[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 Chinese woman presented to the First Hospital of Jilin University with complaints of abdominal pain, vomiting, and bloody stool for 24 hours. On admission, her general condition was good. Her temperature was 37.1 °C, respiratory rate was 18 times per minute, and heart rate was 80 beats per minute. She did not have cutaneous or scleral icterus. No superficial tumescent lymph nodes were observed. A physical examination showed distended abdomen with no stomach outline, peristalsis, and varicose veins. Abdominal breathing was slightly limited. Abdominal tenderness could be detected in her right abdomen accompanied by rebound tenderness and muscle tension. A palpable mass could be detected in her right lower abdomen. Liver, spleen, and gallbladder could not be touched below the costal arch. Murphy’s sign and shifting dullness were negative. Bowel sound was found to be approximately 7 beats per minute with gurgling. A neurological physical examination had no significant findings. A physical examination of her heart and chest was normal. She was a housewife in a small city with no special family history. She had a history of hypertension for 10 years, and the use of captopril helped maintain a satisfactory level of blood pressure. She denied a history of hepatitis, tuberculosis, and diabetes. Also, no history of drug allergy, surgeries, tobacco smoking, and long-term alcohol consumption was reported. The results of complete blood count, liver function, and blood biochemical indexes are shown in Tables and . The results of coagulation markers of hepatitis B virus, hepatitis C virus, syphilis, and human immunodeficiency virus were found to be negative. Abdominal computed tomography (CT) was performed, which showed some intestinal canals and mesentery entering into the right colon. The CT scan showed a target sign suggesting intussusception in her right abdomen (Fig. , ).
Surgical exploration revealed that the ICD entered her ascending colon with edema (Figs. ,

[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 62-year-old Chinese man who had myocardial infarction on anterior wall was recommended for cardiac surgery after diagnosed with unstable angina. His cardiac function was grade III according to the New York Heart Association classification. Coronary angiography showed triple-vessel lesions. Echocardiography revealed paradoxical cardiac movements in the apex of the left ventricle in the systolic phase without mural thrombosis. The left ventricular ejection fraction was 0.40 and the left ventricular end-diastolic diameter was 55 mm. Preoperative 12-lead electrocardiography (ECG) showed premature ventricular contractions (PVC). 12-lead Holter monitoring confirmed the presence of frequent multifocal VA (26400/24 h) and paroxysmal ventricular tachycardia. The patient had non-sustained ventricular tachycardia, and did not show mural thrombi. The patient took at least three kinds of anti-arrhythmic drugs including beta-blocker, lidocaine, and amiodarone to reduce the occurrence of VA before the operation. However, those anti-arrhythmic drugs did not seem effective for the patient.
Standard median sternotomy incision was used to expose the heart. Off-pump coronary artery bypass (OPCAB) grafting was performed. A left internal mammary artery was grafted to the left anterior descending artery and a saphenous vein was anastomosed to the diagonal branch, the obtuse marginal artery, and the right coronary post-descending artery sequentially. The border of the aneurysm wall was clear on the beating heart.
A bipolar intramural electrode placed at the base of right ventricle via right femoral vein was used to record a reference electrogram. Ventricular tachycardia appeared spontaneously during the operation. We used more than 40 predetermined locations on the left ventricle to record bipolar potential to construct ventricular epicardial depolarization map. The time point when the epicardial spike moved the most rapidly, approximately 7 ms, represented the moment at which electrical

[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 25-year-old lady without any co-morbid illness presented in May 2006, with history of nonspecific abdominal pain and backache of one year duration. General condition was unremarkable. There was no pedal edema. Examination of abdomen revealed a 6 × 5 cm nodular retroperitoneal swelling in the right hypochondrium. Radiological imaging with ultrasonography, computed tomography and magnetic resonance imaging and magnetic resonance angiography revealed a retroperitoneal mass arising probably from the IVC, encasing the right renal vein and infiltrating the right kidney with ?tumor in the IVC []. Multiple large collateral vessels were also demonstrated []. The infra-renal IVC was completely blocked by the tumor [Figures and ].
She underwent exploratory laparotomy under general anesthesia on 5 July 2006. The tumor was found to be arising from the suprarenal IVC (around 2 cm below the hepatic veins) with dense adherence to right kidney and extension of tumor down to right renal vein and both common iliac veins (whitish discoloration and thickening) []. Left renal vein was free and IVC was patent at its entry. The collaterals were large and well-developed. But the IVC below the renal veins was blocked completely by the tumor which became circumferential. The tumor which extended downwards was intra-luminal in the lowermost part of the IVC. She underwent resection of the infra hepatic IVC distally up to just beyond the bifurcation of both common iliac veins with right nephrectomy and legation of left renal vein. The IVC was resected beyond the bifurcation of common iliac veins because of the suspicious thickening and whitish color of the IVC. In the immediate postoperative period, she developed anuria and azotemia (5 mg/dl of creatinine and 80 mg/dl of urea.) The USG and Doppler study done then showed congested left kidney with sluggish flow in the left renal vein. She was re-explored within 18 h. Intraoperatively the left kidney appeared congested and there was a small

[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 28-year-old Asian woman (G3P1) who had undergone emergency cesarean delivery owing to a compound presentation at full term was referred to our institution with a suspicion of abnormally located gestational sac. She had undergone laparoscopic cholecystectomy and open appendectomy previously. She did not have any medical, family, or psychosocial history. She had missed her menstrual period without any other symptom and visited a private obstetrical clinic to confirm the pregnancy. However, she was diagnosed as having an abnormal pregnancy such as cervical or CSP by USG.
At our institution, she reported that her last menstrual period was just 5 to 6 weeks prior. However, USG revealed a gestational sac in the anterior lower uterine segment with a fetus measuring 4.83 cm crown-rump length (CRL) with positive cardiac activity, corresponding to 11 weeks and 6 days of gestation. Color/power Doppler images depicted a hyperechoic rim of a choriodecidual reaction with excessive vascularity (Fig. ). Although we could observe a definitive abnormally located gestational sac, our patient did not have any pain during the physical examination. She admitted that her last menstrual period was different from her usual menstrual periods. Because CSP or cervical pregnancy was suspected, we performed computed tomography (CT) for a definitive diagnosis. The CT scan showed an intrauterine gestational sac in the lower uterine segment bulging through the anterior uterine wall at the site of the cesarean scar. No invasion of the urinary bladder was observed (Fig. ). On presentation, her β-human chorionic gonadotropin (β-hCG) level was 66,536.8 IU/L (Day 1). Initially, we injected 50 mg of methotrexate (MTX) mixed with 9 mL of normal saline in the amniotic sac through a 22-G needle transabdominally under USG guidance. Simultaneously, 2 ml of amniotic fluid was aspirated for termination of the pregnancy. However, fetal cardiac activity was still observed 2 days later (Day 3), without significa

[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 with no remarkable medical and family history was admitted to our hospital. When the patient was admitted to our hospital, the patient was of moderate build, was well nourished, had no yellowing of the bulbar conjunctiva, had no conjunctival pallor, and displayed no unusual finding in the heart or lungs. The abdomen was flat; the liver and spleen were not palpable. No remarkable finding was observed. An elastic, hard tumor approximately 30 mm in diameter with relatively distinct boundaries was felt in the left C/D region. The tumor was observed to be not fixed to the pectoral muscle and had not infiltrated the skin. No abnormal nipple discharge was observed, and axillary lymph nodes were not palpable. Peripheral blood and blood biochemistry test results were normal.
By mammographic examination, a local asymmetric shadow was observed in the left M area, and the tumor was classified in Category 3 (Fig. ). Ultrasonographic analysis revealed that a hypoechoic area measuring 18 × 31 × 24 mm with partially calcified areas and a hyperechoic margin was observed in the C/D region of the left breast. The lesion had a Tsukuba elasticity score of 2 and internal blood flow, strongly suggesting malignancy (Fig. ). By CT examination, a thoracoabdominal CT scan did not reveal anything unusual, such as enlarged axillary lymph nodes or distant metastases in other organs.
Based on the above findings, the patient was given a preoperative diagnosis of T2N0M0 Stage IIA cancer of the left breast, and left modified radical mastectomy and axillary lymph node dissection were performed.
The tumor was a solid, light gray nodular lesion with distinct borders and measured 32×22 mm. Histologically, the tumor was a squamous cell carcinoma with prominent keratinization exhibiting an infiltrative growth pattern. The tumor had no connection to the epidermis and partially transitioned into the atypical ductal epithelium (atypical metaplasia) in the area surrounding the focus. These

