abdominal discomfort but denies jaundice, ascites, or pruritus. Liver function tests show elevated ALT and AST levels, suggestive of hepatocellular injury. Fatty (change of) liver, not elsewhere classified (K76.0) - Hepatomegaly with steatosis. The patient's ultrasound confirms hepatomegaly with diffuse hyperechogenicity of the liver parenchyma, consistent with fatty liver. No signs of portal hypertension or liver cirrhosis are noted. Prescribed weight loss through diet modification and increased physical activity. Follow-up in 3 months for reevaluation. The patient was discharged in stable condition with instructions to follow up with a hepatologist for further management of fatty liver. 52 Female Caucasian ICD Code: K76.0

The patient has a history of congestive heart failure and long-standing right-sided heart valve disease. The patient presents with abdominal distension, lower extremity edema, and mild jaundice. Liver function tests show elevated bilirubin levels and prolonged prothrombin time. Imaging reveals hepatomegaly and splenomegaly. Chronic passive congestion of liver (K76.1) Patient shows classic signs of chronic passive congestion with hepatomegaly, ascites, and splenomegaly. No evidence of cirrhosis, abscesses, or granulomas. Diuretics prescribed to manage ascites. Close monitoring of liver function and cardiac status recommended. Patient responded well to diuretic therapy with resolution of ascites. Discharged with follow-up for heart failure management. 68 Female Caucasian ICD Code: K76.1

The patient has a history of occasional episodes of mild upper abdominal discomfort after fatty meals over the past few months. No previous history of cholecystitis or gallstones. The patient presents with severe right upper quadrant abdominal pain radiating to the back, associated with nausea and vomiting. The pain is sharp and constant, exacerbated by deep inspiration. Ultrasound of the abdomen shows a thickened gallbladder wall with pericholecystic fluid and a single large gallstone impacted in the neck of the gallbladder. No signs of bile duct obstruction. Calculus of gallbladder with acute cholecystitis without obstruction. Verbatim EHR quote justifying the code: "Patient presents with severe right upper quadrant abdominal pain, nausea, and vomiting, along with ultrasound findings of a thickened gallbladder wall and a large gallstone without evidence of obstruction." On examination, Murphy's sign is positive. The patient has a low-grade fever of 100.8°F. Laboratory tests show elevated white blood cell count and mild elevation of liver enzymes. The clinical picture is consistent with acute cholecystitis without obstruction. The patient was started on intravenous antibiotics and kept nil per os. Pain management was provided, and the patient was prepared for a laparoscopic cholecystectomy once the acute episode subsides. The patient responded well to treatment, with resolution of symptoms and normalization of inflammatory markers. Discharged home with a plan for elective cholecystectomy in the outpatient setting. 52 Female Caucasian ICD Code: K8000

The patient has a past medical history significant for recurrent episodes of right upper quadrant abdominal pain, especially after consuming fatty meals. No history of diabetes, liver disease, or recent abdominal trauma. The patient presents with sharp, crampy pain in the right upper quadrant of the abdomen, radiating to the back, associated with nausea and occasional vomiting. No fever, jaundice, or signs of acute inflammation. Abdominal ultrasound reveals multiple calculi in the gallbladder without signs of acute inflammation or obstruction. Blood work shows normal liver enzymes and bilirubin levels. Calculus of gallbladder with chronic cholecystitis without obstruction. Verbatim EHR quote justifying the code: 'Patient presents with recurrent right upper quadrant abdominal pain, ultrasound shows multiple gallbladder calculi without signs of acute inflammation or obstruction.' The patient's symptoms and imaging findings are consistent with chronic cholecystitis without evidence of acute inflammation or obstruction. No signs of complications such as choledocholithiasis or cholangitis. The patient is advised to follow a low-fat diet and is prescribed oral analgesics for pain management. Referral for elective cholecystectomy is recommended. The patient's symptoms improved with conservative management. Discharged home with instructions for dietary modifications and scheduled follow-up for surgical consultation. 58 Female Caucasian ICD Code: K8010

The patient has a history of intermittent right upper quadrant abdominal pain and discomfort for the past year, which has worsened over the last week. No prior history of similar symptoms or cholecystitis. The patient presents with severe right upper quadrant abdominal pain, radiating to the back, accompanied by nausea and vomiting. The pain is sharp and constant, exacerbated by fatty meals. Abdominal ultrasound shows multiple gallstones in the gallbladder, thickening of the gallbladder wall, and pericholecystic fluid collection. The common bile duct is not dilated. Calculus of gallbladder with acute and chronic cholecystitis with obstruction. The presence of multiple gallstones, thickened gallbladder wall, pericholecystic fluid, and clinical symptoms of acute and chronic cholecystitis with obstruction support this diagnosis. The patient's symptoms, along with the imaging findings, are consistent with a diagnosis of Calculus of gallbladder with acute and chronic cholecystitis with obstruction. The patient is scheduled for urgent laparoscopic cholecystectomy. The patient was started on intravenous fluids, antibiotics, and analgesics. NPO (nothing by mouth) status was initiated in preparation for surgery. 54 Female Caucasian ICD Code: K8013

The patient has a history of intermittent right upper quadrant abdominal pain and occasional dyspepsia over the past few months. The patient presents with sharp, intermittent, non-radiating pain in the right upper quadrant of the abdomen. No fever, jaundice, or signs of acute illness noted. Abdominal ultrasound shows the presence of multiple calculi in the gallbladder without evidence of inflammation or obstruction. Calculus of gallbladder without cholecystitis without obstruction (K80.20) - The patient presents with multiple gallbladder stones on imaging without signs of acute inflammation or obstruction. No evidence of acute cholecystitis or obstruction. The patient's symptoms and imaging findings are consistent with a diagnosis of gallbladder stones without associated cholecystitis or obstruction. No signs of acute infection or blockage. The patient is advised to follow a low-fat diet and is prescribed pain management for symptomatic relief. Surgical consultation for cholecystectomy is recommended. The patient's pain is well managed with medications. They are discharged with instructions to follow up with the surgical team for further evaluation and discussion of treatment options. 56 Female Caucasian ICD Code: K80.20

The patient has a history of intermittent episodes of right upper quadrant abdominal pain and occasional indigestion over the past year. The patient presents with severe right upper quadrant abdominal pain radiating to the back, accompanied by nausea and vomiting. Abdominal ultrasound shows multiple gallstones causing obstruction of the cystic duct without signs of cholecystitis. Calculus of gallbladder without cholecystitis with obstruction. The patient's symptoms and imaging findings are consistent with gallstones obstructing the cystic duct without evidence of cholecystitis. Plan for conservative management and pain control. The patient was advised to follow a low-fat diet and given pain medication. Surgical consultation for cholecystectomy was discussed. The patient's pain improved with conservative management. Discharged home with instructions for follow-up with the surgical team. 56 Female Caucasian ICD Code: K8021

The patient has a history of recurrent upper abdominal pain and episodes of jaundice. The patient presents with right upper quadrant abdominal pain, fever, and elevated liver enzymes. Ultrasound shows a calculus in the common bile duct without evidence of cholecystitis. Blood tests reveal leukocytosis and elevated liver function tests. Calculus of bile duct with cholangitis, unspecified, without obstruction. Verbatim EHR quote justifying the code: 'Ultrasound demonstrates a calculus in the common bile duct without signs of cholecystitis. The patient's symptoms of right upper quadrant abdominal pain, fever, and elevated liver enzymes are consistent with cholangitis without obstruction.' The patient is stable and responding well to intravenous antibiotics and supportive care. The patient is being treated with intravenous antibiotics to manage the cholangitis and is closely monitored for improvement. The patient responded well to treatment and is being discharged with a follow-up appointment in two weeks. 55 Female Caucasian ICD Code: K8030

