[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 patient was a 68-year-old man with a 30-year history of hypertension and regular hemodialysis for 11 years who had undergone forearm arteriovenous fistula surgery to treat end-stage renal disease 9 years prior. A long-term hemodialysis catheter (14.5F/23 cm, BARD) had been placed in the right internal jugular vein for hemodialysis 2 years prior. 2 days before the current visit, the hemodialysis cuff catheter ports caused blood oozing during hemodialysis, and the right cuff catheter was pulled out to stop the blood oozing. 1 day before the current visit, a cuff catheter was placed in the patient's left internal jugular vein for hemodialysis. Using the Seldinger puncture technique, the operation was performed under DSA in an interventional radiology room. The cuff catheter was introduced via smooth introduction and positioning of the guidewires. After dilator and guidewire removal, the catheter was inserted into the left internal jugular vein with the removal of the peel-away sheaths (). The patient reported mild pain in the left side of his chest during catheterization. The surgeon immediately checked the location of the catheter placement and found that there was no venous blood being drawn from the cuff catheter. DSA analysis revealed that the tip of the catheter could not reach the upper 1/3 of the right atrium (the tip of the catheter was in this position, which can meet the requirements of hemodialysis, as shown in ). The surgeon decided to adjust the catheter the next day because the patient could not continue to tolerate the operation.
The next day attempts were made to adjust the catheter via a rotating method, but during that process, the catheter pierced the brachiocephalic vein and entered the mediastinum (). Opening the breast area and suturing the brachiocephalic vein were initially considered, but it was surmised that this could be lethal given the patient's history of long-term anemia and uremia. Immediate multidisciplinary consultation with interv

[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 37-year-old female presented to the emergency room at our institution with intractable abdominal pain and fever. She has a history of dysuria and hematuria for 10 months, which at the time prompted an MRI demonstrating an abdominal wall mass with extension into the bladder. Outside biopsy was reported as “inflammation”. She was initially treated with antibiotics. A cystoscopy was performed and a transurethral bladder biopsy showed acute and chronic cystitis and Von Brunn nests. Cytology report indicated presence of atypical urothelial cells and she was then referred to the urology service due to suspicion for malignant neoplasm. Follow up CT scan imaging demonstrated a heterogeneous ill-defined enhancing soft tissue density in the space of Retzius inseparable and compressing the anterior aspect of the urinary bladder measuring 11.3 × 4.5 × 12.8 cm with a peripherally enhancing loculated collection measuring 4.7 × 6.0 × 3.0 cm along with marked thickening of urinary bladder . As strong suspicion for malignant lesion persisted, a repeat percutaneous biopsy was done that again demonstrated infiltrative granulation tissue and chronic inflammation.
As the patient’s symptoms continued to progress, including persistent hematuria diagnosis was uncertain despite multiple percutaneous and transurethral biopsies, she was referred to Surgical Oncology team for multidisciplinary management. As there were still concerns for neoplastic malignant process vs desmoid vs pseudoinflammatory neoplasm, the multidisciplinary team recommendations were to offer operative management in coordination with the surgical oncology and urology teams with an intention to provide larger tissue for definitive diagnosis to guide extend of surgery, which would include complete bladder removal with construction in the form of ileal conduit, abdominal wall resection with abdominal wall reconstruction if malignancy were to be confirmed intraoperatively.
Intraoperative cystoscopy demonstrated an ulcerated

[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 64-year-old woman presented with large varicose veins, CEAP C2s, in the left lower limb. The patient had never been treated before because she was afraid of surgery. She had no history of migraine headaches or cardiac diseases. She had never smoked cigarettes, never had high blood pressure, and never been overweight. Her only medication was 20 mg sinvastatin once a day, and her last lipid profile, and all blood tests were normal. Except for the large varicose veins in her left lower limb, physical examination was normal, including normal peripheral pulses and absence of bruits. The patient was treated in the Trendelenburg position with a total of 10 ml of 3% polidocanol foam via direct punctures, 5 mL into an 8 mm diameter great saphenous vein and 5 mL into large collaterals in the leg. Foam was prepared with a 1:4 ratio of liquid to room air, using the Tessari technique involving 40 passes of agitation through a three-way stopcock using one 5 mL syringe and one 3 mL syringe. With ultrasound guidance, foam was injected immediately after each of three preparations, 5 mL, 2.5 mL, and 2.5 mL. No air boluses occurred. Ultrasound scanning showed no foam in the deep venous system. The patient remained lying down for 10 minutes after the injections, before being discharged wearing compression stockings. Less than 1 hour after leaving hospital, impairment of speech capacity was observed. She encountered difficulties when she tried to talk, with incomplete and incomprehensible words. No other alterations were noted. She was taken to another hospital, where the clinical presentation was misdiagnosed as an allergic reaction. One gram of hydrocortisone IV was infused and 20 mg prednisone was prescribed per day for 5 days. The next morning she came to the office to report the allergic reaction. After detailed history taking and physical examination, including the Wells DVT clinical model, the only alteration detected was aphasia. This was Broc

[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 30-year-old female with no known medical condition, underwent a caesarian section in 2014 and started to complain of abdominal mass 2 years later. She underwent resection in another institution and the pathology showed insufficient resection reaching the superior margin, <1 mm from the lateral margin, and 1 mm from inferior and deep margins. The patient was offered radiotherapy, however she refused.
She was followed up with biannual MRI’s with no recurrence. Two years later, the patient noticed a growing mass. The follow-up MRI revealed development of a well-defined oval-shaped soft tissue lesion at the site of the previously resected anterior abdominal wall desmoid tumor measuring 4.3 × 2 cm, heterogeneously hypertense on T2, hypointense on T1 and significant enhancement on the delayed post contrast images, in keeping with a recurrent desmoid tumor (Fig. ). Following the MRI, the patient was referred to our institution.
The mass presented with a gradual increase in size and moderate pain. On physical examination there was a 5 × 3 cm hard, well-defined mass in the right lower quadrant. There were no skin changes. An MRI revealed a well-defined soft tissue mass confined to the right rectus abdominus muscle. A Tru-cut biopsy from the mass revealed a spindle cell neoplasm consistent with recurrent desmoid tumor. The patient’s family history was insignificant for malignancy. All her laboratory investigations and tumor markers were normal. After counseling the patient, resection was performed, using the advantage of intra-operative ultrasound (US) to localize the margin providing the patient maximal surgical benefit with minimal risk of a positive margin.
Rather than simply using palpation, intraoperative ultrasound guidance was used to determine the margins of the desmoid tumor. The ultrasound was used to define a 2 cm margin at each qudrant, which was then marked using electrocautery. The marks were then connected in a ring giving a 2 cm margin 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 36 year-old female complained of persisted dull pain over epigastric area for 2 months. No associated symptoms such as heartburn, nausea, and vomiting can be elicited. She visited local clinic and a mass was palpated in the left upper quadrant area. At the same time, abdominal sonography showed a huge hepatic mass at left lobe of liver. So, she received examination of abdominal computed tomography (CT) thereafter. Abdominal CT () revealed a huge left hepatic mass with a size of 20 x 15 cm. She was then transferred to our institution for further management. Initial laboratory data were only notable for a decreased hemoglobin level of 9.7 g/dL and a mildly elevated level of alkaline phosphatase (139 U/L). The serum marker of hepatitis B or hepatitis C was also negative. Tumor markers, including serum carcinoembryonic antigen (CEA), CA19-9, and α-fetoprotein level (AFP) were within normal value. Angiography revealed this huge hepatic mass was supplied by left hepatic arterial (). After studies, she received operation for excision of the tumor. The excised liver measured 20 x 15 x 10 cm and weighed 793 gram. The cutting surface showed a huge soft mass of size 14 x 12 x 6 cm with whitish to pinkish surface (). There was no central necrosis in the tumor. The tumor margin was greater than 5 cm away from the nearest section margin. There was no cirrhotic change at the remaining part of liver parenchyma. Microscopically, the lesion was mainly composed of hyperchromatic and mild pleomorphic spindle cells admixed with many reactive plasma cells and lymphocytes. These neoplastic cells formed fascicles, storiform and whorls pattern. They had plump cytoplasm and indistinct cell borders with vesicular or granular chromatin and small nucleoli. Some giant cells and fibrous bands were seen but rare mitotic figures were found within the tumor (). These tumor cells were positive for expression of CD21 and CD35 by immunohistochemical staining and positive for expression 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 24-year-old female patient was initially referred to our vascular department for investigation of bilateral lymphedema. Her echocardiogram showed mildly impaired LV with evidence of segmental wall motion abnormality and hypertrabeculation in the apex suggestive of noncompaction. Further questioning revealed a history of sudden death in two of her brothers. One of the deaths was related to an unknown cardiomyopathy. The history of the patient started at birth when she had difficulty swallowing and several delayed milestones such as walking and talking at the age of 5. Due to socioeconomic issues, the parents did not seek medical assistance. As the patient matured, there was an additional history of palpitations, which were occasionally associated with syncopal attacks. The patient had generalized, but progressive weakness throughout the years. Her weakness increased with activity and decreased with a rest. The weakness was mainly proximal, worse in the upper limbs. Due to constant fatigability, she dropped out of school.
Her vital signs were normal on physical examination, she demonstrated normal heart sounds. Lower limbs bilateral nonpitting edema up to the knees, proximal bilateral upper and lower limbs weakness with intact sensation, waddling gait, and easy fatigability with few steps were noted.
Computed tomography coronary angiogram was performed to exclude coronary artery disease. Results showed segmental wall motion abnormality and revealed normal coronaries, LV dilatation, and lateral wall and apical noncompaction with the noncompacted myocardium to compacted myocardium ratio in the range of 2.5–3.5 []. CMRI was done for further evaluation of LV function and volume. Her CMRI showed mildly dilated LV with mild global hypokinesis and a marked decrease in longitudinal shortening. End-diastolic volume was 120 mL, end-systolic volume was 61 mL and the ejection fraction was 50%. In addition, multiple areas of noncompacted myocardium, particularly in the apex 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 12-year-old mentally subnormal boy from rural background was brought by his family with a lump in the left subareolar region which was first noticed 6 years back as a small pea sized nodule and grew painlessly to the size of presentation. The patient had no other complaints and his relatives denied any history of similar complaints in the family. The family members reported delayed milestones for the patient who performed poorly for his age and had poor speech and mental development. On examination the patient showed hypertelorism, low set ears, and left sided undescended testis. The breast examination showed a 6 × 6 cm size lump underlying the areola which was firm to hard in consistency and fixed to the overlying thinned skin. The lump was mobile over the underlying muscle. The patient had no axillary lymphadenopathy. On evaluation, otorhinolaryngoscopic evaluation of the patient was within normal limits. Core needle biopsy of the patient showed fibrocollagenous tissue with mild epithelial hyperplasia and was suggestive of gynaecomastia. Ultrasonography of the axillae and the abdomen was normal. Ultrasonography of the scrotum localised the left testis to the left inguinal region.
In view of clinical suspicion the patient was advised a wide local excision of the lump and axillary sampling which on histopathological examination revealed a 5 × 4 cm firm grey lesion harbouring secretory carcinoma with foci of stromal fibrosis and apocrine change with pathologically negative 8 lymph nodes. The margins were negative for presence of the tumor. The tumor was negative for estrogen and progesterone receptors and Her2neu. On immunohistochemistry the tumor stained positive for S-100 stain ().
In view of the subnormal mentation of the patient and the lack of definitive supportive data in the disease subset, his relatives refused adjuvant therapy. The patient subsequently is on periodic surveillance and is healthy after 6 months of follow-up.

