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

[User]
RADIOLOGY NOTE:
A 26 year-old man attended our ophthalmic ward in April 2017 with intermittent bleeding of the right eye, from which there was also strong odor. The patient was a heavy smoker but had no other underlying conditions. He had no history of drug-use. From his medical history it was noted that the patient had undergone a right ophthalmectomy 24 years previously due to retinoblastoma, and implantation of an artificial right eyeball in 2014 (timeline shown in Additional file ).
On admission, his pulse rate was between 80 and 100 beats/min. His body temperature and respiratory rate were both normal. Physical examination showed narrow conjunctival sac in right eye and the exposure of ocular prosthesis, which was discharging a yellow-green secretion along with a strong odor. The visual acuity of left eye was 0.3, and the intraocular pressure was 15 mmHg. All other characteristics of the left eye were normal. A auscultation did not show any abnormality in the lungs, and no signs of carotid murmur were found. Interestingly, laboratory investigations did not reveal abnormal inflammatory markers such as leukocytosis or any increase in neutrophils or C-reaction protein. According to clinical and laboratory investigations, infectious endocarditis was not suspected. The patient had no history of other immunosuppressive conditions, except smoking and a retinoblastoma 24 years previously. The patient did not report any direct contact with animals; however, he did work in a clothing factory so would have been contact with wool and cowhide for one month of the year. Three months had elapsed between the patient last coming into contact with wool and cowhide and the appearance of clinical symptoms. Considering the results of these investigations, partial artificial eye infection, especially anaerobic organism infection, was suspected.
Imaging workups were completed, which included chest x-ray, transthoracic echocardiography and eye magnetic resonance imaging. As shown in Fig. , eye magnet

[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 81-year-old male presented for consideration of vertebral augmentation due to diagnosis of stage IV, metastatic prostate adenocarcinoma, and worsening back pain. Lupron therapy was initiated at diagnosis four months prior. Docetaxel treatment was planned for six cycles but was subsequently stopped after the first cycle secondary to side effects. No radiation therapy was previously given. PSA level was 120.73 at diagnosis and 0.6 before radiofrequency ablation.
At the first appointment, the patient reported mild back pain and required a walker but was able to ambulate without difficulty. He did have pain upon palpation of the thoracolumbar junctional level. He did not have any neurologic deficit at presentation. Computed tomography (CT) scans showed 40% compression deformity of T12. Magnetic resonance imaging (MRI) showed pathologic involvement of T12 and L1 and metastatic involvement of the epidural component, resulting in 40% spinal canal stenosis (Figure ). At this time, vertebral augmentation was recommended although it was believed the epidural component would not be addressed and Radiation Oncology would need to be consulted. In a short period of two months, the patient’s condition deteriorated where he was wheelchair bound due to severe pain, not controlled with NSAIDS or opioids. In addition, repeat studies showed further tumor infiltration involving T11, prompting augmentation of T11, in addition to T12 and L1.
The procedure was performed under monitored anesthesia care (MAC) and fluoroscopic guided imaging. Under this image guidance, 10-gauge introducer needles were advanced into the T11, T12, and L1 vertebral levels using a bilateral transpedicular approach (Figure ). A drill and osteotome were used to create cavities at the anterior aspect of the vertebral bodies. Bilateral 17-gauge bipolar radiofrequency probes were advanced into the vertebral cavities and simultaneous application of radiofrequency energy was performed as part of the protocol for volu

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


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

[User]
RADIOLOGY NOTE:
A 65-year-old woman was admitted to the ICU with acute respiratory distress and circulation insufficiency. Besides a history of Waldenstrom’s macroglobulinemia that had not required active treatment, she had no history of health problems, infections or recent hospitalisations. She was a lifelong non-smoker, lived in a rural home with her husband, and handled firewood for home heating. Four days prior to admission the patient noted fever, chills, dyspnoea with dry cough and diarrhoea. On the day of admission, these symptoms were more severe, and an ambulance had been called because of syncope. Her ability to oxygenate deteriorated progressively during the first hospital day, and she was intubated and mechanically ventilated.
Chest X-ray on admission showed bilateral diffuse lung infiltrates and signs of interstitial oedema. Large bilateral pleural effusions were noted, and >1000 ml were drained. Echocardiographic examination identified normal left ventricular wall motion, and no signs of structural abnormalities or of pulmonary hypertension. Thin-cut CT images of the lungs on the third ICU day showed diffuse bilateral alveolar and interstitial infiltrates with dependent consolidation (Fig. ). The clinical course during the first seven days was dominated by respiratory insufficiency requiring maximal ventilatory support with high levels of inspired oxygen, as well as circulatory shock requiring treatment with vasopressor and inotropic infusions. Other important clinical aspects included coagulopathy with diffusely spread petechiae, progression of renal failure with anuria requiring dialysis, and elevated levels of LDH (Table ). She was treated presumptively for bacterial pneumonia and sepsis with a series of broad spectrum antibiotics and corticosteroids, without apparent response.
Hantavirus infection was verified with the detection of PUUV RNA in plasma (630,000 copies/ml) on the day of admission, while IgM and IgG were negative. Seroconversion with positive IgM 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 67-year-old man with a history of chronic obstructive pulmonary disease, cerebral vascular accident, necrotizing pancreatitis complicated by pseudocyst requiring splenectomy and heart failure with preserved ejection fraction was transferred to our hospital following one month of treatment for pneumonia. He was a distant alcoholic but had since gone through rehabilitation and admitted to drinking one time per week and smoking four cigarettes a day. He had previously presented to his primary care physician with fever and malaise and was diagnosed with community-acquired pneumonia. He was treated with five days of azithromycin. He continued to worsen, and was admitted to an outside hospital with hypoxemia and right lower lobe pneumonia for which he was started empirically on vancomycin and piperacillin-tazobactam. His hospital course was complicated by respiratory failure requiring intubation for three days and a recurrent exudative right lung loculated effusion that required decortication and placement of a catheter that remained in place for two weeks. All blood and pleural fluid cultures were negative.
On transfer to our hospital for physical rehabilitation, the patient complained of mild shortness of breath. He denied hemoptysis, chest pain, orthopnea, nausea, chills or night sweats. Physical exam was significant for bilateral rhonchi with signs of consolidation in the right lower lobe. His labs were notable for a white blood cell count (WBC) of 17,000 cells/mcl with 87% neutrophils, and a chest radiograph revealed a right middle lobe infiltrate. He was continued on intravenous (IV) vancomycin and piperacillin-tazobactam at admission. Over the next two days his WBC climbed to 21,000 cells/mcl. Computed tomography scan of the chest revealed a right-sided empyema with extensive bilateral airspace disease consistent with severe pneumonia. A new chest tube was placed, which drained dark brown exudative fluid with gram-positive cocci on gram stain. The fluid was cultu

[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 non-hypertensive diabetic male, farmer by profession, presented with complaints of blackish discoloration of distal part of the left foot for 15 days predominantly involving four small toes. He had similar blackish discoloration of left great toe for last one month, which was amputated 15 days back in a local hospital. He also complained of ulcerative wound over the distal part of left foot and amputated great toe (Figure ). He was diagnosed as a case of uncontrolled type-2 diabetes mellitus with poor glycemic control on irregular oral hypoglycemics for five years. He had a history of claudication pain in lower limbs for the last one year, which gradually progresses to pain even at rest and loss of sensation of digits for the last three months. He is a chronic smoker and alcoholic for the past 20 years. There was no history of fever, pus discharge from the distal lower limb, chest pain, blurring of vision, blackouts, or abdominal pain.
On clinical examination, there were no signs of pallor, icterus, pedal edema, lymphadenopathy, clubbing, or cyanosis with random blood glucose of 344 mg/dl. Extensive ulceration and necrosis were present over the ankle, heel, and great toe region of left lower limb along with blackish discoloration of second to fifth toes. The peripheral arterial pulses were not palpable in all major peripheral arteries of both lower limbs. Computed tomograghy (CT) angiogram of lower limbs showed high-grade occlusion and luminal narrowing in almost all major arteries of both lower limbs. The provisional diagnosis was made as bilateral lower limb peripheral vascular disease due to uncontrolled diabetes mellitus. The patient was planned for above-knee amputation of left lower limb.
The patient had developed few episodes of mild grade fever, for which automated blood culture was collected and sent to the microbiology laboratory. The bottle was loaded in BacT/Alert Virtuo system (

