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

[User]
RADIOLOGY NOTE:
A 30 year old male presented at the Surgery OPD with chief complaint of discharging wound in the upper part of the abdomen for 1 month. The problem started 6 months back when he underwent an emergency exploratory laparotomy at another medical college for 3 days old abdominal pain. A small peptic perforation was detected and was repaired with an omental patch. On fourth post-operative day the patient developed burst abdomen. It was managed conservatively. Over a period of time the bowel got contained and the patient was put on oral nutrition. The patient was discharged was doing fine at home. However his abdominal wound was not healing. In the fourth month it was covered with the split thickness skin graft. The procedure and the post-operative period was uneventful till one month. However in the fifth month a serous discharge from the upper part of the grafted surface was noticed. It was coming from a small ulcer and was small in amount. Over a the period of time till he presented at our OPD it remained small in output. It was managed by applying gauge pieces over the wound which has to be changed once or sometimes two to three times a day.
The examination of the abdomen revealed a 12 cm × 5 cm elliptical patch of skin graft over the middle of the abdomen. There was a small depressed ulcer of around 1 cm × 1 cm in its upper part covered with pale granulation showing serous ooze. Apart from this ulcer there were few other spots showing exuberant pale granulation (). A scar was seen at previous drain site. Palpation of the abdomen showed deficient abdominal wall below the skin graft.
The blood reports were all but normal. Haemoglobin was 11.4 gm/dl with total WBC count as 11.6 × 103/mm3. The total serum protein was 7.9 gm/dl with serum albumin as 3.5 gm/dl. A left subphrenic collection of size 8 cm × 7 cm was seen on the ultrasound. With a suspicion of some missed pathology at previous

[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 married male patient presented to our outpatient clinic with complaint of severe dysuria, weak stream and suprapubic pain that had lasted for 1 week accompanied by complete urinary retention and a month history of incontinence. Due to incontinence, he began self-treatment by instilling superglue into his urethra for 2 weeks. The patient had no urination problem during the early days of insertion. After 4 days, he complained about oliguria and dysuria which emerged simultaneously. By the time of referral to our center (2 weeks later), he was suffering from urinary retention. There was no history of psychiatric disorders. On perineal examination, his penis had erected form. A FB was palpable within the penile urethra and brittle fragments of superglue were seen on the meatus. An abdominal ultrasound revealed bilateral mild hydronephrosis, with normal cortical thickness, and without any sign of stone in the bladder. Laboratory examinations were normal. The patient was taken to the operating room urgently. He underwent a cystoscopy however, it failed due to obstruction.
So the glance was incised in 2 cm length at 6 o'clock position ().
The urethra was then washed with 3 liters of normal saline for approximately 15 minutes. During that period we managed to make the solution permeate across the solid material by performing certain maneuvers thereby shedding the adherent layer off the urethral wall. Eventually, a 10 cm rod-shaped solid block of dried superglue () came out with the aid of forceps and was removed successfully. The incision was sutured with nylon. After surgery, urination was normal in caliber and direction and the patient was satisfied with urinary drainage. The urine analysis was normal and we did not have requirement for cystoscopy. A 16F Foley catheter was left in place for 10 days. Amikacin 500 mg BD and cefazolin 1gr QID were administrated and he was discharged on the 5th postoperative day without any complication. By

[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 26-year-old young woman was admitted to the West China Hospital, Sichuan University, China, complaining of spontaneous nipple discharge in her left breast for one month. Her past history showed that she had accepted a lumpectomy on her left breast because of a palpable breast mass. The postoperative pathological report showed a complex fibroadenoma, with stromal cells proliferation, local lobulated structures were observed. She denied any family history of breast cancer or ovarian cancer.
On physical examination, a firm mass with a clear margin was palpated in lower inner quadrant near the nipple of the left breast, which measured approximately 2.5 cm in diameter. Single duct non-bloody discharge from the left nipple was evident after squeeze. There was no nipple retraction and skin dimpling evident.
An ultrasonography detected mammary duct ectasia and a solid-cystic mass measured 28 × 20 × 20 mm near nipple-areola complex (NAC) of the left breast (Fig. ). Left breast galactography showed mammary duct actasia and multiple irregular filling defects in the dilated duct (Fig. ).
The mass and the related mammary duct were excised through a circumareolar incision. Two intraductal neoplastic lesions measured 20 × 20 × 20 mm and 28 × 20 × 20 mm respectively were found in the dilated duct system. The cytology of the nipple discharge showed no tumor cells. The histological examination showed a biphasic tumor, with mesenchymal and epithelial components (Fig. A). The mesenchymal cells highlighted moderate stromal hypercellularity (Fig. B), marked nuclear atypia and occasional mitoses (Fig. C). Ki67 immunohistochemistry to assess the index of proliferation showed 20% to 30% positive (Fig. D). The histologic diagnosis was a borderline PT. The margin of resected tissue showed to be free of tumors.
After operation, the patient is undergoing surveillance through ultrasonography and physical examination every 3 months. Till now, she has been followed up for 12 months,

[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 man aged 72 years underwent elective surgery, a surgical revascularization of the myocardium, for a previously verified triple vessel coronary artery disease (CAD) with LAD 100%, CX 90%, RCA 90%. In the previous history of the disease he had diabetes mellitus type 2, arterial hypertension, myocardial infarction, hyperlipidemia and a positive family history of cardiovascular diseases.
The operation and early postoperative recovery went without any complications, and the patient was discharged on home care by protocol. On the first postoperative visit, 15 days after surgery, echocardiography showed a neat finding and upon recommendation, the patient continued with the previous treatment recommended for discharge. A month after the first visit or two months after the surgery, the patient was sent from a local hospital to our Heart Center with verified pericardial effusion and with the susceptible signs of right ventricular compression. At this point the patient had symptoms like fatigue and mild chest pain, more on his left side. On physical examination there were slightly pointed veins on the neck. He was afebrile and with neat diuresis. Heart tones were quieter, without murmurs and the action of the heart was rhythmic. Auscultatory findings on the lungs were without pathological murmurs. Measured blood pressure was 90/60 mmHg and the pulse was 96/min. Laboratory blood tests were in reference values range (white blood count - WBC, CRP). In addition to other discharge therapy, he had all that time acetylsalicylic acid 100 mg and clopidogrel 75 mg, without anticoagulation therapy.
The patient was kept for the observation. On the admission, a X-ray P/A of the chest was performed, that showed a regular size of the heart (). Transthoracic echocardiography (TTE) showed free fluid by the lateral and posterior wall of the right ventricle and possible compression of it, but there was no visible fluid in some views e.g. long axis view (). Due to a difficult visualization, it

[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 is a 54-year-old female with a past medical history of hypothyroidism and very severe obesity (BMI 48 kg/m2). She underwent laparoscopic gastric sleeve surgery in the year 2012. Results were non-satisfactory in terms of weight loss with a difference of 6 kg/m2 in BMI post-procedure. So after six years, she underwent a laparoscopic biliopancreatic diversion with a duodenal switch. She had an uneventful postoperative recovery period. An upper gastrointestinal (GI) study contrast post-procedure did not reveal any evidence of obstruction or leak. The patient was discharged home two days after the procedure. A few days later, she started experiencing three episodes of nausea with brown-colored vomitus. She was found to be septic, with a heart rate of 110 beats per minute and temperature of 100.2oF. Her white blood cells count was 12/mm3.The source of infection was presumed to be intraabdominal considering her symptoms. Computed tomography (CT) of the abdomen and pelvis showed mildly dilated proximal small bowel loops. The patient was started on empiric antibiotic therapy with ceftriaxone 1 gm intravenous (IV) daily and metronidazole 500 mg IV every eight hours. Symptoms did not improve, so she was taken back to the operating room for diagnostic laparoscopy. Partial small bowel obstruction was noted along with ischemia of a segment of the ileum that was part of the duodenoileostomy due to mesenteric dissection. She underwent an open revision of the small bowel anastomosis with resection and anastomosis for the obstruction revision of the duodenoileostomy. Her hospital stay post-surgery remained uneventful. Diet was advanced gradually throughout the hospital course and a week later, the patient was discharged home with outpatient follow-up. Three weeks after that procedure, she noticed a productive cough with thick, yellow, foul-smelling phlegm and shortness of breath. She saw her primary care physician. A chest X-ray performed showed a right lung infiltrate wi