[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 15-year-old male presented to the emergency department for evaluation of neck and chest pain. He was running at a brisk pace when he felt a sudden sharp pain in his neck followed by sustained pain in the center of his chest and neck. He reported the sensation of shortness of breath and nausea, but no dysphagia or dysphonia. There was no history of trauma to the head, neck, or chest. He was previously healthy with no prior medical problems or prior surgeries and had no history of familial or congenital medical conditions. Most notably, the patient had no family history of sudden cardiac death, aortic disease, or connective tissue disease. The patient endorsed having no known allergies and did not take any medications on a daily basis.
On arrival, he displayed mild tachypnea with a respiratory rate of 22 breaths per minute, but otherwise had normal vital signs with a blood pressure of 128/80 millimeters of mercury, heart rate 66 beats per minute, temperature 37 degrees Celsius, with 98% oxygen saturation on room air. His airway showed no evidence of impending compromise. He appeared to be in moderate distress secondary to pain. He demonstrated respiratory splinting and held his neck and shoulders still to prevent worsening of pain. He had mild nasal flaring, but his lungs were clear to auscultation bilaterally. He had no evidence of stridor. Palpation of the chest revealed tenderness near the right sternoclavicular region of his chest. Pulses were palpable and equal in all extremities.
A chest radiograph showed lung markings to the periphery bilaterally, no consolidations, and no opacities (). The mediastinum appeared widened, which prompted a computed tomography (CT) angiogram of the chest and neck to better evaluate vascular anatomy. This revealed a pseudoaneurysm of the proximal innominate artery (). There was also high attenuation blood tracking from the superior mediastinum to the descending aorta suggesting rupture of the pseudoaneurysm and formation of a medi

[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 second case refers to a 48-year-old woman, a busy manager with a history of depression and sleep disturbance. She has had three terminations of pregnancy and one delivery by cesarean section. She smokes approximately ten cigarettes per day and has high cholesterol serum levels. She takes several medications: a selective serotonin reuptake inhibitor (escitalopram), two benzodiazepines (delorazepam and clonazepam), and a statin. She reports a four-year history of urinary symptoms: daily UUI episodes, mild stress urinary incontinence (SUI), and two episodes of nocturia per night. She wears pads every day. The urology consultation revealed some degree of pelvic pain, especially during vaginal examination. The urine dipstick was negative and there was no PVR. No specific causes of the symptoms such as urine tract infection were identified. The patient also complained of mild dyspareunia and occasional constipation. The urine culture turned out to be sterile, with no blood in urine, and the pelvic ultrasound scan and urine cytology were also negative. The cystoscopy, which was performed as a result of the presence of storage symptoms and to rule out a bladder tumor in this current smoker, was normal.
In OAB patients, it is of utmost importance to consider all comorbidities. Anxiety and depression may play a role, feeding a vicious circle. Moreover, medications to treat neurological or psychiatric disorders can influence OAB and be responsible for side effects [, ]. Gastrointestinal disorders are frequently associated with OAB, such as constipation in this case, but patients rarely raise the topic. An overlap exists between irritable bowel syndrome and OAB [].
The patient was prescribed a β3 agonist, pelvic floor muscle training (PFMT) and bladder retraining. Four months later, she noticed some degree of improvement, but had stopped the treatment as she felt that she had no time for PFMT. She was not compliant with the bladder drill either, and soon stopped

[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 29-year-old male was referred to our clinic with an 8-year history of multiple painless scrotal nodules that had progressively increased in size and number. The few 0.5–1 cm subcutaneous papules on both hemi-scrotal tissues were sometimes itchy. The patient denied a history of scrotal trauma or ingestion of any medication before the onset of a papule. There was no urethral discharge, penile ulceration, or inguinal swelling. The patient noticed some of the papules disappeared after discharge of a whitish or chalk-like substance from them. He had no previous history of sexually transmitted infection. As the number and size of the nodules were increasing, he became uncomfortable, embarrassed, and did not want others to see the lesion. He reported that he was not sexually active and had avoided intimate relationships because of his scrotal lesions. There was no history of any chronic illness or medication use. Physical examination showed multiple palpable but painless dark brown intradermal nodules on the scrotum. The calcified nodules involved both hemi-scrotum, but were preponderantly on the left. No other skin lesion was noticed. The phallus was circumcised and the testes were palpable and grossly normal. Laboratory evaluation revealed normal serum phosphorus and a slightly lower calcium level. The patient underwent excision of the lesions near the median raphe under local anesthesia using a single elliptical incision. Other individual nodules on both hemi-scrotums were excised individually and closed separately to preserve some uninvolved skin and to allow for adequate scrotal skin closure. The defects were closed using 3-0 prolene suture interrupted technique (). There were no postoperative complications to date, and the patient had an excellent scrotal cosmetic outcome.
Histology sections revealed calcium deposition, and basophilic globules of varying sizes and shapes within the reticular dermis. There was an occasional scalloped appearance, with some of the sma

[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 man visited our hospital complaining of anterior chest pain. He had no significant medical or family history, and the vital signs were stable. Ischemic events were not observed in electrocardiography, but chest X-ray and computed tomography (CT) showed a cystic lesion (6.0 × 7.0 × 10.0 cm) in the anterior mediastinum (Fig. a). Although the cystic capsule demonstrated contrast enhancement, its fluid component had low radiation absorbance. Based on these findings, we suspected the mass to be a thymic cyst. Blood tests indicated the presence of inflammation (white blood cell count 11,200/μL and C-reactive protein 3.38 mg/dL).
Two days after hospitalization, the patient developed dyspnea and his chest pain worsened. Subsequent chest CT showed that the cystic lesion had become inhomogeneous and the radiation absorbance of the cyst’s fluid component had increased (Fig. b). The cyst wall became thickened, and bilateral effusion was observed. Blood tests indicated that hemoglobin levels had decreased from 15.8 to 12.8 g/dL, and levels of inflammatory markers had increased, with the fever exceeding 38.5 °C. Needle aspiration biopsy and tumor wall biopsy with a small skin incision were performed; however, we could not obtain a diagnosis. One week after admission, general condition and laboratory data of the patient gradually improved. A chest CT on day 13 showed that the tumor had become small in size with a thickened wall (Fig. c). The effusion on the right side had decreased and that on the left side had disappeared.
The patient had recovered enough to undergo surgery; the tumor was resected by sternotomy on day 18. The tumor was found to be encased in a smooth, yellow, and elastic coat. The tumor was densely adhered to the junction of the left brachiocephalic vein and superior vena cava, and it was required to detach the tumor from the dense adhesion site carefully. The right phrenic

