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

[User]
RADIOLOGY NOTE:
A 32-year-old woman presented with a one-month history of a perianal lesion. She had a CD4 count of 18 cells/µL. Herpes simplex virus (HSV) and Cytomegalovirus (CMV) inclusions were both present in the perianal biopsy (). No serological testing for HSV or CMV were performed.
Infection with HSV2 typically presents as genital ulcers. There is a strong association between HIV and HSV2 infection. Individuals infected with HSV2 have sixfold higher odds of HIV infection compared with those uninfected with HSV2, and 68% of patients with genital ulcers caused by HSV2 were found to be co-infected with HIV. Locally, HSV2 remains the leading cause of pathogen detectable genital ulcer disease. Histologically, cells infected with HSV2 show intranuclear inclusions with a glassy appearance, margination of chromatin and multinucleation. Infected keratinocytes are best demonstrated at the ulcer edge (). However, in hypertrophic or tumourous HSV2 lesions, the dense inflammatory cell infiltrate may obscure the viral inclusions. Careful search of multiple levels through the tissue block and immunohistochemistry may be required to identify the virally infected cells. Sparse infected cells within the deep dermis derived from ruptured hair follicles may be seen. It has been postulated that the florid inflammation noted in these hypertrophic lesions is due to immune reconstitution. Tissue may be submitted for drug resistance testing in those cases not showing clinical response to standard therapy. Cells infected with HSV and varicella-zoster virus show identical features on histological examination. Immunohistochemical stains are available to help distinguish among them.
Characteristic intracytoplasmic and intranuclear CMV inclusions were also seen in case 6 (, inset) but atypical histological features are well documented. Immunohistochemistry can also be used in those cases that are densely inflamed. The role of CMV that is detected in mucocutaneous lesions is controversial. It is thought

[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 49-year-old Japanese woman with a history of NF1. There was no family history. She had brown spots on the skin and multiple dermatofibromas, and she was diagnosed with sporadic NF1 by biopsy in her teens. After small intracranial aneurysms (< 2 mm) were found in the right middle cerebral artery 2 years ago, she underwent annual magnetic resonance imaging (MRI) follow-up (Fig. left). In addition, she was orally administered phenytoin for the treatment of genuine epilepsy. There were no aneurysms anywhere other than in the brain. She also had a history of untreated hypertension. She had no other complications, such as intracranial neurofibroma and brain tumors.
She was transported to our hospital because of acute headache and disturbance of consciousness and was diagnosed with subarachnoid hemorrhage by computed tomography (CT) (Fig. A). Regarding the disturbance of consciousness, she had a score of 13 on the Glasgow Coma Scale, grade III in the Hunt and Kosnik grading system, and grade II in the World Federation of Neurosurgical Societies grading. Blood pressure was over 200 mmHg. Computed tomography angiography revealed multiple intracranial aneurysms (Fig. B, and C). Based on the distribution of hematoma, we suspected that one of the aneurysms in the peripheral branch of the left middle cerebral artery, rather than known intracranial aneurysms in the right middle cerebral artery, was the source of hemorrhage. These multiple small intracranial aneurysms in the left middle cerebral artery were considered de novo aneurysms because they were not found on brain MRI in the previous year (Fig. right). Accordingly, she underwent emergency surgery on the day of admission. After a left frontotemporal craniotomy, the Sylvian fissure was opened, exposing the superior and inferior trunk (M2) of the middle cerebral artery. We found small intracranial aneurysm (< 2 mm) in the bifurcation of the left middle cerebral artery. During surgery, only one small aneurysm

[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 female, known case of hypertension and osteoporosis presented to the emergency department with complaints of absolute constipation for five days, abdominal distension for three days and vomiting for one day. Abdominal distention was gradual in onset and generalized. Vomitus was feculent and large in quantity. Apart from an uneventful caesarian section 35 years prior, she had no other past surgical history. On examination, the abdomen was tense, tympanatic and mildly tender on the right side on deep palpation. DRE revealed collapsed ano-rectal canal with no fecal staining. Her Xray abdomen supine shown below () demonstrated dilated small bowel and cecal distension with fecal loading and no gas under the diaphragm was seen in the chest x-ray (). She had history for similar complaints one year back, for which she was managed conservatively. She was on medications for osteoporosis, and had family history of Chron’s disease.
CT scan with IV contrast demonstrated marked diffuse dilatation of small bowel loop and the cecum with abrupt point of transition at the junction of cecum and the ascending colon. Mild ascites was seen in the peri-hepatic region, in the pericecal region and the pelvis (, ).
Based on radiology, no proper cause of intestinal obstruction could be identified. The patient was offered colonoscopy before laparotomy but she chose to get operated. Surgery was performed by consultant surgeon and senior registrar. Patient was counselled for right hemicolectomy, diversion and stoma formation.
On laparotomy, around 200 ml reactionary fluid was aspirated. The cecum and small bowel were distended but healthy looking. Cecum was found rotated anteriorly upon itself (). Distal to the caecum, the large bowel was collapsed. There was no other obvious pathology observed. Liver and peritoneum were normal. Cecectomy was done with end to end ileo-colic anastomosis.
Post operatively, the patient was kept in the general ward, and she developed ileus (

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


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

[User]
RADIOLOGY NOTE:
A 59-year-old male was admitted to another hospital in March 2014 with symptoms of hematemesis and tarry stool. He had a history of hypertension, cardiac infarction, and aortic regurgitation. Laboratory data collected on admission revealed anemia (hemoglobin concentration, 6.4 g/dl), and he received a transfusion of four units of packed red blood cells. A CT scan showed the presence of irregular dilated arteries in the pancreatic head, and he was diagnosed with pancreatic artery pseudoaneurysm presenting with multiple arterial feeder vessels.
The patient was referred to our hospital for treatment. On admission, a CT scan showed the presence of meandering irregular dilated vessels in the pancreatic head (Fig. ) and an early appearance of the portal vein at the arterial phase (Fig. ). Further evaluation using 3D imaging showed feeder vessels from the superior mesenteric, celiac, and splenic arteries (Fig. ). Magnetic resonance imaging showed the strong enhancement of the conglomeration in the pancreatic head (Fig. ), and reformed maximum intensity projection imaging showed feeder vessels from the superior mesenteric and celiac arteries with an early appearance of the portal vein at the arterial phase (Fig. ). Selective angiography showed the proliferation of a vascular network in the pancreatic head and early visualization of the portal vein at the arterial phase (Fig. ). Color Doppler imaging revealed a mosaic-like structure comprising pulsatile waves. The preoperative diagnosis was AVM of the pancreatic head.
The intraoperative examination revealed that there were no abnormal vessels and/or collateral vessels on the surface or around the pancreas except dilated drainage veins at the top of the pancreatic head (Fig. ). But, serial sections of the resected specimens revealed dilated and tortuous vessels in the pancreatic head (Fig ). Four feeder arteries from the superior mesenteric artery and two feeder arteries from the common hepatic artery were detected during the

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


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

[User]
RADIOLOGY NOTE:
A 60-year-old man who had had diabetes and hypertension for the last 15 years presented with a history of right-sided weakness which progressed slowly over a period of 2 weeks. A week before presentation he had also developed headache, vomiting, and difficulty in swallowing. At presentation, he had loss of speech followed by altered sensorium. The patient had also been having cough with minimal sputum off and on and loss of weight for the last 3 months.
The patient had a focal lesion on a brain MRI, along with a left pleural effusion on a chest radiograph, and had been treated for tuberculosis. When he was finally seen in our hospital, the patient was afebrile and had a raised pulse rate and blood pressure. The liver was mildly enlarged. Respiratory and cardiovascular system examination was unremarkable. He had altered sensorium, with aphasia and complete weakness of the right side of the body (grade 0/5 power in both upper and lower limbs). The plantar was upgoing on the right side and there was gaze preference to the left. Fundus examination revealed a few microaneurysms at the macula, a few cotton wool spots, and mild arteriolar attenuation in both the eyes.
The laboratory examination revealed normal red blood cell and renal function parameters, with normal sodium and potassium levels. The total leucocyte count was reduced.
Contrast-enhanced CT of the head [] revealed conglomerate, ring-enhancing lesions in the left parietal lobe, with significant surrounding edema and contralateral shift. There was no abnormal meningeal enhancement. Contrast-enhanced MRI of the brain revealed perpherally enhancing conglomerate lesions in the left parietal lobe [], with significant surrounding edema. These lesions showed central hyperintense signals with low signal intensity walls on the T2W images []. On T1W images, the central contents appeared hypointense. USG of the abdomen showed a small right pleural effusion and hepatomegaly. Contrast-enhanced CT scan of the chest revealed

