[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 59-year-old male with a postoperative union of a left tibial plateau fracture who, after open reduction and internal fixation, underwent surgery for implant removal at a local hospital (Fig. ). The first day after surgery, at approximately 9 a.m., he complained of severe pain in the wound region and developed a fever in which the highest temperature reached was 39 °C. Upon examination, the patient was conscious without chills and other discomfort, and the incision was severely swollen and filled with hemorrhagic content. Analgesic therapy was given, but the patient did not feel pain relief. Early on the second morning, the patient started to become irritable and apathetic and the incision was inflamed. The following afternoon, at approximately 3 p.m., the patient felt increasing pain out of proportion to the physical findings accompanied by progressive swelling, numbness, and weakness of the limb. The skin around the wound was darkened, and tension blisters were visible (Fig. ). The patient was delirious on the third morning after surgery, the systemic skin turned yellow, and there was a large amount of dark red, bloody discharge drainage from the incision with bubbles of gas, and a foul, sweetish, unpleasant odor was smelled in the incision. A physical examination revealed subcutaneous crepitus extending along the length of the limb, roentgenograms revealed the accumulation of gas in soft tissue (Fig. ), the lower limb skin temperature decreased, the dorsal artery of the foot could not be touched, and the patient had no response to pain in the lower extremities. Anaerobic infection gas gangrene was highly suspected, and the patient was transferred to our hospital at approximately 7 p.m.
Left lower extremity incision decompression was carried out immediately. Upon incision, the musculature was found to be extensively necrotic and crepitant, the appearance of the affected muscles was purplish red and brown with a characteristic foul odor,

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


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

[User]
RADIOLOGY NOTE:
A 50-year-old male presented with complaints of chronic, intermittent abdominal pain. The patient had a 20-year history of mild-to-moderate amount of alcohol consumption. There was no history of jaundice, fever or weight loss. His laboratory tests revealed no significant abnormal findings. Serum amylase and lipase, and tumour markers [CA 19-9, carcinoembryonic antigen (CEA)] were within normal limits. The patient was subjected to a CT examination. On unenhanced CT image, a poorly defined soft tissue mass was seen in the pancreaticoduodenal (PD) groove with a hypodense cystic lesion within the mass (). On post-contrast study, the lesion showed minimal enhancement in the portal venous phase ( and ), but delayed imaging at 2–3 min showed mild persistent enhancement of the lesion compared with the pancreatic parenchyma that was consistent with scar tissue () and a non-enhancing cystic lesion within the lesion. The lesion showed poorly defined fat planes with the adjacent second part of the duodenum on its right side and pancreatic head on the left side. Mild thickening of the wall of the second part of the duodenum adjacent to the lesion with variable luminal narrowing was noted. The common bile and pancreatic ducts appeared grossly normal. The pancreatic body and tail were normal. In order to clearly delineate the ductal system and the periampullary region, and to know the extension of the lesion, the patient was also subjected to an MRI examination. Axial two-dimensional fast imaging employing steady-state acquisition () sequences showed soft tissue signal intensity lesion in the PD groove with a cystic lesion within the lesion and the aforementioned CT scan findings. MR cholangiopancreatography sequence () revealed smooth and regular tapering of the pancreatic and common bile ducts. The gallbladder was distended and the cystic duct was normal. Incidentally, a few simple cysts (Bosniak 1) were noted in both the kidneys. The patient was advised further surgical interve

[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 66-year-old man, presented to our hospital in February of 2010, about five months after the occurrence of soft tissue swelling on the right laterocervical area that had gradually increased in size. An ultrasound and a CT scan of the neck showed an inhomogeneous and irregular lesion in the right laterocervical area. A biopsy of this lesion was performed, indicating a carcinoma ex pleomorphic adenoma of the right parotid gland.
The patient underwent adjuvant radiation therapy consisting of 1.50 Gy in 25 fractions and a boost of 2.10 Gy in 5 fractions to the right parotid area.
After a staging CT scan and a total parotidectomy with ipsilateral laterocervical lymphadenectomy, a CXPA of the right parotid infiltrating the skin surface and the next muscle tissue of stage pT4a pN0 M0 was confirmed. Histologic examination showed a poorly differentiated malignant epithelial component originated from a pleomorphic adenoma. Immunohistochemically, cells were positive for p63 and a cocktail of cytokeratins. Moreover, Ki67 labeling index was 50% (Figure ).
The patient underwent adjuvant radiation therapy consisting of 1.50 Gy in 25 fractions and a boost of 2.10 Gy in 5 fractions to the right parotid area.
In March of 2011, during a surveillance CT of the neck an irregular and inhomogeneous lesion measuring 4 cm in the right supraclavicular region was detected. The patient underwent dissection of right supraclavicular lymph nodes with histopathological confirmation of a secondary localization of CXPA of salivary glands. The patient was subjected to radiation therapy consisting of 50 Gy in 25 fractions to the right supraclavicular region.
Follow-up of the patient demonstrated no locoregional recurrence or distant metastases; however, in February of 2013 the patient underwent a surveillance CT scan showing a low-density nodular lesion measuring 1.2 cm in the apical segment of the upper lobe of the left lung and another similar lesion measuring 2.5 cm in the superior-medial portion

[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 Indian female patient reported to the Department of Conservative Dentistry and Endodontics with a chief complaint of yellowish discoloration and poor appearance of her teeth with the rehabilitation of the same. Family history and medical history was non-contributory. Patient was unmarried, well qualified medical student and there was no history of similar condition in the family. Her parents and siblings were fine and no other family member presented with similar dental findings. Her past dental history disclosed that she underwent root canal treatment of 36 due to caries involvement. Extra-oral examination disclosed normal mouth opening and no temporomandibular joint problems. The patient was healthy with no co-morbidities.
On intraoral examination, the enamel thickness was highly thinned down and partially flaked off from few surfaces of teeth. Teeth revealed well defined pitted surfaces along with yellowish brown discoloration. Surfaces of teeth were rough with minimal enamel present. The teeth also revealed short clinical crowns with multiple spacing between teeth. The occlusal plane was uneven worn-down posterior teeth. On frontal view, the patient presented with deep bite with less horizontal overlap. Dentin which was exposed were brown in color. The periodontal examination revealed normal healthy gingiva with no abnormalities (Fig ).
Radiographic examination included full mouth Orthopantomogram (OPG) and Intraoral periapical radiograph (IOPA) showed features of AI. (Fig ) Occlusion was assessed after obtaining the diagnostic casts. Based on clinical and radiological examination, it was diagnosed as hypoplastic type of amelogenesis imperfecta. Based on the arrived diagnosis, a full mouth rehabilitation was planned. A well formulated treatment plan involving endodontic, and prosthetic department was charted out to furnish a functional occlusion with good esthetics and further prevent the tooth loss. The entire treatment plan was explained to the p

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


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

[User]
RADIOLOGY NOTE:
A 3-year-old male with a history of autism along with cognitive, language, and behavioral delays presented to the emergency department after falling 4 feet from a window. Head computerized tomography (CT) revealed a 5 × 5 × 4 cm AC of the left frontal convexity with subjacent mass effect. Before the fall, he had delays in cognitive advancement with difficulty following commands, naming objects, and making eye contact. He was able to ambulate with assistance but unable to climb stairs. He also banged his head against walls frequently while screaming and it was unclear if this was secondary to headaches. The patient received physical, occupational, and behavioral therapy through early intervention therapies with no real improvement. On neurological examination, he made no eye contact, did not follow commands, was not cooperative, did not speak or verbalize, but did demonstrate symmetric movement. The patient’s family stated that he had undergone neuropsychiatric testing which diagnosed autism but the patient’s family did not provide reliable follow-up with us; we were unable to obtain this report. The patient was lost to follow-up for 6 months, and on representation, a magnetic resonance imaging (MRI) was obtained which demonstrated a 5.6 × 5.2 × 4.5 cm left frontal AC with associated mass effect on the adjacent parenchyma and frontal horn of the left lateral ventricle. Ophthalmological assessment revealed no papilledema. The patient underwent a left frontal craniotomy for microsurgical fenestration of the AC with excision of the cyst wall without complication. At 10-day follow-up, his parents reported much calmer behavior with no further labile outbursts and less head banging. At 1 month follow-up, his parents reported significant improvement in cognitive function whereby he was following instructions in computer games and solving multistep problems. His behavior was completely altered and more appropriate for 3 years old and he was making eye contact and interacting