[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 69-year-old woman who presented to her primary care physician with worsening cough and pain wrapping around her chest to her back. The chest pain was initially thought to be pleuritic in nature and related to an exacerbation of her chronic obstructive pulmonary disease (COPD). When there was no improvement in her symptoms with treatment of her COPD, and considering the confounding radicular distribution of her pain, a plan was made to have an MRI of the spine performed to explore other possible etiologies of her pain.
Prior to the scheduled MRI, the patient was seen in the emergency department and diagnosed with a myocardial infarction due to hypertensive emergency. During her admission to the hospital, the patient was noted to be experiencing neck pain, bilateral upper extremity pain in a C8-T1 dermatomal distribution and a loss of urinary and fecal urges. On examination, the patient’s force of flexion and abduction in her upper extremities were mildly reduced. The strength in her lower extremities was decreased. Her deep tendon reflexes were 3+ in her bilateral upper extremities and 3+ in her bilateral lower extremities with clonus at the ankles.
She had bilateral extensor plantar responses. In light of these progressive myelopathic symptoms a spinal MRI was done.
The initial pre and post -contrast MRI of the entire spine showed extensive, mostly brightly enhancing intradural extramedullary nodules extending from C5–6 to T11 (Fig. ). Some nodules at the T6 level were only minimally enhancing, with pre-contrast T1 hyperintensity apparent. The lesions were causing multilevel severe central canal stenosis with multilevel cervical and thoracic spinal cord compressions. The largest mass conglomeration extended from C6 to T4, measuring up to 1.2 cm AP × 1.9 cm transverse × 10.0 cm CC. Despite the extensive mass effect with flattening of the spinal cord, the spinal cord demonstrated no intramedullary T2 hyperintensity except for a small focus of enhancin

[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 49-year-old Iraqi male presented in February 2011 to the American University of Beirut Medical Center (AUB-MC) with fever, chills, chest pain, anorexia, and weight loss after being operated on for a presumed malignant thymoma in India. His initial history goes back to May 2010 when he was diagnosed with myasthenia gravis in Iraq and was started on prednisone 60 mg orally and mestinon 60 mg orally three times per day. A computed tomography (CT) of the chest done in Iraq showed a cystic mediastinal mass abutting the right ventricle described as thymoma (images not available) but very similar to the CT done at our institution later. No interventions were undertaken in Iraq. He was then referred for right lateral thoracotomy in India in November 2010. Pathology revealed malignant thymoma. The patient remained hospitalized in India for 3 weeks where he reported chills, weight loss, and sweating without any documented fever. He was started on chemotherapy (unknown regimen) and was discharged home on levofloxacin 500 mg orally daily for ten days. No microbiological work-up was initiated in India to try to detect an underlying infectious process. The period from December 2010 until February 2011 in Iraq was characterized by recurrent chest pain, fever, chills, sweating, cough, and greenish sputum production. Blood tests at that time showed a WBC of 26,000/μL. Repeated CT of the chest showed multiple cystic masses impinging on the right ventricle and left atrium described as metastasis in concordance with his history of malignant thymoma (). At a local hospital, he received blood transfusion, fluconazole, and cefotaxime both at unknown frequency and dosage without improvement. He then had a PET scan in Lebanon showing cystic masses in the chest with necrosis and invasion of the pericardium described as metastasis. He presented to our institution where echocardiography showed two large anterior fluid collections one of which was compressing the right ventricle with a third

[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 Caucasian patient was referred to the periodontology department for evaluation of a gingival recession on the maxillary left second molar. The patient's medical history revealed no systemic diseases or allergies. The clinical () and radiographic () evaluation revealed 5 mm Miller Class II recession [] on the second molar buccal aspect. There was discomfort during tooth brushing, described by the patient, and permanent inflammation in this area. The probing depths were ≤2 mm, and apically to the recession, there was absence of keratinized gingiva. The proposed treatment was a connective tissue graft combined with a laterally displaced flap.
Prior to the surgery, the patient underwent one session of scaling and polishing and received oral hygiene instructions in order to reduce the local inflammation. After explaining the objectives of the surgery, a written informed consent was obtained. The surgery started with the administration of local anesthesia and careful scaling of the exposed root surface, and a partial-thickness flap dissection was extended down into the vestibule, permitting passive coronal positioning of the flap. While preparing the flap, an oroantral communication was found apically to the first molar mesial buccal root with 3 mm diameter ().
Oroantral communication closure started by suturing the Schneider membrane with a 6 0' absorbable suture (monofilament polyglecaprone suture, Surgiclryl-Monofast ®SMI-Belgium) to close the perforation (). A connective tissue graft was harvested from the palate according to the technique described by []. The recipient bed was measured as well as the palate thickness. Using a #15 blade, oriented perpendicular to the palatal surface, a single incision was made 3 mm apical to the gingival margin of the maxillary teeth. The partial-thickness dissection was made as apically as needed to obtain a graft measuring 12 mm length and 7 mm width. The connective tissue was elevated from the palate, and the d

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


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

[User]
RADIOLOGY NOTE:
A 16-year-old male patient reported with a chief complaint of swelling on the right side of the face for the past 2 months []. The swelling was initially noticed as a small lump which gradually increased to the present size. Medical and family histories were noncontributory. Examination revealed swelling in the right side of the face about 1.5 × 2 cm in size in the region of angle of mandible. There was no draining sinus and the skin over the swelling was clinically normal.
Intraorally the swelling was present in the buccal aspect of right mandibular second molar measuring about 1.5 cm × 1 cm in dimension. Mucosa over the swelling was clinically normal. Buccal cortical bone expansion was seen along with obliteration of buccal sulcus. On palpation the swelling was firm, nontender and extended superiorly to involve the anterior border of ramus of the mandible.
CT scan revealed an osteolytic lesion about 2.5 cm × 2 cm in dimension, extending from the distal aspect of 47 to the ramus of the mandible. Destruction of buccal cortical plate was evident. The clinical and radiologic findings were suggestive of odontogenic tumor [Figures –].
Subsequently, an incisional biopsy was performed under local anesthesia and the specimen was sent for histopathologic examination. Microscopic evaluation of the sections revealed interlacing fascicles of spindle-shaped cells arranged in a biphasic pattern set in a collagenous stroma. Spindle cells were seen with oval, round and tapering nuclei with pale eosinophilic cytoplasm. These cells were seen alternating with closely packed cells with small rounded nuclei and eosinophilic cytoplasm []. Vascular spaces mimicking the hemangiopericytoma pattern were also observed []. Cellular atypia was not noted. Based on these findings we arrived at a diagnosis of myofibroma.
Immunohistochemical staining was carried out for vimentin, S100, αSMA, CD68, and desmin. Positive immunoreactivity was observed for vimentin and αSMA [Figures and ]

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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 20-year-old woman presented to the emergency department with complaints of severe abdominal pain, multiple episodes of vomiting and obstipation for one day. She was a known case of abdominal tuberculosis and had received anti-tubercular treatment for two months. Vital signs showed a blood pressure of 100/64 mm Hg, heart rate of 110 per minute, respiratory rate of 18 per minute, oxygen saturation of 96% on room air and a temperature of 100.5°F. She was cachectic with a weight of 28 kg which was less than 5th percentile for gender and age matched normal population. Physical examination revealed diffuse abdominal tenderness and rigidity. Her erect abdominal radiography showed gas under right dome of the diaphragm. Clinical diagnosis of perforation peritonitis was made and the patient was wheeled to the operating room for emergent laparotomy. Intraoperatively, a 3 cm x 2 cm single ileal perforation was found 1 foot proximal to the ileocecal junction, with unhealthy bowel margins and multiple mesenteric lymphadenopathy. Resection of perforated bowel segment with proximal ileostomy and mucus fistula of distal ileum was performed. Later, histopathology report confirmed tubercular etiology showing caseous necrosis in mesenteric lymph nodes and epithelioid granuloma in ulcer edge biopsy. Two days after the surgery, the patient was started on oral feeds and was accepting meals orally subsequently. Ten days following surgery, the patient had multiple episodes of bilious vomiting with stoma output decreasing to less than 100 mL per day. Her abdomen remained flat with no increase in bowel sounds. Abdominal radiography showed dilated stomach with no air fluid levels. Oral feeds were stopped and a nasogastric tube was placed for drainage of gastric contents. A contrast enhanced computed tomography (CECT) abdomen was done to determine the cause of obstruction which revealed a decreased aortomesenteric angle of 15° (Figure ).
As a result of this decreased angle, an abrupt collapse