[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 lady presented to the Accident & Emergency (A&E) department immediately after a fall from standing height with a painful deformed right elbow. Initial radiographs demonstrated a dislocation of the elbow with no associated fractures (). The joint was manipulated by the A&E staff and the arm was placed in an above elbow plaster back slab with 90° flexion. Postmanipulation radiographs confirmed the reduction albeit with some subluxation of the radio-capitellar joint (). The patient was discharged home. Four days later she was reviewed at the fracture clinic by a locum doctor who also did not appreciate the importance of subluxation on the post-reduction film and did not repeat the radiographs. The arm was placed in an above elbow complete cast and a review was scheduled in a further two weeks. At this review, three weeks following her injury she was in severe pain and the elbow was noted to be obviously clinically dislocated with extensive bruising and swelling. Fortunately the hand remained neurovascularly intact. Radiographs confirmed the now chronic dislocation (). At this point the soft tissues prevented further closed reduction.
The patient had significant medical comorbidities: ischaemic heart disease with previous coronary stents; left ventricular failure; complete heart block with a permanent pacemaker; type 2 diabetes; a BMI > 35 and emphysema treated with long-term steroids. She was discussed in the departmental trauma meeting and due to her high anaesthetic risk, poor soft tissues and general frailty she was assessed as not suitable for our standard operative treatment with collateral ligament repair and stabilisation with a hinged external fixator. The options suggested by the consultant body at the trauma meeting were to offer either non-operative treatment (pain control medications and a brace) or percutaneous trans-articular pinning. Both these options have significant drawbacks in terms of functional outcome. We have previously described a

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


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

[User]
RADIOLOGY NOTE:
This 79-year-old man presented to his local hospital in May 2007 with a 2-month history of a chronic non-productive cough, weight loss of 1.5 stone (9.5 kg) over 1 month, anorexia and general malaise. Other gastrointestinal or respiratory symptoms were absent. Examination was consistent with the finding of a left-sided pleural effusion and of note, abdominal exam was normal. An admission chest X-ray showed a left-sided pleural effusion with basal collapse. His inflammatory blood markers were also elevated (WCC 21.3, CRP 286). He was commenced on intravenous antibiotics but showed little improvement after 3 days of treatment, at which point a computed tomographic (CT) scan of the thorax and abdomen was performed. The CT showed a loculated pleural effusion consistent with an empyema plus thickening of the pleura and diaphragm as well as an abnormal thickened splenic flexure adjacent to the diaphragm (Figure ). The patient was subsequently transferred for further management.
On the day of transfer, the patient was taken to theatre for pleural decortication. A posterolateral thoracotomy was performed and the abscess collection was evacuated. A small perforation of the diaphragm was also found and it was established that the abscess cavity was extending through the diaphragmatic defect (Figure ). At this point a laparotomy was performed. It was found that the patient had a locally perforated splenic flexure tumour, which had formed a collection that communicated with the thorax and also invaded the spleen. The tumour, along with the adherent spleen was removed (Figure ) and a transverse colostomy and distal mucus fistula were fashioned. An omental patch was used to close the defect in the diaphragm.
The patient made an uneventful postoperative recovery and was discharged from hospital 15 days after the operation having received the relevant vaccinations. Pathological assessment showed a Dukes B moderately differentiated adenocarcinoma with the pathological staging of T4

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

[User]
RADIOLOGY NOTE:
A 56-year-old male without any previous medical history presented to our emergency room (ER) with multiple traumas from a 10 meter fall in a construction field. Physical examination revealed a male patient with a body mass index in the normal range and an acutely ill looking appearance. His right lower leg and ankle were swollen and bruised, and he had a 2 cm laceration wound on the plantar aspect of his right foot. The patient's right ankle had limited range of motion due to pain. The patient had tenderness at the right anterolateral aspect of the mid lower leg and anterior aspect of the ankle. There was grade 1 anterolateral instability of the left ankle. The neurologic examination was normal. Based on the patient's clinical history and physical examination, the orthopedic surgeon suspected a fracture of the right fibular diaphysis and ligament injury of the right anterolateral ankle.
Initial radiographs of the ankle in the anteroposterior and lateral views showed fractures at the diaphysis at the fibula and anterior lip of the tibial plafond (Fig. ). The patient was not able to undergo ankle Mortise view because of his limited range of motion due to extreme pain. In a subsequent lower extremity computed tomography (CT), the orthopedic surgeon in the ER noticed a segmental fracture of the right fibular shaft and the anterior lip of the tibial plafond.
To evaluate the ankle ligaments, a turbo spin-echo (TSE) two-point mDixon technique applied to an ankle MRI (Table ) was performed after procuring written informed consent. In addition to the fractures of the right fibular shaft and tibial plafond, this MRI demonstrated a tiny chip fracture of the lateral talar dome. A tiny wafer-shaped talar dome chip fracture fragment about 7 (anterior–posterior diameter) × 3 (head to toe diameter) mm was clearly delineated only in the sagittal T2-weighted mDixon opposed-phase MRI (Fig.

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


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

[User]
RADIOLOGY NOTE:
A 55-year-old male had continuously visited the Department of Oral and Maxillofacial Surgery at Yonsei University College of Dentistry for MRONJ which had primarily developed after zoledronic acid and capecitabine administration for previous bone metastasis of medullary thyroid cancer. Pain, bone exposure, and pus discharge in the right mandible and left maxilla first occurred 5 years after discontinuing bisphosphonate and capecitabine administration. At that time, the patient was going through chemotherapy with another antineoplastic drug, everolimus. Clinical, radiological features of both jaws, and pathological evaluation of the mandible confirmed the diagnosis as MRONJ.
Symptoms of the left maxilla started as chronic apical abscess with tooth mobility in the left premolars. Primary bone exposure with osteonecrosis at the left maxilla was observed after extraction of these teeth in a local clinic. The remaining sockets showed delayed bone healing with pus discharge and incomplete soft tissue covering.
Radiologic examination by CT () revealed that there was an irregularly mixed radiolucent/radiopaque area in the left maxilla with discontinuity of the cortical barrier adjacent to the left buccal vestibule, palate, nasal cavity, and maxillary sinus. Mucosal thickening was seen in the left maxillary sinus and nasal cavity. These radiologic features persisted in the additional CT views taken 2 years later (data not shown).
After a year of conservative treatment and another year and a half without periodic follow-up, the patient re-visited the hospital for recurrent bone exposure in the left maxilla with pus discharge. An ill-defined radiolucent/radiopaque lesion with definite alveolar bone loss was seen at the left maxilla on panoramic views (). The exposed sequestra were removed and sent for pathological evaluation.
On pathological examinations, the tissue specimen revealed mostly several necrotic bone fragments with surrounding nonspecific bacterial colonies and nec

[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 woman underwent a lower segment cesarean delivery for her fourth pregnancy two years before; she was transfused two units of blood for continuous vaginal bleeding. After delivery she failed to lactate, did not resume cycles and complained of fatigue. Three months before admission she complained of cough and intermittent fever with night sweats. She was seen at a primary health center where sputum was found positive for acid fast bacillus on multiple occasions, with no findings suggestive of tuberculosis on chest radiograph. The patient was started on antiitubercular treatment (ATT) in the form of isoniazid, rifampicin, ethambutol and pyrazinamide in appropriate doses. She felt more fatigue and weakness in the first week after starting ATT. On the tenth day she was found to be unconscious in the morning and was brought to the hospital. Examination in emergency revealed a sick, pale looking lady with a feeble pulse rate of 100 beats per minute and unrecordible blood pressure with a temperature of 99°F. She had breast atrophy and sparse axillary and pubic hair. She also had a systolic murmur at the mitral area suggestive of mitral regurgitation. Her deep tendon jerks revealed a marked delay in relaxation suggestive of hypothyroidism. In view of her postpartum hemorrhage (and need for blood transfusions), lactation failure, secondary amenorrhea, hypotension and features of hypothyroidism, a clinical diagnosis of Sheehan syndrome with adrenal crisis was made. The patient was given emergency treatment in the form of oxygen inhalation, intravenous fluids and a nasogastric tube was inserted. After taking a blood sample she was started on hydrocortisone 100 mg every 6 hours, levothyroxine 100 μg through the NG tube and ATT was continued. She regained consciousness after an hour and her blood pressure rose to 80/60 mm Hg. Investigations revealed a hemoglobin of 9.2 g/dL, total leukocyte count of 3.2×103/mL with polymorphonuclear leucocytosis, a platelet count of