[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:
63-year-old woman who had suffered from the right medial knee pain for 5 years and was not responsive to conservative treatment was admitted to our clinics. 30° varus-valgus stress X-ray indicated that the patient had an intact MCL and LCL. After the detailed physical examination and reviewing of X-ray images, it was decided that UKR would be the most suitable option for the patient with anteromedial knee osteoarthritis. After spinal anesthesia application and sedation, the UKR surgery was performed with a standard minimal invasive midline vertical incision and a medial parapatellar approach; the patella was removed laterally but not dislocated or everted. The patient received a medial partial knee implant with a mobile-bearing insert (medium size with 4 mm thickness; Oxford®, Zimmer Biomet Inc., Warsaw, IN, USA). Following the UKR surgery (), weight bearing was allowed as tolerated by the patient and a standard postoperative physiotherapy was started on the first postoperative day. The patient was discharged at postop 2nd day when she met the following criteria: independent ability to get dressed, to get in and out of the bed, and to sit and rise from a chair/toilet; independence in personal care; and mobilization with crutches. After discharge, a home-based exercise program was given to the patient. At postoperative follow-up, our patient acquired a full knee RoM in the postop 1st month and returned to independent daily activities without any external support in the postop 3rd month.
At postoperative 1st year after first UKR application, the patient fell down while getting on a public bus; this caused that the right knee of the patient was exposed to the valgus force vector. After that moment, the patient heard a pop sound and felt an incredible pain that prohibited the flexion and/or extension of the medial side of the right knee. And then she was admitted to our emergency department. 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 40-year-old previously healthy woman underwent a curative resection of the medical compartment of the right thigh for a malignant spindle cell tumour. Due to clear resection margins and absence of any metastatic deposits in imaging, she was not given any adjuvant therapy. She was followed up for 5 years, and she was otherwise well and asymptomatic without any evidence of local recurrence.
After a period of 5 years, she developed an acute onset generalized severe abdominal pain and collapsed. She did not have any external bleeding manifestations such as haematemesis or melaena. There was no history of abdominal trauma. She was immediately admitted to the emergency department, and she was found to be in class III haemorrhagic shock with a pulse rate of 125 beats per minute and a blood pressure of 90/60 mmHg. Her abdomen was distended and diffusely tender. She was immediately resuscitated with intravenous crystalloid boluses and blood transfusion. Her serum beta-Human Chorionic Gonadotropin (beta-HCG) was negative, excluding a ruptured ectopic pregnancy. Her full blood count revealed a haemoglobin level of 5 g/dl, and a massive transfusion protocol was initiated. Her other basic investigations and clotting profile were within normal limits. Despite resuscitation, her vital parameters did not improve and her abdominal girth was gradually increasing. The abdominal ultrasound scan revealed moderate amount of free fluid with a mass around the proximal part of the pancreas. There was no evidence of abdominal aortic aneurysm, and other solid organs were normal. Hence, a decision was taken to proceed with an emergency exploratory laparotomy. A computed tomography was not done as the patient was haemodynamically unstable.
A midline laparotomy was performed. There was 4.5 litres of haemoperitoneum, and a linear tear in the gastrocolic omentum with a haematoma in the lesser sac. Active bleeding was noted from a nidus which was situated posterior to the body of the pancreas, an

[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:
After a multidisciplinary evaluation, at the end of November 2019, a 13-year-old girl attended the Pain Therapy Clinic of the Ospedale Pediatrico Bambino Gesù in Rome, where acupuncture is also practiced as an analgesic technique. She reported pain in the left wrist and hand, with intensity 10 on the Numeric Pain Rating Scale (NRS), pulsating, and always present, thus preventing any movement. Marked hypersensitivity and allodynia were present at the level of the left fingers, wrist and hand. Pain was present in both flexion and extension of the wrist and caused a marked reduction in strength in the left wrist and hand, making a handshake impossible for the girl. There was no redness but swelling and sweating at the level of the fingers of the left hand. The pain was so intense that it interfered with her regular attendance at school, generating social withdrawal phenomena, which are unfortunately very frequent in patients with chronic pain.
Pain began three months before the consultation, after an accidental fall with trauma to the left wrist. It gradually increased and did not respond to either NSAIDs or limb immobilization. The diagnostic tests performed at the time (X-ray, Doppler ultrasound and magnetic resonance imaging) were negative, as were the blood chemistry tests ( and ).
From the age of 8, the girl was followed by a pediatrician in our hospital for a history of cramps and pain in the lower limbs, especially in the ankle and left knee, both in the absence of trauma or caused by frequent falls. In the following years, clinicians found bilateral flatfoot (with subsequent surgery), mild ligamentous hyperlaxity and vitamin D deficiency. In addition, borderline cognitive level with motor coordination disorder and executive function deficit, as well as stuttering, were then diagnosed. Elements of anxiety emerged from the administration of Self Administered Psychiatric Scales for Children and Adolescents (SAFA-A, D and 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 60-year-old Kashmiri female presented to our department after having sustained a fracture of femur in the supracondylar region. After initial management, the fracture was fixed with a dynamic condylar screw assembly. After an uneventful postoperative period, the patient was discharged with advice to undergo supervised physiotherapy. 3 months into the postoperative period, the patient reported to our emergency department with pain in the thigh. X rays revealed a fracture above the dynamic condylar screw at the plate bone interface. The patient was admitted and revision surgery with a longer barrel plate performed. The patient followed up for a period of 4 months and was bearing weight when she again had pain in the peri implant area. Radiographs revealed a fracture of the femur at the new peri implant region. The patient's femoral neck radiograph revealed an osteoporosis grading of 3 according to Singh's classification []. Keeping in view the potential morbidity associated with the repeat plating we planned a method that would be less invasive and less destructive to the local fracture environment. The proposed surgery was explained to the patient and her attendants. The ethical board permission was sought and obtained. The patient was taken to the operating room and placed on a fracture table. The screws in the plate were removed percutaneously under image intensifier control to ensure the patency of intramedullary canal leaving the plate insitu to avoid reexposure of the bone surface. The fracture was reduced and fixed with a reamed antegrade intramedullary nail. Anticipating the difficulties in distal locking with an insitu plate an external locking device comprising of a distal full ring and a proximal Italian arch connected by two threaded rods were used. No blood transfusion, bone grafting were used and the mean operating time was 40 minutes. The patient was ambulated on the first post operative day and discharged from the hospital on the same day after advis

[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 89-year-old gentleman was admitted to a district general hospital with right groin and thigh pain. He was known to suffer from Alzheimer's dementia, osteoarthritis, previous proximal femoral fracture with dynamic hip screw (DHS), and severe aortic stenosis. He was living in the local area in a nursing home, requiring care with all activities of daily living, spending the vast majority of the day in bed. He was able to transfer with assistance of two into the chair but unable to walk prior to admission.
On admission, he was found to have an externally rotated right hip and pain on movement of the hip. His abbreviated mental test score (AMTS) on admission was zero, and that was felt to be his baseline. On auscultation of the precordium, a very quiet second heart sound was heard with an additional ejection systolic murmur present.
Basic blood tests showed a haemoglobin of 115, white cell count of 11.9, C-reactive protein of 130, sodium of 137, potassium of 3.8, urea of 8.3, and creatinine of 113.
Pelvic X-ray was reported to identify generalised osteopenia, left DHS, and displaced surgical neck fracture of the right femur. An urgent echocardiogram identified an ejection fracture of 60% and a severely stenosed aortic valve with an area of 0.8 cm2 and a gradient of 71 mmHg.
Based on his cardiac, cognitive, and functional status, the decision was made that his outcome was extremely poor and he was deemed not to be a surgical candidate.
As a result of him not undergoing a conventional operation and him being managed conservatively, we felt that consideration for a phenol nerve block would aid pain relief and assist in being able to discharge him into the community for end-of-life care. As the patient lacked capacity to consent for a proposed intrathecal phenol injection for intractable hip pain, secondary to the fracture, it was deemed in his