[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:
The second patient was a 70 year-old male admitted to our hospital for progressive cognitive decline. He had a history of ISS stage I IgG kappa MM (in the absence of chromosome 17 deletion or a 4;14 translocation) with onset six years previously. He had initially been treated with two VAD induction cycles and a subsequent hematopoietic stem cell autograft and had shown a partial response. After three treatment-free years, the patient presented with a progression of MM. Combination therapy with bortezomib and an anti-insulin-like growth factor-1 antibody was introduced. These agents were withdrawn after 4 months because of the occurrence of severe neuropathy and were not replaced. Eighteen months later, combination therapy with lenalidomide, dexamethasone and an anti-CS1 antibody was initiated following an increase in the M component, with no signs of hyperviscosity syndrome. After one month of treatment, the patient complained of memory loss, apathy and word-finding difficulties, with repercussions on ADL. An initial cognitive assessment revealed a severe impairment in episodic memory (with poor free and cued recall in the FCSRT, see Table
), whereas other cognitive functions (such as executive function and construction) were within the normal range. The patient’s global cognitive efficiency was scored as 128 out of 144 on the Mattis Dementia Rating Scale (DRS)
[] and 26 out of 30 in the MMSE. The neurological examination was normal. Brain MRI revealed widespread white matter lesions and overall atrophy. The patient was offered regular clinical monitoring. Seven months later, the patient developed erythroderma and so lenalidomide was withdrawn. The patient and his wife both reported an overall improvement in cognitive function, with a decrease in apathy and improved memory. The patient had recovered his independence in ADL. A cognitive assessment was performed six months after the withdrawal of lenalidomide treatment. Although the patient’s global cognitive efficie

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


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

[User]
RADIOLOGY NOTE:
A 56-year-old man with no background medical history or past ophthalmic history was referred by his general practitioner for a left nasal pterygium. The lesion had been causing ocular irritation and had initially been reviewed by an ophthalmologist 10 years earlier. Since that time, the patient reported that the lesion had slowly grown and his irritation had worsened. On examination, best-corrected visual acuity was 20/20 bilaterally and anterior and posterior segment examinations were unremarkable apart from a left conjunctival lesion. This pearly white lesion was situated on the nasal limbus of the left eye and was circular in shape with a 4 mm diameter. It was easily mobilized and appeared to be free of any deeper scleral invasion. Overall, the lesion had an appearance in keeping with an ocular surface squamous neoplasm and wide local excision of the lesion, and reconstruction with a superior autoconjunctival graft was recommended with adjunctive mitomycin C. This uncomplicated procedure was undertaken 3 weeks later.
Histopathology of the operative specimen reported a possible low-grade mucoepidermoid carcinoma, and the specimen was referred to an ophthalmic pathologist who confirmed the diagnosis of low-grade conjunctival mucoepidermoid carcinoma 2 weeks later. Initial hematoxylin and eosin stains were followed by periodic acid-Schiff diastase stains, which confirmed the mucinous components of the lesion ( and ). The specimen showed conjunctival and limbal tissue that was infiltrated with carcinoma at the limbus. It was composed of islands of well differentiated epithelial cells showing both squamous and glandular differentiation with the glandular lumina containing inspissated mucoid material (). No immunohistochemical testing could be conducted on the specimen. A course of 0.04% mitomycin C was prescribed four times a day for 1 week, followed by only ocular lubricants for 1 week, followed then by another week of mitomycin C four times a day.
On review 2 months

[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 77-year-old man with left groin pain and swelling was referred to our hospital. He had a history of hypertension, dyslipidemia, interstitial pneumonia, chronic kidney disease, and myocardial infarction requiring percutaneous coronary interventions. He underwent aortic valve replacement and the Maze procedure for aortic valve regurgitation and atrial fibrillation at 68-year-old, followed 3 months later by endovascular aortic repair (EVAR) for abdominal aortic aneurysm. At one month after EVAR, he underwent femoro-femoral arterial bypass (FFB) for limb graft occlusion following EVAR. He also had a history of repeated ventricular tachycardia and underwent implantation of an implantable cardioverter defibrillator (ICD). In addition, he had prostate carcinoma treated with radiation therapy. On physical examination, the subcutaneous FFB graft was palpable in the suprapubic region, and left inguinal hernia was identified. Computed tomography (CT) revealed a left inguinal hernia and a FFB graft anastomosed between bilateral common femoral artery in the subcutaneous space anterior to the pubis (). Because the patient was considered at high risk for general anesthesia and had previous radiation therapy to the pelvis which can develop adhesions in the preperitoneal and peritoneal cavity, we scheduled an anterior tension-free hernioplasty under local infiltration anesthesia. Aspirin was continued in the perioperative period to reduce the risk of cardiovascular ischemic events. The location of the subcutaneous FFB graft was marked on the skin with a pen (). The surgical field was prepared and draped with an iodine-impregnated occlusive dressing, then step-by step local infiltration anesthesia was administered, starting prior to making the incision with the combination of 1% lidocaine with epinephrine 1:100,000 and 0.25% bupivacaine. A 6-cm skin incision was made from 1-cm above the center of the left inguinal ligament toward the midline, and the subcutaneous tissue was dissect

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


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

[User]
RADIOLOGY NOTE:
A 56-year-old Moroccan woman with no significant past medical history presented to gynecological consultation in June 2009 with a one-month history of dysuria, burning urination, and progressive lower abdominal distention. She had previously given birth to one child. The patient was menopausal since ten years ago.
Clinical examination revealed a painful distended abdomen with bulky uterus. The adnexa were normal on palpation.
Transabdominal ultrasonography demonstrated a solid uterine mass. The ovaries were not visualized and there was no ascite. Magnetic resonance imaging (MRI) of the pelvis showed a voluminous and heterogeneous uterine mass measuring 12 × 10 cm. The lesion was located at the uterine corpus and was displacing bladder and rectum. The ovaries appeared normal and there was no lymphadenopathy. The tumor appearance suggests a calcified fibroma.
The patient underwent a total simple hysterectomy. During surgery, a 12 cm mass was attached to the uterine corpus. The en bloc resection of this voluminous mass was impossible and the tumor was fragmented. Up to 20 pieces were removed. On sectioning, the fragments were macerated and showed various tissue consistencies.
Microscopically, the tumor was an immature teratoma, composed of a mixture of embryonic mature and immature elements. The tissue types found included nerve ovoid cells involved in a fibrillar background, active cartilaginous foci, and glandular formations. The immature component was dedifferentiated cells around epithelial tubes with the presence of mitoses ().
Our patient recovered well from surgery and a surveillance approach was taken.
Three months later, the patient presented with vaginal bleeding. On digital examination of the vagina, she was found to have friable mass filling the upper half of the vagina with severe bleeding.
Pelvic and abdominal computer tomography (CT) scan revealed a bulky mass of 14 × 8 cm filling the pelvic cavity. The tumor was involving the bladder and the rectosigmoi

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


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

[User]
RADIOLOGY NOTE:
A 56-year-old lady presented to shoulder clinic with a one-year history of pain over her left dominant acromioclavicular joint. Her pain originated following a fall onto her shoulder having been knocked off of a pushbike during a collision with a motor vehicle. The primary complaint was of pain, making the patient's work as a machinist difficult. She also complained of a visible but subtle deformity of her acromioclavicular joint resulting in problems keeping the strap of her bra in place.
Clinical examination in the outpatient clinic revealed an obvious acromioclavicular joint dislocation with palpable crepitus on reduction, dynamic instability on clinical testing, and painful movements above 90 degrees of forward flexion and abduction. Radiographs confirmed a diagnosis of grade II ACJ dislocation []. As she presented with a symptomatic shoulder, she was counseled for an elective ACJ reconstruction. This was a chronic ACJ dislocation and the indication for operation was pain with dynamic instability on clinical examination. At operation, she underwent an uncomplicated ACJ reconstruction using the synthetic ligament technique. Bone quality appeared normal intraoperatively and a chronic grade III injury was noted at time of operation in contrast to the preoperative imaging. Immediate postoperative radiographs were entirely satisfactory.
First follow-up appointment at 2 weeks postoperatively demonstrated no obvious clinical concerns, good wound healing, and no signs of infection or of failure of reconstruction. For the first six weeks postoperative, she undertook passive shoulder exercises under the supervision of the physiotherapists with movement restricted to less than 90 degrees of forward elevation and abduction. At six weeks, this was increased to active range of movement exercises. Follow-up appointment at six weeks revealed no clinical problems and her preoperative symptoms had completely settled.
At 3-month follow-up, the patient reported a firm, painful lump

