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

[User]
RADIOLOGY NOTE:
The patient is a 35 year-old woman who was diagnosed with GSD Ib at the age of 10 months. Dietary treatment was started with good metabolic control. Since the age of 9 years the patient has received G-CSF treatment for neutropenia and recurrent infections. Since the age of 10 she has suffered from inflammatory bowel disease. The clinical course was further complicated by recurrent abdominal abscesses. At age 25, subtotal colectomy was performed due to long-distance stenosis of the transverse colon with an abscess in the right upper abdomen. Postoperative wound healing was impaired and required surgical wound revision and closure. Pancreatic fibrosis was observed at age 28, exocrine pancreatic insufficiency was diagnosed at age 31, and supplementation with pancreatin was initiated. Hepatosplenomegaly was observed, and the thrombocyte count was significantly reduced to around 40 G/l, possibly due to the massive splenomegaly. At age 33, the patient presented with acute abdominal pain in the lower abdomen. MRI was suggestive of a pelvic abscess, enlarged pelvic retroperitoneal and mesenterial lymph nodes as well as inflammatory alterations of the intestine. The patient had bloody stools, and her overall clinical condition was reduced. Antibiotic therapy with meropenem, ampicillin and metronidazole was started. Explorative laparotomy with extensive resection of the small bowel (side-to-side jejuno-jejunostomy 70 cm distal of the ligament of Treitz and end-to-end jejuno-jejunostomy 150 cm distal of the ligament of Treitz, resection of the stenosing ileodescendostomy) was performed. Abdominal bleeding occurred in the postoperative course, which required 4 further laparotomies within 3 weeks. Secondary surgical closure of the wound could be performed 4 weeks after the initial operation. However, within the consecutive weeks a large wound dehiscence developed with severely impaired wound healing. At its maximum the wound had a diameter of 29 × 18 cm. Surgical revision of the

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


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

[User]
RADIOLOGY NOTE:
A 14-year-old girl came to the Department of Pedodontics and Preventive Dentistry, Bapuji Dental College and Hospital, Davangere, Karnataka, India, with a chief complaint of missing or unerupted maxillary anterior teeth. A previous history of trauma to her maxillary anterior region about eight years back was recorded, due to which there was avulsion of few deciduous teeth and few fractured teeth, which were subsequently removed. The patient's medical history was noncontributory. Both parents reported no previous history of tooth or genetic anomalies on either side of the family.
On examination, the patient had a deficient maxilla on the right side leading to facial asymmetry. In the maxillary arch on the right side, the central incisor, lateral incisor, and canine were missing or unerupted; the associated alveolar mucosa was enlarged and covered by fibrous tissue []. Also there was a rotated first premolar, erupting second premolar, and unerupted first and second molar on the right side. However, on the left side of the maxillary arch only a central incisor was missing and the rest of the teeth were present. In the mandibular arch, on both sides, all the teeth were present except the third molars. All the teeth showed some degree of hypoplasia. The oral hygiene was poor with an active carious lesion on the mandibular left first molar. There was deficient maxillary growth on the right side, showing signs of arch collapse [].
Panoramic, occlusal, and periapical radiographs were taken. The mandibular dentition was normal, as was the left maxillary dentition, except the central incisor. In the maxillary anterior region, the right central incisor, lateral incisor, and canine showed malformed and retarded development as compared to the age of the child. There was complete absence of the left central incisor and the right first molar. The second molar was also malformed, but it was not as severe as the other malformed teeth.

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


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

[User]
RADIOLOGY NOTE:
The informed consent was obtained from the patient. In March 2012, a 22-year-old female with iron-deficiency anemia, secondary to recurrent episodes of melena, presented as an outpatient to the Department of Gastroenterology at the Second Affiliated Hospital of Nanjing Medical University (Nanjing, China). Since infancy, the patient had exhibited massive characteristic venous malformations of the skin, which were deep blue, soft, rubbery and easily compressible. Between 1991 and 2012, the patient had a history of recurrent GI bleeding and iron-deficiency anemia. The patient did not have any history of non-steroidal anti-inflammatory drug use or peptic ulcers. The patient had received several blood transfusions and, at 12 years of age, an abdominal surgery was performed to resect the hemangiomas in the stomach. A pathological report revealed hemangioma. According to laboratory examinations, the patient exhibited a hemoglobin level of 41.0 g/l, a red blood cell count of 2,410/mm3, a reduced white blood cell count and an increased neutrophil granulocyte count. Skin lesions of various sizes occurred on the abdomen, hip and leg of the patient (). The patient received a blood transfusion and hemostatic therapy. Following hemostatic therapy, a fecal occult blood test yielded negative results. In order to detect the origin of the hemorrhage, a colonoscopy and capsule endoscopy were performed. Endoscopy revealed several strawberry-like mucosal polypoid lesions with abundant vasculature in the colon and lesions ranging between 8 and 20 mm were blue-violet and sessile (). Colon lesions were removed in an attempt to eliminate bleeding under colonoscopy. During surgery, hemangiomas were ligated with a nylon cord and several small blue mucosal polypoid lesions were treated with sclerosing agent during colonoscopy (). The patient was discharged in a good condition. A repeat endoscopy at 3 months revealed completely normal mucosa in the original lesions. A number of small lesions th

