[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:
RJS, a 30-year-old woman, was seen at the health post of Corte de Pedra, Tancredo Neves—Bahia, a reference center for diagnosis and treatment of CL. The patient complained of a small papular lesion in her right leg developing over seven to 10 days. When she was 10 years of age, she had an ulcer in the left thigh suspicious of CL that spontaneously healed in about 4 months. Given her prior history of ulcer, she decided to seek help at the health post when the new lesion appeared. On physical examination, a depressed papular lesion measuring 8 × 7 mm in the right leg suspicious of folliculitis was noted. There was also a well-defined atrophic scar in the left thigh, measuring 30 × 20 mm (). There was no lymphadenopathy. Because early CL lesions in L. braziliensis infection may have a papular and nonulcerated aspect [] and the patient lived in an endemic area, the diagnosis of CL was suspected. LST was prepared as previously described []. Briefly promastigotes of L. amazonensis were disrupted initially by multiple freeze and thaw and later by sonication. The material was adjusted to 250 μg/mL with sterile PBS containing Tween 80 and phenol []. An intradermal injection of 0.1 mL was administered in her left forearm. After 48 hours, the intradermal reaction was highly positive with an induration of 38 × 32 mm. Eight days after the skin test, while the folliculitis in the right leg disappeared, a cutaneous round ulcer with raised borders measuring 26 × 24 mm, typical of leishmaniasis, was observed in the site where the LST was administered (). The clinical picture was typical of an ulcerated CL lesion, but the culture of the aspirated material from this lesion was negative for Leishmania. The histopathological analysis () showed chronic perivascular inflammation with granuloma formation and the presence of neutrophils, lymphocyte, monocyte, and plasma cells. Parasites

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

[User]
RADIOLOGY NOTE:
A 16-year-old male patient was brought by his parents to a genetics clinic with complaints of developmental delay and tremor. He was a full-term infant with an uneventful delivery. He started walking around 18 months of age, spoke his first words at the age of two. Other problems included nervousness, immature behaviors, lack of eye contact during conversations, and aggressive behavior. His mother reported that he began to have a tremor in the hands around three years of age. Diagnostic workup included magnetic resonance imaging (MRI) of the brain, urine organic and amino acids, lactate, pyruvate, and lead levels along with chromosomal and DNA analysis for fragile X which were all unremarkable. His family history was significant for mental retardation. Maternal grandmother had three mentally retarded brothers with tremors, two of whom died in their forties. The patient’s brother also seems to have a speech delay along with tremors since the age of three.
His tremors worsened gradually, and he started to have difficulties with fine motor control including difficulty with drinking out of a cup along with increased aggression and behavioral changes. His teachers reported that he was biting, kicking, spitting and getting into conflicts with other children. He was seen by a child psychiatrist at that time and was started on risperidone, valproic acid and Adderall (amphetamine and dextroamphetamine) which seemed to help with his behaviors.
On examination, he has high nasal bridge, slightly down-slanting palpebral fissures, long philtrum, and thin upper lip. On neurological exam, he has slightly increased deep tendon reflexes throughout. Babinski sign was positive on the right, but a normal plantar response was noted on the left side. Bilateral hand tremors were noted, both at rest and in action. He was walking slowly without much arm swing and had a slightly stooped forward posture. A full psychological evaluation was done which showed a Leiter scale IQ of

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

[User]
RADIOLOGY NOTE:
A 59-year-old man was admitted to our center with the chief complaint of consistent fatigue in March 2017. He had a 30-year history of hypertrophic obstructive cardiomyopathy, a 20-year history of chronic viral hepatitis B, and had suffered from gastric ulcers for five years. In addition, he often got pneumonia at least 2 or 3 times a year in the past few years. A Chest CT revealed a 3.7 cm × 2.1 cm mass encircling the main pulmonary artery in the right middle lobe of the lung and another 2.2 cm × 1.5 cm mass in the left upper lobe of the lung, both of which showed slightly contrast enhancements with clear boundaries (Fig. ). However, the patient declined our suggestion for further examinations.
As fatigue aggravated 8 months later, he was admitted to our hospital for a second visit. A repeated CT showed that the mass of the right lung increased to 4.7 cm × 3.4 cm, with a little decrease in the lesion on the left side. Meanwhile, hepatic multiple enhanced nodular signals were also detected by the abdominal CT, but liver tumors were further excluded by the abdominal magnetic resonance image (MRI). Apart from fatigue, the patient did not have any other complaint, without cough, chest pain, fever, or other findings by physical examinations. The laboratory findings were negative, white blood cell count, hemoglobin level, platelet count, C-reactive protein, elevated sedimentation rate, and cancer-related antigen were within the normal ranges. The CT-guided lung biopsy of the mass in the right middle lobe of the lung was performed in December 2017. The corresponding histological results revealed that the mass comprised spindle cells without the infiltration of atypia inflammatory cells. The immunohistochemical examination showed that the cells were positive for smooth muscle actin (SMA) and Ki-67 (10%), but negative for CD34, S-100 protein, epithelial membrane antigen, and ALK1 (Fig. ). Thus, the diagnosis of pulmonary

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


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

[User]
RADIOLOGY NOTE:
An 8-year-old girl, who suffered from chronic cyanosis, was referred to our hospital for further evaluation. The patient was well developed with normal growth. On physical examination, a 2/6 systolic heart murmur on the middle left sternal border and mild cyanosis (O2 saturation=80% by pulse oximetry) were the only findings. Her blood pressure and heart rate were 110/70 mmHg and 100 bpm, respectively. She had no history of stroke, dyspnea, dizziness, and syncope. Electrocardiography was normal, and there was no finding in favor of the enlargement of any chamber. Chest X-ray showed mild cardiomegaly with normal pulmonary vascular markings. Her hemoglobin and hematocrit levels were 14 g/dL and 41%, respectively. Transthoracic 2D echocardiography, via the segmental approach, demonstrated the normal continuation of the inferior vena cava to the right atrium. However, the orifice of the RSVC to the right atrium could not be visualized. Instead, it seemed that the RSVC was draining into the left atrium. The left atrium and the left ventricle were mildly enlarged (). The function of both ventricles was normal. Other echocardiographic findings were mild mitral regurgitation and trivial tricuspid regurgitation. The peak pressure gradient of the tricuspid regurgitation was 20 mm Hg, and there was mild pulmonary valve regurgitation. In addition, there were no intracardiac defects or shunts. The pulmonary veins were connected to the left atrium normally. The diagnosis was confirmed through contrast study with agitated normal saline. Injection via the left brachial vein showed the drainage of the SVC into the left atrium, no atrial septal defect, and no left SVC ( & ). Cardiac catheterization and angiography confirmed a systemic oxygen saturation rate of 80% and a normal pulmonary artery pressure (mean pulmonary artery pressure=15 mmHg). Because transthoracic echocardiography and catheterization confirmed the diagnosis (), there was no need to utilize any other imaging modalitie

[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 70-year-old male presented with an eight month history of looser stools. His medical history included a right lung lobectomy for tuberculosis aged 20, chronic obstructive airways disease and ischaemic heart disease. He was a long-term smoker.
General examination showed him to be well with no lymphadenopathy. No mass was palpable on digital rectal examination. Full blood count, urea and electrolytes and liver function tests were all within normal limits.
Flexible sigmoidoscopy and biopsy identified a rectal adenocarcinoma at 8 cm from the anal margin. MRI showed a normal liver and no para-aortic lymphadenopathy. A moderately bulky tumour was identifiable in the mid/low rectum, 5 cm in length. Local staging with MRI was T2 although the tumour was noted to be very close to the levator plate especially on the left. Perirectal and presacral lymph nodes were seen, the largest of which was 1 cm in short axis. CT scan of the chest did not identify any metastatic disease.
At laparotomy no peritoneal disease, liver metastases or abnormal lymph nodes were seen. A low anterior resection with total mesorectal excision was performed. Recovery was complicated by chest sepsis and prolonged ileus and the patient was fit for discharge on day 14 post surgery.
Microscopic examination showed complete resection margins of a moderately differentiated adenocarcinoma extending through the muscularis propria. Metastatic adenocarcinoma was also identified in one of the twenty one lymph nodes. By UICC staging this was therefore pT3 N1 MX. There was no evidence of extramural vascular invasion. Several lymph nodes showed partial effacement of the normal lymphoid architecture by an infiltrate of small lymphoid cells in which many pseudoproliferation centres were evident.
Immunohistochemical studies confirmed the presence of CD20 positive B lymphoid infiltrate that co-expressed CD5, CD23 and BCL2 and was negative for cyclin D1, CD10 and BCL6 (DakoCytomation, Ely, UK).
This overall picture was co

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


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

[User]
RADIOLOGY NOTE:
A 35-year-old Caucasian female with extensive history of pelvic surgery but without prior urological history underwent robotic-assisted laparoscopic excision of endometriosis by gynecological surgery team secondary to chronic pelvic pain with suspected endometriosis. On initial laparoscopic evaluation of pelvic contents, visible vermiculation of bilateral ureters was noted as well as suspected findings of endometriosis-like lesions covering the pelvic peritoneum. The pelvic peritoneum was excised with sparing of the urinary bladder. Careful ureterolysis was performed bilaterally, during which the distal left ureter was found to be partially denuded, spanning 2 cm in length (). An intraoperative urologic consultation was requested, and denuded ureteral injury was confirmed by urology on laparoscopic evaluation. Given no evidence of ureteral laceration or obvious extravasation of urine from left ureter, no cystoscopy or contrast studies were performed. A 2 cm x 12 cm AmnioFix membrane was wrapped three times around the left ureter using laparoscopic robotic assistance (Figures and ). The procedure was completed without anesthesia complications and the patient was discharged on postoperative day one in stable condition.
The patient was seen by her gynecologist on postoperative day six after experiencing lower urinary tract symptoms and was subsequently started on PO antibiotic therapy. However, her symptoms did not improve, and she developed new left flank pain which brought her back to the hospital for further evaluation on postoperative day seven. She underwent noncontrast CT imaging of the abdomen and pelvis demonstrating moderate left hydroureteronephrosis to the level of the distal ureter. She underwent cystoscopy with left retrograde pyelogram demonstrating 1.5 cm distal ureteral stricture with moderate hydroureteronephrosis (). Continued contrast injection showed a small amount of extravasation from the vicinity of the narrowed ureteral segment (). However, 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 45-year-old female presented with macular extremity and facial rash from a rehabilitation center after having been discharged a month earlier from a revision surgery on her gastric bypass for anastomotic bleeding. The gastric surgery itself had been done four years prior to the presentation. On this admission she was noted to be lethargic for the past few days with neurological assessment revealing a Glasgow Coma Scale [] score at 4, necessitating intubation and mechanical ventilation.
During this time, extensive investigations were done including imaging of the head. The Magnetic Resonance Imaging (MRI) of the brain showed symmetrically restricted diffusion (Figure ) was read as suspicious for hypoxic injury. This stood in contrast to any clinically documented hypoperfusion. Routine blood investigations did not offer a significant clue as her electrolytes, hepatic and renal functions were well within normal limits and the only thing that was seen abnormal was normocytic anemia, which in comparison to her past admissions, was found to be stable without an acute drop. Her thyroid profile, cortisol level, vitamin B12, and ammonia levels were checked for completion of the neurological workup and she was found to have elevated ammonia at 142 micromoles per liter (mmol/L) at the initial check. In the next few days of the critical care admission, she had progressive hyperammonemia to 432 mmol/L, despite treatment with lactulose and rifaximin. Ultrasound exams of the liver done during two different stages of the admission revealed no nodularity or fibrosis.
Continuous Renal Replacement Therapy (CRRT) was initiated despite normal renal function with the express intent to clear the ammonia and observe for improvement in encephalopathy while awaiting the results of extensive laboratory testing including serum levels of amion acids, essential minerals and vitamins to reveal the etiology. MRI (Figure ) was repeated at that time showing worsening of diffusion weighted abnormal

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


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

[User]
RADIOLOGY NOTE:
A 63-year-old female with a history of prior lacunar stroke, hypertension, chronic back pain, and hypothyroidism presented to a community emergency department one hour after the acute onset of severe bilateral lower extremity pain which progressed, within minutes, to bilateral lower extremity generalized weakness and then flaccid paralysis. In addition, within an hour of symptom onset, she developed dull, diffuse abdominal pain with radiation to the bilateral flanks, lasting one hour with subsequent resolution.
At presentation, she was found to have a blood pressure of 131/88 mmHg, tachycardia with a heart rate of 110 beats per minute, oral temperature of 96.8 degrees, F and SpO2 of 97% on room air. The patient presented with 0/5 strength and decreased sensation to light touch and areflexia of the bilateral lower extremities. Noncontrast computed tomography (CT) of the head showed a remote lacunar infarct. CT angiography of the abdomen and pelvis showed no evidence of pulmonary embolus, abdominal aortic aneurysm, or aortic dissection. Surface electrocardiogram showed sinus tachycardia without ischemia.
The patient was transferred to a tertiary care center for advanced imaging and care, where a T2-weighted magnetic resonance image (MRI) showed a nonspecific central intrinsic signal hyperintensity in the conus region extending to the level of T8, concerning for acute spinal cord ischemia (Figures and ). Transthoracic echocardiogram, performed to determine if there was a cardiac source of emboli, showed atypical dyskinesia with left ventricular apical ballooning and an ejection fraction of 35%, a characteristic of neurogenic stunned myocardium (Figures and ). Cardiology was consulted, and a diagnosis of takotsubo cardiomyopathy was made, with no further recommendation for heparinization or catheterization. Pertinent laboratory results are shown in .
The patient was admitted to the neurology inpatient service for supportive care including physical and occupational thera

[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 2-year-old male child was referred from a peripheral hospital to our institute as a case of progressively aggravating dyspnea at rest, cough, intermittent fever, and recurrent chest infections from the last 5 months. The chest X-ray showed a large opacity of the entire left hemithorax (). The child had been put on various antibiotic regimes, but the child's condition worsened day by day. On admission in our institute, the child was in acute distress. On chest auscultation, breath sounds on the left side were absent. There was no adenopathy or testicular mass. Computed Tomography chest was advised which revealed a huge mass occupying the entire left hemithorax with mediastinal shift to the opposite side (). It was adherent to the left anterolateral subcostal pleura and the mediastinal pleura. The lesion showed heterogeneous density. No mediastinal lymphadenopathy, pleural effusion, or thickening was noted. Routine hematological tests and abdominal sonography were within normal limits. Mantoux test was negative. Tumor markers (α-fetoprotein and β-human chorionic gonadotropin) were both normal. Surgical management was first in the priority list of therapeutic options. A left-sided thoracotomy revealed a cystic tumor arising from the left lung. Many adhesions existed with the left pulmonary artery, the left main bronchus, the pericardium, the aorta, diaphragm, and parietal pleura. A combination of blunt and sharp dissection for the division was applied. A purse string suture permitted aspiration of sebaceous content via a small incision in the wall of the mass. As the size diminished, manipulation was facilitated. A pneumonectomy had to be carried out in order to remove the tumor mass. The child was shifted intubated to the Surgical Intensive Care unit in the immediate postoperative period. The child could not maintain oxygen saturation, and his condition deteriorated, and he expired on the second postoperative day. The histopathological examination revealed a benign

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


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

[User]
RADIOLOGY NOTE:
A 63-year-old man, who had had ankylosing spondylitis, was involved in a motor vehicle accident that caused a C6 burst fracture and incomplete spinal cord injury. He presented with marked left paraparesis, particularly weak in his left shoulder and arm. Also, he had had Type 2 diabetes and was wearing a neck collar for cervical spondylosis when the accident took place.
There was a burst fracture of the C6 and a fracture of the lamina in addition to a herniated disc at C5-6 level, which caused spinal cord compression and increased intramedullary signal intensity on T2 weighted magnetic resonance imaging (MRI) (Figure ). In order to improve the spinal alignment, the patient was admitted to the intensive care unit for halo traction prior to surgery. The patient then underwent circumferential decompression and fixation, which involved a corpectomy of C6 and total laminectomies of C3 to C7 with anterior instrumentation of plate and screws and posterior lateral mass screws at C5 and C7 (Figure ). The surgery went smoothly and the hospitalization was uneventful. There was a significant improvement in muscle power, and he was able to ambulate at discharge. The patient had been kept in a neck collar postoperation.
Three weeks postoperation, there was a sudden onset of right hand weakness, the opposite side of his initial presentation. The CT scan demonstrated plate and cage dislodgement that was anteriorly dislocated over the C7 vertebral body (Figures -). There was no dysphagia so we decided to treat him conservatively. He was then put into a halo-vest for immobilization, and his muscle power gradually improved to that of postoperation in a few days. Thus, the patient was discharged to a rehabilitation facility with a halo-vest. At three months postoperation, the patient opted to undergo revision surgery due to the discomfort caused by the halo-vest. Unfortunately, we could only remove the cervical plate rather than restore the corpectomy

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


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

[User]
RADIOLOGY NOTE:
A 75-year-old woman presented to our clinic with diplopia, left-sided excessive lacrimation, a history of chronic rhinosinusitis, and redness of the ipsilateral eye. The patient’s medical history was significant for glioma resection and radiation therapy 8 years before presentation, without evidence of recurrence. After several years, she began experiencing excessive tearing of the left eye, followed by generalized redness. These symptoms began approximately 2 to 3 years before presentation. Diplopia began 6 weeks before presentation. She subsequently underwent a limited functional endoscopic sinus surgery (ESS) at a different facility for suspected infection. Pathology results were nonspecific. On our examination, the patient had strabismus, generalized redness, and moderate ptosis of the left eye, with an otherwise nonfocal neurologic examination result. According to the patient, ptosis and redness worsened over the past year. She had slight exotropia of the left eye and did not have pain or a history of orbital trauma.
A review of previous imaging demonstrated a chronic inflammatory change in the left medial orbital wall and sinuses for several years before presentation. The last computerized tomography (CT) before the operation at a different facility documented erosion of the left medial orbital wall, with loss of the fat plane separating the wall from the medial rectus, and again identified a soft-tissue density in the medial orbit (). Magnetic resonance imaging after the procedure revealed dehiscence of the left lamina papyracea, enlargement of the ipsilateral medial rectus, thickening of nasal mucosa along the medial orbital wall, and a lesion of the left sphenoid sinus (). A CT detected decalcification of the left lamina papyracea. Nasal endoscopy demonstrated crusting and a bulging of the medial orbital wall, with purulent discharge into the nasal cavity (). Cultures from nasal mucosal swab and tissue biopsy were positive for pansensitive Candida tropicali

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


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

[User]
RADIOLOGY NOTE:
A 31-year-old female presented with c/o progressive breathlessness since 6 months and recurrent episodes of cough with streaky hemoptysis since 2 months. She was initially evaluated elsewhere. Fiberoptic bronchoscopy (FOB) showed a tumor mass obstructing the left main bronchus (LMB). A biopsy was inconclusive, and, hence she was referred to our institute for further management. She has had an esophageal stent inserted for corrosive stricture of esophagus 3 years ago.
Chest examination revealed few crepitations in the left base. Complete blood count and liver and renal function were within normal limits. Pulmonary function test showed a restrictive pattern. A computed tomography (CT) scan of the thorax was done, which showed the esophageal stent eroding into the LMB []. There was no evidence of any major thoracic vessel invasion in the contrast CT scan. FOB was performed which showed the stent almost completely obstructing the LMB and mimicking a tumor mass []. Upper gastrointestinal endoscopy was performed in which only the upper part of the stent was visible, and the rest of the stent was embedded into the esophagus and covered with granulation tissue []. Since the stent could not be removed endoscopically, the decision for surgical removal was made after discussion with the thoracic and gastro intestinal surgeons.
The patient underwent thoracotomy with closure of the esophagobronchial fistula along with laparoscopic esophagectomy and gastric pull through. The esophagogastric anastomosis was done in the chest. Postoperative period was uneventful. Repeat bronchoscopy showed a patent LMB. Patient's symptoms improved, and she did not have any hemoptysis after the surgery. She was started on liquid diet 5 days after the surgery, following a gastrografin study which showed no leak.
On the 4th day after starting a liquid diet (postoperative day 9), she developed high grade fever along with cough and breathlessness. Repeat CT scan with oral contrast revealed a microleak a

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


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

[User]
RADIOLOGY NOTE:
A 68-year-old Caucasian male presented with a 2-mo history of worsening intermittent dysphagia, persistent cough, and postprandial retrosternal pain. He also complained of persistent dull pain on the left side of his neck, radiating to his left ear, which was not related to meals.
Suspecting gastroesophageal reflux disease, the patient was started on proton pump inhibitor pharmacotherapy. Upon no relief of symptoms, the patient was referred to an otolaryngologist to evaluate the pharynx with a laryngoscopy; no abnormalities were seen, and therefore the patient was referred to a gastroenterologist. An esophagram was first performed, which showed a voluminous intraluminal lesion within the thoracic esophagus, possibly being a neoplastic process such as a leiomyoma (Figure ). An esophagogastroduodenoscopy was then performed, identifying a polypoid mass, which started at the level of the upper esophageal sphincter with a single stalk and extended all the way down to the esophagogastric junction. The polyp occupied about a third of the esophageal lumen, was heterogeneous in surface appearance, and consistent with a giant fibrovascular polyp; concurrently a small hiatal hernia was also seen. Biopsies from the head of the polyp exhibited benign squamous mucosa with mild acute and chronic inflammation. A computed tomographic (CT) scan of the chest showed a large mass along the entire course of the esophagus (Figure ). After an endoscopic ultrasound excluded the presence of major vessels within the main stalk, endoscopic resection was pursued. While using a flexible esophagoscope to visualize the mass, a snare was passed around the distal end of the polyp on retroflexion and then pulled up around the stalk, which was located on the left side of the esophagus just at the level of the upper esophageal sphincter. The proximal stalk was cauterized and divided with the snare, causing the polyp to drop into the distal esophagus. The polyp was then retrieved transorally using the e

[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 complained of inability to flex his left elbow since 1 year prior to admission. One and a half year before, he fell down and hit his elbow during football practice. He felt pain and there was swelling on his elbow. However, he didn't seek for medical treatment. He had his elbow massaged every week for 5 months but there was no improvement. His elbow became fixed in extended position. A month later, he went to an orthopaedic surgeon and underwent x-ray examination which revealed a fracture and dislocation on his left elbow. He was then referred to our institution for further treatment.
From clinical examination, range of flexion-extension of the elbow was 300-00 with normal pronation-supination. There was no neurological deficit (). From radiological examination, there was a malunion of medial epicondyle with subluxation of left proximal ulna (). From 3D CT reconstruction, there was a deformity and malunion fracture in humeral capitellum with radial and ulnar postero-superior dislocation (). The patient was diagnosed with extension contracture of the left elbow due to malunion of left capitellum, neglected dislocation of the radiohumeral joint, and neglected dislocation of the ulnohumeral joint. The patient was scheduled to have a contracture release, open reduction and internal fixation, and ulnar interposition.
Intraoperatively, we did a posterior approach to the elbow. The ulnar nerve was identified and preserved. The fibrotic tissues and heterotopic ossification were excised. We did a contracture release and open reduction and internal fixation using K-Wire. The flexion and extension of the elbow were evaluated and we managed to get 300 - 130° of flexion-extension ROM. Afterwards, ulnar interposition was performed to prevent ulnar impingement. The wound was closed and a single drain was placed. The elbow was immobilized with back-slab in 900 flexion position for two weeks.
After 1 week, the patient went back to our hospital for follow-

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

[User]
RADIOLOGY NOTE:
The patient is a 62-year-old male with a recent history of left frontal ICH (Fig. , ), hypertension, and atrial fibrillation (not anticoagulated) who presented to the emergency department after a fall due to suspected seizure while in rehabilitation. There was no other history of risk factors related to ischemic or hemorrhagic stroke. At presentation, the patient was unconscious and intubated with pupils that remained reactive to light. Computed tomography (CT) scan of the brain showed a right cerebellar hemorrhage with surrounding edema and mass effect on the fourth ventricle (Figure , ). The patient’s family was counseled and, after review of the potential risks and benefits, consented to the surgical evacuation of the cerebellar ICH.
A suboccipital craniotomy was completed without complication. His hospital course was complicated by Klebsiella pneumoniae pneumonia, and despite treatment for this, he required re-intubation and subsequent tracheostomy and gastrostomy placement due to failure to progress. He was later discharged back to rehabilitation in improved condition.
Radiological assessment regarding the etiology of this patient’s stroke included multiple CT scans, magnetic resonance imaging (MRI) of the brain, including MR angiography of the head and neck, and cerebral angiography. The CT scans demonstrated his prior left frontal ICH and his new right cerebellar ICH at this presentation. His MRI scan did not show any acute ischemic stroke in the cerebellum associated with the new ICH. His cerebral angiography was unremarkable and did not reveal any evidence of vascular pathology or mycotic aneurysms to explain his recurrent intracranial hemorrhages. His blood workup at presentation showed normal coagulation studies and his platelet count was low normal at 119 x 109/L. Post-resection pathology report showed acute intracranial hemorrhage but special stains did not reveal any evidence of amyloid angiopathy or vasculitis (Figure ). Through persistent patient and

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


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

[User]
RADIOLOGY NOTE:
A 59-year-old woman was admitted to the emergency department with sudden onset of chest pain for five hours. She had hypertension (treated with β-blockers) as a cardiovascular risk factor. She was diagnosed with advanced non-small-cell lung cancer with liver metastases one month previously. The patient was not considered for surgical resection, she was scheduled for chemotherapy, and, consequently, no antineoplastic treatment had been initiated yet. Prophylactic anticoagulation was not indicated On clinical examination, her blood pressure was 150/90 mmHg with a pulse of 100 beats per minute, oxygen saturation of 95%, and normal heart sounds. The 12-lead electrocardiogram showed sinus rhythm with a heart rate of 102 beats for minutes and ST-segment elevation in all leads except aVR where ST-segment depression was noted (Figure ). Her laboratory test results revealed a baseline troponin T level of 1212 ng/ml (normal range < 26 ng/ml). Also, the echocardiography findings revealed akinetic walls from the mid to apical septum and anterior and inferior walls. The ejection fraction was estimated to be 39%. Therapy was started with clopidogrel, aspirin, and low-molecular-weight heparin. The patient underwent a coronary angiogram from the right radial approach, which revealed the presence of an extended thrombus in the left anterior descending artery (LAD), and another thrombus was found in the second segment of the right coronary artery (RCA) with thrombolysis in myocardial ischemia (TIMI) III flow and without any atherosclerotic lesions in the coronary artery tree (Figure and Figure ), therefore, balloon angioplasty and/or stent placement was not considered. The patient was taken to the coronary care unit (CCU) and tirofiban infusion was administered for a period of 48 hours. In view of persistent breathlessness, pulmonary embolism was suspected. There were no symptoms or clinical signs suggestive of deep venous thrombosis. A computed tomographic pulmonary angiography was

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

[User]
RADIOLOGY NOTE:
An 82-year-old female patient with a symptomatic gallstones disease and a recent weight loss was admitted to our hospital. The patient’s past medical history was free of other diseases and on physical examination, a Murphy sign was present. The abdominal ultrasound mentioned a large gallstone in the gallbladder and a hypoechoic liver mass. Liver blood tests, including tumor markers CEA and CA 19-9 were normal. Magnetic resonance imaging-magnetic resonance cholangiopancreatography (MRI-MRCP) revealed a liver tumor mass (4.5x3.5 cm) located mainly in segments IVa and VIII of the liver with an extent to segment I (Figure ).
The tumor displaced the adjacent hepatic veins and the inferior vena cava (IVC) without any signs of vessel invasion. There were no signs of liver cirrhosis and no dilated bile ducts or capsular retraction were noted. There was no associated lymphadenopathy. At this point, imaging characteristics were controversial regarding diagnosis. The differential diagnosis tilted in favor of ICC, mainly due to the enhancement characteristics and the absence of liver cirrhosis, as seen in Figure .
The patient was scheduled for exploratory laparotomy with a provisional diagnosis of an ICC. Intraoperatively, a cholecystectomy and lymph node sampling from the hepatoduodenal ligament were performed and both specimens were negative for malignancy on frozen section. Next, the liver was mobilized and the tumor was carefully dissected free of the hepatic veins, the IVC, and the rest of the liver parenchyma. The gross morphology of the liver specimen revealed a solid, grey-yellow liver lesion with a soft consistency. In the center, a light yellow region was noted, as can be seen in Figure .
The frozen section was negative for malignancy. Histologically, the tumor was characterized by a heavy inflammatory infiltrate in myxoid collagen stroma, consisting primarily of plasma cells, lymphocytes, and eosinophils. Fibroblast cells without significant fibrosis composed the str

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


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

[User]
RADIOLOGY NOTE:
This is the case of a 57 year old female who presented to the surgical clinic with a one month history of attacks of right upper quadrant abdominal pain, nausea and vomiting. An abdominal ultrasound demonstrated the presence of cholelithiasis and biliary sludge. The patient was diagnosed with symptomatic cholelithiasis and laparoscopic cholecystectomy was recommended to the patient on an elective basis. At the beginning of the procedure the peritoneal cavity was inspected with no masses, scar tissue or other abnormal pathology noted. During dissection of the gallbladder there were chronic omental adhesions noted but the gallbladder was not acutely inflamed. The cholecystectomy was able to be performed without complication and the gallbladder was sent for histopathological assessment. The pathology report was consistent with metastatic adenocarcinoma with signet ring features consistent with metastatic lobular carcinoma as well as chronic cholecystitis and cholelithiasis (see , ). Breast biomarker studies performed on the gallbladder were significant for PASD positive staining, antibodies that were positive included CK88, CK7, BRST2, and GATA3 (see ). Estrogen and progesterone receptors were both strongly positive, HER2 was negative.
At her follow-up appointment in the office a focused breast history and physical exam was performed. The patient denied family history of breast cancer. Full risk stratification and oncologic workup was pursued. Her BMI was 32.4, age of menarche was 13, her first pregnancy was at age 35, menopause began at 37 years old at which time she briefly was placed on estrogen therapy. She denied family history of cancer. She had a right breast lumpectomy in 2012 with benign pathology. Her last mammogram was in 2018 with no concerning findings at that time. A Gail score was calculated revealing a 12.5 % lifetime risk of breast cancer.
Breast MRI revealed several spiculated masses in her right and left breasts as well as suspicious bilateral axilla

[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 was admitted to hospital with a history of dyspnea at rest for 2 d, a cough producing mucus, loss of appetite and diarrhoea. Pneumonia was suspected, and the patient received intravenous antibiotic treatment. During the patient's second night in hospital, he was found groggy and walking near his room by the nurses. They took him back to his room and connected a new antibiotic dose to his venous catheter. A few hours later, he was found unconscious, lying on the floor next to his bed. His peripheral venous catheter was connected to a nasal cannula delivering O2 from the wall, with a flow rate of approximately 2 L/min, and the antibiotic dose was found in the garbage can. As post-mortem lividity was present, no resuscitation attempts were performed by the clinicians and the death was pronounced. The body was immediately brought to the University Center of Legal Medicine (Lausanne, Switzerland).
Before any manipulation of the corpse, a native CT scan was carried out at around 10 h post-mortem using an eight-row CT unit (CT LightSpeed 8, GE Healthcare, Milwaukee, WI). All scanning parameters are detailed in . A forensic pathologist immediately viewed the native CT images. To evaluate the distribution of gas because of physiological changes in the body after death, the radiological alteration index (RAI) was used as proposed by Egger et al. []. The RAI was based on the analysis of samples from seven sites (heart cavities, liver parenchyma and vessels, left innominate vein, abdominal aorta, kidney parenchyma, L3 vertebra and the subcutaneous pectoral tissues).
All images were interpreted in a consensus reading by one board-certified radiologist and one forensic pathologist who were trained in forensic imaging. A post-mortem radiological report was prepared and described all findings from the native CT scan. The native CT scan revealed the presence of subcutaneous, intramuscular and intravascular gas,

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


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

[User]
RADIOLOGY NOTE:
A 45-year-old male patient reported with a chief complaint of continuous and radiating pain in relation to left maxillary first molar for several days. On clinical examination, the patient’s oral hygiene was found to be fair. Dental examination revealed a left maxillary first molar with a deep carious lesion and there was a full coverage restoration in relation to left maxillary second premolar. The patient also complained of episodes of sensitivity to hot and cold in the involved tooth. Clinical diagnosis was irreversible pulpitis. A preoperative radiograph was obtained []. After detailed clinical and radiographic examination, the left maxillary first molar was prepared for nonsurgical endodontic therapy. After administration of local anesthesia, tooth was isolated with a rubber dam and a conventional endodontic access opening was made []. After removing pulp tissue located in the chamber, four orifices were observed – palatal, mesiobuccal and distobuccal located in regular locations and an extra orifice was located very close to the palatal orifice and was presumed to be a second palatal orifice. The conventional triangular access was modified to a trapezoidal shape to improve access to the additional canal []. The working length of each canal was estimated by means of an electronic apex locator (Root ZX; Morita, Tokyo, Japan) and then confirmed by a radiograph [] and then access was closed with a temporary restoration.
There were no variations like second palatal root/ canal observed in the pre-operative radiograph and working length radiograph suggested that the instrument in the extra canal was an MB2, but at an unusual location i.e., adjacent to palatal orifice.
At the next visit, the canals were initially instrumented with #15 nickel titanium files (Dentsply Maillefer) under irrigation with 5% sodium hypochlorite and 17% EDTA. Coronal flaring was carried out by using gates glidden burs (numbers 3 and 2; Dentsply Maillefer). Cleaning and shaping of the canals

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


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

[User]
RADIOLOGY NOTE:
A 22-year-old male patient, a labour worker by occupation, had presented to our outpatient department with a diagnosis of concomitant nonunion of the shaft and neck of the left femur of eight months duration. On the basis of history and previous records, it was known that the patient had sustained an open grade IIIA fracture of shaft femur and a closed ipsilateral femoral neck fracture of the left side following road traffic eight months prior to the above presentation. The femoral shaft fracture was managed with an external fixator application, and the femoral neck fracture management was delayed due to unhealthy soft tissue conditions around the proximal lateral aspect of the thigh. The treatment of both fractures was further delayed because the patient developed an infection of the open wound of the femoral shaft fracture. To add to the complications, he had developed pin site infection as well. Following that, open debridement of the femoral shaft wound site was performed, and the external fixator was removed at the primary treating institution. Thereafter, the limb was kept splinted on a Thomas splint. Subsequently, the wound and pin sites were healed and the patient was referred to our center, which is a tertiary care center and teaching medical institute, after a total duration of eight months following injury. Clinicoradiological examination confirmed the non-union of the left femoral shaft fracture and ipsilateral femoral neck fracture (Figure ). Blood investigations revealed raised serum inflammatory markers (erythrocyte sedimentation rate (ESR)=25 mm/hr and C-reactive protein (CRP)=12 g/L). However, there were no clinical signs of local inflammation around the fracture sites, the healed wound, and the pin sites. An MRI evaluation of the hip joint and the affected thigh was planned but was deferred as the patient was claustrophobic and not comfortable. Instead, an ultrasound evaluation along the femoral shaft and the hip joint was performed, which revealed

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


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

[User]
RADIOLOGY NOTE:
A 78-year-old male, who had been a patient of the osteopathic family clinic for over 10 years, presented with his wife to discuss a pre-surgical assessment for the placement of an intracranial shunt. He had a past medical history of diabetes mellitus, hypertension, hyperlipidemia, and a stroke in 2013. The stroke resulted in left hemiparesis affecting the lower extremities more than the upper extremities but was followed by a complete recovery. For the past two years, he developed a progressive short-stepped shuffling gait with hesitancy occurring with turning and swaying only to the right side while walking. Additionally, he described nocturia with increased bladder frequency and urgency and subjective memory difficulty without any mental impairment. The patient ambulated with a cane and stated that his biggest concern was swaying to the right with a fear of falling. He described difficulty in turning and freezing due to this feeling of loss of balance. The patient denied dyskinesias, hallucinations, nightmares, tremors, headache, or nausea. His most recent MRI suggested stable mild-to-moderate diffuse ventriculomegaly. He was referred to a neurologist at NYU Langone who diagnosed NPH and subsequently was referred to a neurosurgeon at Columbia Presbyterian who deemed the patient a candidate for a surgical shunt.
Due to his hesitancy toward the recommended invasive procedure, the patient agreed to try craniosacral therapy to relieve the NPH prior to getting the shunt recommended by the neurosurgeon. The patient tolerated the first osteopathic therapy session well and returned to the office one week later. He stated that he noticed a significant improvement with his gait two to three days after the first session, but symptoms had slightly returned towards the end of the week. A second craniosacral session was performed, and the patient felt an improvement in his NPH symptoms after the therapy.
Craniosacral therapy sessions were conducted one week apart lasting 15 min

[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 76-year-old Caucasian woman was admitted with a 2-week history of intermittent colicky lower abdominal pain associated with bilious vomiting and mild abdominal distension. She was previously diagnosed with left breast cancer 18 years ago for which she had undergone an oncological wide local excision, focused external beam radiotherapy and adjuvant treatment with tamoxifen for 5 years. Unfortunately, she developed regional recurrence with bony metastases 17 years following her original diagnosis. She was treated with palliative chemoradiotherapy and had an excellent response to treatment.
Physical examination revealed an elderly lady with stable vital signs. The abdomen was mildly distended with tenderness and guarding noted in the peri-umbilical region. Laboratory investigations, including haematological, biochemical, inflammatory and coagulation profiles, were all within normal limits.
A plain abdominal radiograph was also unrevealing. She proceeded to have computerized tomography (CT) scan of her abdomen and pelvis, which showed dilated small bowel loops consistent with small bowel obstruction. There were two filling defects noted, one in her proximal ileum suspicious for a non-calcified gallstone and the second distally in her terminal ileum (Figs and ). Appearances were suggestive of gallstone ileus. She was adequately resuscitated and underwent a laparotomy. The small bowel was narrowed in two segments: proximally secondary to an impacted gallstone and an area of stricturing noted distally. Both segments were resected with end-to-end anastomosis performed in a two-layer standard hand-sewn fashion. The clinical impression was one of dual pathology including Crohn's disease and gallstone ileus. She did not undergo a cholecystectomy or repair of her cholecystoduodenal fistula. She made an uneventful post-operative recovery and was discharged home well on Day 7.
Histopathological examination of the resected specimens showed a 3-cm intraluminal gallstone within th

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


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

[User]
RADIOLOGY NOTE:
A 32-year-old, nonsmoker, systemically healthy man presents to our clinic with the chief complaint of an opening at the extraction site of the upper right first molar (). The extraction had been performed more than 3 months previously, and since that time, the patient could not eat properly because the food would exit from his nose. Radiographs were taken, and a diagnosis of chronic OAF was acquired (). The patient was advised to undergo surgery to close the opening and eliminate the communicating tract between the oral and nasal cavities. A written and informed consent form was obtained from the patient for surgery and publication of the data. Under local anesthesia, a three-sided flap was created; the bone was then exposed, and a large bone defect (greater than 5 mm) was found (). The soft tissue tract was removed, and bone curettage was performed with a spoon excavator and a round bur drill. Slow-resorption collagen membrane extracted from bovine tendon containing collagen type I (Genoss, Gyeonggi-do, South Korea) was used to cover the bone defect and was fixed in place with nylon suture (). PRF was prepared after blood was withdrawn from the patient (40 mL) and centrifuged for 14 minutes at 1,500 rpm. A PRF clot was isolated from the middle part of the test tube between the red blood corpuscles at the bottom and the platelet-poor plasma at the top; the PRF clot was filtered from the plasma in the form of a thin membrane. The PRF clot was placed above the collagen membrane in two layers (). Periosteum scoring was performed with flap release. Primary closure of the tension-free flap was performed with 4/0 nylon suture. Horizontal and vertical mattress suturing was performed with interrupted stitches between layers (). The patient was given antibiotics (amoxicillin/clavulanate 625 mg, metronidazole 500 mg) and an analgesic (ibuprofen 400

[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 57-year-old man who had lost his teeth because of caries, and had been referred to the dental school of Tehran university to replace them by implants in 2005. He had a history of controlled high blood pressure and controlled diabetes. Clinical examination showed that teeth number 18, 19, 30 and 31 had been lost. A comprehensive treatment plan was given to the patient and he was first referred for endodontic, periodontal and restorative treatment of the remaining teeth, and then for placement of dental implants.
Implant surgery was preformed under local anesthesia (2% lidocaine, 1:100000 epinephrine). On the right side of the mandible, two Replace Select wide platform implants (10mm × 5mm), were placed in teeth 30 and 31 positions. A 10mm × 4.3mm Replace Select regular platform implant was placed in tooth number 19 position on the left side of the mandible and for position 18, a Replace wide platform implant (10mm × 5mm) was inserted.
There were no complications during implant placement. The type of bone in the implant areas was type 1.
A post-operative antibiotic regime of 500mg amoxicillin was prescribed three times daily for 7 days, 400mg gelofen 4 times a day for 3 days and a chlorhexidine mouth rinse 2 times a day for 14 days was also prescribed for the patient. The sutures were removed 10 days later. After initial healing and taking a panoramic radiograph an appointment was set for the patient for impression taking, but he did not refer until 6 years later, in 2011, to continue the treatment. After clinical examination, the implants on the left mandibular side were healthy, BOP was negative without suppuration, with a pocket depth of 2 to 3 mm and without a radiographic sign of bone loss. However, on the right mandibular side, implants 30 and 31 had 7 to 9 millimeter pockets, respectively and were BOP and suppuration positive

[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-year-old Brazilian woman presented with a cutaneous ulcer on her left ankle and was treated in the Division of Infectious and Parasitic Diseases, Hospital das Clínicas, University of São Paulo, Medical School, São Paulo, Brazil. She reported had been receiving various drugs to control rheumatoid arthritis, diagnosed several years before. The treatment schedule included 25 mg of methotrexate intramuscularly once a week for two years, 5 mg of prednisone orally and daily for five years, and chloroquine 400 mg orally and daily for two years. During her childhood, the patient used to live in an endemic county for cutaneous leishmaniasis (São Lourenço da Serra - São Paulo) and described the presence of a long-lived skin ulcer, which had appeared at that time and diagnosed as cutaneous leishmaniasis. At examination, the lesion presented as a painful, foul smelling, and edematous 8 cm-diameter ulcer in the fibular malleolus region, which showed fibrin but without infiltrated edges (A). Another atrophic circular scar has also been found on the left pretibial region. Histology of the biopsy obtained from the border of the lesion was compatible with a venous stasis ulcer with intense granular tissue and scarring (B). The patient had started empirical treatment with piperacillin, tazobactam and clindamycin. The patient developed fever, but with no growth in blood cultures. The patient’s treatment was altered to imipenem 500 mg/ day for 7 days resulting in improvement in the patient’s condition and renal function. During the investigation, Leishmania PCR analysis from the aspirate of the lesion was positive (C), resulting in treatment with 3 mg/kg/day of a liposomal amphotericin protocol for ten days (total cumulative dose of 35 mg). The possible reactivation of the cutaneous leishmaniasis diagnosed during her childhood was considered at this point. During the last few doses, amphotericin treatment was discontinued due to worsening of the renal function, but the treatment 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 71-year-old male presented to our Emergency Department with a short history of reduced vision and pain in the left eye. His only known previous ophthalmic history was of corneal foreign body removal 45 years previously although previous medical history included peripheral vascular disease, ischemic heart disease, chronic obstructive pulmonary disease, and osteoporotic vertebral fractures. Initial ophthalmic assessment revealed vision of light perception only, with an inferior descemetocoele and positive Seidel test. His right eye was unremarkable with no evident corneal pathology. Emergency tectonic keratoplasty was performed and culture of samples taken at the time of surgery revealed skin flora only. Recovery following tectonic keratoplasty was complicated by a nonhealing epithelial defect which necessitated an amniotic membrane graft. Eight months following surgery, the patient developed a graft rejection episode; poor concordance with topical steroid medication being a likely contributing factor.
Four weeks following this rejection episode, he presented again with a painful, injected left eye. Visual acuity remained at hand movements only. Anterior segment examination revealed a large, central, white corneal infiltrate within the tectonic keratoplasty []. A 1 mm hypopyon was present. An initial corneal scrape failed to identify a causative pathogen, and there was no clinical response to topical antibacterial and antifungal medication. A further corneal scrape revealed tiny, fine colonies of long Gram-positive rods [], consistent with mycobacteria. Subsequent auramine phenol staining was positive. Line probe assay of mycobacterial genetic material (Genotype Mycobacterium CM, Hain Lifescience) was performed, which resulted in the diagnosis of M. chelonae.
Treatment was commenced with topical cefuroxime, amikacin, and gentamicin supplemented by oral linezolid. Following 1 month of therapy, an epithelial plaque and significant scarring remained, so the patient und

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


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

[User]
RADIOLOGY NOTE:
A 68-year-old female Asian patient was admitted to our hospital with epigastric pain and jaundice for 1 week. Before admission, the patient had noted epigastric pain after eating greasy food, especially affecting the upper right abdomen with sustained pain. Gradually jaundice accompanied by darker urine and white, clay-like feces had appeared. She was diagnosed with cholelithiasis and obstructive jaundice in the local clinic, and concurrent anti-inflammatory treatment had been undertaken and her condition improved. Since the onset, she had no nausea or vomiting, no chills or fever, no significant weight loss. She had no appreciable loss of appetite. She had a 20-year history of gallstones. Physical examination showed yellow sclerae, flat abdomen, slight tenderness in the right upper abdomen, no guarding, and no rebound tenderness. The results of laboratory studies are shown in . In addition, hepatitis B surface antigen and hepatitis C virus antibody were negative.
Ultrasonography showed an atrophic gallbladder that was full of stones. Enhanced CT scanning of the upper abdomen demonstrated a smooth liver edge and uniform liver parenchyma, as well as dilatation of the intrahepatic bile duct and the upper pancreatic duct. The gallbladder was irregularly shaped, with thickened walls and uneven internal density. Radiologic observations indicated the presence of cholecystitis and gallstones; biliary stones were observed in the hilum, with secondary biliary obstruction (). MRCP revealed dilatation of the intrahepatic bile ducts and the left and right hepatic ducts, as well as truncation of the common hepatic duct (internal diameter was 5.1 mm). Multiple faint signals were seen in the common hepatic duct and gallbladder (). The MRCP results indicated the presence of cholecystitis, cholelithiasis, common hepatic duct stones, and ascites. The radiologist did not suspect MS or left hepatic atrophy pre-operatively. However, our surgical team had considered the possibility of MS

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


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

[User]
RADIOLOGY NOTE:
A 69-year-old female patient present to our hospital with right upper abdominal severe pain for several hours after a fall. It was accompanied by fatigue. Her upper abdominal CT scan showed intrahepatic round cysts with the largest of size 14 cm × 16 cm. Irregular high-density shadows were seen on the edges of the cysts (). She was initially diagnosed as hepatic cysts with hemorrhage and underwent puncture and drainage of liver cysts. About 600 mL of dark red liquid was drained from the largest of the liver cysts, which improved the symptoms, but the cysts relapsed quickly. She underwent partial hepatectomy (fenestration of hepatic cysts), cholecystectomy and T-tube drain placement in the common bile duct. During the surgery, we found a large cyst large cyst of 20 cm diameter occupying the right lobe of the liver. The common bile duct was dilated about 1.5 cm. We resected the thinner part of the cyst wall and about 2000 mL of bile-like liquid mixed with blood clots and fresh blood were drained. Blood clots were mostly concentrated at the thicker part of the cystic wall and we biopsied the thicker cyst wall. Postoperative pathological report was simple hepatic cyst. 10 days post-operatively, the patient was complaining about paroxysmal abdominal pain which was also colicky. She had flatus but no defecation. Conservative treatment was in vain and hence, on POD 11 she underwent laparotomy as intestinal obstruction was suspected. It was observed that the transverse colon was wrapped around the T tube in the abdominal cavity. There were adhesive tissues due to which the intestine and transverse colon were folded. The adhesive tissues were relieved. 17 days after the surgery, the patient was discharged. 68 days later, the patient came back complaining about right upper abdominal pain and jaundice. Conservative management had no effect. Her CT scan shows a mixture of density at the liver which may be hemorrhage, recurrence

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


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

[User]
RADIOLOGY NOTE:
Patient B is a 76-year-old white male who presented with microscopic hematuria in 1986 on a routine urinalysis and a diagnosis of left RCC was made by imaging. He then underwent nephrectomy for a 7 × 6 × 5.5 cm tumor extending though the fascia into the perinephric fat. He did well until March of 2006 when he had a routine chest X-ray that showed new lung nodules and a CT scan was ordered. A large retroperitoneal mass posterior to the stomach measuring 10 × 9 × 8 cm was also found along with bilateral lung nodules, with the largest lung lesion measuring 2 cm. Biopsy of the retroperitoneal mass confirmed RCC. MRI of the brain and bone scan was negative. He was seen for the first time at our institution in April of 2006. He was determined to be a candidate for high-dose IL-2 (600,000 IU/kg). After 8 weeks, he did show some response, but was only able to tolerate half of cycle 2 and he declined further IL-2. He was then started on sorafenib and had a minor response at all disease sites until CT scan in January 2007 after 24 weeks showed progression. He was then switched to sunitinib 50 mg daily for 4 weeks of a 6 weeks cycles, and after 12 weeks on therapy had a significant response which he enjoyed until week 54 when CT scanning showed marked disease progression. Sunitinib was discontinued and in January of 2008 he was started on temsirolimus 25 mg IV weekly. He required a 20% dose reduction for thrombocytopenia and oral ulcers. He remained on temsirolimus until April of 2008 when he developed symptomatic mTOR interstitial pneumonitis, so temsirolimus was discontinued. His disease continued to progress off therapy and in October of 2008, bevacizumab 10 mg/m2 given every 2 weeks was started as fifth line therapy. After 24 weeks of treatment the patient was found to have a pulmonary embolus. Lovenox was started and bevacizumab was continued without incident. At the time of submission

[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:
RC is a 62-year-old male who initially presented with a T3N2M0 midrectal cancer and underwent neoadjuvant chemoradiation four weeks prior to a laparoscopic low anterior resection with diverting loop ileostomy. He completed adjuvant chemotherapy and returned for an elective reversal of his ileostomy nine months postoperative. His preoperative workup included a colonoscopy which revealed exclusion colitis for which he was treated. He also underwent a gastrografin enema and computed tomography (CT) imaging of his abdomen and pelvis with no evidence of recurrence, obstruction, or distant metastases. On CT imaging, the proximal ileum appeared normal, but the distal ileum was not imaged. After his reversal, his postoperative course was complicated by persistent small bowel obstruction, for which he was managed conservatively for two weeks. He subsequently underwent a CT abdomen and pelvis, which was highly suspicious for anastomotic stricture.
On postoperative day 14, the patient underwent a diagnostic laparoscopy showing multiple adhesions around the previous reversal site with normal-appearing dilated proximal and collapsed distal small bowel. There was no localized stricture in the defunctionalized distal ileum. He underwent a resection of the prior reversal site and creation of a new side-to-side primary anastomosis. Despite creation of new anastomosis, his small bowel obstruction continued for additional two weeks. CT imaging and small bowel series were obtained, both modalities showing a narrowing of the ileum distal to the previous anastomosis (Figures and ). On hospital day 27, the patient underwent a final exploratory laparotomy with intraoperative findings of persistent collapsed bowel loops distal to the new anastomosis. The collapsed distal segment was resected, and an ileocolic anastomosis was created. On gross examination, the entire distal ileum was thickened without stricture (Figures and ). The pathology of the distal ileum showed submucosal fibrosis with

