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

[User]
RADIOLOGY NOTE:
A 72-year-old Japanese woman was referred to our hospital for the treatment of a tumor of the ascending colon. The tumor was found by colonoscopy during a checkup for a rectal cancer, which had been resected 5 years earlier, finally staged as pT1 pN0 M0, according to TNM classification of Union for International Cancer Control (UICC). Computed tomography and positron emission tomography revealed that the tumor arose from the appendix and invaded the adjacent ascending colon to expose the mucosal surface. The laboratory data were within the normal range. Because the biopsy from the tumor showed malignancy, ileocecal resection with lymph node dissection was performed. The period after surgery was uneventful, and there was no evidence of recurrence at a 9-month followup, under administration of infusional 5-fluorouracil-based chemotherapy.
Macroscopically, after formalin fixation, the resected specimen showed a clearly demarcated ulcer, measuring 28 × 20 mm maximum dimensions, in the ascending colon (). The representative cutting surface revealed that the tumor was mainly located at the peripheral part of the appendix and invaded the adjacent ascending colon to expose the mucosal surface. Pathological findings revealed appendiceal mucinous adenocarcinoma showing extraluminal expansive growth, with one pericolonic metastatic lymph node, finally staged as pT4b pN1 M0, according to UICC TNM classification. The tumor contained massive mucin pools, and well-differentiated adenocarcinomas were found floating in the mucin pools. No goblet cell carcinoid or neuroendocrine cell was observed. The noticeable finding of this present case was the SSL which included serrated structure, crypt dilation, and horizontally arranged basal crypts, in the root of the appendix (). Moreover, the SSL combined with dysplastic change extended to the adjacent mucinous adenocarcinoma with an area of gradual transition (); this SSL was pathologically regarded as a potential precursor lesion of 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 previously healthy 14 year-old boy presented to the Emergency Department (ED) for evaluation of right eye injury that was sustained one to two hours prior to arrival. According to the patient, he was standing on a street corner on his way to school when he was struck in the right eye with a rock thrown from a passing car. He reported no loss of consciousness and no other injury. He denied nausea or vomiting. His past medical history and family history were not significant. The patient did not have any prior ocular injuries, history of ocular disease, or prior ocular surgeries. The patient reported that he does not wear glasses.
In the ED, he was alert, awake, answering questions, and following commands with a GCS of 15. His only complaint was pain to the right eye. His vital signs were as follows: temperature 98°F, heart rate 79 beats/minute, respiratory rate 18 breaths/minute, blood pressure 151/73 mmHg, and oxygen saturation 99% on room air. On examination, blood was oozing and pooling in his right eye with eye lid swelling and surrounding abrasions ().
The patient expressed severe photophobia in his right eye and was unable to open it. Detailed examination of the right eye could not be performed due to the possibility of right ocular globe rupture. A metal eye shield was placed on the patient's right eye for protection. His left eye refractory status was normal with a visual acuity of 20/20. The patient had a negative battle sign, no hemotympanum, no rhinorrhea, and no cervical spine tenderness. The remainder of his examination was noncontributory.
A non-enhanced CT scan of the orbits was obtained and revealed rupture of the right globe with associated orbital and periorbital swelling with intraconal hematoma ().
An ophthalmology consultation was obtained. He was then taken to the operating room where a 20 mm linear laceration was noted crossing 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 34-year-old female was transferred from an outside hospital with a sudden onset of diffuse abdominal pain. Her history is significant for malrotation with subsequent volvulus, small bowel resection done for ischemic bowel, carcinoid tumor of the stomach, multiple gastric ulcers, and a tubular adenoma of the colon. She first presented in 2005 with suspected ischemic bowel, which was resected and repaired with an ileocolic anastomosis. Her next presentation was in January of 2013 at which time she had severe anemia with a hemoglobin of 4.2 mg/dL. An EGD revealed a carcinoid tumor in the lesser curvature of the stomach that was endoscopically removed. A polyp removed during colonoscopy was identified as a tubular adenoma. She presented again the next month and an abdominal CT revealed two lesions in the liver, a left adrenal nodule, and an umbilical hernia. The liver nodules prompted a workup carcinoid syndrome, but the urine was negative for 5-HIAA.
Upon her arrival to our hospital in August of 2013, she was noted to have moderate generalized tenderness on physical exam and her last bowel movement was earlier that day. An abdominal CT scan done prior to her arrival was suggestive of new marked mechanical traction of the distal small bowel. There were also three target signs present on imaging, a classic representation of intussuscepted bowel (). The patient consequently underwent an exploratory laparotomy. The operation was initiated using a midline incision, and an area of intussusception was revealed in the proximal jejunum () and multiple fibrotic implants were present throughout the bowel and mesentery. The lead point of intussusception was identified (). The compromised portion of bowel was resected and a jejunojejunal anastomosis was created. The bowel was then run from the Ligament of Treitz to the ileocecal anastomosis. An area of narrowed bowel was seen in the distal ileum near the site of the patient's previous ileocolic anastomosis (). An ileoileal anasto

[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, otherwise healthy female was assessed in June of 2017 for her isolated right olecranon injury. She described being bucked off a horse with a direct blow to her right elbow. Her physical exam revealed a closed injury, soft compartments, and intact neurovascular status. Initial X-rays demonstrated a simple transverse fracture pattern of her olecranon with no evidence of articular depression, osteopaenia, or substantial comminution (). She was splinted for comfort and consent was obtained for open reduction internal fixation of the right elbow.
In the operating room, she was positioned in lateral decubitus with the right side up and right elbow prepped and draped, and positioned on a sterile padded mayo stand. Alternatively, the patient may be positioned supine or prone with a radiolucent arm board. A tourniquet was applied to the proximal arm prior to prepping and draping, but was not inflated. A 7-cm longitudinal incision was made over the posterior aspect of the elbow. The incision may be curved medially or laterally around the olecranon, so as not to sit directly over the prominence of the olecranon process, and continued along the subcutaneous border of the proximal ulna. Sharp dissection was carried on through the skin and the subcutaneous tissue. The facia was incised midline, and the location of the ulnar nerve medially was identified and protected throughout the remainder of the case. The fracture site was identified and assessed. The broad insertion of the triceps on the proximal fragment was maintained, and control of the fragment was obtained using a sharp towel clip. The elbow joint and fracture surfaces were irrigated and anatomically reduced using sharp bone reduction clamps. The proximal tine was placed away from the olecranon tip as to avoid the start point for the screw. At this point, additional temporary K-wires can be used peripherally to help maintain the reduction

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


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

[User]
RADIOLOGY NOTE:
A 55-year-old male was referred to our department for a palpable, slow-growing, painless mass in his left hemiscrotum. The patient admitted that the mass had progressively increased in size during the last 6 years without however causing pain or other symptoms. The patient’s medical history was significant for BPH and diabetes mellitus. At clinical examination, a painless, large, solid, mass was palpated in the left hemiscrotum extending to the perineal region, without being clearly distinguished on palpation from the surrounding scrotal components. The inguinal lymph nodes were not palpable. Laboratory tests were normal and serum markers for testicular cancer (β-HCG, AFP, LDH) were within normal limits.
Ultrasonography showed a large (5×6 cm), hyperechoic scrotal mass separated from the ipsilateral testis. A pelvic magnetic resonance imaging (MRI) was scheduled in order to better define the nature of the mass. MRI confirmed the presence of a mass in the left hemiscrotum extending up to the base of the corpus cavernosum. The mass showed a high T1 signal intensity characteristic of fat-containing tumors (both benign and malignant) and was clearly separated from the ipsilateral testicle. The signal intensity was heteroge-neously high in T2 sequences as well ( and ). The finding was considered indicative of a benign tumor with the differential diagnosis also including a liposarcoma of the scrotum. A routine chest X-ray was normal and the patient having been informed about the, albeit small but present, possibility of malignancy agreed to undergo surgical exploration of the scrotum and excision of the mass.
An inguinal incision extending into the left hemiscrotum was carried out and the scrotum was entered revealing a solid vascularized mass. The mass was remote from the testis and epididymis and was completely extirpated with relative ease from the adjacent structures sparing the testis and epididymis. The patient’s postoperative course was uneventful and he was discha