[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 woman was referred for low abdominal pain after TOT procedure in a private gynecologic clinic. Abdominal pain lasted for 7 hours after procedure and she went to our emergency care center. On arrival, she appeared pale and acute illness. Her blood pressure was 102/75 mmHg and heart rate was 95/min. She complained lower abdominal tenderness and rebound tenderness. Vagina and cervix were no specific findings in pelvic examination. Vaginal bleeding was scanty. After arrival, her hemoglobin was 12.6 g/dL and coagulation factors, electrolytes, chemical batteries were within normal range. Abdomen and pelvis CT showed a 10-cm-sized hematoma in left pelvic cavity with extravasation of contrast. Abruptly, her blood pressure dropped to 96/63 mmHg. Hemoglobin dropped from 12.6 to 10.9 g/dL. During resuscitated with intravenous fluid and two units of packed red blood cells, we made a diagnosis as retroperitoneal pelvic hematoma with active bleeding. She was taken to operation room for evacuation of hematoma and bleeding control. We found a large amount of hematoma in abdominal cavity and undertook hematoma removal. Although we tried to find bleeding focus but we couldn't, and bleeding persisted at pelvic wall. We sent her to our angiographic room for embolization to confirm pelvic vessel injury. Left iliac artery angiography showed extravasation of contrast from pubic branch of Left obturator artery (). After use of glue, post embolization angiography showed remained bleeding foci. Left external iliac artery angiography showed extravasation of contrast from Left inferior epigastric artery (). After insertion of microcoil and use of gelfoam, extravasation of contrast was stopped. After embolization, her vital signs stabilized and hemoglobin was 11.4 g/dL. Patient was given 8 units of packed red cells during her hospitalization. Since the overall amount of vaginal bleeding diminished, she had no longer complained of leakage symptom. She was discharged on postoperativ

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


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

[User]
RADIOLOGY NOTE:
A 24-year-old man was referred to our gastroenterology department for the specialized management of persistent symptoms such as intermittent epigastric and lower abdominal pain that had begun approximately 7 months earlier. The pain had developed gradually and tended to aggravate after meals.
One month prior to his referral to our department, the patient had visited a primary outpatient clinic several times and was administered medication to control symptoms, but his symptoms did not improve. The patient was later admitted to a primary hospital for 1 week, where gastroduodenoscopy, colonoscopy, abdominal sonography, and laboratory testing was performed to identify the cause of the symptoms. On the basis of these examinations, he was diagnosed with IBS and administered medication. However, because of poor symptom control, the patient was referred to our hospital for specialized management of IBS. The patient had no medical history, including drug history, and had lost approximately 5 kg over the previous 7 months. The patient had a history of 5 pack-years of smoking and social alcohol consumption. The patient's father was diagnosed with pulmonary tuberculosis 1 month earlier and was receiving medication. The patient was employed as a cell phone salesman, but helped with work on his father's farm every weekend. His associated symptoms were frequent nausea with vomiting and diarrhea-like loose stools.
Physical examination findings were nonspecific and he showed chronic rather than acute illness. He had no tenderness or rebound tenderness on his abdomen. Laboratory test results of peripheral blood, blood biochemistry, and serum electrolytes were all within the normal ranges. Urine analysis and stool occult blood test showed no abnormal findings. Because of his weight loss, we tested his glucose and thyroid-associated hormone levels. His fasting blood glucose level was 87 mg/dL and the results of the thyroid function test were normal. We reviewed the imaging studies perf

[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 male patient presented with sudden blurring of vision in the right eye that had persisted for 2 days. He reported that discomfort and redness had occurred in the eye, along with periorbital skin rashes over the affected side, almost 2 weeks prior to the visual obscuration. He had no history of systemic illnesses such as diabetes mellitus or bleeding disorders. He had not been in contact with persons with any skin disorders, and he had no history of drug abuse.
On examination, his best corrected visual acuity was hand motion in the right eye and 6/6 in the left eye. Crusted skin lesions were distributed along the ophthalmic division of the trigeminal nerve on the right side, as well as on the tip of the nose (Hutchinson's sign). A corneal dendritic ulcer accompanied by reduced corneal sensation was found in the right eye. The same eye showed a positive relative afferent pupillary defect []. Fundus examination of this eye revealed a cherry-red spot surrounding pale retinal nerve fiber layers, box-carring over the superotemporal arcade, and attenuation of the retinal arteries []. Anterior and posterior segment examinations of the left eye revealed no significant abnormalities. The intraocular pressure (IOP) in both eyes was 14 mmHg. The patient's blood pressure was 106/75 mmHg, while his random blood sugar was 7.0 mmol/L.
HZO with CRAO was diagnosed in the right eye. Intermittent ocular massage and breathing into a paper bag were performed. Oral acetazolamide (500 mg) and topical timolol (0.5%) were initiated immediately. The patient was also started on oral acyclovir (800 mg, 5 times daily) as well as acyclovir ophthalmic ointment in the affected eye (5 times daily). The next day, the vision in his right eye improved to counting fingers at 1 foot.
A number of investigations were performed during the patient’s first presentation. Laboratory analyses showed a white

[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 male with a history of chronic obstructive pulmonary disease, type 2 diabetes, chronic kidney disease, and persistent atrial fibrillation was brought to hospital after being successfully resuscitated following a brief pulseless electrical activity (PEA) cardiac arrest. During his convalescence, he had a second PEA arrest, from which he was again successfully resuscitated. Telemetry revealed atrial flutter with atrioventricular conduction that slowed markedly to ventricular rates as low as 34 beats per minute. A balloon-tipped temporary pacing catheter was floated in via left internal jugular vein until adequate ventricular capture was observed. Fluoroscopy was not used during insertion. A follow-up chest X-ray confirmed appropriate placement of the lead, which revealed the lead in the right ventricle with redundant lead slack forming a loop ().
The patient subsequently had a PPM implanted. The PPM was implanted without complication using a standard left cephalic vein access. The lead was advanced under fluoroscopic guidance. Implantation of the PPM lead was carried out without difficulty with active fixation to the right ventricular septal wall. The lead pin was attached to a pacemaker pulse generator which was then placed in a pocket located in the prepectoral plane below the left subclavicular fossa.
The TVP was then removed under fluoroscopic guidance. The large loop of redundant wire was noted, but it exited the cardiac silhouette without any resistance or interaction with the newly implanted PPM lead. However, significant resistance was noted when attempting to pull the tip of the TVP lead out through the introducer sheath. This resistance was only encountered when the TVP lead tip was at the level of the skin; fluoroscopy was not performed at this stage to determine the cause of resistance. The resistance was overcome and the TVP lead was successfully removed. It quickly became evident that the reason for the resistance was that the TVP lead had

[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 53-year-old man manual worker with a 13-year history of gout in his right hallux presented to his general practitioner with right knee pain, stiffness, and giving way with no history of trauma. He had been taking allopurinol for 11 years. He drank 10 to 12 units of alcohol per week and his body mass index was 24.4. On examination, he had anterior knee pain and crepitus was felt from the patellofemoral joint. He had a range of motion from 0 to 90 degrees.
A magnetic resonance imaging (MRI) was performed and reported a grossly abnormal patella tendon showing heterogenous characteristics with areas of architectural distortion and altered signal in all sequences. The appearances were not typical for a tendinosis but more in keeping with findings seen in gout (
).
The patient was commenced on anti-inflammatory medication in addition to his regular allopurinol and referred to an orthopaedic knee surgeon. At assessment, he was found to be significantly compromised by his knee. He was unable to ride a pushbike, walk with his dog, or even get out of a chair. Plain films showed calcification within his patellar tendon (
).
A multidisciplinary discussion with rheumatology and radiology consultants confirmed that the likely diagnosis was a tophaceous gouty deposit within the patella tendon. His uric acid level was 560 μmol/L (above the target of <300 μmol/L set by the British Society for Rheumatology [BSR])
and estimated glomerular filtration rate was 52 mL/min. He was referred to rheumatology who advised increasing the dose of allopurinol. A subsequent ultrasound (US) scan showed the superficial fibers of the patellar tendon relatively intact, but within the deep fibers, there were multiple hyperechoic areas with distortion of the tendon architecture. There was no significant cyst. A computed tomography (CT) scan demonstrated a markedly thickened patellar tendon with areas of mineralization within the tendon itself (
). He was seen in 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:
The patient was a 27-year-old woman with four previous pregnancies resulting in two births and two abortions. She had no history of appreciable disease. She was diagnosed with class IIIa high-grade squamous intraepithelial lesion by a cervical smear conducted at 14 weeks of pregnancy and diagnosed with squamous cell carcinoma by punch biopsy. She was referred to our hospital at 16 weeks and 6 days of pregnancy for further examination and treatment. No clear macroscopic abnormality was recognized by colposcopy. She was admitted for conization at 18 weeks and 3 days of pregnancy. An exophytic papillary tumor was observed by colposcopy at the time of admission; it may have grown rapidly before admission. We fully explained to the patient and family members that the cancer had advanced and when the baby would be able to survive outside the uterus if the patient continued the pregnancy. The patient and her family desired surgical treatment and termination of the pregnancy. A radical hysterectomy with pelvic lymphadenectomy was conducted at 19 weeks and 0 days of pregnancy ().
Postoperative pathological diagnosis revealed the following: uterine cervical carcinoma (pT1b1N1MX), squamous cell carcinoma with a keratinizing type, lymph vascular space positive for invasion, vaginal stump negative for invasion, and lymph nodes metastases (right external iliac lymph nodes, right inguinal lymph nodes, and right obturator lymph nodes).
Metastasis to the para-aortic lymph nodes was detected on positron emission tomography/computed tomography (PET-CT) performed postoperatively. Additional treatment options were discussed and explained. The patient and her family desired treatment that could be administered by visiting the hospital; therefore, chemotherapy was chosen. Weekly TN therapy (taxol 80 mg/m2, nedaplatin 25 mg/m2, i.v., once weekly) was conducted. Most of the metastases disappeared on PET-CT three months postoperatively and after the completion of nine cycles of chemotherapy.