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


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

[User]
RADIOLOGY NOTE:
A 30-year-old male, driver by occupation, presented with complaints of neck pain on and off for the past six months. He also gave history of pain radiating to the right upper limb, which aggravated on bending the neck forward. Occasional episodes of numbness over the thumb and adjacent areas were present.
On clinical examination of neck, the patient was found to have no obvious external deformity. Minimal spinal tenderness was present over the C5 and C6 regions. Paraesthesia was present over the area of distribution of C6 nerve root, but there was no distal neurological deficit. The cervical X-ray showed obliteration of the normal cervical lordosis with no obvious vertebral lesion. The MRI of cervical spine [] confirmed the presence of diffuse annular bulge with right posterior paracentral and foraminal disc protrusion seen at C5-C6 disc with impression on the dural sac and exiting nerve root on the right side with stenosis of right exiting neural foramina. There was no evidence of cord edema. All the routine haematological investigations were found to be within normal limits. Therefore final diagnosis of C5-C6 prolapse bulge with C6 radiculopathy was made. The patient had been on conservative management for the past six months with no satisfactory improvement in symptoms. Therefore the patient was planned for anterior discectomy and bone grafting and stabilization with cervical locking plate.
On the day of surgery under general anesthesia and through right lateral approach to the cervical spine, skin and the platysma were incised in the line of incision. While trying to retract the pretracheal fascia medially we noticed a bulging structure [] protruding out, that felt soft like muscle but was compressible.
Stopping there we then retrospectively studied the pre-operative MRI film [] of the cervical spine, which showed the right internal jugular vein to be enormously dilated in comparison to the left. This preoperative finding had been missed by the radiologist too

[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:
Abdominal computed tomography for regular monitoring of uterine fibrosis in a 49-year-old woman found a hypodense lesion 7 cm in diameter with a clear boundary near the gallbladder (Fig. a, b). No obvious change in size and internal density of uterine fibrosis had been observed during these 5 years (Fig. b). She had no previous history of alcohol or drug abuse. Ultrasound revealed a well-defined, non-calcified tumor between the gallbladder and liver (Fig. ). Magnetic resonance imaging demonstrated a hypointense tumor that compressed the gallbladder and liver on precontrast T1 mapping (Fig. a). T2-weighted images revealed hyperintense tumor with delayed enhancement on arterial phase and portal venous phase (Fig. b) followed by a delayed washout on the hepatocyte phase. Clinical evaluation and laboratory results were nonspecific, and serum tumor markers including carcinoembryonic antigen, cancer antigen (CA) 19-9, alpha-fetoprotein (AFP) and squamous cell carcinoma antigen were within their normal ranges. The findings were consistent with a gastrointestinal stromal tumor (GIST) or another benign tumor originating from the liver or gallbladder. Accordingly, we planned firstly laparoscopic partial hepatectomy concomitant with gallbladder resection. Lymphadenectomy among the hepatoduodenal ligament were also planned under the situations where malignant tumor was suspected intraoperatively. Under the laparoscopic view, a soft tumor had expansively progressed behind the gallbladder, with dorsal compression of the liver (Fig. ). The tumor was easily separated from Laennec’s capsule of the liver at the gallbladder neck and body without adhesion, which indicates the tumor is benign. Therefore, operative policy changed to tumor enucleation with cholecystectomy. Frozen sections including the surgical margin of the cystic duct were negative for tumor cells. As the tumor was moderately attached to the liver at the fundus of the gallbladder, the liver parenchyma was partially rese

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


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

[User]
RADIOLOGY NOTE:
A 73-year-old male smoker presented with a mass in the right upper lobe associated with mediastinal lymph node enlargement. The radiological profile was consistent with primary lung cancer; however, during endoscopic aspiration biopsy of the subcarinal lymph node, uncertainty arose as to whether it was a granulatomous lesion. Therefore, we opted for performing a transthoracic biopsy, as well as a mediastinal lymph node biopsy by mediastinoscopy, and, depending on the results of the intraoperative analysis, we would also insert an indwelling central catheter for chemotherapy. The patient was brought to the HOR, and the procedures were performed sequentially. Elective endotracheal intubation, large-bore peripheral venous access, and an indwelling urinary catheter were used. The patient was initially placed in the right lateral decubitus position for performance of a percutaneous Tru-Cut needle biopsy, with the gantry (Artis Zeego; Siemens, Munich, Germany) set to tomographic mode, by the interventional radiology team. Pathological examination of the biopsy specimen revealed that it was a carcinoma. The patient was then placed in the supine position to undergo mediastinoscopy with biopsy of the lesion, with the gantry set to fluoroscopic mode. Examination of a frozen section biopsy specimen confirmed an epidermoid carcinoma in the infracarinal lymph node. In view of the diagnosis of (stage N2) lung cancer, we proceeded to insert a catheter for chemotherapy, again with the gantry set to fluoroscopic mode.
The use of an HOR in the case described here allowed all procedures to be performed sequentially, in the same setting, without need for transportation. In addition, we would have the flexibility of adding pulmonary lobectomy if the pulmonary mass was positive for cancer and did not extend into the mediastinum. We were planning to use the gantry set to tomographic mode during mediastinoscopy in order to assist the intraoperative localization of the mediastinal lesion. H

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


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

[User]
RADIOLOGY NOTE:
This 31-year-old P0323 was 12 weeks into her sixth pregnancy at the time of initial referral to the Maternal Fetal Medicine Unit at the Gold Coast University Hospital, for planning of antenatal management, given her past obstetric history. Each of her previous three confinements resulted from preterm premature rupture of membranes and ensuing preterm labour between 27 and 28 weeks of gestation. She had to be delivered by Caesarean section in her last two confinements (fetal distress and elective repeat, resp.). She had retained placenta following her last Caesarean section, for which two separate hysteroscopy-guided curettage procedures had to be performed, placental histology confirming placenta accreta.
At the initial ultrasound assessment using the Voluson E8 (GE Healthcare) [], the fetus appeared morphologically normal. A transvaginal ultrasound with a RIC5-9-D transducer demonstrated a shortened cervix, 23 mm in closed length. A complete posterior placenta previa was recognized. The posterior decidual interface was not clearly visualized and turbulent blood flow was visualized at the interface, further raising suspicion about abnormal invasiveness of the placenta. An elastogram was performed at the same time []. Subjective interpretation of the elastogram was that this was a case of morbidly adherent placentation (MAP) in the posterior uterine wall, not to the extent of percreta. This was based on lack of a distinct zone of elasticity interspersed between the placental zone and the myometrial zone, which measured 2 mm in thickness. The uterine serosa appeared intact along its entire length on elastogram (Figures and ). An urgent MRI was arranged soon after this first visit, which confirmed MAP based on regional discontinuity of the uteroplacental interface ().
Despite being on vaginal progesterone supplementation, the cervix continued to efface and two weeks from the initial assessment, the patient presented with heavy vaginal bleeding. On ultrasound assessment

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


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

[User]
RADIOLOGY NOTE:
A 24-year-old female sustained an injury, while pillion riding a bike, and she was hit and run over by a tractor over both lower limbs and was brought to the trauma center 5 hours after the injury. The patient was normotensive with a blood pressure of 110/80 mmHg and a pulse of 90/minute in the emergency department. The right thigh and knee were swollen and tender with absent anterior tibial artery (ATA) and posterior tibial artery (PTA) without any knee instability ( and ). Capillary refill time and pinprick were delayed. The limb was cold, associated with diminished toe and ankle movements, and diminished sensation over the foot. The left lower limb was shorter with crepitus and abnormal movement in the left thigh and intact distal pulses. Radiographs were performed, which showed left femoral shaft fracture and no bony injury on the right lower limb. Radiographs also showed abnormal soft tissue shadow in the medial aspect of the right distal thigh (). Doppler showed absent ATA and PTA on the right side following which computed tomography (CT) angiogram was performed, which showed non-opacification of right distal superficial femoral artery (SFA) (length of 6 cm) () with popliteal artery reformation, non-opacification of ATA and opacification of PTA and peroneal artery.
The patient was taken up for surgery, and the SFA was explored, which was found to be transected with a 7 cm contused segment of the vessel around 10 cm proximal to the knee joint. The contused segment was resected, fogartisation of distal and proximal ends was done, and reconstruction with reversed saphenous vein interposition graft was undertaken using 5-0 prolene. Medial and lateral fasciotomy for right leg was conducted and external fixator was applied for left femur fracture.
Postoperatively, heparin and low-dose aspirin were given. The limb was warm with normal capillary refill, and Doppler showed biphasic flow in

