[System] You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings.

[User]
RADIOLOGY NOTE:
An 80-year-old man was found to have early gastric cancer during his yearly check-up by gastrointestinal endoscopy. He was 158 cm in height and weighed 62 kg. Gastrointestinal endoscopy showed a depressed lesion that was diagnosed as early gastric cancer by pathological examination of biopsy specimens. He underwent LADG with regional lymph node dissection (D1 including the nodes surrounding the origin of left gastric artery). A 12-mm trocar for the laparoscope was placed in the umbilicus. Pneumoperitoneum was then established with carbon dioxide and the intraperitoneal pressure was maintained at 10 mm Hg. Two more 12-mm trocars were inserted in the midclavicular line below the costal margin and 2 cm above the umbilicus on each of both flanks and were used for active surgical instruments. All trocars used were the non-bladed type. The specimen was removed through a small medial incision which was 55 mm in length placed after resection of the stomach, and then Roux-en-Y reconstruction (RY) was carried out (Fig. ). A tubular shaped drainage tube 10 mm in diameter was inserted and placed through the upper trocar site made on the right flank. Wound defect at the umbilical port site was sutured completely including the peritoneum with 0 absorbable suture and fascial incisions at all other trocar insertion sites were closed with 2-0 absorbable sutures. Surgical duration was 263 min, and the volume of blood loss was less than 50 mL with no blood transfusion.
Postoperatively, the patient complained of an acidic feeling in his stomach; however, there were no remarkable abnormalities on biochemical examination of serum. Radiological findings did not suggest bowel obstruction until 3 days postoperatively, although mild symptoms such as general malaise and vague abdominal pain were reported on day three. However, on day 4, the patient started to complain of upper abdominal pain and developed a high grade fever (38°C). Complete obstruction of the small bowel and leakage

[Assistant]
ICD-10-CM Coding based on findings:
Assign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing.


[System] You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings.

[User]
RADIOLOGY NOTE:
A 45-year-old male referred to Shahid Beheshti Maxillofacial Pathology Department with a two year history of generalized proliferative gingival maxillary lesions with palatal right side swelling and mandibular labially gingival lesions ().
The lesions were asymptomatic, without any bleeding or purulent discharge. The right submandibular lymph node was palpable and the patient noticed this swelling after the extraction of the third molar one month prior to his visit to our department. The gingivally lesions were red and soft with irregular surfaces, and the palatal swelling had a purple-gray appearance with intact overlying mucosa ().
Radiographic examination revealed a moderate bone loss similar to a periodontal disease.
Laboratory test results were normal, so the patient’s diagnosis was stated as inflammatory and reactive hyperplastic lesions.
The patient’s teeth were extracted. Only 2 maxillary central incisors were preserved for esthetic. Tissues needed for histopathologic evaluation were obtained from the gingivectomy of gingivally proliferative masses and with a full thickness flap from the palatal swelling.
Soft tissue specimens were fixed in 10% neutral buffered formalin and embedded in paraffin blocks. For standard pathological examination, the sections were prepared with H&E stain.
The slides of both gingival and palatal specimens showed a dense cellular infiltration under the epithelial layer in deeper portions.
The cells were mononuclear which showed pleomorphism with moderately amount of cytoplasm and round to oval nucleus with prominent nucleoli. These cells did not have a characteristic phenotype. Therefore, a series of differential diagnosis such as large cell lymphoma, plasmacytoma, poorly differentiated carcinoma and lymphoblastic leukemia was suggested (-).
For the final diagnosis, a panel of antibodies was applied using the Immunohistochemistry (IHC) method. The tumor cells were diffusely positive with antibodies against LCA, negative with CD20, C

[Assistant]
ICD-10-CM Coding based on findings:
Assign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing.


[System] You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings.

[User]
RADIOLOGY NOTE:
A 50-year-old male presented with 6 months of radiating pain and numb to right leg. Physical examination revealed a positive straight leg raising test at 40°on the right side. There was weakness of the ankle and great toe dorsiflexion (muscle strength graded IV and III, respectively). MRI revealed a herniated disc compressed on the right nerve root and right lateral recess stenosis at L4-5 (Fig. ). The surgical protocol was set as L4/5 PELD.
After the general anesthesia, the patient was placed in a prone position on a soft cushion for spinal surgery. C-arm fluoroscopy was used for anteroposterior and lateral view to ensure L4-5 intervertebral space. The position of the fluoroscope and the height of the operating table should be checked for convenience for the operating team. The patient was marked for puncture orientation and prepped and draped in standard sterile procedure. 0.5 wt% of lidocaine was used for local infiltration anesthesia around the skin, fascia, and the facet joint. Aided by C-arm fluoroscopy, a puncture needle is inserted into the intervertebral foramen of L4/5 by layers. The tip was confirmed in the anteroposterior position at the inner margin of the vertebral pedicle, while the lateral position was in the posterior and upper margin of vertebral pedicle of L5 (Fig. ). After the intraformational infiltration anesthesia was completed in the right intervertebral foramen, the guide wire was inserted along the puncture needle. A 7-mm cut was made in the center of the puncture point on the skin. The guide wire was inserted along a tapered cannulated dilator to enlarge surgical access, as well as an ongoing dialogue with the patient. The working sleeve was implanted along tapered cannulated dilator to separate the surrounding soft tissue (Fig. ), then the protective sleeve of trephine was also inserted. The soft tissue was expanded step by step using the protective sleeve until its tip was at

[Assistant]
ICD-10-CM Coding based on findings:
Assign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing.


[System] You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings.

[User]
RADIOLOGY NOTE:
A 12-year-old Saudi boy of Arab ethnicity, with no past relevant medical, surgical, family, or psychosocial history, presented to the King Saud Medical City emergency department with bleeding per rectum and mild abdominal pain 3 days after blunt abdominal trauma while playing football. On examination, his abdomen was slightly tender and bowel sounds were present. Initially, focused assessment with sonography for trauma (FAST) showed mild intraperitoneal fluid in his pelvis. A subsequent computed tomography (CT) scan of his abdomen revealed mild pelvic hemoperitoneum, but there was no definite solid or hollow visceral injury. So, he was admitted to the general ward for serial abdominal observation. On admission to the surgical ward, he was stable with a heart rate (HR) of 86 beats per minute (bpm) and blood pressure (BP) of 100/70 mmHg. His hemoglobin (Hb) was 9.6 gm/dl. We kept him nil per mouth and a nasogastric tube was inserted. The intake and output chart was regularly calculated. Serial Hb monitoring showed a continuous fall in his Hb level during the following days. He continued to have altered rectal bleeding. On day 3 his Hb dropped to 6.1 gm/dl, despite having received 2 units of packed red blood cells (PRBC). He started to develop a mild fever with a temperature of 37.8 °C, tachycardia with a HR of 140 bpm, and the BP dropping to 70/40 mmHg. He was resuscitated and stabilized with intravenously administered crystalloid fluids and 2 units of PRBC. He did not require any inotropes or vasopressors. Due to this clinical deterioration, he was urgently taken to the operating room for further diagnostic and therapeutic management. The nasogastric tube revealed bile without hematemesis. After initiating general anesthesia, an on-table colonoscopy was performed to identify the bleeding site. There was altered blood within the whole colon and terminal ileum without a definite bleeding site. Therefore, we proceeded to a laparotomy.

[Assistant]
ICD-10-CM Coding based on findings:
Assign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing.


[System] You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings.

[User]
RADIOLOGY NOTE:
A 54-year-old Caucasian female proceeded to our institution with epigastric pain, nausea and vomiting along with pain located around the lumbar area lasting for one week. No previous surgical history or commorbidities existed. Clinical examination did not reveal any palpable abdominal masses or abdominal tenderness and the patient’s vital signs were within the normal spectrum. Blood test detected hypercalcemia (serum calcium: 10.2 mg/dL) and parathyroid hormone level of 111.8 pg/mL. All the findings in conjunction with the clinical presentation lead to the assumption that the patient had primary hyperparathyroidism (PHPT).
Then, an ultrasound was performed but it was negative for any thyroid or parathyroid abnormalities. Subsequently, the thoracic and abdominal CT revealed a soft tissue in the anterior mediastinum 7 × 1 cm. Additional Tc-99m-MIBI scintigraphy followed, which detected an ectopic adenoma located in the lower anterior mediastinum, on the left of the median line (). Following these, a mid-sternal thoracotomy was finally scheduled.
During the operation, after the thoracotomy, surgeons attempted to detect deep into the mediastinum the parathyroid adenoma according to the preoparative localization. Indeed, the mediastinal mass was detected on the left of the median line, at the anterior mediastinum, in front of the anterior surface of the pericardium and close to the left pericardiophrenic vessels and the left phrenic nerve (). The adenoma was covered by a thin fibrous capsule. When surgeons removed the capsule, a dark red mass of 7 × 2.8 × 1 cm was finally revealed (Figs. and 4 ). The detailful preoperative localization of the present mediastinal adenoma which was in close relation with various anatomical structures of the thorax, reduced effectively the difficulty of the mass excision and the potentiality of accidental surgical injuries which may lead to thoracic bleeding and subsequent obstructive symptoms.
Then, the operation continued in the usual fas

[Assistant]
ICD-10-CM Coding based on findings:
Assign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing.


[System] You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings.