[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 61-year-old female with past medical history significant for type 2 diabetes mellitus, hypertension, and dyslipidemia and family history of breast cancer in her brother and maternal aunt presented to the emergency room for recurrent chest pain. She also reported fatigue for the past few months and was being evaluated for worsening anemia by her primary care physician. Her hemoglobin was 6 gm/dl with iron panel consistent with anemia of chronic disease. Her electrocardiogram (ECG) at arrival showed an “RSR pattern” in V1 and V2 leads but was otherwise normal. She underwent a stress myocardial perfusion imaging (MPI) which was negative for cardiac ischemia. A transthoracic echocardiogram revealed a 1.6 cm × 1.5 cm atrial mass attached to the anterior wall of the left atrium, which appeared to cross the mitral valve in ventricular diastole. The left atrial mass was further characterized by a transesophageal echocardiogram (TEE) as a solid, irregularly shaped, partly mobile mass attached to the atrial septum and extending to the anterior mitral valve leaflet (). The segment attached to the septum measured 2.6 cm × 1.43 cm, and the segment attached to the valve measured 1.4 cm × 2.22 cm. In addition, MRI of the heart with gadolinium was done preoperatively which confirmed the circumscribed hypodense mass with speckled appearance which originated at the atrial septum and extended along the anterior mitral valve leaflet (). The mitral valve flow was normal with no evidence of obstruction, stenosis, or regurgitation. The patient underwent a minimal incision valve surgery for resection of the mass which was presumed to be myxoma due to its location. Intraoperatively, on open examination of the left atrium, it was noted that the mass originated from the fossa ovalis region of the interatrial septum and infiltrated the atrial wall down onto the entire anterior leaflet of the mitral valve. A fibrotic density that surrounded the tumor was also noted. The mass along with a port

[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:
In October 2012, a 46-year-old woman was referred to our center for the presence of a large mass (50 × 70 mm) in the superior lobe of the left lung with homolateral pleural effusion. The patient was never smoker, without family history of cancer and without comorbidity. The cytological diagnosis was made using a CT-guided fine needle aspiration of the primary tumor and revealed an adenocarcinoma of the lung (TTF1+, CK7+) with the EGFR ex19del mutation. A PET-CT demonstrated the presence of liver and bone metastases and a nodule in the right breast, confirmed as a metastasis by fine needle aspiration. The patient received zoledronic acid 4 mg every 28 days and gefitinib 250 mg daily since November 2012 obtaining a partial response (PR). In August 2013, a disease progression (PD) was documented, with an increase in size of the primary tumor and size and number of liver metastases. A brain MRI revealed the presence of two cortical nodules, which were treated with stereotactic radiotherapy. The patient was enrolled in the IMPRESS trial and received 6 cycles of cisplatin and pemetrexed plus gefitinib obtaining again a PR that lasted until June 2014. Thereafter, a new lung metastasis appeared in the superior lobe of the left lung and the mammary nodule increased in dimensions. From June 2014 to December 2014 the patient received erlotinib 150 mg daily obtaining an initial stabilization of the disease (SD); however, within 6 months, she experienced again a PD with the increase of the mammary nodule and the appearance of a new bone metastasis in the sacrum. In December 2014, EGFR ex19del and T790M mutations were detectable in a new needle biopsy of the primary tumor; only at this time a digital PCR-based method was available for the analysis of circulating tumor DNA (ctDNA). Briefly, the method was optimized in order to recover a suitable amount of ctDNA for molecular analysis from 3 ml of plasma using the QIAmp Circulating Nucleic Acid Kit

[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 male patient reported to the Department of Periodontology Government Dental College, Calicut with a chief complaint of bleeding from gums and bad breath of 3 months duration. On clinical examination, generalized moderate to deep periodontal pockets and bleeding on probing was noticed. Radiographic examination revealed generalized bone loss. Based on the history, clinical and radiographic findings, the patient was diagnosed with chronic generalized periodontitis. Six weeks after performing thorough scaling and root planning and following a strict plaque control regime, the case was reevaluated. Since the pocket depth was 7 mm distal to 36, it was decided to proceed with flap surgery [].
After giving block anesthesia in the left mandibular posterior area, internal bevel incision was given, and a full thickness flap was raised. Meticulous defect debridement and root planing was done to remove subgingival plaque, calculus, and inflammatory granulation tissue. A deep two wall defect was observed distal to first molar, heavy ledges were noticed extending bucally from second premolar to the second molar area []. First it was decided to remove the ledges as a part of osteoplasty procedure and then utilize the removed bone to fill the two wall defect. For this purpose, a sharp sickle scaler (PDT Cruise Scaler U15-33 R113, PDT Inc., US) [] was used in a scrapping motion with sufficient force such that the bone was essentially shaved off []. The harvested bone was carefully collected in a dappen dish and then transferred to the defect with a periosteal elevator [Figures and ]. The flap was repositioned, single interrupted sutures were placed and periodontal dressing was given [Figures and ]. The patient was reviewed after 1-week, the healing was found to be uneventful. The sutures were removed, and the area was irrigated with saline. The patient was put on the maintenance phase with oral prophylaxis performed every 3 months. Radiographs were taken

[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 female with pain in her right ankle and paresthesia along the medial plantar aspect of the foot reported to our outpatient clinic. No history of trauma was reported. Last 8 years, she was regularly monitored by a rheumatologist due to Raynaud's syndrome. Since the ankle symptoms started about a year ago, she significantly gained weight due to medications and inactivity. She was initially examined in an emergency department regarding her ankle pain. No definitive diagnosis was set at the time, and she was referred to a rheumatologist for further assessment. Her symptoms persisted after the initial conservative therapy with NSAIDs and rest. She was further treated with high doses of intravenous corticosteroids despite unremarkable capillaroscopy and regular laboratory work-up for immune diseases. As the pain persisted, sulfasalazine was added to therapy with no effect on symptoms. She was further referred for a three-phase bone scan and ultrasound (US) of the ankle, which were also unremarkable. At that moment, she was diagnosed with complex regional pain syndrome, and lidocaine patches were added into therapy. In the meanwhile, she was referred to a physical therapy specialist, and physical therapy for alleviation of pain was scheduled. Rheumatologist referred her for an MRI of the right ankle, which was reported as unremarkable by a musculoskeletal radiology specialist. As symptoms persisted, she was further referred to a pain management clinic and for an orthopedic surgeon's examination. Opioids and pregabalin were introduced into therapy, and the patient was referred for hyperbaric chamber therapy. Following hyperbaric chamber therapy, she noticed an improvement in sensation in her foot while ankle pain persisted. In the meantime, she presented to our outpatient clinic, where an orthopedic surgeon issued a plain radiograph of the right ankle, and a dense area was noted in the right calcaneus (). Requested computerized tomography (CT) scan of the righ

[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 11 year-old right-handed girl was referred to our clinic for her painful and swollen left wrist. The patient was a successful student and there was no relevant family history. She had painful wrist without swelling for past two years and had no history of antecedent trauma. The pain was constant, dull and more intense at nights and was not activity-related, so she referred to a health medical center where the general practitioner took an X-ray from her left wrist and referred her to an orthopaedic surgeon because a lytic lesion was in her carpal scaphoid bone (). At that time, the patient was advised for a complete work up but her parents refused further investigation. In spite of constant pain, the patient did not take any pain killer or anti inflammatory agent to subside the pain. Gradually the wrist started to swell and pain became worse and finally two years later she was referred and admitted to an orthopaedic surgery unit in a university hospital where a complete work up was done. At this time, left wrist was swollen, there was a tumor with hard consistency on dorsal and wrist palmar especially on radial side with mild tenderness. The wrist was stiff with minimal motion range and grip power was de-creased. Physical examination otherwise was normal. New X-ray revealed marked osteopenia of the wrist and adjacent bones and an osteolytic expansile lesion with opacities in its matrix in the scaphoid area ().
Bone scan showed increased uptake in the scaphoid area. CT scan revealed lytic expansile lesion with internal calcification in scaphoid ().
MRI of wrist reported a relatively welldefined heterosignal mass lesion in the scaphoid bone, which was surrounded by edema in adjacent soft tissues with central signal void foci, which could be calcification, hemosiderin or flow void vascular structures and no evidence of fluid-fluid level. Chest X-ray and blood tests were normal. The patient underwent a biopsy through volar approach and specimen sent to histology revea