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


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

[User]
RADIOLOGY NOTE:
A 30-year-old man presented to our outpatient clinic with radiating pain both legs. The pain in both legs was aggravated with walking and relieved with rest, symptoms typical of neurogenic claudication. The patient reported that he had been shot in the left lateral side of the back on 1 year ago. We determined on physical examination that the wound on the left flank had already healed (). At the time that he was shot, the patient had no other complaints, except for pain at the entrance wound. At that time of gun shut, he had to have absolute bed rest and conservative treatment because of a liver injury caused by the gunshot. After several months of treatment, his liver was healed enough to ambulate and walk; however, he needed a cane to walk. After he started walking, he began to experience continuous radiating pain on both lower extremities.
On neurologic examination, dorsiflexion of the ankle and big toe on the right leg revealed mild motor weakness (Grade IV). The patient also complained of numbness on the right lower limb; however, patellar and Achilles reflexes were normal. On admission, his ESR and CRP were elevated slightly. Other laboratory findings were normal. A mild degree of voiding difficulty was detected, although that symptom did not bother the patient.
Plain radiographs revealed a round, radiopaque mass in the spinal canal at the L3-4 level (). Non-contrast reconstructed CT images of the lumbar spine were taken after admission, which revealed that the bullet-shaped mass was within the spinal canal, pointing cephalic at the L3-4 interspace (). The bullet within the spinal canal was located in the intradural space, compressing the nerve root ().
Because of his claudication and pain, we decided to surgically remove the bullet from the spinal canal. With the patient prone on a Wilson frame, fluoroscopic guidance was used to plan an incision over the L3-4 spinous process. The L

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


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

[User]
RADIOLOGY NOTE:
A 36-year-old Caucasian male presented to the emergency room complaining of a one-day history of abdominal pain. His main symptoms were that of nausea and vomiting, but he also reported periods of diarrhea. In the emergency room, his initial evaluation was significant for lab studies demonstrating a mild metabolic acidosis with a bicarb of 16.6 mEq/L, an elevation of his creatinine to 1.93 mg/dL, and a serum lactate level of 5.4 mmol/L. A computed tomography (CT) scan of the abdomen and pelvis was obtained and reviewed. The appendix was thought to be normal. There was no evidence of free intraperitoneal air, abscess, or volvulus. There did appear to be evidence of enterocolitis involving the ilium, cecum, and the proximal ascending colon. There was no evidence of pneumatosis or obstruction. Over the course of 12 hours the patient underwent conservative medical management, which included intravenous hydration, intravenous steroids, Toradol and Dilaudid for pain management, and the occasional dose of Ativan for agitation. Failure of conservative management along with medical decline lead to an exploratory laparotomy with a right hemicolectomy for an ileocolic intestinal infarction. Postoperative repeat CT scan of the abdomen incidentally showed pulmonary nodules in the lower lobe. A CT scan of the chest was then obtained, which revealed air in the left chest wall and axilla (Figure ). On physical exam there was very subtle mottling of the left shoulder. The patient was emergently taken back to the OR for further exploration of the shoulder with excisional debridement. Seropurulent fluid and extensive subcutaneous emphysema along the fascial planes of the left chest wall were consistent with necrotizing fasciitis. Both wounds were packed with a gauze bandage roll soaked in saline and then the patient was transferred back to the intensive care unit.
Over the course of 15 days the patient underwent repeat trips to the OR for re-exploration, incision 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:
Patient is a 73 year-old right hand dominant female who initially presented to the office complaining of atraumatic right shoulder pain with activity and limited range of motion of longstanding duration. On physical exam, she was found to have significantly limited active range of motion of the right shoulder and clinical signs of impingement. Radiographs at that time demonstrated superior escape of the humeral head with impingement of the greater tuberosity on the acromion and early acetabularization of the acromion (Fig. ). MRI findings were consistent with her x-ray and also demonstrated a lack of contiguous supraspinatus or infraspinatus tendon. At this juncture, the patient was diagnosed with rotator cuff arthropathy and elected to proceed with reverse total shoulder arthroplasty.
The patient was brought to the operating room and placed in the beach chair position. An incision was made from just lateral to the coracoid to the medial border of the proximal humeral shaft in line with the axillary fold. Subcutaneous tissue was dissected and the cephalic vein was identified. As the cephalic vein was mobilized and the clavipectoral fascia was incised, a discrete, branching, fascicular nerve was identified lateral and deep to the cephalic vein within the deltopectoral groove (Fig. ). The nerve was further dissected and traced both proximally and distally. Distally, the nerve and all branches were found to be diving into the anterior deltoid muscle. Proximally, it was found to run deep to the conjoined tendon, towards the brachial plexus. The nerve was freed from the deltoid muscle belly, allowing enough excursion to access the glenohumeral joint via a small deltoid window. The remainder of the operation concluded without complication and the wound was closed primarily (Fig. ). The patient was neurovascularly intact post-operatively with intact sensation in the axillary nerve distribution and able to fire her deltoid muscle. She healed without complications. At 4-

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


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

[User]
RADIOLOGY NOTE:
A 35 year-old female, gravida 3 para 2, presented to the emergency department with her first ever episode of angina pain 9 weeks and 3 days following an uneventful caesarian section. The patient noted constant chest tightness with radiation to both arms while getting ready for work. The pain was associated with diaphoresis but she denied dyspnea or nausea. Six years prior she underwent catheter pulmonary embolectomy for a thromboembolism thought to be related to oral contraceptive use. Since then she had been taking warfarin and warfarin was restarted postpartum. Otherwise the past medical history was only significant for hypertension. The family history was notable for a younger sister who was diagnosed with cardiomyopathy six weeks postpartum and a grandmother who died of unknown causes suddenly at age 42 without a relationship to pregnancy.
Upon physical examination the pulse rate was 83, respiratory rate 16 and blood pressure 130/67. The EKG demonstrated evidence of anterior ischemia. Serial troponin-t peaked at 1.17 ng/mL. The INR measured 1.9 IU. Initial treatment consisted of loading with 300mg clopidogrel. Emergent cardiac catheterization showed left anterior descending (LAD) coronary artery dissection complicated by extensive thrombus (Figure , Additional file ). Otherwise the coronary anatomy was without lesions in the left main coronary artery, the circumflex coronary artery or the right coronary artery (RCA) (Figure Panel A, Additional file ). The dissection affected the mid LAD to the distal LAD with irregular severity. Intravascular ultrasound demonstrated subintimal thrombosis but there was no evidence of a free dissection plane. Three everolimus eluting stents (Xience, Abbott Laboratories, USA) measuring 2.5 × 18 mm, 2.5 × 23 mm and 2.5 × 18 mm were deployed and dilated to 3.5 mm proximally. However, an edge dissection of the most distal stent became apparent after treatment of the target lesion. This was covered with an additional 2.5 × 18 mm