[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 woman presented with two supernumerary nipples located along the milk line on each side of the upper abdomen. During a few months before referral, the patient had noticed a firm palpable mass in close relations to the supernumerary nipple on the right side (). She had no other symptoms. Bilateral mammogram and ultrasound revealed normal breast parenchyma. Ultrasound of the supernumerary nipple on the right side confirmed a small mass in relation to this nipple, presenting as a hypoechoic, well-defined area, measuring approximately 10 mm in diameter ().
Upon clinical examination, the supernumerary nipple on the right side presented with inversion and a palpable firm mass underneath this nipple. Ultrasound-guided needle core biopsy (16G) was performed (). The pathology report described elongated epithelial islands composed of cubic cells, with a small centrally located lumen with focally identifiable cuticles. The epithelial structures were surrounded by a dense fibrous stroma. The microscopic analysis indicated the possibility of SyT and the lesion was categorized as a B3-lesion (a lesion with uncertain malignant potential) ().
Following a Multidisciplinary Team Conference, it was decided to recommend resection with a 5 mm rim of normal tissue, which was subsequently performed ().
Macroscopically the tumour measured 7 x 5 x 5 mm and was described as a firm and grey-white tumour, in close relations to the supernumerary nipple. Microscopically the tumour measured 13 mm in diameter and was localized in the deep part of dermis and underlying subcutaneous tissue with no relation to the epidermis. The tumour was composed of solid trabecular and glandular imitating formations with focal cysts. The epithelium consisted of cells with slightly irregular nuclei and indistinct nucleoli, surrounded by an eosinophilic cytoplasm. The glandular structures were lined by cuboidal cells. The tumour was in close association with the lactiferous ducts and smooth muscle of t

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


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

[User]
RADIOLOGY NOTE:
A 42-year-old woman presented to the neurology emergency department with headaches, lack of mobility in right hand and foot and lost speech ability. On physical examination, there was complete Broca's aphasia and right hemiplegia. Brain computed tomography (CT) scan showed an evidence of embolic infarction in the left middle cerebral artery (MCA) zone and the treatment for cerebrovascular accident was started. Then, the heart and carotids were evaluated.
Carotid Doppler ultrasound and electrocardiogram (ECG) were normal. The heart rhythm in ECG was normal showing a sinus rhythm. Transthoracic echocardiogram (TTE) was normal in chambers and heart valves, A suspicious mobile mass was seen in the aortic arch in assessment of suprasternal notch. To investigate further, the CT angiography of the thoracic aorta was performed and a filling defect was observed in the aortic arch. TEE was performed emergently. Hypermobile mass was seen in the aortic arch with the dimensions of 4.0 × 0.5 × 0.5. On the histopathology, the resected intra-aortic mass showed a blood clot. Regarding the nature of mass, hypermobility and lack of intracerebral hemorrhage in brain CT scan, the decision was made to urgently resect the tumor. The patient was immediately transferred to the operating room.
Midsternotomy was performed right after receiving heparin and arterial cannulation of the right atrium was performed with a grade 7 cannula. Anonymous artery was cannulated with a cannula number 14 and the patient was cooled to 18 degrees and then was given health care assistant (HCA). The base of the anonymous artery was clamped and arterial flow was maintained through the anonymous artery cannula to 800 cc/kg. First arc opening and cutting was undertaken during septum.
A red mobile mass of 4.0 × 0.5 × 0.5 cm was observed at the junction of the ascending aorta and arch, with a soft consistency which was attached with a pike of 0.5 × 0

[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 75-year-old otherwise healthy woman was referred to us with a large tender erythematous morpheaform plaque without ulceration on the lower part of her leg. This plaque had begun as a small nodule on the shin 1 month prior to this visit. It had gradually extended outward in a centrifugal pattern despite oral antimicrobial treatment by her family physician. She was initially diagnosed and treated as a case with cellulitis and with poor clinical response. This patient denied having had a sore throat or arthralgia in the previous months. Other than diabetes mellitus type II, she had no significant medical history. She had been taking oral hypoglycemic agents for many years. On physical examination, it became evident that she had a large erythematous plaque measuring 30 × 30 cm2 on the anterolateral aspect of her lower left leg []. There was mild edema and local tenderness on the leg plaque. The color of this morpheaform plaque varied from red to brown, and its surface was mildly scaling. A skin biopsy specimen was then taken from the newly extending area on the left calf. Histopathological examination revealed that the pathologic changes were mainly in the subcutaneous tissue, in which the septa were thickened and there existed lymphohistiocytic infiltrate and a few neutrophil and occasional multinucleated giant cells. Some inflammatory cells had infiltrated into the periphery of the fat lobules (Septal panniculitis) []. The vessels have not any obvious pathology. A mild perivascular inflammatory infiltrate was also present in the dermis. The overlying epidermis was mildly acanthotic and hyperkeratotic. These findings suggested a diagnosis of erythema nodosum migrans. The results of laboratory investigations were within normal limits. A skin test of PPD and the titer of antistreptolysin O (ASO) proved negative. The chest radiograph has normal appearance. On the basis of the clinical pathological findings, we diagnosed the patient's eruption as erythema nodosum migrans

[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 years-old man presented at our emergency room with fever, cough and left thoracic pain. His past medical history was unremarkable. Blood test showed WBC and C-reactive protein elevation. He had started antibiotics therapy and, given the persistence of symptoms, CT scan was performed showing lower left pneumonia. Incidentally, a 2.5 cm mass was found in the upper anterior mediastinum, with positive contrast enhancement and a 5 mm vessel arising from left brachio-cephalic vein (, ). Because of size and position fine needle aspiration nor anterior mediastinotomy were performed. Radiologic features were consistent with thymoma that usually appears as an ovoid or lobulated, smooth, well-marginated mass, projecting over the mediastinum typically protruding unilaterally, therefore patient underwent (1) neurologic evaluation that excluded myasthenia (2) PET/CT scan that showed the absence of any pathological uptake. However, thymoma was felt to remain a diagnostic possibility and patient was referred for radical surgery, with particular attention to abnormal vascularization. He underwent left thoracoscopy and, in spite of extreme attention, during pleural dissection between mediastinum and sternum, a sudden massive bleeding occurred (about 1,500 cc) requiring emergency conversion to median sternotomy. It was then clear that the bleeding came from tumor and not from brachiocephalic vein or its branches, as initially thought. After controlling the bleeding, we removed the mass but it was necessary to sacrifice the left laryngeal nerve.
Intra-operative emergency required significant blood transfusions and precautionary transfer in intensive care for 24 h. The patient eventually made a complete recovery. We only recorded transitory dysphonia as in case of laryngeal nerve paralysis. At specimen analysis, the cut surface seemed to have some fresh blood and the soft tissue was taupe with multifocal thrombosis in various stages of organization up to phlebolithes. Histopatholog

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


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

[User]
RADIOLOGY NOTE:
A 4-year-old male patient was brought to the pediatric dental clinic of a public teaching institution for dental treatment. The child had no relevant medical history.
During clinical and radiographic examinations, extensive carious lesions were observed in the deciduous second molars. Because of the patient's poor oral hygiene, the final restorations were not placed until the patient's oral environment had improved. Temporary restorations were placed in the decayed teeth using glass-ionomer cement and the caregiver was instructed about her child's oral hygiene and dietary habits in order to control caries-promoting risk factors.
Unfortunately, the patient did not show up for treatment for 10 months, and when he returned there was irreversible pulp damage in the lower right primary second molar. As a result, a pulpectomy was performed, and the root canals were filled with iodoform-based paste. Because of extensive coronal destruction involving the occlusal, buccal, and lingual surfaces, the treatment of choice was biologic restoration using a deciduous molar crown obtained from the tooth bank at the same institution ().
After 12 months, a clinical followup of the provisional restorations was carried out. Upper right primary second molar, which had been restored with glass-ionomer cement, was treated with a formocresol pulpotomy and class I restoration with photoactivated resin composites (TPH; Dentsply, Rio de Janeiro, RJ). The other temporary molars were restored in a direct way with resin composite. Clinical visits took place every 3 months and radiographs taken every 6 months to observe the patient on a routine basis and to reinforce the caregiver's and patient's oral health preventive practices.
Five years after finishing the treatment of the lower right primary second molar, even though there was partial resorption of the root canal filling material, we did not observe any periapical lesion or clinical evidence of unsuccessful endodontics. The same applies to th

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


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

[User]
RADIOLOGY NOTE:
A 67-year-old Caucasian woman presented to her primary care physician with a 1-year history of epigastric abdominal pain, occasional nausea, and emesis, and an unintentional 10 pound weight loss. An abdominal CT scan showed a 4.5 × 4.1 cm periampullary mass arising from the pancreas without evidence of metastatic disease. Interestingly, the CT scan also showed the colon to be in a dorsal position in relation to the SMA (). Laboratory analysis revealed normal liver function tests and serum CEA level but an elevated CA 19-9 level. At operative exploration, the entire transverse colon was found to be retroperitoneal and lies dorsal to the SMA and SMV. The duodenum coursed anterior rather than posterior to the mesenteric vessels. The SMA lies further to the right than normal and the SMV–portal vein confluence lies further to the left than usual. Inspection of the duodenum and head of the pancreas revealed a firm mass in the head of the pancreas. A classic pancreaticoduodenectomy was performed. The anterior placement of the duodenum made division of the jejunum beyond the ligament of Treitz relatively easy. The tumor dissected nicely away from the SMA with no uncinate process of the pancreas present. Our standard procedure is to bring the jejunal limb for reconstruction up in a retrocolic position, through a defect made in the transverse mesocolon to the right of the middle colic vessels. This limb is used to create the pancreaticojejunostomy, hepaticojejunostomy, and gastrojejunostomy. Due to the retroperitoneal position of the transverse colon, we brought the jejunal limb up in an antecolic position. Pathology revealed a moderately differentiated PDA with all surgical margins being free of tumor and 1 out of 11 specimen lymph nodes was positive for metastatic disease. The patient tolerated the procedure well and was discharged to home on postoperative day 5. The patient eventually developed recurrent disease and died 34 months postresection.