[User]
RADIOLOGY NOTE:
All patients in our case series were Caucasian male between 32 to 47 years old when the symptoms started (). However one patient presented to us at the age of 70 years and another at 61 years of age. All of our patients presented with slowly progressive ataxia and 2 had fall on multiple occasions. Only one person had family history of undiagnosed ataxia. All of them were referred by either the GP or the peripheral hospitals as the cause of their symptoms were unclear.
All of them demonstrated spasticity in the lower limbs. First three patients revealed some degree of horizontal ophthalmoplegia (). The third patient had asymmetric ptosis in addition to ophthalmoplegia. All of them had signs of cerebellar ataxia.
All 4 patients were subject to routine bloods, B12, folate, thyroid function test, copper, nerve conduction studies, etc. Then all had routine genetic testing for ataxia including spinocerebellar ataxia, Friedreich’s ataxia (Frataxin) Fragile X Associated Tremor/Ataxia syndrome (FRXTA) (). They subsequently had next generation sequencing of 21 gene panel for hereditary spastic paraparesis.
The Magnetic resonance imaging (MRI) showed some degree of cerebellar atrophy in first three patients. However the last patient had significant pan-cerebellar atrophy in MRI scan (). None of them showed any evidence of cord compression, demyelination or space occupying lesion in whole spine magnetic resonance imaging. The genetic screening for spinocerebellar ataxia (SCA 1,2,3 and 6) were negative for all. Patient 4 had additional testing for mutation in SCA 7 which turned out to be negative.
The next generation sequencing involving 21 genes in the spastic paraparesis panel revealed autosomal recessive hereditary spastic paraparesis due to the mutation in Spastic paraparesis 7 gene (SPG 7) in all of them with a novel mutation in one of them (). All these mutations were comfirmed by conventional Sanger sequencing.
All the patients were informed approximately their

[Assistant]
ICD-10-CM Coding based on findings:
Assign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing.


[System] You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings.

[User]
RADIOLOGY NOTE:
A 3.5-year-old girl was referred to pediatric neurology department with ataxia and dancing eye movements starting since 1.5 years ago. The patient was admitted for further evaluations. Initial laboratory workups including hematological and biochemical parameters were in normal range. The 24-hour urinary vanillin mandelic acid (VMA) concentration showed an increase. Imaging studies including chest and abdominal computed tomography (CT) scan revealed a tumoral lesion located in posterior mediastinum extending from T6 to T10. The patient was scheduled for thoracotomy and the mass was resected as much as possible.
Surgical specimens were submitted to the histopathologic laboratory. Microscopic evaluation was compatible with poor stroma, undifferentiated neuroblastoma. N-myc was amplified to more than 10 copy numbers using fluorescence in situ hybridization (FISH). Bone survey study was performed and show no abnormality. Bone marrow aspiration and whole body Tc-99 m was unremarkable and brain CT scan was normal.
Chemotherapy started referring to N6 protocol []. Within the first weeks following chemotherapy patient's symptoms and signs remarkably alleviated except opsoclonus-myoclonus syndrome which was the main complaint of the patient. It was planned to prescribe corticosteroids and clonazepam to treat the syndrome. After about 4 weeks, the debilitating problem for the patient was ataxia which showed no acceptable improvement. It was decided to prescribe intravenous immunoglobulin (IVIG) 1 g/Kg, monthly to improve ataxia and opsoclonus. After 2 courses of IVIG for 2 consecutive months, no obvious change was observed. Finally rituximab 375 mg/m2 as the last recognized option was considered to control patient's symptoms.
OMS Evaluation Scale was applied to evaluate clinical outcome of the patient as previously described []. A significant improvement in patient's ataxia and eye movements was observed after first dose of rituximab. About 3-4 weeks later the symptoms returne

[Assistant]
ICD-10-CM Coding based on findings:
Assign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing.


[System] You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings.

[User]
RADIOLOGY NOTE:
A 46-year-old woman (gravida 2, para 2) was referred to our hospital complaining of a lower abdominal mass and pain. Her medical history was unremarkable. She was initially diagnosed with a uterine leiomyoma by transcervical needle biopsy. CT revealed a large heterogeneous tumor occupying the pelvic cavity and an intravascular tumor within the dilated left internal iliac and ovarian veins (Figures and ). Her preoperative cervical cytology results were negative for intraepithelial lesions and malignancy. The endometrial cytology and needle biopsy results were also negative. Thus, the preoperative diagnosis was IVL, with extension of the tumor into the left internal iliac and ovarian veins.
Intraoperatively, multiple myomas were found within the uterine corpus and cervix, and the tumor extended to the parametrium and paracolpium. Detachment of the tumor from the left ureter and vaginal wall was very difficult. Intravenous tumors in the left internal iliac and ovarian veins could be palpated. The left internal iliac vein forming the common iliac vein was transected at the bifurcation region. In addition, TAH and bilateral salpingo-oophorectomy (BSO) were performed, resulting in the complete surgical resection of the tumor (operative time, 11 hours; blood loss, 8462 g). The resected uterus and adnexa weighed 897 g (Figures and ). There was no residual tumor detected in the venous resection stump.
The nodule resected from the uterus and the internal iliac and ovarian veins consisted of a proliferation of spindle cells. There was no nuclear atypia and the mitotic index was low. In addition, vessel endothelium cells and a vascular smooth muscle layer covered the IVL (Figures and ). The tumor cells stained positive for Alcian blue (pH = 2.5) and the staining disappeared after hyaluronidase digestion. However, compared to that in Case 1, the intensity of the staining was weaker and less diffuse (Figures and ). Similar findings for hyaluronan expression were obtained using th

[Assistant]
ICD-10-CM Coding based on findings:
Assign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing.


[System] You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings.

[User]
RADIOLOGY NOTE:
A 27-year-old woman, gravida 1 para 0, underwent the routine prenatal examinations in our hospital from 6 gestational weeks. Till 30 gestational weeks, the prenatal course was unremarkable, including systemic prenatal ultrasound diagnosis and the routine fetal cardiac screening (at 24 gestational weeks). Fetal growth was within the normal process and the alpha fetal protein was 23.91 U/ml (the normal reference value:0–25 U/ml).
At 30 gestational weeks, the B-mode ultrasound revealed that the liver of the fetus was enlarged with a heterogeneous solid mass located in the right quadrant of the fetal abdominal cavity, with a close relationship to the liver. The mass measured 5.8cmx4.7cmx5.2 cm and pushed the portal vein and gall bladder. The lesion seemed to have an ill-defined margin, irregular shape, partial capsule with multiple cystic cavities inside, and maximal diameter of 2.1 cm. The portal and hepatic veins were not dilated. In the color Doppler ultrasound, the mass appeared to be highly vascularized (Fig. ) and RI was 0.67. The three-dimensional power Doppler ultrasound showed the feeding vessels were mainly around the lesion but there were less vessels inside it (Fig. ). Due to the rapid enlargement of this mass and the imaging features of ultrasound, the diagnosis of HBL was highly considered. But IHH, mesenchymal hamartoma or other rare liver tumors such as hepatic cysts or adenomas could not be ruled out.
According to the pediatrician, the final diagnosis depended on the postnatal biopsy of the hepatic lesion and the prognosis of HBL was uncertain. Finally, the parents chose to give up this fetus because of the uncertain outcomes involving tremendous emotional and economic impacts on the family. Furthermore, they refused to take any further prenatal examination, like fetal MRI. A male fetus was aborted, weighing 1409 g and measuring 36 cm long.
Medical ethics committee of West China Second Hospital of S

[Assistant]
ICD-10-CM Coding based on findings:
Assign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing.


[System] You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings.

[User]
RADIOLOGY NOTE:
A 38-year-old female G4P1112 at 34-week and 1-day gestational age dated by last menstrual period presented to the outpatient clinic for her first obstetrical visit. She was referred for evaluation of a large vaginal mass by an outside provider over concern of potential malignancy. There were also vulvar lesions which were punch biopsied showing squamous vaginal mucosa with some reactive cellular changes. A transvaginal ultrasound detailed the presence of varicosities within the vaginal wall. The patient had no prior history of vaginal varicosities. Her obstetrics history was significant for 2 prior C-sections, 1 ectopic pregnancy, and diet-controlled gestational diabetes. The patient had been complaining for the past 2 months of yellow vaginal discharge, dysuria, and discomfort made worse with walking. She had been treated unsuccessfully with fluconazole for this pain in the past. Fetal anatomy survey at 26 weeks and 2 days demonstrated no maternal anomalies of the cervix. The fetus was found to have mild bilateral hydronephrosis at 4 mm.
Our patient began menarche at age 12 and has been regular with a moderate flow lasting approximately 3 days. She has no known history of gynecologic diseases; STI screening with her last pap smear and HPV test were negative for abnormalities in October 2016. She has no history of past varicosities, coagulopathies, or hepatic disease. The patient had a significant past surgical history of laparoscopic cholecystectomy and hernia repair in 2014. She denied any personal or family history of cancer.
On physical exam, significant anterior and lateral vaginal wall clusters of soft varicosities were noted. The varicosities filled the vagina and protruded beyond the hymenal ring (Figures and ). A second opinion obtained by a Gyn-Onc physician confirmed large vaginal varicosities by clinical exam. The patient was sent back to referring provider to continue prenatal care. The oupatient OB/Gyn consulting physician recommended repeating C-secti

[Assistant]
ICD-10-CM Coding based on findings:
Assign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing.


[System] You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings.