[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 patient is a 50 year old male who received a LURT 8 years prior to presentation. He had previously undergone bilateral native nephrectomies 2 months prior to transplant for PKD. His early course was complicated by biopsy-proven acute cellular rejection, vascular type, 5 days after transplant, which was effectively treated with anti-thymocyte globulin and intravenous immunoglobulin. He subsequently went on to enjoy excellent graft function. Initially, he was maintained on standard triple immunosuppression with tacrolimus, mycophenolate mofetil (MMF) and prednisone.
Two years prior to presentation, he developed numerous squamous cell carcinomas of the skin treated with resection and radiation. One of these lesions was an invasive poorly differentiated SCC (Bowen’s type) of the left auricle, requiring auriculectomy and reconstruction. Tumor margins were negative. His immunosuppression was reduced by stopping his MMF.
One year prior to presentation he developed a parotid mass found to be SCC by fine needle aspiration. It was felt that this was a metastatic lesion from the auricular tumor. At this time, he was switched from a dual immunosuppressive regimen of tacrolimus and prednisone to sirolimus (SRL) and prednisone. He underwent a left parotidectomy and neck dissection with pathology showing invasive keratinizing squamous cell carcinoma, poorly differentiated. The tumor was 4.6 cm with lymphovascular and perineural invasion. Surgical margins were negative, but 5 out of 23 periparotid and cervical LNs were positive for metastasis with focal extranodal extension. He underwent radiation therapy and cetuximab. A surveillance PET CT performed 6 months after treatment revealed 5 bilateral pulmonary nodules, which grew over 2 months from 6 mm to 10 mm. He initiated systemic treatment with carboplatin, paclitaxel and cetuximab with minor improvement initially, followed by disease progression in the lungs and mediastinum after 7 months of treatment. He was then treated wit

[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 59-year-old man with hypertension and a family history that included two brothers who died of an aortic aneurysm was brought to the Emergency Department after falling from his bicycle. He reported abdominal pain since one day. On examination, he was pale and had a pulse rate of 64/min, a blood pressure of 70/50 mmHg, a body temperature of 36°C, and a respiratory rate of 16 breaths/min. He had abdominal tenderness with muscular rigidity, especially in the upper abdominal region. A full blood count showed a haemoglobin level of 6,4 mmol/L, while all other laboratory tests were within the normal range. A chest X-ray showed normal lung fields and no pneumoperitoneum. As a vascular incident was feared, an abdominal ultrasound revealed free abdominal fluid around the liver and spleen without an aortic aneurysm. An abdominal computed tomographic (CT) demonstrated fluids in the omental bursa with a normal aspect of the pancreas but was unable to point to the origin of the free fluid. After resuscitation using standard techniques, the patient was transferred to the operating room under the diagnosis of intra-abdominal haemorrhage of unknown origin. During laparotomy, three litres of blood were obtained from the abdominal cavity but no active bleeding was found. Inspection of the omental bursa revealed a hematoma surrounding the pancreas. The patient was packed using several large volume gauzes and admitted to the intensive care unit. The next day, these gauzes were removed and again no active bleeding was seen. The next four days were uneventful. However, on the fifth day, the patient developed acute severe abdominal pain. An abdominal computed tomographic angiography (CTA) revealed a 14 mm splenic artery aneurysm () as well as a 12 mm aneurysm of the coeliac trunk. In retrospect, on the first CT, a 9 mm focal contrast-filled dilatation of the splenic artery could already have been identified in a large hematoma (). This was initially missed.
A ruptured splenic aneurysm wa

[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 51-year-old man was admitted to the Department of Surgery at our hospital for complaints of fever and anorexia. There was no abdominal pain, nausea, or abdominal distension. He had a high fever, anorexia, tachycardia, and tachypnea. He had no comorbidities or surgical history. The white blood cell count, liver enzymes, and C-reactive protein level were elevated. Abdominal ultrasonography showed a hypoechoic lesion with a maximum diameter of 40 mm in the left lobe of the liver (Fig. ). Abdominal contrast-enhanced computed tomography (CT) revealed a lesion with coexisting low- and high-density areas in segment III of the liver. The lesion was adjacent to the stomach antrum and had a maximum diameter of 55 mm, with enhancement at the edge. The lesion contained air and a high-density linear object measuring about 24 mm (Fig. a, b). We suspected a liver abscess secondary to gastric perforation caused by a foreign body. The patient underwent abscess drainage and removal of the foreign body using five-port laparoscopic surgery. Adhesions had formed between the liver and reticulum due to inflammation (Fig. a). We confirmed pus leakage, performed lysis of adhesions, and found a fish bone inside the reticulum (Fig. b–d). The fish bone was removed laparoscopically. We lavaged the abscess cavity with saline. The operation was completed with the insertion of a drain inferior to the left lobe of the liver. There was no bile leakage from the abscess cavity. The total operative time was 62 min, and the total intraoperative blood loss was 20 ml. The pus culture showed the presence of Streptococcus anginosus, which matched the result of the blood culture. We used meropenem until postoperative day 10. The clinical course was uneventful, and the patient was discharged on postoperative day 11. When the patient was discharged, we changed the antibiotic treatment from meropenem to a combination of potassium clavulanate and amoxicillin hydrate according to the indications

[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 59-year-old Hispanic male with a past medical history of diabetes, hyperlipidemia, chronic obstructive pulmonary disease (COPD), and remote smoking history (quit 29 years ago) was admitted to the hospital by his pulmonologist for recurrent bilateral pneumonia over the past 10 months. The patient's initial symptom was a cough associated with lying supine, eating, or drinking. He also reported that his oxygen saturation would decrease to the 80s while sleeping and unintentional weight loss of 40 pounds over the past 10 months. On further questioning, the patient reported having progressive dysphagia from solids to liquid over the past 10 months.
He reported being admitted to a different hospital approximately three-weeks prior, where he was diagnosed with persistent pneumonia and treated with antibiotics and steroids. The patient's hospital course was complicated secondary to pleural effusion, which required a thoracentesis. Pleural fluid analysis was negative for malignancy. CT scan of the chest during his previous hospital stay revealed extensive bilateral infiltrates and a 3 cm density in the left upper lobe. He was discharged and to follow up as outpatient with his pulmonologist.
On this admission, his initial vital signs were temperature 98.2 F, pulse 84 beats per minute, respiratory rate 15 breaths per minute, blood pressure 111/69 mmHg, and oxygen saturation 93% on room air. Physical examination was significant for rhonchi and lymphadenopathy. Chest X-ray and CT of the chest showed pneumonic infiltrates and pleural effusion (Figure and Figure , respectively), which required drainage by thoracentesis.
As the patient had dysphagia and weight loss, a barium swallow was done, which was remarkable for slow emptying and severe backflow in the esophagus followed by coughing associated with dysphagia. The patient had undergone an esophagogastroduodenoscopy (EGD) due to findings on barium study. EGD revealed a gastric fundi mass approaching the gastroesophageal juncti

[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 (G3P2) presented with abdominal swelling 10 weeks after her second vaginal birth. She had a normal pregnancy follow-up and birth process, until now, and her medical and family history did not show any feature. In the gynecological examination, external and internal genital organs were normal in size and structure. Postpartum uterine involution was regular. In the abdominal examination, a mass starting from the pelvic level, but with indistinct relation to genital organs and extending to the right upper quadrant, was palpated. In the abdominal ultrasound screening, a multiloculated mass divided with septal structures, including cystic and solid areas starting from the suprauterine level reaching to the subxiphoid region, was detected. In the further evaluation using computerized tomography () and magnetic resonance imaging () a mass starting from the pelvis and extending to the transverse colon, 26 × 22 × 16 cm in size, solid, loculated, hypervascular, and in certain regions associated with some colon segments was observed. CT angiography was performed in order to evaluate the resectability of the mass showed invasion into the superior mesenteric artery and distal branches. Biochemical tests and tumor markers were not diagnostic. According to these findings, a general surgery consultation was requested with the prediagnosis of extragenital tumoral mass.
Intraoperative observation showed an association between the mass and an approximately 15 cm of jejunal segment; furthermore many millimetric implants were diagnosed on the peritoneum. En bloc mass with a 20 cm jejunal segment resection and a left pelvic side wall peritonectomy with omentectomy was performed (). Additionally, peritoneal implants were sampled. Frozen section examination was reported as malign stromal tumor. The postoperative period was uneventful and the patient was discharged on the postoperative 7th day.
Pathologic Examination. Three peritoneal biopsies (measuring 1 cm