The patient has a history of recurrent episodes of right upper quadrant pain and intermittent jaundice over the past year. The patient presents with severe right upper quadrant pain, fever, and jaundice. Abdominal ultrasound shows dilatation of the common bile duct with evidence of choledocholithiasis and laboratory tests indicate elevated liver enzymes and bilirubin levels. Calculus of bile duct with cholangitis, unspecified, with obstruction. The patient presents with severe right upper quadrant pain, fever, and jaundice. Abdominal ultrasound shows dilatation of the common bile duct with evidence of choledocholithiasis. The patient is diagnosed with Calculus of bile duct with cholangitis, unspecified, with obstruction based on the clinical presentation and imaging findings. The patient is started on intravenous antibiotics, fluid resuscitation, and scheduled for endoscopic retrograde cholangiopancreatography (ERCP) for stone extraction. The patient responded well to treatment, and symptoms of cholangitis resolved. The patient was discharged with a plan for outpatient follow-up after the ERCP procedure. 58 Female Caucasian ICD Code: K8031

The patient has a history of recurrent episodes of biliary colic and has previously been diagnosed with asymptomatic bile duct stones during a routine ultrasound. The patient presents with right upper quadrant abdominal pain, fever, jaundice, and elevated liver function tests. Laboratory tests show leukocytosis, elevated alkaline phosphatase, and direct bilirubin levels. An abdominal ultrasound reveals dilated intrahepatic and extrahepatic bile ducts with no evidence of gallbladder involvement. Calculus of bile duct with acute cholangitis without obstruction. The patient presents with right upper quadrant abdominal pain, fever, jaundice, and elevated liver function tests. An abdominal ultrasound reveals dilated intrahepatic and extrahepatic bile ducts with no evidence of gallbladder involvement. The patient's symptoms and diagnostic tests are consistent with acute cholangitis without obstruction. There are no signs of acute or chronic cholecystitis. The patient is hemodynamically stable and responsive to initial supportive treatment. The patient is started on intravenous antibiotics, fluid resuscitation, and pain management. Close monitoring of vital signs and liver function tests is initiated. The patient showed significant improvement with treatment and was discharged with oral antibiotics and instructions for outpatient follow-up to discuss the need for further management of bile duct stones. 54 Female Caucasian ICD Code: K8032

The patient has a history of recurrent episodes of biliary colic and previously diagnosed with asymptomatic bile duct calculi. The patient presents with severe right upper quadrant abdominal pain radiating to the back, associated with fever and jaundice. Ultrasound and MRCP confirmed the presence of a 1.5 cm bile duct stone causing obstruction and evidence of acute cholangitis. Calculus of bile duct with acute cholangitis with obstruction (K8033): The presence of a bile duct stone causing obstruction and acute cholangitis with characteristic symptoms and imaging findings. The patient is in significant discomfort due to the obstructive bile duct calculus and is showing signs of systemic inflammation. Urgent intervention is required to relieve the obstruction and treat the cholangitis. The patient underwent endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy and stone extraction. Antibiotics were initiated to manage the cholangitis, and the patient's symptoms improved post-procedure. The patient was discharged in stable condition with resolved cholangitis and advised to follow up for a cholecystectomy to prevent future episodes of calculus formation. 56 Female Caucasian ICD Code: K8033

The patient has a history of intermittent right upper quadrant abdominal pain and occasional episodes of nausea. The patient presents with sharp pain in the upper right side of the abdomen, especially after meals. No fever, jaundice, or generalized itching reported. Abdominal ultrasound shows the presence of gallstones in the gallbladder and bile duct without signs of inflammation or obstruction. Calculus of bile duct with cholecystitis, unspecified, without obstruction. The patient presents with right upper quadrant abdominal pain, and imaging reveals gallstones in the gallbladder and bile duct without signs of inflammation or obstruction. The patient's symptoms and imaging findings are consistent with the diagnosis of Calculus of bile duct with cholecystitis without obstruction. No evidence of acute cholecystitis, chronic cholecystitis, or cholangitis. The patient is advised to follow a low-fat diet, increase fluid intake, and take over-the-counter pain medication for symptom management. Surgical consultation for possible cholecystectomy is recommended. The patient's symptoms improved with conservative management. Discharged home with instructions for follow-up with a surgeon for further evaluation of the gallstones. 56 Female Caucasian ICD Code: K8040

The patient has a history of recurrent episodes of right upper quadrant abdominal pain and a previous diagnosis of cholelithiasis. The patient presents with severe right upper quadrant abdominal pain, fever, and jaundice. Ultrasound shows multiple calculi in the common bile duct with associated cholecystitis. Blood tests reveal elevated liver enzymes. Calculus of bile duct with cholecystitis, unspecified, with obstruction. Verbatim EHR quote justifying the code: 'Ultrasound demonstrated multiple calculi in the common bile duct along with findings suggestive of cholecystitis and laboratory results showing elevated liver enzymes.' The patient is experiencing obstructive jaundice secondary to the common bile duct obstruction. Urgent intervention is needed to relieve the obstruction and treat the cholecystitis. The patient was started on intravenous antibiotics, fluid resuscitation, and scheduled for endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy and stone extraction. Following the ERCP procedure, the patient showed improvement in symptoms, with resolution of jaundice and pain. The patient was discharged home with oral antibiotics and advised to follow up with the gastroenterologist in two weeks. 58 Female Caucasian ICD Code: K8041

The patient has a history of recurrent episodes of biliary colic and intermittent right upper quadrant abdominal pain. No prior history of cholecystitis or bile duct issues. The patient presents with severe right upper quadrant abdominal pain radiating to the back, associated with nausea and vomiting. Physical examination reveals tenderness in the right upper quadrant. Ultrasound shows the presence of gallstones in the gallbladder and a stone impacted in the cystic duct causing dilation of the common bile duct. Calculus of bile duct with acute cholecystitis with obstruction Patient is diagnosed with Calculus of bile duct with acute cholecystitis with obstruction based on symptoms, physical examination, and imaging findings. No signs of cholangitis or chronic cholecystitis observed. The patient was started on intravenous antibiotics and fluids. An urgent endoscopic retrograde cholangiopancreatography (ERCP) was performed to remove the obstructing stone. The patient responded well to treatment, with resolution of symptoms. Discharged home with oral antibiotics and advised to follow up with a gastroenterologist for further management. 58 Female Caucasian ICD Code: K8043

The patient has a history of recurrent episodes of right upper quadrant abdominal pain, especially after fatty meals, suggestive of chronic cholecystitis. No history of acute cholecystitis or acute pancreatitis. The patient presents with chronic right upper quadrant abdominal pain radiating to the back, associated with nausea and occasional vomiting. No fever, jaundice, or signs of acute infection. Ultrasound shows multiple calculi in the common bile duct with associated dilatation. Liver function tests indicate mild elevation of liver enzymes due to chronic inflammation. Calculus of bile duct with chronic cholecystitis with obstruction. The presence of multiple calculi in the bile duct, chronic cholecystitis symptoms, and bile duct dilatation on imaging support this diagnosis. The patient's symptoms and imaging findings are consistent with chronic cholecystitis and bile duct obstruction. No signs of acute infection or pancreatitis. Plan for endoscopic retrograde cholangiopancreatography (ERCP) to remove the stones. The patient was started on Ursodeoxycholic acid to dissolve the stones and scheduled for an elective ERCP procedure for stone extraction. The patient responded well to treatment and had no complications post-ERCP. Discharged with instructions for a low-fat diet and follow-up in the outpatient clinic in two weeks. 56 Female Caucasian ICD Code: K8045