[User]
RADIOLOGY NOTE:
A 32-year-old multiparous woman was admitted at 37 2/7 weeks for induction of labor for abnormal antenatal testing. She had a history of a prior cesarean delivery for arrest of active labor at 7 cm and after extensive counseling chose to undergo a TOLAC. The initial cervical exam was 2 cm dilation and 50% effacement. Her labor was induced with oxytocin and amniotomy was performed at 5 cm dilation with clear fluid noted. She progressed from 2 cm to 5 cm over the course of 10 hours; interval time to progression to 6 cm was 3.5 hours. The patient then began to have a moderate amount of vaginal bleeding with associated minimal fetal heart rate variability and variable decelerations that did not improve with intrauterine resuscitation. She was taken to the operating room for repeat cesarean delivery due to concern for a uterine rupture and/or a placental abruption. Upon entry into the abdomen, there was no uterine rupture or dehiscence, nor was there evidence of a significant placental abruption. She delivered a male infant with a weight of 2659 g and Apgar scores of 9 and 9 at 1 and 5 minutes, respectively; arterial cord pH was 7.26. No extension of the hysterotomy was noted following delivery of the infant. Following repair of the hysterotomy, the bladder was noted to be distended and edematous, despite the presence of a patent Foley catheter. This finding prompted a vaginal exam to assist in evaluating the integrity of the lower uterine segment behind the bladder due to concern for an occult uterine rupture or dehiscence. The vaginal exam revealed a spontaneous detachment of the anterior rim of the cervix from approximately 9 to 3 o'clock. The avulsed portion of cervix appeared necrotic () and there was no bleeding noted at the site of cervical detachment. The cesarean delivery was completed, and an attempt was made to repair the site of the detachment vaginally, at which time the entirety of the cervix completely detached. No excessive bleeding was noted and

[Assistant]
ICD-10-CM Coding based on findings:
Assign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing.


[System] You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings.

[User]
RADIOLOGY NOTE:
A 57-year-old female with a prior history of hypertension, was diagnosed with Stage IIIC high-grade serous ovarian carcinoma (HGSOC) nearly 5 years ago. The patient received neo-adjuvant chemotherapy with paclitaxel and carboplatin every 3 weeks for 3 cycles. A repeat scan done post 3 cycles showed partial response to treatment and patient underwent a cytoreductive surgery at an outside center. The surgical pathology was consistent with Stage IIIC disease noted earlier with lack of good response to carboplatin and paclitaxel given neoadjuvantly. Hence treatment was switched to gemcitabine, cisplatin and bevacizumab during adjuvant therapy for 3 cycles. A repeat scan done post completion of treatment showed complete resolution of disease.
The patient remained disease free but had a relapse with the PET scan showing FDG avid lesions in the liver and pouch of Douglas after 3 years. The patient was started on second-line chemotherapy with gemcitabine, cisplatin and bevacizumab. However, bevacizumab was discontinued after first dose as the patient developed internal bleeding in the operative bed. Next two cycles of chemotherapy were continued with gemcitabine and cisplatin alone without bevacizumab. A CT scan done post completion of 3 cycles of treatment showed response to therapy. The patient did not continue any further chemotherapy at this time due to toxicity issues. No PARP inhibitor was offered due to BRCA negative status on germline testing at the time. The patient developed progressive disease after 9 months and underwent a second surgery with excision of the vaginal vault and the pelvic mass and omentectomy. Histopathology was suggestive of metastatic HGSOC. For the ideal therapeutic options, the sample was sent for multi-analyte Exacta® analysis. The overview of the treatment given is summarised in ().
The integrative, multi-analyte Exacta® test includes molecular analysis of comprehensive gene expression, DNA mutation profiling, chemosensitivity assay, immunoh

[Assistant]
ICD-10-CM Coding based on findings:
Assign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing.


[System] You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings.

[User]
RADIOLOGY NOTE:
A 47 year-old-man, human immunodeficiency virus negative, with a recent diagnosis of central nervous system lymphoma presented with perianal skin lesions and nonbloody diarrhea. The skin lesions began as nodules that progressed to a roughened plaque and in the minority, ulceration. The lesions began eight weeks prior to presentation, were multiple, scattered in the perianal area and upper thigh bilaterally, and three centimeters at the widest diameter (). A more distinct lesion with irregular border was present over the sacrum consistent with a decubitus ulcer. The patient had been diagnosed with a CNS lymphoma six weeks prior to admission when he presented to another hospital with lower extremity weakness, saddle anesthesia, and fecal incontinence, and was found to have a L1-L2 intramedullary spinal mass. He had emergent surgical resection of the mass and was treated with high-dose dexamethasone and further radiation therapy. He was additionally found to have a right temporal lobe mass that was resected and pathology was consistent with a B-cell lymphoma with T-cell infiltration. He had no other significant past medical history or immunocompromising condition. The lower extremity weakness persisted and primarily confined him to bed. For ongoing fecal incontinence and the nonhealing sacral decubitus ulcer, he ultimately had a diverting colostomy. Two weeks prior to presentation, his bowel movements became more liquid in consistency and increased in frequency. He denied abdominal pain. The perianal skin lesions were not painful, but the initial loss of sensation from the compressive spinal mass had not recovered. He remained on a dexamethasone taper and was transferred to this hospital for further evaluation for chemotherapy. His complete blood count was notable for a normocytic anemia, and his liver function tests for an elevated alkaline phosphatase. An excisional biopsy of one of the skin lesions from the upper thigh was obtained and sent for pathological examinat

[Assistant]
ICD-10-CM Coding based on findings:
Assign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing.


[System] You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings.

[User]
RADIOLOGY NOTE:
A 65-year-old postmenopausal lady (Patient A) and a 32-year-old homemaker (Patient B) presented with history of exertional dyspnea of 1-year duration and 6-month duration, respectively. Both gave history of occasional cough with expectoration. They also gave history of recurrent respiratory infections. However, neither of them had a history of tuberculosis or associated comorbid illness like diabetes mellitus. On presentation, both were clinically stable and maintained normal saturation at room air. On examination, they had mild deviation of trachea to the left with reduced breath sounds in the left hemithorax and laterally placed apex beat. Their chest X-ray (CXR)/scanogram demonstrated shift of the mediastinal structures to the left and hyperlucent right lung []. A possibility of left lung collapse/left lung hypoplasia was considered. Contrast chest computed tomography (CT) showed hypoplastic left lung with bronchiectatic changes in the left lower lobe with herniation of right lung. Mediastinal structures were to the left []. Further on CT, Patient A had a rudimentary left pulmonary which was interrupted/abrupt termination within 1 cm of origin from the main pulmonary artery. The diameter of the left pulmonary artery and main pulmonary artery of Patient A are 7 and 23 mm, respectively. Patient B CT showed a left pulmonary artery of about 9 mm in diameter but was also abruptly terminated within 1 cm of origin from the main pulmonary artery. A possibility of left-sided pulmonary artery agenesis with left lung hypoplasia was suspected and both the patients underwent a perfusion scan which revealed no perfusion in the left lung with normal perfusion in the right []. Fiberoptic bronchoscopy showed narrowed segmental openings of the left lung. The left main bronchus and lobar bronchus were normal. Bronchial washings were collected from all the narrowed segments, but no organism was isolated. Patient B also had a more distally placed right upper lobe bronchus probably du

[Assistant]
ICD-10-CM Coding based on findings:
Assign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing.


[System] You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings.

[User]
RADIOLOGY NOTE:
This case report describes the fracture of a temporary femoral hemodialysis catheter during placement in an old man with gastric carcinoma and extensive abdominal and retroperitoneal metastasis, in an attempt to draw lessons from and nurture experience among practitioners.
A 76-year-old man was admitted with acute kidney injury and anuria. He underwent a subtotal gastrectomy for gastric carcinoma 7 years ago. Three months prior, he had a similar admission with anuria which required temporary hemodialysis. At that time, a computed tomography and magnetic resonance imaging of his abdomen revealed an atrophic right kidney, extensive intra-abdominal metastasis, and retroperitoneal involvement causing bilateral hydronephrosis. A temporary double lumen dialysis catheter was inserted in the right femoral vein for acute hemodialysis. A double J stent was placed in the left ureter. His urine volume gradually returned. The dialysis catheter was removed after 7 days. During his second admission with acute oliguric kidney injury, ultrasonography of his bilateral femoral and iliac veins revealed no stenosis or thrombus in femoral and distal iliac veins. A 19.5 cm/13.5 Fr acute dual lumen dialysis catheter [Mahurkar, Covidien, Minneapolis, MN] was placed into right femoral venous using universal Seldinger technique. The procedure was relatively straightforward although the patient experienced some moderate, transient pain during the advancement of the catheter. At the end of the procedure, there was no flow in one of the two lumens.
Subsequent radiography showed that the end of the catheter had doubled back and the first 4 cm of the catheter had fractured (Fig. ). Venography showed a stenosis in the middle of his right iliac vein (Fig. ). The stenosis was thought to have veered the curve end of the guide wire back toward the direction of advancement, and “misguided” the catheter which subsequently broke off. A second dialysis catheter was inserted successfully in the right intern

[Assistant]
ICD-10-CM Coding based on findings:
Assign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing.


[System] You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings.

[User]
RADIOLOGY NOTE:
A 23-year-old woman, gravida 3 para 0, presented for a routine prenatal visit at 34 weeks and 5 days with complaints of constant right upper quadrant pain, headache, and visual disturbance. Serial readings of her blood pressure were all in the normal range and there was minimal proteinuria. Workup revealed an elevation of alkaline phosphatase at 2365 U/L (normal range 35–115 U/L). The patient did not have a history of bone, liver, or renal disease. Past pregnancies were remarkable for a spontaneous abortion and therapeutic abortion requiring dilatation and curettage. Prenatal lab work was unremarkable and the patient was Rh negative. She received RhoGAM during her prenatal care and in the postpartum period. An abdominal ultrasound was performed and failed to show any biliary stones or biliary duct dilatation. To identity the cellular source of the alkaline phosphatase, it was fractionated and showed that 97.8% of the alkaline phosphatase was placental in origin.
During workup the patient was also found to have an elevated glucose tolerance test and was confirmed to have gestational diabetes several days later. The patient was closely monitored for the remainder of the pregnancy and noted to have good glycemic control with dietary modification alone with a hemoglobin A1C of 5.5%. Her alkaline phosphatase was serially monitored and noted to rise to a peak of 4053 U/L (35x upper limit of normal) on the day of delivery. The patient was induced at 40 weeks and 2 days of gestation and had an uneventful vaginal delivery of a vigorous baby boy. Shortly after delivery the infant was noted to have significant bruising and petechiae. A complete blood count was obtained six hours after delivery and revealed significant thrombocytopenia with a platelet count of 20,000. The infant was eventually diagnosed with neonatal alloimmune thrombocytopenia with the parents having an incompatibility in the HPA-1a (PlA1) and HPA-5b (Bra) platelet antigen systems.
Subsequent postpartum monito

[Assistant]
ICD-10-CM Coding based on findings:
Assign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing.