[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 had pyothorax after surgery and chemotherapy for lung cancer. He developed sepsic shock and DIC 13 months after undergoing respiratory surgery to excise lung cancer. He was admitted to the intensive-care unit and required dialysis for renal failure. His condition worsened as he developed accompanying PF that affected both hands and feet (). Methicillin-Sensitive Staphylococcus Aureus detected in the pyothorax was considered the main pathogen responsible for sepsis.
Part of the purple-colored skin changed to black, indicating total necrosis. This brought up the issue of how to proceed with surgical treatment for multiple-leg necrosis considering the patient’s pyothorax, which carried a risk of worsening the general condition. Although general anesthesia was possible, we planned to perform the surgery with local and spinal anesthesia in order to minimize the risk of complications, such as pneumonia, after the surgery. The ultimate goal was for the patient to be able to walk again under his own power.
First, we decided to save as much of the left leg as possible, as the necrosis did not involve the heel (). The left foot was therefore amputated at the level of the metatarsal bone, and all necrotic tissue was excised (). The exposed bone associated with the stump presented a problem in connection with the next surgery, skin graft. As a result, negative pressure wound therapy (NPWT) was applied to the wound exposed bone in order to speed up the healing process and cover the bone with granulation tissue. The effectiveness of this therapy for wounds with exposed bone in the lower extremities has been previously described []. The device we used was an ACTIV.A.C® (K.C.I, San Antonio, USA), and the pressure was adjusted 50 mmHg. After three weeks, the wound improved and exposed bone was now almost completely covered with granulation tissue. The wound bed preparation before performing skin grafting was thus considered to be sufficient (). Finally, a partial-t

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


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

[User]
RADIOLOGY NOTE:
A 25-year-old female, teacher by profession, with complaints of weakness and pain in left hand involving 3rd, 4th, and 5th digits associated with pain in wrist, elbow, and shoulder joint on the same side for 2 months. Over the next 15 days she started developing swelling and redness involving last three digits along with blackish mottling of the overlying skin on the dorsal aspect. She also had increased pain sensation in those digits to the slightest of touch such that she would keep her fingers flexed and avoid movements. She sought medical consultation at the dermatology clinic before consulting various other specialties and ultimately being referred to our rheumatology clinic.
At dermatology clinic, on clinical examination, ulnar nerve was found to be minimally thickened and palpable along with skin changes including hyperpigmented patches and hypoaesthetic plaques. There was reduced sensation to cold with preserved fine touch and pain sensations. Ulnar nerve biopsy was ordered which came out to be normal. Skin biopsy showed hyperkeratotic epidermis with large number of budding yeasts in stratum corneum and was prescribed fluconazole along with NSAID’S and topical ointments but to no relief.
Patient visited neurology clinic for her complaints of excessive pain apparently in the ulnar nerve distribution. A possibility of mononeuritis multiplex was considered clinically. She underwent nerve conduction studies of all four limbs and MRI of cervical spine were revealed normal. Patient was started on Tramadol 50 mg twice daily, Gabapentin 150 mg twice daily, duloxetine 30 mg once daily, and Vitamin B-12 supplements but without any relief in her symptoms.
Meanwhile, the patient consulted many orthopaedicians and physical medicine and rehabilitation centers but to no relief. With every passing day, her pain increased to the extent that she stopped venturing out in public places to avoid any touch on her fingers. Pain became so debilitating that she used to cry and could

[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 an 82-year-old female with dyspnea as the primary complaint. She had no particular past or familial history. She used to be a nurse (until the age of 72 years) and had no history of occupational asbestos exposure. There was also no history of residence in an asbestos-contaminated environment.
Regarding the history of the present illness, she presented with abnormal chest radiographs (a) during a community health screening in July 2006. Still, she left the findings unattended because of the absence of symptoms. On a retrospective review of the plain chest radiographs taken one year before, in July 2005, the right costophrenic angle was already blunted. The plain chest radiographs taken during the community health screening in July 2007 indicated abnormalities again (b). At this time, as the chest radiographs showed a mass in the right thoracic wall in addition to right pleural effusion, the patient was referred to a hospital for close examination. In the chest CT scans taken in July 2007 (), a small amount of pleural effusion was noted on the right side, and pleural masses were found in the right anterior mediastinum and anterior and lateral thoracic regions. A percutaneous pleural needle biopsy was performed for the mass of the right lateral chest wall, and a diagnosis of pleural mesothelioma was made. The pathologist in charge of the needle biopsy described the pathological findings as epithelioid mesothelioma with edematous stroma, and intracytoplasmic mucinous vacuoles are outstanding. However, when we re-evaluated the specimen, it was an epithelioid mesothelioma with abundant myxoid stroma and was completely homogeneous with the histological image at autopsy as described below.
Therefore, the clinician recommended anticancer drug treatment. However, as the patient did not wish for aggressive treatment, she was followed-up without treatment.
shows a plain chest radiograph taken in April 2008. Masses were observed in the area corresponding to the r

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


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

[User]
RADIOLOGY NOTE:
A 68-year-old man presented to us with complaints of a recurring cough and occasional blood-streaked sputum. The problem started after a dental procedure during which he had a choking episode and aspirated a dental drill, which was being used for a root canal treatment. He denied any fever, chest pain, or shortness of breath. He had no other medical problems of note beside the above. Clinical examination was essentially normal. The patient had brought with him an X-ray of the chest, which was normal, and CECT of the thorax with reconstructions in which the slender metallic FB was seen lodged in one of the basal sub-segments of the left lower lobe [Figures –]. A decision for bronchoscopic extraction was taken. After obtaining informed consent the patient was taken up for fiberoptic bronchoscopy under conscious sedation.
A bronchoscopy for evaluation was done with a videobronchoscope, outer diameter 5.8 mm, under conscious sedation with intravenous midazolam. The trachea-bronchial tree was largely normal except for the left lower lobe lateral basal segment, where the tip of the FB, a dental drill, was seen pointing straight up. The plastic blunt end of the drill was lying distally embedded in the subsegmental bronchus. An attempt was made to hold this metallic sharp end with a rat tooth forceps but failed. Then, a snare was coiled around the tip, but it slipped through on account of it being too thin. A magnetic tip probe for extraction of metallic FBs also failed to pull out the FB. Finally, a thin fogarty catheter was pushed from the side of the FB with the intention of inserting it distal to the FB, inflating the balloon and then pulling it up to dislodge the FB. However, this attempt resulted in the FB getting pushed in with the catheter and then slipping out of sight into the distal subsegment

[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 9-year old girl was seen at a pediatric cardiac clinic of a university hospital for complaints of palpitation and decreased exercise tolerance of around two years duration. History of past illness revealed that the girl was admitted for chronic cough and pulmonary right lung mass at the age of 5 years. Her family report that a CT scan of her chest showed a right lung mass on that admission. They were told that she will undergo thoracotomy but later were told that medical treatment was sufficient (detailed record not available). On physical examination, She weighed 34 kg and her height was 149 cm. Her blood pressure was 121/53 mmHg and her pulse rate was 72 beat per minute. Her saturation was 93% at room air. She demonstrated no pallor or icterus. The chest was clear with good air entry. Peripheral pulses were palpable and there was no precordial bulge. No heave or thrill was noted. Point of Maximum Intensity (PMI) was in the 5th intercostal space along the left mid clavicular line. There was no murmur or gallop. There was no organomegaly or peripheral edema.
Frontal chest X-ray performed at the time of current presentation showed no lung parenchymal abnormality, no pleural effusion and normal cardio-thoracic ratio and normal cardiac borders. Electrocardiography showed sinus rhythm with 80 beats per minute without any remarkable abnormality. A transthoracic echocardiogram demonstrated a large cystic mass measuring 3.8 cm × 3.4 cm within the interventricular septum, bulging in to the left ventricle (–). No cysts were seen in the liver, kidney or spleen. LV systolic function was reduced (left ventricular ejection fraction of 40% and fiber shortening fraction of 20%). Minimal mitral regurgitation was noted. There was no pericardial effusion.
The patient was started on preoperative albendazole to be taken for 3-months. However, due to a misunderstanding during dispensing from the pharmacy, the patient took albendazole for only