[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 was diagnosed with endometrial cancer by curettage because of vaginal bleeding. In a preoperative examination, chest computed tomography (CT) showed a tumor that was located at the right anterior mediastinum. Total hysterectomy with double appendages was performed on 13 March 2019. A pathological examination showed that the tumor was 3.5 × 2.5 cm, it was highly differentiated endometrial adenocarcinoma, and it invaded the superficial myometrium (<1/2 of the myometrium). There was no metastasis in bilateral pelvic lymph nodes. Because the endometrial lesion only invaded the muscle layer, there was little possibility that the anterior mediastinal tumor was related to the endometrial cancer. The staging of endometrial cancer was pIA. The patient did not receive any adjuvant therapy and was told to seek further treatment for her mediastinal tumor.
Six months after the radical operation, the patient was admitted to the Department of Thoracic Surgery without any discomfort. Preoperative thoracoabdominal CT showed a solitary 5.2- × 8.0- × 7.1-cm (W × L × H) tumor in the right mediastinum near to the pericardium (). A bone scan did not show bone metastasis. We explained the treatment plan for the patient and obtained consent for the treatment.
On 7 September 2019, the patient had an operation under video-assisted thoracoscopy. The tumor was in the right cardiophrenic angle, approximately 8 cm in maximum diameter, with a hard texture and clear boundary. The tumor adhered to the pericardium and lower lobe of the right lung. After separating the adhesions, we found that the tumor had grown in the diaphragm rather than in the mediastinum (). To completely remove the tumor, we performed thoracotomy through the right fifth intercostal space. The diaphragm was resected along with 1 cm from the margin of the tumor (). We then found that the tumor had grown into the abdominal cavity (). We stripped the tumor from the liver’s surface and removed the tumor with 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 3-year-old female presented to the Accident and Emergency Department at Alder Hey Children's Hospital in Liverpool with a 2-day history of spontaneous pain, reduced oral intake and a left-sided cervicofacial swelling. On observation, she was pyrexic at 38.4°C. All other observations were within normal limits. The patient was otherwise fit and well with no relevant medical history and no known allergies. She was born at full term with a normal delivery. Both parents reported no previous history of tooth or genetic anomalies on either side of the family.
Clinical examination revealed a diffuse swelling extending from the left buccal space to the infraorbital margin. The left eye was open and visual acuity was 6/6 on the Snellen chart. There was no evidence of cervical lymphadenopathy.
Intraoral examination demonstrated a marked fluctuant buccal swelling adjacent to the upper left deciduous canine and upper left deciduous first molar and a discharging sinus with pus exudate above the upper left deciduous central incisor []. The left maxillary dentition was partially erupted with hypoplastic and hypocalcified teeth and associated gingival enlargement. The primary teeth had abnormal morphology and were yellowish with a mottled, irregular surface. The upper left deciduous canine had a vertical crown fracture down to the amelodentinal junction []. The pulp horns were exposed on the upper left deciduous first molar [], and the upper left deciduous second molar was unerupted. The remaining dentition was caries free and had developed normally.
An orthopantomogram [] showed an abnormal morphological dentition to the upper left quadrant affecting the primary teeth from the upper left central incisor to the upper left deciduous second molar which was unerupted. It also showed that the upper left first permanent molar dental germ was affected. These teeth were radiolucent with a characteristic ghost appearance and appeared less developed in comparison to the primary teeth on 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 68-year-old male was admitted to hospital with a history of dyspnea at rest for 2 d, a cough producing mucus, loss of appetite and diarrhoea. Pneumonia was suspected, and the patient received intravenous antibiotic treatment. During the patient's second night in hospital, he was found groggy and walking near his room by the nurses. They took him back to his room and connected a new antibiotic dose to his venous catheter. A few hours later, he was found unconscious, lying on the floor next to his bed. His peripheral venous catheter was connected to a nasal cannula delivering O2 from the wall, with a flow rate of approximately 2 L/min, and the antibiotic dose was found in the garbage can. As post-mortem lividity was present, no resuscitation attempts were performed by the clinicians and the death was pronounced. The body was immediately brought to the University Center of Legal Medicine (Lausanne, Switzerland).
Before any manipulation of the corpse, a native CT scan was carried out at around 10 h post-mortem using an eight-row CT unit (CT LightSpeed 8, GE Healthcare, Milwaukee, WI). All scanning parameters are detailed in . A forensic pathologist immediately viewed the native CT images. To evaluate the distribution of gas because of physiological changes in the body after death, the radiological alteration index (RAI) was used as proposed by Egger et al. []. The RAI was based on the analysis of samples from seven sites (heart cavities, liver parenchyma and vessels, left innominate vein, abdominal aorta, kidney parenchyma, L3 vertebra and the subcutaneous pectoral tissues).
All images were interpreted in a consensus reading by one board-certified radiologist and one forensic pathologist who were trained in forensic imaging. A post-mortem radiological report was prepared and described all findings from the native CT scan. The native CT scan revealed the presence of subcutaneous, intramuscular and intravascular gas,

[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 female patient presented suffering from pain in the left upper arm over two months. The patient had been diagnosed with CCD at another hospital based on clinical features, radiographic findings, and genetic testing. The clinical characteristics included hypoplasia of the clavicles, narrow pelvis, short stature, and craniofacial malformations (). Physical examination of the left upper arm revealed no findings of redness, swelling, or tenderness. Radiographic examination revealed radiolucent lesions without any periosteal reaction in the humerus (). Magnetic resonance imaging (MRI) showed a low-signal-intensity lesion on T1-weighted images and a high-signal-intensity lesion on short-tau inversion recovery (Figures and ). In addition, a remarkable signal enhancement in the segment was found on contrast-enhanced T1-weighted MRI. A plain computed tomography (CT) showed calcification in the whole diaphysis of the left humerus (). Bone scintigraphy demonstrated increased focal uptake in the lesion (). For definitive diagnosis, we performed an open biopsy of the lesion. Based on histopathologic examination of the biopsy specimen, we diagnosed the patient with conventional chondrosarcoma in the left humerus (). On the other hand, we could not find any positive immunostaining cell for Runx2 in the lesion () and excluded metastasis of pulmonary or other lesion based on the findings of radiographs, CT, and bone scintigraphy. Thereafter, we performed wide resection of the lesion in the proximal humerus and sling procedure using free VFG for reconstruction of the large bone defect (). The distal end of the grafted bone was fixed to the proximal stump of the humerus with a locking plate. The tendons of the biceps femoris and palmaris longus, which were looped around the acromion with rotator cuff resection, were used to suspend the head of the fibula for reconstruction of the shoulder joint (Figures and ). The resected tumor was finally diagnosed as chondrosarcoma gr

[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 presents a 68-year-old female patient with a chief complaint of swollen gums and pain on mastication which has been recurring for the past 5 years. According to the patient, she started taking amlodipine 5 mg/day 7 years ago and started experiencing enlargements of the gingiva 5 years ago. She stopped taking amlodipine for 6 months and claims the enlargements improved. However, her physician recommended that she continue taking amlodipine 10 mg/day due to her uncontrolled hypertension. Medical history was taken in which the patient reported having diabetes mellitus type II and hypercholesterolemia for the past 8 years. She takes a series of drugs for her medical conditions (). She has been hypertensive for the past 7 years and has been taking amlodipine since then. She stopped amlodipine 2 years ago for 6 months due to gingival overgrowths; however, amlodipine had to be continued due to her uncontrolled hypertension.
On taking dental history, it was found that she underwent multiple gingivectomies in the past with recurrence every few months. During previous episodes, the patient had described the condition as similar to the one presented currently with excruciating pain and pus discharge. Furthermore, the patient described the treatment advised as “gum shaping by the doctor”. From patient's explanations, it was assumed that the clinical picture matched the current situation, and a history of NUG could have been prevalent at that time period.
The patient presented with a dental history that includes thick deposits of calculus and plaque on all remaining teeth with fibrous, nodular, hard gingival overgrowths extending to most of the clinical crown in the anterior and posterior parts of the maxillary and mandibular arches (). The overgrowths can be classified as grade III according to Bokenkamp's 1994 classification for gingival overgrowth [] (). Additionally, a yellowish-white pseudomembranous slough was found covering the interdental papilla in the mandibu

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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 74-year-old woman with sudden chest pain and dyspnea was admitted to the emergency room and intubated on arrival owing to disturbed consciousness. She had hypertension but no history of asthma or chronic obstructive pulmonary disease. Chest radiography showed mediastinal widening (Fig. a). Computed tomography (CT) of the chest revealed rupture of the descending thoracic aortic aneurysm, which compressed the lower trachea and both main bronchi. The maximal diameter of the aneurysm at the level of the carina was 9 cm (Fig. b, c).
Even with aneurysmal rupture, after intubation and during the diagnosis, her vital signs were maintained stable enough to be transferred to our hospital. We performed an emergency thoracic endovascular aortic repair (TEVAR, seal stent graft S&G Biotech Inc., Yongin-si, Korea, proximal 34 × 30 × 110 and distal 28 × 110). TEVAR was performed uneventfully and following admission to the intensive care unit, her vital signs were stable.
However, even with the mechanical ventilator support, carbon dioxide (CO2) retention was not easily resolved, and sudden oxygen desaturation with unusually high airway pressure and low tidal volume was repeated. Moreover, the suction tube was difficult or unable to pass the endotracheal tube. We were aware that the patient had airway compression in the initial CT, but anticipated that the extrinsic compression pressure of the ruptured aneurysm would be relieved after the TEVAR. Due to the failure to wean the patient from the mechanical ventilator, the follow-up chest CT was performed. Despite the stent graft in the aorta (Fig. a), the hematoma of the ruptured aneurysm continued compressing the lower trachea and both main bronchi (Fig. b, c).
We planned to insert a silicone bronchial stent under rigid bronchoscopy. However, after removal of the endotracheal tube, the rigid bronchoscopy was unable to enter the trachea. Further, re-intubation was not possible even with the anesthesiologist owing to the extrinsic pre