[System] You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings.

[User]
RADIOLOGY NOTE:
A 48-year-old man, who was diagnosed with advanced primary HCC with right atrial metastasis and sought medical treatment, was admitted to our hospital. A computed tomography scan revealed a large mass (approximately 7.6 × 7.6 cm in size) in the right lobe of the liver and intracavitary metastasis to the right atrium, an extremely rare secondary cardiac malignancy of primary HCC metastasis (Fig. ). According to the classification of IVCTT as previously described,[ the present case was intra-cardiac type III IVCTT with a cardiac TT above the diaphragm that extended to the right atrium of the heart. The patient underwent surgical treatment on September 25, 2018, during which time right atrial metastasis in the heart was actually observed, extending from the right liver via the IVC to the right atrium (Fig. A); the gross specimen of resected cardiac mass is shown in Figure B.
After full assessment, surgical treatment, consisting of hepatectomy, resection of the involved IVC and right atrium thrombus, and reconstruction of the resected IVC, was performed in this patient. After blocking the right Glisson pedicle and marking the ischemic line at the junction of the left and right half liver, the liver was split along the line under the blocking of the first hepatic hilar and subhepatic IVC. The right Glisson's pedicle was then dissected. Subsequently, the chest was opened, the mediastinum and the diaphragm muscles around the hepatic IVC were cut, the pericardium was opened, allowing fully exposure of the heart, and cardiopulmonary bypass (CPB) was performed in the patient. In the following operative procedures, the right atrium was cut, the right half liver was removed at the root of the right hepatic vein; a longitudinal 8-cm long incision was made on the surface of the superior hepatic IVC, followed by complete removal of the IVCTT and secondary thrombosis. The right atrium incision was closed and the resected IVC was then reconstructed in which autologous pericardial tu

[Assistant]
ICD-10-CM Coding based on findings:
Assign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing.


[System] You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings.

[User]
RADIOLOGY NOTE:
A 67-year-old man was admitted to our hospital because of liver dysfunction during a screening examination. Enhanced abdominal computed tomography (CT) revealed a hypervascular mass of 35 mm in diameter in the descending portion of the duodenum (Fig. ), and the left three sections of the liver were occupied by multiple cystic tumors with contrast enhancement of the cystic wall, 13 cm in diameter (Fig. ). A duodenal tumor was identified on gastrointestinal endoscopy (Fig. ), and a biopsy revealed a NET. The serum levels of insulin, gastrin, and glucagon were within normal ranges. CT did not initially reveal evidence of pancreatic invasion between the tumor and the pancreas; however, irregularities of the duodenal wall and swelling of the lymph nodes around the pancreatic parenchyma were observed. Thus, the patient was diagnosed with non-functional duodenal NET with multiple liver metastases, T2N1M1 stage IV (UICC 8th). In addition, CT revealed the anatomical variation of the CHA, which branched from the SMA and ran fully through the head of the pancreatic parenchyma (Fig. , Additional file Figure S1). The CHA branches into the left hepatic artery (LHA), the middle hepatic artery (MHA), and the right hepatic artery (RHA) (Fig. a, b). Furthermore, a developed gastric arterial arcade, 4 mm in diameter, was found between the left gastric artery (LGA) and the right gastric artery (RGA). The RGA was branched from a distal portion at a distance of 10 mm from the root of the LHA (Fig. ). Incidentally, we did not observe stenosis of the celiac axis due to compression by the median arcuate ligament. We planned PD and left trisectionectomy with caudate lobectomy combined resection of the tp-CHA with the preservation of the gastric arterial arcade in order to maintain arterial flow of the remnant liver, preserving the route of the celiac artery to the right posterior hepatic artery (

[Assistant]
ICD-10-CM Coding based on findings:
Assign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing.


[System] You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings.

[User]
RADIOLOGY NOTE:
A 32-year-old woman was evaluated for abdominal pain in another hospital. A mass was seen between the pancreatic head and duodenal wall on ultrasound examination of abdomen. She was referred to our institution for further evaluation. EUS confirmed a 5.5 cm × 4.5 cm hypoechoic mass between pancreatic head and duodenal wall. The mass appeared to be outside the duodenal wall. No calcifications or vessels were seen inside the mass. Multiple small nodes were seen around the lesion. No vascular involvement was seen. The possibilities considered on EUS were gastrointestinal stromal tumor, lymphoma, and solid and papillary epithelial neoplasm (SPEN) of pancreas. EUS FNA was done. Air dried and alcohol fixed smears were prepared from the FNA material. Material was also procured in formalin for cell block preparation.
May-Grunwald Giemsa and Papanicolaou stained smears were examined. Smears were of good cellularity. The cells were present dispersed singly, in small groups and fragments. In few fragments, cells were seen adhering to fibrovascular cores []. The cells were round in shape and monomorphic. The nuclei had fine nuclear chromatin and small nucleoli. The most striking feature was that the cytoplasm of almost all the cells had multiple fine vacuoles imparting a foamy appearance to the cells. Most of the cells had eccentric nuclei [Figures and ]. At low power examination, these cells were almost indistinguishable from foamy histiocytes. Occasional bare nuclei were seen in the background. Hematoxylin and eosin stained sections from cell block showed small nests of similar foamy cells entrapped in blood clot. The cells had well defined cytoplasmic membranes []. Keeping in view, the cytologic features of the tumor, location of the tumor, and the young age of the patient possibilities of neuroendocrine tumor (NET) with clear cell change and SPEN with clear cell change were considered. Other differentials considered were primary clear cell adenocarcinoma, metastatic clear ce

[Assistant]
ICD-10-CM Coding based on findings:
Assign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing.


[System] You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings.

[User]
RADIOLOGY NOTE:
A 72-year-old lady was referred to the emergency department with chest pain occurring during her twelfth cycle of carfilzomib infusions (56 mg/m2 received on Days 1, 2, 8, 6, 15, and 16 of every 28-day cycle) as a treatment for her multiple myeloma. She had been receiving this therapy for the preceding 12 months but reported 3 months of similar intermittent chest pain. She described her pain as localized, central chest tightness with radiation to her right arm and the right side of her neck. The pain would typically last 5–10 min before spontaneously resolving. This could occur at rest or with exertion and did not have diurnal variation. She also described associated dyspnoea on exertion for the preceding 3 months without orthopnoea, paroxysmal nocturnal dyspnoea, or leg swelling. She had no traditional cardiac risk factors but was referred for cardiovascular assessment given the nature of her presentation. Clinical examination revealed a slim, normotensive woman with a normal cardiopulmonary exam.
Intercurrent medications included dexamethasone, thalidomide, and trimethoprim/sulfamethoxazole in addition to carfilzomib as part of her treatment for multiple myeloma. She was on no other regular medications.
The differential diagnosis at this time included obstructive coronary artery disease, disorders of coronary vasomotion including microvascular and/or vasospastic angina, congestive cardiac failure, and pulmonary emboli.
An electrocardiogram while pain free in the emergency department demonstrated sinus rhythm at a rate of 70 b.p.m. There was poor R wave progression and ischaemic T wave inversion through the anterior leads without conduction abnormalities (Figure ). High sensitivity troponin T was 8 ng/L (reference range <16 ng/L). A transthoracic echocardiogram demonstrated normal left ventricular size and function with no regional wall motion abnormalities. There was no evidence of pulmonary hypertension or valvular disease. She was discharged from the emergency d

[Assistant]
ICD-10-CM Coding based on findings:
Assign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing.


[System] You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings.

[User]
RADIOLOGY NOTE:
A 25-year-old man was referred to our hospital in 2014 for a suspected right bronchogenic cyst. He underwent a trans-esophageal biopsy to confirm the diagnosis. After a few days, he started to complain of fever and acute chest pain. A contrast-enhanced CT scan revealed a massive pleural effusion in the right hemithorax with complete atelectasis of the ipsilateral lung (Fig. ).
A right thoracoscopy was performed, in order to achieve a complete debridement and drainage. During the procedure, no esophageal perforation was seen. The following clinical course was normal, so the patient was discharged on postoperative day 15.
In December 2019, the patient was referred to our Emergency Department because of the sudden onset of fever (39 °C) with acute chest pain. He underwent a CT-scan which revealed a suspected esophageal perforation with acute mediastinitis and right pleural effusion. A subsequent gastroscopy showed, at 35 cm from dental arch, an erosion of the esophageal wall 1,5-cm long and a 2-mm perforation with a small leak of purulent liquid. Furthermore, an endoscopic ultrasound revealed the presence of the bronchogenic cyst just outside the erosive area. Thus, a right thoracotomy with intraoperative endoscopy was performed. An esophageal perforation at the level of the cyst was found, so the right hemithorax was cleaned, the cyst was opened in order to better understand its margin, and then resected, while the esophageal wall was closed with two interrupted, absorbable stitches. A 24-Ch drain was left in place. After 2 days, salivary material appeared into the drain, so the patient underwent an EGDS, which revealed a 7-mm hole of the esophageal wall at the level of the previous suture (Fig. a). Thus, an E-Vac therapy was placed directly into the perforation (Fig. b) only during the first placement, with the aim of cleaning the mediastinum and healing the esophageal wall, which was locally compromised by the

[Assistant]
ICD-10-CM Coding based on findings:
Assign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing.