[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 emergency department with an 8-hour history of an acutely painful enlarged right hemi-scrotum and obstipation. His medical history includes a previous left inguinal hernia repaired laparoscopically at another institution nine years prior. He had noticed an enlarging but easily reducible right groin mass for the past 2 to 3 years, for which he had not sought care. During this current presentation, he appeared in significant discomfort, and diaphoretic. Heart rate was 110 beats per minute but he remained afebrile with normal blood pressure. There was a mass present in the right groin which extended into the right hemi-scrotum measuring approximately 15 cm in size. The mass was firm, tender, and non-reducible. His scrotum had overlying skin erythema. His abdomen was diffusely tender with mild distension but no peritoneal signs.
A diagnosis of an incarcerated right inguinal hernia with concern for strangulation was established immediately after a physical exam. Further imaging or laboratory evidence was deemed unnecessary based upon his clinical findings and concern for strangulation. Intravenous fluid resuscitation and antibiotics were initiated, and the patient was brought immediately to the operating room for open inguinal hernia repair. A large indirect hernia sac was identified and dissected from the cord structures. The hernia sac was then opened revealing markedly dilated necrotic bowel. A gentle retraction did not result in adequate mobilization of the necrotic bowel to the operative field as the bowel appeared to be fixed in the right groin. Therefore, a lower midline laparotomy was made. The bowel was reduced through the hernia defect and examined through the midline incision. A 20 cm segment of necrotic bowel was identified, including a large Meckel’s diverticulum measuring approximately 15 cm in length (). There was no perforation. A wound protector was inserted (not shown), and a bowel resection of the necrotic segment and

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


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

[User]
RADIOLOGY NOTE:
A 46-year-old male, with no known comorbidity, presented with an episode of urticaria along with shortness of breath. According to the patient, the urticaria had started from the extremities, progressed to the trunk, and was associated with generalized itching and swelling of lips. This was accompanied by shortness of breath and a cough that progressed from dry to productive with white sputum. He had a history of undocumented weight loss over the last few months. The rest of the symptom review was unremarkable. The patient was a long-term smoker who had recently quit smoking in the past six months and was currently an active betel nut chewer. He had no known allergies, no prior hospitalizations or surgical procedures, and was not on any routine medications. His family history was unremarkable.
A chest radiograph revealed a left-sided pleural effusion. A pleural tap showed a predominantly lymphocytic exudate. The pleural effusion was recurrent and had not settled despite repeated pleural taps. A subsequent computed tomography (CT) scan of the chest revealed a large, left-sided pleural effusion, as well as a large soft tissue mass in the posterior mediastinum in a paravertebral location without extension into the spinal canal, as can be seen in Figure .
Biopsy attempts had proven inconclusive. Routine laboratory investigations were unremarkable. The patient was advised tumor excision. A left posterolateral thoracotomy was done, in which a large posterior mediastinal mass was seen adherent to the left lung, as seen in Figure .
The mass was completely excised, as shown in Figure .
The patient had an uneventful postoperative recovery. Histopathology of the mass, which measured 12.5 x 8.5 x 7.5 cm, showed it to be a giant, predominantly cystic Schwannoma, with medium- to large-sized, congested hyalinized vessels with surrounding hemorrhage, as well as dense acute and chronic inflammatory changes without evidence of malignancy. The S-100 immunohistochemical

[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 female patient reported to our institute with a complaint of swelling in the left side of lower jaw since 2 months []. Post its onset, the swelling gradually increased in size over a period of 2 months. The swelling was associated with dull pain. The patient is a known diabetic since 5 years and is under oral anti diabetic medication. Concurrent with the history of swelling, the patient gives a history of weight loss in past 2 months. No history of cold, cough or fever.
Examination revealed a swelling of 9 × 4 cm in size which extended anteriorly 1 cm in close proximity to chin on left side and posteriorly in line with the ear lobe []. Skin over the lesion was pinchable, normal in color and texture. Margins were well-defined and the swelling was firm, fixed to underlying tissues and non tender on palpation. There were no signs of paresthesia. No local rise of temperature was seen in the concerned area. Left submandibular lymph node was 0.5 cm in size and mildly tender on palpation. A provisional diagnosis of benign tumour of left submandibular salivary gland was given. Few differential diagnoses such as Sarcoidosis, Sjogren's syndrome, Lymphomas and Mikulicz disease were considered. Sarcoidosis was ruled out because only one of the submandibular glands was involved. Generally, all the salivary glands are involved. Sjogren's syndrome was ruled out as there was no history of dryness. In both Sarcoidosis and Sjogren's syndrome, the patient did not give any relevant history. Mikulicz disease is an autoimmune disease and thus was ruled out.
The following investigations were done:
FNAC gave an impression of chronic non specific lymphadenitis. No evidence of cytological atypia seen Ultra sonography report showed a circumscribed mixed area of 3 × 1.5 cm in the anterior region of left submandibular gland. Moderate blood flow was seen and the region showed two enlarged lymph

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


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

[User]
RADIOLOGY NOTE:
A 47-year-old premenopausal Caucasian woman presented in December 2009 during a multidisciplinary tumour board for nonpalpable lesions. Mammography revealed microcalcifications and gentle densities suspicious for invasion in the area of 6 × 8.6 cm in her left breast (Figure ). An ultrasound showed indistinct hypoechoic lesions with posterior acoustic shadows. A core biopsy revealed high grade DCIS with calcifications. Due to the extensive microcalcifications, the patient was recommended to undergo a mastectomy and immediate breast reconstruction with expander implant. The surgery was performed on 23 March 2010. The mastectomy specimen weighed 238 g and measured 13 × 12 × 3 cm. Grossly, in the upper lateral quadrant of the breast a suspicious area was found. The suspicious focus measured around 2 cm in the largest diameter and consisted of somewhat harder yellow-whitish tissue of granular appearance. In the other parts, the breast tissue was mainly fatty without macroscopically suspicious changes. Careful sampling of the suspicious area and surrounding parenchyma was performed. Altogether, 12 tissue blocks were taken from that area. Besides, one paraffin block was taken from each quadrant and central part of the breast. Microscopic examination revealed massive, high grade DCIS with multiple foci of microinvasion that measured up to 0.1 mm in the largest diameter. Deeper sections from the paraffin blocks with microinvasion were also performed, but no invasive focus ≥1 mm was found. DCIS was located mainly in the upper lateral quadrant but multicentric foci of DCIS were present in all breast quadrants. The dimension of the DCIS was approximately 8 cm. Surgical margins were free (the basal margin was 6 mm). Tumour cells were negative for oestrogen (expressed in less than 1% of cells) and progesterone receptors (0%). Testing for HER2 status was not performed. In the pathologist’s opinion, the invasive clusters were too small for a reliable determination of HER2 status. I

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


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

[User]
RADIOLOGY NOTE:
A 64-year-old woman was admitted to our hospital for fever and headache. She was hospitalized in the Infectious Disease Department for observation and study. Chest X-ray and abdominal ultrasound examination were normal. Magnetic resonance imaging (MRI) with gadolinium revealed a right frontobasal brain abscess, compressing the homolateral frontal horn of the lateral ventricle, with a second mass partially occupying the right orbital cavity (Figure ). She presented also with inflammatory sinusopathy involving the right frontal, ethmoid and maxillary sinuses. After 14 d of clinical observation and intravenous broad-spectrum antibiotic therapy, nasal culture was performed on day 14 of hospitalization, which showed evidence of low levels of Candida albicans. Ophthalmological consultation revealed visual loss from her right eye, and contrast computed tomography (CT) showed an increase in abscess size, so the patient underwent prompt surgery with right frontobasal craniotomy (Figure ). Thanks to neuronavigation and under operative microscopy, the abscessual capsule was opened widely, in order to drain its content, and it was coagulated to avoid damage to nervous structures, given that the cerebral parenchyma in the right orbit appeared to be involved in an inflammatory reaction. Some of the mass content was sent for microbiological examination in Bactec broth and, 8 d after surgery, R. ornithinolytica was isolated by conventional microbiological tests. On the basis of an antibiogram, determined according to the European Committee on Antimicrobial Susceptibility Testing, and after consulting an infectious diseases specialist, the patient started intravenous therapy with metronidazole and ceftriaxone, four times and twice daily, respectively (Table ). She received a basal CT scan that showed no residual or recurrent brain abscess.
Her general clinical conditions were improved but, on day 30 in hospital (approximately 2 wk after surgery) she developed right-side pneumonia wi