The patient has a history of recurrent episodes of right upper quadrant abdominal pain and discomfort after fatty meals over the past year. The patient presents with severe right upper quadrant abdominal pain radiating to the back, nausea, and vomiting. Ultrasound shows multiple calculi in the bile duct with associated gallbladder wall thickening and pericholecystic fluid collection. Liver function tests indicate mild elevation of liver enzymes. Calculus of bile duct with acute and chronic cholecystitis with obstruction. The presence of multiple calculi in the bile duct, gallbladder wall thickening, pericholecystic fluid collection, and elevated liver enzymes support the diagnosis of K8047. The patient's symptoms and imaging findings are consistent with a diagnosis of acute and chronic cholecystitis with obstruction due to bile duct calculi. Urgent intervention is required to relieve the obstruction and prevent complications such as cholangitis or pancreatitis. The patient is scheduled for an endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy and stone extraction. Antibiotics and analgesics are initiated to manage the infection and pain. Surgical consultation for possible cholecystectomy is planned post-stabilization. The patient responded well to the ERCP procedure with successful stone extraction. Symptoms improved post-procedure, and the patient is discharged with a plan for close follow-up to assess the need for elective cholecystectomy. 56 Female Caucasian ICD Code: K8047

The patient has a history of recurrent episodes of biliary colic but no prior history of cholangitis or cholecystitis. The patient presents with intermittent right upper quadrant abdominal pain, especially after fatty meals. No fever, jaundice, or signs of infection are reported. Abdominal ultrasound shows the presence of a solitary 1.2 cm calculus in the common bile duct without any signs of inflammation or obstruction. Calculus of bile duct without cholangitis or cholecystitis without obstruction. Verbatim EHR quote justifying the code: 'Patient presents with a solitary 1.2 cm calculus in the common bile duct without any signs of cholangitis or cholecystitis.' On examination, there are no signs of jaundice, abdominal tenderness, or fever. The patient's vital signs are stable, and there are no systemic signs of infection. The patient is started on Ursodeoxycholic acid to help dissolve the bile duct calculus. A follow-up appointment is scheduled for repeat imaging to monitor the resolution of the calculus. The patient responded well to medical management, with a significant reduction in abdominal pain. Discharged home with instructions to continue Ursodeoxycholic acid and return for follow-up imaging in four weeks. 56 Female Caucasian ICD Code: K8050

The patient has a history of recurrent episodes of upper abdominal pain and discomfort after fatty meals. The patient presents with severe upper abdominal pain radiating to the back, associated with nausea and vomiting. Ultrasound shows a 1.5 cm stone in the common bile duct with mild dilation of the intrahepatic bile ducts. Calculus of bile duct without cholangitis or cholecystitis with obstruction. Verbatim EHR quote justifying the code: 'Calculus of bile duct without evidence of cholangitis or cholecystitis with obstructive jaundice.' The patient is experiencing obstructive jaundice due to the stone in the common bile duct. No signs of acute cholangitis or cholecystitis are noted. The patient is scheduled for endoscopic retrograde cholangiopancreatography (ERCP) with stone extraction. The patient underwent successful ERCP with stone removal and is recovering well. Discharge instructions include a low-fat diet and follow-up with the gastroenterologist in two weeks. 58 Female Caucasian ICD Code: K8051

The patient has a history of occasional indigestion but no prior gallbladder issues. The patient presented with sudden onset right upper quadrant abdominal pain, tenderness, fever, and elevated white blood cell count. Ultrasound showed gallbladder calculi without any signs of obstruction. Calculus of gallbladder and bile duct with acute cholecystitis without obstruction. Verbatim EHR quote justifying the code: 'Patient presents with right upper quadrant abdominal pain, tenderness, fever, and elevated white blood cell count. Ultrasound revealed gallbladder calculi without any signs of obstruction.' The physician noted the classic signs of acute cholecystitis without any signs of chronicity or obstruction. The patient was started on intravenous antibiotics and scheduled for a laparoscopic cholecystectomy. The patient responded well to treatment, and after surgery, was discharged home in stable condition. 56 Female Caucasian ICD Code: K8062

The patient has a history of recurrent abdominal pain, especially after consuming fatty meals. No history of pancreatitis, hepatitis, or other significant gastrointestinal issues. The patient presents with severe right upper quadrant abdominal pain radiating to the back, accompanied by nausea and vomiting. Positive Murphy's sign is noted on physical examination. Laboratory tests show elevated liver enzymes (AST, ALT) and a marked increase in white blood cell count. Abdominal ultrasound reveals gallbladder distension with thickened walls and a visible stone impacted in the cystic duct causing obstruction. Calculus of gallbladder and bile duct with acute and chronic cholecystitis with obstruction. The presence of a visible stone causing obstruction in the cystic duct aligns with the diagnostic criteria for ICD-10-CM code K8067. The patient's symptoms, physical exam findings, and diagnostic test results are consistent with acute and chronic cholecystitis with obstruction due to a stone in the cystic duct. The patient is scheduled for urgent cholecystectomy to address the obstruction and inflammation. The patient is started on intravenous fluids, antibiotics, and pain management. Surgical consultation for cholecystectomy is obtained, and the patient is prepared for surgery. 58 Female Caucasian ICD Code: K8067

The patient has a history of occasional episodes of mild indigestion but no prior history of gallbladder or bile duct issues. The patient presented with intermittent episodes of sharp, colicky right upper quadrant abdominal pain radiating to the back. No fever, nausea, vomiting, or jaundice reported. Abdominal ultrasound revealed multiple calculi in the gallbladder and common bile duct without signs of inflammation or obstruction. Calculi of gallbladder and bile duct without cholecystitis without obstruction. Verbatim EHR quote justifying the code: 'Abdominal ultrasound confirmed the presence of multiple calculi in the gallbladder and common bile duct without evidence of cholecystitis or obstruction.' The patient denies any recent fevers, chills, or worsening abdominal pain. No Murphy's sign elicited on physical examination. Laboratory tests showed normal white blood cell count and liver function tests. The patient was started on ursodeoxycholic acid to help dissolve the calculi. Symptomatic management with analgesics was provided for pain relief. The patient responded well to treatment with resolution of abdominal pain. Discharged home with instructions for dietary modifications and follow-up in the outpatient clinic in two weeks. 45 Female Caucasian ICD Code: K8070

The patient has a history of occasional episodes of biliary colic. The patient presents with severe right upper quadrant abdominal pain, fever, and nausea. Ultrasound shows gallbladder wall thickening without evidence of gallstones. Acute cholecystitis without obstruction Patient exhibits Murphy's sign and has elevated white blood cell count. The patient was started on intravenous antibiotics and scheduled for a cholecystectomy. The patient responded well to treatment and was discharged home in stable condition. 56 Female Caucasian ICD Code: K810