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

[User]
RADIOLOGY NOTE:
A 53 year-old man was transported from another hospital with the high suspicion of a traumatic aortic rupture after acute blunt thoracic trauma. Following a high speed car accident he was admitted in another hospital with injuries in the chest and fracture of the left femur. A thorax-CT scan was performed without contrast medium because of a known chronic renal failure (creatinine levels = 2.2 mMol/L). It showed hemothorax on the left, minimal left lung contusions (of the posterior segments), rib fractures and a periaortic hematoma at the level of the isthmus area (figure ). Because of a high-suspicion index of thoracic aortic rupture, we decided to do an emergency aortography. It revealed an interruption of the normal contour of the thoracic aorta in the aortic isthmus area. A protrusion of the aortic lumen in the corresponding inner curve of the aorta supported our suspicion for the disruption of the intima and the initiation of a pseudoaneurysm's process (figure ). Therefore, an emergency operation (the interventional management was abandoned because of technical reasons) by using partial right femoro-femoral bypass for aortic isthmus repair was decided. Surprisingly, and after a postero-lateral thoracotomy at the 4th intercostals space, we inspected an "intact" outer thoracic aortic wall, without haematoma or related pathology at the aortic isthmus area. However, because we did not totally exclude a possible limited disruption of the intima, or even another pathology (see discussion), we decided to check from inside the thoracic aorta. Following proximal and distal dissection of the aorta, a partial cardiopulmonary bypass was initiated with flow level 2-2.6 L/min to restore a distal aortic pressure of >55-60 mm. After double clamping and vertical opening of the aorta wall, an intact endothelium was observed. In the inner curve of the aortic isthmus area and in the site of occluded ligamentum arteriosum, a local vestigial dilatation 0.5 × 0.8 cm 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:
We present a case of a 25-year-old male who presented with complaint of clawing of his left great toe. The patient had sustained a left-sided distal tibia fracture treated with open fixation of the tibia fracture 3 years ago. The implant was removed 18 months after the procedure due to the patient’s preference. After 6 months, the patient initially noticed clawing of his left great toe when he climbed stairs barefoot. He also complained that he had started to find it difficult to sit cross-legged, squat, as well as ride his bicycle due to the tightness he felt in his toes with certain ankle movements on examination, the patient walked with a normal bipedal unassisted gait. He had well-healed surgical scars and a plantigrade foot. Active dorsiflexion of the ankle joint produced an exaggerated flexion of the great toe. With the ankle held in dorsiflexion, it was not possible for the patient to actively or passively fully extend any of the toes (Figs. and ). The diagnosis of checkrein deformity of the left great toe was made and attributed to the previous fracture of the distal tibia resulting in scarring or ischemic injury to the toe flexors. The possible patterns of injury could have been an isolated injury to FHL muscle or tendon causing fixed flexion of the great toe. The patient elected for surgical intervention and surgical exploration of FHL tendon at the level of the midfoot was planned. Exploration at the midfoot would give easier access to both tendons free from scar tissue making correction easier. The patient was suitably consented and the exploration was performed under spinal anesthetic with an inflated tourniquet at 250 mmHg. The tendon of FHL was identified (). Subsequent z-plasty of FHL tendon gave a full correction of the great toe flexion contracture (). The patient made an uncomplicated post-operative recovery and after final review, 3 months post-surgery had

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

[User]
RADIOLOGY NOTE:
A 51-year-old woman was presented with complaints of diarrhoea for 3 years. She had no medical history. Colonoscopy revealed slight extrinsic compression of the hepatic angle. CT examination showed a right retroperitoneal mass of 65 × 60 × 90 mm. The well-defined solid lesion was located in the right retroperitoneum, posterior and inferior to the duodenum, on the right side of the cava, and anterior to and on the left side of the right kidney. Based on these findings, the differential diagnosis was between a neurogenic tumour and a mesodermal tumour.
Blood tests for tumoural markers, chromogranin A and urine metanephrines, were negative.
At a sarcoma multidisciplinary meeting, surgery was favoured over biopsy. Due to the inconclusive diagnosis, a conservative laparoscopic approach treatment was decided.
With the patient placed in left lateral decubitus position, four trocars were placed in a semicircular line in the right hemiabdomen. The right angle of the colon was mobilized to locate the tumour in the right side of the duodenum and the cava. The tumour was then dissected by ultrasonic shears and by blunt dissection from the cava; the right gonadal vein and the ureter were found to be in contact with the tumour but without infiltration.
Dissection indicated the tumour arose from the gonadal vein, and this was therefore clipped and divided. The tumour was maintained and completely removed by an accessory incision in the right flank.
En bloc resection was ruled out in view of the uncertain diagnosis. Postsurgical recovery was uneventful. Oral intake was started on the fourth day because she had nausea and vomiting in the immediate postoperative period. She returns slowly to a regular diet and was discharged on the ninth postoperative day.
The histological report confirmed a high-grade leiomyosarcoma (grade 2), with areas of focal necrosis, dystrophic calcification, and positive resection margins (R1). The tumour was described as a fusocelular sarcoma with crossed bu

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

[User]
RADIOLOGY NOTE:
A 32-year-old male patient reported to the dental clinic with the chief complaint of unesthetic appearance of the gums and hypersensitivity in relation to his upper right canine. No significant medical history and habits were reported.
On clinical examination, he had relatively fair oral hygiene. Periodontal examination revealed localized gingival inflammation in relation to maxillary right canine, with a probing pocket depth of 2 mm and clinical attachment loss of 5 mm with deep/wide Class I gingival recession []. The keratinized tissue (KT) thickness was around 2 mm which was measured at the center of an imaginary line from mucogingival junction (MGJ) to marginal gingiva, using an endodontic file with stopper after anesthetizing the region. Intraoral radiograph in relation to the tooth concerned showed no bone loss.
Considering the height (3 mm) and width (5 mm) of the defect, the treatment decided on was root coverage using an epithelial embossed graft technique. The treatment plan was explained to the patient, and a duly signed written consent was obtained. Oral prophylaxis was done 2 weeks before surgery.
Under local anesthesia, a sulcular incision was made in the right canine region, also involving mesial aspect of the first premolar and distal aspect of the lateral incisor as described by Raetzke.[] Envelop flap was raised without making vertical incisions []. Thorough root planing was done. The connective tissue graft was procured from the contralateral side of the palate between the left first and second premolar region. A tinfoil template was cut fitting the defect size precisely and transferred to the palate from where the donor tissue was to be obtained. It was placed in relation to the upper left premolar palatal region, and an incision was made around the tinfoil which extended 3 mm close to the gingival margin on either side []. The epithelium was undermined 3 mm from the incision. Releasing incision was given so that only the connective

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


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

[User]
RADIOLOGY NOTE:
A 60-year-old right hand dominant male suffered a blast injury from a stick of dynamite. He was complaining of left hand, forearm, and elbow pain. Patient also endorsed significant numbness and tingling in the left hand. On physical exam, there was significant degloving of the palm and partial amputations of the second and third distal phalanges. Radial pulses were intact, with no evidence of an arterial bleed. A photograph of the hand on presentation can be seen in . Figures and are the initial radiographs of the hand and elbow, respectively, showing the extent of the injury.
The patient went for emergent washout and exploration by hand surgery. He was found to have complete obliteration of the superficial and deep palmar arches. Approximately half of the flexor tendons were intact. The thumb was attached via a single flexor tendon and remnant skin. The median nerve was completely severed at the level of the wrist. Open reduction and internal fixation (ORIF) of the distal radius and the distal ulna was not performed because of a lack of viable soft tissue coverage secondary to the traumatic injury from the blast effect as determined by the hand surgeon intraoperatively. The amputation level was partially based on the level at which viable soft tissue coverage was available for coverage of bone. The hand surgeon proceeded with a transradial amputation.
Closed reduction of the ulnohumeral joint was performed by the orthopaedic team once hand surgery was done with their part of the procedure. The patient required 90 degrees of flexion at the elbow to maintain reduction due to gross instability. 3D reconstructions from the postreduction computerized tomography (CT) scan are seen in Figures and showing the terrible triad injury of the elbow.
Twelve days after the initial injury, the patient returned to the operating room for definitive fixation. A Kaplan approach was used, which demonstrated rupture of the lateral collateral ligament (LCL) as well as a comminuted radial