[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 15-year-old boy of average built presented to the orthopaedics department with a draining non-healing sinus at the lateral aspect of his right lower thigh for the last 9 months (Figure
). Pain was minimal. The margins of the sinus were hyperpigmented and thickened with excoriation of the surrounding skin; pus was expressed out on pressure. Palpation was painful but did not reveal any mass around the sinus. Regional lymph nodes were enlarged compared to the contralateral side. Distal neurovascular status was normal. The knee joint was not swollen, and the range of motion was normal except for a mild terminal restriction of flexion due to pain. Detailed history revealed that about 9 months ago, he fell down from a tree which is approximately 15 feet in height and sustained injury from wooden branches at the right thigh. He also had transient loss of consciousness from the impact. After consciousness was regained, he noticed a small wound over the outer aspect of his right thigh. There was not much bleeding, and he considered it a minor injury. The wound, however, nearly healed. After about 3 weeks, he noticed swelling and frank pus started coming out of the wound. He sought traditional treatment and got some temporary relief. The amount of pus decreased in-between and the size also diminished, but complete healing never occurred. During the whole course, he did not develop any fever, loss of weight, cough, or chest pain. After 9 months from the day of injury, he visited our hospital.
After admitting him for detailed evaluation, the differential diagnosis considered chronic osteomyelitis, fungal infection, tuberculosis, and implanted foreign body. Blood parameters and X-ray examination of the area came out to be normal and osteomyelitis was ruled out (Figure
). Pus culture revealed growth of Staphylococcus aureus. FNAC obtained from the enlarged regional lymph node showed nonspecific findings. Implanted radiolucent foreign body was thought as a possibility for persis

[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 19-year-old male patient reported to the department of conservative dentistry and endodontics following trauma to the maxillary anterior region due to a road accident around 20 days back. He complained of fractured maxillary incisors and presented a desire to get them restored in order to have an aesthetic smile. Clinical examination of the patient revealed complicated crown fracture of the upper incisors. An intraoral swelling with a sinus tract was present on the labial gingiva between upper right central and lateral incisor (Figures and ). A radiograph of the maxillary anterior region illustrated horizontal root fracture at the middle third of the upper right central and lateral incisors () but clinically no mobility of the coronal fragment was evident. On the other hand the roots of the upper left central and lateral incisors were intact and endodontic treatment had been done for the upper left central and lateral incisors ().
After explaining the treatment plan to the patient and obtaining his consent, endodontic treatment with the upper right central and lateral incisors was initiated. The working length was correctly determined and canals were cleaned, shaped using K files in a step-back manner to an apical file size #60. The remainder of the canals were shaped to obtain a uniform taper from apex towards coronal. An interappointment calcium hydroxide dressing was given and the patient was recalled after 7 days.
On the second visit, when the swelling had resolved, root canals were sectionally obturated with gutta percha cone and AH plus sealer. A gutta percha cone of the same size of the prepared root canal (size #60, with a taper of 2%) was selected and tried into the canal to obtain a snug fit. It was then cut to obtain a section which would be 2-3 mm short of the apical fragment of the root. A suitable plugger which loosely fits 2-3 mm short of the apical root fragment was selected and a stopper was set at this length. The sectioned gutta percha was then

[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 Brazilian male patient was admitted to the hospital with a palpable lump in his right breast, located at the junction of the upper quadrants of the right breast (Fig. ). On physical examination, the lesion appeared firm with irregular margins. Axillary lymphadenopathy was negative and there were no palpable supraclavicular nodes. On breast imaging, ultrasonography showed a hypoechoic mass with partially defined contours measuring 4.0 × 3.0 cm, located at the upper region of the right pectoralis major muscle at the 12 o’clock position with muscle infiltration (Fig. ). Histological examination of core biopsy samples revealed a malignant tumor. Preoperative exams, such as X-rays and chest CT scan, abdominal US did not show any signs of disease. Radical mastectomy was then performed, due to pectoralis major muscle infiltration, consisting in removal of the breast along with the major and minor pectoralis muscles. Biopsy of the sentinel lymph node was performed. Gross examination revealed a solid tumor measuring 3.7 × 3.5 cm with a yellowish-tan cut surface and local foci of hemorrhage. Histopathology showed intravascular papillary proliferation of endothelial cells, spindle cell areas and necrosis, atypia and prominent mitotic figures, consistent with the diagnosis of high-grade angiosarcoma with areas of infiltration of the pectoralis major muscle (HE staining, magnification of 400×) (Fig. ). Histopathology also demonstrated a surgical specimen with clear margins, absence of angiolymphatic and perineural invasion, in addition to sentinel lymph node free of metastasis. Immunohistochemical study revealed a tumor positive for CD31 marker (Fig. ), confirming the vascular nature of the tumor. At the two-week follow-up of the surgical procedure, adequate wound healing was observed, without any evidence of the disease. The patient was transferred to the clinical oncology department, where he presented with severe headache and seizures after the second cycle of a

[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 Japanese girl, gravida 0 para 0, who was the monozygotic twin sister of the patient in Case 1, visited our gynecologic department for ovarian screening 3 months after the first operation of Case 1. Transrectal echography revealed bilateral ovarian cystic tumors with calcified structures. Tumor marker levels (CA125, SCC, CEA, and CA19-9) were normal. The bilateral ovarian cystic walls were extracted, and normal ovarian tissues were preserved by laparotomy. Pathological analysis of the cyst wall disclosed that there were benign teratomas in both ovaries.
Sixteen months after the first surgery, bilateral ovarian tumors were detected with echogram and pelvic MRI (right side: 4.4 cm, left side: 8.0 cm in diameter) during her regular check-up (). The ovarian tumors were accompanied by a solid part and high echoic part inside. Blood examination of tumor markers revealed a mild, elevated CA125 (37.5 U/mL). Bilateral cystectomy was performed 20 months after the first surgery. Examination of the other pelvic and abdominal organs found no disseminated and metastatic lesions in the surgery. There were no swollen pelvic lymph nodes. The histological diagnosis was an immature teratoma of grade 1 with International Federation of Gynecology and Obstetrics stage I in the right ovary and a benign mature teratoma in the left ovary. The girl's postoperative condition was good, and she was discharged without any complications. An additional surgery and chemotherapy were not planned according to a deliberated discussion with her family.
After being discharged, she continued to be followed every other month. Four months after the last surgery, a right ovarian cystic mass (4 cm in size) was detected, and it enlarged to 6 cm two months later (). The blood CA125 level (32.3 U/mL) was in the normal range. Therefore, a third laparotomy was performed 7 months after the second surgery. The right adnexa, appendix, and greater omentum were resected. Examination of the other

[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 13-month-old female with no significant prior medical history, prior significant infections, or developmental concerns presented with worsening fatigue and intermittent fevers. The initial evaluation demonstrated leukocytosis, anemia, and elevated inflammatory markers. Infectious evaluation, including chest X-ray, monospot test, rapid streptococcal screen, HSV testing, and UA, was unremarkable. A viral etiology was considered most likely and the patient was discharged home with return precautions. Over the following week, the patient had no significant improvement, and she was admitted to the hospital for further evaluation after repeated laboratory investigations yielded similar results.
On admission, her symptoms included intermittent fevers with concurrent irritability, fatigue, and decreased solid food intake; she appeared at her baseline when not febrile. No signs or symptoms of localized infection were present at that time, and her family denied sick contacts. On the morning following admission, the patient experienced a right upper extremity focal seizure requiring prompting immediate brain MRI. MRI demonstrated an extensive left subdural fluid collection consistent with a subdural hematoma and associated left to right midline shift []. Several posterior components of the fluid collection demonstrated diffusion restriction and raised suspicion for the superinfection of the hematoma. Blood cultures were sent, and the patient was taken for immediate surgical evacuation with ultrasound-assisted burr hole drainage and subdural drain placement. Intraoperatively, the drained fluid was consistent with chronic blood products with foul-smelling superimposed infection. The fluid was collected for microbial analysis, and the patient was started on empiric antimicrobial coverage. The fluid cultures demonstrated M. morganii, and the antibiotic regimen was subsequently converted to meropenem monotherapy. Blood cultures and subdural fungal cultures remained negative at 5