[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 woman presented to our hospital with left-sided abdominal pain. The patient had no significant past medical history. An abdominal examination revealed left flank fullness. Abdominal sonography and a CT scan of the abdomen revealed a large left (10 × 12 cm) upper pole hydatid cyst in the left kidney. The remaining blood tests and urine examination were normal. No serological test was done and a diagnosis of renal hydatid cyst was made from the typical radiological finding. The patient was given albendazole for three weeks, preoperatively.
The patient had undergone sonography guided PAIR (puncture, aspiration, injection, re-aspiration) via the retroperitoneal route, by percutaneous means, on two occasions. Thus we decided to use the transperitoneal route, with necessary precautions, to avoid peritoneal contamination. The patient was given general anesthesia and placed in a supine position, with the left side elevated at 60 degrees. Pneumoperitoneum was established using a veres needle and CO2 insufflation. The retroperitoneum was exposed by mobilizing the left colon. The cyst was demonstrated and exposed all around by blunt dissection. The cyst was then isolated on all sides by packing it off using betadine-soaked gauze pieces (10% povidon iodine), to avoid contamination of the peritoneal cavity even if spillage occurred. A trocar was inserted into the cyst under vision, with due care taken to avoid spillage. The contents of the cyst were aspirated using an aspiration needle, and hypertonic saline was instilled for 10 minutes. The scope was inserted into the cyst to confirm complete evacuation. This was followed by cystotomy, and the endocyst was removed completely. This was introduced into an endobag. Partial cystectomy was carried out using a harmonic scalpel. Complete hemostasis was achieved. Omentoplasty was performed. The drain was kept in the retroperitoneum. The procedure lasted for 90 minutes. There were no intraoperative or early postoperative c

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


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

[User]
RADIOLOGY NOTE:
A 15-year-old boy with normal birth and developmental history and no history of febrile seizures or encephalitis-like illness had a history of seizure onset at the age of 2.5 years. The seizures were automotor in type with ictal speech and were, therefore, localized at the nondominant temporal lobe. Video-electroencephalography (VEEG) was suggestive of ictal onset from the right anterior temporal region. It was concordant with the finding of right mesial temporal lobe sclerosis on magnetic resonance imaging (MRI). Ictal single-photon emission computed tomography (SPECT) revealed hypoperfusion in the right mesial temporal lobe. There was no history of any psychiatric comorbidity. The seizures remained refractory to the medical treatment; therefore, the patient underwent a right selective amygdalohippocampectomy. He remained seizure-free following the surgery. There were no symptoms of anxiety, depression, or psychosis during the first 2 years after the surgery but the patient had two episodes of nonepileptic events after 2 years. The patient developed feelings of constant sadness and worthlessness, along with feelings of guilt and suicidal ideations 2 years after the surgery. He also started excessive alcohol consumption. At that time, he was on valproate, oxcarbazepine, and clobazam as a part of his antiepileptic treatment. He was diagnosed with major depression as per the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM IV) criteria, and was started on oral escitalopram at a dose of 10 mg/day, to which he responded adequately within 2 months, and the medication had to be continued for the next 1 year. He developed features of mania with inflated ideas 5 years after the surgery. The development of mania coincided with tapering and then withdrawal of sodium valproate, which had been part of his AED treatment, which we had decided to taper very slowly. He was restarted on sodium valproate and initiated on antipsychotic treatment with risperid

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


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

[User]
RADIOLOGY NOTE:
A 69-year-old male presented for evaluation of known moderate to severe PVR with symptoms of progressive dyspnea on exertion, orthopnea, and weight gain 2 months after coronary artery bypass surgery and aortic valve replacement at another institution. His past medical history included nonsmall cell lung cancer, type 2 diabetes mellitus, chronic obstructive pulmonary disease, and 3-vessel coronary artery disease. The patient had originally presented after a non-ST elevation myocardial infarction with severe aortic stenosis and severe coronary artery disease. At the time of his 3-vessel coronary artery bypass grafting and open surgical aortic valve replacement the surgery was complicated by inability to advance a 23 mm sizer through the sinotubular junction due to severe calcium, which resulted in the placement of an undersized 21 mm Magna valve (Edwards, Irvine, California). At the completion of the surgery, intraoperative imaging revealed moderate to severe aortic regurgitation, but the calcium was felt prohibitive for repair and the patient was referred to our institution.
On presentation, the patient was wheelchair bound with New York Heart Association Class IV symptoms and was hypoxic requiring supplemental oxygen. Examination identified a diastolic murmur, 4 + lower extremity edema, and bibasilar rales.
TEE revealed a left ventricular ejection fraction of 55% to 60%, grade III diastolic dysfunction, and moderate PVR with two distinct jets in the noncoronary sinus (Figure ). The patient improved clinically with careful diuresis and further imaging with computed tomography suggested his aortic annulus actually measured 2.2 x 2.6 cm, larger than the 21 mm valve placed at surgery. Based on this, the PVR was felt to be due to the placement of an undersized 21 mm valve. Given excessive open surgical risk for this bedridden patient, transcatheter options were considered. This magna valve true inner diameter of 19 mm. ViV TAVR with balloon fracture of the surgical valve

[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 66-year-old male patient, with a history of smoking (30 pack-years) and no known medical or surgical history, was admitted in our department for a spontaneously resolved inferior ST elevation myocardial infarction (STEMI). The intra-hospital treatment included enoxaparin 0.6 ml twice a day, clopidogrel 75 mg once a day, aspirin 100 mg once a day, bisoprolol 2.5 mg once a day and atorvastatin 40 mg once a day. The coronary angiogram (performed at day 3 through the right radial artery) showed a severe thrombotic lesion of the distal circumflex. The patient underwent an ad-hoc successful angioplasty of the circumflex with a drug eluting (everolimus) stent. Initial laboratory tests at admission were normal except elevated troponin. Echocardiography showed a 65% left ventricular ejection fraction. The patient was discharged after 5 days of anticoagulation by low molecular weight heparin (enoxaparin). Laboratory tests were not controlled during the hospitalization. The discharge treatment included clopidogrel 75 mg once a day, aspirin 100 mg once a day, bisoprolol 2.5 mg once a day and atorvastatin 40 mg once a day.
One week later, the patient was referred again to our department for both chest and right lower limb pain. The electrocardiogram showed an inferior STEMI and the physical exam of the right lower limb found ischemic signs with absence of the femoral pulse. There was no history of aspirin or clopidogrel discontinuation. An urgent coronary angiogram (performed through the left femoral artery) showed total thrombosis of the circumflex stent (
). The patient underwent a successful primary angioplasty of the circumflex by simple balloon (
). Urgent lower limb contrast-enhanced computed tomography was performed immediately after the angioplasty, revealing total acute thrombosis of the right common femoral artery (
). The patient underwent an urgent successful thrombectomy with Fogarty catheter. Immediate evolution was favorable with total regression of coronary and

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


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

[User]
RADIOLOGY NOTE:
A 41-year-old man, working in a furniture confection plant, experienced severe “tearing” chest pain upon heavy lifting. On presentation in another health facility, a chest computed tomography (CT) scan, with incomplete imaging of the iliofemoral axis, revealed a type A aortic dissection (DeBakey type I). Following transfer to our center, physical examination showed a pulseless left femoral artery, while no sign of acute limb ischemia was present. The patient underwent a mechanical Bentall procedure with hemiarch replacement under circulatory arrest for a total procedure time of 7 hours, 45 minutes. The immediate postoperative course was uneventful. The femoral pulses were symmetrical and well palpable once the patient rewarmed. Thirty-six hours after surgery, the patient was extubated and complained of severe pain to his left buttock. The lower limb pulses were present and no sensory or strength deficit was found. The left limb was normal, while the buttock was tense and painful especially upon flexion and adduction of the hip. A GCS was suspected. A CT angiography scan of the pelvis showed a dissection flap ending proximal to the iliac bifurcation without direct involvement of the iliac arteries. The false lumen was thrombosed and preferentially oriented toward the common left iliac artery. The opacification of the left internal and external iliac arteries was good. Preoperative CT angiography showed left gluteus muscle swelling (
). This was likely related to a malperfusion following thrombotic or embolic occlusion (
). The patient was diagnosed with GCS, further supported by a peak creatine kinase of 91 865 U/L.
A Kocher-Langenbeck procedure (
) was performed under general anesthesia with the patient placed in a right lateral decubitus position, with his legs bent at a 30° to 40° angle. An incision was made from the posterior superior iliac crest up to 5 cm of the greater trochanter and then to the lateral aspect of the femoral shaft.