[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 woman presented to our university hospital emergency department in 2007 with complaints of occipital headache of increasing intensity and worsening blurred vision in her left eye for the last seven months prior to her visit. Recently, she had also noticed that her menstrual periods were becoming irregular. The patient had a history of acromegaly treated with trans-sphenoidal resection of a pituitary tumor in 1989. She was also known to have primary infertility for which she had not sought any medical help. She had been lost to follow-up since her surgery until this visit. On examination, she was found to have acromegalic features and a left eye temporal visual field defect on confrontation and visual field mapping. An x-ray of her skull revealed thickened calvaria with a wide, double-floored sella. An MRI of her brain revealed a multiloculated cystic mass seen in the suprasellar region with extension more to the left side, causing a mass effect on the surrounding structures without midline shift or hydrocephalus (Figure ).
In the two months since her first visit, the patient had noticed a significant decrease in her left eye vision with an ability only to perceive light. On examination, her right eye was found to have a new temporal visual field defect. At that time, endocrine testing revealed hypogonadotropic hypogonadism with a serum prolactin level that was mildly elevated at 45 ng/mL. She was also found to have central hypothyroidism. Her GH was not suppressed even after an oral glucose load test. The baseline GH was 17.3 ng/mL; it became 13.0 ng/mL and 10.3 ng/mL at one and two hours. The IGF-1 level of 1006 ng/mL along with the unsuppressed GH confirmed the previous diagnosis of acromegaly. She underwent a left pterional craniotomy with subfrontal approach under microscopic guidance to obtain a tissue diagnosis and drain the cystic tumor. She developed transient diabetes insipidus postoperatively, but her vision improved significantly following s

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


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

[User]
RADIOLOGY NOTE:
A 38-year-old woman (gravida 5, para 3+1) had been delivered of 2 healthy sons and 1 healthy daughter via lower segment CSs in other hospitals 15, 11, and 8 years, respectively, prior to the current presentation. At 32+1 weeks of gestation, she presented at the emergency department of our hospital because of spotting. Her current pregnancy was not registered with any hospital and she had received no antenatal care. She had noted intermittent minor spotting between 28 and 30 weeks of gestation but had not visited any hospital or received any treatment.
On presentation to our hospital, she was found to have a hemoglobin (HGB) concentration of 87 g/L. Ultrasonography revealed that the lower edge of the placenta was completely covering the internal cervical orifice and was suspicious of the presence of PPP (Fig. ). A plain magnetic resonance imaging (MRI) revealed that the pernicious placenta previa was completely covering the internal cervical orifice, she had diffuse placenta accreta and also placenta percreta on the lower anterior uterine wall, and distended and twisted vessels were visible on the surface of the lower anterior uterine wall (Fig. ). A diagnosis of PPP was made. The patient was admitted to the obstetric ward and treated with dexamethasone to promote pulmonary maturation.
At 33 weeks gestation, she had 450 mL vaginal bleeding and was immediately transferred to the operation room for emergency CS. On arrival at the operating room, her blood pressure was 125/75 mm Hg and heart rate 90 beats/min. A resuscitation team comprising senior staff of the departments of gynecology, obstetrics, anesthesiology, and neonatology, the intensive care unit (ICU), blood bank and laboratories, and a nursing team was immediately established. The anesthesiologist immediately punctured an artery to enable invasive blood pressure (BP) monitoring, and devices for autologous blood recovery were assembled. Nurses established four 16 G intravenous lines immediately for fluid infus

[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:
Our patient was an 85-year-old Caucasian man with a 30-year history of type 2 diabetes. Sixteen years after being diagnosed with hypertension following a stroke that caused mild residual right hemiparesis, he was successfully treated for prostate cancer with radiotherapy. Ten years later an electromyogram showed mixed peripheral polyneuropathy with axonal predominance.
While the patient was ambulatory, a 2 cm ulcer appeared on his right heel after prolonged exposure to heat, and it increased in size despite appropriate wound care and glycemic control. Less than three months later the patient was unable to walk and was subsequently admitted to our hospital for congestive heart failure.
A skin examination performed at the time of admission showed the heel ulcer to be extensive (Figures and ), and it was evaluated as grade III according to the Wagner grading system []. Three additional decubital lesions had developed on the sacral area, external malleolus and flexure of the right ankle. These lesions were evaluated as Wagner grade II and were well delineated with a necrotic appearance, without granulation tissue, and covered by purulent exudates.
A general examination indicated that the patient had congestive heart failure probably due to ischemic heart disease. Echocardiography was not performed, and electrocardiography showed no evidence of myocardial infarction. The patient's diabetes was poorly controlled, with neutral protamine Hagedorn insulin measurements of 40 IU in the morning and 15 IU in the evening, and glycosylated hemoglobin levels >8%, which required adjustments of his insulin dose and addition of on-demand fast-acting insulin. He was also receiving bicalutamide 50 mg/day, candesartan 16 mg/day, furosemide 20 mg/day, triflusal 600 mg/day and calcium dobesilate 500 mg twice daily. These medications were continued throughout the patient's ulcer-specific treatment.
Treatment of the ulcer itself was initiated by the patient's general practitioner with oral c

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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 9-year-old boy reported to the Department of Oral and Maxillofacial Pathology, SIBAR Institute of Dental sciences, with an asymptomatic extraoral swelling on the right body of the mandible, which had been evident for 2 months []. According to the patient, the swelling was initially small and gradually progressed to the present size and was asymptomatic. His past medical history and family history were noncontributory. On clinical examination, right facial asymmetry was observed. A solitary, extraoral swelling was seen on the right side of the body of the mandible, which was oval in shape and was 4 × 3.5 cm in size, extending anteriorly 2 cm away from the corner of the mouth and posteriorly 1 cm in front of the angle of the mandible. Superiorly, the lesion was extending up to the line joining the corner of the mouth and the tragus of the ear and inferiorly to the lower border of the mandible. It was hard and nontender on palpation []. Intraorally, the overlying mucosa was intact and smooth and there was no tooth mobility. The regional lymph nodes were not enlarged. The clinical differential diagnosis including central ossifying fibroma, central giant cell granuloma, neurofibroma, neurilemmoma, myofibroma of the mandible and osteoma was considered.
On radiographic investigations, the panoramic radiograph of the right mandibular premolar-molar region showed faint periosteal reaction in the vicinity of permanent first molar. The developing tooth buds of right canine and premolars appeared to be uninfluenced by the pathosis in the region as compared to the left side. The periosteal bone reaction was noted []. As the panoramic radiograph revealed no significant findings, an axial computed tomography (CT) was advised. The axial CT view in bone window at the level of inferior border of the mandible showed a massive periosteal reaction on the buccal surface, demonstrating the sclerotic borders of the lesion. The lesion appears to have

[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 male presented with a chief complaint of a painless swelling in his right mandible and mobility of lateral and canine teeth in the same side. Swelling was begun from 3 years ago until 8 months before was reached to present size; mobility of teeth revealed from 3 months ago. There were no lymphadenopathy and tenderness [].
Panoramic radiograph showed a large, multilobular radiolucency with ill-defined borders, located in the body of partial edentulous right mandible and extending from the lateral incisor to the first molar area []. According to preoperative management of patient, routine biochemical and hematological investigations were done, and all were within normal limits. With a differential diagnosis of central giant cell granuloma or odontogenic tumors or any other centrally located mesenchymal tumors, the patient posted for further evaluation.
Incisional biopsy was done, but the resected tissue was found to be insufficient to arrive at a histopathological diagnosis. The patient refused further incisional biopsy; based on the suggestion of the surgeon, the patient posted for surgery. Under general anesthesia, removing part of the jawbone including tumor with right lateral and canine teeth was performed. In gross, tumor appeared as a combination of cystic and solid areas [].
Histopathology survey of surgical specimen revealed a combination of cystic and solid areas. The peripheral layer of cystic areas consisted of a parallel arrangement of tall cylindrical cells with reverse polarity [, white arrow] of their hyperchromatic nuclei and vacuolization of the cytoplasm, and in solid area, the accumulations of cell rich in eosinophilic granular cytoplasm were found [, black arrows]. Furthermore, in the periphery of solid part of islands and cords of epithelium, a row of cell similar to ameloblast was found. According to above findings, diagnosis of GCA was given. After 2 months, the radiography which was taken showed acceptable healing improvement 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 cardiologist calls as they are planning a coronary angiogram for a 68-year-old trans woman and are concerned because the estimated glomerular filtration rate (eGFR) is unknown. They are uncertain how to risk stratify her for potential contrast-induced nephropathy. She has a history of longstanding hypertension and hypercholesterolemia, vaginoplasty, and has been on various formulations of estradiol therapy for over 20 years. On review of her investigations, her serum creatinine is 109 umol/L (1.23 mg/dL) but her eGFR has not been reported for the last 18 months. Laboratory providers cannot report eGFR if a male or female marker is not provided on the request form, as this is required along with age to estimate eGFR. Using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formula, if classified as female, the eGFR would be 45 mL/min/1.73m
classed as Stage 3 chronic kidney disease and would meet the guidelines for intravenous hydration prior to procedure. However, if classified male, the patient would have an eGFR of 60 mL/min/1.73m
which would be classed as Stage 2 chronic kidney disease and would not require prehydration. Which is the most appropriate eGFR to use?
Accurately assessing renal function is essential for not only assessment of renal diseases, but also clinical situations that may potentially affect renal function (such as diabetes or radioiodine contrast administration) as well as considerations for medication dosing of renally cleared drugs. The most commonly used marker of renal function in clinical pathology laboratories is eGFR, which is calculated based upon an individual’s serum creatinine level, age, and sex (). Typically, people presumed male at birth have a higher eGFR than people presumed female at birth at the same level of serum creatinine because the formula assumes a higher muscle mass in men contributing to the serum creatinine independent of renal function. The difference between these groups (given the same age and weight