[System] You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings.

[User]
RADIOLOGY NOTE:
A 65-year-old man came to our attention in October 2018 due to the appearance of a right frontotemporal swelling with progressive growth for about a month and a half. In anamnesis, he had a single kidney. The patient’s neurological exam was negative. Contrast-enhanced brain magnetic resonance imaging (MRI) revealed a large lesion (28 x 20 x 38 mm) in the right frontotemporal cranial theca. The lesion had caused complete bone lysis involving the full thickness of cranial planking and extending widely into the subcutaneous soft tissues while extending approximately 4 mm into the extradural space. In the T1 sequence, the lesion was homogeneously intense and, after administration of contrast, it was characterized by inhomogeneous enhancement (Figure ).
As metastasis was suspected, the patient preoperatively underwent a total body computed tomography (CT) scan, which showed the presence of diffuse thickening of the left postero-lateral bladder wall and a solid endoluminal protrusion at the ureteral outlet, characterized by irregular endoluminal margins and discrete enhancement (Figure ). Urinary cytology showed the presence of carcinoma cells (Figure ).
The patient gave informed consent for the surgery and to the use of the data for scientific purposes. During the operation, which took place on July 11, 2018, the patient underwent gross total removal (GTR) of the head lesion and subtotal resection (SR) of the bladder lesion. The cranial lesion was of a hard-elastic consistency and was resected en bloc, involving bone margins apparently without disease. The dura mater was infiltrated so it was removed keeping very wide edges. Dural plastic surgery using NeoDura and cranioplasty with titanium mesh were performed. The temporal fascia and epicranial tissue over the lesion were removed.
During the transurethral cystoscopy, in the left postero-lateral bladder wall, a solid lesion of about 2 cm with a large implant base with significant periwound edema was identified. The lesio

[Assistant]
ICD-10-CM Coding based on findings:
Assign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing.


[System] You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings.

[User]
RADIOLOGY NOTE:
A 60-year-old woman presented to a local hospital after she began to experience right upper quadrant pain, nausea, and vomiting. Abdominal ultrasonography showed marked dilatation of the intrahepatic bile duct (IBD) in the left lobe of the liver and common bile duct with intraductal stones.
She was diagnosed with cholangitis and then referred to our hospital in May 2011 for further investigation and treatment. She underwent laparoscopic left lobectomy for a left IBD stone and choledocholithotomy with t-tube drainage for a common bile duct stone. After one year, follow-up computed tomography (CT) showed no definite abnormalities, but laboratory data showed elevated serum levels of cancer antigen 19-9. Thus, CT scan was performed at three-month interval and a mass was observed at the atrophied right posterior segment of the liver. In addition, a palpable mass was found at the t-tube site and histologic diagnosis of the lesion by excisional biopsy was interpreted as adenocarcinoma (stage IV).
She was referred to our department for palliative chemo- therapy and received treatment with gemcitabine and cisplatin. She neither consumed any alcohol nor smoked and she reported no family history of illness. After eight cycles of gemcitabine and cisplatin (days 1 and 8: cisplatin 25 mg/m2 followed by gemcitabine 1,000 mg/m2; repeated every three weeks), the follow-up CT showed progressive disease, showing an interval increase in the size of the metastatic lesion in the abdomen, thus, the regimen was changed to cisplatin 60 mg/m2 on day 1 and 5-fluorouracil 1,000 mg/m2 on days 1-5.
However, two months after the first infusions of cisplatin and 5-fluorouracil, the patient developed gait disturbances on day 6 of the third infusion. She could not maintain a standing position with her eyes open, and a tandem gait was impossible because of severe positional imbalance. Brain magnetic resonance imaging (MRI) with T2-weighted images (-) and diffusion-weighted images (-) showed high sign

[Assistant]
ICD-10-CM Coding based on findings:
Assign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing.


[System] You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings.

[User]
RADIOLOGY NOTE:
A 27-year-old healthy man who lived in a major urban area in Japan admitted to our hospital with complaints of sore throat and abdominal discomfort and diminished appetite persisting for 2 months. Sore throat and nasal congestion appeared 2 months before the date of admission (day 0), at which time the patient visited a otolaryngology department of local hospital (Hospital A) and was prescribed amoxicillin following a diagnosis of pharyngitis. The patient's throat symptoms persisted, and abdominal pain appeared. Body temperature measurements taken at home consistently remained at approximately 37℃. Eighteen days later (day 18), the patient was seen by the gastroenterology department of Hospital A due to persistent abdominal symptoms and was prescribed a proton-pump inhibitor. Three days later (day 21), the patient developed malaise, accompanied by chest and abdominal pain, and was transferred to another medical facility (Hospital B) via ambulance. The patient presented with a fever of 38.3℃ at the time of transfer, and the electrocardiograph, blood tests, and chest computed tomography scan yielded no noteworthy results. He was subsequently placed under observation and then released, free to return home. The patient's symptoms were found to persist after an additional week of monitoring. Although abdominal ultrasonography and urinalysis had also been performed at Hospital A, no issue was flagged. One month after the initial onset of symptoms (day 31), the patient underwent another blood test as well as an upper gastrointestinal endoscopy at another medical institution (Hospital C), but no abnormalities were detected. After another four weeks (day 58), the patient underwent an abdominal CT at Hospital C. As a result, he was diagnosed with functional dyspepsia (FD) and was prescribed Acotiamide and Bifidobacterium. From that day onwards, the patient began to experience glossodynia, difficulty consuming food, and he visited our clinic on day 59. Except for slight sign o

[Assistant]
ICD-10-CM Coding based on findings:
Assign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing.


[System] You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings.

[User]
RADIOLOGY NOTE:
A 23-year-old male was referred to our hospital in May 2008 due to severe traumatic brain injury caused by a traffic accident and was diagnosed as brain dead shortly after admission. Dextrocardia was found during physical examination and situs inversus totalis was verified by further X-ray and ultrasonic inspection. During the retrieval of donor organs, it was found that the liver, pancreas, and stomach were located in the opposite positions. The descending aorta was located directly in front of the spine and the inferior vena cava was found in the front left of the spine. Organ procurement was smoothly performed without great difficulty even though the procedure took a little longer due to the operator's habitual thinking about the anatomy. During preparation of the donated liver, the anatomical relations were clearly identified, that is, liver artery locating in right side and common bile duct in the left, and portal vein still being behind common bile duct and liver artery. The hepatic superior and inferior vena cava was cut to angle well in preparation for vascular anastomosis.
A 58-year-old female recipient was diagnosed with end-stage liver disease caused by type B hepatitis. Preoperative condition was evaluated with Child-Pugh (class A) and MELD (4.3). The liver transplantation was performed in May 2008. The incision was made double subcostally. Following isolation of porta hepatis and hepatic ligament, the retrohepatic inferior vena cava was partially clamped and then the diseased liver was removed preserving the inferior vena cava. The right hepatic vein was suture ligated while preserving the left and middle hepatic veins. At the point of left hepatic vein entering the hepatic superior and inferior vena cava, a transection was taken on an anterior wall of the interval between the left and middle hepatic veins, and meanwhile, the anterior wall of inferior vena cava was cut downward 2 cm, thereby forming a “T” type anastomotic rim in preparation for hepatic

[Assistant]
ICD-10-CM Coding based on findings:
Assign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing.


[System] You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings.

[User]
RADIOLOGY NOTE:
A 33-year-old primigravida woman in her third trimester of pregnancy presented to the obstetrics department with severe itching. Examination of the patient confirmed a single, live intrauterine pregnancy of 33 gestational weeks. A widespread erythematous rash was also evident, with tense fluid-filled blisters accompanied by severe itching. The patient indicated these symptoms had begun two weeks previously. The patient was referred to the dermatology polyclinic, where examination showed erythematous maculae scattered over the arms, legs, trunk, and neck (Figures , , , , and ), some with burst and crusted tense blisters on them. The patient's personal history was unremarkable. Routine hemogram and biochemical tests produced normal results, and vitamin B12, folic acid, thyroid hormones, and antibody levels were all within normal ranges. Anti-BP 180-NC16 could not be obtained because this test could not be carried out in the biochemical laboratory of our hospital. Subepidermal disintegration was detected by means of punch biopsy (). Direct immunofluorescence showed linear C3 deposition () and weak IgG deposition () at the basement-membrane zone. A diagnosis of PG was made from these findings. Systemic corticosteroid treatment was initiated at a dose of 40 mg/day prednisolone. Since a regression was observed in the lesions of the patient after two weeks, the prednisolone dose was reduced gradually. No new blister formation was observed during hospitalization. Prednisolone treatment was started at a dose of 10 mg/day on the 15th day of hospitalization and the patient was then discharged. The patient had a mild relapse after 10 days, prednisolone dose was increased to 20 mg/day, and an improvement was observed. The dose was reduced after one week and maintained at 10 mg/day. The remaining follow-up period of the pregnancy was uneventful and the patient gave birth to a live baby measuring 3600 g in weight and 50 cm in length through vaginal delivery in the 39th gestational

[Assistant]
ICD-10-CM Coding based on findings:
Assign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing.


[System] You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings.