[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 woman was referred to a private practice specializing in periodontics, dental implants and advanced restorative techniques to replace a 'failed' implant. The author informed the patient that the soft and hard tissues around her implant (tooth position 34 according to the World Dental Federation notation) showed evidence of peri-implantitis. The implant had been placed 20 months prior to her visit (to the current practice), and the crown fitted 4 months after the implant surgery. She reported a problem-free implant surgery and subsequent healing period; however, she reported that from the day the crown was fitted, the crown and adjacent gum had never felt 'comfortable.' The patient completed normal hygiene visits during her dental check-ups, but since the crown was fitted onto the implant in position 34, she had visited a hygienist every 3 months for help with this implant site. During visits to the hygienist, topical antibiotics were inserted on several occasions into the pocket to treat infections and pocket/implant surface debridement was carried out. The referring dentist had already warned the patient that the implant should be removed. Upon visiting our office, the patient described feeling very unsatisfied with the loss to her buccal tissue and bone at the implant site and asked if the implant could be replaced. Additionally, the tooth anterior to the implant (position 33) had also suffered extreme recession, which she felt was attributed to the development of peri-implantitis at position 34. The patient had no contraindicating medical condition. Clinical examination showed a very pronounced loss of attachment at positions 33 and 34 (). The patient was diagnosed as having a mixed 'thin and thick' gum phenotype. The width of keratinized gingivial tissue (KGT) in the lower arch varied between 0 and 6 mm. We performed a radiographic examination that produced periapical, panoramic and linear tomograms (). The initial diagnosis was controlle

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


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

[User]
RADIOLOGY NOTE:
A 4-day-old Asian Chinese female newborn was admitted to our department because she presented with six round, soft, multiple, pedunculated swelling masses with two on her upper anterior ridge and four on her lower anterior ridge. The size of the largest mass was 3.5×3cm (Figure ). No family history of hereditary diseases was reported. The baby was delivered in the 38th week of gestation via Cesarean. Her birth weight was 2650g. She was unable to close her mouth and thus feeding was not possible. Her respiration was normal. The size of the swelling masses increased slowly after birth. Because of the feeding problems, an immediate surgery was planned. General anesthesia was placed in spare to manage intraoperative complications including blood asphyxiation and other airway-related problems. The feeder vessels were seen to originate from the alveolar ridge. Hence, a transfixion suture was placed slightly away from the lesion on the alveolar ridge so as to achieve pre-excision hemostasis and minimize the chances of intraoperative bleeding, which could endanger the airway.
All lesions were well defined, firm, round, smooth and pink in color on the cut surface. All alveolar masses were excised surgically without complications under general anesthesia on the sixth day after the birth of the baby, who was discharged on the third postoperative day. Postoperative recovery and surgical site healing were satisfactory.
The excised masses were fixed in 10% neutral buffered formalin. The tissue was submitted for histopathological examination. Immunohistochemical analyses were also carried out using a panel of antibodies, including vimentin, Ki-67, smooth muscle actin (SMA), synuclein (Syn), neuron-specific enolase (NSE) and S-100. Corresponding positive and negative controls were performed in parallel for all the antibodies tested.
Microscopic examination showed a benign tumor composed of sheets of closely packed, large, rounded polygonal cells with abundant granular, eosinophilic

[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 28-year-old woman visited the emergency room with confused mental status after a few generalized tonic-clonic seizure attacks. She had been treated for spinal cord glioblastoma for 4 years. She had undergone surgical removal of a spinal cord tumour and had been on concomitant chemoradiation therapy, which was terminated 2 weeks before the visit. CSF tap was not performed due to an intracranial space occupying lesion.
Brain MRI performed 3 months before the visit showed extension of the tumour from the brainstem to the upper thoracic spinal cord and another lesion at the right temporal pole.
Figure on presentation, she was drowsy and vital signs were as follows: blood pressure, 125/65 mmHg; body temperature, 36.4 °C; pulse rate, 100 per minute; respiratory rate, 19/min. The emergency medical faculty immediately gave her intravenous LEV 1000 mg; however, there was one more generalised tonic-clonic seizure without mental recovery. Video-EEG monitoring was initiated 2 h after the end of LEV loading; at that time, she started to show choreoathetoid movements in her face and bilateral limbs (see Additional file ), but no epileptiform discharges were noted on concomitant electroencephalography (EEG) as seen in Fig. . Laboratory findings including complete blood counts, electrolytes, blood urea nitrogen, creatinine, and arterial ammonia levels were normal. Review of her medical history revealed that she had been treated with solifenacin, esomeprazole, baclofen, and escitalopram for more than 3 months. She was not on concomitant drugs such as dopamine receptor blockers or antipsychotic agents. Considering the temporal relationship between the onset of involuntary movements and administration of LEV, further treatment with LEV was withheld. Chorea movement continued for about 30 min. She could communicate with her caregiver and physician until the end. After administration of 4 mg of lorazepam and 1200 mg of phenytoin, the involuntary movements ceased gradually. The next da

[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 53-year-old, asymptomatic female with no significant past medical history was diagnosed to have a mass in the left atrium (LA) on routine cardiac evaluation. Transthoracic echocardiography revealed a mass of size 1.5 cm × 2.6 cm in LA attached to the interatrial septum (IAS). Considering patient's age, coronary angiography was done which showed normal coronary arteries and a tumor blush due to feeding arteries supplying the LA mass. Coronary angiography also showed feeding arteries arising from the left circumflex (LCX) and left anterior descending vessels (LAD) []. The patient was posted for excision of LA mass.
The patient was induced as per the standard anesthesia protocol and a TEE probe was introduced without any difficulty. Precardiopulmonary bypass (CPB) TEE examination demonstrated a homogenous and irregularly-shaped mass in the LA of size 2.4 cm × 2.2 cm arising not only from IAS [] but also seen attached to the roof of LA, without prolapsing through the mitral valve. The aforementioned findings were confirmed by the surgeon intraoperatively.
Under standard hypothermic CPB with cold blood hyperkalemic cardioplegia, the LA mass was excised through the right atrial approach, and IAS was reconstructed using pericardial patch. The patient was weaned from CPB without any pharmacological support. Postprocedure, TEE showed complete excision of LA mass and absence of flow across IAS. However, an unusual single continuous jet with a peak velocity of 0.9 m/s was seen from LA roof into the LA chamber near the opening of right pulmonary vein [ and ]. With a suspicion of CCF, the coronary arteries were looked at, for any dilated course by direct visualization on the surface of the heart as well as on TEE and found that the coronary arteries were not dilated. The possibility of tumor-feeding vessel draining into LA was considered and protamine was administered with simultaneous monitoring of the continuous jet using TEE. Thirty-five minutes after administration of prot

[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 was 24 years-old male, born in Maua, Sao Paulo, Brazil. He was the eighth child of a 32 year-old woman, who had two miscarriages, did not do prenatal care and smoked during pregnancy. His parents were not consanguineous and he was delivered through vaginal delivery without perinatal complications, and born at term with adequate weight.
His neurodevelopment was normal until five years of age, when the patient, previously healthy, presented with vomiting and diarrhea lasting about a month, staying in hospital at the beginning of the clinical features to correct dehydration.
After this episode the mother told that he started to lose weight and ceased growth. He no longer understood commands and the difficulty to communicate worsened slowly. He had major mood swings, with periods of agitation, aggression and insomnia.
Since the age of six he used hearing aids. At the age of nine he was transferred to a “special school” where he remained for two years, however, he had no progress in learning.
He had several hospitalizations for diarrheal episodes and bronchopneumonia. He underwent bilateral orchiectomy at 12 years of age due to cryptorchidism.
He presented diagnosis of bilateral allergic conjunctivitis and myopia on the right eye. Dental agenesis was observed in the second premolar bilaterally and the right maxillary central incisor.
Absence of subcutaneous fat was noted on his general physical examination. Skin and hair were undernourished. He had dry and aged appearance with multiple nevi on the face and trunk (Figure
). His lips were thin and ears were prominent. He had teeth in bad condition. He had clinodactyly on hands and feet (Figure
). There were no pulmonary, cardiac and abdominal alterations.
Our patient could keep contact with the environment through sight and hearing (a hearing aid in use). He had poor language, speech difficult to understand, in a hoarse and high voice

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


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

[User]
RADIOLOGY NOTE:
A 35-year-old woman presented to the Provincial Maternal and Child Health Care Hospital (Changsha, China) in March 2017 because of irregular vaginal bleeding for more than 1 year and presence of a lower abdominal mass for 4 mo.
The patient was nulliparous and overweight (body mass index = 28.1), with a 15-year history of primary infertility. Her age at menarche was 12-years-old, and the menstrual period lasted for 10 d. She got married at 20-years-old, and had been married for more than 15 years to date. Several characteristics were observed, including nulliparity, limited sexual activity (intercourse 1-2 times a year) in recent years, and irregular vaginal bleeding for 2 years without a pathological report. In April 2017, the patient found a palpable lower abdominal mass in the supine position, but there was no tenderness in the local area. By February 2018, the mass had increased in size, with the patient experiencing occasional lower abdominal pain and discomfort.
The patient denied a history of hepatitis, tuberculosis, typhoid fever, and other infectious diseases, as well as chronic hypertension, diabetes, coronary heart disease, and other chronic diseases.
The patient was born in Guizhou Province, China. She did not have a history of smoking or drinking. Her occupation was housewife and the working conditions of such were general. She denied contact with toxic chemicals, poisons, or radioactive substances. She had married at the age of 20 and they were separated at the time of her case management. She reported her experience of sexual frequency in recent years as approximately every half year. She also reported not using contraception and never having been pregnant.
Findings from the gynecological examination revealed an enlarged uterus, similar to the uterus size in the fourth month of pregnancy, and the uterine wall was relatively hard.
Laboratory tests showed a white blood cell count of 7.7 × 109/L,