[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 patient (PT2), a black female, was a 43-year-old non-smoker with weight of 300 lbs and height of 6–2" at the time she presented for care at the clinic. She was diagnosed in New York in 2000 with right upper extremity lymphedema (Figure ) following treatment for breast cancer in 1998 including mastectomy, axillary dissection of 24 lymph nodes, radiation, and chemotherapy. A side effect of the radiation was fibrosis of the lateral chest wall and breast tissue. The patient's first CDT began in 2002 after the lymphedema progressed with increased discomfort and recurrent infections. Between 2002 and 2006, she had four episodes of cellulitis treated with multiple antibiotics. She received three courses of intensive CDT, including two to three visits weekly for three months. In 2004, she began using the programmable ProACT 1 pump (Fore Tech Medical, Williamstown, NJ; HCPC code E0652) intermittently for temporary relief of pain when her symptoms were most bothersome. This device did not provide treatment of her truncal lymphedema.
In 2006, she stopped using the ProACT 1 pump due to development of a fibrotic cuff (at the limb root nearest the axilla), skin irritation, and lack of sustained reduction of lymphedema. She then moved to Georgia and in March 2007 began a fourth course of CDT, which required treatment five days a week for four months. At the time she began this treatment, arm volume measurements showed that the affected arm had 31% greater volume than the unaffected arm.
The patient's self-MLD was not successful, because she was unable to reach all affected areas and did not have anyone at home to assist with her care. The FT system was recommended because, in addition to treating her affected arm, it treated the chest wall, trunk, and shoulder areas that the patient could not reach. In December 2007, she began using FT for 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 45-year-old woman was on a flight and suffered from a sudden onset of right temporal pain for 30 min, followed by a tingling sensation on the right cheek. After she arrived at her destination, she experienced a throat blockage for approximately 20 min; therefore, she visited an ear, nose, and throat (ENT) doctor as well as a neurologist at another hospital. Neurological examination only revealed a tingling sensation in the area of the second branch of the right trigeminal nerve (the maxillary nerve). Otolaryngological examinations were unremarkable, except for percussion pain from the upper right central incisor to the first molar and gingival sensory disturbance in those regions (Fig. ). The patient was examined using head magnetic resonance imaging (MRI), which detected inflammatory findings in the right ethmoid sinus and slight fluid retention in the right sphenoid sinus (Fig. ). No pathological findings in or around the brainstem and cisternal portion of the trigeminal nerve were noticed. Under a diagnosis of idiopathic trigeminal neuralgia, the woman received conservative treatment. Because her symptoms persisted, the patient revisited the neurologist 1 month after the onset, and an additional MRI scan revealed chronic sinusitis in the right sphenoid sinus (Fig. ).
Seven weeks after onset, the patient's symptoms continued, such as a tingling sensation from the right side of her nose to around her upper lip, and, therefore, she visited our hospital for a further workup. During the entire period, she noticed no febrile episodes. Neurological examinations revealed only sensory disturbance on the second branch area of the right trigeminal nerve. Other cranial nerves were intact, and a blood examination revealed no abnormal findings. The CT examination indicated sphenoid sinusitis with a small amount of fluid retention. And the coronal thin-sliced bone CT revealed the absence of the bony boundary between the sizeable sphenoid sinus and maxillary nerve (Fig. ).
Acc

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


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

[User]
RADIOLOGY NOTE:
A 38-year-old female patient presented with a sudden left-side motor disorder and loss of consciousness. The patient was otherwise in good health and had no history of hypertension or diabetes. During the physical examination, she appeared lethargic and manifested left limb paralysis with level zero muscle strength and a positive pathological reflex.
Head computed tomography findings showed lesions with hemorrhage occupying the right temporal lobe space, compression of the ipsilateral ventricle, and the midline structure offset to the contralateral side (Fig. A,B). Further, magnetic resonance imaging examination revealed a right temporal lobe space-occupying lesion with an uneven signal surrounded by an edema and a vascular flow signal. After contrast agent enhancement, lesions were observed in the enhanced vascular image. Inside the lesion, low signals of filling defect were detected suggesting thrombus (Fig. C,F).
Intracranial lesion resection was undertaken because the patient was diagnosed with a right temporal lobe tumor with hematoma. The operation was performed under general anesthesia using a right temporal operative approach. A reddish cystic mass was observed on the surface of the brain the dura was opened. It felt tough and had a large number of nourishing arteries on its surface. Because the lesion was considered to have a vascular structure, we immediately closed the skull and transferred the patient to the catheter room for digital subtraction angiography. The angiography showed that the lesion was a PAVF fed by the right middle cerebral artery. Blood flow was through the lateral fissure vein and Labbé vein to the sigmoid sinus (Fig. ).
The PAVF was completely embolized with endovascular treatment using coils and onyx (Fig. ). Subsequently, the patient was transported to the operating room for removal of the PAVF and release of the mass effect. During the surgery, it was observed that the PAVF mainly comprised blood clots, and these structures, includi

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

[User]
RADIOLOGY NOTE:
A 51 year old man presented to the ED for the third time in 2 weeks with complaints of flank pain and hematuria. He had complained of left sided flank pain during the initial 2 visits. During the first visit, the patient was diagnosed to have renal colic. X-ray KUB did not show any renal stone. He was treated symptomatically with analgesia and discharged. During the second visit with complaints of persistent left flank pain despite taking analgesia given at discharge, he was admitted to the emergency observation ward for pain management. Bedside ultrasound done then was noted to have mild left sided hydronephrosis. He was pain free at the end of the observation and was then discharged with analgesia and an outpatient follow-up with the urology department. He was also scheduled to have an outpatient computed tomography scan of the kidneys, ureters, and bladder (CT KUB). However, 2 days before the scheduled CT, he represented to the ED with right sided flank pain since morning on the day of his visit. The pain radiated to the right groin and was associated with hematuria. He was not passing blood clots. He denied any other complaints of fever, weight loss, vomiting, diarrhea, or constipation. He had a past medical history of hypertension, diabetes mellitus, and hyperlipidemia. He had previous surgeries for appendicectomy and cholecystectomy.
His vital signs were stable. There was tenderness over the right flank on physical examination. There was also a palpable tender mass measuring about 5x5cm over the right lumbar region. There was no renal angel tenderness. Bedside ultrasound in the ED showed an appearance of a 6 cm cystic lesion around the inferior pole of the right kidney with internal echogenicity within the cyst. The provisional diagnosis was a bleeding renal cyst versus a tumor. Blood tests done in the ED showed a mildly elevated white cell count 12.64 × 10(9), hemoglobin of 14 gm/dL, and creatinine of 109 Umol/L.

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


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

[User]
RADIOLOGY NOTE:
A 59-year-old African-American man, with history of renal insufficiency, diabetes, hypertension, severe peripheral vascular occlusive disease, and a 100 pack-year tobacco history, was incidentally found to have an abnormal chest radiograph showing bilateral large lower lobe airspace opacities. Images taken three years previously were reviewed; the abnormalities were present at that time and had not changed in size significantly. The patient was lost to follow-up after that initial abnormal radiograph. He was experiencing only mild respiratory complaints of dyspnea on exertion and occasional dry cough. There were initially no symptoms of hemoptysis, fever, chills, weight loss or night sweats. No laboratory abnormalities were discovered. A history of diagnosed autoimmune disease, cancer or family history of lung disease was not present. A computed tomography (CT) scan of his chest confirmed dense consolidation with air bronchograms involving several segments of his bilateral lower lobes. No mediastinal lymphadenopathy was seen (see Figure ). Our patient underwent bronchoscopy with a transbronchial biopsy. The pathology of the biopsy specimen showed extranodal marginal zone B-cell lymphoma of BALT (see Figure and ). Further staging with positron emission tomography-CT and bone marrow biopsy revealed stage IV disease involving the subcarinal lymph nodes as well as the bone marrow.
Our patient was treated with single-agent rituximab and received four total doses, one dose given weekly. His clinical course remained stable with no evidence of progression and some improvement on CT imaging post-treatment. Our patient was seen every three months by his oncologist after his initial diagnosis. Two years after the diagnosis and treatment with rituximab our patient's clinical course worsened. He described new symptoms of worsening shortness of breath, weight loss, night sweats and fevers. He had elevated lactate dehydrogenase at 350IU/L, uric acid measuring 10.0 mg/dL and creati

[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 10-year-old male patient reported to the department of Pedodontics complaining of pain in the lower lip that began 15 days before. The patient’s medical history revealed traumatic injury to the upper anterior teeth in addition to a lower lip laceration due to a fall while playing approximately 10 months previously. However, at the time, no attempt was made to locate the fractured tooth fragment at the site of the accident neither by the patient nor by his parents. The patient consulted a nearby general medical practitioner for the soft tissue injury, and the lip laceration was sutured by the medical practitioner. Subsequently, the patient did not receive any treatment for the fractured upper teeth. For approximately 10 months, the patient did not feel any discomfort in the lip. Fifteen days before presenting at the clinic, the patient began to have pain in the lower lip. Clinical examination showed scarring and discoloration of the skin to the right of the midline of the external aspect of the lip [Figure ]. On palpation, a small hard mass was felt in the lip mucosa. Intraoral examination revealed an Ellis and Davey class II fracture involving the permanent maxillary right central incisor. Suspecting a foreign body, a radiograph of the lip was taken, which showed a radiopaque structure similar to that of the fractured tooth fragment [Figure ]. Based on the patient’s history and on clinical and radiographic findings, the present case was diagnosed as a case of embedded fractured tooth fragment in the lip following trauma. The embedding of the tooth fragment in the lower lip was explained to the patient, and its removal under local anesthesia was planned. A small incision was made under local anesthesia in the proximity of the hard mass, which exposed the embedded tooth fragment [Figure ]. The tooth fragment was completely removed followed by suturing with 3−0 black silk suture [Figure ]. Examination of the tooth fragment [Figure ] confirmed that 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:
An 8-month-old girl without specific past medical history was admitted to the hospital due to nausea and diarrhea. On physical examination, a firm mass was detected in the left upper quadrant of the abdomen. Abdominal computed tomography (CT) revealed a 6.8×5.8×5.3 cm sized left renal mass without lymph node enlargement (). There were no suspicious metastatic lesions in chest CT. Laboratory data showed leukocytosis. Radical nephrectomy with lymph nodes dissection was performed. Gross examination revealed a well circumscribed, ovoid, firm mass in the lower pole of the kidney (). The mass was abutted on the renal capsule, and the surface of the mass was whitish gray with multifocal hemorrhages. The remaining renal parenchyma was unremarkable. Microscopic findings revealed that the tumor was a highly cellular neoplasm composed of tumor cells of varying size with prominent nucleoli and abundant cytoplasm (). Histological examination was consistent with the diagnosis of malignant rhabdoid tumor. Immunohistochemistry showed loss of INI1 protein staining ().
One week after the operation, weakness of both lower extremities and voiding failure were noted. On neurological examination, she failed to respond to pain in both legs. Brain magnetic resonance imaging (MRI) did not show evidence of metastatic disease, but lumbar MRI revealed a 6.5×1 cm sized intradural extramedullary tubular mass with heterogeneous enhancement at L1-S1 level (). On the next day from onset of symptoms, laminoplastic laminotomy was performed by a neurosurgeon to remove the tumor and decompress spinal cord. Conus medullaris was displaced by the hypervascular tumor with yellowish color, however the upper margin of the tumor was clear (). The tumor was densely adhered to the left side of L5 nerve root. Near total removal of the tumor was performed using cavitron ultrasonic surgical aspirator, and there was no root injury during the surgery (). The pathologic findings were consistent with metastatic malign