The patient has a history of occasional episodes of mild upper abdominal discomfort after fatty meals over the past year. No previous history of gallbladder disease or cholelithiasis. The patient presents with mild epigastric pain, bloating, and nausea. No fever, jaundice, or signs of acute inflammation. Abdominal ultrasound reveals distension of the gallbladder without evidence of gallstones or wall thickening. Normal liver function tests. Hydrops of gallbladder without cholecystitis or cholelithiasis. The patient's symptoms and imaging findings are consistent with Hydrops of the gallbladder. No signs of acute cholecystitis or cholelithiasis. Recommend conservative management. Prescribed a low-fat diet, oral hydration, and follow-up in two weeks for reassessment. The patient's symptoms improved with conservative management. Advised to continue the low-fat diet. No surgical intervention required at this time. 47 Female Caucasian ICD Code: K821

The patient has a history of recurrent episodes of biliary colic and gallstones for the past two years. The patient presented with sudden and severe abdominal pain localized in the right upper quadrant, radiating to the back and right shoulder. The pain worsened upon movement or palpation. Abdominal ultrasound revealed free fluid in the peritoneal cavity and a collapsed gallbladder, indicative of perforation. Perforation of gallbladder The patient's symptoms, coupled with the diagnostic findings of free fluid and a collapsed gallbladder on ultrasound, confirm the diagnosis of gallbladder perforation. The patient underwent emergency laparoscopic cholecystectomy to remove the perforated gallbladder and received intravenous antibiotics for postoperative infection prevention. The patient recovered well post-surgery without complications and was discharged in stable condition. 56 Female Caucasian ICD Code: K822

The patient has a history of recurrent episodes of biliary colic and chronic cholecystitis. The patient presents with right upper quadrant abdominal pain, fever, and jaundice. Ultrasound shows a distended gallbladder with evidence of a fistulous connection to the adjacent duodenum. Fistula of gallbladder (ICD-10-CM code K823): A fistulous connection between the gallbladder and the duodenum, confirmed by imaging studies. The patient's symptoms and diagnostic tests are consistent with a fistula of the gallbladder. No evidence of cholelithiasis, cholecystitis, or other gallbladder diseases. The patient underwent a laparoscopic cholecystectomy to remove the gallbladder and repair the fistulous tract. Antibiotics were administered to treat the infection. The patient recovered well post-surgery and was discharged with instructions for follow-up care and monitoring of liver function tests. 56 Female Caucasian ICD Code: K823

The patient has a history of intermittent right upper quadrant abdominal pain and occasional indigestion over the last few months. The patient presents with sharp, episodic pain in the right upper abdomen, especially after consuming fatty meals. No fever, jaundice, or vomiting reported. Abdominal ultrasound shows gallbladder wall thickening without gallstones. Liver function tests are within normal limits. Disease of gallbladder, unspecified (ICD-10-CM code K829): The patient presents with episodic right upper quadrant abdominal pain, gallbladder wall thickening on ultrasound, and normal liver function tests. The patient's symptoms and imaging findings are consistent with gallbladder pathology. Given the absence of specific features for acute or chronic cholecystitis, the diagnosis of unspecified gallbladder disease is appropriate. The patient is advised to follow a low-fat diet and is prescribed pain management. Cholecystectomy is considered if symptoms persist. The patient responded well to pain management and dietary changes. Discharged home with instructions for follow-up if symptoms worsen. 54 Female Caucasian ICD Code: K829

The patient has a history of intermittent right upper quadrant abdominal pain and was diagnosed with acute cholecystitis two days ago. The patient presents with sudden onset severe abdominal pain, rebound tenderness, guarding, and signs of peritonitis. Abdominal ultrasound shows evidence of gallbladder perforation with pericholecystic fluid and air in the biliary tree. Perforation of gallbladder in cholecystitis is present, with evidence of rupture in the gallbladder wall and pericholecystic fluid. The patient meets the criteria for ICD-10-CM code K82A2. Patient is stable but requires urgent surgical intervention for cholecystectomy to address the perforation and prevent further complications. The patient was taken for emergency laparoscopic cholecystectomy. Intravenous antibiotics and analgesics were administered postoperatively. The patient recovered well post-surgery without any immediate complications and was discharged home with a plan for follow-up in the surgical outpatient clinic in two weeks. 58 Female Caucasian ICD Code: K82A2

The patient has a history of autoimmune disorders, including ulcerative colitis. The patient presents with fatigue, pruritus, jaundice, and right upper quadrant abdominal pain. Liver function tests show elevated alkaline phosphatase and bilirubin levels. MRCP reveals multifocal strictures and beading of the intrahepatic and extrahepatic bile ducts. Primary sclerosing cholangitis (K83.01): The patient presents with fatigue, pruritus, jaundice, and right upper quadrant abdominal pain. MRCP shows multifocal strictures and beading of the intrahepatic and extrahepatic bile ducts. The patient's symptoms and imaging findings are consistent with primary sclerosing cholangitis. No evidence of acute cholecystitis or gallbladder pathology. Ursodeoxycholic acid for symptom management, referral to a hepatologist for further evaluation and management. The patient was discharged with close follow-up with the hepatologist for ongoing management of primary sclerosing cholangitis. 45 Male Caucasian ICD Code: K83.01

The patient has a history of recurrent episodes of abdominal pain and jaundice. The patient presents with severe right upper quadrant abdominal pain, fever, and yellowing of the skin. Laboratory tests indicate elevated liver enzymes (AST and ALT). Abdominal ultrasound shows dilation of the bile ducts. Other cholangitis (ICD-10-CM code K8309) - The patient presents with severe right upper quadrant abdominal pain, fever, and jaundice. Laboratory tests indicate elevated liver enzymes and imaging studies show dilation of the bile ducts. The patient is likely suffering from Other cholangitis, a condition characterized by inflammation of the bile ducts. Immediate treatment is necessary to prevent complications. The patient will be started on intravenous antibiotics and scheduled for an endoscopic retrograde cholangiopancreatography (ERCP) to relieve the bile duct obstruction. The patient responded well to treatment, and symptoms resolved. Discharged home with a course of oral antibiotics and advised to follow up with the gastroenterologist in two weeks. 56 Female Caucasian ICD Code: K8309

The patient has a history of gallstones and recurrent episodes of abdominal pain after meals. The patient presents with severe right upper quadrant abdominal pain, jaundice, and dark urine. Abdominal ultrasound shows dilatation of the bile ducts and a common bile duct stone. Obstruction of bile duct (K831): The presence of a common bile duct stone causing obstruction is consistent with the patient's symptoms and diagnostic test results. The patient's symptoms and imaging findings are indicative of a common bile duct stone obstructing the bile duct, leading to biliary colic and jaundice. The patient underwent endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy and stone extraction. Subsequently, the patient's symptoms improved, and liver function tests normalized. The patient was discharged in stable condition with recommendations for a low-fat diet and follow-up with the gastroenterologist in two weeks. 56 Female Caucasian ICD Code: K831

The patient has a history of chronic cholecystitis and recurrent episodes of biliary colic. The patient presented with right upper quadrant abdominal pain, jaundice, and weight loss. Imaging studies revealed a contrast-enhanced MRI showing a fistulous tract between the bile duct and the duodenum. Fistula of bile duct (K833): The fistulous communication between the bile duct and the duodenum is clearly documented on imaging studies. The patient's symptoms and imaging findings are consistent with a bile duct fistula, and there is no evidence of gallbladder involvement. The patient was started on antibiotics and scheduled for endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy. The patient responded well to treatment, and there were no complications post-ERCP. Discharged home with a follow-up appointment in two weeks. 58 Female Caucasian ICD Code: K833

The patient has a history of recurrent episodes of right upper quadrant abdominal pain, especially after consuming fatty meals. No history of alcohol abuse or recent illness. The patient presents with sharp, intermittent pain in the right upper abdomen, which radiates to the back. No fever, jaundice, or generalized abdominal tenderness noted. Abdominal ultrasound shows sludge in the common bile duct without evidence of gallstones. Liver function tests are within normal limits. Other specified diseases of biliary tract (ICD-10-CM code K838): The patient presents with recurrent right upper quadrant abdominal pain, sludge in the common bile duct on imaging, and normal liver function tests. The patient's symptoms and imaging findings are consistent with a diagnosis of other specified diseases of the biliary tract. No signs of acute cholecystitis, cholangitis, or pancreatitis observed. The patient is advised to follow a low-fat diet and is prescribed Ursodeoxycholic acid to help dissolve the sludge in the common bile duct. Follow-up ultrasound in 6 weeks is recommended. The patient's symptoms improved with conservative management. Discharged home with dietary recommendations and medication. Follow-up scheduled in the outpatient clinic in 6 weeks. 56 Female Caucasian ICD Code: K838

The patient has no history of gallbladder disease, alcohol abuse, drug use, or biliary tract issues. The patient presented with sudden onset severe abdominal pain radiating to the back, nausea, and vomiting. Amylase and lipase levels were significantly elevated. Abdominal ultrasound and CT scan showed characteristic findings of acute pancreatitis without evidence of necrosis or infection. Idiopathic acute pancreatitis without necrosis or infection. The patient's presentation is consistent with idiopathic acute pancreatitis without any identifiable cause. The patient denies any history of alcohol consumption, gallstones, recent medication use, or biliary issues. Physical examination revealed epigastric tenderness with no signs of jaundice or gallbladder abnormalities. The patient was kept nil per os, received intravenous fluids, pain management, and was closely monitored for any signs of complications. The patient responded well to treatment, with resolution of symptoms and normalization of pancreatic enzyme levels. Discharged home with instructions for a low-fat diet and follow-up with the primary care physician in one week. 45 Female Caucasian ICD Code: K8500

The patient has a history of gallstones and biliary tract issues. The patient presents with severe abdominal pain, jaundice, and elevated amylase and lipase levels. CT scan shows evidence of pancreatic necrosis without signs of infection. Biliary acute pancreatitis with uninfected necrosis. Patient shows typical signs of biliary acute pancreatitis with uninfected necrosis, responding well to treatment. The patient was treated with pain management, IV fluids, and antibiotics to prevent secondary infection. The patient responded well to treatment and was discharged with instructions for follow-up care. 58 Female Caucasian ICD Code: K8511

The patient has a history of chronic alcohol abuse. The patient presented with severe abdominal pain radiating to the back, nausea, and vomiting. Laboratory tests showed elevated serum amylase and lipase levels. Abdominal CT scan revealed necrotic areas in the pancreas without signs of infection. Alcohol-induced acute pancreatitis with uninfected necrosis (K8521) Patient reports a recent binge drinking episode. Physical examination revealed epigastric tenderness with no signs of jaundice. The imaging findings are consistent with alcohol-induced acute pancreatitis with uninfected necrosis. The patient was kept nil per os, received intravenous fluids, pain management, and was closely monitored for any signs of infection. The patient responded well to treatment, with a gradual improvement in symptoms and normalization of pancreatic enzyme levels. Discharged with recommendations for alcohol cessation and follow-up with a gastroenterologist. 45 Male Caucasian ICD Code: K8521

The patient has a history of gallstones but no history of alcohol abuse or recent medication changes. The patient presents with severe abdominal pain radiating to the back, elevated serum lipase levels, and no signs of biliary obstruction. CT scan shows evidence of acute pancreatitis with necrosis but no signs of biliary or alcohol-induced pancreatitis. Other acute pancreatitis with uninfected necrosis (K8581) The patient's symptoms, lab results, and imaging findings are consistent with a diagnosis of Other acute pancreatitis with uninfected necrosis. The patient was started on IV fluids, pain management, and close monitoring of pancreatic enzymes. The patient responded well to treatment and was discharged with instructions for a low-fat diet and follow-up with a gastroenterologist in two weeks. 56 Female Caucasian ICD Code: K8581

The patient has a history of occasional alcohol consumption but no history of chronic alcohol abuse, biliary diseases, or recent medication changes. The patient presented with acute onset severe epigastric pain radiating to the back, nausea, and vomiting. No history of jaundice, recent alcohol binge, or new medications. Amylase and lipase levels were significantly elevated. Abdominal ultrasound showed pancreatic enlargement without evidence of necrosis or fluid collections. Acute pancreatitis without necrosis or infection, unspecified (K85.90) The patient's symptoms, elevated pancreatic enzymes, and imaging findings are consistent with acute pancreatitis. No evidence of biliary, alcohol-induced, or drug-induced etiologies. The patient was kept nil per os, received intravenous fluids, pain management, and was closely monitored for signs of complications. The patient responded well to treatment, with a gradual improvement in symptoms and normalization of pancreatic enzymes. Discharged in stable condition with instructions for a low-fat diet and follow-up with a gastroenterologist in two weeks. 45 Male Caucasian ICD Code: K85.90

The patient has a history of occasional alcohol consumption but denies excessive or binge drinking. No history of drug use. The patient presented with severe abdominal pain radiating to the back, nausea, and vomiting. Amylase and lipase levels were significantly elevated. Abdominal CT scan showed evidence of acute pancreatitis with areas of necrosis but no signs of infection. Acute pancreatitis with uninfected necrosis, unspecified (K8591): The patient presents with severe abdominal pain, elevated pancreatic enzymes, and imaging evidence of necrosis without signs of infection. The patient's symptoms and test results are consistent with a diagnosis of acute pancreatitis with uninfected necrosis. No signs of alcohol intoxication or drug use were noted. The patient was kept NPO, received intravenous fluids, pain management, and was closely monitored for any signs of complications. The patient responded well to treatment, pain subsided, and pancreatic enzyme levels normalized. Discharged with instructions for a low-fat diet and to avoid alcohol. 45 Male Caucasian ICD Code: K8591

The patient has a history of alcohol use disorder and recurrent episodes of acute pancreatitis. The patient presents with severe abdominal pain radiating to the back, nausea, vomiting, and fever. Laboratory tests show elevated amylase and lipase levels. Imaging studies reveal infected necrosis of the pancreas. Acute pancreatitis with infected necrosis, unspecified. The patient has acute pancreatitis with infected necrosis of the pancreas, supporting the assignment of ICD-10-CM code K85.92. The patient's condition is consistent with acute pancreatitis with infected necrosis, requiring immediate intervention to prevent complications. The patient is admitted for bowel rest, intravenous fluids, pain management, and broad-spectrum antibiotics. Surgical consultation for possible drainage is planned. The patient responded well to treatment and drainage procedures. Discharged home with close follow-up for further evaluation. 45 Male Caucasian ICD Code: K85.92