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


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

[User]
RADIOLOGY NOTE:
This report presents a case of aggressive periodontitis in a 23-year-old female who had previously received periodontal therapy. She was presented to the Department of Periodontics, Seoul National University Dental Hospital in 2004 with the chief complaint that her gums had been swelling (). She requested for dental treatment to address the issue of gum swelling and tooth mobility. Her medical history was unremarkable. Subsequent clinical and radiographic examination led to the diagnosis of generalized aggressive periodontitis (, ). The patient reported of becoming aware of swelled gums and mobile teeth when she was at the age of 13. At that time, she had received scaling and root planning in conjunction with systemic antibiotics which were periodically repeated through the years with no definitive results.
In 2008, the patient was referred to the Department of Prosthodontics for evaluation and treatment planning. The objectives of treatment were patient motivation and education, improvement of oral hygiene, improvement of esthetics, and a stable and predictable outcome.
All teeth including the canine in the maxilla and left mandibular lateral incisor through right mandibular canine, and left mandibular second premolar were extracted.
Initially fixed prosthesis using implants in the maxilla were planned, but rapid and severe bone resorption after extraction was observed. Because the maxillary lip required additional support as a consequence of bone loss, the fixed prosthesis treatment plan for the maxilla was changed to an implant-supported overdenture. Facebow transfer and mounting on the casts on the articulator were performed for the diagnostic wax-up procedure.
The remaining teeth in the mandible were prepared for the fixed partial prosthesis. A provisional complete denture in the maxilla and provisional fixed partial dentures in the mandible was delivered. A computerized tomography scan with implant stent was taken to select suitable implant sites in the maxill

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


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

[User]
RADIOLOGY NOTE:
A 40-year-old female presented with chronic headache with infrequent exacerbations. She presents with worsening headache for three months with associated vertigo, nausea, and vomiting not responding to analgesics or vestibular sedatives. Her symptoms initially started twelve years ago as a diffused mild headache, which persisted through the day. Gradually, the headache worsened to a severe headache episodically associated with vertigo, nausea, and vomiting. These episodes lasted for two to three days and got resolved. She was treated with flunarizine for suspected basilar migraine but did not show any response. From the last year, she had monthly exacerbations of headache associated with distressing vertigo, unsteadiness of gait, and right-sided body numbness. In between these episodes, she had a significant dull diffuse headache not responding to simple analgesia. She did not complain of fever or night sweats but had constitutional symptoms lasting for several months. All of these symptoms severely affected her daily activities and functionality.
During the last 17 years, she had repeated episodes of neurological deficits. Even before the headache appeared, she has presented with visual impairment of the right eye and right lateral rectus palsy and was treated as retrobulbar neuritis with good response to methylprednisolone. One year later, she developed left-sided visual impairment, which fully responded to methylprednisolone. MRI imaging at that time revealed normal results. Few months after this event, she got admitted with right hemisensory loss with hemiplegia, and a demyelination disease or hemiplegic migraine was suspected. Second MRI was performed at this admission, and no abnormalities were detected again. Eight years ago, she had developed a left lower motor type facial nerve palsy, which was attributed to Bell's palsy. Within the last year, she was diagnosed to have depression and anxiety for which she was treated for few months. Other than the first two

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


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

[User]
RADIOLOGY NOTE:
A 48-year-old male with a past medical history of cystic acne, but otherwise insignificant medication and social history, presented with concern for a parasite on his face. He reported that on the previous night he thought a parasite had crawled out of a healed cystic lesion on his right cheek. He presented a jar with a bloody napkin and paper, stating that he had scraped the parasite from his face with a scalpel and brought it with him to the ED. His physical exam was notable for diffuse excoriations and scaly patches, a 3 × 4 centimeter (cm) abrasion on his right cheek and mild anxiety. Otherwise his vital signs and physical exam were unremarkable.
No obvious parasites were appreciated on examination of his skin or in the jar. Basic blood tests including a complete blood count (CBC) and basic metabolic panel were within normal limits. A urine toxicology test was evaluated and reported negative. During his stay, the patient called a provider to the bedside to evaluate his thumb for a parasite actively crawling out of his skin. The provider documented that no obvious insects or wounds were apparent at that time. Delusional parasitosis was suspected and psychiatry was consulted, but the patient eloped from the ED prior to being evaluated.
The patient returned to the ED two days later with a complaint of parasitic infection. This time he described seeing white maggots crawling from his skin and presented us with a jar with a flaky material. The patient presented to the outpatient infectious disease (ID) clinic and was directed to come to the ED to obtain a formal ID consult. Although there was low clinical suspicion for an infectious component, ID was consulted for the presumed benefit of reassurance from a consultation service. The flakes presented by the patient were analyzed for ova and parasites and reported to the patient as negative. He was then evaluated by psychiatry who reported that his presentation was consistent with

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


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

[User]
RADIOLOGY NOTE:
A 56-year-old female without comorbidities and a 50-pack-year smoking history was referred to the emergency department with a severe right frontal headache. The onset was abrupt and the preceding symptoms and signs included nausea and ataxic gait. Neither cranial nerve abnormalities nor focal limb weakness was spared. Initial laboratory values were within the reference range. The patient underwent a magnetic resonance imaging (MRI) which revealed multiple nodular lesions throughout both cerebral and cerebellar hemispheres with an unusual lamellated pattern of enhancement. The demonstrated significant vasogenic edema did not led to midline-shift (Figures –). Chest X-ray detected opacity with a lobulated contour in the right upper lobe (). A contrast-enhanced chest computed tomography (CT) showed an ill-defined mass in the anterior segment of the right upper lobe and right hilar lymphadenopathy (). No additional abnormalities were observed on subsequent detailed metastatic work-up including abdominal CT and whole body bone scintigraphy. Due to the neurological symptoms, the patient underwent whole-brain radiotherapy (WBRT). Fractionation of 3 Gy per day was used, reaching a total dose of 30 Gy in two weeks; in addition, the patient received intravenously dexamethasone during WBRT. The performed bronchoscopy detected a bulging lesion located at the membranous portion of bronchus of the anterior segment of the right upper lobe. The lesion did not appear to be covered with normal bronchial mucosa. Subsequently, a biopsy was performed (), and the histopathology showed infiltration by atypical melanocytes containing melanin pigmentation (Figures and ). Positive immunohistochemical staining of MART-1, S-100 protein, and HMB-45 and lack of expression of cytokeratin (CK), epithelial membrane antigen (EMA), synaptophysin (Syn), and high molecular weight cytokeratin confirmed the diagnosis of pulmonary melanoma. Molecular profiling was conducted which failed to detect any mutat

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


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

[User]
RADIOLOGY NOTE:
A 66-year-old Hispanic female presented with vague abdominal pain and exertional chest pain. She had a ten-year history of worsening epigastric pain attributed to gastritis that was treated with Dexilant. A general physical exam was done and did not reveal any significant abnormalities; she also denied any fevers, chills, weight loss/gain, or change in bowel habits. Environmental history was noncontributory as she denied extensive sun-exposure or use of tanning beds and reported that she regularly would use sunscreen with a 30 SPF. Still, there was an extensive past medical history for anemia, diabetes mellitus type II, coronary artery disease, asthma, hypertension, hyperlipidemia, hemorrhoids, and osteoarthritis. She also had a broad surgical history, involving a coronary artery stent in the left anterior descending artery [2016], percutaneous transluminal coronary angioplasty [2016], tubal ligation [1985], cholecystectomy [2007], bladder prolapse repair [2012], rectal prolapse repair [2012], hysterectomy [2012], and total right knee replacement [2013].
There is no report of primary tobacco use; however, she does report an extensive second-hand smoke exposure as a result of her biological father. Her family history is significant for multiple cancers, with her father dying of cancer related complications from a head and neck malignancy at the age of 65. The patient's sister died of breast cancer at the age of 44 and half paternal sister also died of breast cancer at the age of 38. Lastly, her brother died of colon cancer at the age of 70 and her mother's death at the age of 67 was due to a myocardial infarction unrelated to cancer. Interestingly, her eldest daughter was diagnosed with melanoma found in a cutaneous lesion, in 2016. Her physical exam did not reveal any concerning skin lesions or palpable abdominal lesions and her vitals were stable.
A near total gastrectomy was performed and multiple adhesions from prior surgeries were divided at the beginning 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 19-year-old girl presented to our outpatient department with a swelling of the tongue of 1-year duration, which was initially slowly growing but later started progressing rapidly in the past 3 months. She was complaining of inability in the movement of the tongue leading to difficulty in speaking and chewing of food. This also resulted in nasal regurgitation of food. She was not suffering from any co-morbid conditions.
On examination, her general health was fair (Eastern Cooperative Oncology Group performance status was 1). On intra-oral examination, there was a lobulated swelling involving the entire tongue with an intervening ulcer and there was restriction of the tongue movement. Multiple bilateral level 1A and 1B nodes of varying sizes were palpable and which were fixed to the underlying structures. The largest node was around 3 cm in size, which was on the left side (clinical staging was T4bN2cM0).
Examination of the skin, abdomen, respiratory system, cardio vascular and the central nervous systems were found to be normal. Magnetic resonance imaging (MRI) of the tongue showed an enhancing mass of more than 5 × 4 cm in its greatest dimension. The mass involved both sides of intrinsic as well as extrinsic muscles with loss of definition of lingual septum []. Extension of the mass was seen into the right-sided sublingual space with encasement of the neurovascular bundle which was also extending anteriorly to the tip of tongue. There was no bony erosion. No extensions were seen into the carotid and bucco-masticator spaces. Magnetic resonance imaging of the neck showed metastatic cervical lymphadenopathy at the level I, II, III, IV on the left and level II on the right []. Clinically, the diagnosis of the lobulated swelling with an ulcer on the tongue, was that of an infiltrative epithelial malignancy or a minor salivary gland malignancy. Limitation of punch biopsy in this case was the presence of a limited intervening area with ulceration on the tongue swelling,