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


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

[User]
RADIOLOGY NOTE:
A 53-year-old man presented with a gradually increasing mass located in the soft tissue of the oral cavity. The lesion was biopsied, and the pathology report showed increased infiltration of the buccal mucosa with monoclonal plasma cells. Immunochemistry demonstrated positivity for CD138, CIgA, and negativity for CD56, Cyclin D1 and CD20. Therefore, the diagnosis of soft tissue plasmacytoma was confirmed, for which he received localized radiotherapy with a total dose of 40 Gy, due to the absence of systemic disease as the bone marrow biopsy revealed the absence of neoplastic infiltration and serum and urine immunofixation were all negative.
After five years, the patient noticed a painless swelling in his right testis. An ultrasound of the scrotum was performed that showed a hypoechoic mass in the right testicle with increased vascularization, and a normal-appearing left testis (Figure ). The patient subsequently underwent a right radical orchiectomy and the histopathology report showed testicular infiltration by a plasma cell neoplasm with identical immunophenotype (CD138+, CIgA+, CD56-, CD20-, Cyclin D1-) to the primary site in the oral cavity. Subsequently, the patient underwent a bone marrow biopsy that showed the absence of monoclonal plasma cell infiltration, and a PET/CT scan that was negative for reactive lesions suspicious of malignancy. In addition, serum and urine protein electrophoresis, as well as serum-free light chain assay were all within normal range, thus, excluding the presence of systemic disease, while complete blood count and full biochemical profile were normal.
However, after one year, the patient presented again with painless swelling of his left testis that was attributed to disease relapse based on the imaging findings (Figure ). He refused to undergo left orchiectomy, thus he proceeded with systemic treatment based on lenalidomide, bortezomib and dexamethasone. Following 4 cycles of treatment, the patient underwent high dose melphalan 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 four-month-old Saudi Arabian male baby was presented to our neurosurgical clinics with a progressive increase in head size for four weeks. He was the first child for an unrelated couple and the outcome of an uneventful pregnancy. An antenatal ultrasound at week 34 of gestation reported mild ventriculomegaly. Nevertheless, he was delivered at full term with spontaneous vaginal delivery. At birth, his head circumference was in the 90th percentile, without clinical evidence of increased intracranial pressure, and his general examination was within normal limits. His mother brought him because of vomiting and her concern with the rate of increase in his head size over his second month of life.
On examination, our patient was alert and active with a normal physical examination, apart from ‘setting-sun’ eyes. His head circumference exceeded the 90th percentile and he had a full anterior fontanel measuring 2 × 3cm in diameter. A cranial magnetic resonance imaging (MRI) scan demonstrated obstructive hydrocephalus due to congenital aqueductal stenosis (Figure ). His routine laboratory tests, including a complete blood count, electrolytes, renal and coagulation profiles, were within normal limits. He underwent an uneventful endoscopic third ventriculostomy and was discharged home after 48 hours in good condition.
A follow-up after four weeks revealed recurrence of vomiting and increasing head circumference with a full anterior fontanel. He was admitted and a repeat MRI scan revealed a patent third ventriculostomy with no significant changes in the size of the ventricles (Figure ). He had a medium pressure VPS (P.S. Medical, Medtronic, Minneapolis, USA,) inserted. The procedure was carried out in the routine fashion and a ventricular catheter was introduced through a right parieto-occipital burr hole. Adequate placement was confirmed by the drainage of clear cerebral spinal fluid (CSF) under pressure, with care taken to drain less than 5cm3 to send for a cell count, chemistr

[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 reported with the chief complaint of chronic, dull, localized, intermittent pain in the left mandibular first molar for the past 1 month. The pain aggravated on chewing hard food. There was no history of any radiation of pain. However, the patient gave an account of occasional enlargement of the left submandibular lymph node and mild fever. On examination, clinical probing depth of 8 mm on the buccal surface of the left mandibular first molar along with Grade 3 furcation defect was noted. The tooth had been root canal treated 3 years back and had been restored with a complete metal crow []. The patient was systemically healthy and did not report any oral abusive habits such as smoking, tobacco or betel nut chewing, or alcohol consumption. An intraoral periapical radiograph revealed incomplete obturation of the mesiobuccal root with a broken endodontic file in the root canal along with extrusion of the gutta-percha and furcal perforation []. The IOPA of the concerned tooth revealed the presence of a broken endodontic file and furcal perforation with extruded gutta percha.
Nonsurgical periodontal therapy with complete full-mouth scaling and root surface debridement was initiated. The crown and amalgam core was removed []. The access opening was enlarged and the gutta-percha that was extruding from the perforation was removed. The perforation was sealed internally using mineral trioxide aggregate [Figure –]. The broken H-file was retrieved from the root canal using an instrument removal system. The biomechanical preparation was then accomplished by a step-back technique using 2% sodium hypochlorite and 17% ethylenediaminetetraacetic acid. Obturation was completed, and core build was done with amalgam []. The radiograph at 4 months revealed a significant reduction in the periapical radiolucency at the apex of the tooth []. The gingiva showed no signs of inflammation or bleeding on probing. However, Grade 3 furcation with the horizontal

[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 healthy 20-year-old female came to our clinic with a complaint of progressive, continuous, and long-standing history of bilateral nasal obstruction that was worse on the left side. She was having frequent thick mucoid nasal secretions, left-sided facial pain, and intermittent hyposmia, also it was associated with moderate to severe allergic rhinitis symptoms; she had no visual disturbances. The patient had already tried intranasal corticosteroids with no satisfactory improvement.
A nasal endoscopic exam revealed a deviated nasal septum to the right side, a mildly hypertrophied right inferior turbinate, and a large mass occupying the left nasal cavity. This mass had displaced the nasal septum to the contralateral side and compressed the left inferior turbinate. Using the freer and fraiser suction, the mass was found to be hard but with normal overlying mucosa (Figure ).
It originated from the skull base on the endoscope, with small nasal polyps noted beside it, but a further passage to the nasal cavity was not possible. The rest of the clinical exam, including her cranial nerves and orbital exam, was unremarkable.
The patient came to our clinic for a second opinion, as she was concerned about the results of her medical imaging, which included CT scans and magnetic resonance imaging (MRI) of the paranasal sinuses. These reports commented on a bony nasal lesion measuring 1.7 × 3.7 × 3.0 cm and arising from the left skull base. The lesion was obstructing all ipsilateral paranasal sinuses with complete opacification and displacing the nasal septum to the contralateral side. Fortunately, there was no intracranial or orbital extension. No comments were made regarding heterogeneous opacification. These findings were thought to be an aneurysmal bone cyst, mucocele, mucopyocele, or other sinonasal tumors.
However, upon careful study of the imaging, AFS was considered due to the heterogeneous nature of the content, the bony expansion of the lesion in the CT scans,

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


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

[User]
RADIOLOGY NOTE:
A 27-years-old female patient presenting with recurrent coughing and hemoptysis for more than 10 years first came to our hospital in January 2019. According to the medical history information provided, the patient was previously diagnosed as pneumonia and treated symptomatically in local clinical institution. The symptoms of patient were once relieved after the treatment, but recurred frequently. The patient has no family history of primary lung malignancy and genetic disease, 155 cm in height and 42 kg in weight with a lean body shape, symmetrical thorax without deformity. The trachea of the patient deviated to the right slightly, no obvious rhonchi and moist rale as well as wheezing rale were heard. The heart rhythm was regular, the auscultation area of heart sound apparently deviated to the right thorax, and no obvious abnormality was found in abdominal physical examination.
A chest radiograph and computed tomography were performed for the patient showed a giant abnormal space-occupying lesion in the hilum of right lung. The tumor was closely related to the right pulmonary artery and bronchus (Fig. a, b). The right lung was atelectasis and some of the left lung as well as heart were obviously deviated to the right thoracic cavity. A Chest MRI showed a mass abnormal signal tumor in the region of right hilum about 10.0 × 4.5 cm in size. The T1WI was isointense, while T2WI and DWI were both hyperintense. A 3D reconstruction of the hilar structures have shown a complete anatomical disorganization of right pulmonary artery and vein (Fig. c). A neoplasm with smooth surface was observed in the right main bronchus by bronchoscopy examination. However, a biopsy was not performed concerning that existing hemoptysis might be aggravated (Fig. d). Pulmonary function showed a severe obstructive mixed ventilation dysfunction. The forced expiratory volume in 1 s (FEV1) was 1.36 L, accounting for 45% of the predicted value, Maximal voluntary ventilation (MV

[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 healthy male with complaints of a gradually increasing growth of 9 months duration on right wrist presented to Dermatology OPD. The lesion became more prominent on movement of wrist. There was a history of similar growth in the father. No abnormality was detected on general physical examination. Local area examination revealed a 3 × 3 cm, soft to firm, hemispherical, non-tender, mobile lesion on the medial aspect of right wrist []. Clinically, a diagnosis of lipoma was made and confirmed by FNAC. The patient was not open to any surgical intervention and was given the option of injection lipolysis. After discussing the possible side effects like hyperpigmentation, skin loss, prolonged pain, swelling, or tenderness, late onset hives or itching and skin contour irregularities in detail, an informed written consent for three sessions at 6-8 weeks gap was taken.
The lesion was cleaned and draped. The area was divided into small grids (1.5 cm apart) []. Solution of phosphatidyl choline and deoxycholate (50 mg/ml) was filled in insulin syringes (4 injections of 16 units of formula). The pinch and pull technique was used. The lipoma was pulled away from the underlying structures and four units were injected in each of four grids (total of 16 units). Care was taken not to inject any material while withdrawing the needle to avoid any intradermal deposition of the drug. The injections were not perceived as painful by the patient. Immediately after the injections there was swelling, redness and burning sensation which persisted for around half an hour []. No external compression was used and gradually the swelling settled. In the next 48 h, the lesion shrunk to half of its original size and disappeared completely within next 3 weeks, after the first injection itself. The patient is under follow up for the last 9 months with no evidence of any recurrence [].