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


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

[User]
RADIOLOGY NOTE:
A previous healthy 43-year-old woman was seen for evaluation of swelling in the right submandibular region. The patient first noticed the mass 2 months before visiting the hospital. She had no pain, trismus, or discomfort during eating, but complained of cosmetic problems. The mass was very soft and movable within the submandibular region; no tenderness was reported during physical examination.
Ultrasonography (USG) showed that the mass was of a relatively heterogeneous, hypoechoic nature, with ill-defined margins compared to typical submandibular glands. The tumor was located in the superficial and deep portions of the normal submandibular gland and extended externally to the gland (). A computerized tomography (CT) image revealed a fatty mass with an irregular margin. Multiple soft tissue density was seen inside the mass in the right parapharyngeal space and submandibular region (). Because the mass was located at the superior and medial aspect of the submandibular gland, the residual gland was displaced inferolaterally, creating the cosmetic problem about which the patient complained. As we had no previous experience with sialolipoma, our clinical impression of the mass was that it was a simple lipoma of the submandibular gland.
Tumorectomy with preservation of submandibular gland was performed under general anesthesia via submandibular incision. A marginal mandibular branch of the facial nerve was identified and preserved. Because the tumor was well-encapsulated, it could be easily dissected from the main submadibular gland. The tumor measured 4 cm in its largest dimension and had a fatty consistency like a simple lipoma. Gross examination revealed that the tumor was well-circumscribed, soft, yellowish, and had a well-demarcated light pink-colored nodular component surrounded by fatty tissue. Ill-defined brown lesions were scattered around the nodule; histological examination identified these as an oncocytic nodule and glandular tissue ().
Microscopic examinatio

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


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

[User]
RADIOLOGY NOTE:
In 2013, an 11-year-old Japanese boy was referred to our department for painless bone expansion in the right maxillary alveolus, delayed eruption of the permanent second molar teeth, and altered occlusion. He had no significant medical or family history. A panoramic X-ray showed a unilocular cystic lesion in the right maxilla containing a calcified large mass associated with an impacted tooth (Fig. ). Computed tomography showed a cystic lesion of size 3.6×3.1×2.7 cm that included calcified structures (Fig. ). A horizontal view showed right maxillary bone expansion (Fig. ).
In 2013, the patient underwent tumor extirpation combined with impacted tooth extraction. The incisional line was started from the labial mucosa in the right maxillary central and lateral incisor area. It extended to the gingiva in the right maxillary lateral incisor and canine area by arch-like incision, and to the gingiva of the right maxillary second molar by crestal incision with distal releasing incision. The goal of this procedure was to make a mucoperiosteal flap from the lower border of the pyriform aperture, vertically to the infraorbital foramen and surrounding areas, and horizontally to the lower border of the zygomatic bone. The infraorbital neurovascular bundles were preserved. Upon opening of the sinus from a thin plate of bone in the canine fossa and surrounding areas in the anterior wall of the right maxilla (the same level as the lower border of the pyriform aperture), bone-like hard tissues that were strongly adhered to the maxilla were found. When these tissues were separated from the surrounding areas and removed using a fissure bar, a solid, bone-like, hard odontogenic tumor (similar to a complex odontoma) was found to have occupied almost the whole sinus. The mass was too large to remove from the opening.
For complete removal of the mass including the tumor capsule, which was adhered to the surrounding bone, the tumor was divided into several pieces using a fissure

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


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

[User]
RADIOLOGY NOTE:
A previously healthy male in his 30s presented to the emergency department with a 2-day history of pain and swelling in his right upper extremity after striking a heavy bag with an uppercut punch. At the time of event, the patient felt a sudden sharp pain radiating from the wrist to the elbow, which eventually localized to the elbow. Over the next 2 days, the patient gradually developed swelling and diffuse erythema from the proximal aspect of the right arm to the wrist, tension, and decreased elbow, wrist and finger mobility. He reported a history of compartment syndrome requiring fasciotomy in his right distal arm and proximal forearm due to an automobile accident-induced crush injury 10 years prior. On exam, he was tender to palpation, weak to grip, but had intact sensation and vasculature. Initially, cellulitis was suspected, partly because of the appearance of his extremity and an unlikely traumatic mechanism for ACS. Radiographs were unremarkable for fractures. Magnetic resonance imaging (MRI) revealed extensive edema in the proximal brachioradialis muscle and extensor carpi radialis longus muscle, as well as increased signal in the extensor musculature at the dorsal aspect of the arm, but no fracture or tendinous, ligamentous or muscular tear (Fig. ). Ultrasound showed a non-occlusive thrombus in the right axillary and brachial veins, for which the patient was eventually started on anticoagulation. All initial labs were unremarkable except the CPK of 973 and the patient was subsequently admitted.
On hospital Day 4, due to lack of improvement on antibiotics, worsening of pain and growing suspicion for ACS, the patient was taken to the operating room (OR). After dissection of the fascia, it was found that the muscles of the mobile wad had a dark and dusky appearance along with an associated hematoma, consistent with the diagnosis of ACS. The hematoma was evacuated and vacuum assisted closure of the wound was performed (wound VAC). Four days later, the wound was

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


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

[User]
RADIOLOGY NOTE:
A male patient aged 65 years reported to the Department of Periodontics, K. V. G Dental college and Hospital, Sullia, on September 29, 2011 complaining of bleeding and swollen upper and lower gums with pain since six months. On clinical examination, the gingiva was red in color, soft, and edematous in consistency with spontaneous bleeding on probing. The size of the gingiva was enlarged with severe calculus deposit and probing pocket depth measuring 6 mm with exudation on digital pressure. Routine intraoral photographs were taken []. The patient's oral hygiene was poor with no significant history of medication. The case was diagnosed as Generalized Chronic Periodontitis. The patient was advised to rinse his mouth with chlorhexidine 0.12% mouth wash and was advised to carry out the following hematological investigation like fasting blood sugar, bleeding time, clotting time, differential count, and total count. The test was advised prior to the treatment so as to rule out any systemic condition and patient was advised to report to the department for the necessary periodontal treatment next day.
On September 30, 2011, the patient reported as per the scheduled appointment. The blood investigation results were normal. On extraoral examination, face was symmetrical with no palpable lymph nodes. On clinical examination, gingiva was covered with a loosely adherent yellowish white slough on the attached gingiva extending from lower canine to canine on the labial surface []. The lesion extended apically to the alveolar mucosa up to the vestibule with erythematous margins. The patient reported with severe pain. These findings were absent on the previous day. The affected area was gently cleansed and irrigated with betadine and saline. History about placement of any tablet or medicine or application of any medicament was elicited. On detailed questioning, the patient disclosed that he had visited a local physician for the routine general check up on the previous day. He also ca

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


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

[User]
RADIOLOGY NOTE:
An 8-year-old boy, Greek, presented in the emergency department with abdominal pain, abdominal distension, diarrheas and fever. A physical examination revealed multiple palpable painless abdominal masses that were mainly confined to the lower abdomen and around the omphalic region. He had a history of acute abdominal pain and anaphylactic reaction with urticaria rash 2 months previously, but this had regressed without medical therapy.
An ultrasound and computed tomography examination revealed a cyst containing a “floating membrane” in the spleen and numerous unilocular cysts in the peritoneal cavity, measuring from a few millimeters to 3 cm ( and ) Floating membrane in the splenic cyst and multiple cysts in the peritoneal cavity). Laboratory data were within normal limits except for the eosinophil count (12%) and antibodies against Echinococcus granulosus (1/4096). The diagnosis of multiple hydatid disease was established based on imaging findings and positivity for anti-echinococcal antibodies.
We applied chemotherapy (albendazole, 10 mg/Kgr/day) for 6 months, since the spread of the disease into the peritoneal cavity and the multiplicity of lesions were strong contraindications for a radical surgical approach. At around 3 months the cysts in the peritoneal cavity had disappeared and the splenic cyst had reduced in size. However the echinococcal antibody titers, (which were measured monthly), did not fall noticeably throughout the 6-month chemotherapy period.
Our fundamental concerns on exploration were to avoid spreading the disease and to preserve the spleen. A wide trocar was used to open the splenic cyst and suck the contents out. The result was negative since the contents appeared to be gelatinous rather than watery. The splenic cyst cleared and drained externally. The exploration of the abdominal cavity revealed a myriad of cysts, measuring from a few millimetres to 3 cm located only in the great omentum () numerous cysts in the great omentum). The surgical h