[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:
Mr. BH, 39 years old, right-handed, presented with a Bennett fracture of the first right metacarpal following a work accident. The fracture was initially treated in another institution by reduction and percutaneous pinning using Iselin’s technique. Three weeks later, the patient developed an inflammatory reaction around the entry point of the distal pin, at the second metacarpal. A purulent discharge led to early removal of the distal pin. The isolated organism was a methicillin-sensitive Staphylococcus aureus. Regular topical treatment was given, and antibiotic therapy was initiated for five weeks based on laboratory results. Bone healing of the Bennett fracture was obtained in the sixth week after the accident, and the proximal pin was removed.
Three months later, the patient was referred to us by his doctor because of persistent pain at the second right metacarpal, accompanied by attacks of inflammation and intermittent purulent discharge. Standard hand X-ray demonstrated the presence of an area of osteolysis surrounded by osteocondensation at the second metacarpal, indicating a focus of osteomyelitis along the path of the distal pin (). An MRI was performed on the hand. It confirmed the diagnosis, revealing the extent of the focus of osteomyelitis, the path of the fistula, and the inflammatory extension into neighboring soft tissues ().
Surgical treatment called for the induced membrane technique.
The first stage included a segmental resection of the area of osteomyelitis through a dorsal approach with excision of the reformed tissue while preserving the index finger extensor tendon.
The second metacarpal was stabilized with a mini external fixator, and a cement spacer was interposed ().
Antibiotic therapy was initiated for six weeks based on sensitivity testing. The external fixator was then removed, and the hand temporarily immobilized with a splint until there was healing along the path of the inserts.
The second stage was performed in the eighth week. The ce

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


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

[User]
RADIOLOGY NOTE:
A 40-year-old woman presented for cesarean delivery for fetal breech presentation at 39 weeks' gestation under spinal anesthesia. Her previous obstetrical history included two previous first trimester abortions and a full-term pregnancy delivered by cesarean section due to breech presentation. Her present antenatal course was smooth, except for a progressive painless swelling in the right flank noticed at 20 weeks' gestation. Multiple ultrasound examinations were done at different intervals during the course of pregnancy. They demonstrated a rapidly growing sharply defined abdominal mass, heterogeneous in echogenicity and smooth in contour, highly suggestive of a subserosal uterine leiomyoma. No other signs and/or symptoms were reported. The patient denied smoking, drinking alcohol, or taking any medications besides her prenatal vitamins.
Intraoperatively, the tumor was found to be extra-peritoneal originating from the right abdominal wall. It was whitish in color, hard in consistency, and fixed to its surroundings. It was arising from the lateral wall (rectus and external oblique muscles) reaching the vicinity of the anterior superior iliac spine. Following the delivery of a live male newborn (Birthweight: 3560 g; Apgar score 9 at 5 min) through a lower segment transverse uterine incision, a general surgeon was called in for an intraoperative consultation. Frozen sections revealed benign spindle cells suggestive of a desmoid tumor (), although a sarcoma could not be ruled out in view of the tumor rapid growth. The patient consented to a wide surgical excision of the mass within the same surgery. Radical resection of the tumor was performed including affected abdominal wall muscle and a peripheral margin of healthy tissues surrounding it. The patient tolerated the procedure well. She developed right femoral lateral cutaneous neuralgia that resolved spontaneously a few weeks later.
Grossly, the tumor was a 12 × 9.5 × 7 cm mass weighing 457 g, ovoid in shape, firm in

[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 81-year-old gentleman with past medical history of diabetes, hypertension, and peripheral vascular disease presented to the emergency department with acute onset right-sided vision loss. The patient had been in his usual state of health 4 weeks prior when he experienced transient visual loss in his right eye and later started having left-sided headache along with difficulty in chewing food. He underwent a color-duplex ultrasound as outpatient for the evaluation of his symptoms which showed undetectable blood flow indicative of complete occlusion in right internal carotid artery and critical stenosis of more than 70% in left internal carotid artery (ICA). Bilateral common (CCA) and external carotid arteries (ECA) were patent though diffusely atherosclerotic with an estimated plaque burden more than 50% (,)).
Based on the carotid duplex findings, he was diagnosed to have symptomatic carotid stenosis secondary to wide-spread atherosclerosis. His right ICA was not considered amenable to surgery and after a discussion with vascular surgery, he underwent a left carotid endarterectomy with no immediate complications. However, he continued to have persistent symptoms with progressive deterioration. He also noticed weight loss, anorexia and morning stiffness in his shoulders. On the morning of presentation, he lost complete vision in his right eye while experiencing blurry vision in his left eye. He was examined by his ophthalmologist who detected ischemic optic changes highly suggestive of GCA and thus referred him to the emergency department with recommendations to be immediately started on high dose IV corticosteroids.
His vitals, on presentation, were as follows: BP 126/72 mm Hg, Pulse 92/min and afebrile. Detailed examination revealed cachexia along with left temporal and shoulder girdle tenderness. Pulses were diminished in all extremities except left dorsalis pedis which was absent. Bilateral carotid bruits were also appreciated. Visual acuity was noted to be 0/20

[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 describe the case of a 26-year-old man who suffered a severe cranio-facial trauma in 2004, caused by a car accident. Consequently, the patient presented subarachnoid hemorrhage and panfacial fracture. After an initial assessment in the emergency services, the patient was admitted to the intensive care unit of our Hospital. Here, the profesionals involved in the case decided that the subarachnoid hemorrhage did not require surgical treatment. Notwithstanding the above, the patient needed close monitoring in the intensive care unit for several week. Therefore, in the light of these developments, we also adopted a conservative attitude with regard to the facial trauma. In fact, during ICU stay the patient presented an unstable neurological status. Due to all this, we decided to reassess the patient in a year with the aim to estimate the fallout of trauma. Finally, when the patient came to the outpatient department of Maxilofacial unit we could observe the typical signs of CCF. Indeed, the physical examination of the patient showed zygomatic-orbital dystopia with pulsating exophthalmos and chemosis of the right eye. Moreover, the patient referred decreased vision in this eye. In addition to all this, we note the presence of an orbital murmur. This finding made us suspect the existence of CCF secondary to trauma. Bearing this in mind, a craniofacial CT scan was performed in order to confirm the diagnosis. As expected, this test showed the presence of CCF draining into the right superior ophthalmic vein. Thus, we decided to present the case to the interventional neuroradiology service of our Hospital.
After evaluating the case, Neuroradiologists decided to carry out a bilateral arteriography of the head. This test also proved the existence of a direct posttraumatic CCF. In addition, this test also showed that the fistula presented high blood flow, with significant impact on intracranial hemodynamics (Fig. ). Against this backdrop, neuroradiologists decided to treat 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 52 year-old woman presented to our hospital (University Hospital, Newrak, New Jersey) in February 2011 with complaints of irritable, anxious mood and inability to focus for one month. She also gave history of decreased need for sleep and excessive spending in the same time period. On exam, she was well groomed, had fast speech but not pressured, irritable and labile affect but no grandiose ideas.
Patient denied ever having similar symptoms in her life before. Treatment history revealed that patient had taken nefazodone, bupropion, duloxetine and clonazepam but has never taken any antipsychotic medication in her life. Her routine laboratory examinations (complete blood count, liver function test, and urine analysis) were within normal limits. CT scan of head and brain (without contrast) was negative for any acute changes or other pathology.
Patient was diagnosed with bipolar disorder with current episode of mixed type. Patient did not want to take lithium or valproate medications fearing about their side effects. She was started on aripiprazole 15 mg at bedtime which was increased to 15 mg twice a day after 4 days. Patient started feeling better and was discharged on day 10 with aripiprazole 30 mg/day at bedtime and clonazepam 0.5 mg twice a day.
On patient's first follow up visit no medication side effects were reported or observed. On her second follow up visit, she complained of disturbing motor symptoms which included intermittent involuntary painful jaw clinching and abnormal tongue movements. Physical exam showed involuntary chewing movements of jaw, lip smacking, infrequent tongue protrusion and twisting and side to side movement of the tongue. Patient scored 14 on abnormal involuntary movement scale (AIMS). She had never experienced these symptoms before in her life and was not taking any other medications which could explain these extrapyramidal symptoms. Serum copper, serum ceruloplasmin and serum thyroid stimulating hormone levels were found to be in nor

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


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

[User]
RADIOLOGY NOTE:
A 23-year-old African American woman presented with a roughly 40 × 20 cm left flank tumor () to the Surgical Oncology Group of Rutgers Cancer Institute of New Jersey. The patient reported having a left-sided hemangioma removed at the age of 3 years but persisted with a port wine stain on her left flank since that time. Approximately 3 years prior to presentation, the patient had her first pregnancy and reported that during her third trimester, she noticed a mass developing on her left flank. During this time, the mass slowly grew to approximately its size at the patient's presentation at our institution. Following delivery of her first child, the patient reported medical evaluation had demonstrated the mass to appear to be a recurrence of her hemangioendothelioma. Following her second pregnancy, the size of her tumor did not significantly change, nor did it affect her pregnancy. It was at this time when she presented to us for evaluation for possible surgical resection after undergoing biopsy showing a Dabska tumor. The patient then presented to the Plastic Surgery Division at Rutgers-Robert Wood Johnson Medical School for evaluation of reconstruction in conjunction with her planned tumor resection.
During radical resection, the tumor was dissected down to the abdominal wall fascia, as the tumor did not appear to violate the fascial space. Specimens were submitted intraoperatively to pathology for frozen section, with final diagnosis ultimately showing a 30 × 22 × 4 cm3 Dabska tumor. After tumor extirpation, the patient had a defect extending from the umbilicus to the mid-posterior back from the tenth rib to below the hip (). Abdominal wall reconstruction was performed with 2 fasciocutaneous-type flaps raised to the level of the costal margin, medially to the umbilicus and posteriorly to the area of the trapezius. Inferiorly, the flaps were extended onto the lateral tensor fascia lata area, posterior to the superior buttock region, and medially into the groin crease