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


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

[User]
RADIOLOGY NOTE:
An elderly man in his seventies presented to the Urology department with two episodes of acute urinary retention. There were no rectal symptoms and rectal examination revealed an enlarged prostate. He underwent a laser transurethral resection of prostate during which a large palpable pelvic mass was noted. The subsequent urgent MR pelvis revealed a large tumour in the mesorectum arising from the anterior rectum 10 × 8.5 cm (Figs and ). A transrectal ultrasound and biopsy were performed; histology revealed a spindle cell tumour, with positive immunostains for CD117 and DOG1 with 5 mitoses per 50 high power fields. This was confirmed to be a locally advanced high-risk GIST.
The multidisciplinary team review advised neoadjuvant treatment with imatinib mesylate and further reassessment. Repeat MR pelvis and staging PET CT abdomen, thorax and pelvis were then performed. These showed a large extra-luminal tumour with downsizing in tumour bulk (6 × 5.7 × 5.4 cm) (Figs –) but in close approximation with the right seminal vesicle.
Further examination under anaesthesia, flexible sigmoidoscopy and cystoscopy were performed. The tumour was a large right-sided mass with no prostatic involvement. An elective Hartmann's procedure plus possible pelvic clearance was organized. Intraoperatively a large tumour in close proximity to the posterior bladder and seminal vesicles was found. Although there was no evidence of invasion, dissection of the plane between the GIST and posterior bladder was not possible, thus cystectomy and prostatectomy were performed with an ileal conduit and urostomy. The sigmoid colon and rectum were resected leaving an end colostomy as planned. In the postoperative period the patient developed signs of sepsis. A subsequent CT revealed an anastomotic leak at the ileo-ileal site. The patient returned to theatre, the anastomosis was taken down and a double barrel ileostomy sited. He initially went on to recover well. Operative histology revealed reduced mitotic a

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


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

[User]
RADIOLOGY NOTE:
The second case involved a 70-year-old Native American man presenting with upper back pain and numbness of his right foot for approximately 10 days. The symptoms had worsened, and he noticed some difficulty with walking. He did not have any past medical or surgical history. He was a former tobacco smoker and stopped smoking approximately 20 years ago, but it is unknown how many packs or cigarettes per day he smoked. He drank alcohol very rarely and not significantly. He did not have family history of any significance. He was never on medications until he was diagnosed as having HCC. He worked at a warehouse in the past. His job position was unknown. He has no known environmental or drug allergies. On admission, his BP was 166/119 mm Hg, HR was 97 beats per minute, and temperature was 36.7 °C. His physical examination had the following results: he was normocephalic, he had a non-traumatic skull, he had normal hearing, he had no nasal discharge, his chest wall movement was symmetric, his breath sounds were clear, he had no rales/wheezing, his HR was within the normal limit and had regular rhythm with no murmurs or thrills, his abdomen was soft with no distension, there was no palpable mass, there was no hepatomegaly or splenomegaly, a bilateral pedal pulse was present, there was no visible joint swelling, his skin was warm to the touch, he had normal color, and he had no rash/ulcers. A neurological examination had the following results: he was alert and awake; he was oriented to time, his name, and his location; his cranial nerves were grossly intact; he had no gait disturbance or motor deficits; his superficial reflexes were intact; a slight decrease in sensation over his right lower extremity was noted. Abnormal laboratory results were as follows: aspartate aminotransferase level of 104 U/L and alanine aminotransferase level of 90 U/L. CT of his chest

[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:
Mrs SA was a 35-year-old housewife with three living children, who was referred from a peripheral hospital to the accident and emergency department of Abuja Clinics Ltd. on the 5th of July 2010 with a 6-h history of lower abdominal pain. The pain was of sudden onset, sharp and radiated to the anal region. It was aggravated by movement but relieved by lying still. There was associated weakness and dizziness, but there was no fainting sensation. There was no bleeding per vaginum and no constitutional or urinary symptoms. Her last menstrual period was about 5 weeks prior to presentation. She claimed to have had a regular 28-day cycle with 4 days menstrual flow. She had right ectopic pregnancy and salpingectomy in 1997 and a miscarriage in 1998. She had spontaneous vaginal deliveries in 1999, 2001 and 2005. She wore an IUCD in between the pregnancies for an average of 13 months. She had Cu T IUCD in June 2005, about 6 weeks after her last confinement. She experienced pain during the Cu T IUCD insertion, which prompted an ultrasound scan to be done the same day. The ultrasound scan suggested that the IUCD was in situ and normally placed. She was reassured and was given paracetamol tablets for 2 days and the pain stopped.
Examination on presentation revealed a young woman in painful distress, pale, anicteric and not dehydrated. Her pulse rate was 88 bpm while her blood pressure was 120/80 mmHg. Her abdomen was generally tender, but the tenderness was more marked at the right iliac fossa. Vaginal speculum examination showed the tail of her IUCD protruding from the external cervical Os. There was cervical excitation, tenderness and a bulging pouch of Douglass on digital vaginal examination. Rectal examination revealed no abnormality. An impression of acute abdomen due to ectopic pregnancy or acute appendicitis was made. Her packed cell volume (PCV) was 34%, genotype AA and blood group A

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


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

[User]
RADIOLOGY NOTE:
A 22-year-old young female presented in outpatient department (OPD) for uncontrolled hypertension from past 3 years, she has a past history of subarachnoid hemorrhage in 2016 for which she underwent craniotomy with right middle cerebral artery aneurysm clipping. On clinical evaluation, she had a blood pressure (BP) of 180/110 mm Hg in both the upper limbs, with no palpable pulses in both the lower limbs, prominent suprasternal pulsations with a systolic murmur in the left side precordium and a soft bruit over the back on both the sides. Her routine blood investigations were within normal limits
Having a possibility of coarctation of aorta, she was subjected for detailed cardiac evaluation. Electrocardiogram (ECG) revealed normal sinus rhythm. 2-D echocardiogram (ECHO) had evidence of coarctation of the aorta (post ductal) with high gradients (94 mm Hg), normal left ventricular function. Chest X-ray showed signs of bilateral posterior rib notching in the inferior aspect and no evidence of aortic dilatation (). The patient was subjected for computed tomography (CT) aortography for localizing the site and extent of coarctation of aorta which revealed coarctation of aorta 22 mm caudal to the origin of the left subclavian artery, measuring 4 mm in length and about 2.3 mm in caliber. Bilateral extensive collaterals were seen in the scapular, paravertebral and posterior thoracic wall with hypertrophied right internal mammary artery (RIMA), left internal mammary artery (LIMA) and intercoastal arteries. B/L renal arteries were normal (). The diagnosis of coarctation of the aorta with secondary hypertension was made, and the patient was planned for coarctoplasty. The patient underwent successful coarctoplasty through right femoral artery approach using a Tyshak balloon measuring 15 × 30 mm (). The stent was not placed as the results were very good with gradients across the coarctation of aorta reducing from 95mm Hg to 10 mm Hg post balloon dilatation. The patient tolerated 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:
An 86-year-old woman was admitted from an outside institution to our neurological intensive care unit with fluctuating consciousness after hitting her head during a fall. Four weeks before admission, she was in normal health for her age with a history of arterial hypertension. Because of atrial fibrillation, she was treated with rivaroxaban 20 mg once daily. Two weeks before hospitalization, she experienced pain in her lower abdomen accompanied by a feeling of illness and fatigue which she self-medicated with aspirin. She experienced nose bleeding but continued to take aspirin. She was then admitted to an external clinic after falling. During the first in-hospital night, she fell out of bed and struck her head. Thereafter, consciousness decreased and she was transferred to the neurocritical care unit of our institution. She presented with dysarthria and mild motor aphasia, but language comprehension was fully preserved. In addition, mild right-sided hemiparesis was noted. Most of the time, she was awake but intermittently somnolent. Body temperature was 37.6 °C. Routine laboratory tests revealed prolonged prothrombin time, increased international normalized ratio (INR), increased CRP, leukocytosis and corresponding signs of a urinary tract infection. She was treated with prothrombin complex concentrate and antibiotics.
The initial computed tomography (CT) on day 0 showed contusions in the left frontal and temporal lobes and tSAH. Figure a shows this first CT scan with subarachnoid blood in two sulci of the left frontal cortex. A contre-coup injury was found in the right posterior cranial fossa with an epidural hematoma and corresponding tSAH. In addition, a small intra-parenchymal hemorrhage was observed in the right basal ganglia. Arterial aneurysms or arteriovenous malformation were ruled out using CT angiography (CTA). Blood was also detected in the fourth ventricle, but signs of disturbed cerebrospinal fluid circulation were not seen. Accordingly, the patient di