[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 51-year old man with CD. He was initially diagnosed with CD at 23 years old. He had undergone ileocecal resection, owing to a stricture of the terminal ileum, at 36 years old, and the residual small intestine was 230 cm long. After the initial operation, he was prescribed 5-aminosalicylic acid and home parenteral nutrition. He did not accept a recommended colonoscopy examination, owing to anal pain.
In August 2008, the patient complained of difficulty in defecation and consulted a physician at our hospital. A colonoscopy examination showed a pedunculated rectal polyp, 4 cm in diameter (Figure ) and an anal stricture due to proctitis. Histological examination of the biopsy from the lesion showed an adenoma; no dysplasia was detected around the polyp. A transanal resection of the polyp was performed for treatment and final diagnosis (Figure ). The pathological findings revealed that the polyp was an adenoma with well-differentiated adenocarcinoma without lymphatic or vascular invasion with negative margin of cut end, and that no dysplasia or inflammation was present around the polyp; thus, the polyp was diagnosed as a sporadic adenocarcinoma in an adenoma, rather than a colitis-associated adenocarcinoma (Figure ). Consistent with the results of the biopsy, an endoscopic exploration showed no dysplasia in the rectal mucosa, and immunohistochemistry showed no p53-staining of the crypt base. These findings were not consistent with colitis-associated CRC (Figure ). In July 2010, follow-up colonoscopy showed a longitudinal ulcer scar from the descending colon to the ascending colon and stenosis of the ileocolic anastomosis. We did not find any apparent lesion in the rectum.
Three years after the second surgery, in August 2011, colonoscopy examination revealed a reddish, elevated lesion in the rectum (Figure ). This lesion was located at a different site from the initial lesion. A colonoscopic biopsy revealed a signet ring cell carcinoma. We performed an 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 38-year-old Caucasian male patient presented to our dental office with a 1 year history of recurrent swelling on the buccal aspect of lower right mandibular region. He reported pain/tenderness on chewing over the past year. Medical history was unremarkable and there was no contraindication to dental treatment. There was no history of trauma to the teeth and jaw; a previous dental root treatment in the lower right region was reported.
Clinical examination revealed that the first right lower molar was tender to percussion and had a large coronal restoration; the adjacent premolar and molar teeth were vital and intact with no signs of caries or anomalies such as occlusal tubercle. The buccal soft tissue of lower molar teeth was normal. The probing depths were within normal limits. The molar tooth had no mobility. Radiographic examination showed a large circumscribed radiolucency at the apex the mesial root of first mandibular molar (). However, lamina dura surrounding the root of second premolar was apparent circumferentially. Further history revealed that the molar tooth had been endodontically treated 5 years ago and restored with an amalgam restoration. The obturation was deemed inadequate and a diagnosis of persistent AP due to inadequate root canal filling of lower right first molar was ascertained. After full explanation the patient consented to nonsurgical endodontic retreatment, followed by coronal restoration with amalgam.
First, patient was asked to rinse with 0.2% chlorhexidine mouthwash. After administering local anesthesia, and isolation with rubber damn, the amalgam restoration was removed using a water-cooled high-speed fissure bur and straight line access to the root canals was made. Working length was determined radiographically, confirmed by electronic apex locator and using hybrid instrumentation (mixed technique) the canals were shaped and cleaned; copious irrigation with 5.25% NaOCl solution was carried out. Canals were dried and obturated by lat

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


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

[User]
RADIOLOGY NOTE:
A 39-year-old Japanese woman consulted a doctor because of back pain, and UPJO was detected after an examination. She was referred to our department and agreed to undergo laparoscopic surgery. A renogram showed that the function of her left hydronephrotic kidney was maintained to some extent, and surgery was thought to be effective. However, CT data revealed that the network of arteries and veins was very complicated. Therefore, we decided to use our simulator before surgery, and our patient agreed.
CT data were saved in the DICOM (Digital Imaging and Communications in Medicine) file format. CT was performed with slices of 1mm in thickness from the chest to the pelvis, and its DICOM file was reconstructed to obtain three-dimensional (3D) volume data. The reconstructed organs were shaped with 3D mesh by using computer graphic techniques. After 3D conversion, the data were transmitted to our simulator, and relations and locations of organs were set. Fibrotic tissue and fat were added appropriately around the organs, and reconstruction of the body was completed (Figure
).
During the simulation, we first placed the camera and trocars on the body surface and obtained a virtual view of the abdominal cavity. When we changed the position of the trocar, the virtual view of the abdominal cavity also changed. Thus, we could choose a better position of the trocar in this pre-operative simulation. There were four renal arteries, two renal veins, and one gonadal vein that bifurcated in the middle. The lumbar vein was not important during surgery and therefore was not depicted.
During surgery, we chose the right flank position and four trocars. The pneumoperitoneum pressure was 10mmHg. We approached the retroperitoneum from the lateral aspect of the descending colon. We found the gonadal vein and ureter and then reached the renal hilum. We found an anonymous vein that tightened the ureter. We removed the target vein and ureteral

[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 is a case of a 59-year-old male who presented to a fracture clinic with a 7 month history of an infected surgical site wound overlying the left tibia, which was thought to be complicated by underlying osteomyelitis. During his initial consultation, the patient reported that, 7 months prior, he was hit by a motorcyclist while crossing a road in Bangkok (Thailand), where he had sustained a displaced spiral fracture of the left distal tibia. He was subsequently operated on in Thailand, where he underwent an open reduction and internal fixation. Upon return to the UK his surgical site wound began to discharge, over the course of a 7 month period prior to presentation to our institution. The patient reported that he had received multiple empirical courses of antibiotics for a non-healing surgical site wound. He had no significant past medical history, nil reported allergies and was fully mobile prior to this incident.
The patient was admitted to hospital (Day 1) for further management of his infected surgical site wound. Initial laboratory analyses including a full blood count, liver function tests and serum urea and electrolyte tests were conducted upon admission. All results were unremarkable. An X-ray of the left tibia and fibula performed on admission indicated periprosthetic lucencies. There was no evidence of healing at the site of the proximal fracture aligning with the initial clinical presentation of osteomyelitis.
The patient was subsequently taken to theatre on Day 4 for removal of all metalwork (including 12 screws), debridement and deep tissue and bone sampling for bacterial culture. During this operation vancomycin was incorporated in bone cement and intravenous (IV) ceftriaxone (2 g/q24h) was initiated pre-operatively. Purulent discharge was encountered from the skin and deeper skin layers from the distal tibia during the procedure. A CT scan of the left lower leg was performed the following day and suggested osteomyelitis of the medial aspect of the