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


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

[User]
RADIOLOGY NOTE:
A 59-year-old Caucasian female presented in April 2008 for a consultation. She had a history of osteopenia and had been treated with alendronate (Fosamax) for 3 years. Until recently, her history of dental treatment had been uncomplicated. Her third molars had been extracted and four of her permanent teeth had been restored with amalgams. Throughout her life, she had visited her general dentist for semiannual recall appointments. Her dental hygienist and dentist had recently detected periodontal pockets around her maxillary and mandibular right molars. They referred her to a periodontist, who recommended extraction of teeth 17 and 47 (FDI) and possible surgical treatment of the upper left molars. Since she had a history of bisphosphonate use, she was concerned about the potential for development of osteonecrosis of the jaw (ONJ) after the extractions []. This motivated her to seek a second opinion to explore options for nonsurgical treatment.
The patient brought duplicates of periapical radiographs that had been obtained one month earlier by her general dentist. The radiographs revealed the presence of moderate periodontal bone loss around teeth 17 and 16 and early to moderate periodontal bone loss around 27 and on the distal aspect of 37 (not shown). There was severe periodontal bone loss on the distal aspect of 47, which had a pronounced root dilaceration (). In addition, there was a radiopaque mass associated with the distal aspect of 47, near the level of the cementoenamel junction. The size and shape of this mass suggested that it was either calculus or a fragment of a third molar root. The patient's oral hygiene was good and clinical signs of inflammation around the premolars and anterior teeth were minimal. However, there were probing depths of 5 to 6 mm on the mesial aspect of 17 and the distal aspect of 16 and probing depths of 7 mm on the direct palatal and distopalatal aspects of 27. Tooth 47 had 5 mm depths on its distofacial and direct lingual aspects a

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


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

[User]
RADIOLOGY NOTE:
A 54 year old woman with OI type 1 presented in October 2014 with acute back pain without any history of trauma or fall. Computed tomography (CT) scan of the thoracic spine demonstrated a burst compression fracture of the 11th thoracic vertebra (T11), as well as a 2.6x1.3x1.5 cm soft tissue density involving the left transverse process of the 7th thoracic vertebra (T7) (). A CT-guided biopsy of the T7 lesion revealed a heavy infiltration by kappa restricted CD138 expressing plasma cells. Further investigations confirmed the diagnosis of kappa light chain myeloma with lytic lesions involving the right parietal bone and right iliac bone, normal renal function and 30% light chain restricted plasma cells in the bone marrow. A radiographic skeletal survey demonstrated a radiolucent line at the left femur diaphysis with localized periosteal reaction compatible with an incomplete insufficiency fracture, consistent with the diagnosis of AFF (). There was no involvement of the contralateral femur, but both femurs were noted to be significantly bowed. The cortices were not thought to be thickened. Correlation with radionuclide bone scan demonstrated focal increased radiotracer uptake at the left femur fracture site. The patient denied thigh or groin pain. Orthopedic consultation was sought and the consultant recommended against prophylactic femoral nailing in view of the absence of symptoms and of the concurrent diagnosis of MM that might negatively affect the post-operative course.
The patient had been diagnosed with OI type 1 in early childhood and never received bisphosphonates until the age of 40 years, when alendronate was initiated for ongoing bone loss at the time of menopause and a patellar fracture. Calcium and Vitamin D supplementation was begun, and low dose transdermal estrogen (estradiol 0.025 mg/day twice a week) was prescribed to alleviate menopausal symptoms. Alendronate was stopped after 10 years of continuous therapy since her bone density had stabilized 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:
This is a case of a term male born at 39 1/7 weeks of gestational age by spontaneous vaginal delivery to an 18-years-old mother G2P1A0. The mother had no history of systemic illness. There was no consanguinity in the family. Prenatal screening tests (Human Immunodeficiency Virus, Hepatitis B, and Syphilis) were negative; Group B Streptococcus was positive; the mother did not receive antenatal antibiotics during pregnancy. No prenatal complications were reported, and no fetal anomalies or abdominal findings were detected on antenatal ultrasound. Patient had an Apgar 8 at one minute and 9 at 5 minutes. No complications during labor and delivery were reported.
At first day of life, the patient presented with hypoactivity, poor sucking, and cyanosis for which he was admitted to the Neonatal Intensive Care Unit due to suspected early onset of neonatal sepsis. Diagnostic studies were performed and therapeutic management was instituted, including antibiotic coverage. On day #2 of life, the patient presented with marked abdominal distention and marked bright red bloody stools. Oral feedings were discontinued, an orogastric tube was placed for gastrointestinal decompression, and metronidazole therapy was added to antibiotic therapy. The abdominal radiography revealed bowel dilation with no distal air. The clinical findings and presentation raised concern of bowel obstruction. On follow-up X-rays, a persistent radio opaque shadow in the lower abdomen raised the concern of urinary bladder obstruction. A Foley catheter was placed, obtaining 60 ml of urine. On day #4, an abdominal ultrasound was performed and revealed bilateral hydronephrosis, more prominent on the right side due to compression and a prominent parenchymal mass. A barium enema revealed a presacral soft tissue mass. On day #5 of life, an abdominopelvic computed tomography (CT) scan revealed a well-defined mass in the presacral space compressing the rectum and causing severe small and large bowel dilation. The mass