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


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

[User]
RADIOLOGY NOTE:
A 63 year-old female with longstanding type-1 diabetes mellitus and hypertension developed chronic renal failure in 2002 and underwent a pre-emptive renal allograft transplant from her donor husband in 2004 without requiring prior dialysis. Both the donor and recipient were cytomegalovirus-negative. She received basiliximab 20 mg prior to her transplant surgery and another 20 mg on day 4 post-transplant. Following transplantation she was immunosuppressed with mycophenolate mofetil, prednisone and tacrolimus. She had longstanding stable kidney function following transplantation with a baseline GFR of 84 mL/min and a creatinine of 80 micromol/L. Her past medical history was remarkable for iatrogenic hypothyroidism following parathyroidectomy for primary hyperparathyroidism, and she had no prior history of malignancy.
In April 2015, after ten years of immunosupression, she developed an irregular hyperpigmented and evolving lesion on her left upper back which was resected in May 2015. The biopsy of the left scapular site revealed a superficial spreading invasive melanoma with a maximum Breslow thickness of 2.59 mm, Clark level of IV, with, mitoses of 5/mm2. No ulceration was identified, but tumor infiltrating lymphocytes and tumor regression were present. Peripheral margins were uninvolved, but deep margin was involved by a satellite nodule and microsatellitosis was also present. Wide-local excision and bilateral axillary lymph node biopsies were performed July 2015, as lymphoscintigraphy had identified drainage of each of the lesion to the contralateral axilla when injected with technetium 99 sulfur colloid. Three right axillary lymph nodes were removed and were negative for malignancy, but 1 left axillary lymph node was removed and pathology revealed an 8.5 mm × 7.5 mm melanoma deposit with extranodal extension. As a result, the patient required a wide local excision with a 2 cm margin and pathology demonstrated residual disease and microsatellites, with negative marg

[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 Caucasian woman was admitted to our hospital presenting with a painful mass in her right groin, without fever, rectal bleeding or any other bowel symptoms. She had no history of malignant diseases. A physical examination showed an irreducible palpable mass in her right inguinal region protruding through the external inguinal ring. Routine blood examinations showed she had chronic anemic status with an hemoglobin value of 8.9g/dL. Tumor markers values of carcinoembryonic antigen and carbohydrate antigen 19.9 were 4ng/mL and 24U/mL, respectively. A computed tomography scan of her abdomen showed the presence of the cecum in her inguinal canal, with an irregular thickening of its wall suggesting a cecal neoplasm within the inguinal hernia involving the femoral vessels (Figure ).
A colonoscopy was not completed due to the large involvement of the cecum into the hernia sac. Surgical exploration was made through a midline laparotomy that confirmed the herniation of the cecum into her right inguinal canal (Figure ), without the possibility of reduction in her abdominal cavity owing to the tumor infiltration into her abdominal wall and inguinal structures. Thus, a right inguinal incision was made, which revealed an aggressive cecal tumor infiltrating her inguinal wall, right round ligament and femoral artery. The mass was resected en bloc, with complete vascular control of her femoral vessels, and reduced into her abdomen.
Finally, a right colectomy was performed with a manual ileocolic anastomosis and her inguinal wall was repaired by a direct suture without mesh. The operative field of the femoral region was also marked with surgical clips for further postoperative radiation therapy (Figure ). Histopathological examination of the specimen showed a poorly differentiated adenocarcinoma of the large bowel with lymphovascular and perineural invasion, microscopic involvement of the resection margins, and metastases of 8 out of 17 regional lymph nodes (pT4b pN2b M0

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


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

[User]
RADIOLOGY NOTE:
We present the case of a cardiac benign metastasizing leiomyoma incidentally found in a patient who presented to our hospital after a motor vehicle accident.
A 36-year-old female patient presented to the emergency department of our hospital with right-sided blurry vision after being involved in a motor vehicle accident. The patient was a restrained back seat passenger and sustained a right eye trauma with no other injuries nor loss of consciousness. She was found to have traumatic uveitis. CT scan of the head and sinuses showed no evidence of fracture or acute pathology. A CXR was performed to rule out any rib fracture and found a 1.1 cm pulmonary nodule in the right midlung. A contrast CT scan confirmed the presence of 1.1 cm nodule within the anterior inferior aspect of the right upper lobe and found an additional 1 cm nodule within the posterior superior aspect of the right upper lobe. Both nodules were well circumscribed, compatible with benign nature. Unexpectedly, a large defect was noted within the contrast-enhanced right ventricle and was thought to be a large thrombus extending to the right ventricular outflow tract (). The patient was started on therapeutic anticoagulation overnight. A transthoracic echocardiogram (TTE) and a subsequent transesophageal echocardiogram (TEE) disclosed the presence of a large mobile mass in the right ventricle arising from the interventricular septum. Turbulent flow was demonstrated in the right ventricular outflow tract (Supplemental Material video ()). Cardiac magnetic resonance imaging showed an oblong soft tissue mass that measured 4.9 cm in length abutting the pulmonary valve. The mass occupied the entire RV outflow tract ().
The patient denied any symptoms including chest pain, dyspnea, syncope, or weight loss. Physical exam was significant for a systolic murmur. On further history taking, she reported that she underwent a hysterectomy 12 years earlier for “myomas” but denied any personal or family history of malignancy

[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 female with symptoms of hoarseness and Horner's syndrome presented with a left cervical mass that was diagnosed to be undifferentiated carcinoma based on the findings of aspiration cytology (Figure ). The patient's chest computed tomography (CT) findings showed a mass measuring 5.0 cm in size spreading from the left upper mediastinum to the left supraclavicular area, which pressed against both the trachea and esophagus and it seemed to involve the left common carotid artery (Figure ). Based on these findings, and cytology findings a clinical diagnosis of stage IIIB (T4N3M0) non-small cell lung cancer (NSCLC) originating from the apex of the left lung involving both the mediastinum and the supraclavicular lymph nodes was made []. The patient received concurrent chemo-radiotherapy (cisplatin 80 mg/m2 for days 8 and 36 + UFT 400 mg/m2, both on days 1–14 and on days 29–42 plus radiotherapy, 2 Gy/day on days 1–20 for a total of 40 Gy) []. After this treatment regimen, the tumor size decreased by 35.0%. Thereafter, the patient underwent a surgical resection though a median sternotomy with a combined resection of the left clavicle. During the operation, an encapsulated tumor was detected in the mediastinum. Although the tumor was easily ablated from the left common carotid artery, it involved both the left vagus and the sympathetic nerves. As a result, both nerves had to be sacrificed in order to achieve a complete resection of the tumor. Grossly, the tumor was in continuity of the vagus nerve was whitish in color and oval shaped measuring 5 × 3 cm in diameter (Figure ). Both cytological and histological examinations revealed 1) Continuity between the vagus nerve and tumor was seen, while the no continuity between the tumor and the sympathetic nerve was found. 2) The findings of aspiration cytology of the tumor diagnosing it to be undifferentiated carcinoma before the treatment included