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


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

[User]
RADIOLOGY NOTE:
A 48-year-old woman, gravida 1, para 1, visited the internal medicine department at another hospital with a complaint of abdominal fullness and weight loss of 10kg during the last year. A huge abdominal mass was palpated, and she was referred to the gynecology department to search for a tumor of uterine origin. She was premenopausal and had no significant past medical history. Physical findings revealed a large elastic hard mass extending from the xiphoid to the pubic bone. The magnetic resonance imaging (MRI) examination revealed a huge tumor on the uterine corpus, and a number of dilated vessels were observed between the tumor and the myometrium. Therefore, the tumor was suspected to derive from the uterus. The tumor showed an uneven signal on T2-weighted sagittal section (), and the enhanced MRI study showed that the tumor edge but not the center was enhanced (). As such, necrosis was suspected to have occurred in the center of the tumor. Uterine sarcoma was primarily suspected due to the large size, degeneration, and necrosis on MRI imaging. Computed tomography (CT) examination showed no lymph node swelling or distant metastasis. Preoperative laboratory testing revealed anemia (hemoglobin level, 5.6g/dl). We transfused 18 units of RCC before surgery. CT examination and ultrasonography on lower extremities indicated an absence of thrombosis. Preoperative serum levels of CEA, CA 19-9, CA 125, and LDH were within normal limits. A biopsy of the endometrium was not collected as the sounding examination of the endometrium was unsuccessful due to a deviated uterine cervix. At this point, preoperatively, we suspected the tumor was a leiomyosarcoma or leiomyoma with degeneration.
The patient underwent laparotomy, where we identified a huge tumor occupying a space from the pelvis to the diaphragm. The tumor surface was smooth and hard with many dilated veins (). A massive tumor with a diameter of 30 cm was observed arising from the posterior uterine wall with a smooth con

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


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

[User]
RADIOLOGY NOTE:
A 35-year-old woman, gravida 3, para 2, was referred to our center at 15 + 0 weeks of gestation for suspected TTTS in a monochorionic-diamniotic pregnancy []. Our center serves as the national referral center for fetoscopic laser surgery for TTTS in the Netherlands. Ultrasound examination showed a normal amount of amniotic fluid (deepest vertical pocket (DVP) 4 cm) in one twin (twin A) and a reduced amount of amniotic fluid (DVP 2 cm) in the other twin (twin B). Both twins had normal bladder filling. Diagnostic criteria for TTTS were thus not fulfilled. The estimated fetal weight (EFW) of fetus A was p50, biometry of fetus B revealed growth <p10. Doppler ultrasound revealed intermittent absent end-diastolic flow in umbilical artery in the smallest twin. These findings suggest a type III selective intrauterine growth restriction (sIUGR) []. After counseling, the parents opted for expectant management and no interventions were performed. Ultrasound examination was repeated weekly. At 17 + 1 weeks of gestation, mild pericardial effusion was seen in the larger twin, in a furthermore normal heart. At 19 + 1 weeks, the pulmonary valve in the larger twin had a normal diameter for gestational age, but they showed echogenic valve cusps and a mildly elevated peak systolic velocity across the pulmonary valve (1 m/s). Two weeks later, at 21 + 3 weeks of gestation, the abnormalities progressed with myocardial hypertrophy of the right ventricle and a peak systolic velocity across the pulmonary valve of 1.75 m/s. The antegrade flow was combined with mild insufficiency at the beginning of the diastole (). In addition, tricuspid regurgitation was present and the ductus arteriosus showed retrograde flow. The right ventricle had a normal size. The myocardial hypertrophy progressed during the pregnancy, the other cardiac abnormalities remained stable until birth.
The patient was admitted to our hospital at 34 + 3 weeks of gestational age for

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


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

[User]
RADIOLOGY NOTE:
We present a 40-year-old male with a history of chronic back pain and a recent, acute progression of bilateral lower extremity paresthesias and weakness. Over a seven-day period prior to presentation, the patient experienced a sudden onset of bilateral leg numbness, with no history of trauma or another precipitating event. The right leg was affected more severely than the left, traveling primarily in a distribution down the lateral leg into the dorsum of the foot and great toe. He eventually began having a shooting pain in this same distribution. He also reported a progressive weakness with bilateral ankle and toe dorsiflexion and five days duration of perineal numbness and mild urinary retention. On exam, he was unable to dorsiflex his ankles or great toes against gravity and had reduced sensation in the lateral aspect of both lower legs and the dorsum of bilateral feet. The patient’s Achilles reflexes were also diminished bilaterally, though reflexes were present and brisk at the knee. It is also pertinent that no upper motor neuron signs were present.
Magnetic resonance imaging (MRI) of the lumbar spine revealed a somewhat heterogeneous, but predominately T2-weighted, hyperintense mass in the left lateral and dorsal epidural spaces (Figure ). There was significant lumbar stenosis present at the level of L4-5 secondary to the mass, with the rightward displacement of the thecal sac. There was no clear connection to the adjacent facet joint although the dorsal mass did seem to be contiguous with the dorsal aspect of the L4-5 disc (Figure ).
Due to the acute onset of symptoms, as well as the severity of neurologic involvement, the patient was taken to surgery for exploration and removal of the epidural mass. An L4-5 laminectomy was performed, which revealed a very large dorsally migrated disc fragment that erupted as soon as the ligamentum flavum was removed. The large mass, which was displacing the thecal sac

[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:
Kathy (this is a representative composite case that does not reflect any single patient) was a 67-year-old woman who suffered an out-of-hospital cardiac arrest. She received 5 min of cardiopulmonary resuscitation and defibrillation by emergency medical services at the scene before the return of spontaneous circulation. In the hospital, she was diagnosed with an ST-elevation myocardial infarction and underwent thrombolysis, followed by 24 hours of induced therapeutic hypothermia, a treatment intended to reduce the risk of brain injury after cardiac arrest. Unfortunately, Kathy sustained severe anoxic brain injury and remained comatose after restoration of normal body temperature.
Additional tests were done to help determine her neurological prognosis. These tests showed mixed results. On the one hand, an MRI scan showed no structural abnormality, and somatosensory evoked potentials were bilaterally present with normal latency and amplitude. While the bilateral absence of the N20 somatosensory evoked potentials response indicates a poor prognosis, its presence does not predict neurological outcome. On the other hand, Kathy displayed persistent seizure activity on her electroencephalogram, which is associated with increased mortality following cardiac arrest.
The neurocritical care team met with Kathy’s husband and son and explained that they were uncertain about her likely outcome and needed more time and information to develop a clearer picture of Kathy’s prognosis. The care team was aware of an ongoing research study at the hospital involving functional MRI for which Kathy was eligible. The study involved recording brain responses to stimuli and comparing patient responses with eventual outcome to determine if functional MRI could be a useful prognostic test for future patients. Functional MRI shows promise as a candidate prognostication method in patients with acute brain injury.
There are ethical issues associated with enrolling patients like Kathy in functional M

[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:
61-year-old female patient with multiple comorbidities, including diabetes mellitus, hypertension, and diverticulitis, presented with pelvic abscess, small bowel obstruction, and sepsis, requiring emergent exploratory laparotomy. She had left upper extremity single lumen PICC, placed two weeks ago for antibiotic therapy which was now inadequate for her resuscitation needs, vasopressors, and central venous pressure monitoring. Right internal jugular (RIJ) vein cannulation was considered due to its straight course and ease of insertion. PICC was not removed before attempting central venous cannulation as that was our only venous access. We used standard Arrow® 7 French triple lumen Kit with soft spring J-tip guidewire, introducer needle puncture was guided by peripheral vascular ultrasound, vascular anatomy was found to be normal, needle placement was uneventful with free back flow, j-tip guidewire was introduced using Seldinger technique, wire position was confirmed with ultrasound, guidewire was advanced smoothly to about 15 cm at the needle hub, 9 cm into the vessel after which it encountered resistance, and we tried manipulating guidewire by changing angle of insertion, but it was not possible to advance further. Hence, left internal jugular (LIJ) vein cannulation was attempted, which was also met with resistance to guidewire insertion approximately 17 cm at needle hub or 11 cm into the vessel, and right internal jugular access was successfully cannulated at 2nd attempt with manipulation of guidewire. Patient did not have history of previous internal jugular cannulations, thoracic surgery, or any other condition predisposing to central venous stenosis or thrombosis. Postprocedure chest X-ray was obtained, which shows CVC in appropriate position, in proximity with PICC, with approximate 45-degree angle at convergence of two catheters and no evidence of complications (). PICC was removed after radiological confirmation of optimal CVC placement. Patient remained crit

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

[User]
RADIOLOGY NOTE:
A fourteen-year-old girl presented with history of fever, painful subcutaneous nodules with ulcerations in both the lower limbs for two months, and digital gangrene of the right index finger for one-month duration. There was no history of purpura, Raynaud's phenomenon, recurrent oral ulcers, hair loss or malar rash. The history of throat pain, jaundice or past tuberculosis was negative. The general physical examination showed normal vitals with multiple subcutaneous ulcers predominantly distributed over both the lower limbs [Figures and ] and bluish black discoloration of distal phalanx of the index finger. The laboratory investigations are shown in . The renal function and liver function tests were normal. The peripheral smear showed elevated total count and Anti-streptolysin O (ASLO) titer was elevated. The throat and urine culture showed no growth of bacteria. The ultrasonography of the abdomen and echocardiography of the heart were normal. The deep incisional skin biopsy taken from the subcutaneous nodule revealed leukocytoclastic vasculitis of the dermal vessels [Figures and ]. The patient was treated with methyl prednisolone (three pulses doses of 750 mg/day) followed by oral prednisolone of 1 mg/kg/day. She also received a course of oral penicillin for antecedent streptococcal throat infection. The skin lesions completely healed over a period of six months with scarring [Figures and ], and patient was on regular follow up for one and half year after which she lost to follow up and treatment.
She presented to us again in July 2010 (three years after the initial episode in December 2007) with similar complaints of bluish black discoloration of left middle finger and subcutaneous nodules. The skin biopsy was repeated which showed leukocytoclastic vasculitis of the dermal vessels suggestive of CPAN. There was no systemic involvement by clinical examination and investigations. The ASLO titer was normal. The patient was treated with injection cyclophosphamide 750 m