[User]
RADIOLOGY NOTE:
A 12-year-old Vietnamese boy presented to our emergency department with bilateral knee pain and swelling. The mechanism of injury was sustained as a result of tripping with bilateral knee strikes on the ground while playing sports at school. The subject and his parents denied jumping in relation to the injury or any knee pain prior to the injury. The history revealed immediate pain and the inability to mobilise or bear weight.
On physical examination, the boy had an athletic constitution. There was significant appreciable bilateral knee swelling with a fixed flexion deformity on observation with pain being the limiting factor disabling knee extension. Generalised tenderness and an intra-articular effusion were present on palpation with the predominant source of pain at the tibial tuberosities. Any attempt of motion provoked severe pain. Given the pain, it was difficult to assess the integrity of the cruciate and collateral ligaments; however the limited examination did not reveal obvious instability. Neurovascular examination was normal and compartments were soft.
Interestingly, the boy's past history was significant for a type IIIA left knee avulsion fracture that he sustained 13 months priorly. This happened via a different mechanism (jumping) where pain was felt while pushing off. On that occasion an MRI showed an injury to both ends of the patella ligament with some avulsion of the patella proximally and some lifting up of the tibial tuberosity distally. He was managed conservatively on that occasion in a hinged-knee brace locked in extension for six weeks with physiotherapy to progress ROM thereafter. The paediatric orthopaedic surgeon who reviewed him in the outpatient clinic made a specific note in his letter stating that “this injury will have changed the relative length of his patella by a small amount”, going on to say that “we will need to take this slowly in terms of protecting this.”
On this presentation, plain radiographs (Figures and ) showed bilatera

[Assistant]
ICD-10-CM Coding based on findings:
Assign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing.


[System] You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings.

[User]
RADIOLOGY NOTE:
Presentation and diagnosis
Our patient is a 62-year-old Caucasian man who went to a health fair at his church where abdominal sonograms were being performed. After receiving a sonogram the patient was told to see his primary care provider about possible kidney stones. The primary care physician performed an additional sonogram and confirmed kidney stones with an incidental finding of gallstones. The patient was referred out for a CT scan for workup of kidney stones. The patient underwent stent placement and lithotripsy. Soon after lithotripsy, the patient developed fever, and a CT with contrast was performed. This scan showed incidental findings of masses on the gastric fundus. An endoscopic exam was performed with a biopsy taken which showed spindle cells, and the first diagnosis of GIST was made.
Treatment
The patient underwent a cholecystectomy, during which time the surgeon also removed the gastric masses. A light tan nodular mass, 4.5 x 2.2 x 1.8 cm, was removed from the posterior stomach, with histological findings as noted in Figure . We also obtained a light pink and tan wedge-shaped sample measuring 2.9 x 2.5 x 2 cm from the anterior stomach. Samples were sent to pathology where they showed spindle cell neoplasms composed of interlacing bundles of spindle cells with rounded to tapered nuclei. The mitotic count was low, with only one mitotic figure found in an examination of 15 high powered fields. Calcifications were seen and the edge of the tumor was well-demarcated with a thin fibrous membrane.
Follow up
The patient was sent home to recover, and roughly three weeks after the procedure returned for a kidney/ureter/bladder x-ray, which had no relevant findings. Follow up with his primary care provider showed well healing surgical incisions, improved energy and positive affect regarding his own health. We advised the patient to have follow-up visits every six months for the next five years to check for a possible resurgence of

[Assistant]
ICD-10-CM Coding based on findings:
Assign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing.


[System] You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings.

[User]
RADIOLOGY NOTE:
A 46-year-old man was admitted to Matsushita Memorial Hospital, Osaka, Japan because of an abnormal electrocardiogram. The patient had noticed exertional chest discomfort for a few months, but did not seek medical care because his symptoms improved with rest and had not changed in frequency or severity over time. One day before admission, he had a 30-minute episode of chest discomfort at rest in the morning. The next day, his chest symptoms reportedly recurred during rest in the morning and lasted for approximately one hour. The patient visited his physician in the afternoon and was found to have an abnormal electrocardiogram. He was transferred to the emergency room of the hospital, when his symptoms had already disappeared. The patient had a history of hypertension but had taken no drugs. He was a current smoker with a 25 pack-year history.
His physical examination was normal, other than a blood pressure of 189/130 mmHg. An electrocardiogram showed normal sinus rhythm, a heart rate of 65 beats per minute, ST-segment elevations in V1 and V2, and negative T waves in anterior and lateral leads []. His chest radiograph was unremarkable. His troponin T level was 1.74 ng/mL (reference, < 0.1 ng/mL). Echocardiography demonstrated borderline abnormalities of wall motion in the ventricular septum. A diagnosis of acute myocardial infarction was made, although the infarcted area remained undetermined.
Intravenous administration of isosorbide dinitrate, followed by heparin (5000 units), did not alter his electrocardiogram. Emergency coronary angiography, which was performed after initiation of aspirin (200 mg) and clopidogrel (300 mg), revealed no significant stenosis with a delayed flow in the second septal branch of the LAD []. Intravascular ultrasound was done in the second septal branch for further examination because the delayed flow in the second septal branch of the LAD did not improve after administration of intracoronary isosorbide dinitrate, intravascular ultrasound

[Assistant]
ICD-10-CM Coding based on findings:
Assign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing.


[System] You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings.

[User]
RADIOLOGY NOTE:
An eighty-one-year-old male visited the clinic complaining of abdominal pain along with pulsating mass. He had been diagnosed with infrarenal aortic aneurysm and this was treated with EVAR 6 years previously. After EVAR, a gradual increasing of the aneurysm sac was found without evidence of any type of endoleak. Eventually, the aneurysm reached a diameter of 9.7 cm on the computed tomography (CT) angiography and abdominal pain redeveloped. CT angiography showed a huge aortic aneurysm without evidence of endoleak, and it was considered that this was due to endotension.
CT-guided sac aspiration was performed through the translumbar puncture of the aneurysm sac, and 400 mL of a dark brown-colored liquid was aspirated (). CT scan was performed the day after the puncture and the sac shrunk back to its original size (). Abdominal pain subsided and the palpating mass disappeared. One month after the aspiration, a CT scan was retaken, and the scan showed that the aneurysm sac increased back to the size before the aspiration (). Additionally, the scan showed no signs of endoleak. A second aspiration was performed again, and a further 300 mL of the dark brown colored fluid was aspirated. During the second aspiration, small amounts of contrast media was administered through the lumbar puncture site in order to search for the presence of collateral flow induced endoleak and to detect any possible rupture of the aneurysm sac. But no contrast media leakage from the sac was found, and no endoleak was found. So it was concluded that the increase of the aneurismal sac was due to endotension.
Finally, with the consent of the patient, the endovascular relining technique was performed on the patient to treat the endotension. Since the diameter of the main body of the original endograft was 28 mm, it was planned that the relining process would be carried out by inserting two customized, tubular stent-grafts each of

[Assistant]
ICD-10-CM Coding based on findings:
Assign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing.


[System] You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings.

[User]
RADIOLOGY NOTE:
A 39-year-old man presented at our hospital with a thyroid nodule in the neck region, which the mass had been detected during a routine medical check-up. FNA were performed twice prior to the visit to our hospital, but the results of the cytological evaluations at both instances were atypia of undetermined significance (AUS). The patient had no clinical symptoms and the laboratory results were in normal range. Ultrasonography, performed at our hospital, revealed the presence of a relatively well circumscribed mass (2.2 cm in diameter) with microcalcifications on the right lobe of the thyroid gland (Fig. a). Additionally, another FNA conducted at our hospital. The cytologic evaluation showed some follicular cells with enlarged nuclei and pale chromatin pattern. However, the cytologic findings were not sufficient to diagnose a specific tumor, thereafter we diagnosed the cytologic specimen as AUS (Fig. b). Subsequently, the patient underwent right hemithyroidectomy for diagnostic and treatment purposes.
The results of the cytology could not confirm whether the mass was benign or malignant. Hence, histologic evaluation of a frozen section using hematoxylin-eosin (H&E) staining was performed. A relatively well-circumscribed mass comprising cells that were mostly arranged in a trabecular or solid sheet-like pattern and intersected by homogenous eosinophilic material was noted (Fig. ). The tumor cells consisted of amphophilic cytoplasm and round to oval-shaped nuclei with condensed chromatin and indistinct nucleoli (Fig. b). The eosinophilic material was suspected to be amyloid deposition and the mass was diagnosed as a medullary thyroid carcinoma. Neck lymph node dissection was additionally performed due to the results of the frozen biopsy. And the patient has been warned that if the results of permanent biopsy was confirmed to medullary thyroid carcinoma as of the frozen biopsy, total thyroidectomy is necessary.
Subsequently, a permanent section obtained from the patient

[Assistant]
ICD-10-CM Coding based on findings:
Assign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing.


[System] You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings.

[User]
RADIOLOGY NOTE:
A-17-year-old previously healthy female presented to THP with a history of fever for 2 days associated with body aches and nausea. She didn’t have any abdominal pain, bleeding manifestations or postural symptoms. On examination, she was flushed and febrile but was not pale or icteric. She was mildly dehydrated. Blood pressure was 100/70 mmHg, pulse rate 100 beats/min and capillary refilling time (CRFT) was less than 2 s. On abdominal examination, there was no free fluid. Lung fields were clear on respiratory system examination. Other systems examination was normal.
Her NS1 antigen was positive and serotype was identified as DEN1. She was managed as dengue fever with continuous monitoring. On the 3rd day of fever, she complained of retrosternal chest pain and undue tiredness. At that time her cardiovascular system examination was normal and electrocardiogram (ECG) showed acute T wave inversion in V2-V5 leads. Troponin I was negative and 2D echo showed global left ventricular hypokinesia and mild impairment of LV function. Ejection fraction was 40–45%. She was treated as having dengue fever complicated by myocarditis. Intravenous hydrocortisone 200 mg 8 hourly was administered for 2 days to reduce myocardial inflammation. On the 4rd day following admission, she complained of abdominal pain and ultrasound scanning revealed free fluid in hepato-renal pouch. Blood pressure was 100/70 mmHg, pulse rate 70 bpm, and CRFT was less than 2 s. She was taken to High Dependency Unit (HDU) and was managed as having DHF complicated with myocarditis with continuous monitoring and with careful administration of fluid to avoid fluid overload. She was discharged on day 7 of illness after recovering from critical phase of dengue fever. She was advised on limiting physical activities. During the follow up on day 14 of the illness, ECG showed reversal of T inversions. Echocardiogram showed improvement of left ventricular function with an ejection fraction of 55

[Assistant]
ICD-10-CM Coding based on findings:
Assign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing.