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


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

[User]
RADIOLOGY NOTE:
A 7-year-old Malay girl was admitted to our institution presenting with fever for 4 days that was persistently above 38°C, with a maximum temperature of 39.9°C. This was associated with a papular and pruritic rash over her chest and limbs for 4 days, as well as a tender right neck swelling for 3 days, diarrhea, and bitemporal headaches for 2 days. This was accompanied by early morning vomiting and nausea, but no blurring of vision or other neurological deficits. She also had red eyes and a dry cough that was not accompanied by coryzal symptoms for 1 day. She initially presented to a family physician and was given 3 days of oral azithromycin. However, her right neck swelling grew in size and redness over the last 2 days prior to admission. It was reported that she did not have contact with any sick persons. However, she had travelled to South India a month ago.
On physical examination, the child was febrile with a temperature of 38.4°C, and lethargic. Her heart rate was 122 beats per minute, blood pressure was 100/60 mm Hg, and respiratory rate was 27 breaths per minute. There was no pallor or jaundice. An erythematous papular rash was noted over her trunk and limbs, but with no skin peeling. Her conjunctiva was extremely injected bilaterally without any eye discharge. Her lips were red, and she had a strawberry tongue. Her throat was mildly injected with no tonsillar enlargement or exudates. Tympanic membranes were normal bilaterally. There was a palpable right cervical lymph node, measuring 5 by 3 cm, which was tender and warm to touch with overlying erythema, causing limited lateral rotational movement of her neck. On auscultation of her chest, both her heart sounds were heard without any murmurs, and her lung fields were clear bilaterally with no adventitious sounds heard. Her abdomen was soft and nontender, with no hepatos

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


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

[User]
RADIOLOGY NOTE:
The patient was a 24-year-old woman, 1 gravida and 0 para. She was diagnosed with a normal intrauterine pregnancy. There was no abnormality in her medical history and allergy history.
At 36 weeks and 2 days of gestation, she was diagnosed with a placental abruption and underwent emergency cesarean section immediately. A female baby weighing 2439 g was delivered with umbilical artery pH of 7.140. The amount of bleeding during surgery was approximately 658 ml including the amniotic fluid. Until the 2nd postoperative day, there were no abnormalities in her vital signs or urinary volume.
Blood tests were performed on the 3rd postoperative day and revealed severe anemia with a hemoglobin (Hb) level of 3.9 g/dl. Performing an abdominal ultrasound examination and enhanced computed tomography (CT) of the lower abdomen, we found a hematoma with a diameter of 9 cm between the uterus and bladder (). A blood transfusion improved the anemia immediately. She did not complain of abdominal discomfort, and no signs of infection were observed. Thus, a conservative therapy was chosen. She was discharged on the 10th postoperative day and was followed as an outpatient.
On the 28th postoperative day, she came to our department with a complaint of abnormal vaginal bleeding. Blood tests did not reveal anemia (Hb 12.0 g/dl). Enhanced CT and magnetic resonance imaging (MRI) were performed, and there were no apparent findings of infection associated with the hematoma; however, we were concerned about a fistula at the site of the uterine incision. To remove the hematoma and check the incision site, we performed laparoscopic surgery.
We inserted a 12 mm port in the umbilical region and observed the abdominal cavity. The hematoma was located extraperitoneally inside the chorda umbilicalis (). Then, we performed resection of the hematoma laparoscopically. We cut the peritoneum inside the chorda umbilicalis and successfully reached the interior of the hematoma. The uterine incision site was locate

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


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

[User]
RADIOLOGY NOTE:
A 35-year-old male presented with a 6-month history of the appearance of multiple discrete fluid-filled lesions over erythematous skin, of size around 0.1–0.2 cm, which gradually increased to a size of around 1–3 cm. The lesions first appeared over the trunk and gradually over other parts of the body. The lesions used to rupture after 5–6 days leaving behind raw erosions, which were nonspreading in nature. The erosions used to get crusted in the next 4–5 days which fall off leaving behind light-colored skin. There was no history of any drug intake before the appearance of the lesion. On cutaneous examination, few tense bullae of size around 0.5 cm were found to be present in the perineal region []. There were multiple healed hypopigmented lesions with perifollicular hyperpigmentation, with some lesions showing crusting over them. A peculiar finding of the distribution of lesions was that the lesions covered the whole body but spared a band-like area in the hip region both in anterior and posterior aspects []. Oral mucosa was not involved. Remaining systemic examinations were within normal limit. A provisional diagnosis of bullous pemphigoid with the reverse Koebner phenomenon was made with the probable cause of sparing being the tightness of clothing in that particular area. Suspecting the same biopsy was sent for histopathology and direct immunofluorescence from both the lesion and the spared area. The histopathology of the lesion showed subepidermal split with a mixed inflammatory infiltrate, which was composed of predominantly eosinophils, neutrophils, and lymphocytes [], but the histopathology of the spared skin showed no abnormalities []. However, the direct immunofluorescence from the perilesional area showed linear deposits of immunoglobulin G and C3 in the dermoepidermal junction [], but the direct immunofluorescence from the spared area showed no deposits. Indirect immunofluorescence and salt splitting could not be done because of resource constraints. Rest

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


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

[User]
RADIOLOGY NOTE:
A 41-year-old female was admitted to our hospital (Ruikang Hospital Affiliated to Guangxi University of Chinese Medicine, Nanning, China), presenting with recurrent abdominal pain (apparent for >1 year) and paroxysmal abdominal pain accompanied by bloating and loose stools, but no nausea or vomiting. The results of the physical examination revealed abdominal distension and visible intestinal peristaltic waves; however, there was no whole abdominal or rebound tenderness. Orthostatic images of the abdomen showed an incomplete intestinal obstruction, while the results of an oral colonoscopy revealed a narrow lower end of the jejunum, no ulceration and a new neoplasm, which was considered to be narrow small intestine (possibly the lower end of the jejunum). The narrow section was surgically biopsied (2011–6099) and judged to be a chronic mucosal inflammation of the lower end of the jejunum. Laparotomy revealed a hardening and narrowing of the small bowel at the junction of the jejunum and ileum, with significant expansion proximal to the jejunum and a large volume of intestinal contents. Numerous lymph nodes were observed on the mesentery, and the intestinal canal had significant hyperemia and edema. There was a section of diseased small intestine ~1.5 m to the ileocecal valve, and the lumen was hardened and narrow. The two mucous membranes of the small intestine exhibited pathological changes and were smooth and complete. The lesions did not penetrate the mucous layer. Small bowel resection and anastomosis surgery were performed on the narrow section (). The postoperative pathological results revealed a poorly differentiated/undifferentiated carcinoma of the small intestine, with invasion of the cancerous tissue into the intestinal submucosa, muscularis externa and placenta percreta. Extensive invasion of the cancerous tissue was also observed inside the mesenteric layer; however, there was no cancer present in the mucous layer and no metastasis into the intestinal lym

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


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

[User]
RADIOLOGY NOTE:
A 71-year-old male patient visited Yeungnam University Hospital with abnormal chest computed tomography (CT) findings on a routine medical examination. The patient was taking medications for hypertension, diabetes mellitus, and hypothyroidism and had a history of traumatic abdominal aortic aneurysm surgery 40 years previously. Chest CT revealed a 3.5-cm oval mass in the posterior mediastinum at the level of the eighth to ninth thoracic vertebrae in addition to multiple pulmonary nodules (). Magnetic resonance imaging (MRI) of the abdomen showed multiple poorly enhanced masses in the liver. The liver masses were smaller than 2 cm and emitted a low T1 signal and a high T2 signal (). We considered the possibility that the lung and liver lesions were metastatic, but blood tumor marker tests were normal. Percutaneous needle biopsy (PCNB) of the pulmonary lesion failed to yield a meaningful sample. With the possibility of neurogenic tumor or pulmonary and hepatic metastases in mind, we decided to perform surgery. We planned to resect the mediastinal tumor and biopsy the pulmonary lesion for diagnosis. We decided to determine the treatment plan for the hepatic lesions based on the surgical pathology results. We performed surgery with the patient in the left lateral decubitus position via video-assisted thoracoscopic surgery. We made 3 ports (5 mm, 10 mm, and 12 mm) using a 10-mm telescope. We identified the mediastinal tumor as observed on chest CT. The mediastinal tumor was located in the posterior mediastinum, close to the sympathetic chain and supplied by feeding vessels from the intercostal vessel. The tumor was well-demarcated without invasion into adjacent structures. After ligation and division of the feeding vessel with a hemoclip, the tumor was removed without difficulty. A pulmonary examination revealed multiple well-circumscribed nodules of different sizes, diffusely distributed on the lung surface. We performed wedge resection to obtain tissue for diagnosis. Af

[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 37-year-old, single, Caucasian woman presented to the emergency department with a 3-month history of experiencing progressive shortness of breath that was associated with bilateral lung infiltrates. She was examined in several clinics and was treated with several courses of different oral antibiotics; however, her condition did not improve, and her shortness of breath progressively worsened over time. She reported a history of low-grade fever, a dry cough, fatigue, and the loss of appetite. Furthermore, she did not have a history of skin lesions, joint pains, or any symptoms that suggested connective tissue diseases. Additionally, her past history revealed that she had been suffering from severe depression for which she was taking oral antidepressants. Upon presentation, she was found to be on daily doses of two SSRI medications. She was prescribed paroxetine 50 mg to be taken once daily, which she was taking for the last 1 year, and owing to a misunderstanding, she was also prescribed escitalopram 10 mg to be taken once daily. As a result, she was taking both medications together for at least the last 6 months.
A physical examination disclosed that the young lady was suffering from moderate respiratory distress and peripheral cyanosis and that her oxygen saturation, measured by pulse oximetry, was 84% in the room air. During chest auscultation, she exhibited fine bilateral basal crepitations, but she did not exhibit wheezing. Furthermore, she did not present finger clubbing, skin abnormalities, or palpable lymphadenopathy. The examination of her cardiovascular system was unremarkable, and an abdominal examination did not reveal palpable organomegaly. The musculoskeletal and central nervous system examinations also did not reveal any abnormalities.
Furthermore, her initial investigations revealed a normal complete blood count (CBC), and her renal and liver function tests were normal as well. Her arterial blood gases showed type I respiratory failure with a partial

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


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

[User]
RADIOLOGY NOTE:
A 31 year old female with a history of two cesarean sections, the last one of them three
years prior, presented with a painful mass in the left lateral side of the Pfannenstiel
incision which had been steadily growing. The same patient went a month ago to our
institution's urology clinic with pain in the inguinal region. After a detailed history
and physical examination an ultrasonography was performed that revealed a 20X12 mm
hypo-echoic nodular mass, neighboring the rectus abdominis muscle, with minimal
vascularization. The differential diagnosis included endometriosis and a possible
desmoid tumor. The patient was referred to our clinic for further evaluation. The pain
started on the left lower quadrant and radiated towards the inguinal region, and was
associated with menstruation. In physical examination a 2 cm wide mass was palpated in
the previously described localization. Magnetic resonance imaging was performed which
revealed a 20x11 mm mass which is slightly hyper-intense in the T1 sequence, and
contrast enhanced after IV gadolinium injection in the T2 sequence, with increased
signal intensity and nodular appearance in diffusion weighted sequences. These were
found to be consistent with an endometrial implant ( and ). Examination of the
uterine cavity showed effusion which was at most 15 mm in width when measured. A little
free fluid, indicating peritoneal irritation was present in between the intestinal
loops. No pathological lymph nodes were present in the lower abdomen.
The patient was admitted for surgical removal of the mass 2 cm wide fibrotic appearing
mass was excised () and was sent for
pathological examination. The patient's complaints resolved after the surgery. She was
discharged with no complications two days after the operation. Four months after the
surgery, the patient came in for a follow-up visit, and had no complaints or
complications. Histopathological examination was consistent with glandular structures of
the endometrium with accompanyin