[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 2002, a 52-year-old asian woman underwent a lumpectomy for a stage II infiltrating duct carcinoma over her right breast, followed by four cycles of adjuvant chemotherapy combining doxorubicin, cyclophosphamide and paclitaxel. Chemotherapy was followed by locoregional radiation. Eight years after the completion of chemotherapy, she found a slowly growing mass on her right neck. Positron emission tomography (PET) scan revealed large infraclavicular mass and a supraclavicular adenopathy of the right neck and right nasal cavity. Analysis of biopsy samples from both masses was consistent with metastatic carcinoma and suggestive of the metastasis having arisen from primary breast cancer. She underwent removal of the right supraclavicular and infraclavicular masses at that time, followed by adjuvant chemotherapy. However, one year after the surgery, she found a mass in the upper outer quadrant of her right anterior chest wall. Ulceration and bleeding of the mass caused her to have a painful disability of her right upper limb. A computed tomography (CT) scan (Figure a) revealed a mass in the upper outer quadrant of her right anterior chest wall. The mass had invaded the ribs and pleura. Magnetic resonance imaging (MRI, Figure b) revealed that the mass involved the axillary artery and occluded the right lateral subclavian vein and axillary vein.
After a multimodality assessment followed by discussion of the available options and risks, benefits and subsequent rehabilitation associated with forequarter amputation with the patient and her family, she consented to the amputation. Surgery revealed a fungating tumor in the anterior superior chest wall that involved the right first, second and third ribs. This tumor had adhered to the right lung as well as the brachiocephalic-subclavian vein and artery.
During surgery, the patient was placed in a semi-lateral position on her left side with her right side elevated at a 45° angle. An incision was made over her sternocleidomastoid

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


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

[User]
RADIOLOGY NOTE:
A 55-year-old male patient reported with mild swelling and pain in the left zygomatic region. The history of present illness revealed that the patient had noticed the swelling in the last few weeks and it also had an associated intraoral ulcer. The patient was a known diabetic who was under medication. He had a habit of smoking cigarettes for the past 15 years. He smoked almost 15 cigarettes per day. The clinical examination revealed a firm swelling in the left zygomatic region measuring approximately 3 cm to 5 cm. It was mildly painful on palpation. The left maxillary region had significant paresthesia, nasal obstruction, and episodes of pain. A palpable left submandibular lymph node was present, which was also tender and fixed. The cervical lymph node on the left side was also palpable (Figure ). The intraoral examination revealed an ulceroproliferative growth measuring 4 cm to 6 cm in dimension.
The lesion was extending in relation to teeth 23, 24, and 25. The ulcer was covered with necrotic slough. Purulent discharge and bleeding were present in the lesion. The other teeth in the quadrant were missing (Figure ). A panoramic radiograph revealed extruded teeth 23, 24, 25.
There was increased radiopacity in the left maxillary sinus (Figure ). Water’s view showed the opacification of the entire left maxillary sinus.
An intraoral extension of this mass was also evident. The inferior, posterior, lateral, and medial walls of the left maxillary sinus appeared to be destroyed (Figure ). A computed tomography (CT) scan showed a lesion extending into the maxillary space and the nasal cavity. A heterodense soft tissue lesion showing heterogeneous contrast enhancement in the left maxillary sinus and hard palate with the destruction of the posterolateral wall, medial wall, and floor of the left maxillary antrum, extending into the adjacent retro maxillary space and medially extending into the left nasal cavity, obliterating all meati with the destruction of nasal turbinates.

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


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

[User]
RADIOLOGY NOTE:
A 52-year-old lady presented with history of gradually progressing, painless swelling of the left lower eyelid of 1 year duration. She was diagnosed as chalazion elsewhere for which she had undergone incision and curettage twice following which the swelling recurred to the present size. There was a history of gradual increase in the size of the swelling following incision and curettage. There was no history of similar lesion anywhere else in the body. There was no significant family history. On clinical examination there was a firm, nodular mass measuring 10 × 10 × 8 mm (). The mass was fixed to the underlying tarsus, nontender and nonmobile. On eversion of the eyelid there was an area of scarring in the tarsal conjunctiva and the overlying skin was normal (). The examination of rest of the anterior and posterior segment was unremarkable. The right eye was essentially normal and systemic examination revealed normal findings. Full thickness excision biopsy was done under local anesthesia and eyelid defect was repaired by Tenzel's semicircular flap. The specimen was sent for histopathological examination.
On gross examination, it was a pentagonal full-thickness segment of the eyelid measuring 11 × 9 × 9 mm consisted of a nodular mass lesion with smooth overlying surface. Cut section revealed a unilocular cyst measuring 9 mm in diameter. Cyst was filled with yellowish homogenous solid material with focal gritty white areas ().
Microscopic examination showed lining keratinized stratified squamous epithelium of eyelid skin. Subepithelium showed a cyst, wall of which was composed of epithelial cells with absence of clearly visible intercellular bridges. The epithelial cells close to the cystic cavity appeared swollen filled with pale cytoplasm. The peripheral layer of cells showed distinct palisade arrangement. Cyst was filled with homogeneous, amorphous keratinous material. Patchy calcification of this keratinous material was noted. Cholesterol clefts were seen at places

[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 20-year-old lady presented with complaints of headache and vomiting from past one and half months; headache was increasing in severity and there was relief on vomiting. She had no history of blurring or diminution of vision or seizures. There was also no history of motor or sensory disturbances. On examination, no abnormality was detected. The patient underwent computed tomography (CT) scan of brain, which showed space occupying lesion in the right frontal lobe, measuring about 6×6 cm []. Fundus was normal. She underwent near total excision of the lesion. Postoperative period was uneventful. Histopathology of the specimen showed features suggestive of papillary carcinoma of choroids plexus. There was increased cell density, increased mitotic figures (greater than 5 per 10 high-power fields), nuclear pleomorphism, and necrosis. Diffuse invasion of the adjacent brain parenchyma was present []. On immunohistochemistry, it was positive for glial fibrillary acidic protein and negative for epithelial membrane antigen []. Since the diagnosis of papillary carcinoma of choroid plexus is very rare in adults, patient was worked up to rule out any primary disease elsewhere in the body. Thyroid scan, chest X-ray, and ultrasonography of abdomen and pelvis were normal. Stool for occult blood was negative. Complete blood count and peripheral smear was normal. Cerebrospinal fluid (CSF) was examined for the presence of malignant cells and it was found to be negative for malignant cells. The patient received radiation to whole brain on telecobalt unit, using German helmet technique, with two lateral portals. Initial dose was 4000 cGy/20 fractions (200 cGy/fraction). Later, she received boost to the primary tumor bed, using antero-lateral wedge pair technique, to a dose of 2000 cGy/10 fractions. Along with radiation, the patient also received four cycles of intrathecal methotrexate (12 mg), cytarabine (50 mg) and hydrocortisone (20 mg) weekly. The patient tolerated the treatment well

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


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

[User]
RADIOLOGY NOTE:
A 32-year-old man was admitted to our clinic with ear discharge, pain, and hearing loss. From otoscopy, a mass was identified, covered by skin and protruding from the postero-inferior wall of the entrance to the external auditory canal. The passage of the canal was significantly narrowed by the tumor, and the tympanic membrane was not visible. After 1 week of topical treatment (ciprofloxacin, dexamethasone), the patient’s symptoms and clinical findings were observed to improve. Audiological tests and a computed tomography (CT) scan were performed. The pure tone audiogram indicated conductive hearing loss with a mean air-bone gap of 25 dB. The CT scan showed a soft tissue density mass protruding from the postero-inferior wall of the entrance to the external auditory canal and obstructing the canal with no invasion of other tissues (). Fine-needle aspiration biopsy was performed; however, an insufficient number of specialized cells were present in the pathological samples to permit diagnosis.
One month after the appearance of symptoms, surgical excision was scheduled under local anesthesia. Under microscopic view, after transcanal lateral circumferential skin incision, a skin flap was elevated and the encapsulated tumor with a diameter of approximately 20 mm was seen and excised en bloc. The skin flap was replaced to cover the surgical area and two Merocel® ear packs were placed in the external ear canal. After surgery, the patient was prescribed analgesics (paracetamol, 3 × 500 mg/day) for 7 days.
The tumor was off-white in color with the dimensions of 20 × 12 × 15 mm3. Microscopic examination showed glandular structures which were composed of two cell layers: epithelial and myoepithelial. The inner layer consisted of middle-sized cylindrical or cuboidal cells. Abundant eosinophilic cytoplasm, arranged in a columnar to cuboidal shape, was seen in the luminal cells. The outer layer consisted of spindle cells with elongated nuclei. Neither atypia nor mitotic activity w