[System] You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings.

[User]
RADIOLOGY NOTE:
An 83-year-old man with headache was referred to our clinic. He had a history of a chronic headache with different degrees of severity and changing patterns that continued for 2 weeks before his admission. The headache was global. Besides, it sometimes localized to the back of his head and neck. There was no association with nausea, vomiting, seizure, or fever. Physical examination did not demonstrate any neurological deficit. The patient was also suffering from a severe renal disease.
Brain magnetic resonance imaging (MRI) showed a well-defined epidural mass lesion in the left side of posterior fossa, with severe compression of the cerebellum. Opacification of adjacent mastoid air cells was seen. Craniocervical junction and upper cervical cord signal and thickness were normal []. These findings considered with an extradural posterior fossa mass lesion. Gadolinium images were not performed because of the presence of severe renal disease.
Gross total resection of the tumor was performed via the left retrosigmoid craniectomy. The tumor was a well-defined, large intracranial and completely extradural cystic lesion with a thin layer of a white capsule, containing yellow cheesy material. The cyst including the capsule and its contents was totally resected. The tumor eroded the inner surface of the skull at that site. Gross involvement of dura mater was not seen. The surface of the dura was shaved and coagulated, and eroded bones were removed. Microscopic examination showed interosseous epidermal inclusion cysts, filled with keratinous needle-like material []. The patient had a satisfactory recovery after the surgery.
Two months after the operation, the patient came back with a chief complaint of watery discharge from the surgery site. He also suffered from increased severity of headache, neck pain, and bulging site of surgery. Physical examination showed that the bulging was very loose. Fluid collection and leakage of clear to xanthochrome liquid via an orifice on the su

[Assistant]
ICD-10-CM Coding based on findings:
Assign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing.


[System] You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings.

[User]
RADIOLOGY NOTE:
The first case shows a 30 year old female. Clinical and radiographic examination showed a skeletal Class II pattern with an anterior open bite and a transverse maxillary deficiency with a lateral posterior crossbite on the right and the tendency to a lateral crossbite on the left (Fig. ).
The treatment plan involved a first stage of maxillary expansion with SARME to correct the transverse discrepancy followed by the leveling of the dental arches with lingual fixed appliances and finally two jaw surgery to correct the open bite as well as the Class II malocclusion.
Impressions of the upper and lower arches were obtained for the lingual appliances.
During the planning for the production of the lingual brackets, it was noted that a surgically assisted rapid maxillary expansion takes place. In the set-up, therefore, the transverse width of the upper jaw should be adapted to the lower jaw.
Four Benefit mini-implants were inserted: two in the anterior area of the T-Zone and two 12 mm distally on each side of the midpalatal suture. A silicon impression was taken and the laboratory analogues were placed on the transfer caps. The maxillary expansion appliance was manufactured using a Hyrax screw anchored only to the four mini-implants, named the Quadhyrax.
During the same appointment the lingual appliance was indirectly bonded using a dual cured composite (Fig. ) and the Quadhyrax was inserted and attached to the mini-implants using Benefit fixation screws. The first lower arch wire 14 NiTi was placed while the upper brackets were securely ligated with a continuous steel ligature in each quadrant to prevent accidental dislodgement during surgery (Fig. ).
The surgery for SARME was performed on all three patients according to the same procedure: First Le Fort I osteotomy with an oscillating saw. After that, the sutura palatina mediana was chiseled up for the midpalatal split. The tuber region was also

[Assistant]
ICD-10-CM Coding based on findings:
Assign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing.


[System] You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings.

[User]
RADIOLOGY NOTE:
A 4 year old female presented with huge abdominal swelling first noticed by her parents at 2 years of her age (See Figure ). The swelling had increased in size since then to occupy almost whole of the abdomen. Right labia had a swelling which increases in size on standing and decrease on lying down. On examination abdomen was found to be distended, felt tense with flanks full. The swelling over the labia was reducible on manipulation suggesting its continuity with the abdominal swelling.
Ultrasound abdomen showed 30 × 20 × 20 centimeters huge, multiloculated, multiseptate, lesion extending from xiphisternum to pelvis with extension into the right labia majora. Lesion was causing lateral and posterior displacement of bowel loops and compression of liver and both kidneys. A provisional diagnosis of omental, mesenteric or ovarian cyst was made. CT scan was done to throw some more light on the site of origin. Non-contrast film showed the cyst filled with clear fluid possibly arising from the mesentery. Contrast film was suggestive of multiloculated cyst. Pelvic films proved the labial extention of the cyst (See Figure ), but still the exact site of origin remained unclear.
Patient was taken up for exploratory laparotomy and midline vertical incision was kept. After opening the peritoneum a thin walled cyst was seen popping out of the skin incision (See Figure ). On exploration it was found attached to the greater omentum (See Figure ).
Cyst was deflated partially by aspiration and we found the swelling over labia majora got reduced as we deflated the cyst and no adhesions were found between the cyst wall and labia. Complete excision of the cyst wall along with part of omentum was done. Histopathological report of the cyst wall showed endothelial cell lining, foam cells, lymphatic spaces, lymphoid tissue and smooth muscles which are diagnostic of lymphangiomatous cyst (See Figure

[Assistant]
ICD-10-CM Coding based on findings:
Assign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing.


[System] You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings.

[User]
RADIOLOGY NOTE:
A 78-year-old female presented initially to our cancer center, after being diagnosed with ACC of the right parotid gland. She was complaining of a mass in the right side of her neck, which was associated with jaw discomfort. Her symptoms worsened gradually over 6 months. Head and neck computed tomography (CT) scan revealed soft tissue mass in the right side of the face, destroying the mandibular ramus and extending to the right sphenoid bone and inferior temporal lobe. A head and neck magnetic resonance imaging (MRI) scan showed a parotid tumor with extension into the foramen ovale and destruction of the right mandibular ramus. The patient underwent a fine needle aspiration biopsy, which showed ACC of salivary glands. The mass was deemed to be unresectable, and the patient was referred to radiation oncology department where she was treated with neutron beam radiotherapy. The parotid neoplasm responded well to treatment, and she had disease remission confirmed with follow up MRI.
A year later she developed right sided hip pain. After an unremarkable plain X-ray, she underwent a right femur and pelvis MRI that showed an osseous mass within the right ilium extending inferior to the acetabulum concerning for metastatic disease. CT of the abdomen and pelvis showed an abnormal lucency in the right acetabulum and a larger area of the right ilium, which measured 3.3 cm in maximum transverse dimension, as well as hepatic hypo-densities suggestive of metastatic disease. CT scan of the chest revealed numerous bilateral noncalcified lung nodules scattered throughout both lungs () and a lytic bone lesion in the right scapula measuring 3.1 × 3.6 cm. This was followed by a bone scan that revealed uptake within the medial right ilium and the right inferior and superior pubic rami. There was also uptake within the right frontotemporal calvarium, right scapula, and anterior left third rib.
Subsequently, she underwent right ilium biopsy, which confirmed the diagnosis of recurrent meta

[Assistant]
ICD-10-CM Coding based on findings:
Assign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing.


[System] You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings.

[User]
RADIOLOGY NOTE:
D.N. is a 75-year-old Caucasian man with a history of malignant melanoma of the left shoulder resected in 2011, who presented with progressive dysphagia. An upper endoscopy revealed a gastric mass, and biopsy specimens demonstrated a poorly differentiated malignant neoplasm. Staging CT of the chest, abdomen, and pelvis demonstrated numerous pulmonary nodules bilaterally and scattered liver lesions consistent with metastatic disease. Biopsy of a liver lesion confirmed metastatic melanoma, negative for BRAF mutations. A brain MRI was negative for intracranial involvement. Pertinent medical history included acetylcholine receptor (AChR) autoantibody positive myasthenia gravis (MG) diagnosed at age 64. At that time, he had primarily ocular symptoms and AChR binding antibodies were positive at a titer of 2.1 nmol/L (normal range = 0.0-0.4 nmol/L). Over the years, his MG progressed and he developed other symptoms such as dysphagia, chewing fatigue, dyspnea on exertion, and neck and limb weakness. He responded well to prednisone and was eventually transitioned to mycophenolate mofetil. Just before the metastatic melanoma diagnosis, his MG was asymptomatic with mycophenolate mofetil 750 mg daily and pyridostigmine 60 mg 3 times daily.
For lack of a more robust treatment option, and after discussing the potential side effects with the patient and the neurologist, pembrolizumab was started at 2 mg/kg every 3 weeks. The dose of mycophenolate mofetil was decreased to 500 mg daily and pyridostigmine was continued unchanged. After his second dose, the patient developed symptoms of diplopia and worsening bilateral ptosis concerning for an exacerbation of MG. Pembrolizumab was held, and pyridostigmine was titrated up to 180 mg 3 times daily, along with prednisone 30 mg daily. The patient’s condition continued to deteriorate, and he was admitted to the intensive care unit with respiratory distress and worsening dysphagia, where he required noninvasive ventilation and gastrostomy tub

[Assistant]
ICD-10-CM Coding based on findings:
Assign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing.