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


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

[User]
RADIOLOGY NOTE:
A 40-year-old female was admitted to our hospital due to a progressively enlarging mass over four years of her anterior chest wall. Since October 2008, she had experienced intermittent anterior chest pain with the pain intensifying in August 2012. Physical examination revealed a warm 10 × 8 × 6 cm mass fixed to the upper sternum, and tender to palpation. No pulsation was noted. Computed tomography revealed an osteolytic lesion with discrete calcification in the bone marrow of the sternum. The tumor extended across the destroyed cortex to the parietal and visceral soft aspects, involving some of the costal cartilage and most of the sternal body (Fig. ).
During the surgery, the manubrium sterni, two-third of corpus sterni, both of the proximal clavicular heads as well as bilaterally the first three ribs and the costal arch with more than a 2.0 cm surgical margin were removed. Frozen section analysis of margins confirmed the complete resection. This resection left a defect measuring 18 × 15 cm2 on the anterior chest wall (Fig. ). According to the reconstructed images of the chest CT, an individual-specific stainless steel plate was made in the same shape as the thoracic bony structure of the patient, using for the reconstruction of the upper sternum, the costal arch and both sternoclavicular joints. The placement and fixation of the plate were straightforward without any difficulty. The securement of the plate was achieved with claw fixator and screws to the remaining ribs and clavicles (Fig. , ). The surgery was successful, and the reconstruction of the chest wall was satisfactory both in appearance and function (Fig. ). The postoperative course was uneventful, and with a body belt, the patient was discharged on the 14th postoperative day. The histological examination of the surgical specimen confirmed the diagnosis of chondromyxoid fibroma (Fig. ).
However, nine months after the first surgery, the patient presented with aggravated chest pain 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:
The patient was a 31 y/o Gravida 3 Para 2 who presented to our center at 19-week gestation. She had two prior uncomplicated full term vaginal deliveries and received Rh immunoglobulin during and after each of her previous pregnancies. She has no significant past medical or surgical history.
During this pregnancy, her first trimester studies revealed an anti-D titer of 2048. The fetal status was noted to be RHD positive on amniocentesis.
On her initial evaluation at 19-week gestation at our center, the middle cerebral artery (MCA) Doppler revealed a peak systolic velocity (PSV) of 2.37 MoM. There was mild ascites and cardiomegaly.
After counseling the patient underwent the first in a series of combined intravascular/intraperitoneal intrauterine transfusions (see ). The ascites and cardiomegaly resolved after the second transfusion.
The fourth transfusion was complicated by an episode of transient bradycardia with spontaneous recovery after removal of the procedure needle from the umbilical vein. On a preoperative ultrasound prior to her sixth procedure, thrombosis of one of the umbilical arteries was noted (see ). A review of earlier ultrasounds indicated two patent umbilical arteries although visualization of the cord was not specifically undertaken postoperatively after the fourth procedure or before and after the fifth procedure. Based on the reassuring status of the fetus, a decision was made to continue serial intrauterine transfusions. Antenatal testing was initiated with weekly biophysical profiles and daily kick counts.
In addition to fetal anemia, this pregnancy was complicated by diet controlled gestational diabetes and mild polyhydramnios with an AFI of 29. The estimated fetal weight at 35 weeks ultrasound was 3193gms (87th %ile). She underwent a cesarean section at 37 weeks, delivering a 3480-gram male fetus in vertex presentation with APGARS of 8 and 9 at 1 and 5 minutes, respectively. After delivery the umbilical cord was examined and a 3-vessel cord wi

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


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

[User]
RADIOLOGY NOTE:
A 56-year-old woman received a diagnosis of cancer of the right breast 6 years prior. At that time, she underwent right mastectomy with placement of a tissue expander. This was followed by exchange to 650 cc silicone implant for right breast reconstruction and concurrent left breast reduction using inverted-T incision with inferior pole technique to achieve symmetry. Unfortunately, she developed ductal carcinoma in situ with microinvasion in her left breast 4 years later. After left-sided vertical mastectomy, her first tissue expander failed secondary to infection and was removed. After debridement and resolution of the symptoms, a second tissue expander was placed and later exchanged with a 650 cc implant. Within 2 weeks, there was again evidence of infection and the implant was removed. Now, 6 years after being diagnosed with breast cancer, she had a successful right breast reconstruction and a failed left breast reconstruction (a).
At this point, we had essentially exhausted implant-based reconstruction techniques and offered alternative autologous tissue options for further repair. She elected to pursue several rounds of fat grafting instead of a pedicled flap or free tissue transfer. Next, the left breast was fit with a Brava dome external tissue expander device (Brava, LLC, Miami, Fla). This was worn only in the preoperative period for 6 weeks, 8 hours per day, in an effort to best prepare the recipient site to receive and support large volume of fat grafts. Over a 2-year period, she received 5 rounds of AFT using the TLL system. Fat was harvested from various sites including abdomen, flanks, posterior hips, thighs, saddlebags, bra line, and lateral chest wall. After 4 AFT procedures, 250, 300, 250, and 270 mL were transferred to the left breast, respectively. In the fifth and final round of AFT, 180 mL of fat was grafted to her left breast and 120 mL to her right breast

[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 Japanese man with no past psychiatric history, but with a past neurologic history of PKD, was referred by the neurologic department at our hospital to the Department of Psychiatry because of severe anxiety and hyperventilation. When the patient was 16 years old, he was clinically diagnosed as PKD by a neurologist based on characteristic symptoms including involuntary movement induced by voluntary movements and various examination findings, such as test using blood and cerebrospinal fluid, and several image findings. After that, he had been maintained on carbamazepine (CBZ) at 200 mg/day since 16 years of age without any attacks.
In February 2013, on a regular follow-up in the neurologic department, the neurologist changed CBZ to topiramate after the patient complained of long-term symptoms of drowsiness and wobbliness, which he thought might be the side effects of CBZ. Two days later, he visited the emergency department at our hospital with chest pain and hyperventilation. Although the neurologist suspended topiramate and resumed CBZ, his anxiety and hyperventilation did not improve as was expected. The following month, the patient was referred to our department, but he stated that he had no anxiety about PKD or any other psychosocial stressors. He presented as a gentle young man without any abnormal affect, but seemed somewhat nervous with an impassive facial appearance. We took time to have a good discussion about his history and symptoms. At last he confessed that, 10 years before this referral, he became aware of a feeling of breakdown in his overall physical functions to what he considered as about 70% of his earlier state. He had then avoided becoming familiar with people out of concern that his physical dysfunctions might be perceived in a negative light. It means that his anxiety symptoms had existed and persisted 10 years before a change of drug, CBZ to TPM, though we could not completely deny it affected these symptoms. Then we began treatmen

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


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

[User]
RADIOLOGY NOTE:
A 16-year-old male runner fell forward over an outstretched left leg during a race. He felt a popping sensation with his left hip in deep flexion and the left knee in forced extension and a sharp pain in the posterolateral aspect of the left distal thigh. He could not bear weight on the affected leg, which prevented him from walking and he was immediately transferred to our hospital. He had no history of other trauma, chronic disease, or use of corticosteroids. A clinical examination revealed swelling and tenderness at the posterolateral aspect of the left distal thigh. The ridge formed by the left biceps femoris tendon was distinctly deficient to both visual inspection and palpation. Active extension or flexion of the left knee was prevented by severe pain. Ligamentous instability of the knee was not evident and the left knee appeared normal on plain radiography images. T2-weighted magnetic resonance images of the left thigh revealed a loss of continuity of the distal biceps femoris tendon at the musculotendinous junction surrounded by a hematoma with high signal intensity (). Isolated rupture of the distal part of the left biceps femoris tendon was diagnosed and surgical exploration proceeded under lumbar spinal anaesthesia. A lateral incision over the belly of the biceps femoris revealed that the biceps femoris tendon had completely ruptured at the musculotendinous junction (). The tear was repaired using a modified Kessler method with strong nonabsorbable sutures.
The knee was postoperatively immobilized in a plaster cast at 30° of flexion. However, the patient described numbness and sensory loss over the anterior aspect of the left foot and dorsiflexion of the foot was weak on the day after surgery. Common peroneal nerve palsy at the fibular head due to compression by the plaster cast was diagnosed and the cast was removed to decompress the nerve. However, this did not result in any neurological improvement. Surgical assessment was applied 2 months after the co

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


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

[User]
RADIOLOGY NOTE:
In June 2002, a 36-year-old woman presented to her primary health care doctor with a history of flushing, diarrhoea, night sweats, and a clinically detectable mass in her left medial supraclavicular fossa. Her past medical history consisted only of essential hypertension for which she did not require prescribed therapy. Her family history included a brother with a diagnosis of sarcoma and two other non-first-degree relatives with primary brain malignancies.
Fine needle aspiration confirmed the diagnosis of medullary thyroid cancer, and in July 2002, she underwent total thyroidectomy with left-sided modified radical neck dissection and central compartment clearance. At this point, concerns were raised regarding optimal cytoreduction as the appearances of the central compartment, level 4 and level 5 nodes, were that of extensive disease. In order to maximise local disease control, she received adjuvant radical radiotherapy delivering 60 Gy to the thyroid bed.
Two years after completion of treatment, in February 2004, follow-up repeat imaging reported a recurrent nodule at level 4 of her neck. Subsequent resection confirmed this to be recurrent medullary thyroid cancer with no evidence of distant spread at the time. She continued to be monitored at the oncology clinic and remained disease-free until four years later, in May 2008, when computer tomography (CT) imaging revealed new pulmonary parenchymal metastases. These were closely monitored for the next 2 years with repeat imaging and measurement of calcitonin levels. In May 2010, it was decided that the patient should embark on systemic anticancer treatment.
She was offered participation in a phase 2 clinical trial with the agent lenvatinib (E7080) and she commenced treatment with 24 mg once daily in May 2010. One week into therapy, it was noted that she was marginally hypertensive with a blood pressure of 140/100 mmHg. No proteinuria was identified at this point, but she was commenced on 5 mg of amlodipine to manage