[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 Emirati male presented to Cleveland Clinic Abu Dhabi (CCAD) emergency department (ED) for the first time in Sept 2015 complaining of severe abdominal pain. The pain has been episodic for the last 4 years and had significantly affected his work and family life. He was seen and admitted to multiple hospitals across Abu Dhabi, including our own, attended different specialists, and underwent a wide range of investigations including blood tests (CBC and differential count, liver and renal profiles and CRP), gastroscopies, colonoscopies, and CT scans and a laparoscopy. The results of all his clinical assessments and investigations did not show any sign.
On one of his acute admissions to CCAD, the immunologist was asked to review the patient. Detailed examination of the patient's medical history starting from the onset of symptoms reveled that he used to get 2 swelling episodes every week affecting his face, hands, feet or scrotum and severe abdominal pain twice a week. These swelling episodes and abdominal pain appeared suddenly without any obvious triggering factor, developed over 36 hours and resolved spontaneously in 5-7 days without any medication including analgesics. He reported no laryngeal swellings or respiratory compromise. He denied any fevers, night sweats, weight loss, change in bowel habits or blood in his stools. His swelling episodes were occasionally associated with non-pruritic red skin rash that was mistaken for chronic urticaria for which he was treated with Omalizumab (300mg every 4 weeks) for 9 months without any benefit. Moreover, his response to different types of analgesia, high dose antihistamines, antibiotics and corticosteroids was unsatisfactory. He is a thalassemia carrier; otherwise he is fit and healthy and has no past medical history of note. He has no family history of immunodeficiency, inflammatory bowel disease, autoimmunity or FMF. On examination, he was in pain and his abdomen was soft, tender with guarding and decreased

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


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

[User]
RADIOLOGY NOTE:
In this study, we report a 27-year-old single man with no history of psychiatric disorder or drug abuse. His illness initiated with some pure psychiatric symptoms; for 3 years, the case had a fear with the feeling of being followed by others, without any external stressor. His symptoms were then exacerbated to hesitation and muttering, irritability, anger outbursts, bad tempering, and antisocial behavior. He thought his colleagues at work are likely to harm him due to his good skills at his job. His symptoms gradually tended toward depression, severe fatigue and loss of energy, loss of appetite, and weight loss and were followed by joint stiffness and loss of movement control at upper and lower limbs. After 6 months from the appearance of symptoms, he was brought to a psychiatric office being uncertain of hallucinogenic drug abuse. The psychiatrist prescribed citalopram 20 mg daily, risperidone 2 mg three times a day, and biperiden 2 mg three times a day; however, no improvements in the symptoms were observed.
Although there was no history of psychiatric disorders and drug abuse, due to some motor neuron involvement, the patient was referred to carry out a brain imaging (magnetic resonance imaging [MRI] without contrast) to rule out organic disorders in a month. He was referred to psychiatrist after 6 months from the appearance of symptoms. The psychiatrist also asked the patient to carry out brain MRI following the medical treatment. The T2-weighted MRI demonstrated periventricular and white matter multiple sclerotic plugs with lesions (). Because of the presence of paresthesia, upper and lower limb muscle weakness, ataxia, and urinary incontinency, he was referred to a neurologist. MS diagnosis was made based on the patient’s signs, symptoms, and imaging findings. He took methylprednisolone (5 mg three times a day/until remission) and interferon therapy, which resulted in improvements in sensory and motor neuron involvement and socio-occupational behavior and disa

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


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

[User]
RADIOLOGY NOTE:
A 45-year-old male patient presented with complaints of a nasal forehead mass which had gradually increased in size over the past 5 years and influenced his appearance.
The patient found the nasal-root mass 5 years ago. The mass was the size of a peanut, soft, of normal skin color and with a swollen smooth surface, often exhibiting self-absorption with no other discomfort. In October 2018, nasal mass resection was performed at a local hospital and postoperative pathology was unclear. A relapse occurred in January 2019 and the mass gradually increased in size over the next 10 months, to approximately the size of 5 cm × 2.5 cm. The patient came to our department for a clear diagnosis and treatment.
The patient was in good health and had no history of chronic disease. In 2012, he underwent appendectomy in a local hospital due to acute appendicitis.
Physical examination of the nose upon admission showed that the shape of the nose was normal. The left part of the nasal-root mass was about the size of 5 cm × 2.5 cm. It was soft, with a smooth surface, no redness or swelling, no ulceration, and no tenderness.
No abnormalities in terms of renal function, erythrocyte sedimentation rate (ESR), rheumatism, serum complement (C3/C4), quantitative immunoglobulin determination, immunoglobulin IgG4, antinuclear antibodies or ANCA were found. The possibility of Kimura's disease was not considered before surgery, and IgG4 and IgE levels were not detected before the operation. Positive laboratory results are shown in .
After admission, computerized tomography (CT) and magnetic resonance imaging (MRI) examination of the patient's paranasal sinuses were performed. MRI showed an iso-intense signal in the T1 sequence, iso- and hyper-intense signal in the T2 sequence () and enhancement in the T1 enhanced sequence with an unclear boundary. CT showed a soft tissue signal in the nasal forehead with an unclear boundary ().