[System] You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings.

[User]
RADIOLOGY NOTE:
This is a case of 70 years old female, with no known co-morbidities, who presented to the Otolaryngology clinic with complaints of increased somnolence and reduced appetite for past the 3–4 years. These complaints were not associated with any other associated symptoms. Her past medical history and family history were unremarkable. She had a history of the cesarean section under spinal anesthesia 30 years ago. On examination, she was well oriented to time, place, and person. She had a heart rate of 64 beats per min, a respiratory rate of 16 breaths per min, a blood pressure of 110/70 mm Hg, and she was afebrile. Her general physical and systemic examination was also unremarkable. Her serum calcium was 14.1mg/dl (8.8–10.6) and serum parathyroid hormone showed a value of 457mg/dl (7-53). Her vitamin D level, serum albumin, and creatinine were all within a normal range. 24-hour urinary calcium and phosphorus were also within normal limits. She underwent neck ultrasonography which showed a complex solid and a cystic nodule on the left side close to the lower pole of the thyroid measuring 3.6 × 2.8 cm ().
The clinical picture was suggestive of a parathyroid adenoma and she was admitted electively for its resection. After relevant investigations and anesthesia fitness, she underwent complete excision of the left parathyroid lesion and left lobectomy of thyroid gland under general anesthesia. Intra-operative findings were enlarged left parathyroid gland which was inseparable from the multi-nodular left lobe of the thyroid gland. A recurrent laryngeal nerve was identified and saved. Neck drain was placed and the sample was sent for histopathology (). The lesion was not involving any other structure other than the thyroid gland. No level VI lymphadenopathy was observed intraoperatively.
The patient remained hemodynamically stable with no signs of recurrent laryngeal nerve palsy. Her post-op serial serum calcium monitoring was done which decreased to

[Assistant]
ICD-10-CM Coding based on findings:
Assign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing.


[System] You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings.

[User]
RADIOLOGY NOTE:
A 69-year-old Caucasian male was referred to our hospital with 3 weeks of abdominal distension and worsening right lower quadrant pain. He was diagnosed with IgG kappa multiple myeloma four years prior to presentation. He was initially treated with bortezomib/dexamethasone with monthly zolendronic acid with good response initially; however, a year after diagnosis, he was found to have disease progression which manifested as a right radius fracture. His regimen was switched to lenalidomide with dexamethasone with good response and clinically depressed levels of paraproteins. After completion of 9 months of therapy, he underwent autologous stem cell transplant with high-dose melphalan. 7 months after bone marrow transplant, his disease progressed with involvement of pericardial fluid. Salvage therapy was initiated with pomalidomide, bortezomib, and dexamethasone which was discontinued a year later due to peripheral neuropathy; however, at the end of treatment, there was no evidence of ongoing disease.
When the patient presented to our hospital, he had an acute abdomen. Initial blood work revealed a normocytic anemia with hemoglobin of 8.4 g/dl and elevated ESR of 44. He also had acute kidney injury with creatinine of 3 mg/dl (baseline of 1.9 mg/dl). CT scan of the abdomen and pelvis revealed extensive stranding seen throughout the abdomen within the peritoneal space with edema in the mesentery ().
He underwent an exploratory laparotomy which revealed induration of the entire base of the mesentery and retroperitoneum. He had an IgG level of 4407 units with predominantly kappa light chains whose level was 4833 units (kappa to lambda ratio 540). Pathology revealed extensive mesenteric infiltration by kappa restricted plasma cells positive for CD138 on immunohistochemistry, without evidence of amyloidosis. Bone marrow biopsy revealed a 30% involvement by plasma cells (Figures –). Cytogenetics showed 1q22 duplication, trisomy 7 and 15, and gain of 8q24.1. The skeletal surv

[Assistant]
ICD-10-CM Coding based on findings:
Assign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing.


[System] You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings.

[User]
RADIOLOGY NOTE:
A 65-year-old woman was referred to our interventional radiology department for investigation of a palpable mass and irritating audible bruit on her right neck. Two months prior to this visit, she had developed an acute exacerbation of chronic renal failure secondary to viral gastroenteritis and underwent temporary hemodialysis using a central venous catheter placed in her right jugular vein. Upon arrival at our hospital, a 50 × 30 mm soft mass was palpable over the right side of her neck, and systolic bruit was heard during auscultation. Laboratory data showed elevated levels of serum creatinine and blood urea nitrogen at 155.6 μmol/L and 10.0 mmol/L, respectively. Duplex ultrasonography evaluation of the neck was performed, which showed a 48 × 27 × 46 mm aneurysmal sac that connected the craniomedial side of the thyrocervical trunk via a short narrow neck approximately 3 mm in length and 2.5 mm in diameter (). The aneurysmal sac also continued to the internal jugular vein, and the cranial aspect of the internal jugular vein was occluded by a thrombus. Computed tomography angiography of the neck showed a high-density-flow jet of contrast agent shunting from the thyrocervical trunk into the aneurysmal sac via the short neck in the arterial phase (Figures and ). Continuity between the aneurysmal sac and internal jugular vein was also noted (). Based on these findings, the diagnosis of iatrogenic PsA of the thyrocervical trunk with an AVF involving the internal jugular vein was made. We discussed surgical versus endovascular intervention with the patient, and the latter was elected. A 4-Fr sheath (Terumo, Tokyo, Japan) was inserted through the right brachial artery, and the right subclavian artery was selectively catheterized by a 4.2-Fr Judkins Right 4.0 angiographic catheter (Goodman, Nagoya, Japan). Selective digital subtraction angiography of the right subclavian artery showed a PsA originating from the thyrocervical trunk root; the PsA

[Assistant]
ICD-10-CM Coding based on findings:
Assign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing.


[System] You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings.

[User]
RADIOLOGY NOTE:
A 70-year-old Japanese man, who had undergone esophagectomy with gastric conduit reconstruction via the antesternal route for spontaneous esophageal rupture 28 years previously, was hospitalized due to redness of the precordial skin, which had persisted for 1 month (Fig. a). Gastric juice was discharged from the gastric conduit through the skin fistula. He had taken low-dose aspirin due to a past history of left carotid artery obstruction and stenosis of the right carotid artery but had not taken proton pump inhibitors (PPIs). Laboratory studies showed mild inflammatory findings (WBC 9200/ul, C-reactive protein 5.7 mg/dl). No evidence of Helicobacter pylori infection was seen.
Computed tomography (CT) revealed a fistula between the thickened gastric conduit and skin (Fig. ). He was diagnosed with a gastric conduit ulcer that penetrated through to the chest wall and was managed conservatively with fasting, the administration of a PPI and antibiotics, and continuous compression of the gastric conduit over the skin with a cotton ball. Upper gastrointestinal fiberscopy on day 14 revealed the ulcer was located at the anterior wall of the middle gastric conduit (Fig. a). An esophageal biopsy revealed no evidence of malignancy.
The fistula healed with conservative management. Although the fistula relapsed twice on the 37th and 58th days, respectively, it healed with conservative management.
On the 174th day from the onset, discharge was recognized again. A fistula of 1.5 cm in diameter was observed on the operation scar of the precordium at the nipple line, from which the gastric mucosa was seen. The skin around the fistula was reddish (Fig. b). On the 196th day, when the infection was completely controlled, resection of the refractory cutaneous fistula was performed with the transfer of a pectoralis major muscle pedicle flap and a split-thickness skin graft.
First, a skin incision of 3 cm × 2 cm in size was made on the fistula. The area around the

[Assistant]
ICD-10-CM Coding based on findings:
Assign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing.


[System] You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings.

[User]
RADIOLOGY NOTE:
A 56-year-old Japanese woman was referred to a clinician in April 2013 because of a 5-month history of occasional epigastric pain, 2-month history of intermittent abdominal pain/watery diarrhea, and a recent loss of appetite and worsening of watery diarrhea. Enhanced computed tomography (CT) revealed a thickening of the ascending colon and rectum. She was diagnosed with ileus and admitted to a local hospital. Fasting initially alleviated her symptoms. Eventually, she was discharged on the fifth day of hospitalization after she was able to eat without the recurrence of abdominal pain.
A week later, she experienced abdominal pain and watery diarrhea. Gastroenteroscopy and colonoscopy did not detect any abnormalities, and positron emission tomography/CT revealed no significant uptake of the tracer. Considering that a previous CT study had revealed the presence of gall bladder stones, cholecystectomy was planned after a provisional diagnosis of cholecystitis. On June 20th, her abdominal pain and watery diarrhea worsened, she was unable to eat, and she suffered from intermittent severe abdominal pain, predominantly in the upper abdomen; she was then referred to our hospital. She did not give history of travel abroad or consumption of uncooked meat, fish, or seafood in the recent past.
The patient gave a past history of two episodes of ileus, first in her twenties and then at 41 years of age. She had undergone laparotomy without an alimentary tract resection for both episodes. In addition, when she was in her thirties, she had been treated with a 10 mg/day dosage of prednisolone for 1 year because of the preliminary diagnosis of idiopathic thrombocytopenic purpura (ITP), on the basis of the decreased platelet counts. At the age of 54 years, she was referred to a rheumatologist because of elevated titers of autoantibodies against Ro/SSA and La/SSB and was diagnosed with Sjögren's syndrome. Serological testing at that time had revealed hypocomplementemia, but no other colla

[Assistant]
ICD-10-CM Coding based on findings:
Assign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing.