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

[User]
RADIOLOGY NOTE:
A 61-year-old male with no previous medical history, presented with right upper quadrant pain and mild elevation of total bilirubin to 2.9 and Ca 19-9 was elevated at 559 u/mL. All other laboratory values were within normal limits. Evaluation included a right upper quadrant ultrasound (U/S) and computed tomography (CT), which demonstrated left intrahepatic bile duct dilatation. No stones were noted in the biliary system or gallbladder. ERCP and MRCP demonstrated a mural nodule arising from confluence of the left hepatic duct and the common hepatic duct (). Brushings were nondiagnostic. During staging laparotomy, what initially appeared to be metastatic satellite lesions proved to be dilated intra-hepatic biliary system (, arrow head). The planned surgical resection was undertaken with curative intent: resection of the common bile duct with en bloc left hepatectomy, caudate resection, and regional lymphadenectomy. Reconstruction was performed with a Roux en Y hepaticojejunostomy to the secondary right hepatic bile ducts. Two exophytic polypoid tumor masses were identified within the left intrahepatic bile ducts, 2.5 and 2.9 centimeter in size (). Microscopic analysis demonstrated well-differentiated adenocarcinoma arising within a hepatobiliary cystadenoma (). Multifocal severe dysplasia was seen within the left intrahepatic biliary tree without evidence of invasive carcinoma. The remaining right biliary ducts and distal common bile duct were uninvolved. A 1 mm focus of metastatic disease was identified in the regional nodes (1/13).
This patient was taken to surgery for treatment of a suspected intrahepatic cholangiocarcinoma not hepatobiliary cystadenocarcinoma. Radical resection with regional lymphadenectomy was performed with curative intent and frozen section only obtained at the right biliary margin (negative for dysplasia and cancer). Microscopic analysis demonstrated well-differentiated adenocarcinoma arising within a biliary cystadenoma with multifocal severe

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


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

[User]
RADIOLOGY NOTE:
A 29-year-old female patient was referred to our department with acute onset postpartum paraplegia with bowel bladder involvement after delivery of her third child by normal vaginal delivery. Her antenatal course had no significant history with any history of antepartum low-back pain, trauma, drug use, or any physical exertion. On examination, she was conscious, well oriented, and afebrile. Neurological examination showed complete paraplegia (power 0/5 with decreased tone), associated bowel bladder involvement, and absent deep tendon reflexes at knee and ankle joint with complete sensory deficit below the level of L1. All necessary blood investigations including coagulation profile came out to be normal. Patient was planned for magnetic resonance imaging (MRI) of dorsolumbar spine with screening whole spine, which revealed extradural broad based ellipsoid lesion, measuring 50 × 9 mm along T12 to L2 vertebra displacing the dura anteriorly and T1 hyperintensity (
), T2 hypointensity with minimal postcontrast enhancement suggestive of early subacute bleed causing mass effect on adjacent cord with areas of altered signal intensity at the level of lesion.
On the basis of clinical evaluation and MRI report, the patient was planned for urgent decompression in emergency operation theater. After preoperative marking of D12–L2 vertebral levels under fluoroscopic guidance, midline exposure done and paraspinal muscles elevated upto medial edge of transverse processes on both sides with the help of cobb's and broad osteotome. Intraoperatively, bilateral complete laminectomy of L1 vertebrae was done with removal of ligamentum flavum, a well-defined firm organized hematoma dark reddish black in color (5 × 1 cm) was seen over the dura which was removed (
) and checked for adequate decompression utilizing infant feeding tube. Sample removed was sent for histopathological examination reported as organized hematoma. Postoperatively, patient recovered rapidly in terms of neurological d

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


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

[User]
RADIOLOGY NOTE:
A 16-year-old male presented to the emergency department of the local primary hospital with abdominal pain and a bruised bulge on the left lower abdominal quadrant immediately after a bicycle accident. He was examined by an emergency physician, and a supine chest and abdominal radiography were performed. He was hemodynamically stable and had abdominal tenderness but no signs of peritoneal irritation. No serious pathologies were revealed, and a dressing was applied to the wall hernia. He was discharged to home with follow-up instructions and next-day review. After 3 hours, he began vomiting, and the abdominal pain slowly increased in severity. Approximately 9 hours after the accident, he returned to the same hospital, and an on-call general surgeon examined the patient. The patient was in diffuse abdominal pain but with stable vital signs except for tachycardia. US revealed intraperitoneal pelvic free fluid and bowel wall thickening, and the patient was administered intravenous fluid and monitored. However, the pain developed in intensity and became unbearable for the patient, and before the general surgeon was able to recheck the patient, the family refused further care and transferred to our hospital 20 hours after the accident. On examination, the patient was unable to walk, anxious, pale due to severe pain, dehydrated, tachycardic, and hypotensive. He had diffuse abdominal tenderness and peritonism. He reported that while he was performing an acrobatic maneuver on his bicycle, one of his slippers fell off, causing him to lose his balance and fall. UAXR in a sitting position revealed pneumoperitoneum and air-fluid levels the in intestine. US was repeated and revealed free fluid in the abdomen. Ileal and sigmoid perforations were detected on emergent exploratory laparotomy and were repaired with resection and anastomosis and with primary anastomosis, respectively. Peritoneal lavage was also performed. A drain was inserted into the rectovesical pouch. The postoperat

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


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

[User]
RADIOLOGY NOTE:
A 50-year-old female was referred by an otorhinologist with a large chin ulcer and toothache. The medical history was unremarkable, having never had a medical consultation due to the poor socioeconomic situation. There was a 20-year history of gradually enlarging black papule on her chin. The patient complained of unpleasant facial appearance and a dull pain in the chin region. On extra oral examination, there was a large ulcer (10×6.5 cm) with a firm and indurated margins on the chin extending to the mandibular vestibule and necrosis was evident in surrounding bone (). On palpation, drainage of pus was evident from the ulcer. The mandibular right lateral incisor and canines were mobile. Central incisors were prior to admission due to extreme mobility. Radiographic examination revealed an ill-defined radiolucency of the mandibular symphyses (). Cytological examination did not show any evidence of spirochete infection. Although the lesion had an atypical appearance, the slow course, in addition to clinical characteristics such an enrolled boarders, destructive ulcer, and concurrent involvement of skin and bone led the diagnosis of BCC as the first possibility. Incisional biopsy was performed at the margin of the ulcer. Other differential diagnosis included necrotizing ulcerative gingivostomatitis with facial involvement (noma), osteomyelitis, leishmaniasis, Wegener granulomatosis, deep fungal infection, and amelanotic melanoma. The histopathologic sample consisted of uniform ovoid, and dark staining basaloid cells with moderate sized nuclei and relatively little cytoplasm. The cells were arranged into well-demarcated islands and strands, which appeared to be raised from the basal cell layer of the overlying epidermis and invaded into the underlying connective tissue (). The histopathologic evaluation of the resected bone showed secondary osteomyelitis due to the extensive ulcer. The clinical diagnosis of BCC was confirmed. Surgical resection was planned for the lesio

[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 female known case of rheumatoid arthritis affecting both knees presented to our clinic complaining of severe right knee stiffness post TKA 4-years-ago done in an outside facility ( and ). She lives in a rural community and was on hydroxychloroquine, but her disease was active as she was not compliant to her medication. On physical examinations, the right knee was larger in size compared to the left knee without joint effusion. Range of motion was zero on flexion, −10° in extension. Standing knee X-ray showed HO around the prosthesis (). Computed tomography (CT) demonstrated extensive HO with implants fixed in place (). Revision surgery and replacement of the prostheses was considered to restore function.
The old medial parapatellar approach was utilized. The medial and lateral gutters were completely released up to the posteromedial corner. When the knee was too stiff to be mobilized further, the patellar tendon was found to be severely contracted and shortened with patella baja deformity. A tibial tubercle osteotomy was needed for adequate exposure. Osteotomy fragment measured 6 cm with 1.5 cm thickness, after which we became able to flex the knee. The components were completely engulfed by capsular heterotopic bone (). Using osteotomes and burrs, the tibial and the femoral components were slowly visualized. Both components were found to be well fixed. Carful removal of the posterior heterotopic bone was done with a bone curette, which finally allowed for component removal. Intraoperative culture samples were taken as routine measure for revision surgeries. RT-Plus modular rotating hinge knee system (Smith & Nephew, Memphis, TN, USA) was used. The procedure was started with reaming the tibia up to size 12 mm. It was sized to be size four. Proximal drilling and rasping were done, and posterior offset stem was used.
After that, reaming of the femur was carried out reaching size 14 mm, giving a good

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


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

[User]
RADIOLOGY NOTE:
A 50-year-old male with a history of intravenous (IV) drug abuse presented to the hospital with acute onset back pain. The patient had a 10-year history of chronic back pain as well as a history of cervical radiculopathy, for which he underwent anterior cervical discectomy and fusion 6 years ago. The patient stated that his back pain had been worsening over the past 3 weeks. The patient presented to the emergency room several times in the last couple of weeks prior to admission. His back pain was presumed to be related to his previous history, and he was discharged home on opioid analgesics.
On admission, the patient reported severe squeezing back pain extending from his lower to middle back. The pain was described by the patient as a 10/10 in intensity with radiation to his buttocks. The pain was not relieved by lying down and was aggravated by activity. The patient did not exhibit any lower extremity weakness, numbness, or bladder/bowel dysfunction, and he denied any fevers or night sweats. On physical examination, palpation of the spine revealed diffuse tenderness. Straight leg raising test was negative.
In the ED plain X-ray of the lumbosacral spine revealed degenerative changes of the lumbosacral spine but no evidence of infection, malignancy, or fracture (see ). The patient was sent to the inpatient ward for observation with an initial diagnosis of chronic back pain.
Initial laboratory findings revealed a mildly elevated white blood cell count at 12,000 and anemia with hemoglobin at 9.5. Erythrocyte sedimentation rate was found to be 92. With these laboratory abnormalities and persistent symptoms, magnetic resonance imaging (MRI) was done to further evaluate the back pain. MRI examination of the lumbosacral spine revealed osteomyelitis with discitis at T10-T11 level with some retropulsion of both vertebral bodies causing mass effect on the spinal cord (see ). The patient was immediately started on IV dexamethasone, and he underwent CT-guided aspiration 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 65-year-old man was diagnosed with pulmonary adenocarcinoma, then treated with chemotherapy. The cancer metastasized, and the patient was diagnosed with end-stage lung cancer. Cancer pain was treated with oral opioid therapy. Metastasis of the cancer caused obstructive jaundice and cholangitis, and the patient experienced septic shock. The attending physician performed emergent endoscopic biliary stent placement, in order to treat obstructive jaundice. The patient was medicated with continuous infusion of noradrenaline (0.2 μg/kg/min) through a peripheral vein, in order to maintain blood pressure. He underwent repeated placement of peripheral venous catheters, such that it became difficult to identify adequate peripheral veins for placement and maintenance of indwelling catheters. In the context of this treatment, the patient's congestive heart failure continued, which caused ascites and edema of the lower extremities.
The patient experienced orthopnea and could not sleep at night. The attending physician requested that the anesthesiologists secure a reliable venous line. The anesthesiologists checked the patient's groin and thighs; they excluded the femoral vein as a candidate for central venous access due to massive edema of the thighs. The anesthesiologists attempted to allow the patient to assume the supine or reverse Trendelenburg position; however, these positions caused worsening of the patient's dyspnea. The patient could solely tolerate the sitting position. The anesthesiologists then discontinued attempts to catheterize via the internal jugular and subclavian veins, because of the risk of air embolism during central venous catheterization of the patient in the sitting position.
The right subclavian vein was suspected to exhibit narrowing, based on computed tomography scan images (Fig. ). Thus, the anesthesiologists chose the left arm for insertion of a PICC, and found that the medial brachial vein exhibited sufficient size (diameter 4 mm) to place a PICC

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


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

[User]
RADIOLOGY NOTE:
Our case was a 70-days old male child that has presented with respiratory distress and cyanosis following breastfeeding. Physical examination was normal except the tachypnea, subcostal retraction.
The infant's arterial oxygen saturation was 92% at room air. The patient has admitted with initial diagnosis of pneumonia and subsequently an antibiotic therapy has initiated. Initial laboratory investigations were normal ().
A chest radiography has shown an opacity in the lower part of the left lung. A computerized tomography (CT) of the thorax has revealed a well-defined heterogeneously enhancing mass measuring 45 mm × 40 mm in the lower lobe of the left lung ( and ). There was no pleural effusion. Differential diagnoses has proposed by radiological service has included pulmonary sequestration and congenital adenomatoid malformation.
The exploration has revealed a mass measuring 50 mm × 40 mm × 20 mm, involving the lower lobe of the left lung, having a solid appearance. The mass has resected via the left lower lobectomy. There was no spread to the chest wall. After installing chest tube, infant has supported through mechanical ventilation during the post-operative period and has discharged from Pediatric Intensive Care Unit after 4 days with no further problems with respiratory distress.
Macroscopic examination has consisted of a lung lob measuring 50 × 40 × 20 mm. Cross-section shown a gray-white well circumscribed soft to firm mass with irregular brown border. Histological examination of tissue sections has revealed proliferation of neoplastic cells in lung tissue ().
There was atypical proliferation of spindled to fusiform cells have arranged in interlacing long fascicules. The neoplastic cells has shown little pleomorphism, scanty cytoplasm with indistinct cell borders and have separated by interwoven collagen fibers and have arranged in a parallel fashion. Occasioned mitotic were were present (1-2 HPF). The tumor has contained areas of hemorrhage and necrosis.
There

[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 6-year-old boy with no pathological history accidentally fell from the top of an approximately 3 m climbing pole and injured his right extended elbow and wrist joint. Due to pain and deformity in the right elbow and wrist joints, he visited our hospital. Swelling and a dinner fork deformity of the right wrist joint and pronounced swelling of the right elbow joint were observed. No skin damage was observed. No findings of nerve injury or arterial injury were obtained in the right upper limb. Radiography revealed lateral dislocation of the radial head, a fracture of the proximal ulnar metaphysis, and mild bending deformation at the fracture site. In addition, fractures of the distal radius and ulna, as well as dorsal displacement of the distal fragment, were seen (). Thus, the patient was diagnosed with Bado type III Monteggia injury with ipsilateral fracture of the distal radius and ulna.
Manual reduction under nerve block was attempted on the day of injury. However, because it was difficult to maintain the reduction of the radial head, as shown in , open reduction and percutaneous procedures were performed under general anesthesia. A Kirschner wire was inserted, percutaneously, from the olecranon into the ulnar diaphysis. When the Kirschner wire was in place, the dislocation of the radial head immediately showed good reduction. Further, open reduction and fixation of the fractured distal radius and ulna were performed with Kirschner wires (). A long-arm cast was used for external fixation with the elbow in 90° flexion and the forearm in an intermediate position.
Two weeks after surgery, callus formation at the fractured bone was observed. Therefore, the cast was removed, and range of motion (ROM) exercises of the elbow and wrist joints were initiated. Since bone union was achieved at 6 weeks postsurgery, the Kirschner wires were removed. Pain, ROM limitation, and lateral instability were not observed in the elbow or wrist joints at 3 months after surgery. Addition

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


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

[User]
RADIOLOGY NOTE:
A 78-year-old woman was presented to the hospital without prior colorectal cancer screening. Physical examination was significant for Virchow's node (Troisier's sign). Colonoscopy revealed innumerable uniform polyps most heavily concentrated in the cecum. Biopsy revealed mantle cell lymphoma. A 78-year-old woman with history of hypertension and hyperlipidemia presents to the surgical clinic for colonoscopy. Upon review of systems, patient reports dysphagia. Her physical examination was remarkable for a soft nontender anterior cervical lymphadenopathy, and a left supraclavicular lymph node enlargement (Virchow's node; Troisier's sign). Upper endoscopy and colonoscopy were scheduled within the next week. Upper endoscopy revealed a partially occluding oropharyngeal submucosal lesion. There were no signs of ulceration or any mucosal involvement. Some polyps were observed within the esophagus, but the stomach and duodenum were unremarkable. Colonoscopy revealed numerous polyps were increasing in quantity from the transverse colon to the cecum. On colonoscopic inspection, polyps were uniform in size and shape resembling a polyposis syndrome. Multiple biopsies were obtained in the cecum, and ascending and transverse colon, and then sent to pathology. Initial pathology report returned with the polyps as atypical lymphocytic infiltrate, which was later identified to be mantle cell lymphoma. Outside of the lymphatic system, mantle cell lymphoma is seen as a multiple lymphomatous polyposis, or lymphomatous intestinal polyposis. Its detection and identification are of utmost importance due to the aggressive nature of the disease. This is a patient who presented with a physical examination concerning for malignancy, which was later confirmed via biopsies in the colon and in a cervical lymph node. Mantle cell lymphoma is known as a late-presenting aggressive cancer. Outside of the lymphatic system, it can present as lymphomatous intestinal polyposis or multiple lymphomatous polyp