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


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

[User]
RADIOLOGY NOTE:
A 52-year-old male with a one-year history of renal cell carcinoma was admitted for routine follow-up. The general physical examination and laboratory tests were normal. We observed hypodense-hypovascular cystic lesions with thin septi in the uncinate process and body of the pancreas, and the pancreas measured 5 cm in diameter on the abdominal CT scan (). Contrast-material enhanced MRI revealed numerous diffusely distributed cysts with thin septi, and these cysts ranged in size from a few millimeters to 14 mm in diameter in the body and uncinate process of the pancreas. Contrast-material enhancement in the pancreatic lesions was not observed on the postcontrast (arterial and portal venous phase) T1 weighted (W) images (). The main pancreatic and extrahepatic bile ducts were normal on the T2W sequences. Our preoperative diagnosis was "cystic neoplasm of the pancreas", and pancreaticoduodenectomy was performed by general surgeons.
Macro- and microscopic examination revealed numerous cysts ranging from 2 to 12 mm in diameter with a thin translucent wall in the body and head of the pancreas. The tumor was 5 cm in diameter. The internal surface of the cysts was pink, smooth and glistening and the surface of the cysts had no solid areas or papillary projections. There was no discrete tumoral lesion, necrosis, calcification or hemorrhage observed on further examination of the pancreas (). The duodenum was normal in appearance.
Microscopic examination revealed numerous small and large cysts diffusely distributed throughout the pancreatic tissue. The cysts seemed to develop from the surrounding acinar tissue and they were lined by cells with the typical features of normal acinar cells. There were disseminated patchy acinar structures within some small and large cyst walls (). The small cysts were lined by a single layer of bland cuboidal or columnar acinar cells with tendency for crowding. Their nuclei were basally located and regular, and they contained small nucleoli. 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 31-year-old man came to our emergency room seeking medical attention for severe neck pain. He informed us that 2 days before, after excessive consumption of alcohol, he had made an incision into the skin of his penis below the frenulum by means of a needle in order to insufflate air into the opening with a standard ball pump (fig. ) for autoerotic purposes. He had been suffering from severe pain in the neck area since the morning.
Below the frenulum, a reddened incision of approximately 5 mm in diameter could be seen which extended into the hypodermis. Apart from that, the penis was without pathological symptoms such as swelling, hyperthermia or redness. Also, the penis was not rigid and there were no crepitations. In the neck area and on the remaining trunk, crepitations could be felt. This was where the patient's pain was located, radiating dorsolaterally from the cervical area into the trapezius muscle.
The psychological exploration of the patient's sexuality clarified that he had distinctive sadomasochistic masturbation fantasies. The patient had not pursued these sadomasochistic thoughts so far because he had not been aware of them.
The laboratory results were unremarkable. Because the patient was capable of spontaneous and pain-free micturition and the external examination showed no anomalies, a cystoscopic examination of the urethra was not carried out. A CT examination of the abdomen revealed generalized subcutaneous emphysema extending from the scrotum to the abdomen and the cervix (fig. ).
The patient was admitted for observation. He received antibiotic treatment with a gyrase inhibitor in order to avoid an infection of the area around the frenulum. The medical focus was on the neck pain caused by the air gradually travelling through the hypodermis from the genital area to the cranial area. The pain was stabilized without difficulty by means of metamizole. After 2 days, it was no

[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 80-year-old woman complained of visual disturbances in her right eye that began in July 2002. She did not have a history of any systemic illness, and there was no family medical history of any disease. In 2001, she had undergone a peripheral iridotomy on the right eye for angle closure glaucoma, and she developed the pseudoexfoliation syndrome. Her postoperative intraocular pressure (IOP) in the right eye was 12 mmHg. The depth of the anterior chamber of the left eye was normal and the IOP was 11 mmHg.
In May 2002, although the IOP in her left eye was 12 mmHg, the right IOP was 22 mmHg, and we concluded that she had ocular hypertension secondary to the pseudoexfoliation syndrome. We began topical latanoprost in the right eye, and the IOP decreased to 13 mmHg by June. The IOP in the left eye remained at 12 mmHg. In July, she returned reporting visual disturbances and monocular double vision. The lens was partially dislocated in the right eye. At this time, the IOP in the right eye was 20 mmHg and the left eye was 10 mmHg. The right lens had a mild cataract. There were no clear glaucomatous changes in the optic discs, and no other specific findings. The Goldman perimetric fields were full.
To examine the effect of latanoprost on the position of the lens, we stopped the latanoprost for two weeks. The IOP was measured with a Goldman applanation tonometer one hour before and after topical latanoprost, and the position of the lens was assessed by slit-lamp biomicroscopy. In addition, ultrasound biomicroscopy (UBM) was performed to measure any changes in the thickness of the ciliary body []. (Figure )
One hour after one drop of 0.005% latanoprost, the right IOP decreased from 20 mmHg to 17 mmHg and the IOP in the left eye was reduced from 10 mmHg to 7 mmHg. Slit-lamp bi

[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 5-year-old girl was referred to our hospital for the investigation of urinary incontinence. The patient had continuous low volume urine leakage requiring 4–5 daily pads. The parents could not specify whether there was any connection with standing, coughing, or effort and she had no urge to void.
She was constantly wet but had normal voiding habits. On initial physical examination the external genitalia appeared normal with no vaginal pooling of urine or ectopic ureteral orifice. However, a long-term external genitalia examination revealed normal urethral and vaginal openings, with an intermittent urine leakage through the vaginal orifice, which slightly increased in abdominal pressure.
In her past history she had recurrent febrile urinary tract infections (UTIs) since her infancy. At the age of 3 she underwent an abdominal ultrasound that suspected a double left kidney. A voiding cystourethrogram (VCUG) was performed and a vesicoureteral reflux (VUR) grade III on the right kidney was found. She was given chronic chemoprophylaxis without any UTI recurrence. She had a good toilet training and gave up daytime diapers around the age of 3. At this moment parents noticed the urinary incontinence, but this didn't bother them. At the age of 4 parents asked a urologist for help, who considered the symptoms to be the result of an overactive bladder and anticholinergic treatment was recommended. No improvement was noticed, and for this reason the little girl was sent to our department for further investigation.
Complete blood count, biochemical tests, and urinalysis were all normal and the urine culture was negative.
An abdominal ultrasound was performed and both kidneys had normal parenchyma and size, with a duplex-system suspicion on left side; the bladder was normal in appearance. The VCUG was repeated but no VUR was visualized. As we had a high suspicion of an ectopic ureter a contrast-enhanced computed tomography (CT) of the abdomen and pelvis was performed to visualize

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


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

[User]
RADIOLOGY NOTE:
A 38-year-old woman was admitted to the emergency room for a clinical picture characterized by the episodes (duration 5–10 min) of atypical chest pain irradiating to the upper left limb. The patient reported previous cocaine and heroin abuse and current smoking of about 20 cigarettes per day. Body mass index of 31 was calculated. The electrocardiogram (ECG) showed normal ECG pattern, and the high-sensitivity troponin I resulted normal on several determinations.
Since 2006, the patient underwent serial echocardiographic examinations that revealed and confirmed alleged bicuspid aortic valve (BAV) with no aortic dilation and mild aortic regurgitation.
In her past clinical history, the patient reported noncomplicated peptic ulcer and chronic gastritis, lymphatic adenopathy of undetermined etiology, and recurrent episodes of anorexia/bulimia and panic attacks, treated with antidepressants – selective serotonin reuptake inhibitor, valproate, and diazepam. She reported two pregnancies: one child was diagnosed with right-sided aortic arch congenital anomaly and cleft palate and the other one was in good health status. Patient's father died from myocardial infarction at the age of 55, and her mother was affected by systemic hypertension.
At admission to our unit, the clinical examination revealed regular heartbeat and 2/6 levine diastolic murmur; blood pressure was 140/80 mmHg and SpO2 was 98% breathing room air. The ECG showed sinus rhythm, and no abnormal findings were detected: the ECG pattern was overall normal and ventricular repolarization was actually within the normal limits; no changes on ECG were detected when compared to previous ones performed in the emergency room.
A transthoracic echocardiography (TTE) was performed: biventricular systolic function was considered normal, ejection fraction was estimated 60%, no wall motion abnormalities were found, and left ventricular dimensions were within the normal limits; according to age and body surface area (LVIDd: 53 mm

[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.