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


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

[User]
RADIOLOGY NOTE:
A 52-year-old woman with a 3 month’s history of cough and hemoptysis consulted a nearby clinic. Chest X-ray showed atelectasis of the right upper lobe caused by locally advanced lung cancer with mediastinal invasion. Bronchoscopic biopsy showed squamous cell carcinoma. Chest computed tomorgraphy (CT) showed atelectasis of right upper lobe tumor invasion into the right main pulmonary artery. The SVC was compressed and narrowed but remained patent (Fig. ). No significantly enlarged mediastinal lymph nodes were seen. Bronchoscopy revealed an exposed tumor in the right upper bronchus which completely obstructed the lumen. Brain and abdominal CT, and bone scintigraphy revealed no signs of distant metastases. On the basis of these findings, the tumor was evaluated to be resectable by intrapericardial pneumonectomy. The surgery was performed through a right thoractomy. The pericardial was opened from SVC to the level of right upper pulmonary vein 2 cm posterior and parallel to the phrenic nerve. The SVC was isolated from the atrium to the brachiocephalic trunk, which involved SVC denudation at the point of its connection with pericardium. Then the right pulmonary artery was dissected and ligated between the ascending aorta and the SVC. The right upper pulmonary vein was ligated intrapericardially. The right lower pulmonary vein was dissected and ligated outside of the pericardium. Finally the right main bronchus was manipulated using a stapler to complete the right pneumonectomy. No direct tumor invasion into the SVC was detected. The lower part of pericardium was closed interruptedly and the upper defect was left open. The chest was drained using an intercostals tube that was kept clamped and released for half an hour the next morning. The patient was transferred postoperatively to Intensive Care Unit, and the tracheal tube was withdrawn 2 h after operation. About 18 h after operation, the patient was transferred to an ordinary room. Immediately after a short period of ha

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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 52-year-old male epileptic patient was brought to our tertiary care hospital with uncontrolled seizure. He had history of focal epilepsy since 5 years and was on antiepileptic medication. He was on carbamazepine, with a total dose of 1000 mg per day, since 1 year. He was apparently doing alright for some time and his quality of life had improved on carbamazepine. However, the seizures recurred once in every 2-3 weeks for the last 3 months because of which he was admitted in neurology department for further management and drug optimization.
His general physical examination was normal. There was no history of prior behavioral problems or cognitive deficits. There was no family history of psychotic disorder. His blood investigations for electrolytes, renal function test, thyroid, liver function and other related tests were within normal limits. His computed tomography (CT) scan of brain showed left frontal calcified lesion suggestive of cysticercosis. His CT brain with contrast showed no further new or active lesions. His EEG was normal. His serum carbamazepine level was 10 μg/ml.
In view of his poor seizure control and serum carbamazepine level reaching the upper limits of normal, he was added on LEV with an initial dose of 250 mg twice a day and was planned to increase the dose gradually over 2-4 weeks to reach a dose up to a total 1000 mg per day. However, by day 3 the patient developed severe behavioral abnormality characterized by agitation, emotional liability, hostility and depersonalization. He was evaluated by the psychiatrist and was diagnosed as acute psychosis. His mental state examination was normal except for abnormal mood and thoughts. Psychiatric assessment revealed features of depression, mood and thought abnormality, suspicious and withdrawal state with visual hallucination suggestive of psychosis. Delirium was ruled out as there was no fluctuation in sensorium, focal deficits and meningeal signs. As mentioned earlier, the lab investigations were do

[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 was admitted to a hospital in June 2016 because of right arm asthenia and dysarthria and was diagnosed as having cerebral infarction in the left middle cerebral artery area along with deep vein thrombosis. ECG demonstrated normal sinus rhythm and echocardiography revealed no intra-cardiac thrombus or vegetation. The patient was discharged from the hospital following administration of apixaban.
In August 2016, the patient was readmitted to the hospital because of recurrent right arm asthenia and dysarthria. MRI revealed multiple cerebral infarctions in not only the bilateral cerebral hemispheres but also the cerebellum. Trousseau’s syndrome was suspected at this time. Apixaban administration was stopped and an intravenous drip of heparin was started. Echocardiography revealed mild mitral regurgitation with vegetation on the mitral valve. Although the laboratory data suggested no evidence of infection, ceftriaxone and gentamicin were added as a precaution against infective endocarditis. The patient was then referred to our hospital for surgery.
A CT scan revealed a left renal infarction and multiple swollen lymph nodes around both the abdominal aorta and stomach with antral hypertrophy, suggesting an advanced gastric cancer or lymphoma. As the vegetation showed no change despite the heparin and antibiotics therapy, cardiac surgery was performed on day 5 after referral. Extracorporeal circulation was instituted employing aortic and bicaval cannulation. After aortic cross-clamping, the mitral valve was exposed via a left atriotomy. Both mitral leaflets had vegetation on the surface, and major vegetation 15 mm in width was evident on the anterior leaflet (Fig. ). These were resected in their entirety and replaced with a 25-mm Epic bioprosthesis (Abbott). Continuous intravenous heparin administration was resumed on the following day, aiming for an activated partial thromboplastin time of between 40 and 50 s. Histologic analysis revealed that the vegetat

[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 years old girl came to our hospital with a complaint of pain and swelling over her left hand with history of fall. She also complained of occasional pain over lower third and inner aspect of her forearm. While we were managing the patient for hand injury we took x-ray of hand with wrist and forearm suggesting of fracture of fifth metacarpal. X ray also showed findings of expansile lytic lesion with multiple septas in diaphyseal region of left ulna. Examination of forearm revealed a mild diffuse swelling over the lower third and inner aspect of her left forearm. The overlying skin was normal. No signs of inflammation were visible. On palpation, there was tenderness over the swelling. The swelling was soft in consistency with a feeling of ‘egg shell crackling’. Movement at all the joints was full in range and was painless. There was no neurovascular deficit. Clinically diagnosis came out to be either Aneurysmal bone cyst or Simple bone cyst. We decided to take FNAC. The report of FNAC was suggestive of Giant cell tumor. For confirmation of diagnosis, we took open incisional biopsy which came out to be giant cell tumor. Diagnosis of giant cell tumor was confirmed as we sent specimen at two different histo-pathology laboratory, both suggestive of GCT. Then after proper counseling of patient and relatives, we decided to excise whole tumor and reconstruct it with a fibular graft. We expose entire tumor with standard ulna surgical approach. We had removed tumor with 1 cm clinically normal looking bone both side. We had also sent intra operative frozen section for safe margin. Report came as negative. The bone gap after excision of tumor in ulna was about 8 cm. We took cortical bone graft from ipsilateral fibula of respective size. We took cancellous bone graft from ipsilateral proximal tibia. Implantation of fibula at recipient site after appropriate freshening of margins, fixation of fibula in between the two ends of ulna with intramedullary ulna nail from

[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 man with no relevant medical history attended the School of Dentistry of the University of Granada reporting strong oral pain after a weekend of abundant alcohol and tobacco consumption and lack of rest. Clinical examination revealed multiple ulcers covered with a grayish pseudomembrane in the palatal rugae, papillary necrosis at teeth 21 and 22, and ulceration throughout the gingival margin and gingival papillae of the second quadrant (). Periodontal probing was not possible due to the intense pain.
Panoramic X-ray examination of the patients ruled out maxillary bone involvement in both cases (). Several exfoliative cytology specimens were obtained from necrotic palatal gingival papillae using sterile swabs. Samples from both cases were stained with hematoxylin-eosin to evaluate cytological features and the presence of bacteria. Histological analysis evidenced acute inflammatory cells and polymicrobial microbiota with a wide variety of bacterial morphotypes and forms compatible with spirochetes and fusobacteria (). Following Mombelli’s technique [], blotting paper tips (No. 30) were inserted in the gingival sulcus for microbiological culture of the crevicular fluid in regenerated Schaedler broth supplemented with hemin and vitamin K. The isolation and identification procedures yielded no conclusive results.
After the two cases were diagnosed with necrotizing stomatitis and written informed consent was obtained, 3% hydrogen peroxide was gently applied to the lesions using sterile swabs, for debridement of the necrotic areas. Both patients were prescribed oral 875/125 mg amoxicillin/clavulanic acid and 600 mg ibuprofen every 8 hours and oral rinses with 0.2% chlorhexidine every 12 hours. Both cases showed a rapid response to treatment, and a major improvement in symptoms was observed at 48 hours, with almost complete resolution of the ulcerated areas, which were covered by a layer of fibrin, and the detachment of necrotic areas with partial decapitation