[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 5-month old female Swiss Mountain dog presented to the local veterinary practice for clinical evaluation of gait abnormalities of the hind limbs. The orthopedic examination revealed lameness in the lower right hind limb and a bony thickening at the level of the metatarsophalangeal joint between the II and III digit phalanges, covered with normal skin. The complete blood count, serum chemical and electrolyte analyses were within normal limits, apart from elevated levels of calcium and phosphorus, which were attributed to the young age (5 month) of the animal (Table ). The dog underwent a radiographic examination. Two well-defined lesions within the right II and IV phalanges of the right pelvic limb were found (Fig. a), in the shape of well circumscribed, mineralized new bone formation with a trabecular pattern. The dog underwent surgery to remove the lesion on the II phalange, and the excised tissue was sent for a histopathological examination. This revealed well-differentiated bone tissue, hyaline cartilage, and fibrous tissue in addition to hematopoietic tissue and connective tissue. Based on the histopathological findings, multiple cartilaginous exostoses (ostechondromatosis) were diagnosed. In the 1 month follow-up examination, the dog showed progressive ataxia of hind limb, a stiff gait and hyperesthesia in the thoracolumbar vertebral column. Radiographs of the hips and vertebral column exposed similar lesions to those in the pelvic limb. They were located in the distal part of the femur, on the tail and on the thoracic spinous processes of the lumbar vertebral bodies (Fig. b, c) and on the ribs (Fig. b).
At the age of 8 months, the dog was presented to the Wrocław University of Environmental and Life Sciences at the Department of Internal Medicine with Clinic of Horses, Dogs and Cats for neurological assessment. The neurological examination revealed a wide-based stance and proprioceptive ataxia in the hind limbs, moderate proprioceptive deficits in the hind l

[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 presented with a 2-month history of facial pain and limited mouth opening associated with a 3-week history of swelling of the right cheek. Radiographic analysis revealed a loculated, fluid-filled, well-demarcated lesion destroying and expanding the ascending ramus, extending out into the soft tissues, from the condyle down to the angle (Fig. ).
Incisional biopsy and histological examination revealed KCOT.
A decision was made to decompress the lesion to try and shrink the cystic space, encouraging bony infill. Over the following 3 months the patient underwent a further three re-packing procedures with irrigation of the cavity. The site of the cyst and difficulty of access necessitated general anaesthesia. The patient was admitted on one occasion for intra-venous antibiotics following an acute infective episode affecting the area. During the third operative procedure a split nasopharyngeal tube was inserted into the cyst cavity and sutured in position (Fig. ). The patient was encouraged to flush the cavity clean through the tube drain.
Radiographic examination over the following few months showed new bone formation and within 9 months of the initial biopsy the drain was expelled by formation of new bone (Fig. ). One year after the commencement of treatment the patient was admitted for enucleation of the cystic remnant. At the time of this procedure a small cyst was removed from the right upper ramus and condylar neck, together, with a separate cyst associated with the lower right wisdom tooth. The patient made an uneventful post-operative recovery and histology revealed two KCOTs with a thick parakeratinized type of epithelium typical of radicular cysts.
Plain films along with CT scan, with 3 mm slices, were performed a further year later and showed good bone regeneration in the right ramus and condylar neck (Figs and ). No evidence of cystic recurrence was seen and no abnormalities within the adjacent soft tissues. High-resolution magnetic resonance

[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 52-year-old Caucasian male presented to dermatology for initial evaluation of multiple recurring cysts, nodules, and papules. For several years, his family medicine physician treated him for sebaceous cysts (by local excision) located mostly on his upper back, but recurrence and complexity warranted further evaluation. At this visit, he described the presence of cysts that would come and go, occasionally becoming inflamed and tender. He also inquired about numerous white facial papules that were otherwise asymptomatic.
This patient had struggled with inflammatory cysts and other skin lesions for many years before being tested for BHD. In 2011, he had a large 11 cm x 7 cm painful fluctuant cystic structure located over the upper thoracic spine, along with about 20 small scattered furuncles distributed across his back. The examination also revealed a chronic non-inflamed sebaceous cyst, 2 cm x 4 cm, located anterior to the left knee. In 2015, the patient developed another sebaceous cyst, 1 cm in size, located near his right jaw. The smaller nodules scattered across his back were still present and would come and go.
Physical exam findings from the dermatology visit showed a 1 cm firm mobile nodule on the right cheek, a 2.5 cm firm mobile nodule on the right upper back (epidermoid cyst), and several 1 cm firm mobile nodules on the right superior back. Additionally, the patient had numerous white 0.2-0.4 cm papules distributed across his nose, cheeks, and forehead.
The numerous white facial papules raised concern for genodermatosis, specifically BHD syndrome or Cowden syndrome. Interestingly, the patient reported they had been present for many years, but they were not mentioned in previous records. A shave biopsy of one of the papules was sent for histopathological analysis and identified as a perifollicular fibroma. This piece of information was instrumental in leading toward an eventual diagnosis. The further genetic evaluation confirmed the presence of an

[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 Afghan woman from Afghanistan presented with abdominal pain and swelling in her right hypochondrium. The clinical differential diagnosis included simple liver cyst and hydatid cyst. A CT scan of her abdomen and pelvis showed a large cystic lesion in her right upper abdomen measuring 17.0 × 17.0 × 15.0 cm in dimensions. It was pushing the hepatic flexure inferiorly and right kidney posteriorly and abutting the head of her pancreas and the anterior abdominal wall anteriorly. It was abutting the right lateral abdominal wall on the right side and lesser curvature of her stomach on the left side. It demonstrated few enhancing septa. No solid areas or calcification were seen. It was difficult to determine the exact site of origin. However, it seemed to be arising from her liver with exophytic growth in a downward direction. Her intrahepatic ducts were not dilated. The cystic mass was pushing her portal vein upward. Her portal vein was however normal in diameter. The mass was pushing her gallbladder and her right kidney downward (Fig. ). Differential diagnoses of hydatid cyst of the liver and large necrotic abscess were given. She underwent excision of “liver cyst” in November 2012. The specimen was received as a single, flattened, irregular, firm tissue piece, which appeared to be part of a cyst wall. It measured 4.5 × 3.5 cm in diameter and was 0.4 cm in thickness. The outer surface was gray white and shiny. The inner surface was tan brown with hemorrhagic areas. Solid or nodular areas were not seen. The microscopic sections showed a cyst wall lined by a single layer of mucinous columnar epithelium with subepithelial spindly ovarian-type stroma. There was no dysplasia. The acid mucin in the epithelial cells was highlighted on mucin stain (PAS+/−AB); epithelial cells and stroma were positive for IHC stains CK AE1/AE3 and ASMA respectively. A diagnosis of intrahepatic

[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 male was admitted to hospital emergency due to 4 h of chest pain in 13 January 2016. In fact, he had suffered from fatigue after activity for more than 10 days and felt chest tightness and chest pain for 4 days before admission. The patient, a taekwondo trainee, had a healthy body, and his family history was unremarkable. Emergency aortic computed tomographic (CT) scan showed a thickened aortic wall, bilateral pleural effusion and pericardial effusion (Figs. a and b). Cardiac colour ultrasound suggested aortic hematoma or dissection (Fig. ). On the basis of the condition and the results of auxiliary examination, the formation of aortic dissection should be considered. The next day, after excluding surgical contraindications, the patient was performed an emergency operation. Cardiac surgeons underwent ascending aortic replacement and aortic arch replacement. They developed postoperative comprehensive treatment measures, including anti-infection, adjustment of cardiac function, nutritional nerve and symptomatic supportive treatment, and the patient recovered well and was discharged after 15 days. The cause of aortic dissection was unclear, although the surgeons extracted arterial tissues and pericardial tissues and sent them for pathological examination. In fact, postoperative pathology of the aortic wall tissue showed aortitis, such as visible necrosis, granulation tissue hyperplasia and a large number of acute and chronic inflammatory cell infiltration (Figs. b, c and d). However, the surgeons and the pathologist at the time did not consider the cause of aortitis or aortic dissection due to GPA because of a lack of understanding of GPA-induced aortitis or aortic dissection. This event is one of the starting points of our study. We want to attract the attention of clinicians. GPA is also a common cause of aortitis and even aortic dissection.
On the first day of 2017, the patient was re-examined for aortic CT because of a 6-day fever and right chest pain

[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 58-year-old woman at the time of the first operation was referred after identification of a tumor embolus inside the hepatic vein on abdominal ultrasonography during a medical examination. The tumor was suspected to be leiomyosarcoma of the IVC localized to the middle segment on dynamic CT, and surgery was performed (). The segment of the IVC from the renal vein junction to the diaphragm was approached using an epigastric region L-shape incision and de-rolling of the liver. First, the IVC and bilateral renal veins were clamped on the distal side, but no decrease in blood pressure was observed. Then, the IVC on the proximal side of the hepatic vein junction was clamped after performing hilar clamping with the Pringle technique. The tumor had originated in the venous wall of the middle segment of the IVC, reaching the porta hepatis and growing into the lumen. The tumor with the IVC was widely excised with adequate margins. The proximal clamp was then transferred to the IVC in the lower liver to release the hilar clamp, and the resected vessel was replaced by an artificial graft (expanded polytetrafluoroethylene (ePTFE); 16 mm with ring) by simple clamping (). She was discharged 20 days postoperatively without any major complications.
Microscopically, the lesion comprised fascicles of spindle-shaped cells with blunt-ended nuclei and was diagnosed pathologically as leiomyosarcoma originating from the IVC (). Excisional margins were negative for tumor cells.
No adjuvant therapy such as chemotherapy or radiation was performed. After discharge, the patient underwent annual follow-up PET-CT and magnetic resonance imaging (MRI). Two years after the first operation, PET-CT showed an intense accumulation of fluorodeoxyglucose (FDG) at the anastomosis on the distal side of the graft, and tumor recurrence was suspected ().
Contrast-enhanced CT revealed an extramural mass approximately 2 cm in diameter growing on the lower side of the pancreas head at the distal anastomosis of

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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 63-year-old man presented to the emergency department with a 1-month history of intermittent nausea, chills, and jaundice. Preoperative laboratories revealed an elevated total bilirubin and alkaline phosphatase. Serum tumor marker analysis revealed a normal carcinoembryonic antigen (CEA) but an elevated CA 19-9. The patient underwent a magnetic resonance imaging (MRI)/magnetic resonance cholangiopancreatography that revealed thickening of the proximal common bile duct with proximal biliary dilatation and an absence of distant disease. Incidentally noted on the MRI was that the third portion of the duodenum did not cross to the left of the superior mesenteric artery (SMA) and superior mesenteric vein (SMV), and the majority of the small intestine lies in the patient's right abdomen, whereas the large intestine lies in the left. Also, the SMA lies to the right of the SMV consistent with gastrointestinal malrotation (). The patient underwent endoscopic retrograde cholangiography with biliary endoprosthesis placement for decompression. Upon surgical exploration, a mass was identified in the proximal common bile duct (with no evidence of disseminated disease) and gastrointestinal malrotation was confirmed. Oncological resection of the extrahepatic biliary tree was performed from the level of the bifurcation of the right and left hepatic ducts to the intrapancreatic portion of the bile duct, along with a portal lymphadenectomy. A biliary enteric reconstruction was created with a Roux-en-Y hepaticojejunostomy. To compensate for the malrotation, the proximal jejunum was divided 50 cm distal to where the duodenum exited the retroperitoneum and the 50 cm Roux limb was brought up in a right paracolic position rather easily, as the hepatic flexure of the colon was absent, such that it simply rested over the top of the duodenum. An end-to-side hepaticojejunostomy was formed in a single layer, and the Roux limb was tacked down to the retroperitoneum to prevent intestinal hernia

[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 73-year-old man was lost consciousness and was transferred to our hospital. The patient had a history of testicular cancer treated with chemotherapy 2 years earlier and was in remission. He was barely able to communicate, and the complaint was unknown. Furthermore, he was in shock with cold extremities. His blood pressure was unmeasurably low, and neither the radial nor the common carotid artery was palpable. However, his limbs were still moving. His Glasgow Coma Scale result was E1V2M4 and his mental status was agitated state. Peripheral intravenous infusion was initiated and transthoracic echocardiography revealed pericardial effusion and almost no systole. Pericardial fluid was hyperechoic, which could signify hematoma formation. Pericardiocentesis was duly considered, but if a hematoma was present, it could have led to insufficient drainage. We decided to initiate ECMO in the emergency ward based on a judgment of obstructive shock or cardiogenic shock. Seven minutes after arrival, cardiopulmonary resuscitation (CPR) was started because of CPA (his breathing and limbs stopped moving), before beginning ECMO. We also considered emergency left thoracotomy, but ECMO was prioritized. We inserted an ECMO catheter under ultrasound guidance. ECMO circulation was started 17 minutes after arrival and 10 minutes after CPA. Twelve-lead electrocardiography (ECG) revealed a QS pattern and ST elevation in leads V1-V5 (Figure ). We did not drain the pericardial fluid, but ECMO flow was stabilized using rapid infusion. The patient was immediately cooled with ECMO and reached a body temperature of 34°C 23 minutes after CPA. He was then transferred for computed tomography (CT) for diagnosis. Contrast-enhanced CT showed no acute aortic dissection (AAD), but the anterior wall myocardium showed poor contrast; hence, we diagnosed LVFWR. According to his family, he had never complained of chest pain. We assumed that the myocardial infarction had occurred 12 to 24 hours before his arri

[Assistant]
ICD-10-CM Coding based on findings:
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[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 35-year-old woman presented to us after an accident in which her back was impacted by an 80-kg-heavy-giant rubber tire with metal wheel hub. When the tire fell down from about 10 m high, the patient was standing right under it and the middle thoracic back was hit by the tire from above. She felt pain in her back and remained in place until emergency personnel arrived. After conservative management in the local hospital for 3 days, the patient was transferred to our hospital safely. During the 3 days in the local hospital, the patient received neurotrophic factors and antithrombotic reagent given by venous transfusion without any reduction treatment and she hesitated to accept a surgery. Upon examination, her blood pressure was 142/94 mmHg, pulse rate 60 per minute, respiratory rate 15 per minute, and body temperature 37 °C. She denied numbness and weakness in her extremities. Physical examination revealed that she was neurologically intact without focal sensory or motor deficits and had normal reflexes. Neurological examinations revealed a Frankel grade E. According to ASIA scoring system, the patient got 112 points for light touch sensation, 112 points for pain sensation, 50 points for the upper limb main muscles, and 50 points for the lower limb main muscles. No perianal sensory was lost. Normal anal contractility and sphincter reflex were observed. A severe tenderness point was found in the middle back. She had Medical Research Council (MRC) grade 5 power in both lower limbs. Associated injuries were pulmonary contusion resulting in right pleural effusion, which was treated by chest tube insertion in the local hospital. No neurogenic bladder or fecal incontinence was observed.
Spine radiography revealed a burst fracture of T7 with complete fracture-dislocation and sagittal displacement of the T6-7 vertebrae (Fig. ). Spinal computed tomography revealed fractures involving the left pedicle of T4; spinous process, vertebral laminae, and bilateral pedicles of the T