[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 man with a past medical history of hypertension, diabetes mellitus, coronary artery disease, and aortic insufficiency was admitted to our hospital with an unprovoked pulmonary embolus. As part of an occult malignancy work-up, a computed tomography (CT) of the abdomen and pelvis with intravenous (IV) contrast was performed and revealed a right persistent sciatic artery aneurysm. Follow-up CT angiography confirmed the diagnosis of a right sided persistent sciatic artery aneurysm and also demonstrated a hypoplastic right superficial femoral artery (SFA). (). Maximal aneurysm dimensions were 40 mm × 35 mm in the right gluteal region (). The patient did not endorse any right lower extremity complaints. Physical exam was notable for a pulsatile right sided gluteal mass, bilateral palpable femoral pulses but no palpable pedal pulses.
After a standard pre-operative evaluation, the patient elected to proceed with surgery to reduce the potential risk of aneurysm rupture, thrombosis or embolization (). From a percutaneous left femoral access, two 16 mm Amplatzer ™ vascular plugs (Abbott Medical, Plymouth, MN) were placed proximally and distally to exclude the PSA aneurysm. Next, standard exposure of the proximal superficial femoral and below knee popliteal arteries was performed. Ipsilateral saphenous vein was harvested and a non-reversed proximal superficial femoral to below knee popliteal artery bypass was performed to restore perfusion to the patients right lower extremity (). The proximal superficial femoral artery was chosen as inflow for the bypass due to limited saphenous vein conduit length. His surgery was performed by one of our fellowship trained vascular surgeons at a facility with an endovascular capable operating suite. After an uneventful three-day hospital stay, the patient was discharged in a stable condition. Aside from the immediate post-operative recovery, he has had no changes to his level of activity or lifestyle.
A CT angiogram of the aorta

[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 female, with a history of left breast cancer and total mastectomy followed by neo-adjuvant radiation in 2009, presented to the Plastic and Reconstructive Surgery clinic in December 2014 to discuss options for breast reconstruction. Other significant past medical and surgical histories at the time of her initial presentation included a left posterolateral thoracotomy for complicated pneumococcal pneumonia, three cesarean sections, and 1 ppd tobacco use. Her disease status was closely monitored by her oncologic team and was deemed disease-free as evident in her then most up-to-date negative screening mammogram in 2013.
Upon successful cessation of her tobacco use for a period of six months after the initial consultation, the patient was taken to the operating room in June 2015. With goals to recreate a full C-cup sized breast in a patient with a very thin body habitus (body mass index = 24), our team utilized a supercharged muscle-sparing fTRAM flap in order to safely utilize all four zones of the abdominal flap. Utilizing a two-team approach, the recipient site of the left chest was entered from her previous mastectomy incision, along with resection of the surrounding radiated fibrotic skin. A laterally based pectoralis flap was utilized to dissect up to the second rib, which was then partially resected to expose the left internal mammary artery and two veins. Simultaneously, the transversely oriented abdominal flap was elevated by the second surgeon, being particularly careful to preserve both the superior and inferior epigastric vessels on both hemi-abdominal flaps. Dissection proceeded in the prefascial plane above the anterior rectus sheath in a lateral to medial approach. After the favorable right-sided lateral row perforators were identified, the fascia was incised and the rectus muscle exposed, allowing us to trace the vessels down to the origin of the deep inferior epigastric artery and vein in the right lower quadrant. Care was taken to preserv

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


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

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

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


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

[User]
RADIOLOGY NOTE:
A previously healthy 3-year-old girl presented with a palpable abdominal mass that was noted on her well-child examination. Her parents reported a gradually increasing abdominal distention for 1 year with no other symptoms. On physical examination, the child had a soft, grossly distended, and nontender abdomen, with a large firm palpable mass on the left side []. Hemoglobin, alpha-fetoprotein, and human chorionic gonadotropin beta subunit levels were normal. An abdominal ultrasound showed a heterogeneous soft-tissue mass with septal walls in the left lower quadrant. A computed tomography (CT) scan revealed a well-circumscribed, heterogeneous, and fatty mass with thin internal fibrous septations in the left lower quadrant measuring 13.5 cm × 10.5 cm × 17.5 cm. The mass appeared to be intraperitoneal and to be causing mass effect on the spleen, left kidney, small intestine, and pancreas. A magnetic resonance imaging (MRI) scan confirmed a multilobulated mass suggestive of a lipomatous tumor of retroperitoneal origin, and a laparotomy was planned for both diagnosis and therapy []. The preoperative diagnosis of this case was a retroperitoneal teratoma.
Subsequently, an exploratory laparotomy with resection of the retroperitoneal mass was performed under general anesthesia. A well-encapsulated mass was loosely attached to the retroperitoneum. A thorough exploration of the abdomen was carried out without identifying other abnormalities. On the superior pole of the tumor, the left diaphragm was adherent and carefully dissected free from the mass. The tumor was easily dissected free from the retroperitoneal space without injury to adjacent structures. Grossly, the tumor weighed 1015 g and was well circumscribed, with a thin fibrous capsule. The specimen had a yellow lobulated fatty parenchyma separated by thin fibrous septa. Histologically, the lipomatous tumor consisted of mature adipocytes mixed with numerous lipoblasts in a focal background. No evidence of cellular atypi

[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 woman, teacher by occupation, presented with a painless progressive oval mass at the lateral canthus of the right eye since 1 year. The swelling to start with was of the size of a mole at the lateral canthus which increased to the present size of a pea and used to bleed intermittently on touch [].
On examination, a single nodular mass of size 18 mm × 11 mm which was pigmented, with well-defined margins was noted. The overlying skin was firmly adherent, irregular, and pinkish in color due to telangiectatic surface. The mass was firm in consistency on palpation with no signs of inflammation. The visual acuity, extraocular movements, and fundus examination were within normal limits. The systemic examination did not reveal any preauricular lymphadenopathy or nodular lesions elsewhere in the body. The patient did not have any abnormal facies or any abnormal pigmentation of the skin. Routine blood investigations, peripheral smear, and computed axial tomography of the orbit were within normal limits.
Surgical excision of the lesion was planned. A 3 mm safety margin was marked around the mass; an incision was taken along the markings under local anesthesia. The lesion was then meticulously dissected out, and no adhesions to the surrounding tissues were found. The mass was then excised in toto along with the 3 mm skin frill. Reconstruction of the wound was done by direct closure in two layers with 6-O vicryl and 6-O prolene without tension [].
Microscopy of the mass revealed that the epidermis had thinned out and showed focal acanthosis. The subepithelial tissue showed a tumor mass composed of cells arranged radially around islands of loose connective tissue (mucoid) giving a lace-like pattern with intervening strands in between. The cells had nuclei showing mild anisonucleosis, at places lumina were surrounded by darker cells resembling glandular cell. Some foci showed peripheral palisading with some squamous differentiation

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


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

[User]
RADIOLOGY NOTE:
A 67-year-old man was admitted to the Department of General Surgery of the University of Catania with a persistent abdominal pain in the left hypochondrium associated with nausea, vomiting, and weight loss (5 kg in two months). Clinical examination revealed a palpable mass in the epigastrium and in the left hypochondrium, which was approximately 40 cm long. The abdominal mass appeared to be fixed to adjacent structures, with its limits poorly defined.
All routine blood test results and levels of tumor markers (CEA, CA 19–9, α-fetoprotein) were within the normal ranges. Ultrasonography and computed tomography of the abdomen showed a large mass of 40 × 25 cm, which extended from the posterior wall of the stomach to the spleen, enveloping the body and the tail of the pancreas (Figures and ). Moreover, the mass was in close proximity to the left colic flexure.
After appropriate fluid resuscitation and positioning of a naso-gastric tube, the patient was urgently taken to the operating room for exploration. A bilateral subcostal approach was chosen. The giant mass occupied the central abdomen and displaced the stomach anteriorly. The tumor abutted surrounding structures closely, especially the left colic flexure, which was compressed. There was no evidence of liver or peritoneal metastasis. After division of the gastro-colic ligament, it became clear that the giant mass derived from the posterior wall of the stomach and encased the body and the tail of the pancreas without infiltrating the celiac trunk or the mesenteric vessels. An intraoperative biopsy of the mass revealed an uncertain ‘spindle cell tumor’.
Once the technical feasibility of the intervention had been established, the splenic vessels were ligated at the superior margin of the pancreas, and the patient was subjected to en-block resection of the mass by distal spleno-pancreatectomy and sleeve resection along the large curve of the stomach. The mass was solid, measured 37 × 24 × 13 cm, weighed