[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 Caucasian male patient was brought to the resuscitation bay of our Emergency Department after a syncopal episode and was noted to be in shock. His initial observations include Heart Rate 126/min, Blood Pressure 102/79 mmHg, Respiratory rate 32/min, temperature 36.8C and oxygen saturation of 98% on 2 L of nasal prongs. The patient had a Glasgow Coma Scale of 14 and was clinically dehydrated. Abdominal examination revealed a distended abdomen that was tender in the left upper quadrant with no evidence of peritonism. Laboratory tests showed polycythaemia with Haemoglobin of 189 g/L and white cell count of 20.3 × 109/L with preserved renal and hepatic functions. Arterial blood gas analysis was consistent with normal anion gap metabolic acidosis with a pH of 7.28 and lactate of 4.5. The patient responded to initial fluid resuscitation.
Further history was obtained: he had a 2-day history of progressively worsening upper abdominal pain associated with multiple episodes of dark coloured emesis and loose bowel motions. The pain was exacerbated by oral intake. He had a background of ulcerative colitis diagnosed at the age of 40 which required one course of oral steroid with no further follow up or treatment.
As the patient remained in a stable state, a CT abdomen was performed which demonstrated a long segment of superior mesenteric vein (SMV) thrombus extending into the portal vein. This resulted in venous engorgement with associated thickening of jejunal wall and extensive mesenteric stranding suggestive of intestinal ischemia. There is also a moderate amount of free fluid with no evidence of intramural gas or perforation (, ).
Acute mesenteric venous thrombosis was diagnosed and management options were explored. Although the CT appearances were sinister and suggestive of intestinal ischemia, the patient had no signs of peritonism. Thus, decision was made for conservative management. Heparin infusion was commenced, nasogastric tube was inserted and the patien

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


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

[User]
RADIOLOGY NOTE:
A 54-year old Thai woman presented to our facility with a two-month history of urinary incontinence induced by coughing.
She had a history of cervical squamous cell carcinoma, stage IIb, which was treated 15 years previously with radiation therapy. Her six-month interval follow-up pelvic examination and cervicovaginal PAP smears had revealed negative findings and the disease had been considered as in complete remission by the attending radiologist. She was first referred to our gynecology department to find out the cause of her incontinence. On pelvic examination by a gynecologist, her uterine cervix was found to be atrophic with an extraluminal compression at the anterior vaginal wall, covered by an intact vaginal mucosa. Laboratory investigation results revealed mild hematuria (3 to 5 red blood cells per high-power field) and mild anemia (hemoglobin 10 g/dL, hematocrit 31.1%). Eventually, our patient was referred to our urology department for further management.
During the process of the Q-tip test, the applicator was passed with difficulty and deviation to the right. Cystoscopy was performed. Her urethra showed no meatal stenosis and unremarkable mucosa, but the device was passed with difficultly due to external compression from the left side of the proximal urethra. Her bladder had a large sessile mass on the left lateral wall with extension to the bladder neck. Both ureteral orifices could be identified clearly with unremarkable appearance and efflux. Clinically, the differential diagnosis included recurrent cervical cancer, bladder cancer and retroperitonal sarcoma. Urine cytology and transurethral resection of the bladder tumor were performed, with a negative cytology report and a pathological diagnosis of high-grade urothelial carcinoma. A computed tomography scan demonstrated a heterogenous enhancing mass, 5.3 × 6.5 × 6.0 cm, at the left inferior-lateral wall of the bladder with invasion of the uterus and attachment to the left pelvic side wall, as shown in

[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 13-year-old boy was hospitalized because of acute abdominal pain, melena, and vomiting. Mild abdominal pain was present for the preceding 6 months in the right lower quadrant. No weight loss or other specific symptoms were present. Before the onset of the symptoms, no signs of malignancy were present and he had not undergone a thorough abdominal examination till then. Additionally, he did not have any chronic diseases and had no family history of malignancy. Distended abdomen and decreased bowel sounds were observed during the physical examination. Diffuse direct and indirect tenderness was present throughout the abdomen. At presentation, melena was present; however, blood pressure and other vital signs were normal.
Plain radiography indicated a suspicious state of ileus; however, we could not see the exact mechanical obstruction. Physical examination and radiographic findings warranted further examination; hence, in view of the patient's age, we ordered abdominal computed tomography (CT) scan immediately. Abdominal CT scan confirmed the presence of ileocolic intussusception with distal segmental ischemic changes (Fig. ). Because the patient had visited our hospital after 24 hours of the onset of his symptoms with suspected ileocolic obstruction, we decided to intervene with emergency surgical resection. The initial laboratory results revealed anemia (hemoglobin = 7.1 g/dL) and he had ongoing melena; therefore, red blood cell transfusion was performed. Inflammatory markers such as white blood cell count, C-reactive protein level, and erythrocyte sedimentation rate were normal. Platelet count and disseminated intravascular coagulation (DIC) score were also within the normal range. These normal laboratory results and a lack of familial history made bleeding diathesis highly unlikely. Since levels of tumor markers like carcinoembryonic antigen (CEA) and cancer antigen (CA) 19–9 were within the normal range, we could not find any indication of malignancy before histol

[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 63-year-old woman complained of a slightly swollen left leg and low lumbosacral pain (visual analog scale score: 4), and was admitted to our department. She had a history of diabetes mellitus and hyperlipidemia for more than 20 years, and these were treated by medications prescribed by her endocrinologist and cardiologist. She had an L3 OVCF, with a visual analog scale score of 8 2 months previously, and was successfully treated with PVP. She was discharged on postoperative day 2, with no cement-associated complications and a visual analog scale score of 2 (. Accordingly, a newly fractured vertebra was suspected at admission to our department. A physical examination showed a slightly swollen left leg with no other major complaints. The intensity of the low lumbosacral pain did not increase when she slightly twisted her spine. No major abnormalities of a regular laboratory test were observed.
The patient suddenly fainted when she was taking a shower on admission night 2. After general resuscitation of moving her back to the bed and resting with electrolyte fluid supplementation, she gradually became conscious and returned to a normal status. The next day, magnetic resonance imaging of the spine, computed tomography angiography, and ultrasonography were performed. No newly fractured spinal vertebra was detected. No major abnormality in the arteries or deep veins in both lower extremities was detected on ultrasound. A cement leakage that started from the L3 level and migrated to the L1 level, and was suspended in the inferior vena cava was detected (. Another cement leakage was detected in the right pulmonary artery (. After 4 days of general conservative therapy, the patient became agitated and her left leg started swelling (. Her condition became severe. General anti-coagulation therapy with 3000 units of low molecular weight heparin daily was empirically implemented. Relevant blood tests were performed again and showed the following: D-dimer concentration, 9.45 mg

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


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

[User]
RADIOLOGY NOTE:
A 39-year-old man presented to the radiation oncology clinic for surgeon’s consultation, requiring an adjuvant radiation to his scalp after extensive resection of a primary scalp lesion.
Six years earlier, the patient had developed a scalp lesion on the right parietal side and underwent a resection. The initial pathology report indicated squamous cell carcinoma. After nearly 6 years of being disease-free, he noted a new lesion on the same spot, which had disseminated and involved almost all scalp tissue within one month. On magnetic resonance imaging, a vegetative and enhancing mass over the right parietal bone measuring 74 mm × 74 mm × 38 mm was noted, with suspicious invasion to the external table of bone and adjacent bone marrow. Multiple suspicious lymphadenopathies on the left cervical levels 2 and 5 as well as the left occipital and parotid regions were reported with short axis diameter (SAD) of about 10 mm. A core needle biopsy of suspicious lymph nodes indicated squamous cell carcinoma and later, the patient underwent an extensive scalp surgery for resection of the lesions. The skin defect was covered with a rotational flap and skin grafting.
The surgical pathology report indicated a 9-centimeter large tumor with 2.5 cm thickness, and the tumor was classified as poorly differentiated SCC. The tumor showed lymphovascular invasive features, but perineural invasion was not detected. Deep margin of the excised tissue was affected by the tumor; however, bone trabeculae and intervening marrow were not involved. The surgeon additionally resected two other suspicious lesions on the right frontal and left parietal regions of the scalp. The former was reported to be actinic keratosis grade 3 (Bowen’s disease), while the latter showed features of early invasive SCC in a background of actinic keratosis with a thickness of 2.2 mm and close medial margin (3 mm).
We intended to treat the patient with adjuvant radiotherapy to a total dose of 66 Gy with 6 MV photons. However