The patient has a history of chronic alcohol abuse for the past 10 years. The patient presents with recurrent abdominal pain radiating to the back, steatorrhea, and unintentional weight loss. Amylase and lipase levels are mildly elevated. Abdominal ultrasound shows calcifications in the pancreas. Alcohol-induced chronic pancreatitis (ICD-10-CM code K860) Patient reports a significant history of alcohol abuse, which is a known risk factor for chronic pancreatitis. Imaging and lab results support the diagnosis of chronic pancreatitis rather than an acute episode. The patient is advised to abstain from alcohol. Enzyme replacement therapy and pain management are initiated. The patient's symptoms have improved with treatment. Discharge instructions include a referral to a gastroenterologist for further management of chronic pancreatitis. 45 Male Caucasian ICD Code: K860

The patient has a history of recurrent abdominal pain, especially after meals, and unintentional weight loss over the past few months. The patient presents with chronic abdominal pain, oily and foul-smelling stools, and steatorrhea. Amylase and lipase levels are within normal limits. Stool tests reveal fat malabsorption. Exocrine pancreatic insufficiency due to other specified diseases of pancreas. The patient has classic symptoms of exocrine pancreatic insufficiency, including chronic abdominal pain and steatorrhea. Diagnostic tests confirm fat malabsorption, supporting the diagnosis of other specified diseases of the pancreas. The patient is started on pancreatic enzyme replacement therapy to aid in fat digestion and absorption. Dietary counseling is provided to optimize nutrient absorption. The patient responded well to treatment and is advised to continue pancreatic enzyme replacement therapy. Follow-up appointment scheduled in one month for reevaluation. 52 Female Caucasian ICD Code: K868

The patient has a history of chronic pancreatitis diagnosed two years ago. The patient presents with steatorrhea, weight loss, and abdominal discomfort. Fecal elastase-1 levels are significantly decreased, confirming the diagnosis of exocrine pancreatic insufficiency. Exocrine pancreatic insufficiency (EPI) as evidenced by the history of chronic pancreatitis, steatorrhea, weight loss, and decreased fecal elastase-1 levels. The patient reports oily, foul-smelling stools and unintentional weight loss over the past few months, consistent with EPI. Physical examination shows no signs of acute pancreatitis or other acute abdominal conditions. The patient is started on pancreatic enzyme replacement therapy and scheduled for nutritional counseling. The patient responded well to treatment and was discharged with instructions to continue pancreatic enzyme replacement therapy and follow up with the gastroenterologist in two weeks. 45 Male Caucasian ICD Code: K86.81

The patient has a history of recurrent abdominal pain and occasional episodes of mild pancreatitis-like symptoms over the past year. The patient presents with persistent upper abdominal pain, radiating to the back, and worsened after meals. No fever, nausea, vomiting, or jaundice reported. Amylase and lipase levels are within normal limits. Abdominal ultrasound shows no evidence of pancreatic necrosis or cystic lesions. Other specified diseases of pancreas (K8689): The patient presents with persistent upper abdominal pain, radiating to the back, without acute symptoms or evidence of necrosis on imaging studies. The patient denies alcohol abuse and has no history of chronic pancreatitis. Physical examination reveals tenderness in the epigastric region without signs of systemic illness. The patient is advised to follow a low-fat diet, stay hydrated, and take over-the-counter pain relievers as needed. Follow-up in two weeks for symptom reassessment. The patient's symptoms improved with conservative management. Discharged home with instructions to return if pain worsens or new symptoms develop. 45 Female Caucasian ICD Code: K8689

The patient has a history of recurrent abdominal pain, bloating, and diarrhea after consuming gluten-containing foods. There is no history of chronic pancreatitis, cysts, or other pancreatic diseases. The patient presents with symptoms of abdominal pain, bloating, diarrhea, and fatigue following gluten ingestion. There are no symptoms suggestive of acute or chronic pancreatitis, cysts of the pancreas, or other pancreatic disorders. Celiac serology tests including anti-tissue transglutaminase (anti-tTG) and anti-endomysial antibodies are negative. Genetic testing for HLA-DQ2 and HLA-DQ8 is pending. Imaging studies show no signs of pancreatic abnormalities. Non-celiac gluten sensitivity without celiac disease (ICD-10-CM code K90.41) - 'Non-celiac gluten sensitivity is characterized by both gastrointestinal and extraintestinal symptoms triggered by the ingestion of gluten-containing foods in individuals who do not have celiac disease.' The patient reports a clear association between gluten intake and the onset of symptoms. Physical examination reveals no signs of malabsorption or pancreatic insufficiency. The absence of positive celiac serology and imaging findings supports the diagnosis of Non-celiac gluten sensitivity. The patient is advised to follow a strict gluten-free diet. Referral to a dietitian for nutritional counseling and monitoring is recommended. Symptomatic treatment for abdominal discomfort and diarrhea is initiated. The patient responded well to the gluten-free diet and symptomatic management. Discharged home with instructions for dietary modifications and follow-up with the gastroenterology clinic in two weeks. 38 Female Caucasian ICD Code: K90.41

The patient has a history of chronic gastrointestinal complaints, including intermittent diarrhea and unexplained weight loss over the past few months. The patient presents with chronic diarrhea, abdominal bloating, fatigue, and muscle weakness. There are no symptoms suggestive of chronic pancreatitis, celiac disease, or postoperative complications. Laboratory tests reveal deficiencies in vitamin B12, iron, and folate levels, indicating malabsorption. Imaging studies do not show any significant abnormalities in the pancreas or signs of surgical interventions. Intestinal malabsorption, unspecified: The term 'malabsorption' indicates the inability of the intestine to absorb nutrients properly, leading to deficiencies. This aligns with the patient's symptoms and test results. The patient's symptoms of chronic diarrhea and weight loss, along with documented vitamin and mineral deficiencies, are consistent with a diagnosis of intestinal malabsorption. There are no findings or history suggestive of chronic pancreatitis, celiac disease, or postoperative complications. The patient is started on a regimen of vitamin and mineral supplements to address the deficiencies. Dietary modifications focusing on easy-to-digest foods and avoiding gluten-containing products are recommended. Upon discharge, the patient is stable with improving symptoms. Follow-up with a gastroenterologist is advised for further evaluation and management of the malabsorption syndrome. 45 Female Caucasian ICD Code: K909

The patient has a history of gastrointestinal surgery for the treatment of a peptic ulcer. The patient presents with persistent vomiting after the recent gastrointestinal surgery. Laboratory tests showed no signs of infection or electrolyte imbalances. Abdominal ultrasound revealed no abnormalities post-surgery. Vomiting following gastrointestinal surgery. Verbatim_EHR_quote_justifying_the_code: "Patient presents with persistent vomiting following recent gastrointestinal surgery." The patient reports frequent episodes of vomiting after meals, with no associated abdominal pain or fever. The surgical site appears to be healing well without signs of infection. The patient was started on antiemetic medication to help alleviate the vomiting episodes. Encouraged to maintain adequate hydration and follow a light diet. The patient's vomiting episodes have reduced in frequency and severity. Discharged home with instructions to continue antiemetics and follow up with the surgical team if symptoms worsen. 56 Female Caucasian ICD Code: K910

The patient underwent gastric surgery in the past. Symptoms include chronic diarrhea, weight loss, and nutritional deficiencies. Laboratory tests show low levels of vitamin B12, iron, and fat-soluble vitamins. Postgastric surgery syndromes (K911): Malabsorption following gastric surgery. The patient presents with chronic diarrhea and weight loss, consistent with malabsorption syndromes following gastric surgery. Treatment includes vitamin supplementation, dietary modifications, and follow-up with a nutritionist. The patient responded well to treatment and was discharged with a plan for ongoing nutritional support and monitoring. 56 Female Caucasian ICD Code: K911

The patient has a history of laparoscopic cholecystectomy for gallstones five years ago. No other significant medical history reported. The patient presents with chronic diarrhea, bloating, and unintentional weight loss over the past six months. The stool appears oily and foul-smelling. Laboratory tests show low levels of fat-soluble vitamins (A, D, E, K) and an increased fecal fat content, consistent with malabsorption. Postsurgical malabsorption, not elsewhere classified The patient reports a history of gastrointestinal surgery, which can lead to malabsorption syndromes. Symptoms and diagnostic tests support the diagnosis of postsurgical malabsorption, characterized by chronic diarrhea, steatorrhea, and weight loss. The patient is started on pancreatic enzyme replacement therapy to aid in fat absorption. Dietary counseling for a low-fat, high-protein diet is initiated. The patient responded well to treatment and dietary modifications. Discharged with a follow-up appointment in one month for reevaluation of symptoms and nutritional status. 54 Female Caucasian ICD Code: K912

The patient underwent a recent laparoscopic cholecystectomy for symptomatic cholelithiasis. The patient presents with abdominal distension, crampy abdominal pain, and no passage of stool or flatus since the surgery. Abdominal X-ray shows dilated loops of small bowel with air-fluid levels consistent with obstruction. Postprocedural intestinal obstruction (ICD-10-CM code K913) - The patient presents with abdominal distension, crampy abdominal pain, and no passage of stool or flatus since the surgery. Abdominal X-ray shows dilated loops of small bowel with air-fluid levels consistent with obstruction. The patient's symptoms and imaging findings are consistent with a diagnosis of postprocedural intestinal obstruction. Surgery consult requested for further management. Nasogastric tube inserted for decompression. Intravenous fluids initiated, and the patient is kept nil per os. Close monitoring for signs of resolution or need for surgical intervention. 56 Female Caucasian ICD Code: K913

The patient underwent recent abdominal surgery for a perforated appendix. The patient presents with severe abdominal pain, bloating, nausea, and vomiting. No bowel movements or flatus since the surgery. Abdominal X-ray shows multiple air-fluid levels and distended loops of small bowel, consistent with bowel obstruction. Postprocedural intestinal obstruction, unspecified as to partial versus complete. Verbatim EHR quote justifying the code: 'Patient presents with symptoms of abdominal pain, distension, and absence of bowel movements post-surgery. Diagnostic tests reveal findings consistent with bowel obstruction.' Patient appears uncomfortable due to abdominal distension. Bowel sounds are hypoactive. Surgical site is clean and dry. Nasogastric tube inserted for decompression. IV fluids initiated. Close monitoring for signs of improvement or need for surgical intervention. The patient showed gradual improvement with decompression. Bowel movements resumed, and the patient was discharged with instructions for follow-up. 45 Female Caucasian ICD Code: K91.30

The patient has a history of laparoscopic appendectomy 5 days ago for acute appendicitis. The patient presents with crampy abdominal pain, bloating, and constipation since the appendectomy. Abdominal X-ray shows signs of partial small bowel obstruction with air-fluid levels. Postprocedural partial intestinal obstruction (ICD-10-CM code K9131): Verbatim_EHR_quote_justifying_the_code The patient's symptoms and imaging findings are consistent with a partial obstruction likely due to postoperative adhesions. The patient was managed conservatively with bowel rest, intravenous fluids, and close monitoring. Surgery was not required. The patient's symptoms improved significantly with conservative management, and he was discharged with instructions for gradual diet advancement and follow-up with the surgical team in one week. 42 Male Caucasian ICD Code: K9131

The patient has a history of gastroesophageal reflux disease (GERD) managed with proton pump inhibitors. The patient presented with acute abdominal pain, tenderness, and guarding following an endoscopic retrograde cholangiopancreatography (ERCP) procedure. Abdominal CT scan showed a puncture and laceration of the duodenum. Accidental puncture and laceration of a digestive system organ or structure during a digestive system procedure (ICD-10-CM code K9171): 'Accidental puncture and laceration of a digestive system organ or structure during a digestive system procedure.' The patient's symptoms and diagnostic imaging are consistent with an accidental puncture and laceration of the duodenum during the ERCP procedure. The patient was managed conservatively with bowel rest, intravenous fluids, and broad-spectrum antibiotics. The patient responded well to treatment, and the abdominal pain resolved. The patient was discharged home with instructions for a follow-up appointment in one week. 56 Female Caucasian ICD Code: K9171

The patient has a history of hypertension managed with medication. The patient presented with abdominal pain and tenderness following a recent laparoscopic appendectomy. Abdominal CT scan revealed a small puncture in the small bowel without signs of perforation. Accidental puncture and laceration of a digestive system organ or structure during other procedure. Verbatim EHR quote justifying the code: 'Accidental puncture and laceration of a digestive system organ or structure during a laparoscopic appendectomy.' The patient experienced sudden abdominal pain post-surgery, and imaging confirmed a small bowel puncture. No signs of infection or peritonitis were noted. The patient was started on intravenous antibiotics, and a surgical consult was obtained for possible repair of the bowel injury. The patient responded well to treatment, remained stable without signs of infection, and was discharged home with a scheduled follow-up appointment with the surgical team in one week. 46 Female Caucasian ICD Code: K9172

The patient has a history of gastroesophageal reflux disease (GERD) managed with proton pump inhibitors. No history of bleeding disorders or recent surgeries. The patient presented with sudden onset severe abdominal pain, hypotension, and tachycardia following a recent laparoscopic cholecystectomy. CT scan of the abdomen revealed active extravasation of contrast from a branch of the hepatic artery into the biliary tree, confirming the diagnosis of postprocedural hemorrhage. Postprocedural hemorrhage of a digestive system organ or structure following other procedure. Verbatim EHR quote justifying the code: 'CT scan confirmed active extravasation of contrast from a branch of the hepatic artery into the biliary tree, indicative of postprocedural hemorrhage.' The patient's vital signs stabilized after fluid resuscitation. Consulted with the interventional radiology team for embolization of the bleeding vessel. The patient was started on intravenous fluids and transfused with packed red blood cells. Interventional radiology performed successful embolization of the bleeding vessel. The patient remained stable post-procedure with no further episodes of bleeding. Discharged home with instructions for close follow-up with the surgical team. 56 Female Caucasian ICD Code: K91841

The patient underwent a total proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis 5 years ago. The patient presents with increased stool frequency, urgency, and abdominal cramps. Colonoscopy showed inflammation and ulceration in the pouch consistent with Pouchitis. Pouchitis (K91.850): Inflammation of the ileal pouch-anal anastomosis. The patient reports a history of Pouchitis flare-ups every few months with similar symptoms. Physical examination reveals tenderness in the lower abdomen. Prescribed a 2-week course of antibiotics (ciprofloxacin) and probiotics. Advised to follow a low-residue diet. Patient responded well to treatment and was discharged in stable condition with advice for follow-up in the outpatient clinic. 42 Female Caucasian ICD Code: K91.850