[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 35-year-old left-handed man who works as a mechanic and firefighter presented to our institution with hand pain and cold intolerance for 3 months. He was referred by a local vascular surgeon who had made the diagnosis of hypothenar hammer syndrome (HHS) following an angiogram of the right upper extremity showing complete occlusion of the ulnar artery (). On initial examination, Doppler signals of the ulnar artery, superficial palmar arch, and ring/small digital arteries were absent in the right hand. Subsequently, the patient developed an ulcer on his right long fingertip after minor trauma that had not healed over a 4-week period. He suffered ischemic hand pain and severe cold intolerance. After conservative management failed, the decision was made for operative intervention. We proposed using an arterial graft versus a venous graft in order to improve long-term patency. Our plan was to utilize the descending branch of the lateral circumflex femoral artery (DLCFA) as an arterial graft.
Intraoperatively, Doppler ultrasound revealed a segmental thrombotic defect extending from the superficial palmar arch, across the Guyon canal, extending 10 cm proximally in the forearm. The ulnar artery was resected back to healthy bleeding pulsatile flow, resulting in a segmental defect of 12 cm. Final pathology of the submitted ulnar artery segment revealed organizing thromboembolus in the lumen, which at the time of resection was adherent to the lumen.
The DLCFA was harvested, with care taken to prevent injury to the lateral femoral cutaneous nerve. A 12-cm segment of the artery was circumferentially dissected, as well as approximately 2 cm of 2 branching vessels at the distal end of the segment that would be used to reconstruct the superficial palmar arch and common digital arteries with one graft. With the arterial graft completely dissected, it was ligated both distally and proximally.
The arterial graft and recipient vessels were examined under the operative microscope. 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 45-year-old lady presented with left supraorbital firm swelling for 3 months which started as a nodule of the size of a grain of rice. Swelling increases in size rapidly involving eyelid, entire orbit, and subsequently to the forehead. It also becomes intermittently painful. She started to loss her left eye vision gradually until it completely loss one month later. The patient presented to the ophthalmology clinic where further investigations were done. On examination, there was a huge soft to firm lesion involving entire left orbit extending to nasal bridge and forehead as shown in . Right eye vision is 6/12 with no visual field loss but left eye completely blind. There is no nodal involvement or organomegaly. Further detailed investigations ruled out systemic involvement. Computed tomography (CT) orbit and CT brain done as shown in . Due to the intracranial extension of the tumor, magnetic resonance imaging brain was done as shown in and the patient was referred to neurosurgical. The patient was planned for surgery electively 2 weeks later. On the day of admission 1 day before surgery, the tumor size has doubled compared to its size in clinic review 2 weeks prior. The patient subjected to craniotomy with total tumor excision and reconstructive cranioplasty approached through a bifrontal incision.
Intraoperatively, the tumor is fleshy, friable, well defined, and highly vascular. The tumor noted to originate from orbital adnexa but sparing the globe. There is an invasion of bone and dura over the frontal lobe with 2 cm by 2 cm intracranial extra-axial tumor in the left frontal convexity. The frozen section was sent intraoperatively and reported as malignant tumor unable to rule out lymphoma. Thus, complete excision of the tumor was done including the bone, dura, and the intracranial tumor. Nasal bridge, frontal bone, and left eye orbital wall completely eroded by tumor, thus, needing reconstructive cranioplasty with titanium mesh, nasal bridge repair with sugar me

[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 patient visited our clinic in May 2005 due to detachment of a porcelain-fused-to-metal crown on the left maxillary central incisor, which had been connected at another clinic in 2000.
There were no special findings in his physical and extraoral conditions. On intraoral examination, mesiodistal fracture lines were found on the remaining tooth structure. A swelling and slight redness were observed on the peripheral soft tissue, but there were no acute symptoms such as purulence or pain [Figure and ].
Radiographic examination showed no inflammatory symptoms, such as an increased periapical space, bone resorption, or periapical radiolucency, thus, the inflammation was judged confined almost exclusively in the gingival tissue. A nasopalatine foramen was found adjacent to the apex of the maxillary left central incisor [].
The maxillary left central incisor had a root fracture and required extraction. After a careful consultation about various treatment options, the patient desired implant treatment. Because there existed no obvious signs of acute inflammation or any other symptoms of the soft and hard tissue, postextraction immediate implant placement was planned. Prior to the implant treatment, the patient was subjected to meticulous scaling of all the remaining teeth and oral hygiene instruction session.
In May 2005, the maxillary left central incisor was extracted. After careful curettage of the extraction site, the mucoperiosteal flap was reflected. There was no resorption of the labial bone and an implant (TiOblast, Astra Tech, Mölndal, Sweden, ø 4.5 mm, length 13 mm) was placed into the fresh extraction socket with good primary stability. The osteotomy was made so that the implants would be located centrally in relation to the socket; however, careful drilling was conducted in order to preserve the buccal wall. The gap between the fixture and the socket wall was filled with autogenous bone particles collected during the surgery. The wound was clos

[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-years old unmarried female from Bajura district of Nepal came to the dermatology out-patient department with a complaint of a single plaque over the right upper lip for the last 6 months. Lesion started as a small red papule which gradually increased in size with central crusting. No history of fever or weight loss was given. There was no significant family or medical history. Multiple over the counter treatment was used as trial without relief. There was no history of travel outside of her village until the time for consultation.
On examination, a single round to oval crusted plaque approximately 1.5 × 1.5 cm was noted over the right upper lip. Neither an induration nor easy bleeding was noted. No regional lymphadenopathy was present ().
A slit skin examination was done for acid-fast and Giemsa stain which was negative for any organism. An incisional biopsy was done which showed multiple epitheloid type multinucleated giant cells suggesting Lupus vulgaris. However, a mantoux test revealed an induration of only 2 mm in 48 hours.
The morphology of lesion prompted us to investigate furthermore for cutaneous leishmaniasis before starting on anti-tubercular medications. We decided to do PCR for Leishmania species from the lesion. The sample was sent to the Laboratory of the Central Department of Biotechnology, Tribhuvan University, Kathmandu, Nepal due to unavailability of PCR in the National Academy of Medical Sciences, Bir hospital. PCR was done using the nested protocol previously described by Noyes, et al. in 1998. The DNA template for PCR was extracted manually from the lesional tissue. After second-round PCR, a band size corresponding to the size of approximately 700 bp was obtained that confirmed the presence of Leishmania parasite (). The band size corresponded to that typical of Leishmania donovani.
A serological test conducted with an rk39 rapid diagnostic test kit also tested positive for this case.
An

[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:
We report the case of a 56-year-old woman presenting with decompensated cirrhosis caused by hepatitis C virus (Genotype 4). As a part of our routine pre-transplant workup, we performed dynamic abdominal computed tomography (CT), which showed 2 focal hepatic lesions, measuring 1.5 and 3 cm, in the liver segments 8 and 5, respectively. On dynamic imaging, the lesion in segment 8 showed the typical vascular pattern of an HCC (), but that in segment 5 showed an atypical vascular pattern and was closely related to the inferior vena cava (). Serum alpha-fetoprotein (AFP) level was normal, but serum carbohydrate antigen 19-9 (CA19-9) level was slightly elevated (63 U/mL); extrahepatic spread was ruled out. The patient was assumed to have HCC on the basis of the presence of 2 focal hepatic lesions within a cirrhotic liver having viral hepatitis, particularly the smaller lesion in segment 8 that showed the typical vascular pattern of HCC on dynamic imaging. The model for end-stage liver disease (MELD) score was below 14; however, because the patient met the Milan’s criteria for selecting patients with an HCC for LT (), she was listed for LT and underwent uneventful deceased-donor LT after a 3-month waiting period. Histopathological examination of the explant confirmed that the lesion on segment 8 was an HCC (), but that on segment 5 was a cholangiocarcinoma (). Further histological evaluation of the lesion on segment 5 revealed that the tumor cells expressed cytokeratin (CK) 7, CK19, and carcinoembryonic antigen (CEA) and lacked AFP expression, liver-specific antigens, CK20, and CD34. The cell morphology and phenotype of the tumor cells were consistent with those of cholangiocarcinoma. Our standard immunosuppression protocol includes tacrolimus, mycophenolate mofetil (CellCept), and a tapering course of steroids; however, on the basis of the findings of the 6-week follow-up examination of the explant after LT, tacrolimus was replaced with sirolimus

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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 62-year-old woman was transferred from another hospital after being diagnosed with COVID-19. She had been admitted to the other hospital after 8 days of fever, when she developed respiratory distress occurred during isolation. At the time of her transfer to our hospital she was being treated with empirical antibiotics and oseltamivir and was receiving 4 L/min of supplemental oxygen via nasal prongs. Her CXR and CT findings at the previous hospital are shown in . The LUS was performed with the patient in the supine position. Multiple B-lines were observed in the anterior right upper lung field, and both anterior lower lung fields, but not the anterior left upper lung field. Her lung aeration score was 3 points (), based on the LUS findings in both anterior areas. Although lopinavir/ritonavir was started immediately after transfer to our hospital, she was intubated on Day 3 after her respiratory symptoms became more severe. LUS performed on Day 4 showed a worsening of her pneumonia, with the lung aeration score of 5 points (). After mechanical ventilation, the patient’s CXR and LUS aeration score improved from 5 to 4, but her hypoxia remained severe (ratio of arterial oxygen partial pressure to fractional inspired oxygen [P/F ratio] 133 on Day 8). As a rescue therapy for ARDS, methylprednisolone (1 mg/kg intravenously) and inhaled nitric oxide were administered.
Despite these interventions, the patient continued to deteriorate, and veno-venous extracorporeal membrane oxygenation (ECMO) support was started on Day 16. Her CXR showed worsening of her pneumonia, and a LUS performed on Day 18 (2 days after ECMO application) showed a lung aeration score of 13 points (), which was worse than it had been on Day 3 (the day of intubation). () The patient was subsequently diagnosed with hospital-acquired pneumonia caused by carbapenem-resistant Acinetobacter baumannii cultured from a respiratory sample.
Under the ECMO support, LUS was performed before

[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.