[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 71-year-old woman with an unremarkable medical history visited our hospital after she accidently swallowed a tuna bone at supper. She complained of mild chest discomfort with slight pain. Chest radiography revealed no abnormal findings and she was permitted to go home at night (A, B). The next morning, she revisited the hospital with deterioration of chest discomfort and a slight fever of 37.4 °C. Non-contrast chest computed tomography (CT) revealed an impacted large fish bone with a length of 35 mm lying across the middle third of the thoracic esophagus and accompanied by local mediastinitis (C, D). She was immediately referred to a larger hospital, where she underwent contrast-enhanced chest CT scan that revealed penetration into the right inferior pulmonary vein caused by the fish bone (A, B). The bone protruded more than 10 mm from the vessel wall inside the pulmonary vein, accompanied by a small amount of free air. Blood tests revealed an abnormally elevated white blood cell (WBC) count of 11,400/μL and elevated C-reactive protein (CRP) level of 20.45 mg/dL. Although the pulmonary vein is a low-pressure system, endoscopic removal may result in a lethal intractable bleeding that would require an emergent cardiovascular surgery. Thus, endoscopic removal of the fish bone was performed in the operating room under general anesthesia (C, D) with cardiovascular surgical standby for a possible urgent surgery with a right thoracotomy approach.
The impacted fish bone was successfully removed endoscopically without massive bleeding. A follow-up chest CT scan was performed just after the endoscopic removal that confirmed the absence of mediastinal hematoma. The patient was carefully managed in the emergency ward not to overlook possible sudden changes of the general condition. Oral feeding was prohibited until the follow-up of chest CT scan and endoscopic inspection planned in the next week. To treat the mediastinitis, 3 g/day of intravenous meropenem was initiated. Feve

[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 male with a history of hyperlipidemia and seizure disorder presented to an outside hospital following a breakthrough seizure, where he was incidentally also found to have punctate areas of acute cerebral infarcts in multiple vascular territories. Additional workup revealed the presence of a left atrial thrombus and newly diagnosed atrial fibrillation. He was ultimately discharged to home on apixaban. The patient then re-presented a month later for evaluation of transient diplopia, expressive aphasia, daily right temporal headaches, and right facial and left leg weakness. MRI of the brain showed new areas of diffusion restriction in the left cerebellar hemisphere and left medial occipital lobe (Figure ). CTA showed no signs of carotid occlusion or stenosis. The etiology of his multifocal strokes was thought to be related to his newly diagnosed atrial fibrillation and left atrial thrombus.
The patient was then transferred to our hospital for further evaluation. His initial NIH stroke scale was 8 (primary deficits were including unilateral facial palsy, bilateral lower extremity pronator drift and ataxia). Stroke labs, including lipid panel and hemoglobin A1C, were unremarkable. MRI of the brain with contrast showed a new infarct in the splenium of the corpus callosum in addition to prominent generalized meningeal enhancement (Figure ). MRI of the spine with contrast showed possible meningeal enhancement as well as punctate areas of encephalomalacia in the C3-4, C7, and T3 spinal levels. A bedside LP revealed a mildly elevated opening pressure of 24 cm H20, lymphocytic pleocytosis (WBC 150 K/cumm, 61% lymphocytes), protein 170 mg/dl, hypoglycorrhachia of 15 mg/dl, and presence of cryptococcal antigen. Other notable CSF labs included the presence of 11 oligoclonal bands. He was diagnosed with cryptococcal meningoencephalitis and started on a four-week course of amphotericin B and flucytosine. A repeat LP after several days of treatment showed a normal open

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


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

[User]
RADIOLOGY NOTE:
A 27-year-old woman, gravida 2, para 1, had undergone aortic valve replacement (mechanical) for aortic regurgitation at the age of 10 years. Since then, she had been receiving anticoagulation with warfarin, 5 mg/day. During the previous pregnancy, she received a combination of warfarin and heparin for anticoagulation, and the pregnancy and delivery were uneventful for both mother and infant. As with the previous pregnancy, oral administration of warfarin was switched to continuous intravenous infusion of heparin in the fifth week of gestation. In the 12 weeks of gestation, oral administration of warfarin was resumed at a dose of 3 mg/day, and then, the dose was increased to 4.5 mg/day. The activated partial thromboplastin time (APTT) was maintained between 50 and 60 sec during heparin use, and prothrombin time by international normalized ratio (PT/INR) was maintained between 1.5 and 2.0 during oral administration of warfarin. On the fifth day of the 31 week of gestation, ultrasonography revealed mild enlargement of the left lateral ventricle of the fetus, measuring 1.0 cm, and it was found to have further enlarged to 1.5 cm on the fifth day of the 33 weeks of gestation (Fig.). Magnetic resonance imaging (MRI) performed on the first day of the 35 week of gestation revealed bilateral intracranial subdural hematoma in the fetus, and the left ventricle was found to have enlarged due to compression by the hematoma (Fig.). We determined that the fetal intracranial subdural hematoma had been caused by fetal intracranial hemorrhage associated with warfarin administration to the mother. On the same day, warfarin was discontinued and replaced with continuous intravenous infusion of heparin. Cardiotocography (CTG) showed that the fetal conditions were favorable and no anemia was observed based on the measurement of middle cerebral artery peak systolic velocity (MCA-PSV). On the second day of the 36 weeks of gestation, the mother underwent elective induction of delivery with ox

[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 medically fit and well 13-year 11-month-old male was referred to the oral and maxillofacial surgery department at Alder Hey Children’s Hospital in Liverpool in regard to an intra-oral swelling of the right palatal region (Fig. ). An incisional biopsy was initially reported as a pleomorphic adenoma of the premolar region. Subsequently, a CT scan showed no significant bony abnormality, and a wide local excision was carried out with the application of a surgical palatal dressing plate. Histopathology of this resected tissue appeared to show tumour of intermediate malignant grade at the base of the specimen.
Further investigations undertaken to stage the tumour included a repeat CT scan which presented no evidence of significant bony involvement or erosion. An MRI scan showed no significant asymmetry or signal abnormality in the region of the hard palate, and there was no evidence of loco-regional metastasis of this tumour.
Following a discussion of the craniofacial multidisciplinary team and numerous paediatric pathologists, a diagnosis of intermediate-grade sarcoma of the oral mucosa and hard palate was re-affirmed. A partial right-sided maxillectomy was planned to gain adequate tumour clearance, and prior to surgery, the patient attended for dental impressions and counselling regarding the procedures involved, together with instructions regarding the obturator prosthesis.
A low-level right-sided standard hemi-maxillectomy was carried out via an intra-oral approach with preservation of the pterygoid plates (December 2013). The anterior alveolar cut was undertaken through the right lateral incisor socket following the extraction of this tooth in order to maximise the bone support on the maxillary central incisor abutment tooth. The residual zygomatic body on the right side was exposed, and two 37-mm zygomatic oncology implants (Southern Implants Ltd, South Africa) (Fig. ) were placed with excellent stability, ensuring that the prosthetic heads were positioned beneath

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


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

[User]
RADIOLOGY NOTE:
A 64-year-old male with a past medical history of coronary artery disease, cardiac stent, COPD, HTN, and dyslipidemia presented as a referral for left testicular teratoma and primary bladder leiomyoma. Prior to presenting to our facility, he underwent left radical orchiectomy, and hernia repair due to enlarging left testicle, had a transurethral resection of bladder tumor (TURBT) due to hematuria, and underwent PSA screening. Pathology determined the testicular mass to be a pT1 teratoma without lymphovascular invasion, PSA was found to be elevated (was 4.2 in 2014, now 4.39), and the 40 g of bladder tumor resected during the TURBT was found to be a leiomyoma of the bladder showing no sarcomatoid differentiation. A CT scan was performed which was notable for bilateral pelvic adenopathy with lymph nodes greater than 2 cm and an interaortocaval lymph node of approximately 1.2 cm. Additionally, outside CT scan with IV contrast of abdomen pelvis showed large 6 cm heterogeneous soft tissue mass within the posterior left aspect of the bladder (). The mass was causing complete obstruction of the left ureterovesical junction (UVJ), which resulted in severe left sided hydronephrosis and hydroureter. Although the CT findings were highly concerning for metastatic process, the TURBT specimen did not support the diagnosis of metastatic disease from a bladder primary as it had returned leiomyoma of bladder without sarcomatoid elements. The disparity between imaging findings and pathology results prompted confirmatory testing on both the initial testicular mass and the TURBT specimens. After discussion at multidisciplinary GU tumor board, the consensus recommendation was for CT-guided lymph node biopsy, repeat transurethral resection of bladder tumor, and decompression of the left upper tract via ureteral stent, or nephrostomy. The patient underwent rigid cystourethroscopy, monopolar transurethral resection of bladder tumor (large >5 cm) and monopolar transurethral resection of pro

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


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

[User]
RADIOLOGY NOTE:
We present the case of a 42-year-old man who presented to the emergency department with a complaint of abdominal pain and diarrhea for 3 days. The abdominal pain started in the periumbilical region and was shifted to the right lower quadrant of the abdomen. The pain started gradually and had been progressing in severity. He described the pain as a stabbing in nature. It was exacerbated by movement and food intake. The pain was partially relieved by oral analgesic medications like paracetamol. The pain was associated with low-grade fever and decreased appetite. The patient also complained of diarrhea with five bowel motions/day. The stools were watery with no mucus or blood. He reported that diarrhea developed after he received an oral antibiotic therapy (cefuroxime) for a recent upper respiratory tract infection.
The past medical history of the patient was remarkable for diabetes mellitus that was well-controlled with oral antidiabetic agents. He did not undergo any previous abdominal surgeries. He had a smoking history of 15 pack-years. He had never drunk alcohol before. He worked as a taxi driver. The family history was unremarkable for any inherited gastrointestinal disorders.
Upon examination, the patient appeared sick. He was not pale, jaundiced, or cyanosed. Vital signs revealed tachycardia (115 bpm), low-grade fever (37.5℃), normal respiratory rate (14 bpm), and maintained blood pressure (122/80 mmHg). The oxygen saturation was 99% on room air. Abdominal examination revealed a soft abdomen with diffuse tenderness. However, the tenderness was more pronounced in the right iliac fossa with a positive rebound sign. Further, the Rovsing sign was positive. Initial laboratory investigation revealed elevated leukocyte count and elevated inflammatory markers, including erythrocyte sedimentation rate and C-reactive protein. The renal and hepatic profiles were within the normal limits (Table ).
In light of the aforementioned clinical information, the patient was diagnos

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


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

[User]
RADIOLOGY NOTE:
A 29-year-old woman was found unresponsive near a snowy mountain trail in winter. On that day, the outside air temperature ranged from − 2.0 to 1.0 °C. When emergency medical services arrived on the scene, they found that the patient was in cardiac arrest and in asystole. It was noticed that she also had mandibular rigidity. On the way to the hospital, emergency medical service staff were unable to insert an oral airway device for ventilation because the mandibular rigidity prevented sufficient mouth opening. The chest was compressible. CPR was performed with manual chest compression and bag valve mask ventilation ratio of 30:2 during transportation. When she was admitted to the hospital, 52 min had passed since she was discovered. She remained in cardiac arrest with an asystolic cardiac rhythm. Her initial core temperature was 22 °C measured by bladder thermistor. Her mandibular rigidity remained, and neck mobility was also restricted. Both elbows and knees could be passively bent with resistance and the chest wall was not stiff. We were concerned that postmortem changes (i.e., rigor mortis) had begun. We tried to force open her mouth for intubation and found that it could be slightly opened. Although this was insufficient to visualize the vocal cords with a conventional laryngoscope because of the impossibility of controlling it, we were able to insert an “Airway scope™” video laryngoscope, which allowed successful intubation. Although the patient was in cardiac arrest due to severe accidental hypothermia, which indicated an enhanced possibility of successful resuscitation, the mandibular rigidity connected, along with the supposition of rigor mortis initiation made us believe that it would be difficult to resuscitate successfully. However, her initial blood gas analysis revealed that her serum potassium level was 5.4 mmol/L (Table ). We decided to use veno-arterial ECMO to generate effective systemic perfusion and to rewarm the patient. After ECMO initiated, her

[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 35-year-old man—who operated a jackhammer. He appeared at the Emergency and Accidents Department with constant and intense pain in the lower left limb, moderate ipsilateral paresis in the ankle, foot, and toes, and coldness. He had suffered these symptoms for around 48 hours. In addition, he had suffered from an irregular fever (not measured using a thermometer) for two weeks with oropharyngeal discomfort and spontaneous pain in the groin and left lower quadrant which increased with time. He did not mention any previous trauma but when pressed recalled hyperpulsatility beneath the inguinal ligament at least a year before. He did not consult a physician as the problem did not appear to bother him.
His medical history included a cerebral venous thrombosis (left transverse and sigmoid sinus thrombosis) which was attributed to mastoiditis in 2006, resulting in occasional attacks of epilepsy being treated successfully with oxcarbazepine. He was a smoker with no known allergies.
A physical examination revealed feverishness, a generally good physical condition, normal thorax and abdomen features, and an expansive throbbing mass below the inguinal ligament and left minor pelvis. The absence of femoral and infrainguinal pulses was obvious as well as severe and acute ischemic symptoms. The other limbs were found normal.
A blood test discovered leukocytosis (16 × 103/microliter) and neutrophilia (N = 80.4%) with a hemoglobin value of 13 g/dL. In a CT scan we observed a saccular aneurysm with a transversal diameter of 45 mm located in the left external iliac artery with no sign of rupture. This was associated with a short occlusion in the bifurcation between the femoral and profunda arteries (). A deep venous thrombosis in the iliofemoral area was found. There was no evidence of aneurysms or malformations in other abdominal organs.
The patient underwent urgent surgery under general anesthesia. During the surgery, we decided first to perform

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


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

[User]
RADIOLOGY NOTE:
A 15-year-old boy with leucoderma was admitted to our service reporting pain while chewing, bulging in the left mandibular angle and aesthetic discomfort because of face asymmetry, but no relevant clinical facts existed.
Physical examination revealed a facial asymmetry, a palpable mass in the angle region of left mandibular, pain, limitation of oral opening and bulging in region of teeth 36 and 37, tooth 38 was lacking. The diagnosis exam, the panoramic radiographic and computed tomography of the face showed suggestive images of injury involving the body and left mandibular ascending ramus ( to ).
Patient’s familiar medical history did not show significant data. Reconstruction possibilities were discussed with patient and his family including the use of autogenous bone grafting of iliac crest and/or off-label use of rhBMP-2. Advantages and disadvantages of both possibilities were presented and patient and family decided for rhBMP-2 off-label. After evaluation of surgical risk and treatment of teeth 36 and 37 canals had are done, the patient underwent surgery in a hospital environment under general anesthesia and nasotracheal intubation. We performed an incision with extension of mandibular ascending ramus to vestibular region to first lower left molar, being elevated the mucoperiosteal graft, therefore achieving a partial exposition of the injury. An osteotomy was need using a 701 drill for higher exposure of the injury (). The dissection was simple because the tumor was encapsulated ().
Recipient site was prepared and, by using the bone grafting technique, the rhBMP-2 was prepared associated with Bio-Oss® (Geistlich Pharma AG, Wolhusen, Switzerland) and fairly adapted to surgical site with subsequent adaptation of titanium mesh 1.0 system that promoted a mechanical barrier. A plate 2.0 system was used on external oblique line to obtain higher stability ( and ).
A polyglactin 910 wire suture was used in deep plans and on the mucosa. Material obtained was forwarded f

[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 right-handed, bilingual 54-year-old woman was admitted at the emergency department for a generalized tonic clonic seizure sustained by a primitive brain tumor located between the posterior part of the superior and middle temporal gyri and the anterior part of the angular gyrus in the left hemisphere. The lesion did not enhance after contrast medium administration and it was hypometabolic at 18F-fluorodeoxyglucose PET/MRI. The functional MRI (fMRI) confirmed that the lesion was located in the dominant hemisphere (). Due to the anxiety of the patient, mostly related to the diagnosis of brain tumor, the fMRI was performed testing only her mother tongue, i.e., Romanian. Interictal EEG showed an irritative activity in left centro–parietal derivations.
Concerning the social and work surrounding the patient had been living in Italy for 17 years with her family, perfectly integrated in the social context, working as a housekeeper. Previously, she had 13 years of education, graduating in a vocational school in her home country.
The patient underwent a comprehensive battery of standardized neuropsychological tests performed in Italian, in order to evaluate the impact of the tumor on cognitive functions. A standardized evaluation of Romanian language was not executable because native language versions of the tests were not available and because none of the team spoke Romanian. The assessment was composed of tests covering different cognitive domains. The Oxford Cognitive Screen [,], a brief screening instrument composed of tasks on language, visual attention, spatial neglect, praxis abilities, visual and verbal memory, calculation, number reading and executive functions. Specific tests were also administered to better evaluate different cognitive functions. The Prose Memory Test (immediate and delayed recall) and Interference Memory test [] were used as a measure of verbal memory. Forward and backward digit span and the Corsi block-tapping test were administered to measure s

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


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

[User]
RADIOLOGY NOTE:
A 32 years old previously healthy fair-skinned male originally noted that a mole on his left calf began to change in 2006. He consulted a doctor and the mole was excised. A pathologic diagnosis of melanoma was made. A sentinel node dissection was carried out, and was negative for metastatic disease. In 2007, the patient noted enlargement of left inguinal lymph nodes, and small melanocytic lesions on the skin of his left leg. He was treated with interferon alpha under a clinical trial at a regional cancer hospital, with reduction of the nodes and resolution of the skin metastases. Interferon was stopped after 9 mo due to side effects.
The patient remained well until 2010, when a new left leg skin metastasis appeared. This was surgically excised. In late 2011, another new cutaneous metastasis was identified on the left leg, within the scar from the original melanoma surgery. This was biopsied and a diagnosis of recurrent melanoma was confirmed. He was then treated with wide excision and skin graft.
In March 2012, the patient was diagnosed with a recurrence within the left leg skin graft. This was excised and a new skin graft procedure was performed. Pathology revealed positive margins of the excised metastasis, so a re-excision was performed, again with positive margins. At the same time, needle biopsy of a left inguinal lymph node confirmed the presence of BRAF-positive metastatic melanoma. A Computed tomography (CT) scan performed in Mar 2012 revealed no evidence of distant metastases. The largest left inguinal node was 8mm in diameter, which was reported as “insignificant by size criteria” (Figure ).
In April 2012, the patient consulted a naturopathic doctor (Shainhouse) and began therapy with the following oral natural anti-cancer agents: Active hexose correlated compound or AHCC (mushroom extract)[], dandelion root[], curcumin[], and astragalus root[]. Parenteral therapy was also started, which consisted of intravenous vitamin C twice

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


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

[User]
RADIOLOGY NOTE:
A 4-year-old girl was referred with a long-standing history of over a year of intermittent vomiting, abdominal pain, and progressive abdominal distension. She was born at term following an uneventful pregnancy and normal antenatal ultrasonography. On clinical examination, she had very marked abdominal distension and a visible and palpable diffuse mass occupying her entire abdomen. She was initially investigated with an abdominal and pelvic ultrasonography which demonstrated a large multilocular fluid filled cystic mass occupying most of her abdomen from the left upper quadrant to her pelvis and extending across the lateral aspect of her abdomen and lying anterior to her bladder. A CT scan of her abdomen and pelvis confirmed a 27 cm × 20 cm × 14 cm multilocular mass extending from the left upper quadrant to her left iliac fossa, with bowel loops invaginating in between, causing mass effect on the rest of the her abdominal contents including her IVC (). She underwent a laparoscopic near total excision of her abdominal cyst. At laparoscopy, the cyst was seen to be enveloping the entire small bowel mesentery, in close relation to the bowel wall. In the portion of the cyst within the root of the mesentery, where it was difficult to achieve complete excision without compromising the vascularity of the bowel, a partial excision was done with electrocauterization of the residual mucosal lining. The operative time was 50 minutes, with no intraoperative complications or need for conversion to an open procedure. She made a good recovery following her surgery with no postoperative complications and was discharged home after 24 hours. Histological examination of the excised specimen revealed a cystic lymphangioma. At 6-month follow-up she continues to remain clinically well with no symptoms. A repeat abdominal ultrasonography suggested a small 2 cm recurrent cyst, which was well localized with the small bowel mesentery, with no mass effect. She continues to remain on regular fol

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


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

[User]
RADIOLOGY NOTE:
A 38 -year-old gravida 2 para 1pregnant woman was referred to our prenatal clinic for a survey at 18 weeks of gestation due to twin pregnancy with the discordant amniotic fluid amount. Sonographic examination revealed polyhydramnios with a maximum vertical pocket (MVP) of 12 cm in the recipient fetus’s sac and another stuck twin fetus showing an absence of end-diastolic velocity of umbilical artery (UA) Doppler flow and thus a stage III TTTS was diagnosed. After consultation with the family about treatment options including amnioreduction and laser therapy, the patient chose to receive fetoscope-guided laser therapy. Under local anesthesia and following procedures as previously described [], ten intertwin anastomoses (six donor artery to recipient vein anastomoses and four recipient vein to donor artery anastomoses) were coagulated with 10 ~ 15 W Diode laser power with Solomen technique. The postoperative course was uncomplicated and the UA Doppler returned to normal in donor twin after the surgery.
Ten days after the laser surgery, high-level ultrasound was done at the previous hospital that referred the case. Both fetuses had their amniotic fluid returning to normal, but incidentally they found both eyeballs of the donor twin were opaque, while the recipient’s were clear. (Fig. ) Therefore, discordant congenital cataract was suspected in the donor twin. At the gestational age of 23 weeks, fetal magnetic resonance imaging (MRI) was arranged to evaluate the central nervous system for both fetuses and to rule out if the donor twin had other associated anomalies; no additional information was gathered about the donor twin. At the gestational age of 27 weeks, sonography still revealed opacity over donor twin eyeballs. (Fig. ) The pregnancy was completed at gestational age 37 weeks by cesarean delivery indicated by malpresentation, resulting in the birth of two male babies, both babies weighing 2460 g each. Ten days after delivery by examination under anesthesia, the sl

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


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

[User]
RADIOLOGY NOTE:
A 42-year-old woman came to Seoul National University Dental Hospital complaining of intermittent stinging pain in her right cheek. Previously, she had visited a local dental clinic due to intermittent pain in the past 6 months. The vitality test of upper-right teeth had been performed. Even though the teeth had been vital, she had received endodontic treatment on the upper-right second premolar due to worsening pain. Then, she was referred to the Department of Oral and Maxillofacial Radiology at our hospital when she complained of new sharpening pain on the right side of her face after two or three days.
There were no clinically abnormal findings in physical and oral examinations. The patient only had a history of orthognathic surgery on both the maxilla and the mandible performed about 21 years prior to this visit. Panoramic and Waters' radiographs revealed increased haziness and dome-shaped homogeneous radiopacities in the lower regions of both maxillary sinuses (). Endodontic retreatment was performed on the upper-right second premolar because it was thought that radiologically, the origins of the pain were not in the maxillary sinuses but in the teeth, resulting in only a temporary reduction of pain that later intensified.
Computed tomography (CT) was performed for finding other origins of the pain, and low-attenuation lesions were detected in both maxillary sinuses. The lesions measured approximately 36mm×27mm×20 mm in the right maxillary sinus, and 30mm×21mm×25 mm in the left maxillary sinus. The margins were undulated, while corticated discontinuously. The lesions extended slightly below the floor of both nasal sinuses. No internal calcifications were present. Postoperative signs including antral wall thickening, sclerotic change, and loss of continuity of the cortical antral wall lining, were not observed on the CT images. Furthermore, there were no characteristic features of distinct expansion or bone destruction of soft tissue (). The lesions were eventua

[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 female with stage IV hormone-sensitive breast cancer to bone presented with rash on the face and arms. She presented twelve years prior with a large right breast mass. She was treated with modified radical mastectomy revealing multifocal invasive lobular carcinoma with 25 of 25 lymph nodes involved with immunohistochemistry staining revealing ER-positivity, PR-positivity, and HER2-negativity. Staging workup revealed bone metastases and she was treated with anastrozole and zolendronic acid. After eight years, progression of osseous metastatic disease was noted and anastrozole was switched to exemestane 25 mg daily. Eighteen months later, progression in the bones occurred and she was treated with investigational orteronel 400 mg twice daily. Two years later, progression in the bone was noted and she initiated fulvestrant 500 mg intramuscular every month. After one year, progression was again noted in the bone, along with increased CA27-19 tumor marker which reached 358 U/ml. Fulvestrant was discontinued and patient was started on capecitabine 2500 mg twice daily for 14 days on and 7 days off for 21-day cycle at the beginning of summer. The patient had minimal symptoms, remained active, and spent much of the summer months out of doors. After 3 cycles, she developed a mild rash on the face, arms, but the tumor marker fell to 256 U/ml. Therapy was continued and after two additional cycles the rash worsened as the tumor marker continued to decline and imaging showed sclerosis of bony metastases, suggestive of healing. The rash appeared in a photo-distributed pattern but the patient was uncertain if the rash was worsened by sun exposure.
The rash was initially described as scattered macules and papules with thin raised plaques that were mildly pruritic on her cheeks and forearms. After the rash became more severe, capecitabine was held and she was referred to dermatology. Other medications at the time were zolendronic acid 4 mg

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


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

[User]
RADIOLOGY NOTE:
A 41-year-old man presented with a 1-month history of abdominal pain. His previous medical and familial histories were unremarkable. Unenhanced transverse CT scan of the abdomen revealed an ill defined, lobulated mass that measured about 13 × 12 × 7 cm in size and it appeared as a heterogeneously low attenuated mass with numerous areas of coarse calcification. It was located in the left side of the retroperitoneal space and involved the body and tail of the pancreas (). Contrast-enhanced CT was performed after mechanical injection of 130 cc of nonionic iopromide (300 mg/ml of iodine) into the antecubital vein at a rate of 2.65 ml/sec. After initiating infusion of contrast material, we used scanning delays of 30 seconds before starting to obtain the arterial phase images. Imaging in the portal venous phase was performed after a scanning delay of 70 seconds from the initiation of infusion of contrast material. On the contrast-enhanced transverse CT scan obtained during the portal venous phase, subtle enhancement was noted in only the periphery of the mass and most of the mass remained without enhancement (). The contrast-enhanced coronal reformatted image showed the ill defined necrotic low attenuated mass with obliteration of the splenic vein by the mass, and there was the development of multiple collateral veins (). Portal venography via the celiac axis also showed tumor invasion to the splenic vein (). The patient underwent exploratory laparotomy and mass excision was done. The specimen was revealed to be a large, firm, fixed hypervascular mass arising from the pancreas, and it occupied the left upper quadrant of the abdomen. A large multilobulated mass that measured 15 cm in maximum diameter was located in the body and tail of the pancreas, and it was attached to the spleen and transverse colon (). Microscopically, the chondroid zone was surrounded by proliferation of undifferentiated cells with abrupt transition (). The pathological diagnosis was extraskeletal me

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


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

[User]
RADIOLOGY NOTE:
The patient is a woman in her 50s who presented to the emergency department (ED) with a two-day history of colicky abdominal pain in the mid-epigastrium and right lower quadrant associated with nausea, emesis, distention, and obstipation. She had a past medical history of hypertension and major depressive disorder treated with losartan and citalopram, respectively; and regarding her surgical history, she did not have any prior abdominal operation. She did not have symptoms or a history of biliary pathology.
On physical examination, her abdomen was distended and tympanitic, but nontender. Laboratory analysis revealed a normal white blood cell count and hemoglobin. Serum electrolytes were indicative of mild volume depletion.
She subsequently underwent a CT scan of the abdomen and pelvis which showed a distal small bowel obstruction with a transition point at a 2.9 cm round intraluminal structure with central calcification (Figure ). There was no evidence of small bowel ischemia or perforation. The patient did not have radiopaque cholelithiasis or imaging findings of cholecystoenteric fistula (Figure ,B). Upon review of prior imaging, screening CT colonography from six years prior for cancer screening purposes showed a similar, but smaller intraluminal structure associated with the terminal ileum (Figure ).
The differential diagnosis included teratoma or other benign or malignant mass, ingested foreign body, and gallstone ileus. While most surgeons hearing the history would suspect gallstone ileus, especially in patients with known biliary pathology, lack of visible cholecystoenteric fistula or inflammatory changes in the right upper quadrant precluded this diagnosis. The patient was a reliable historian and denied a history of unusual foreign body ingestion. While the imaging phenotype of a central calcification and concentric radiolucent material was reminiscent of a mature teratoma, this pathology arising in the small bowel of a middle-aged patient would be very unu

[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 last case is a 74-year-old retired premutation male carrier who is diagnosed with FXTAS and has 91 CGG repeats. This individual has a history of significant ataxia, which began when he was 62 years of age. Initially he started using a cane consistently (67 years old) and then began using a walker (70 years old) before progressing to a wheelchair (73 years old). Over the past 5 years he has suffered several falls that have necessitated surgery, including a Le Fort fracture of the skull, a fractured wrist, a fractured pelvis, and a fractured ankle. He mentioned that he has had some neuropathy symptoms such as pain in his fingertips, but this was after fracturing his wrist. He also has some partial back pain but denies any overall chronic pain. Towards the end of the day, he complains of dizzy spells and becomes tired and subsequently is more prone to falling.
He has a history of kidney stones and nasal polyps, which were removed. His cardiovascular history is significant and includes a myocardial infarction at age 48 after 30 years of smoking. After he underwent a quadruple bypass heart surgery, he stopped smoking and began to treat his high blood pressure with antihypertensives (Terazosin 10 mg in the morning, then alternating with 5 mg every other day). Other medications include simvastatin for hypercholesterolemia and a combined fluticasone furoate and vilanterol inhaler for maintenance of chronic obstructive pulmonary disease. At age 64, he started experiencing memory deficits and complained of anxiety, moodiness, and irritability. These symptoms were managed with memantine and venlafaxine. However, he experienced moderate side effects, including dizziness and more problems with his balance, resulting in cessation of the treatment within a year.
On examination, he was found to have a controlled blood pressure and a normal heart rate. His BMI was found to be 33. Neurological examination revealed anisocoria,

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


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

[User]
RADIOLOGY NOTE:
A 15 year old boy presented to orthopedic clinic with a 2 week history of urinary retention, back pain, bilateral leg numbness and weakness, lumbar pain exacerbated by movement, sweat and fever. He had received conservative medical treatment with a diagnosis of low back pain but there was no response to analgesic and medical treatment. He had also referred to urologist due to his urinary retention. Ultra-sonograohy of bladder and kidneys detected no abnormal finding. He was then discharged after urinary catheterization with an unexplained diagnosis of urinary retention. His lower back pain was exacerbated and severe neurological deficit was also added to his clinical picture. He also developed difficulty in weight bearing and walking. His past medical history was not significant. He denied any previous trauma, spinal surgery, or immunodeficiency. He was not taking any medication. In physical examination, he presented with blood pressure of 100/80 mmHg, pulse rate of 100 pulse/minute and a body temperature of 38.5º C. Hematologic examination revealed a white blood cell count of 18600 /µl (neutrophil 70%), an erythrocyte sedimentation rate (ESR) of 68 mm/hr and a C reactive protein 3-plus positive.
On physical examination, there was a tenderness over the left side of lumbar vertebrae and on the left and right sides of para-lumbar region. Neurological examination showed hyperactive deep tendon reflexes, muscle weakness (3/5), and decreased pin prick sensation in the right leg. Rectal tone and sensation were normal but there was a perineal numbness.
Radiologic imaging showed no significant evidence (). On magnetic resonance imaging (MRI) scan that were taken at the time of admission there were abnormal signal intensity at right paraspinal muscles of L2 and L3 level. The lesion was extended to the posterior aspect of thecal sac and its extra-dural mass effect caused canal stenosis and cauda equina compression to anterior wall of the canal. Radiologist recommended emergen

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


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

[User]
RADIOLOGY NOTE:
A 28-year-old man with no noticeable past medical history was hospitalized for widespread abdominal pain and vomiting at our emergency surgical unit. Three weeks before he had been involved in a motor vehicle accident and was admitted with a diagnosis of blunt thoracic and abdominal trauma; the treatment was conservative, and the patient was discharged after 7 days from hospitalization without need for blood transfusion. Our examination revealed moderate abdominal distention with pronounced tenderness in the lower quadrants, and blood examination showed only mild leucocytosis. An abdominal X-ray showed soft bowel distension with air–fluid levels. A computed tomography (CT) scan was then performed, which showed some calcifications within the mesentery root (), gastric dilatation, distension with multiple air–fluid levels of the small bowel. In the right iliac fossa, there was an ileal loop with frankly thickened walls and signs of parietal suffering at a full-to-empty passage. Free fluid was sparsely evident in all the recesses of the abdominal cavity.
Moreover, several apparently hyperplastic-reactive nodes were present along the mesentery root. Calcifications were not present at a previous CT scan performed in another hospital after the trauma hospitalization. After informed consent the patient was prepared for surgery, and initially a laparoscopic approach was hypothesized but not allowed due to a severe desaturation episode during the intubation. During the exploratory laparotomy, we identified a bulky and hardened mass of the small bowel arising within the mesenteric root and retracting the visceral peritoneum, with a frank malignant appearance. Consequently, a wide resection of the involved intestinal tract with the relevant mesenteric root was performed. Another similar small thickened nodule was removed from the peritoneum of the left iliac fossa. The postoperative course was regular, and the patient was discharged after 5 days in complete wellness and restor

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


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

[User]
RADIOLOGY NOTE:
A healthy Caucasian 28-year old female was referred to our dental clinic with a continuous dull pain in the left mandibular region, which had started after initiation of root canal treatment on the first molar by her general dentist about two weeks before. Upon clinical examination, a localized inflammation overlying the buccal mucosa in furcal region of the tooth #36 became evident which was tender on palpation. The tooth had no tenderness on percussion and no mobility. Careful periodontal probing showed a pocket depth within the normal range (<3 mm). Radiographic examination revealed overextended endodontic access cavity preparation and extensive destruction of pulp-chamber floor ().
In the radiography a small piece of amalgam was evident in the apical extend of the perforation which is believed to have separated from the previous amalgam restoration of the tooth. The location of this small piece was an indicator of wide destruction of the interradicular bone during the preparation of the access cavity ().
The possible treatment options, including tooth extraction with/without replacement, tooth hemisection and non-surgical perforation repair with subsequent continuing of the root canal therapy (RCT) and coronal restoration were explained for the patient. The patient preferred the option of saving the tooth via a non-surgical endodontic treatment and furcal perforation repair with CEM cement. She also read and signed an informed consent.
Before the start of the treatment, mouth rinse with 0.2% chlorhexidine rinse (Behsa Co., Tehran, Iran) was carried out in order to control the oral microbial flora. After administering local anesthesia (2% lidocaine with 1:80000 adrenalin; Daroupakhsh, Tehran, Iran) and proper tooth isolation, the temporary restorative material was removed with a slight correction in the outlines of access cavity and then all canal orifices were located. The cavity and perforation site were copiously irrigated with full concentration of sodium hyp

[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 male patient reported to the outpatient department of the authors' institution with the complaint of pain and swelling in the lower front tooth region for 15 days. The patient gave a history of extraction 1 month back due to loosened teeth following which he noticed a soft-tissue overgrowth in his mandibular anterior tooth region. The patient had the habit of bidi smoking for 30 years. Extraoral examination did not reveal any significant findings. He also experienced dull pain associated with this overgrowth. The submandibular and submental lymph nodes on the ipsilateral side were palpable.
On inspection, a soft nodular growth measuring about approximately 5 cm × 3 cm × 2 cm was seen on the mandibular anterior region. The lesion was pinkish white in color and ulceroproliferative in nature. The lesion was extending labiolingually from labial attached gingiva to lingual attached gingiva and mesiodistally from mandibular left canine to mandibular right first premolar region []. The growth was tender and firm in consistency. Based on clinical findings, a provisional diagnosis of aggressive inflammatory lesion with a differential diagnosis of granulomatous lesion and carcinoma of gingiva was made. No significant findings were noticed in an orthopantomogram. After routine hematological investigations, an incisional biopsy was performed. The tissue specimen was routinely fixed and processed. The H- and E-stained sections showed dysplastic epithelium invading into the connective tissue stroma. Invaded epithelial cells were in the form of nests, islands, and sheets composed of basaloid cells showing hyperchromatic large nuclei and indistinct cytoplasm [Figures and ]. Areas of comedonecrosis were seen in between the sheets of cells []. Frequent mitotic figures were also evident. The stroma also showed numerous blood vessels with areas of hemorrhage. Based on the histopathological findings, a diagnosis of BSCC with differential diagnosis of adenoid cystic carcino

[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 51-years-old Japanese man presented with a tumor in the right temple and underwent resection of the tumor at a medical college hospital in 1979. The histological diagnosis was hemangiopericytoma. Thereafter, he demonstrated local recurrence many times, underwent resection 5 times and embolization was performed 2 times. Despite these treatments, this tumor relapsed in the temple again and was treated by irradiation (total 61.8 Gy) in November 2002. However, the tumor appeared to persist and multiple lung metastases were detected. After 4 months, he consulted our hospital for their treatment. On the first medical examination at our hospital, we evaluated the skull base tumor with MRI (Figure ) and lung metastasis with chest-CT. Because lung metastasis remained stable, we performed Choline-PET and compared findings to those of FDG-PET. Choline accumulated in the tip of the right temporal lobe (SUV max 4.0) but FDG-PET could not detect in the tumor because it accumulated strongly throughout the whole brain without demonstrating the tumor (Figure ). In addition to PET study, angiography via the right external carotid artery demonstrated the lesion strongly (Figure ). Based on these examinations, we diagnosed this lesion as residual hemangiopericytoma. Then he underwent resection of the residual skull base tumor in February 2004. First, we incised the coronary line at the front of the head, and tried to approach this tumor via right temporal craniotomy without facial incision. We resected completely the tumor together with a part of dura because of dural invasion. The tumor showed diffuse invasion of tissue around the mass lesion. We reconstructed the skull base by galeal flap. In addition, we plugged the dead space after tumor resection with abdominal fat tissue (Figure ). There were no complications postoperatively. This tumor demonstrated abundant blood vessels and was composed of round or spindle-shaped cells, including dilated staghorn-shaped vessels (Figure ). Imm

[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 87-year-old woman presented to the accident and emergency department after sustaining a fall while on holiday. She complained of pain and reduced range of movement in her left shoulder. Her past medical history included hypertension atrial fibrillation, for which she took aspirin 75 mg once a day. She had previously undergone a thyroidectomy in 2000 for hyperthyroidism. She was otherwise fit and well with no known drug allergies.
On examination her left arm was bruised and painful when movements were attempted. Her distal neurovascular status of the affected limb was normal with no deficit detected. Plain film radiographs of her left shoulder demonstrated a minimally displaced and impacted fracture of her proximal humerus (as shown in ). After discussion with the orthopaedic registrar on call she was placed in a collar and cuff and sent home to attend the next available fracture clinic.
When she was reviewed in the following fracture clinic it was noted that she had developed a swelling and erythema on the left side of her neck in the distribution of her external jugular vein (as shown in ). It was also found that the collar and cuff had been applied rather tightly. She was referred to the on call ENT registrar who made a diagnosis of thrombophlebitis of her external jugular vein. Further questioning did not reveal a history of further thrombotic events. The ENT registrar felt the erythema may be developing cellulitis and so started the patient on antibiotics (flucloxacillin 500 mg four times a day for 5 days) and placed her in a better fitting sling. The fracture was deemed suitable for nonsurgical management with regular clinical and radiological follow-up. As she was only on holiday in the region, further follow-up was arranged for two weeks in her local hospital.
Two days later, she represented to the accident and emergency department with pain and gross pitting oedema in her left arm. A Doppler scan demonstrated near complete occlusion of the left subclavian

[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 male reported with a chief complaint of unesthetic appearance of the face due to depression in the lip region on the left side of the face. Extra orally, two scars and a prominent depression in lower lip region were noticeable on the left side of the face. On intraoral examination, mandibular anterior and premolar teeth were missing and a bony defect (12 mm × 19 mm) with flabby tissue at the base was present at the respective region []. The complete case history of the patient was taken, which revealed that the patient had undergone treatment for comminuted mandibular fracture in symphseal-parasymphyseal region on the left side of face 3 years back. This segment of the mandible along with five teeth (mandibular anteriors and premolars) was removed during open reduction of the fracture followed by placement of titanium reconstruction plate. The intraoral closure of the defect was done by placing the temporal flap over the defect. The relative positions of the two mandibular segments and the reconstruction plate could be clearly appreciated on orthopantogram []. The tissues in the defect region were 12 mm below the cervical margins of the adjacent teeth, attributing it as a Siebert's Class III defect []. The various treatment modalities were thoroughly explained to the patient. Considering the reluctance for the surgical procedure and economic status of the patient a modification of Andrews bridge was chosen as the treatment option. The modification planned was to replace the costlier prefabricated bar and sleeve attachment of conventional Andrews system with two small disc shaped magnets. The advantages and disadvantages were clearly explained to the patient and informed consent was taken. The step by step procedure is as follows:
Diagnostic impressions were made and casts were prepared The selected abutment teeth (41, 36) were prepared for metal ceramic restorations. The gingival retraction was done using gingival retraction cord (Ultrapak) and putty 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 42-year-old multiparous woman presented to us with complaints of pain in the abdomen of 6 months duration. She underwent laparoscopy for a pelvic mass 3 years before her present complaints. There was a 10 cm × 9 cm mass from the Pouch of Douglas extending into both broad ligaments. Laparoscopic myomectomy was done. The fibroid was degenerated. The specimen was retrieved by morcellation. The specimen weighed 620 g. She was asymptomatic for 3 years and presented to us with abdominal pain and fibroids detected on ultrasonography.
Clinical examination revealed a bulky uterus with a mass in the pouch of Douglas. Ultrasound revealed a mass of 6 × 5cm in the Pouch of Douglas and a 7 × 6 cm mass in the right lumbar region near the right kidney but separate from it. She did not have any complaints pertaining to the right lumbar mass.
Laparoscopy was done with four ports, one primary supraumbilical and three accessory ports, two on the left and one on right side. Laparoscopy revealed a bulky uterus with small fibroids []. There was a 6 × 5 cm degenerated pelvic mass extending bilaterally in the broad ligament. On surveying the upper abdomen, she had a 7 × 6 cm mass engulfed completely by the omentum [].
We proceeded with total laparoscopic hysterectomy with excision of the pelvic mass. The lumbar mass was dissected carefully from the omentum with the harmonic ultracision [] and ensuring that it did not arise from the bowel or from any other structure. The uterus, pelvic mass and the right lumbar mass [] were retrieved vaginally. The vaginal vault was closed with interrupted No.1 delayed absorbable sutures. The uterus and the pelvic mass weighed 300 g. The lumbar mass weighed 80g.
The specimen was sent for histopathology. The pelvic mass and the right lumbar mass were reported as leiomyoma. The patient has an unremarkable postoperative period and is asymptomatic till

[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 with a gradual onset of left-sided hemiplegia and weight loss of 14 kg over a period of ~4 weeks. His past medical history included COPD, hypertension and chronic hyponatraemia. There was no history of immunocompromise however he was malnourished. Of note, there was no history of foreign travel, intravenous drug use or household pets however the patient had undergone four dental fillings in the preceding 12 months. Neurological examination indicated MRC grade 2/5 power throughout the left upper and lower limbs with increased tone. The patient was apyrexic with a CRP of 68 mg/L.
A CT brain revealed a right frontal mass lesion with surrounding oedema which was concerning for malignancy when taken in conjunction with the weight loss. Investigations for a primary tumour were negative including a CT of the chest, abdomen and pelvis in addition to upper GI endoscopy. Tumour markers did not reveal any abnormality. Additional testing for immunocompromise including HIV was negative and no primary source of infection was identified. A subsequent MRI brain revealed a total of five ring-enhancing lesions with vasogenic oedema distributed throughout both cerebral hemispheres with the largest measuring >2 cm (Fig. ).
Commencement of dexamethasone (8 mg twice-daily) initially resulted in a good clinical response. Image-guided excision of the right frontal abscess was undertaken and culture results identified Nocardia farcinica. Despite appropriate treatment with intravenous linezolid combined with imipenem and the subsequent addition of co-trimoxazole, repeat imaging demonstrated a continued increase in size of the remaining abscesses. Two further operations were performed over a 4-week period in addition to ongoing anti-microbial therapy. Resection of all abscesses was achieved through right frontal, right parietal, left parieto-occipital and left temporal craniotomies. Microbiological analysis identified Enterococcus faecium in a second abscess and v

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


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

[User]
RADIOLOGY NOTE:
A 61 year-old Caucasian woman was referred to our colorectal clinic with an 18-year history of severe intermittent anal pain and constipation. She described experiencing intermittent anal spasms lasting around 15 minutes. These episodes were worse when sitting down for longer than 45 minutes or when lying in bed. The frequency of these anal spasms was increasing with time and occurring every hour at night at the time of presentation. Her constipation symptoms constituted experiencing difficulty in defecation and a sensation of incomplete evacuation. She had no response to amitriptyline or topical diltiazem. Her past medical history was unremarkable apart from four normal vaginal deliveries. Her sister had colorectal cancer diagnosed at the age of 49 and had previously been treated for an undiagnosed anal sphincter problem. There was no other relevant history of note.
She initially underwent a flexible sigmoidoscopy and magnetic resonance imaging (MRI) of her perineum. The endoscopy was reported as normal, whereas the MRI showed edema of the IAS. She subsequently had an endoanal ultrasound which confirmed that her IAS was abnormally thick and greater than 5 mm (Fig. ). Anal manometry revealed that although resting and squeeze pressures were within normal limits there were periods of a significant increase in anal resting pressure lasting longer than 2 minutes (Fig. ). Pressures during this period were in excess of 200 mmHg which settled spontaneously. These pressures were even higher than the maximum recorded squeeze pressure (Fig. ).
She had an examination of the anal canal under anesthetic which showed a very prominent sphincter complex. She also received Botox injections (Dysport™) at the 3 and 9 o’clock positions of the IAS which led to no subsequent resolution of her symptoms. She then underwent a lateral internal anal sphincterotomy by dividing half of the length (1 cm) of the IAS on the left lateral aspect. A biopsy of the IAS taken at the time of surgery was

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


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

[User]
RADIOLOGY NOTE:
A 9 year old girl had come to the Department of Pedodontics and Preventive dentistry, Thai Moogambigai Dental College and Hospital, with the chief complaint of multiple swellings in the lower lip that were present for the past 6 months. The patient gives a history of the swellings being small at first with a slow enlargement. The habit of lip biting was also confirmed by the parents. Clinically three enlargements, on the lower labial mucosa, one in the left side and two in the right side, were noticed []. Two of the lesions appeared as an elevated sessile nodule with a smooth surface measuring 4 mm in diameter [Marking F in ]. One of the lesions appeared as a raised, circumscribed vesicle also measuring 4 mm in diameter [Marking M in ], with a bluish translucent cast. No submental or submandibular lymph nodes were palpable. Considering the history and clinical findings, a differential diagnosis of irritation fibroma and mucocele was noted.
Management of the lesions included both surgical and preventive aspects pertaining to the presenting condition. Surgical excision was [] done under local anesthesia revealing multiple cystic mass in relation to the region of the mucocele and a single mass in each of the region which contained the fibroma. The mucocele had inadvertently ruptured, considering the size, during excision due to which the contents could not be preserved. Suturing of the surgical site as done and post-operative instruction was given. The patient was advised lip bumper for management of the lip biting habit, the suspected cause for the lesions. The specimens [] excised were sent to the Department of Oral and Maxillofacial Pathology for confirmation of the diagnosis. hotomicrograph of fibroma reveals the surface showing shortening of stratified squamous epithelium and interlacing collagenous fibers []. Photomicrograph of the mucocele [] revealed a cyst-like cavity with eosinophilic coagulum, infiltrated by dense

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


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

[User]
RADIOLOGY NOTE:
A 68-year-old male with known stage IV sarcomatoid renal cell carcinoma presented to the emergency department (ED) complaining of shortness of breath; his vital signs were unremarkable with stable oxygen saturation, and his physical examination had been normal. Because of the high suspicion of pulmonary embolism related to his risk factors, a CT scan of the chest with IV contrast was done, which had shown bilateral segmental and sub-segmental PE and a cardiac mass in the right ventricle that is consistent with known renal cell carcinoma as shown in Figure . There was no right ventricular (RV) strain on CT or transthoracic echo, and troponin and B-type natriuretic peptide (BNP) had been normal. Given that he was stable, a decision was made to start him on therapeutic anticoagulation with low molecular weight heparin with close follow-up.
Six months later, he presented to the ED with worsening shortness of breath. A CT scan was repeated at that time, showing an increased clot burden in the pulmonary arteries at segmental and sub-segmental levels but now with evidence of new RV strain on CT despite him being on a therapeutic dose of anticoagulation. It was thought that this was not related to hypercoagulability, but instead, these were tumor emboli related to his cardiac metastasis.
Cardiothoracic surgery was consulted, and as recommended, cardiac MRI was done to see if the cardiac metastasis could be removed surgically. Cardiac MRI showed a large right ventricular mass attached to the endocardium on the RV septal aspect and the anterior aspect of the RV outflow tract (RVOT); the mass was highly mobile and prolapsing into the pulmonary artery in real-time view (Figures -).
Surgical option was considered because the mass was near the RVOT and was prolapsing into the pulmonary arteries. It was feared that massive tumor embolization could happen later on, leading to a high-risk pulmonary embolism and cardiac arrest. The patient also had good functional status despite havi

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


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

[User]
RADIOLOGY NOTE:
A 68 year old man presented with a five month history of progressive dysphagia and weight loss of 5 kg. An adenocarcinoma arising in Barrett's epithelium in the lower third of the esophagus was diagnosed, and staging including CT-PET and endoscopic ultrasound suggested clinical T3N1 M0 staging. He was treated with a standard regimen of neoadjuvant chemoradiotherapy prior to esophagectomy []. At surgery, extensive fibrosis was evident, and an en-bloc resection was performed including thoracic duct, part of pericardium, and mediastinal lymph node dissection including complete clearance of the sub-carinal nodes, and a cervical hand-sewn anastomosis was fashioned. Pathology revealed a ypT3N1 tumor, with clear margins, and 7 of 30 glands involved by tumor.
On day four postoperatively he had a neutrophil leucocytosis of 15 × 109/L and evidence of left basal consolidation. This persisted despite antibiotics, and a CT of thorax demonstrated no other abnormalities. He was managed on the ward, and his FiO2 varied from 0.4 to 0.6. Aspiration pneumonia was considered possible, and his nasogastric tube was left in situ. His neck wound was dry with no signs of inflammation or leakage. On day 14 the nasogastric drainage bag dramatically filled with air, and this persisted throughout the day and succeeding days, but without deterioration in respiratory function or evidence of progressive sepsis. A fiberoptic bronchoscopy was performed on day 16 which demonstrated bubbling at a gastro-bronchial fistula in the posterior aspect of the left main bronchus (Fig. ). An endoscopy revealed a healthy gastric tube but a tiny area of granulation tissue in the anterior portion of the anastomosis, the assumed site of fistula communication. A CT scan of the thorax demonstrated air in the mediastinum and the gastric conduit (Fig. )
He was managed conservatively with antibiotics, enteral nutrition via a jejunostomy, and non-invasive respiratory support in the form of humidified oxygen via face mask

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


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

[User]
RADIOLOGY NOTE:
A 26-year-old man was referred to the Conservative Clinic for the management of the discoloration of a previous root canal treatment for tooth 22. The patient claimed to have had a history of trauma during his teenage years, and the tooth had multiple episodes of pain and swelling. The lesion healed after the completion of root canal treatment which was almost 5 years back. However, for the last few months, the tooth started to cause discomfort with a slight pain during biting or chewing. He also noticed that it became darker and blackish in color. The patient otherwise was cleared from any medical illness, and his health condition was fit and healthy. During an intraoral examination, tooth 22 showed dark discoloration and was tender to palpation and percussion. A 1 mm × 1 mm soft tissue swelling was located at the palatal site of the tooth. Thermal test and electronic pulp test indicated a positive response of the adjacent teeth 21 and 23. Periapical radiograph showed that tooth 22 had a well-condensed root canal filling; however, the gutta percha was overextended and there was periapical lesion at the area (). Cone Beam Computed Tomography (CBCT) revealed that the size of the lesion was approximately 2 mm × 2 mm (). The provisional diagnosis was a failure root canal-treated tooth with chronic apical periodontitis and discolored tooth. After discussion and explanation, the patient agreed for nonsurgical retreatment to remove the infection and extruded gutta percha, thus eliminating and healing the apical periodontitis before undergoing an internal bleaching. The patient was also aware of the possibility of periapical surgery as a complementary approach to resolve the pathology if the conventional retreatment failed to succeed.
During retreatment, a Dental Operating Microscope (Zeiss OPMI ® pico, Germany) was used to enhance illumination and magnification to reach the apical root and assess the extruded gutta percha. The gutta percha was

[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.