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


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

[User]
RADIOLOGY NOTE:
A 15 year old male patient presented with a chief complaint of swelling in the mandibular anterior region for 20 days. There was moderate swelling in the chin area, which was nontender and had firm consistency with ambiguous margins. There was no history of trauma and he also had no complaint of fluid, blood, or pus discharge from the swelling. There was no relevant medical history of any disease, especially endocrinal disturbances. He was physically and mentally healthy and not under any medication.
On clinical (extraoral) examination, the swelling existed in the lower third of the face extending from the right to the left parasymphyseal region. Superiorly, the swelling was obliterating the mentolabial sulcus and up to the lower border of the mandible. The overlying skin was normal in color and texture but was stretched. The margins of the swelling were diffuse. On a profile view, there was a slight prognathic appearance []. On palpation, the swelling was firm, nontender, and with a normal temperature.
Intraoral examination revealed an oval, nontender, and firm swelling, measuring 7 cm × 5 cm in size, which was extending from the right second premolar to the left first premolar with buccal and lingual cortical plates expansion. Superiorly, the swelling was at the level of the gingival margins of the anterior teeth. There was no restriction in tongue movements or difficulty in swallowing. The overlying mucosa was nonadherent and with normal color and texture. Severe mesial tilting of all four incisors and mild mesial displacement of left canine and first premolar along with the two right premolars was noticed. The patient had retained his right deciduous canine. No caries was detected. All four anterior teeth were nontender on percussion with Grade I mobility. All findings of inspection were confirmed by palpation.
Mandibular occlusal radiograph revealed a well-circumscribed unilocular radiolucency with radio-opaque border extending from the right second molar to

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


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

[User]
RADIOLOGY NOTE:
A 38-year-old, gravida 0 woman presented to the gynecological emergency room with complaint of severe, constant low abdominal pain (VAS 8). She denied any radiation of pain, fever, chills, nausea, or vomiting. No urinary symptoms, vaginal discharge, or bleeding were presented. She was in middle cycle and was not taking any contraceptive. She reported dysmenorrhea and painful intercourse the last year such as Chlamydia infection ten years earlier.
Three days before, the patient experienced sudden onset of severe, right lower quadrant pain and presented to the emergency surgical department where she was treated for suspect renal colic and urine infection. The pain recurred the next day and became continued. One year ago, the patient was admitted to surgical department for renal colic and during her hospitalization a CT scan was performed and showed an elongated cystic mass on the right adnexa.
On physical examination, focal tenderness was presented in the right lower quadrant. On pelvic examination, right ovarian tenderness was noted and there was no cervical motion tenderness. Complete blood count and urinalysis were normal, CRP was 47, and urine pregnancy test was negative. Endocervical swabs were obtained and were negative.
Sonography examination showed a normal uterus and a normal left ovary. A small amount of simple free fluid was present within the Douglas pouch. A cystic mass measuring 8 × 4 × 3.5 cm was thought to arise from the right adnexa or ovary. Carefully examination demonstrated that the tubular cystic structure was separated from the ovary and was presenting two ecographic features: the first one was a fusiform, thick-walled cystic mass resembling a hydrosalpinx and the second one had the appearance of a cyst containing blood. Differential diagnosis included isolated torsion of Fallopian tube, paraovarian cyst, hydrosalpinx associated with tube-ovarian abscess, or endometrioma. CT examination did not add useful information; the mass was similar at the

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


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

[User]
RADIOLOGY NOTE:
We describe the case of a 34-year-old gravida II para l woman, with a gestational age of 26 + 3 weeks at admission, who had a relatively healthy 4-year-old child with her 40-year-old husband of non-consanguineous marriage. She had been on injectable contraception for 2 years and had regular menses for 6 months before the pregnancy. She had antenatal care at a local health center and was vaccinated with tetanus toxoid once and supplemented with iron for 3 months. She was screened for retroviral infection, hepatitis, and syphilis and it was documented nonreactive. She had no anatomic scan at early gestation. She came to Felege Hiwot Referral Hospital with the chief complaint of severe and persistent headache of a day’s duration which was occipital in location associated with blurred vision and generalized body swelling of 1 week’s duration. She had no other danger signs in pregnancy. Her past gynecologic history, medical history, and surgical history were uneventful. She is Amhara by ethnicity. She had no known family history of hereditary or chromosomal disorders.
Her blood pressure at admission was 180/120 mmHg and pulse rate was 84 beats per minute; her respiratory rate was 22 breaths per minute and she was afebrile. She had pink conjunctiva and non icteric sclera, 24 weeks-sized gravid uterus, no abdominal tenderness, no organomegaly, no sign of fluid collection in her abdomen, and the fetal heart beat was positive. She had no vaginal bleeding or discharge. She had pedal and pretibial edema. She was conscious and oriented to person, place, and time. Her deep tendon reflex was +2 and her motor and sensory examinations showed no motor or sensory problems. Other parts of systemic examinations were normal.
Her hypertension was controlled with intravenously administered hydralazine 5 mg two doses at our emergency department. In her complete blood count her white blood cells were 7300 cells/micL,

[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 male not known to have any chronic medical illness, presented complaining of epigastric and left upper quadrant pain for 1 month, associated with intermittent nausea and vomiting, and aggravated by fatty meals, with no other associated symptoms. He had frequent visits to the emergency department where he was managed with analgesia and antacids with mild symptomatic improvement. Clinical examination was unremarkable with no evidence of jaundice or abdominal tenderness. His blood test results showed a normal complete blood count, kidney function, and liver function. Chest X Ray revealed dextrocardia with stomach fundic gas shadow on Right side (). Abdominal ultrasonography revealed transpositioning of the solid organs with a left sided liver and gallbladder with a solitary stone and mild wall thickening. We elected to perform a Magnetic Resonance Cholangiopancreatography to delineate the anatomy and to rule out any anomalies within the biliary tree. It confirmed the previously noted findings, showed no evident anomaly within the biliary tree, and confirmed the diagnosis of situs inversus totalis (, ). The patient was Scheduled for an elective laparoscopic cholecystectomy.
The Operating room equipment arrangement was adjusted as Mirror Image of Routine Laparoscopic cholecystectomy (). The Monitor was placed on left side of the patient. The surgeon with the camera assistant were on right side of the patient and the first assistant was on left side of the patient. The abdomen was scrubbed and draped in the standard aseptic technique. The first infraumbilical 11 mm trocar introduced and pneumoperitoneum induced using the open technique. Three 5 mm trocars were placed, at the xiphisternum which was used for the surgeon’s left hand, at the left midclavicular line 2 cm below the costal margin which was used as working port for the surgeon’s right hand and at left anterior axillary line 5 cm from the costal margin which was used for retraction 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:
An 8 days old male neonate was born to an Asian mother through vaginal delivery at 37 weeks of gestation, weighed 2,380 g, and had APGAR scores of 9 and 10 at 1 and 5 min, respectively. He was admitted to our hospital with a 2 days history of fever of up to 39°C but did not have respiratory or gastrointestinal symptoms. The infant's family denied any medical history and TB contact. His physical examination at admission documented smooth respiration, clear breathing sound, and no hepatosplenomegaly. The complete blood count indicated a total white blood cell count of 17,500/μL with 69% neutrophils, 20% lymphocytes, 9% monocytes, and 2% eosinophils. The C-reactive protein level was 7.3 mg/dL. The findings of the cerebrospinal fluid (CSF) analysis were normal. Bacterial cultures of the blood, urine, and CSF were negative. Intravenous antibiotics, namely cefotaxime and ampicillin, were administered after admission on the basis of suspicion of neonatal fever. Despite the administration of the antimicrobial combination therapy, the fever persisted and the neonate developed abdominal distension when he was 12 days old. Abdominal radiography exhibited nonspecific dilated bowel loops. Because no improvement in the condition of the patient was observed after changing antibiotics, infection caused by some virus and other atypical pathogen, including Mycobacterium tuberculosis, was considered. Tests for herpes simplex virus, Epstein–Barr virus, cytomegalovirus, hepatitis B virus, rubella, Chlamydia trachomatis, and Toxoplasma gondii were all negative. The repeat C-reactive protein level was elevated to 14.4 mg/dL. Coagulopathy with 323.7 μg/mL of abnormal fibrin degradation product and more than 20 mg/L of D-dimer were also noted. Antibiotics were switched to vancomycin and ceftazidime empirically. Chest radiography displayed only increased right lung field infiltration when the infant was 12 days old (), and chest computed tomography (CT) imaging exhibited a large amount of ri

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


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

[User]
RADIOLOGY NOTE:
A 31-year-old Bosnian male with an unremarkable health history was originally seen in early October 2015 at a walk-in medical clinic after he noticed a change in his voice for 3 weeks. The patient had no smoking history, no prior occupational exposures, was an infrequent social drinker and worked as an assistant manager at a convenience store. Initially he thought the hoarseness was secondary to an upper respiratory tract infection and surprisingly did not notice the neck mass until it was pointed out to him (Fig. ). The physician who examined him at the time felt a large mass in the left anterior portion of the neck and followed up with a neck ultrasound. The neck ultrasound was unremarkable revealing a homogeneous thyroid gland with no solid or cystic soft tissue masses along with normal appearing lymph nodes on both sides of the neck.
Two days later he presented to the emergency department because of increasing hoarseness and mild dysphagia. The department of Otolaryngology Head and Neck Surgery was consulted. At the time of consultation, the patient appeared to be in no airway distress and had normal vital signs. On physical examination, a palpable mass was felt on the left side of the neck. The rest of the head and neck examination was unremarkable. Laboratory investigations were ordered and included CBC, serum ionized calcium, thyroid stimulating hormone, free T4 and T3 and calcitonin. These laboratory findings were all within normal limits with the exception of a slightly elevated T3 level. Direct fiberoptic nasopharyngolaryngoscopy was performed and revealed a supraglottic mass involving the left vocal cord causing immobility (Fig. ). The mass appeared to be submucosal in nature and did not affect the right vocal cord. He was then admitted for observation and further workup for diagnostic purposes.
A CT scan with contrast was performed and showed a 5 × 5.7 cm laryngeal mass centered on the left thyroid cartilage, which was completely destroyed (Fig. ). It di

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


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

[User]
RADIOLOGY NOTE:
A 26-year-old female with a past medical history significant for hypertension and chronic renal insufficiency treated without hemodialysis presented to the emergency department with moderate to severe headaches associated with bilateral visual disturbances. The onset was nine days prior to presentation and was described as a right frontal headache with gradual loss of vision in the right eye, followed by vision changes in the left eye. She reported seeing only hand movement with the right eye, and finger counting only with the left eye. She also had neck pain, chest pain, numbness in both hands, and mild shortness of breath, but denied any other symptoms. Specifically, she denied fever, chills, recent injury, numbness, weakness, or undergoing any spinal procedure. She also acknowledged she went to a hospital out of state a few days prior to the presentation where was evaluated for a “stroke” and confirmed she did not have one and received a CT scan of the brain. On the day of presentation, she noted her left-sided vision was getting worse, so she decided to get a second opinion. Her mother was noted to have had similar symptoms when she was 28 and was diagnosed with a “stroke,” and had received spinal taps.
On physical examination, the patient was found to be morbidly obese with a body mass index (BMI) of 38. Her initial vital signs were blood pressure 196/141 mmHg, pulse 80 beats per minute, respirations 16 breaths per minute, temperature of 36.8° C, and oxygen saturation of 98% on room air. She could not read the top line of the eye chart. The vision in her right eye was grossly reduced to hand waving only. She had light perception, an afferent pupillary defect, and abducens nerve palsy. The left eye vision was grossly reduced to finger counting only. Extraocular movements were intact. There was a mild proptosis. The pupil was mildly dilated and sluggish

[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 healthy boy underwent an office-based surgical circumcision by his physician. During the procedure, profound bleeding was observed that was not controlled by applying direct pressure. The physician attempted to control the bleeding by multiple deep suturing; the bleeding was stopped successfully and the patient was discharged home. During the postoperative period, the child had progressive painful and difficult voiding with only few drops of urine after straining. During this period the child was prescribed painkillers for his discomfort and no additional evaluation was done. After about a week he was referred to a district hospital with fever (temperature=38.1C), agitation, vomiting, urinary retention, and significant abdominal distension. Abdominal examination showed decreased bowel sounds, dull percussion, and severe guarding. Urgent abdominopelvic ultrasound revealed large volume of free fluid in the abdomen and pelvis, with small amount of urine in the bladder. The initial lab tests also showed leukocytosis with left shift and increased blood creatinine and blood urea nitrogen. Catheterization with a 6-Fr feeding tube failed because it did not pass beyond the subcoronal urethra. The patient underwent emergency midline laparotomy with the diagnosis of acute abdomen and the fluid was drained. A small intraperitoneal bladder rupture was noticed at the dome of bladder. The gastrointestinal tract was inspected precisely and was intact. The diagnosis of intraperitoneal bladder rupture with urinary ascites was made probably due to near-total urethral obstruction. The rupture site was repaired in two layers and a suprapubic cystostomy catheter was fixed.
Two months later, the patient was referred to our center for further evaluation and treatment. Antegrade voiding cystourethrography (VCUG) was performed via the suprapubic catheter that showed terminal urethral obstruction (). Urethroscopy was attempted under general anesthesia that failed due to complete

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


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

[User]
RADIOLOGY NOTE:
A 32-year-old male construction worker fell off a ladder sustaining a type A4 fracture of the L2 vertebra. On admission, there were no neurological deficits except for painful paresthesias in both lower limbs, right over left. No signs or symptoms of cauda equina compromise.
After an initial X-ray investigation of the spine that showed the L2 fracture, computed tomography (CT) imaging, and magnetic resonance imaging of the lumbar spine were performed.
These investigations revealed a type A4 fracture with the involvement of both cranial and caudal endplates as well as interruption of the posterior wall. The spinal canal was severely stenosed just below the level of the conus [Figures and - and ].
Considering the segmental kyphosis and the severe canal narrowing as well as the need for early mobilization for maintenance of muscle trophism and performance, we listed the patient for surgery by pedicle screw and rod fixation.
Under general anesthesia and muscle relaxation, the patient was positioned prone on two separate silicone-foam blocks, one of semi-cylindrical shape under the mid-upper chest and the other of wedge shape under the upper thighs and pelvis. In between these two supports, the abdomen is completely free which not only allows for better ventilation and reduced venous pressure but is also crucial in permitting the maximum amount of positional lordosis. Subsequently, and still, before sterile draping, a fluoroscopy C-arm was brought in to identify the fracture in the lateral projection. Two operators would now hold the patient at both ankles and under the armpits and apply simultaneous traction in the craniocaudal directions []. Traction force is applied at maximum intensity for 3–5 s after which a lateral image is performed to check for any reduction. If no or only little reduction is visible on the fluoroscopy image, the procedure is repeated a couple of times with the attempt to hold the simultaneous traction some seconds more.
With this

[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 male with no previous history of heart disease was admitted with rest dyspnoea, found to be due to acute heart failure. He had felt fatigued with progressive limitation of exercise tolerance over the preceding 3 months. Symptoms were exacerbated by an upper respiratory tract infection one month before hospitalization. The patient was treated with antibiotics without noticeable improvement. The patient's mother had died suddenly at the age of 44 with a dilated cardiomyopathy of unknown cause for which she had had a pacemaker implanted.
On admission, the patient was cachectic with a body mass index of 17 and in poor general condition, with rest dyspnoea, tachypnoea of 30/minute and tachycardia of 130/minute. His liver was enlarged, there was evidence of pulmonary oedema and a systolic murmur, maximal at the apex.
Blood analysis showed elevated liver enzymes (aspartate aminotransferase 192 units/L; alanine aminotransferase 400 u/L and creatine kinase 510 u/L) and mildly elevated Troponin I and C-reactive protein levels. Chest X-ray confirmed pulmonary oedema and showed an enlarged heart shadow. Sinus tachycardia and left bundle branch block with QRS duration >200 ms were present on electrocardiogram.
Echocardiography on admission revealed significantly enlarged left ventricle and both atria, severe hypertrophy of both ventricles muscle without left ventricular outflow tract (LVOT) obstruction. Moderate tricuspid and severe mitral valve insufficiency, decreased left ventricular (LV) ejection fraction to 30% with global hypokinesis were observed.
The patient was referred for cardiovascular magnetic resonance (CMR), which was performed on a 1.5 T system with 4 element torso coil. Oxygen was supplied by mask throughout the study at a flow rate of 3 l/min. Function was assessed with steady state free precession (SSFP) sequence in short axis slices covering the ventricles and in 4-chamber, 2-chamber and LVOT orientations. Perfusion was assessed at rest only in

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


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

[User]
RADIOLOGY NOTE:
A 31-year-old Brazilian woman presented to our Surgery Department of Oral and Maxillofacial Surgery for evaluation of cystic lesions in her teeth 13 and 15 and a swelling on her right maxilla (Fig. ). In her anamnesis, she reported that she had already had endodontic treatment for her teeth 13 and 15 without regression of the lesion. Her teeth 14 and 24 had been previously removed for orthodontic treatment. A radiographic and computed tomography (CT) examination showed a radiolucent lesion, diffuse, of approximately 20 mm, involving the teeth 13 and 15. The initial diagnosis was inflammatory periapical cyst (Fig. ).
She underwent preoperative laboratory tests and an excisional biopsy of the lesion was undertaken under general anesthesia. The choice of the use general anesthesia was due to the size of the lesion and possibility of enucleation without removal of the teeth involved. The collected material was sent for pathological examination. The result was compatible with CGCL (Figs. and ), which differed from our diagnostic hypothesis. After the definitive diagnosis, she was advised to carry out regular monitoring because of the risk of recurrence.
She self-monitored for a period of 10 months; she then presented again with a complaint of swelling on the site, but without the presence of pain. A new CT scan was requested and indicated recurrence of the lesion, which now involved the region’s incisor, canine, and premolar (Fig. ). New laboratory tests were carried out: alkaline phosphatase, calcium, phosphorus, and parathyroid hormone (PTH). We ruled out the possibility of the lesion being compatible with Brown tumor of hyperparathyroidism. A possible loss of the four dental elements involved was not ruled out.
We proposed new treatment with intralesional corticosteroid injections to our patient in an attempt to reduce the lesion for a future enucleation. She was given a drug application schedule: nine applications in the affected regions with intervals of 15 days bet

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


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

[User]
RADIOLOGY NOTE:
A 43-year-old male patient presented to hospital, complaining of volume growth of the tongue with numbness for the past 1 month before consultation. The patient reported a long-term smoking and drinking habit.
This study was conducted with the approval of Medical Ethics Committee of Chongqing Cancer Hospital, and was performed in accordance with the ethical standards of the Helsinki Declaration. Written informed consents for his data and images to be used for our study and publication were obtained from patient before operation.
On intraoral clinical examination and palpation, an obvious smooth firm mass of about 2 cm in diameter on the mobile tongue with the same color as that of the surrounding mucosa was observed without other oral lesions. The cervical lymph nodes were not swollen on palpation. A biopsy was carried out and histopathological analysis demonstrated tissues formed by adenoid cystic carcinoma. Computed tomography (CT) of the head and neck enhanced scanning revealed an ill-defined measuring 23 mm × 19 mm high density mass with altered enhanced signal entities involving the anterior 2/3rd of the tongue. There was no obvious abnormality in the adjacent mandibular bone. No obvious enlarged lymph nodes were seen in both sides of the neck (Fig. ). The doppler ultrasound indicated that the submental and bilateral submandibular lymph nodes were all reactive.
The patient was positioned supine and then general anesthesia was given through nasal intubation. Incision was placed over the anteriorly till 2/3rd of tongue after emptying cervical lymph nodes at levels I–III ipsilateral to the tumor, and then the anterolateral femoral free flap (ALFT) was used to repair the defect of tongue and preserve the swallowing and speech function. During the intervention, a preventive tracheotomy was carried out to ensure breathing (Fig. ).
A histopathological examination defined ACC with a cribriform pattern. As is typically observed in ACC, the present case was positive for

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


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

[User]
RADIOLOGY NOTE:
A 23-year-old Asian man was referred to the ER of Xiamen Chang Gung Memorial Hospital with a 1-day history of right-sided chest pain that had been aggravated for 1 hour. He had no known medical illnesses and was well until the evening prior to presentation, at which time he developed obvious right-sided chest pain radiating to his ipsilateral shoulder with persistent chest tightness. This tightness was described as sticking in nature, significantly worse on deep inspiration and with movement, and relieved by leaning forward or lying down. There was an associated dry cough but no hemoptysis. There was no history of trauma, injury, difficulty in breathing, or palpitations. He was tall and thin and described himself as otherwise quite healthy. He had never previously been admitted to a hospital. He reported no significant chronic medical history, such as primary hypertension, any type of heart disease, disturbed microcirculation, peripheral neuropathy, diabetes mellitus, an impaired immune system, malignancies, leukemia, the long-term administration of corticosteroids, liver cirrhosis, renal failure, urinary tract infection, or hemodialysis. He also reported no history of infection, such as tuberculosis, any type of hepatitis, or acquired immunodeficiency syndrome (AIDS). There was no prior history of traumas, blood transfusions, surgical procedures, or other serious events in his medical history. He had not lived in an epidemic area and had no history of toxin or radioactive exposure. He denied a personal or family history of bleeding diathesis but reported a 10-year history of smoking 8–10 cigarettes per day. He was an office worker by occupation. He had experienced similar symptoms on one occasion 4 years previously. No abnormalities were detected at that time, and his symptoms resolved.
A physical examination (PE) revealed a young man who was awake and alert but in mild to moderate painful distress. His respiratory rate was 22–26 breaths/minute with an oxygen satur

[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:
This is a case of a 54-year-old African American man with DPA with an unusual location of his initial tumor and whose management required further assessment of metastasis and need of addressing a lateral positive margin. The patient initially presented to clinic in 2012 with complaints of a six-year history of a bump on his left ankle. The patient described the bump as a non-painful mass that had been steadily enlarging over the past several years. There was no history of ulceration, redness, or discharge from the site and the patient denied any constitutional symptoms. On physical exam, the patient had a skin mass approximately 0.5 cm in diameter on the lateral dorsum of his right foot. The mass was freely mobile, non-erythematous, and smooth. At the time of his initial presentation, he expressed interest in surgical removal of the mass. The patient was lost to follow up prior to his surgery and presented to the clinic again in 2014 with the same complaint and indicated that the mass had now grown in size. The patient again denied any constitutional symptoms. The patient underwent excisional biopsy of this lesion. Pathological examination of this specimen demonstrated a 2.0×1.7×1.5 cm circumscribed unencapsulated dermal-based mass with a homogenous tan cut surface. Microscopically, the lesion proved to be an adenocarcinoma with ductal differentiation and predominantly cribriform pattern. Occasional mitotic figures and foci of comedo-like necrosis were present. The histologic findings were diagnostic of DPA (). The cauterized lateral margin was positive for tumor. Given the natural history associated with this diagnosis and the positive surgical margin, colonoscopy and positron emission tomography (PET) were ordered. Colonoscopy was negative for malignancy. There was no history of physical findings suggestive of thyroid or breast malignancy. PET demonstrated a focus of intense activity in the right iliopsoas muscle neighboring the right femoral neck that was thought

[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 25-year-old female patient presented to our institution with symptoms of melena and presyncope. Her medical history included a cholecystectomy and a combined splenectomy and partial pancreatectomy (carried out due to idiopathic thrombocytopenic purpura without postoperative complications of note). An endoscopy was performed, which demonstrated gastroesophageal varices with a large esophageal varix and bleeding gastric varices (Fig. a). Her religious denomination was that of a Jehovah's Witness, and she declined blood transfusion. Given the active bleed and limited conservative treatment options, the varices were treated via cyanoacrylate injection with successful hemostasis.
However, shortly after the procedure, she was found to be obtunded with neurological deficits, and an immediate noncontrast CT brain and CT cerebral angiogram demonstrated small, scattered bilateral hyperdensities correlating with glue emboli (Fig. b). The patient did recover neurologically despite a follow-up magnetic resonance imaging confirming multiple subacute infarcts.
This embolic ischemic stroke prompted evaluation for a right to left vascular shunt. Initially, an echocardiogram with an agitated saline contrast bubble study was performed, which did not demonstrate a patent foramen ovale.
Endoscopic ultrasound was performed, which demonstrated an extensive gastroesophageal variceal matrix but could not identify a specific vascular shunt. Contrast-enhanced CT of the thorax and abdomen was then performed, which demonstrated a PPVA connecting a large paraesophageal varix to the left inferior pulmonary vein (Fig. c). This study also demonstrated a diminutive right branch of the portal vein, although the main portal vein was normal in appearance.
The patient continued to experience symptomatic anemia requiring iron transfusions and erythropoietin. A decision was made to perform transhepatic portal venography with the aim of definitive identification of the PPVA and potential subsequent coil

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


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

[User]
RADIOLOGY NOTE:
A previously healthy 2-year-old boy presented at the emergency department of a local hospital with persistent pain and oral blood loss after an unwitnessed fall. Immediately afterwards, he was found crying with only the base of a toothbrush in his hand. The head of the previously intact toothbrush was missing. During initial inspection of the oral cavity, the bleeding had stopped and no abnormalities were seen by the otolaryngologist. Although the parents repeatedly expressed their concern about their son's persisting abnormal behavior and the still missing head of the toothbrush, the patient was discharged with instructions to return to the hospital in case of a fever and/or recurrent blood loss. That same night, the boy started vomiting fresh blood and was taken to the hospital by ambulance. Again the bleeding had stopped spontaneously but the persistent character of the blood loss initiated a reinspection of the oronasopharynx under general anesthesia by an otolaryngologist. This revealed the missing head of the toothbrush () lodged horizontally in the lateral walls of the nasopharynx with its sharp end embedded in the left lateral pharyngeal wall. It was removed without problems, making a small lesion visible in the left pharyngeal wall. The patient was successfully extubated and transferred to the pediatric ward.
Several hours afterwards however, he started vomiting large amounts of blood again, rapidly leading to progressive lethargy, tachycardia, and severe hypotension. Because of life-threatening hypovolemic shock with a hemoglobin level of 2.9 mmol/L, large amounts of intravenous saline and an unmatched blood transfusion were given. Crash reintubation followed, and during a second reinspection of the oro- and nasopharynx the bleeding again had stopped spontaneously. The site of the previous blood loss could not be identified. A Bellocq tampon was left in place and given the hemodynamic instability, and the still unknown origin of the massive bleeding the pa

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


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

[User]
RADIOLOGY NOTE:
A 72-year-old man was referred to our clinic with severe bilateral ectropion. In 2015, an abdominal mass was detected in the left lobe of the patient’s liver during his follow-up. The mass was biopsied and pathologically diagnosed as cholangiocellular carcinoma for which he was maintained on treatment with capecitabine, 500mg daily, after the completion of gemcitabine and cisplatin combination regimen. At the end of the 3rd month of capecitabine treatment, the patient noticed increased tenderness and progressive bilateral ectropion in addition to upper lid shortening, hyperpigmentation, and cutaneous sclerosis around the head and neck region. He was consulted to the dermatology department for further assessment, and an incisional skin biopsy was planned. Biopsy results showed nonspecific findings with areas of interstitial granulomatous dermatitis accompanied by elastophagocytosis. These findings without the evidence of any previous periorbital surgery were considered as an adverse effect of the capecitabine treatment. The patient was followed up by the dermatology and ophthalmology departments, and as he had no corneal abrasion and visual problems, he was managed medically with topical Vaseline and clobetasol propionate cream (0.05%), moxifloxacin antibiotic eye drops, and artificial tears for ocular symptoms. Capecitabine was stopped in the 5th month of treatment because of severe bilateral corneal erosion in addition to the progression of lower lid retraction during follow-up. His upper lid shortness did not change, whereas the corneal erosion and lower lid ectropion did not resolve and continued to progress; therefore, he was referred to the plastic and reconstructive surgery department 1 month after the capecitabine treatment was stopped. Physical examination revealed bilateral lower lid ectropion, bilateral vertical shortening of the upper eyelids, and lagophthalmos []. During the 1-month drug-free period leading up to the surgical procedure, the patient’s fin

[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 gentleman presented with a 2-year history of progressive left nasal obstruction. There was no associated dysgeusia or hyposomnia or anosmia. He was a lifelong non-smoker and was not known to have allergies to medications or an atopic type of rhinosinusitis. He did not have any other significant medical or surgical history and no genetic history of nasal pathologies.
On examination, he had severely reduced left nasal airflow. Anterior rhinoscopy revealed a large fleshy tumour in the left nasal cavity, which was not papillomatous or vascular (). Nasendoscopic examination showed a large tumour of solid and polypoidal components. It occluded the posterior nasal choanae, filling the inferior aspect of the nose. Visualized from the right nostril, the tumour prolapsed into the postnasal space. There was no contact bleeding. The right nasal passage appeared normal. The nasopharyngeal vault and the remainder of the upper airway appeared normal. He did not have otitis media with effusion in the left ear and there was no palpable cervical lymphadenopathy. Pre-operative imaging was ordered to determine the extent of the lesion ().
Treatment was local excision under general anaesthetic. The tumour was attached to the lateral wall of the nose at the level of the middle turbinate and was removed in its entirety excision. There was minimal bleeding and the nasal passage looked otherwise normal. Middle meatal antrostomy revealed scant mucus in the antrum, but the mucosa appeared normal. The perioperative course was uneventful, and the patient was discharged home on the sameday.
The resected mass was a grey polypoidal tissue with spicules of bone measuring 36 × 33 × 18 mm.
Histological examination revealed the mass was lined with ciliated respiratory epithelium, which invaginated into the core of the polyp, forming glandular and cystic structures. There was focal calcification within the cysts. There was a component of bland sero-mucinous glands in lobular

[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 62-year-old male with a past medical history significant for a coronary artery bypass grafting 10 years prior presented with 3 weeks of persistent left epigastric pain. He denied dyspnea or chest pain. On exam, he was hemodynamically stable, in no apparent distress, and no audible murmur. EKG showed Q wave on the inferior leads suggest ing old myocardial infarct, which was unchanged from a previous EKG performed 3 months prior. A complete series of cardiac enzymes ruled out acute myocardial infarction. Because of the previous coronary bypass surgery and his atypical symptom, the patient underwent cardiac catheterization which showed patent grafts (left internal mammary artery to the left anterior descending artery and saphenous vein graft to the obtuse marginal artery) and intact right coronary system. Left ventriculography was not performed at that time. Transthoracic echocardiography showed severely decreased left ventricular function. Because of persistent pain in the left epigastric area to the left flank, a contrast CT scan was obtained to role out intraabdominal pathology. The 16 slice spiral CT scan with intravenous contrast demonstrated a large LV pseudoaneurysm (Fig. ). There was no other intraabdominal lesion was observed. Left ventriculogram was subsequently performed and confirmed the LV pseudoaneurysm (Fig. ).
The patient was then scheduled for resection of the LV pseudoaneurysm. After dissection of the anterior wall of the heart, further dissection of the lateral and posterior wall of the heart was performed under cardiopulmonary bypass because of dense adhesion. The LV pseudoaneurysm was located in the posterolateral wall of the LV (Fig. ), adherent to the posterior pericardium. After complete immobilization of the LV, the pseudoaneurysm was opened under aortic cross clamp. The wall of the pseudoaneurysm was thin and filled with clots. The neck of the pseudoaneurysm was identified and closed with a Gore-Tex patch. The ventriculotomy was then closed

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


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

[User]
RADIOLOGY NOTE:
A 43-year-old female with a past medical history of severe allergy-induced asthma and chronic nasal drip presented to the clinic with worsening cough and chest tightness for 10 days and was treated for bronchitis with steroids and antibiotics. She then presented to the emergency department with severe and acutely worsening shortness of breath, sudden onset pleuritic chest pain, and sharp radiating pain between both shoulder blades with deep inspiration. At time of presentation, the patient was afebrile with vital signs within the normal limits. Lab work was insignificant with negative leukocyte count and negative cardiac enzymes. A chest X-ray demonstrated an abnormal right cardiomediastinal silhouette with large opacity over the right mediastinum adjacent to the right atrial border. A follow-up CT scan revealed a large right-sided mass adjacent to the right atrium and extending into the right chest measuring 5.1 cm × 9 cm × 4.3 cm (). Her last imaging study was a fluoroscopy study 10 years ago that showed no indications for a mediastinal mass. An echocardiogram revealed a normal ejection fraction (55–59%), no wall motion abnormalities, and a cyst near the right atrium. The patient had continued pleuritic chest pain and difficulty breathing and the decision was made to perform video-assisted thoracoscopic surgery (VATS) for pericardial cyst removal. The patient underwent general anesthesia with a 37 French left-sided double-lumen tube. Standard ASA monitors were applied. Two large-bore peripheral IVs and an arterial line were placed for continuous blood pressure monitoring. Intraoperatively, a large cystic lesion was adherent to the pericardium (). There was no solid component and no obvious communication with the pericardium. Part of the cyst wall was left on the phrenic nerve to preserve it. The patient tolerated the procedure well, had no postoperative complications, and was discharged home on postoperative day number two. The final pathology report revealed beni

[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 female patient aged 51 years reported with severe, throbbing pain in left upper first premolar, that is, 24, since three days. The pain was aggravated on chewing and lingered on for few hours after removal of stimulus. There was history of sensitivity to cold beverages. The patient could recall episodes of similar pain with the same tooth for the past two years which was only temporarily relieved with desensitising tooth paste.
On clinical examination, no caries was detected nor restoration was present but a very faint craze line could be seen on the distal marginal ridge extending onto the distal proximal surface of 24 (). The extent of the craze line could not be determined. The tooth was tender on percussion, it did not exhibit mobility, and the fracture could not be separated using wedging forces. Periodontal probing depths were normal. Electric pulp test revealed immediate response. Radiograph did not confirm the fracture line or reveal any significant findings (). The patient was given a choice of using cone beam computed tomography (CBCT) to determine the extent of fracture and the prognosis of the tooth. She was explained the benefits and also assured that radiation exposure would be kept as minimal as possible. An informed consent was obtained from the patient. Cone beam computed tomography (Vatech, PaX-Reve 3D plus, pulse type generator, 5 × 5 cm field of view (FOV) and 0.08 mm voxel size) was used to determine the relative depth of fracture apically and the proximity of fracture to the pulp (Figures and ). The fracture line was found to extend mesiodistally involving lingual pulp horn and apically it did not extend below the level of alveolar bone. Prognosis was considered to be favourable. Root canal treatment followed by crown restoration was then decided as most appropriate treatment plan. The suspicion of fracture extending to deeper aspects of root, coupled with acute symptoms of pain in the patient prompted the usage of CBCT for

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


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

[User]
RADIOLOGY NOTE:
A 62-year-old woman presented with a chief complaint of abdominal, back and neck pain. She had developed polymyositis 12 years previously and started taking prednisolone (controlled at 11 mg/day at the visit). She was also taking oral medication for hypertension.
Lower abdominal pain appeared a day after upper gastrointestinal angiography with barium contrast agent. Subsequently, she experienced gradual abdominal, back and neck pain. Chest and abdominal computed tomography (CT) showed mediastinal emphysema and free air in the abdominal cavity. She was referred to our hospital for suspicion of an oesophageal rupture.
The patient’s height was 152 cm, body weight was 41 kg, body temperature was 39.4 °C, blood pressure was 160/99 mmHg, and pulse rate was 140 times/minute. Her abdomen was markedly bloated with an overall rebound tenderness.
On chest and abdominal CT, free gas was observed in the entire abdominal cavity (), and extensive emphysema was also observed in the retroperitoneum (). In addition, it was observed from the mediastinum to both sides of the necks ().
Colon perforation was suspected from the abdominal findings and the finding of free gas in the abdominal cavity. Although emergency surgery was planned, the perforation site could not be identified on the image. In addition, a diagnosis of oesophageal rupture could not be ruled out because of atypical findings of colon perforation, such as pneumomediastinum. Therefore, after general anaesthesia, upper gastrointestinal endoscopy was performed for the purpose of diagnosis and operative decision. Because there was no obvious perforation in the oesophagus, oesophageal rupture was ruled out, and a laparotomy approach was used.
When the abdominal midline incision was performed, extensive emphysema was observed throughout the mesentery (). There was no stool-like ascites in the abdominal cavity, and a small amount of cloudy ascites was observed in the pelvis. When the serosa of the sigmoid colon, where emphysema

[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 with myelodysplastic syndrome treated with double cord allogeneic blood stem cell transplant 34 months ago complicated with chronic GVHD-related glomerular nephropathy, adrenal insufficiency, and end-stage renal disease on hemodialysis presented to clinic after 2 weeks of joint pain. Physical exam revealed normal strength, and he was treated with nonsteroidal anti-inflammatory therapy. Four days later, he developed worsening joint pain, lower extremity calf pain, and hoarse voice. Examination at this time was notable for 3/5 strength in his lower extremities. He was admitted to the hospital and treated with 50 mg intravenous hydrocortisone every 12 hours for three days and intravenous fluids for a suspected postviral myositis. His symptoms resolved, and he was discharged home.
Five days afterwards, he was readmitted to a different hospital for dysphagia and concern of aspiration pneumonia. A gastric tube was placed, he was treated with intravenous ceftriaxone and metronidazole, and he was sent to a rehabilitation facility. Of note, he was not treated with a quinolone or aminoglycoside antibiotic. Another four days later, he presented to our hospital with worsening pneumonia. At this time, physical exam revealed decreased proximal muscle and grip strength, weak palate elevation, diplopia upon prolonged upward gaze, and 3/5 strength in lower extremities. He did not exhibit muscle fatigue from repetitive use. Initial evaluation for this patient was unremarkable for brain or cranial nerve lesions, motor neuron disease, neuromuscular junction disorders (NMJ), or other myopathies (). He was treated with stress-dose steroids (50 mg methylprednisolone every six hours) for concern of myositis, antibiotics, and other supportive measures. Four days after this admission, the antiacetylcholine receptor (AChR) antibody (Ab) panel revealed elevated ACR binding and modulating antibodies correlating with diagnosis of myasthenia gravis. Titers for AChR binding Ab 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 24-year-old woman with a 6-month history of swelling in the left floor of her mouth was referred to our institution. Although she experienced slight difficulty in swallowing, she did not experience pain or tongue paralysis. Her medical and family histories were unremarkable.
Intraoral examination revealed a well-defined 3.5 × 3 × 2 cm-sized solid, spherical submucosal nodule adjacent to the sublingual gland; the nodule was covered with light bluish smooth mucus (Fig. ). The patient experienced slight pain when pressure was applied to the tumor. Mobility and sensory functions of the tongue were normal, and no lymphadenopathy in the submandibular region was detected on palpation. All relevant laboratory test results were normal. Enhanced computed tomography revealed a 2.8 × 1.8 × 2.1 cm-sized well-defined, solid, heterogeneous nodule that did not appear to involve the mandible (Fig. ). In addition, a three-dimensionally reconstructed image showed a nodular lesion occupying the left floor of the mouth with abundant blood flow (Fig. ). No enlarged lymph nodes were found in the submental or submandibular regions.
The initial clinical impression was a benign salivary gland tumor, dermoid cyst, or benign connective tissue neoplasm. The patient was scheduled for surgery via an intraoral approach. First, an elliptical incision was made around the periphery of the sublingual gland through only the oral mucosa, and a full-thickness tissue flap was prepared along the lingual aspect of the sublingual gland. After the sublingual gland was freed from its surrounding tissue with blunt dissection, a well-circumscribed tumor without capsular extension was found beneath the body of the sublingual gland and located above the submandibular gland duct and lingual nerve. The submandibular gland duct and lingual nerve were carefully freed from the tumor surface, and the complete tumor was excised along with the sublingual gland (Fig. ). The tissue sample was fixed with 10% formalin and s

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


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

[User]
RADIOLOGY NOTE:
A 17-year-old male presented in June 1995 with left hip pain for 2-month duration. The patient was a high school student, and he had this pain on and off which was tolerable. At that time, he was active with his high school extracurricular activities. But he went to see his general practitioner as the pain was disturbing his school activities for 1 month. He took oral analgesia for the pain, and he came to our hospital as the pain worsened the last 10 days. There were no constitutional symptoms and no history of trauma.
On physical examination, the range of motion of the left hip was reduced due to pain. There was no lymphadenopathy or neurovascular deficit. The plain radiograph showed osteolytic lesion over the superior aspect neck of left femur with scalloping of medullary canal (). CT scan reported a 4 cm destruction involving the metaphysis and neck of left femur with calcification and joint effusion and no sequestrum (). MRI findings revealed a 4 cm well-circumscribed eccentric mass at neck of femur with abnormal marrow signals (). The erythrocyte sedimentation rate (ESR) was slightly elevated (40 mm for the 1st hour), and the C-reactive protein (CRP) and total white cell count level were within normal range. Based on the history, clinical examination, and imaging, a diagnosis of benign bone tumor involving the neck of left femur was made.
On anterior exploration of left hip joint, the capsule was intact; we opened up the capsule to reach the lesion. There was friable bone tissue of 4 × 3 cm over the anterior cortex of neck of femur which was breached, but the other cortices were intact. Curettage and autologous iliac crest bone grafting was carried out, as the frozen section confirmed the diagnosis of EG. Two cannulated screws were used to pin the neck of left femur prophylactically against pathological fracture. The histopathologic examination revealed a mixed cellular infiltrate consisting of eosinophilic polymorphs with plasma cells and Langerhans histiocyt

[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 57-year-old healthy female underwent colonoscopy in the context of a positive fecal immunohistochemistry test (FIT) of 77 ng/mL. Her medical history was only significant for a remote caesarean section. Her family history was significant for her father having colonic polyps at the age of 70. The patient also endorsed occasional NSAID use. The patient had used Bi-Peglyte solution for bowel preparation.
The patient was sedated before and during the procedure with a total of 3 mg of midazolam and 100 mcg of fentanyl. CO2 was used to insufflate the colon. The colon was quite tortuous and required repositioning of the patient on to her back and right side. Application of counter pressure was also used to reach the cecum. Bowel preparation was suboptimal, and fecal material clogged the endoscope numerous times. Extensive lavage and suction were required during withdrawal. A 1.2 cm pedunculated polyp in the descending colon was injected with methylene blue and completely removed as 2 pieces by hot snare polypectomy. Withdrawal time was 15 minutes. Overall, the patient tolerated the procedure well. Pathology of the polyp demonstrated a tubulovillous adenoma with low-grade dysplasia.
The patient subsequently presented to the emergency department (ED) 2 days after colonoscopy with severe abdominal pain but no bleeding or diarrhea. Initial bloodwork was unremarkable other than an elevated lactate of 5. A CT abdomen with IV contrast demonstrated diffuse large bowel thickening with severe involvement of the sigmoid and small volume of pelvic ascites (). There was no hemoperitoneum, pneumoperitoneum, or bowel obstruction. The patient underwent an urgent flexible sigmoidoscopy. Starting at the rectosigmoid junction, there were patchy, dusky areas of mucosa with submucosal swelling and erythema but no frank ulcerations (). The endoscope was only advanced to the midsigmoid, and biopsies were not taken due to the fear of inducing more complications. The proximal extent of the change

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


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

[User]
RADIOLOGY NOTE:
This is a case report of a 57-year old female patient with a history of left nephrectomy due to clear cell RCC in December 2008. The patient was in favorable prognostic categories according to Motzer et al. The patient had no family history of malignant neoplasm and no history of chronic diseases. Due to metastatic disease (metastases in lungs), interferon immunotherapy was used as a first line therapy. The best response to treatment was partial regression according to RECIST criteria (version 1.0). After 11 months immunotherapy was stopped due to the disease progression – enlargement of existing lesions. In April 2010 the patient was qualified to 2nd line therapy with a tyrosine kinase inhibitor (sorafenib). The patient received a total of 8 chemotherapy courses. The response to treatment was stable disease according to RECIST criteria. In December 2010, due to the disease progression – appearance of new focal lesions in the liver, the patient was qualified to 3rd line therapy using a selective mTOR inhibitor (everolimus). Marked toxicity was observed during the therapy – anemia grade 3 according to CTC AE that required transfusion of packed red blood cells. The treatment was stopped after 13 courses in January 2012 due to the disease progression – appearance of new lesions in lungs, left adrenal gland and the skeletal system. The patient underwent palliative radiotherapy on the tumor site, 11th rib in January 2012, and then in June 2012 on central nervous system (CNS) area due to focal lesions located in the right parietal and temporal lobes and in the right cerebellar hemisphere. In May 2012 the patient started a 4th line therapy, axitinib at a dose of 5 mg twice daily. Partial response to treatment was achieved. The treatment was stopped in November 2012 due to the disease progression. The total time to progression was 37.5 months (). The patient died in December 2012. The total survival time from the disease diagnosis was 45 months.
The treatment was carried ou

[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. P., a 61-year-old woman, was taken to the emergency ward of the Tehran Heart Center, Iran, by her husband and son. On admission, she was suffering from dyspnea, and there was a sewing needle penetrating her chest. During the physical examination, the heart and lungs were normal. Emergency fluoroscopy, echocardiography and computed tomography (CT) scan were performed. The chest CT scan revealed that the needle had penetrated into the heart, and echocardiography demonstrated that the needle had ruptured the pericardium, but it had not entered the left ventricle. The patient underwent surgery 4 hours after admission, and the needle was removed successfully.
An interview with her family disclosed a history of major depressive disorder and pharmacological treatment. During the first 3 sessions of psychiatric counseling after the surgical operation, the patient denied a suicide attempt. She claimed that an accidental fall was the cause of her injury. On the 4th session, however, she admitted that the problem was not accidental, stating that she had attempted unplanned impulsive suicide by swallowing needles twice before, once 10 years and once a year previous to this. In both cases, she had been hospitalized for some days and discharged without any complications.
The patient had been suffering from major depressive disorder since the sudden death of her son, 10 years ago. During the previous 5 years, she had received different pharmacological treatments, namely clonazepam, alprazolam, venlafaxine, and Depakine, which were not followed through. No history of psychotherapy or electroconvulsive therapy was reported.
The patient reported having experienced auditory hallucinations during different periods of taking low-dose benzodiazepine pills. According to her family, during these periods, the patient had experienced disorientation, disturbed consciousness, distraction, and auditory hallucinations. Through these accounts we were guided toward the delirious picture of thos

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


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

[User]
RADIOLOGY NOTE:
A 27-year-old G4P0 lady of 28 of weeks gestation presented with sudden onset of chest pain, radiating to her jaw and back. Her vital signs were within normal limits, electrocardiogram showed normal sinus rhythm and her blood results were unremarkable, in particular cardiac enzymes were not elevated. She reported reduced fetal movements and was therefore transferred to a nearby maternity hospital.
Her past obstetric history included stillborn twins of 27 weeks of gestation at the age of 16, which was attributed to considerable antenatal alcohol and drug use. Later in her early twenties she had two terminations.
Antenatal care for this pregnancy was commenced with a general practitioner and was then referred to a midwifery practice at her request. At 20 weeks of gestation, morphology ultrasound showed a right hydronephrotic kidney in the fetus and she was referred for antenatal care at a tertiary hospital.
At the maternity hospital, she remained haemodynamically stable but she was found to have a faint indeterminate murmur and Troponin T was elevated to 0.04 (normal range < 0.02 μg/L). There was no radio-radio delay or radio-femoral delay bilaterally and she reported no shortness of breath. She complained of ongoing chest and back pain, which settled with analgesia. Cardiotocography (CTG) was normal but she was given corticosteroids in case of preterm birth.
Overnight, the patient went into cardiogenic shock. Chest X-ray showed cardiomegaly, acute pulmonary oedema and a prominent descending aorta. An urgent transthoracic echocardiogram revealed a 6 cm aortic root dissection with occlusion of two out of three aortic branches.
The patient was resuscitated and transferred to the intensive care unit (ICU) of another tertiary hospital. She had an emergency lower segment caesarean section under general anaesthesia and a live male infant (1610 g) was delivered without complication. The neonate was transferred to the ICU for management of extreme prematurity. The cardiothorac

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


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

[User]
RADIOLOGY NOTE:
A 4-year-old male child was referred to us for complaint of pain in abdomen. On enquiry, there was intermittent history of bilious vomiting since infancy. There was no previous history as regard to abdominal distension. However, there was occasional history of abdominal pain, which was relieved by medication. On examination, his abdomen was distended, but it was non-tender. The weight of the patient was 9 kg. Thus he had failed to thrive. His ultrasound (USG) of abdomen suggested some fluid filled cystic spaces. A computerized tomography (CT) scan of abdomen was advised for confirmation of the diagnosis.
On next day, just after CT abdomen, the patient suddenly developed severe abdominal pain. X-ray abdomen showed pneumoperitoneum. Clinically the patient looked septic. His pulse rate was 130/min with a feeble pulse. An urgent laparotomy was planned. After initial stabilization, the patient was explored under general anesthesia. On exploration, we noticed malrotation of the gut, which was associated with two turns of midgut volvulus. The midgut did not have any evidence of ischemia or gangrene. It was complete malrotation having cecum in left hypochondrium and narrow mesentery. Ladd's bands were also present. The peritoneal cavity was grossly contaminated with fecal fluid. The perforation site was about one foot proximal to ileocecal region. The perforation was at the mesenteric side, and it was associated with a soft mesenteric mass communicating with the normal bowel. The mass was about 10 cm in length. The perforation was just at the junction of the mesenteric mass and the normal bowel [].
After performing the Ladd's procedure, attention was placed towards the perforation. On attempting to resect the mesenteric mass, we noticed two lumens in the bowel distal to the perforation site and single lumen proximal to that [Figures and ]. The duplication appeared to be having all the layers of the bowel wall. When an attempt

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


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

[User]
RADIOLOGY NOTE:
A 71-year-old Japanese woman presented with a 10-year history of left hip pain and 1-year history of left leg edema. The left leg edema was apparent particularly after long durations of standing, sitting, or walking. The patient had a history of hypertension, arteriosclerosis, and internal carotid artery constriction. We could feel pulses of the femoral and dorsal arteries well even when the leg edema appeared. Physical examination revealed limitation of the range of motion (ROM) of her left hip, with 80° flexion, 20° abduction, 15° adduction, 45° external rotation, and 5° internal rotation. Plain radiographs revealed advanced OA secondary to developmental dysplasia of the left hip. A huge osseous mass was also observed at the inferomedial portion of the femoral head (Figures and ). Based on a previous radiograph, we determined that this mass was absent 8 years ago (). Computed tomography (CT) images and magnetic resonance imaging (MRI) revealed compression of the femoral vessels by the mass (Figures –). On MRI, the intensity of the mass was almost similar to the surrounding bone marrow, with very high intensity at the surface on the short-tau inversion recovery (STIR) image (Figures –). The Japanese orthopaedic association (JOA) hip score [] was 54 points: 20 points in pain, 12 points in ROM, 10 points in gait, and 12 points in activity of daily life. We diagnosed the mass as a capital drop secondary to OA and performed total hip arthroplasty (THA) with resection of the mass. The mass was observed to be completely inside the articular capsule and there was minimal inflammation and adhesion between the mass and capsule. Cartilage tissue was observed on the surface of the mass (). THA was performed using a short tapered wedge stem with a 32 mm ceramic head (Microplasty, BIOMET, Warsaw, IN) and a 48 mm cementless cup with a polyethylene liner (Trident

[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 21-year-old male was found to have a left hypochondrial mass on physical examination following a trivial soft tissue injury. Ultrasound scan revealed a large retroperitoneal mass in the pancreatic tail region with a mild splenomegaly. No other abnormality was noted in the ultrasound scan. Contrast-enhanced computed topography (CT) of the abdomen showed a 10.3 × 7.6 × 10.3 cm size heterogeneous mass with mild contrast enhancement arising from the body and the tail of the pancreas with no calcifications (). Multiple vascular channels were seen around the lesion. Splenic vein was compressed and displaced by the mass with enlargement of the spleen. Mass effect had displaced the left kidney posteriorly. All other intra-abdominal viscera were normal. All haematological investigations were normal.
He underwent laparoscopic resection of distal pancreatic tumour en bloc with spleen. Patient was operated on in right lateral position with head-up tilt using five ports. shows the ports arrangement. Large tumour was noted originating from the body and tail of the pancreas with dilated veins surrounding the tumour. Patient also had a large spleen and an enlarged liver. Dissection was performed using ultrasound dissector and bipolar diathermy. Splenic artery divided between clips and splenic vein was ligated and clipped before dividing. Pancreas was divided just distal to the portal vein using bipolar diathermy and ultrasound dissector. The specimen () was delivered in a bag through a 7.5 cm incision.
Postoperative period was uneventful and he was discharged on 4th postoperative day.
Histology revealed a tumour predominantly composed of sheets of round to polygonal cells containing sharp cytoplasmic vacuolations and bland nuclei. The eosinophilic cytoplasm was seen as a rim in the periphery. Very occasional mitotic figures were present (). The focal pseudopapillae formation was also evident with vascular cores lined by neoplastic cells (). The stroma was highly vascular (). Ther