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


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

[User]
RADIOLOGY NOTE:
A 16 year old Sri Lankan male, diagnosed with FA, presented to University Medical Unit (UMU) of National Hospital of Sri Lanka for further assessment of central cyanosis and clubbing. He was a product of a non consanguineous marriage and had been "healthy" up to 13 years of age when he had developed petichiae and found to have thrombocytopenia. There was no organomegaly. His platelet counts were persistently low around 20,000/ɥl. A trephine bone marrow biopsy showed severe bone marrow hypoplasia with haematopoietic tissue accounting for less than 25% of marrow spaces. No abnormal cells were noted and it was concluded to be compatible with severe aplastic anaemia. All other routine blood tests including liver function tests, renal function tests, erythrocyte sedimentation rate and tests of coagulation were within normal limits. Ultrasound scan of the abdomen was also normal. A clinical diagnosis of FA was made and genetically confirmed by chromosomal studies. Three chromosomal cultures with a) no mitomycin C (MMC), b) 10 ng/ml of MMC, c) 50 ng/ml of MMC all demonstrated increased chromosome breaks in metaphase chromosomal spreads in the patient when compared with a control. He continued to be followed up at a regional tertiary care centre where the progressive clubbing and cyanosis were noted. A transthoracic echocardiogram (TTE) performed initially by a paediatric cardiologist revealed a structurally and functionally normal heart without any evidence of an intra-cardiac shunt. Increased interstitial shadowing was noted in bilateral lung fields in the chest roentgenogram and lung function tests revealed a severe restrictive pattern. The high resolution CT (HRCT) of the thorax failed to demonstrate any evidence of pulmonary fibrosis.
Upon admission to UMU, in addition to central and peripheral cyanosis and grade 5 clubbing, the patient also had persistent desaturation with paltypnoea (breathlessness worsening on sitting up) and orthodeoxia (desaturation worsening with

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


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

[User]
RADIOLOGY NOTE:
A 32-year-old man presented with colicky abdominal pain in the left lower quadrant for 2 weeks duration. He had a significant weight loss of approximately 30 kg over 2 months associated with decreased appetite. He also has a history of chronic alcoholism and smoking. There was no associated nausea, vomiting, hematemesis, melena, or hematochezia. Review of symptoms was negative for fever, arthritis, skin rash, jaundice, and pruritus. Two months prior, the patient was discharged from another hospital following a 6-week hospitalization for alcohol-induced necrotizing acute pancreatitis, which was treated successfully by conservative measures. Admission vitals revealed an afebrile and normotensive patient with a heart rate of 92 beats per minute and oxygen saturation of 98% on room air. On physical examination, the abdomen was soft with mild tenderness to deep palpation in the left iliac fossa and lumbar region. There were no signs of peritonitis. Laboratory results and abdominal sonogram showed no significant findings. Abdominal CT scan from the episode of acute pancreatitis 2 months ago showed findings consistent with necrotizing acute pancreatitis ().
A colonoscopy was done because of the abdominal pain and significant weight loss. The scope revealed ulceration with a partial stricture at the descending colon approximately 30 cm from the anal verge (). However, the scope could not be navigated beyond the stricture. Controlled radial expansion balloon dilatation was tried without success in dilating the stricture.
Due to tuberculosis (TB) being a possible differential diagnosis, a workup for TB was warranted. This included sputum for acid-fast bacillus, chest X-ray, purified protein derivative test, erythrocyte sedimentation rate, and pathological examination, all of which were negative for TB. Biopsy of the lesion revealed active focal colitis with ulceration, but no granulomas were seen. Barium enema and CT colonoscopy were done to assess the length of the stricture

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


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

[User]
RADIOLOGY NOTE:
A 68-year-old male patient with a medical history of long-standing hypertension, ischaemic heart disease, obesity, type 2 diabetes mellitus and rheumatoid arthritis was referred by his general practitioner to the hypertension clinic in May 2007, due to uncontrolled hypertension despite three antihypertensive agents at maximum tolerated doses (ramipril, felodipine and atenolol). His mean daytime blood pressure at the time of referral was 168/99 mmHg. He was thoroughly investigated for secondary causes of hypertension, but none were found. His antihypertensive medication regimen was progressively optimised over many years, taking into account intolerances, adverse effects and co-morbidities. His medications at the time of the addition of canagliflozin can be seen in .
In view of apparent resistance to treatment, the patient was admitted to hospital for directly observed therapy in June 2013 to exclude non-adherence. His adherence was also confirmed on two separate occasions in 2014 when urinary drug screening became routinely available. Renal denervation (radio-frequency ablation of the renal sympathetic nerves surrounding the renal arteries) was conducted in October 2013. This had no effect, and in fact his blood pressure in June 2014 was higher with a mean daytime blood pressure of 181/105 mmHg.
The patient was started on the sodium glucose co-transporter 2 inhibitor canagliflozin 100 mg in May 2015 in view of a high body mass index of 38 and suboptimal diabetes control (HbA1c of 103 mmol/mol). This was uptitrated to 300 mg daily. A significant reduction in the patient’s blood pressure occurred with the best clinic reading being 137/80 mmHg. The HbA1c also reduced significantly (see ), although this cannot be solely attributed to canagliflozin, as the doses of metformin and gliclazide were also uptitrated. The patient did not experience any unwanted effects although the creatinine measurement did increase over this time. In line with manufacturer recommendations, th

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


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

[User]
RADIOLOGY NOTE:
We are presenting the case of a 61-year-old African American female patient who was admitted to the intensive care unit with right-sided weakness, numbness, and slurred speech. Further workup revealed a left cortical and cerebellar hemisphere ischemic stroke. TEE was performed as part of stroke management, which was uneventful. Feeding and scheduled oral medicines were started via a Dobbhoff tube, and further stroke management was optimized. On the third hospital day, she developed acute respiratory distress, warranting endotracheal intubation. Chest radiograph revealed a near complete opacification of right hemithorax with slight mediastinal shift (). Preliminary diagnosis was aspiration pneumonia. Treatment with broad-spectrum antibiotics was started after cultures were obtained. Bronchoscopy showed copious, thick, and purulent secretions in the right middle and lower lobar area. However, quantitative culture of bronchoalveolar lavage showed no bacterial growth.
The pleural effusion persisted despite thoracentesis. Samples obtained were consistent with exudative effusion (low amylase, high lactate dehydrogenase, low glucose). A chest tube was inserted and drained a fair amount of purulent-appearing fluid. Overtime, her chest tube drainage slowed down but diminished-but-persistent effusion was still obvious in the chest X-ray. Due to notable clinical improvement in her pulmonary status, the patient was weaned off the mechanical ventilatory support and extubated after the 14th day of intubation. Per protocol, she was then referred to the speech therapist for a swallow assessment. A fluoroscopic dynamic swallow assessment showed a clear leaking from the esophagus. A chest computed tomography scan and esophagogram confirmed the leakage of contrast from distal esophagus (esophageal perforation) into the patient’s right chest cavity (). There was no evidence of mass lesion noted.
The patient underwent primary repair of the perforated esophagus with muscle flap construct

[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 Chinese woman was hospitalized on 28 December 2018 with a complaint of anal pressing pain and an anal mass. Anorectal physical examination showed no redness or ulcers in the perianal skin. Preoperative digital anal examination showed moderate anal tightness, a smooth rectum wall, and no swelling or mass. There were also no significant changes in the rectal wall when the mass was pulled. The perianal skin and lower rectal mucosa were smooth, and no ulcers, fistulas, or purulent secretion were found under anoscopy. The tumor was palpable 6 cm from the anal margin at a 7 o'clock direction, with a range of about 5 cm × 5 cm (). Perianal ultrasound suggested an inflammatory mass, with no significant relationship between the mass and the rectum (). The clinical diagnosis was a perianal mass for further examination. The decision was made to perform excision and biopsy. Under general anesthesia, the perianal area was prepped and draped in a sterile manner and the anal mass was identified. Local anesthesia with 25% macaine was injected into the skin around the mass, and an elliptical incision was made around the mass, about 0.5 cm from the edge of the mass. The subcutaneous tissue was taken down by electrocautery. During surgery, the tumor was found to be spreading subcutaneously, with unclear boundaries. It had a hard texture, no capsule, and no fluctuation (indicating a solid mass) and was sent for pathology. The skin was closed using interrupted subcuticular stitches and Monocryl.
Gross examination showed a gray-yellow mass measuring 4 cm × 3 cm × 3 cm (). Hematoxylin and eosin staining revealed nests of mononuclear cells with abundant eosinophilic granular cytoplasm, small central nucleoli, and a small number of vascular structures in the tumor tissues, with no hemorrhage or necrosis. Immunohistochemical examination showed notable and strong positivity for NSE, vimentin, and S-100.