[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 ten-year-old female patient reported to the author’s clinic with a complaint of painful swelling on the left upper lip region. The patient had first noticed the swelling eight months back, which was initially asymptomatic and gradually increasing in size. The patient later developed pain in the region of swelling over the last two months. The pain was dull and continuous in nature. The patient had no known underlying medical conditions. Family history revealed no significant finding.
Extra-oral examination revealed a marked asymmetry, with a swelling arising from the left side of the upper lip at the region of canine fossa. The overlying skin appeared normal. The swelling was hard in consistency, had a normal temperature, was tender on palpation and the overlying skin was pinchable. There was no paraesthesia or lymphadenopathy.
On intra-oral examination, the swelling appeared ovoid in shape, measuring approximately 1.5 cm x 1 cm. The overlying mucosa appeared normal with no secondary changes (Figure ). On palpation, the mass was hard in consistency and was not adherent to the underlying tissues. The patient elicited tenderness on palpation.
CT images revealed a well-defined calcified mass of size 11 mm x 6.2 mm x 10 mm seen on the left subcutaneous plane of the upper lip and extending into the adjacent muscular plane. There was no evidence of communication with the maxilla. No adjacent inflammatory changes were seen (Figure ).
The management involved the surgical excision of the lesion in toto under local anesthetic solution containing 2% lidocaine HCl with vasoconstrictor (1:100,000 adrenaline). The lip was retracted and the lesion was fixed by pressing a finger against the base of the tumor. An incision was placed over the labial mucosa covering the lesion (Figure ). Once the muscle layer was reached, blunt dissection was performed to relieve the lesion from the muscle (Figure ). The lesion was completely excised (Figure ) and placed in 10% formalin solution 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 53-year-old Caucasian female presented with a chief complaint of “twisting” right breast pain, associated with the development of yellow-green bruising on the breast. The patient waited approximately 7 to 8 months before obtaining a mammogram and ultrasound of the right breast, which revealed a right breast mass and right axillary adenopathy (Fig. ). A biopsy was significant for cancer within lymphatic vessels in the skin, and the breast tissue showed grade 2 invasive ductal carcinoma. The tumor was estrogen and progesterone receptor- negative (< 1% each) and HER2+ (3+ by immunohistochemistry). During the initial visit, the patient complained of a productive cough with scant sputum production and mid-back pain for 2 months. The patient suffered from fatigue, and experienced night sweats for the past year with no weight loss. The patient admitted to noticing a change in breast shape and size, but no nipple discharge. The initial physical examination was significant for morbidly obese body habitus. The left breast was large, free of masses, and non-tender. The right breast was significantly larger compared with the left, and tender with a rash. A palpable 2-cm axillary lymph node on the right was appreciated. A positron emission tomography (PET)/computed tomography (CT) scan revealed hypermetabolism within the anterior aspect of the right breast consistent with inflammatory carcinoma, right axillary and supraclavicular lymphadenopathy, and several skeletal metastatic lesions predominantly within the cervical and thoracic spine. The primary tumor, regional lymph node, and distant metastasis (TNM) staging was T4b, N1, M1.
As indicated for the treatment of metastatic inflammatory breast carcinoma in a premenopausal patient, treatment was initiated with doxorubicin and cyclophosphamide every 2 weeks for 4 cycles. After the first week of chemotherapy, monthly zoledronic acid was added to the treatment regimen due to the presence of bone metastases. Treatment was then fol

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


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

[User]
RADIOLOGY NOTE:
We report a case of a 75 year old woman addressed to Allergology Department of our hospital in January 2014 for recurrent episodes of angioedema since the age of 66, with progressively increased severity and frequency. It was first considered to be induced by treatment with angiotensin-converting-enzyme inhibitors (ACEI) for mild hypertension, but she continued to have angioedema attacks for the next 6 years after discontinuation of ACE, with progressive aggravation during the last year. The previous multiple evaluations by many specialists in other hospitals did not succeed to give a clear diagnosis and treatment.
The patient had no relevant medical history and took no medication, except ACEI that was stopped some months after angioedema onset. No relation with possible allergic stimuli could be identified and she had no clinical manifestations between attacks. Angioedema was painful, not accompanied by urticaria or abdominal symptoms, located variably to neck, arms or buttocks, without facial involvement during 6 years. The attacks occurred at weeks or months intervals and usually lasted between 48 and 72 h, irrespective of corticosteroids and antihistamines treatment usually administered. The frequency of attacks had progressively increased from one at 2–3 months intervals to almost weekly during the last year before presentation. The last angioedema attack, determining emergency hospitalization in September 2014, was more severe and prolonged, accompanied for the first time by laryngeal edema and respiratory symptoms. The extended medical evaluation, including complete blood tests for inflammation, allergy, autoimmunity and cancer, were all negative (Table ). Full body CT scan and bone marrow examination were normal. No criteria for lymphoproliferative, mieloproliferative or autoimmune diseases could be found. Measurement of C1 inhibitor (C1INH) in plasma showed significantly decreased level at all measurements, with low activity ranging from 58 to 4% and consta

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


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

[User]
RADIOLOGY NOTE:
A 30-year-old man underwent right hepatectomy at previous hospital, due to trauma, in August 2012. At that time, a thoracotomy in the eighth intercostal space was performed for direct closure of the diaphragm. Pooling of right pleural effusion was treated with drainage up to postoperative day (POD) 9. The patient recovered and was discharged on POD 14. In November 2012, he presented with a right DH and strangulation of the ileus of the small intestine. He underwent laparotomy at the same previous hospital, found the defect which was separated from the previously sutured area of the diaphragm, and repaired it.
In May 2017, the patient presented to the local hospital with abdominal pain and vomiting and was diagnosed with an intestinal obstruction; an ileus tube was inserted and the patient was referred to our hospital for treatment. Upon admission, the physical examination was unremarkable, and laboratory findings, including complete blood count, erythrocyte sedimentation rate, and biochemical tests, were all within normal limits. Chest and abdominal radiographs revealed colon gas in the right intrathoracic space (Fig. a, b). On contrast imaging, the ileus tube in the transverse colon was observed to be incarcerated in the right intrathoracic space (Fig. c), a finding which was confirmed on computed tomography (CT) of the chest and abdomen (Fig. d). The patient was diagnosed with a DH and underwent laparoscopic hernia repair.
The surgical repair was performed with the patient in the left half-lateral decubitus position. Four laparoscopic ports were placed in the abdomen as follows: a 12-mm port at the umbilicus for the scope, two 12-mm ports at the right lateral lesion as working ports, and a 5-mm port at the middle of the upper abdomen used as an assistant. Under laparoscopic view, the transverse colon and small intestine anastomosis were found to be adherent to the right hemidiaphragm (Fig. a), and we proceeded with careful separation

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


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

[User]
RADIOLOGY NOTE:
A 73-year-old man was treated for an esophageal carcinoma. The diagnosis of carcinoma was made when the patient developed a symptomatic, but subacute non-ST-segment elevation myocardial infarction (NSTEMI). Basic diagnostic showed an advanced anaemia with hemoglobin concentration of 5.9 g/dl. Further investigation could explain this by a distal adenocarcinoma of the esophagus (cT3 cN1 cM0 G2). Coronary angiography provided a medium grade stenosis both of the anterior descendant branch of left coronary artery and right coronary artery without any need for intervention. Echocardiographically an ejection fraction of 60% and a low grade diastolic dysfunction could be demonstrated. Given the moderate findings of diagnostics, the myocardial infarction was seen in connection with advanced anaemia. Hence, in interdisciplinary consensus, primary chemoradiotherapy with continuous infusion of 5-FU (1000 mg/qm per day, day 1 – 4) and cisplatinum (60 mg/qm, day 1) including cardiac monitoring was indicated. The therapeutic concept included irradiation of distal esophagus including locoregional lymphatic region with single doses of 1.8 Gy to a total dose of 66.6 Gy. Before the beginning of the therapy the patient's medication was adapted to the new diagnosis of coronary artery disease and myocardial infarction.
During the first cycle of concurrent chemotherapy, after approximately 93 hours of 5-FU-infusion (total applicated dose about 6800 mg), the patient developed an angina pectoris, so that application had to be stopped. Symptoms completely disappeared within few minutes for four hours, then the patient again complained about retrosternal chest pain and ECG showed new tachycardia. The patient was transferred to intensive care unit for monitoring, and further diagnostics revealed new significant ST-segment elevations (Figure ), negative heart enzymes and intermittent atrial fibrillation. Consequently, the patient was treated with digitoxin, the dose of bisoprolol was increased

[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.