[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 Sri Lankan Tamil male with a history of well-controlled type 2 diabetes mellitus and a goitre of 30 years presented with a painful enlargement of goitre on the left side for one month. He had progressively worsening difficulty in breathing with intermittent dysphagia for solids. He did not have any symptoms of local infiltration and was clinically euthyroid. Examination revealed a hard mass arising from the left thyroid lobe measuring 8 cm × 7 cm in size with gross tracheal deviation to the right side. In addition, there were two mobile lumps anterior to the mass in the subcutaneous tissue plane (). There was no retrosternal or retroclavicular extension on the left side. The right thyroid lobe was moderately enlarged and had multiple palpable nodules. There was no cervical lymphadenopathy. Ultrasound scan showed a large calcified left thyroid nodule and few superficial nodules. The outer surfaces of the nodules were delineated by an echogenic line suggestive of surface calcification. The internal echotexture of the nodules was not clearly appreciated due to artefacts from the surface calcifications. Right thyroid lobe showed only benign characteristics. Neck X-ray radiography showed a calcified left lobe with significant tracheal deviation to the opposite side (Figures and ). Thyroid stimulating hormone (TSH) and free thyroxine (T4) levels were within normal limits. Ultrasound-guided fine needle aspiration cytology (FNAC) showed scattered cyst macrophages, lymphocytes, and multinucleated giant cells in an eosinophilic background with scanty colloid. The features were compatible with a benign cyst (Thy 2).
The patient underwent a total thyroidectomy. Two confluent nodules were noted in the subcutaneous tissue plane extending through the deep fascia between the strap muscles to the calcified left lobe nodule. The deep fascia and strap muscles were thinned out and were adhered to the calcified left lobe (). Division of strap muscles on the left side was r

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


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

[User]
RADIOLOGY NOTE:
A Forty five-year-old previously healthy female presented with complaints of swelling and pain in bilateral feet for eight years and history of recurrent episodes of multiple nodules over bilateral legs and feet, which burst to form ulcers for a period of seven years. There was no history of any preceding drug intake. There was no history of similar complaints in family members and no history suggestive of systemic illness. On examination, there was pitting pedal edema, multiple ulcers over bilateral lower limbs (one over medial malleolus of right foot and two over lateral aspect of the left foot) measuring about 1-2 cm in size, slightly tender, irregular margins, sloping edges, floor of the ulcers were covered with slough with erythema and hyperpigmentation of the surrounding skin. Multiple scars of previously healed wounds were present [Figure and ]. There was no palpable thrill or bruit, no clinical evidence of varicose veins and no significant lymphadenopathy. All the peripheral pulsations were well felt. Systemic examination was within normal limits. Routine investigations including complete blood counts, liver and renal function tests, urinalysis, chest radiographs were within normal limits. Enzyme linked immunosorbent assay (ELISA) for HIV 1 and 2 was non reactive. The result of Mantoux test was negative. Bleeding time, clotting time and prothrombin time were within normal limits. Color Doppler study of bilateral lower limbs was within normal limits. Based on the history and investigations, differential diagnosis of chromoblastomycosis, mycetoma, vasculitis and erythema induratum was kept. Histopathological examination of a biopsy sample from the edge of the lesion showed hyperplastic epidermis with an increased number of thick walled capillaries in the papillary, mid and reticular dermis. Moderate amount of hemosiderin deposits were seen around these vessels with perivascular lymphocytic infiltrate and mucin []. Based on the history, examination and histopat

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


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

[User]
RADIOLOGY NOTE:
A 44-year-old man was admitted to our clinic because of left knee pain. He had pulmonary tuberculosis at 6 years old. He presented pus-forming arthritis, which was presumably tuberculous arthritis, in the left knee after 2 years, with spontaneous remission after closure of the draining sinuses. Thereafter, no recurrent symptom of infection was observed. However, the deformity and growth disturbance progressed with the knee pain. He had limb lengthening and alignment correction for the leg length discrepancy and genu valgum. However, his left knee pain continued despite the deformity correction. Radiographs showed a fused knee with severe tricompartmental arthritis (Fig. ). Severe limitation in range of motion was observed on the left knee. We planned to perform one- or two-stage primary TKA depending on the presence of infection [].
Intraoperatively, a large subchondral abscess was found in the lateral femoral condyle and lateral tibial plateau after takedown of the fusion (Fig. d). On the basis of the necrotizing inflammation with granuloma in the frozen-section biopsy, active tuberculosis was suspected. Aggressive debridement and curettage of the infected and necrotic bone and soft tissues were performed.. After bone cuts and soft tissue balancing to prepare for TKA, articulating cement spacers (vancomycin 4 g and streptomycin 2 g per 1 batch) were made intraoperatively and applied to the tibial and femoral sides in sequence using intraoperative cement molds with a previously described technique [, ] (Fig. ). Relative medial and lateral stabilities were confirmed intraoperatively after inserting the articulating cement spacers. The diagnosis of tuberculosis infection was confirmed by isolating Mycobacterium tuberculosis from cultures. We decided to delay the TKA for at least 6 to 9 months to allow the administration of antituberculous drugs []. Evaluation at 1-year follow-up revealed no recurrent infection after sufficient antituberculous drug treatment. Therefore

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


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

[User]
RADIOLOGY NOTE:
A 28-year-old man referred to our department with a 7-week history of left hip limping, difficulty walking, and inability to bend forward. He had aided waddling gait and poor tolerance of weight bearing. There was no history of any major trauma. His vital signs were normal. The examination of the hip elicited an impaired restriction of flexion and both internal and external rotation, with a 2-cm shortening of the left leg. A Harris hip score of 65.5 was achieved by the patient. His distal neurovascular status was intact ().
Other examinations showed poor secondary sexual characteristics with a Tanner’s pubertal and axillary stage of 2. He worked in an automobile repair shop and had normal social activities. A survey of his past medical history showed that at age of 17 years, blurred vision, meningeal signs, and abnormal secondary sexual development were noted; and after investigations, brain magnetic resonance imaging showed a lobulated intra- and suprasellar mass, 38 × 32 × 24 mm in diameter, with extension posteriorly into the interpeduncular cistern and extension superiorly and insinuation into the third ventricle. Consequently, in December 2001, he underwent brain surgery for craniopharyngioma. Ten years later, his previous symptoms recurred, and in April 2011, he underwent a second brain surgery for tumor recurrence. At the meantime, he had been followed up by an endocrine clinic.
According to the patient’s past history, he was born full term with a birth weight of 3.5 kg and his early development was described as normal (menarche was at age of 14 years). Since that age, he had always weighed between 49 and 57 kg. During these years, he was under medical therapy for hormonal disorders. There was no history of delayed dental maturation, hyposmia, or a family history of delayed puberty. He had no midline defects. Complete pituitary evaluation is depicted in .
In 17

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


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

[User]
RADIOLOGY NOTE:
A 48-year-old female had a 2-year history of right hemifacial spasm. She had been treated with clonazepam and other alternative therapies with limited effect. She was admitted to our hospital for microvascular decompression surgery for her hemifacial spasm. Preoperative magnetic resonance imaging (MRI) with T2-based cisternography revealed attachment of her right posterior inferior cerebellar artery (PICA) to her facial nerve exit zone. We carried out microvascular decompression surgery with a lateral suboccipital approach and placed a sponge (polyurethane) between the PICA and the brainstem, fixing them with fibrin glue []. Her postoperative course was uneventful. Her hemifacial spasm disappeared completely 3 days after the decompression surgery. Postoperative MRI showed a PICA running course without attachment to the brainstem [].
Six years after her surgery, she noticed a mild spasm in her superior orbicularis oculi muscle which spread to her prioral muscles and occasionally sustained a tonic state. She visited our department and underwent a MRI scan. T2-based cisternography showed a closed PICA running course compared with the MRI immediately after her initial surgery []. At this point, she was eager to undergo decompression surgery again, even if it was only for inspection. We carried out the second surgery with her informed consent.
Using a lateral suboccipital approach through the previous incision and craniotomy, we dissected the arachnoid adhesion and confirmed that the sponge placed in the first surgery between the offending artery and the brainstem was not dislocated. However, the sponge was degenerated. The structure of the sponge was fragile and easy to collapse. The honeycomb structure or bubbles in the sponge were not preserved []. We attempted to remove the sponge, but its adhesion to the lower cranial nerves was strong. We inserted Teflon between the sponge and the brainstem and moved the distal portion of the PICA to the dura of the petrous surface

[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.