[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 21-year-old man visited the clinic due to a limited MIO of 28 mm and pain in the left TMJ when chewing and opening his mouth. The patient had undergone orthodontic treatment for several years before visiting the clinic and had a history of stabilizing splint therapy in an oriental medical clinic.
Magnetic resonance images were obtained with the expectation that anterior disc displacement without reduction and a masticatory muscle disorder were responsible for the patient's condition, based on physical examinations.() The images revealed anterior disc displacement with reduction on the left TMJ and adhesion of the right articular disc. Anterior positioning splint therapy and botulinum toxin injection were used to relieve the stiffness of the bilateral masseter muscles, but no improvement in TMJ pain or MIO was observed. Arthroplasty of the right TMJ was performed to resolve the adhesion of the articular disc, but the movement of the mandible was not satisfactory in the operating room. A few months after surgery, the patient continued to complain of TMJ pain, a grinding sound in the bilateral TMJs, and mouth opening limitation. CT images were taken to determine the possibility of TMJ osteoarthritis or neoplasm, and an elongated right coronoid process and heterotopic bone formation were detected on the medial and inferior surfaces of the right zygomatic arch.()
The patient underwent a right coronoidectomy under general anesthesia, and the heterotopic bone was removed. Immediately after surgery, the MIO was increased to 43 mm in the operating room. Physical therapy was initiated three weeks postoperatively; at the 15-month follow-up visit, the patient's MIO was found to have increased to 63 mm with protrusive and lateral movements to the right and left of 7 mm, 10 mm, and 7 mm, respectively. No specific abnormality was noted except for a slight right deviation when opening the mouth, multiple grinding sounds from the left TMJ, and mild pain in the right masseter muscl

[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 14-year-old boy with morbid obesity and no known prior psychiatric history underwent sleeve gastrectomy. Prior to the surgery, he weighed 167 kilograms with a body mass index (BMI) of 54.5. Within a few months postoperatively, he weighed 70 kilograms with a BMI of 22.8. The patient’s substance use disorder started at the age of 15, one year after the bariatric surgery. Of note, the patient's parents were separated and he lived with his mother and siblings. None of his family members or relatives had a history of substance use disorder. He initially started using fenethylline (marketed under the brand name Captagon), as it was a common substance used by his peers at school. He started with two tablets daily and increased his use gradually up to 15 tablets daily. He started smoking cannabis a year later, at the age of 16, starting with one cigarette per day and increasing his use gradually until reaching a peak of 20 cigarettes per day. The patient started drinking alcohol occasionally at the age of 16 as well, and it soon became an issue of excessive use on a daily basis. The patient drank different types of alcoholic beverages. He reported incidents of fainting in relation to alcohol use but had never experienced withdrawal. He mentioned that he started using alcohol as a way to reduce his use of other substances. Two years later, at the age of 18, the patient started using methamphetamine, which caused him to develop paranoid ideation, auditory hallucinations, severe insomnia, and aggressive behavior. The patient was admitted to an inpatient psychiatric unit for a few days and was started on haloperidol 3 mg orally twice daily, benztropine 2 mg orally twice daily, and quetiapine 50 mg orally as needed for insomnia. His psychotic disorder improved with the cessation of substance use and the treatments initiated on the inpatient side. After his discharge, he unfortunately relapsed and continued to use the aforementioned substances.
After arranging for close follow-

[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 85-year-old healthy man presented to the surgery clinic of Ghaem Hospital, complaining of abdominal pain, which was generalized, dull, and acute and started two days before he came to the clinic. The pain was constant, and he declared its intensity 4 out of 10, with no radiation. Moreover, he did not reveal any correlation between pain intensity and eating or activity. He did not mention any recent fever, nausea, or vomiting. He did not report any past medical history of surgery or hospitalization.
On his medical examination, vital signs were as follows: heart rate = 98/min, respiratory rate = 14/min, blood pressure = 115/70 mmHg, and axial temperature = 37.3°C. His abdomen was soft, and there was just a mild generalized tenderness without rebound or guarding. There was no sign of organomegaly, scar, or herniation. The rest of his examination was normal.
Complete blood count was normal, and blood chemistry did not show any abnormal findings other than high ESR (53 mm/hr) and high CRP (187 mg/l) with the normal range of ESR (0-22 mm/hr for men) and CRP < 10 mg/l.
Coronal sections of the abdomen-pelvic CT scan with IV contrast showed a hepatic hydatid cyst with water lily sign in the right lobe of the liver with a compressive effect on the adjacent diaphragm and the left lobe of the liver and hydatid cyst of the bladder dome (). In axial sections of the CT scan, hepatic hydatid cysts were seen with water lily sign and pressure effect on the diaphragm and an intact capsule in the right and the left lobes of the liver. Free abdominal fluid was present (). In other axial sections of the pelvis, a hydatid cyst was seen with an intact capsule on the bladder dome ().
Open abdominal surgery was performed with the final diagnosis of hydatidosis. There was an intact cyst without any invasion

[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 43 year old male patient was referred to our hospital for an elective laparoscopic sigmoidectomy due to complicated sigmoid diverticular disease. The patient complained of a 4 month history of mild lower abdominal pain that was predominately localized to the left lower quadrant. The pain was associated with alternating bowel habits and several episodes of bleeding per rectum mixed with stool. The patient also recently noticed onset of dysuria, pneumaturia, and fecaluria. His past surgical history is significant for bilateral laparoscopic hernia repair (TAPP) with mesh placement, which was fixed with tacks 7 years previously and varicocelectomy 5 years ago. He has no relevant medical history of note.
Examination of the patient revealed mild left lower quadrant tenderness to palpation. All laboratory markers were within normal limits. A CT abdomen and pelvis revealed multiple sigmoid colon diverticula, diffuse mural thickening of mid sigmoid colon with severe adjacent fat stranding, abscess formation adjacent to the sigmoid colon with air pockets sized 3 × 7 × 8 cm (), and a colo-vesical fistula formation causing severe mural thickening in the roof of the urinary bladder with air pockets in the urinary bladder. Colonoscopy revealed multiple sigmoid diverticulitis and inflammatory sigmoid lesion that was biopsied; the lesion however could not be bypassed due to fear of perforation. Biopsy revealed mild chronic colitis and was negative for granuloma or dysplasia.
The patient was admitted and prepped for laparoscopic sigmoid colectomy and excision of colo-vesical fistula. Intraoperative findings revealed a sigmoid colon abscess, a colo-vesical fistula, left inguinal region mesh eroded into the colon from his previous laparoscopic hernia repair (). Abscess drainage, excision of the colo-vesical fistula and sigmoidectomy with removal of the mesh was performed. The right mesh was in place.
Post operatively the patient was started on antibiotics (tazocin), had an abdominal