[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 male patient came to the Urgent Trauma Center after being hit in the chest by a bull. Symptoms were mild pain on the right lower ribs posteriorly without visible contusion marks and without cardiorespiratory compromisation. According to the patient’s medical history he had never had any respiratory symptoms or condition before the incident. A chest X-ray was performed and while there was no sign of broken ribs, pleural effusion or pneumothorax, there was a big, sharply marked, round shadow present on the right lung. Laboratory tests (complete blood count, C-reactive protein, renal function and coagulation parameters), thorax and abdominal ultrasound were performed immediately without any pathological finding. Urgent thorax computed tomography (CT) scan was performed and the radiologist described a dense sharply marked formation filled with fluid sized 10.6 × 11.1 × 11.6 cm in contact with the right main bronchus (Fig. ). The patient was admitted, a bronchoscopy was performed and there was no intraluminal evidence of tumor. A pulmonologist was called in, who then recommended an ultrasound or a CT-guided thoracic puncture considering the formation to be an intrapulmonary hematoma and, less likely, a primary lung tumor or an echinococcal cyst. CT-guided transthoracic puncture was performed and the substance was sent for a cytological analysis which showed that the formation is most likely a pleomorphic adenoma but could also be a hamartoma and required histopatholological verification. From the admittance and during his hospital stay the patient was stable and asymptomatic. The operation procedure was scheduled as soon as the cytological analysis was completed. Right lateral muscle-sparing thoracotomy was performed. Macroscopic examination showed a large reddish capsulated tumor with a smooth surface, clearly demarked from the surrounding lung parenchyma. There were no macroscopic pathological findings on the pulmonary lobes. During the extirpation, surgi

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


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

[User]
RADIOLOGY NOTE:
A 73-year-old woman presented with dyspnea on exertion. Chest radiography showed an enlarged mediastinal silhouette. Preoperative computed tomography (CT) and echocardiography revealed a giant cyst (12 × 10 cm in diameter) occupying a large area around the left atrium and ventricle, and it was present behind the pulmonary artery. Based on the preoperative CT findings, a pericardial or an epicardial cyst was suspected. Additionally, attachment of the cyst to the left atrium, left ventricle, pulmonary artery, and pulmonary vein was suspected (Fig. ). Compression of the left atrium and ventricle was considered to be the cause of her symptoms. Her hemodynamic condition was stable. Percutaneous cystocentesis was performed, and 800 ml of serous liquid was aspirated. However, 1 week after cystocentesis, the cyst recurred, and its size was the same as that before the procedure. Therefore, resection was planned.
If the cyst was an epicardial cyst, tight adhesion of the cyst to the left atrium, left ventricle, pulmonary artery, and pulmonary vein was considered possible. However, we believed that the cyst was more likely a pericardial cyst because a pericardial cyst is more common than an epicardial cyst. Therefore, resection involving video-assisted thoracoscopic surgery (VATS) was planned initially. However, the pericardium was intact and an epicardial cyst was diagnosed intraoperatively. As preoperative CT showed compression of the left atrium, ventricle, pulmonary artery, and pulmonary vein, adhesion was suspected. Additionally, the possibility of cardiopulmonary bypass (CPB) was considered. Therefore, open surgery through median sternotomy was performed. The cyst was found to be attached to the visceral pericardium involving the left atrium and pulmonary artery. Contrary to our expectation, the left ventricle was not involved. Additionally, coronary vessels were not involved. The cyst was most tightly attached to the main pulmonary artery. Thus, it was thought to have or

[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 woman Gravid 12 was referred to the Tumor Clinic of Ghaem Hospital, Mashhad University of Medical Sciences in September 2013. Her symptoms were abdominal pain, loss of appetite, nausea, and vomiting from 20 days ago with a history of moderate hematemesis. No severe disease was observed in her medical records. She looked dehydrated and ill in terms of general appearance. Vital signs were blood pressure 70/50 Hgmm, pulse rate 100/minute, temperature 36.1°C and respiratory rate 14/minute. Laboratory studies detected leukocytes 20000 and PMN 87%. Liver and kidney function tests were normal. She was misdiagnosed with the left bundle block view in ECG and the AF rhythm in auscultation which caused her to undergo medical therapy in CCU. At first admission in hospital, abdominal examination revealed tenderness in the right and left lower quadrant of abdomen without rebound tenderness and guarding, and evidence of rigidity and abdominal distention.
In sonography evaluation, size of uterus was 133.5 × 80.5 cm with hypoechoic mass 101 × 109 cm in the left lateral of uterine body, which could be probably interpreted as uterine myoma, and some free fluid in peritoneal cavity was also reported. Paracentesis 5 mL suppurative fluid was aspirated under the guidance of sonography. Findings of CT-scan were a round cystic mass with focal calcification at its periphery located in the pelvic cavity with the diameter about 14 × 11.5 cm probably ovarian cyst adenoma ( and ).
Based on the diagnosis of peritonitis (suppurative fluid aspirated), emergency laparotomy was performed and 700 mL of suppurative fluid in the abdominal cavity with normal appearance bowel and liver was found. The origin of pus draining was a 1 × 1 cm rupture in the anterior wall of uterus. However, there were multiple polypoid tumors in cervical canal yielded stenosis of cervical discharge. After peritoneal irrigation with 5 to 6 L of normal saline, total hysterectomy

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


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

[User]
RADIOLOGY NOTE:
An 80 year old Caucasian male presented to an arthroplasty review clinic 8 and a half years following the insertion of a primary DePuy PFC Sigma Posterior Stabilised (PS) TKA (size 3 tibial tray, size 3 femoral component and 15mm tibial stabilised insert).
The initial procedure had been uneventful and the post operative x-rays were deemed satisfactory. He had complained of some anterior knee pain, 1-2 years post operatively. This was attributed to sight overhang of the patella laterally. The patient declined any further surgery at that time as he was extremely mobile, managing long walks and cycling. His range of movement at that time was from 0-120 degrees flexion. As a precaution, his inflammatory markers were checked and found to be within normal limits.
At 5 years follow up, he had no complaints and was pain free. He was given a review appointment for a further 5 years. He represented early, however, at 8 and a half years post operatively, complaining about pain in the knee, with episodes of swelling and instability. Interestingly, he was able to sublux his knee posteriorly, using his hamstrings []
Radiographs showed an inverse shadow of the polyethylene liner protruding anteriorly over the tibial tray. There was no sign of loosening of the tibial tray or femoral component []. This suggested anterior polyethylene subluxation: this subtle sign has been described as indicative of failure of the locking mechanism in posterior-stabilized prostheses [].
He was operated on one month later. On making the arthrotomy of the knee, it was apparent that the polyethylene liner had dissociated from the tibial tray and was protruding anteriorly []. On removing the tibial insert it was found that the anterior locking flange on the under surface had fractured from the liner, allowing it to dissociate from the tibial tray. There was a line of wear along the base of the anterior aspect of the stabilising