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


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

[User]
RADIOLOGY NOTE:
A 29-year-old female patient presented to our clinic with complaints of a mass located medially on her left upper eyelid which had increased in size over the previous 4 years (). The mass was movable and painless on palpation. The patient had no diplopia, and there was no erythema or warmth in the skin overlying the mass. Visual acuity was 20/20 in both eyes on Snellen chart, and intraocular pressure as measured by noncontact tonometry was within normal limits. The patient’s eye movements were unrestricted. Direct and indirect light reflexes were normal. No pathology was detected on the skin over the mass on slit-lamp examination. Anterior segment structures and fundus examination were normal in both eyes.
The patient first noticed the mass 4 years earlier and since then its growth was documented by annual follow-up with orbital magnetic resonance imaging (MRI) with contrast ( shows orbital MRI of the cystic mass from January 2014). It was documented as a dense cystic mass lesion with smooth borders, approximately 12x8x7 mm in size, located anteromedially to the left eye. It appeared mildly hyperintense on T1-weighted images and markedly hyperintense on T2-weighted images, and showed no enhancement pattern.
To surgically excise the mass, a cutaneous incision was made medially in the fold of the left upper eyelid and the mass was exposed by blunt dissection through the orbicular muscle and septum. Excision was continued by careful blunt dissection in order to avoid capsule rupture and the cystic mass was removed from the surrounding tissues. Following the total excision of the mass (), it was sent for pathologic analysis. Macroscopically the mass was 15x15x6 mm in size and whitish-pink in color with translucent margins; microscopically the mass was determined to be a benign cystic formation lined with a single layer of columnar epithelium. Immunohistochemically, the mass did not exhibit ki-67 staining, while histochemical staining with Alc

[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 present a case of a 51 year-old white female with a 5-year history of ulcerative colitis. She has been taking mesalamine 1.2 gram (2 tablets two times a day) for 1 year with no complications that were reported. No history of allergies and no history of smoking or alcohol abuse were present. Past medical history was only remarkable for ulcerative colitis and there was no significant past surgical or family history. Around March 2018, she started having increased watery diarrhea with occasional blood (10-12 bowel movements per day from a baseline of 1-2 bowel movements per day) as well as cramping abdominal pain. She went to see her gastroenterologist in clinic. On physical examination, she had diffuse tenderness to palpation of her abdomen. Stool studies including stool cultures, stool ova, and parasites were sent which were negative. ESR and CRP levels were elevated. Therefore, she was thought to be in a moderate to severe ulcerative colitis flare based on the current criteria and was prescribed budesonide multimatrix (MMX) 9 mg once daily. Her abdominal pain improved but the diarrhea persisted. She then received a course of oral prednisone 40 mg daily for one month without any improvement of her symptoms and was subsequently started on infliximab therapy. Prior to initiating infliximab therapy, an interferon gamma release assay, hepatitis panel, varicella zoster antibody, and HIV tests were done which were negative. On 4/13/2018, she received her first dose of infliximab 500 mg based on her weight of 100 kg (5mg/kg). Her symptoms got better during the first week after the infusion; however during her second week, she complained of nonradiating chest pain located at the midsternal region, shortness of breath, and worsening fatigue. She went to a hospital where she was admitted. Her initial vitals were significant for low to normal blood pressure and a persistent tachycardia of up to 110. EKG was negative for any acute changes and a CT-PE

[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 Caucasian woman consulted her doctor with symptoms of asthenia, anorexia and weight loss 15 days after they first appeared. In her physical examination, pallid skin and mucous membranes were observed. Her abdomen was soft and yielding and tender to deep palpation of the left hypochondrium, where a mass could be felt.
In the medical tests carried out, the only altered parameters were hematocrit 24%, hemoglobin 8 g/dL, red blood cell count 2,500,000/mm3 and blood glucose 152 mg/dL. An abdominal ultrasound revealed a mass with a diameter of approximately 10 cm at the area between the tail of the pancreas, the left adrenal gland and the upper pole of the left kidney. An abdominal CT scan confirmed the presence of a large retroperitoneal tumor measuring 10 cm × 15 cm that seemed to have its origin in the left adrenal gland, which was surrounded by the tumor, although the possibility of another type of primary retroperitoneal tumor could not be excluded (Figure ). On the basis of these findings, an intravenous pyelogram with contrast dye was obtained, which revealed only a slight displacement of the left kidney in relation to the described tumor. A chest X-ray did not reveal any significant alterations.
We decided to perform surgery with the patient under general anesthesia. We made a bilateral subcostal incision and found a large retroperitoneal tumor in the left hypochrondrium with a grooved surface and a diameter of approximately 15 cm. The tumor was removed, including the kidney and left adrenal gland, together with the spleen and greater omentum. The patient recovered without any post-operative complications.
The anatomopathological study corresponded to a tumor weighing 625 g and measuring 16 cm × 11 cm with a nodular, fleshy appearance and areas of hemorrhage and necrosis. The microscopic study showed a tumor with fusiform and ephithelioid cells, with frequent multi-nucleation, monstrous nuclei, intra-nuclear inclusions, prominent

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


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

[User]
RADIOLOGY NOTE:
A 29-year-old immunocompetent male patient presented to the outpatient department with complaints of gradually increasing low back pain since one and a half years. The pain increased on changing position and relieved with rest. There was associated bilateral lower limb radiculopathy which was more on right side as compared to left. Manual muscle testing of upper and lower limbs did not show any reduction in the grade of power but right lower limb straight leg raising was restricted to 50 degrees. Radical involvement of L4, L5, and S1 nerve root was seen. However, there was no motor weakness present. The patient had radicular pain to right lower limb in posterior gluteal region, lateral and anterior shin. The sensations were intact in all four limbs and reflexes were of two plus grade with a flexor Babinski and negative Hoffman's test. He had associated fever and weight loss of seven kilograms in one year. There were associated voice changes and dry, scaly, erythematous skin, the biopsy of which was previously reported to be inconclusive of any infection. He had lumbar kyphosis and elevated ESR (Erythrocyte Sedimentation Rate) of 94 mm per hour. The patient had been taking anti-Koch's therapy since 1 year with little relief in pain.
The patient had a series of MRI (Magnetic Resonance Imaging) images starting with the first one taken 14 months ago (). It showed spondylodiscitis at lumbar 4 and lumbar 5 region and patient was started on anti-Koch's therapy. The second MRI taken after 4 months of anti-Koch's therapy did not show any improvement in the disc lesion or symptoms. The lesion rather progressed in the second MRI (). The third MRI taken 9 months after anti-Koch's therapy treatment did not even show any improvement (). The fourth MRI was taken after the patient completed 1 year of anti-Koch's therapy (). It showed further destruction of lumbar 4-lumbar 5 disc areas and bodies. 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 22-year-old African gentleman presented with left nasal obstruction and epistaxis for 2 years. Examination revealed a nasopharyngeal mass which upon biopsy revealed an undifferentiated nasopharyngeal carcinoma stage III. He had radiotherapy but in view of persistent symptoms and poor response to radiotherapy, endoscopic tumour excision was planned. Prior to that, he underwent embolotherapy of the maxillary branch of the left ECA under sedation and local anaesthesia. The indication for embolization was intractable epistaxis and to reduce intraoperative bleeding during tumour excision. Intermittent Embozene® Microspheres 250 μm injection under fluoroscopy guidance was done before deployment of a 2 mm × 5 mm coil. He was not given heparin or anticoagulant during or after the procedure.
Approximately 2 h after the procedure, the patient complained of sudden painless profound visual loss in the left eye (LE). Visual acuity in the LE was no light perception with a dense afferent pupillary defect. Funduscopy examination showed a pale retina without cherry red spot; and generalized arterial attenuation (Fig. ). The other eye was completely normal. He did not have neurological deficit.
A diagnosis of left central retinal artery occlusion was made but the absence of a cherry red spot further suggests the absence of choroidal circulation indicating a possible occlusion of the ophthalmic artery as well. Ocular massage and immediate lowering of intraocular pressure with intravenous acetazolamide 500 mg stat and topical antiglaucomas failed to restore the retinal circulation, with visual acuity remaining no light perception after 24 h. We did not do AC paracentesis as the patient was drowsy from the sedation. MRI of the brain and orbit showed high signal intensity foci on diffusion weighted image (DWI) involving the left caudate nucleus and basal ganglia (Fig. ), suggestive of small infarctions. The patent however did not show any clinically apparent neuro-deficits from these i

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