[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 31-year-old man, weighing 56.2 kg and 170 cm tall, was diagnosed with advanced rectal cancer, and after concurrent chemoradiation therapy, underwent laparoscopic low anterior resection. After 2 weeks from discharge, he was readmitted to the hospital for nausea and vomiting and was diagnosed with postoperative small bowel obstruction around the ileostomy. He underwent a small bowel resection because he did not improve from conservative treatment. After reoperation due to the small bowel obstruction, he reported abdominal discomfort and postprandial stabbing epigastric pain with nausea and vomiting. He showed a weight loss of 9 kg over 18 days since the readmission (). An abdominal CT scan was performed under suspicion of postoperative intestinal obstruction, which demonstrated moderate gastroduodenal dilation with compression of the SMA, and 7 mm of aortomesenteric distance, consistent with SMA syndrome (). Gastroduodenoscopy showed reflux oesophagitis grade III and a fluid-filled first and second portion of the duodenum, and stenosis of the third portion. Conservative medical treatment with high-calorie total parenteral nutrition (TPN) and anti-emetics was initially administered for 2 weeks. The administration of nutrients was set at 1500 kcal/day, and the total volume of TPN was 1440 mL. The ingredients of TPN administered during this period were glucose 187 g/day, protein 72 g/day and lipid 58 g/day. Even after TPN treatment, his weight continued to decline. Although we tried to increase the total calorie of TPN, we could not afford it due to the fluid overload. So then surgery was considered first, but the perioperative risk was expected to be high in preoperative risk evaluation due to his poor nutritional status and severe bronchiectasis. Consequently, jejunal feeding tube placement past the obstruction via endoscopy was offered for the treatment of SMA syndrome.
An endoscopy-guided jejunal feeding tube (Abbott’s 12 Fr) was passed through the third portion 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 55-year-old Japanese woman was referred to our hospital because of hepatic tumors detected by abdominal ultrasonography during a screening examination. Her medical and family history was unremarkable; her occupational and residential history showed no apparent exposure to asbestos. She received no medical drugs, and neither smoked tobacco nor drank alcohol. On admission, her general status was unremarkable; her temperature was 36.2 °C and her blood pressure was 110/70 mmHg with a regular heart rate of 80/minute. A physical examination revealed no abnormal findings; neurological examinations were unremarkable. All laboratory data, including levels of the serum tumor markers carcinoembryonic antigen, cancer antigen 19-9, alpha fetoprotein, protein induced by vitamin K absence or antagonist-II, and cancer antigen 125 were within normal ranges (Table ). An abdominal enhanced CT scan revealed four hypervascular, round hepatic tumors. One tumor, which was 32 mm in diameter, was in contact with the lateral liver segment and the hepatic hilus; the other three tumors were in contact with the diaphragm and measured 7 mm in segment 4, 17 mm in segment 7, and 15 mm in segment 8 (Fig. a–d). There was no pleural effusion or ascites, and no other nodular lesions in her chest or abdomen were observed. Similar to the CT findings, magnetic resonance imaging (MRI) revealed a tumor of lower intensity than the liver on T1-weighted images, and with higher intensity than the liver on T2-weighted and diffusion-weighted images (Fig. a–c). Upper and lower gastrointestinal endoscopic examination findings were normal. We hypothesized that the tumor arose from her liver, and diagnosed our patient as having multiple hepatic hemangiomas, at first. However, imaging findings were not typical of hepatic tumor: all tumors were on the edge of the liver and the tumor margins were clear. Moreover, the tumor in segment 7 appeared continuous with the diaphragm with similar high-density contrast medium (

[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 11-year-old girl presented to her local hospital with an acute onset of severe abdominal pain, showing signs of hypovolemic shock and requiring emergency resuscitation prior to transfer to a tertiary pediatric center. She had fainted at school earlier in the day and been sent home. That afternoon, she had vomited once and rested in bed. She woke during the night, screaming in pain. An ultrasound scan at the local hospital demonstrated a ruptured spleen with an associated perisplenic hematoma and a large volume of free fluid in the peritoneal cavity. These findings were confirmed on a contrast-enhanced computed tomography scan (
), which also demonstrated active extravasation of contrast from a branch of the splenic artery. After further resuscitation at the tertiary center, including multiple blood product transfusions, she was transferred to the interventional radiology suite where angiography via a femoral arterial approach showed gross disorganization of the splenic vasculature at the site of parenchymal rupture, with several truncated vessels and active bleed points noted (
). Distal embolization of individual bleeding vessels proved impossible due to anatomical distortion by the surrounding hematoma and vessel spasm. In view of the emergency nature of the situation, coil embolization of the proximal splenic artery was performed, with complete occlusion of splenic arterial flow. This inevitably involved partial devascularization of the pancreatic tail.
The patient's vital signs and transfusion requirements improved immediately after coil deployment. She made a slow but steady recovery on the intensive care unit and was extubated 3 days after admission. Her recovery was complicated by transient pancreatitis that was conservatively managed. She was discharged from the hospital 4 weeks later. Follow-up showed reconstitution of most of the splenic parenchyma, though she was vaccinated and commenced on prophylactic antibiotics in view of presumed hyposplenism.
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 78-years old female patient was diagnosed with a mucosal melanoma of the urethra (patient characteristics: see ).
At the time of primary diagnosis, inguinal lymph node metastases were detected. A complete resection of the urethra and a radical dissection of the left inguinal lymph nodes was performed concomitantly in our surgical department. Only 1 month after the intervention intravaginal mucosal metastases were diagnosed and histologically confirmed (). Computed tomography (CT) scans showed nodal metastases in proximity of the left iliac vessels with no option to obtain a complete resection of the tumor masses. Molecular analyses of the tumor showed wild types in the BRAF- and NRAS gene and a p.K558dup mutation of c-KIT on exon 11. In view of the locally advanced, inoperable melanoma a systemic therapy with the PD-1 inhibitor pembrolizumab was induced and temporary obtained stable disease. After administration of 10 cycles of pembrolizumab the patient started to suffer from recurrent vaginal bleeding, which significantly restricted the patient's quality of life. Clinical examinations revealed ulcerated pigmented intravaginal metastases. Imaging confirmed loco-regional progress without distant metastases (). Hence, 4 weeks after the last dose anti-PD1 antibody and in agreement with our patient, we initiated treatment with the oncolytic virus T-VEC (first administration 106 PFU/ml, followed by 108 PFU/ml at week 3 and followed Q2W, 1–3 mL). In cooperation with our department of gynecology T-VEC was injected directly into the intravaginal mucosal metastases. The injections provoked moderate local bleeding of the mucosa, and the patient suffered from flu-like symptoms a few hours after injections. The patient did not show any signs of a herpes infection at any time. Our patient reported that the T-VEC applications were tolerable and that the side effects did not restrict her daily life. Laboratory investigations did not reveal any significant pathologic findings. Af

[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 82-year-old Japanese man presented with swelling of the gingival in the molar region of the left mandible. Approximately 2 weeks prior to the first visit, the patient noticed swelling of the gingiva, and panoramic X-rays were taken at a dental clinic. The images revealed radiolucent findings at the site, and the patient was referred to our facility for examination. The patient had a moderate physique and was well nourished, but he was taking medication for hypertension.
Intraoral findings showed that the upper and lower jaws were edentulous, with a relatively irregular border from the centre of the mandible to the gingiva of the molar region on the left side. Diffuse swelling and surface ulceration were observed. There was neither tenderness nor numbness of the lips ().
Panoramic radiographs revealed a barely perceptible, polycystic radiolucent area with slightly irregular margins in the left molar region of the mandible ().
Computed tomography showed a radiolucent area with little radiopacity. Internal uniformity was observed at the site, with thinning of cortical bone which lacked continuity in some areas (). After 1 month, a biopsy and a needle aspiration were performed. Five millilitres of yellow-white content was aspirated. The results of bacteriological analysis were negative. Histopathological findings revealed that the squamous epithelium was accompanied by chronic inflammatory cell infiltration. Based on these findings, a diagnosis of benign tumor of the mandible was made, and after 2 months, excision and curettage were performed under general anaesthesia. The lesion partially adhered to the bone, and the surface of the peripheral bone was slightly rough. An inferior alveolar neurovascular bundle was also observed below the tumour, and this was preserved. After excision of the tumor in one piece, curettage was performed and the wound was left open. Seven months after surgery, there has been no recurrence of the tumour, and the patient is currently being

[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 79-year-old Caucasian male, with a past medical history of atrial fibrillation on warfarin and metoprolol, and coronary artery disease on atorvastatin with previous coronary artery bypass grafting and placement of a dual-function pacemaker/ implantable cardioverter defibrillator (ICD), was on a motor boat in a remote location. The patient’s boat went over a wake of a larger boat passing by. He bounced off his seat in a vertical direction and subsequently landed on his tailbone. After the high impact fall, he complained of both immediate lower back and diffuse abdominal pain but did not seek out urgent medical help.
Two days after the initial incident, he started to become pale and diaphoretic; additionally, his ICD delivered three shocks over a 30-min period. He presented via ambulance service to a local community hospital in hemorrhagic shock with a blood pressure of 63/22 and heart rate of 118 beats/min. A primary survey was pertinently positive for hemodynamic instability and diffuse abdominal and lower thoracic spine tenderness.
He was resuscitated with 1 L of normal saline leading to an improvement of his pressure to 106/88. Initial laboratory investigations included a hemoglobin of 95 g/L, lactate of 6.1 mmol/L, creatinine of 129, and a supratherapeutic INR of 8.8. An initial non-contrast CT abdomen and pelvis showed moderate hemoperitoneum with sentinel clot in the left upper quadrant and pericolic gutter, as well as the area adjacent to the posterior wall of the stomach. An additional finding of a severely comminuted, minimally displaced burst fracture of the T10 vertebral body was noted (). Further interventions included INR reversal with 3 mg of Vitamin K and 3000 units of prothrombin complex concentrate, and administration of 2 units of packed red blood cells and 2 L of normal saline. Based on clinical severity, the patient was transferred to the trauma service at a tertiary-care Level 1 trauma center

[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.