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


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

[User]
RADIOLOGY NOTE:
We describe a case of a 36-year-old black African woman with two previous live births by cesarean section and two previous miscarriages who was referred in her fifth pregnancy after 6 weeks of amenorrhea. Her serum quantitative β-human chorionic gonadotropin (bHCG) was 16,124 mIU/ml. However, an intrauterine or extrauterine pregnancy could not be located on a transabdominal ultrasound scan.
A copper intrauterine contraceptive device had been removed 2 months prior to her last menstrual period. She reported using one cycle of clomiphene 50 mg with the hope of achieving a twin pregnancy.
She had delivered twice by cesarean section for failure to progress. Her last two pregnancies had been first-trimester miscarriages; one was managed expectantly, and the other was surgically evacuated, though the actual procedure was unknown to the patient. She did not have any chronic medical illness and was not receiving any medication prior to this presentation. She stayed in a city suburb that was well serviced. She was a school principal in her second marriage with no children in the current relationship. She did not smoke or drink alcohol.
On examination, she had a normal blood pressure of 113/70 mmHg and a pulse rate of 98 beats/min. Her body temperature was 37.5 °C. On examination, her cardiorespiratory and neurological systems were normal. Her abdomen was soft and not tender. The result of her pelvic examination was normal. TVUS showed a gestational sac of 13 mm with irregular margins and a visible yolk sac located on the anterior isthmic portion of the uterus, raising suspicion of a cesarean section scar ectopic pregnancy. She declined a Doppler ultrasound evaluation scheduled for the next day. She was scheduled to have serial bHCG evaluations every 48 h.
A repeat serum quantitative bHCG done 48 h after the initial test revealed a level of 21,521 mIU/ml, a 33% rise. She defaulted follow-up until 1

[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 man who was diagnosed with LDH was referred to our hospital. He complained of radiating pain in the right lower limb for approximately 9 months. The pain radiated from the posterior aspect of the right thigh to the lateral aspect of the leg and right foot. The persistent and intense pain could be aggravated after hip flexion and slightly relieved after rest or hip overextension. The VAS score for pain was 7/10 at the first visit to the clinic, and the pain could wake the patient up from sleep during the night. Moreover, the pain was combined with numbness of the right lower limb. Physical examination revealed a decreased tingling sensation of the right dorsolateral foot and sole skin, grade 3/5 weakness of the quadriceps femoris, grade 2/5 weakness of the extensor hallucis longus and extensor digitorum longus and a positive straight leg raise test. The muscular tension, knee reflex and Achilles tendon reflex were normal, and he had a negative Babinski sign, Chaddock sign, Gordon sign and Oppenheim sign, and there was no tenderness in the lumbar spine. He had received conservative treatment, which included analgesic drugs, acupuncture treatment and local nerve blocks for approximately 6 months in Chengde Central Hospital. Thereafter, the symptoms were slightly alleviated (VAS = 6/10). The patient also underwent a lumbar MRI examination in Chengde Central Hospital that showed L4-5 intervertebral disc expansion. Although LDH was diagnosed in Chengde Central Hospital, the radiological imaging results were inconsistent with the symptoms and signs. To further explore the cause of the radiating pain in the lower limb radiation, the patient was transferred to our hospital and received a detailed physical examination. Fortunately, a soft tissue mass in the area where the sciatic nerve runs in the middle thigh was palpated. The tumour size was approximately 50 × 30 mm, the boundary was not clear, and there was a positive Tinel’

[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 Thai male patient presented with progressive pain and swelling of seven-month duration over the antecubital fossa of the right elbow. Initially, there was only slight swelling. Three months later, he complained of dull pain. The patient went to a private clinic where the diagnosis was distal biceps tendinitis. The first doctor gave a local steroid injection, but the symptoms recurred about one month later. Four months later, the patient complained of pain at night and weakness on supination of the forearm and flexion of the elbow. He had no underlying disease, chest symptoms, fever, weight loss, or history of contact with patients suffering from pulmonary tuberculosis.
Physical examination of the right elbow when patient visited the hospital in Thailand demonstrated swelling at the antecubital fossa, mild tenderness at the distal biceps, and muscle weakness or pain when attempting to supinate the forearm and flex the elbow. All other systemic examinations were normal. There was a high white blood cell count (12,710 cells/mcL); neutrophil count was 72% and lymphocyte count 17%. Erythrocyte sedimentation rate was 17 mm/hr, and C-reactive protein was 6.69 mg/L. Radiography of the right elbow showed swelling at the antecubital fossa, and chest radiographs showed infiltration of the left upper lung. Magnetic resonance images showed disruption of the distal biceps tendon with an associated ill-defined soft tissue mass (about 2 × 2 cm). A less enhanced area was observed at the inferior part, which was likely to be necrotic or cystic. An abnormal marrow signal was detected at the proximal radius with focal cortical erosion at the radial tuberosity ().
In this case, we suspected that the patient had disseminated tuberculosis because preoperative chest radiographs demonstrated left upper lung infiltration, which was likely pulmonary tuberculosis, and there was a soft tissue mass at the distal biceps tendon. We performed an open excisional biopsy and debridement

[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 Hispanic male with a known history of type 2 diabetes mellitus presented with 2 days history of acute epigastric abdominal pain with associated postprandial nausea and vomiting. His other medical conditions include hypertension, hyperlipidemia, diabetic neuropathy and seizure disorder. On examination, he was thin built with body mass index (BMI) of 20.1, and vital signs revealed mild tachycardia and hypotension. Remainder of the exam was unrevealing. Pertinent labs revealed creatinine of 1.4 mg/dl, hemoglobin 10.3 g/dl, albumin 1.5 g/dl, prealbumin 4.7 mg/dl and normal liver function tests. Patient had similar symptoms intermittently for the last 2 years. In the past, his symptoms were attributed to gastroparesis due to his long-standing diabetes mellitus. He had multiple CT scans of abdomen done during this period but most of them were without contrast. These scans were either normal or showed mild gastric distension at times which was thought to be secondary to gastroparesis. Of the several scans, he had one CT abdomen with IV contrast approximately one year prior to this presentation, this revealed mild gastric and proximal duodenal dilatation but there was no evidence of duodenal obstruction. He had an upper GI endoscopy recently and this revealed dilated stomach and duodenum along with pyloric and proximal duodenal circumferential ulceration and was treated with proton pump inhibitors. Due to his intermittent symptoms he had poor oral-intake and had a weight loss of about 15 lbs in the last few months (Figs –).
Patient was admitted for possible gastroparesis exacerbation and peptic ulcer disease. He was treated with intravenous fluids and Pantoprazole. Supportive care with fluids normalized his renal functions but not his abdominal pain, hence CT abdomen with IV contrast was undertaken. This revealed dilatation of stomach and proximal duodenum and decompression of rest of the duodenum and small bowel. The aortomesenteric distance was measured at 3

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


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

[User]
RADIOLOGY NOTE:
A 72-year old female patient presented to us with shortness of breath for the last 2 months. There was no history of fever, cough, chest pain, haemoptysis, abdominal pain, vomiting or bleeding per vaginum. There was no lymphadenopathy, clubbing, or pedal edema, but pallor was present. Air entry was decreased bilaterally in the inframammary and infrascapular regions. The cardiovascular system and gastrointestinal system were normal.
The laboratory value for hemoglobin (Hb) was 8.0 g/dL. The complete blood cell count (CBC), blood sugar, renal function test and liver function test were all found to be within normal ranges. A posterior to anterior (PA) view chest X-ray () was done which showed homogenous opacity in the bilateral lower lung field along with blunting of both costophrenic angles (CPA) suggestive of bilateral pleural effusion.
A cytologic examination of pleural fluid revealed adenocarcinoma cells (). A contrast-enhanced computed tomography (CECT) scan of the thorax was done which revealed only bilateral pleural effusion with absence of any mass lesion or any mediastinal lymphadenopathy (). An ultrasound of the abdomen and pelvis showed only ascites; no other abnormality or mass lesion was detected. A cytologic examination of ascitic fluid also revealed adenocarcinoma cells ().
A CECT scan of the abdomen and pelvis revealed heterogeneous thickening of omentum with nodular appearance and fatty streakiness into the adjacent soft tissues extending up to the anterior abdominal wall and adjacent bowel loops, including transverse and descending colon, suggestive of omental caking with small amount of ascites. The ovaries appeared normal and no other mass lesion was detected ().
A gynecological examination did not reveal any abnormality. An upper gastrointestinal endoscopy and colonoscopy did not show any abnormal lesion. A breast examination was normal. Examinations of the oral cavity and indirect laryngoscopy were also normal. A laparoscopic examination of the ab