[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 male presented to the ED with his wife and followed shortly by their daughter for evaluation of dyspnea which began approximately six hours prior to arrival. He had an associated nonproductive cough which had been worsening over that time period. He reported a subjective fever, chills, and myalgias. He had taken Robitussin and Aleve prior to arrival without relief. He stated that the symptoms began 1-2 hours following the cleaning of an exotic coral which he identified as a species of Zoantharia from his home aquarium. He had cleaned the coral using hot tap water in his basement sink. He identified the coral as a Zoantharia species of coral. He had not previously cleaned that particular coral and did not use any protective equipment while cleaning it. Both his wife and daughter were present in the home while he was cleaning the coral. His wife was in an adjoining basement room and his daughter was upstairs on the first floor of the home. Both presented to the ED with similar but less severe symptoms with the degree of severity commensurate with the distance from the location where the coral was being cleaned.
The patient's past medical history was significant only for hypothyroidism, hyperlipidemia, and psoriasis for which he was taking levothyroxine, rosuvastatin, and glucosamine chondroitin. Social history was significant for prior tobacco use, with a 20 pack-year history, with cessation one year prior to this encounter.
Vital signs included tachycardia at a rate of 112, a blood pressure of 155/83, respiratory rate of 18 with an oxygen saturation of 96% at room air, and a temperature of 102.6°F taken orally. On physical examination, bilateral expiratory wheezes with normal chest excursion were noted, with normal chest excursion. The patient had no evidence of respiratory distress. Cardiac examination revealed a regular tachycardia without murmurs, rubs, or gallops. The patient

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


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

[User]
RADIOLOGY NOTE:
A 46-year-old male patient was first admitted to the emergency department of our hospital 12 years ago with recurrent episodes of collapse and a documented ventricular fibrillation (VF) arrest requiring emergency cardioversion by the paramedic team. The patient gave a 5-day history of general malaise and fever and a 24-hour history of an itchy vesicular rash. He had no relevant past medical history, but both his children had been diagnosed with chicken pox two weeks ago.
On examination, he was apyrexial, with a normal cardiovascular examination. He had multiple widespread erythematous, vesicular lesions approximately 2 mm across with some weeping that involved all limbs and his trunk. The haematological and biochemical investigations were normal, apart from a C-reactive protein (CRP) of 70 mg/L (normal ≤ 5 mg/L). The resting electrocardiogram (ECG) was within normal limits with a QTc interval of 403 msec. Transthoracic echocardiography confirmed normal biventricular structure and function with no regional wall motion abnormalities and normal cardiac valves. Intravenous amiodarone was administered for 24 hours, and no further arrhythmias were detected. In addition, he was treated with intravenous acyclovir for 10 days. He made an uneventful recovery. The patient took his own discharge a few days following the acute presentation.
He represented 8 years later with a further syncopal event lasting for less than a minute. He was on treatment with citalopram 20 mg od prescribed by his general practitioner for anxiety. He had a normal clinical examination, and the biochemical investigations were within normal limits. The resting ECG confirmed sinus rhythm with a normal QTc interval of 430 msec. The cardiac magnetic resonance imaging (MRI) confirmed normal biventricular function but also mild mid-wall myocardial enhancement at the basal inferior and inferolateral walls consistent with myocarditis and no evidence of inducible ischaemia (Figures and ). He was reviewed by the

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


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

[User]
RADIOLOGY NOTE:
A 74-year-old female presented to a local hospital with severe left lower extremity pain and oral thrush. In the emergency department, laboratory data revealed anemia, thrombocytopenia of 10,000 platelets/microliter, and elevated white blood count of 235,500 leukocytes/microliter with 97% blasts concerning for leukemia. Bone marrow biopsy confirmed a new diagnosis of acute myelogenous leukemia (AML). She was subsequently transferred to a major tertiary referral center for management.
On further evaluation, she continued to have worsening left lower extremity pain with physical exam notable for cyanosis of all five toes, erythema to the midshin, and decreased sensation to touch but intact posterior tibial and dorsalis pedis pulses detected using a Doppler device. Bilateral lower extremity ultrasound revealed a left popliteal artery occlusion at the level of the popliteal fossa and acute bilateral deep vein thrombosis (DVTs). The patient was started on a heparin infusion for acute DVT and given nonopioid adjuvants (scheduled oral acetaminophen, scheduled oral gabapentin, lidocaine patch, and ketamine injection as needed) as well as oral and intravenous opioids to control her pain. Despite escalation of pain regimen up to 200 oral morphine equivalents (OME), she continued to experience 10/10 pain at rest and was unable to sleep at night. Palliative care service was consulted for further management.
tGiven her worsening pain, a regional anesthetic technique was considered. Due to her critical thrombocytopenia and continuous heparin infusion, she was not a candidate for neuraxial anesthesia. Consideration was given to the patient's multiple risk factors for peripheral nerve block including bleeding, infection due to severe immunocompromised state, and potential for masking a developing compartment syndrome or a worsening of her CLI. After an extensive discussion with the patient and her family regarding the high risk nature of an invasive procedure, the decision was made

[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 7-year-old male child was presented to the Pediatric Department in Shatbi University Hospital with recurrent chest infections since 1 year. Repeated chest X-ray showed left pleural effusion. The child was managed conservatively and discharged from the pediatric department. During the course of follow-up for the respiratory condition an abdominal ultrasound was ordered to investigate a new onset minor abdominal discomfort. An abdominal cyst was found which, otherwise, was not clinically palpable during abdominal examination. Subsequent computed tomography (CT) scanning of the abdomen and pelvis with intravenous contrast revealed a retroperitoneal thick-walled fluid filled mass, measuring approximately 11.5 × 13 cm in close relation to the main pancreatic duct with inflammation of the adjacent pancreatic tissue. Provisional reports indicated a pseudo-pancreatic cyst with further extension into the posterior mediastinum through one of the diaphragmatic hiatus (
). Serum amylase and lipase were markedly elevated (amylase: 45,630 U/I and lipase: 180,000 U/I).
The decision after surgical consultation was to perform laparotomy. The child was prepared for the operation. Through an upper midline incision, the abdomen was explored. This revealed a large, smooth, and fluctuant mass behind the stomach extending up to the posterior mediastinum through the esophageal hiatus, mostly arising from the pancreas. Aspiration of the coffee ground contents was done followed by a drainage procedure by anastomosing the posterior wall of the stomach to the anterior wall of the cyst wall (cystogastrostomy) using running 4/0 vicryl sutures. A Penrose drain was inserted in the left upper quadrant followed by a layered closure. The postoperative course was uneventful. Nasogastric suction and intravenous fluids were continued for 5 days, after which oral feedings were gradually given. The drain was removed after 5 days and the child was discharged from the hospital on the 9th postoperative day

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


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

[User]
RADIOLOGY NOTE:
A 42-year-old male was assaulted by four persons, and remembers that some of them jumped on his left knee. He was not sure about the exact mechanism of injury, as he stated that he was under the influence of alcohol. The patient presented with swelling of his thigh and inability to weight bear on the left leg. There was bruising and a palpable depression (Fig ) of the left quadriceps tendon. The patient was able to extend the knee, but not against gravity, with an extensor lag of 30°.
The patient reported that, 27 years before the present injury, he had been involved in a road traffic accident sustaining ipsilateral femur and comminuted patellar fractures. The femur underwent intramedullary nailing. The patella was removed, and primary repair of the extensor mechanism was performed. Six years later, the intramedullary femoral nail was removed. In the patient's past medical history, there were no other significant problems to note, and there was no history of quinolones intake. The patient had been generally fit and well.
Plain radiographs of the knee showed a depression in the soft tissue shadow anterior to the distal femur, extraosseus calcification along the tendon, and absence of the patella (Fig ). Other imaging investigations were not performed, as the clinical signs were classical.
We elected to perform a primary quadriceps repair within 24 hours of the injury. A midline incision was made over the previous scar. A complete quadriceps rupture was noted approximately 3 cm proximal to the patellectomy site with a 2.5 cm gap (Fig ). The previous extensor mechanism repair site was well healed. The medial and lateral retinaculums were intact. An end to end repair was performed using continuous, locked heavy absorbable sutures (size 1 Maxon-Monofilament polygyconate synthetic suture, United States Surgical, USA) in multiple layers (Fig ). The ragged margins of the tendon were excised and sent for

[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.