The patient has a history of cholecystectomy for gallstones. The patient presents with recurrent right upper quadrant abdominal pain and occasional nausea. Abdominal ultrasound shows retained gallstones in the common bile duct. Retained cholelithiasis following cholecystectomy. The patient has recurrent right upper quadrant abdominal pain and an ultrasound showing retained gallstones in the common bile duct. The patient shows symptoms consistent with retained gallstones following cholecystectomy. No signs of postcholecystectomy syndrome, hemorrhage, accidental puncture, hepatic failure, pouchitis, hematoma, seroma, or other postprocedural complications are present. The patient will undergo endoscopic retrograde cholangiopancreatography (ERCP) for stone extraction. The patient underwent a successful ERCP with stone removal and was discharged in stable condition. 58 Female Caucasian ICD Code: K9186

The patient has a history of peptic ulcers and gastroesophageal reflux disease (GERD). The patient presents with black, tarry stools for the past three days, associated with weakness and fatigue. Hemoglobin levels are decreased, and fecal occult blood test is positive. Melena (K921): The patient presents with black, tarry stools and positive fecal occult blood test, indicative of upper gastrointestinal bleeding. The patient denies any history of recent trauma, nonsteroidal anti-inflammatory drug (NSAID) use, or alcohol consumption that could explain the bleeding. Physical examination reveals stable vital signs. The patient is started on intravenous proton pump inhibitors (PPIs) and scheduled for an esophagogastroduodenoscopy (EGD) to identify the source of bleeding. 55 Female Caucasian ICD Code: K921

The patient has a history of Crohn's disease, which increases the risk of gastrointestinal mucositis. No history of pouchitis, cholecystectomy, or postprocedural complications. The patient presents with severe abdominal pain, bloody diarrhea, and weight loss. No symptoms of pouchitis, cholelithiasis, or postprocedural complications are reported. Colonoscopy shows diffuse inflammation and ulceration of the colonic mucosa. Biopsy confirms ulcerative mucositis. No evidence of pouchitis or retained cholelithiasis. Gastrointestinal mucositis (ulcerative) (K9281) - Ulcerative inflammation of the gastrointestinal mucosa. Patient reports worsening symptoms despite conservative management. Started on high-dose corticosteroids for induction therapy. Close monitoring for disease progression. 1. Prednisone 40mg orally daily. 2. Proton pump inhibitor for ulcer healing. 3. Nutritional support and diet modification. Patient discharged with close follow-up for tapering steroids and monitoring of symptoms. Advised on dietary restrictions and signs of disease exacerbation. 45 Female Caucasian ICD Code: K9281

The patient has a history of sigmoid colon cancer and underwent a colostomy procedure six months ago. The patient presents with abdominal distension, cramping abdominal pain, and absence of stool output from the colostomy for the past 24 hours. Abdominal X-ray shows dilated loops of the proximal colon with no evidence of obstruction. Colostomy output is minimal and dark in color. Colostomy malfunction: The patient presents with abdominal distension, cramping abdominal pain, and absence of stool output from the colostomy for the past 24 hours. The patient reports no history of recent dietary changes or medication adjustments that could explain the colostomy malfunction. Physical examination reveals tenderness on palpation around the colostomy site. The patient was started on bowel rest, intravenous fluids, and colostomy irrigation. Close monitoring of colostomy output and vital signs was initiated. The patient responded well to treatment, with the return of stool output from the colostomy and resolution of abdominal distension and pain. Discharged home with instructions for colostomy care and a follow-up appointment in one week. 64 Female Caucasian ICD Code: K9403

The patient has a history of ulcerative colitis necessitating a colostomy procedure. The patient presents with peristomal skin irritation and localized pain around the colostomy site. Stoma examination shows no signs of infection or necrosis. Stool output from the colostomy is within normal limits. Other complications of colostomy - The patient presents with peristomal skin irritation and localized pain around the colostomy site. The patient reports no signs of bleeding, no issues with stool output, and no signs of colostomy malfunction. The examination reveals localized erythema and tenderness around the colostomy, consistent with contact dermatitis. Treatment includes topical barrier creams for the skin irritation, proper stoma care education, and pain management. The patient's symptoms improved with treatment, and education on stoma care was provided before discharge. 56 Female Caucasian ICD Code: K9409

The patient has a history of Crohn's disease necessitating the creation of an enterostomy. The patient presents with abdominal distension, lack of stoma output, and mild discomfort around the stoma site. Abdominal X-ray shows no signs of obstruction. Stoma evaluation reveals poor effluent output and peristomal skin excoriation. Enterostomy malfunction: The enterostomy is not functioning properly, leading to abdominal distension and reduced stoma output. The patient reports a decrease in appetite but denies any signs of infection or bleeding. Stoma appears pink and moist, without redness or warmth. Treatment includes stoma care education, dietary modifications, and adjustment of enterostomy equipment. The patient will be closely monitored for improvement in stoma function. The patient's symptoms improved with intervention, and adequate stoma output was achieved before discharge. Instructions provided on stoma care and signs of malfunction to watch for at home. 57 Female Caucasian ICD Code: K9413

The patient has a history of inflammatory bowel disease necessitating the creation of an enterostomy. The patient reports abdominal discomfort and changes in stoma output consistency. CT scan shows no signs of abscess or perforation around the enterostomy site. Other complications of enterostomy (K9419): The patient presents with abdominal discomfort and changes in stoma output consistency. The patient's enterostomy site appears healthy without signs of infection or bleeding. No evidence of gastrointestinal bleeding or mucositis. Treatment includes local care of the enterostomy site, dietary modifications, and monitoring for any further changes. The patient was discharged in stable condition with instructions for follow-up with the gastroenterologist in two weeks. 56 Female Caucasian ICD Code: K9419

The patient has a history of dysphagia and neurological impairment, leading to the placement of a gastrostomy tube for enteral feeding. The patient presents with bright red blood in the stool and hematemesis. Vital signs are stable. Hemoglobin level is 9 g/dL, confirming anemia. Gastrointestinal endoscopy shows active bleeding from the gastrostomy site. Gastrostomy hemorrhage: Bright red blood in stool and hematemesis, with hemoglobin of 9 g/dL and active bleeding from the gastrostomy site. The patient is stable hemodynamically. Plan for conservative management with proton pump inhibitors and close monitoring for hemodynamic stability. Started on intravenous pantoprazole. Blood transfusion initiated for symptomatic anemia. Close monitoring of vital signs and hemoglobin levels. The patient responded well to treatment with resolution of bleeding. Discharged with gastrostomy care instructions and follow-up with the gastroenterologist in two weeks. 68 Male Caucasian ICD Code: K9421

The patient has a history of dysphagia and underwent a gastrostomy tube placement due to oropharyngeal dysphagia secondary to a stroke six months ago. The patient presents with abdominal pain, distension, and leakage of enteral feedings around the gastrostomy site. There is no evidence of hemorrhage, infection, or other complications related to colostomy, enterostomy, or other bariatric procedures. Abdominal X-ray shows no signs of bowel obstruction. Gastrostomy tube study reveals dislodgement of the tube from the stomach into the peritoneal cavity. Gastrostomy malfunction The patient's symptoms of abdominal pain, distension, and leakage of feedings are indicative of a gastrostomy malfunction. No signs of colostomy, enterostomy, or other bariatric procedure complications are present. The gastrostomy tube was repositioned endoscopically under fluoroscopic guidance. Enteral feedings were temporarily withheld, and the patient was started on intravenous fluids. Close monitoring for signs of peritonitis was initiated. The patient's symptoms improved post-repositioning of the gastrostomy tube. Enteral feedings were restarted without leakage. The patient was discharged with instructions for tube care and a follow-up appointment in two weeks. 72 Female Caucasian ICD Code: K9423