[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 44-year-old female was found to have an incidental FDG-avid right thyroid lesion following staging PET for colorectal carcinoma. She was asymptomatic from the thyroid lesion and biochemically euthyroid. There was no personal or family history of thyroid disease and no prior history of radiation exposure to the head and neck region. CT scan of the neck confirmed a 40mm thyroid nodule, and ultrasound guided fine needle aspiration of this nodule was suggestive of a follicular neoplasm.
A right hemithyroidectomy was performed. The gross specimen weighed 67 grams and the cut surface revealed a round solid well-circumscribe tan nodule, with scant compressed residual thyroid parenchyma at the superior pole. The entire specimen was submitted for examination. Sections showed the nodule to be entirely encapsulated by a thick fibrous band without capsular or vascular invasion. The tumour showed predominantly areas in keeping with usual follicular adenoma formed by microfollicles with scant colloid and lined by cells with bland round to ovoid nuclei ().
Present centrally and entirely within the encapsulated and conventional adenoma was an 11 mm focus showing distinct insular growth pattern with atypical cell morphology. The cells contained round to ovoid nuclei with irregular nuclear membranes, small nucleoli, and high nuclear to cytoplasmic ratio. The mitotic count was very high (8/10 high power fields), although tumour necrosis was absent, meeting criteria for PDTC (). In addition there were several regions, one of which was adjacent to the PDTC-like area, showing formation of trabeculae and high nuclear cytoplasmic ratio, without sufficient nuclear morphology or mitotic count for PDTC criteria ().
The PDTC-like focus and adjacent trabeculae region did show noticeably higher proliferation rate by MIB1 immunohistochemical (IHC) staining (). IHC staining showed retained expression of TTF1 (), with loss of thyroglobulin (which was retained in background follicular adenoma comp

[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 presented with vomiting and abdominal pain and had no previous medical history. The patient began experiencing abdominal distension 3 months prior, with intermittent abdominal pain and nausea developing after the first month. As symptoms persisted, the patient consulted the nearby clinic and underwent upper and lower gastrointestinal endoscopy and abdominal CT scan. Findings suggested ileal intussusception, and the patient was referred to our department for detailed examination.
The abdomen was flat and soft, and did not show tenderness or rebound tenderness. There were no palpable abdominal masses or Dance signs.
Abdominal contrast CT scan showed edematous thickening of the distal ileum (), and we observed intussusception developing from a tumor lesion, with fat in the same site (). Mild dilation was observed in the upper gastrointestinal tract, and there were no obvious regions of poor contrast. Based on these findings, the patient was diagnosed with intussusception of the ileum. As there were no findings suggesting gastrointestinal obstruction or impeded blood flow in the intestinal tract, the patient was scheduled for naval single-incision laparoscopically-assisted partial ileectomy.
Laparoscopy was performed by making a vertical incision measuring 3 cm in the navel. A wound retractor was inserted, and we laparoscopically observed the peritoneum via the suspension method until we located the lesion. The intestinal tract was brought out through the incision, and a mass was palpable in the lumen about 50 cm from the end of the ileum. An inversion in the opposite side of the upper gastrointestinal mesentery was thought to be the base of the mass, and we removed approximately 8 cm of the ileum, including this section ().
Examination of the mass showed protruding, raised lesions from the opposite side of the ileal intestinal mesentery to the intestinal lumen, which was considered to be an MD inversion. Furthermore, despite observing erosion at 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 46-year-old male patient with compression and dislocation of the inferior vena cava (IVC) by a giant hepatic haemangioma was referred to our surgical department after two episodes of pulmonary thromboembolism. The second episode occurred while the patient was on oral anticoagulant therapy. Based on abdominal and thoracic CT scan, the patient was diagnosed to have a giant cavernous hepatic haemangioma, arising from the caudate lobe. The tumour was surrounding the inferior vena cava (IVC) and occupying segment I, III, IV, V, and in part segment VIII. A CT scan showed compression of the retrohepatic IVC () with thrombosis of the left and middle suprahepatic veins. On the basis of CT-scan imaging, hepatic malignancy such as haemangiosarcoma could not be ruled out () [].
In order to prevent the risk of further episode of pulmonary embolism, a liver resection was considered. At laparotomy the exploration of the abdomen confirmed the presence of a huge smooth mass, violaceous in colour, occupying the left and the central segments of the liver surrounding and compressing the IVC. An extended left hepatectomy was planned. During the mobilization of the liver, a laceration of the IVC at the junction of right and the middle suprahepatic veins caused an important bleeding which was difficult to control. After Pringle's manoeuvre a running suture by a 3-0 prolene was carried out. The bleeding was controlled only in part. Soon thereafter a worsening of the venous hepatic outflow was evident as suggested by darkening of the whole liver surface. The mass became diffusely hemorrhagic and despite of hilar clamping the bleeding became soon uncontrollable. We decided to proceed to total hepatectomy and to evaluate the feasibility of ex vivo bench liver surgery. The suprahepatic and infra-hepatic IVC were cross-clamped. The hilar structures were quickly double ligated and resected. A heparinless veno-venous bypass (VVBP) was inserted from the right femoral vein and from the portal vei

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


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

[User]
RADIOLOGY NOTE:
A 78-year-old man presented with macroscopic hematuria, urinary frequency, and accidental leakage of urine. His past medical history only included benign prostatic hyperplasia. Initial assessment by fibroscopy showed a unique tumor developed on the anterior wall of the bladder. The patient underwent transurethral resection of the bladder tumor. Pathological analysis reported high-grade muscle-invasive urothelial carcinoma of the bladder (pT2 stage). The uro-computed tomography (CT) scan did not show any abnormality regarding the upper urinary tract. Metastatic workup with thoracic and abdomino-pelvic CT scan showed clinically localized bladder cancer. The patient was then referred to our department to undergo a curative intent surgery according to the multidisciplinary committee recommendations. Bilateral extended pelvic lymphadenectomy with radical cystoprostatectomy and ileal neobladder reconstruction were performed. Definitive pathological analysis rendered pT2N0M0 high-grade urothelial carcinoma (TNM 2009) with free surgical borders, associated with prostatic adenocarcinoma Gleason score 7 (3 + 4), grade 4 involving 20 % of both prostatic lobes. A total of 15 days after surgery, the patient developed penile pain. Physical examination showed painful induration located on the right corpus cavernosum of the penis. PET/CT imaging showed a high focal intense uptake of 18F-FDG in the right corpus cavernosum of the penis (Fig. ). The report concluded that there was a high suspicion of metastatic spread to the penis. Complementary penile magnetic resonance imaging (MRI) associated with simultaneous fine needle biopsy were realized. Penile MRI showed low to intermediate signal intensity as compared with the surrounding corpus cavernosum on an axial T2-weighted image (Fig. ). Histopathological examination from the right corpus cavernosum biopsy revealed carcinomatous tumor emboli from the urothelial carcinoma of the bladder (Fig. ). The patient was referred to the medical

[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 44-year-old woman with no remarkable family history was admitted to our hospital with the following medical history: after undergoing modified radical mastectomy for cancer of the right breast (papillotubular carcinoma, T3N1M0) in March 2009 at another hospital, the patient received postoperative chemotherapy (4 courses of docetaxel+trastuzumab followed by 14 courses of trastuzumab). However, in March 2011, local excision was performed because of a recurrence that appeared at the site of the surgery, and adjuvant chemotherapy was administered. No relapses were observed thereafter.
When the patient was admitted to our hospital, the patient was of moderate build, was well nourished, had no yellowing of the bulbar conjunctiva, had no conjunctival pallor, and displayed no unusual finding in the heart or lungs. The abdomen was flat; the liver and spleen were not palpable. No remarkable finding was observed. An elastic, hard tumor approximately 20 mm in diameter with relatively distinct boundaries was felt in the left C region. The tumor was observed to be not fixed to the pectoral muscle, and it had not infiltrated the skin. No abnormal nipple discharge was observed, and axillary lymph nodes were not palpable. Peripheral blood and blood biochemistry test results were normal.
By mammographic examination, a high-density tumor with irregular margins and internal calcification was observed and was classified in Category 4. Because the imaging system at our institution has been changed and all previous imaging data were deleted, there are no mammograms to display here. Ultrasonographic analysis revealed that a 10 × 11 × 9 mm hypoechoic area was observed in the C region of the left breast. The lesion had a Tsukuba elasticity score of 2 and internal blood flow, and malignancy was suspected (Fig. ). By positron emission tomography and X-ray computed tomography (PET-CT), an area of greatly increased uptake was observed in the upper outer quadrant of the left breast (SUV max: 8.

[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.