[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 man presented with dry cough of five years duration with no associated breathlessness or wheezing. He did not report a post nasal drip or systemic symptoms. He was diagnosed to have Crohn's disease with gastro duodenal involvement ten years earlier. The diagnosis was established based upon typical features on a duodenal biopsy. He was treated with prednisolone and mesalazine. The Crohn's disease was in remission in less than a year following which prednisolone and mesalazine were discontinued. He was continued on treatment with a proton pump inhibitor. He worked as a university lecturer. He was an ex-smoker of ten pack years and had stopped smoking ten years earlier. On examination he did not have cyanosis, digital clubbing or significant lymphadenopathy. Examination of the respiratory system was unremarkable. A chest radiograph demonstrated bilateral apical infiltrates (Figure ). A full blood count, biochemical profile, angiotensin converting enzyme levels and total as well as specific immunoglobulins were all normal.
A fibre optic bronchoscopic examination was macroscopically normal. The appearance of the trachea and the bronchial tree was entirely normal. Based on the chest radiograph, a bronchial wash as well as bronchial and trans-bronchial biopsies and were performed from the left upper lobe. The bronchial wash was sterile and negative for acid fast bacilli on stain and culture. The bronchial biopsy showed evidence of a mild inflammatory cell infiltrate, including eosinophils, in the sub epithelial connective tissue. The trans-bronchial lung biopsy was normal. The trans-bronchial biopsy was complicated by a small pneumothorax which did not need any intervention. A high resolution computed tomography (CT) scan showed a normal trachea and normal proximal airways which narrowed and then dilated peripherally. These dilated peripheral bronchi appeared fluid filled. These changes were seen bilaterally, well demonstrated in the left upper lobe (Figure )

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


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

[User]
RADIOLOGY NOTE:
A 76-year-old Asian female patient with a past medical history of hypertension and adenomyosis presented to the outpatient clinic with a chief complaint of painless hematuria for one day, which was associated with generalized weakness for a few weeks prior to presentation. She denied weight loss, nausea, diarrhea, or abdominal pain. The remainder of the review of symptoms was negative. On physical exam, she was afebrile, with a respiratory rate of 15 per minute, heart rate of 80 beats per minute, blood pressure of 130/90 millimeter of mercury, and saturating 99% on room air. Physical examination revealed a mobile mass in the right lower quadrant. She was subsequently referred to the emergency department. The laboratory results on admission are revealed in Table .
CT scans of abdomen/pelvis with IV contrast showed new right-sided mixed cystic and solid pelvic mass measuring up to 6 cm, which obstructed and invaded the distal right ureter, concerning for malignancy (Figures -).
CT chest with IV contrast showed multiple pulmonary nodules less than 5 mm. PET/CT revealed increased radiotracer activity in the right pelvic mass consistent with malignancy. Tumor markers including CA-125, CEA, and CA 27-29 were negative. Colonoscopy, mammogram as, well as a recent pap smear, were all negative for malignancy. Based on the diagnostic workup, the patient was thought to have a relapse of sarcoma. She underwent laparotomy with excision of the right-sided pelvic mass along with an abdominal washout. At the same time, she also underwent cystoscopy with right ureteral stent placement.
Tissue pathology was consistent with spindle cell neoplasm and histologic features were consistent with a recurrent stromal cell sarcoma as shown in Figure . The microscopic description of the mass revealed a spindled blue cell lesion with no necrosis, but a moderate mitotic rate. Immunohistochemistry was strongly positive for estrogen receptor (ER), progesterone receptor (PR), WT-1, CD99, and CD 56. T

[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 54-year-old man presented with a 3-month history of cough and shortness of breath during exercise. On physical examination, he had an audible expiratory stridor. The chest X-ray was normal. Computed tomography (CT) of the neck and chest revealed a 1.5 cm polypoid tumor arising from the posterior wall of the upper thoracic trachea (). A flexible bronchoscopy showed a double cone shaped, polypoid tumor arising from the posterior wall of the trachea, 5 cm distal to the vocal cords, and 7 cm proximal to the carina (). Based on the biopsy specimens, the mass was diagnosed as a glomus tumor. To check for an extension of the tumor into the surrounding tissue, an endoscopic ultrasonic exam was performed, and it showed that the tumor was confined to the trachea. Since the tumor was located in the upper trachea, we decided to approach the tumor through a cervical collar incision. After exposure of the trachea, the location of the tumor was identified between the 5th and 6th tracheal rings using flexible bronchoscopy. We divided the trachea one cartilage ring below the tumor and a sterile laryngectomy tube was inserted into the distal trachea. A proximal tracheal division was made one cartilage ring above the tumor. A frozen section analysis confirmed negative margins. Anastomotic sutures were placed using interrupted 4-0 Vicryl sutures (Ethicon, Somerville, NJ).
The surgical specimen was 3 cm in length with a luminal diameter of 2.3 cm. There was a 1.3×1.2 cm blue-red protruding nodule on the mucosal surface of the trachea (). The tumor did not show an infiltrative growth into the tracheal cartilage. At the microscopic level, the tumor showed glomus cells, vascular structures, and smooth muscle tissue (). The glomus cells had undergone a transition to elongated, mature smooth muscle cells in some foci (); this feature differentiated this tumor from ordinary glomus tumors. The tumor cells showed

[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 Hispanic male patient presented to the emergency department with intermittent lower abdominal pain and diarrhea. The patient had a previous history of ulcerative colitis and total abdominal colectomy with J-pouch and ileoanal anastomosis (2012) and a laparoscopic incisional ventral hernia repair with mesh (2015) in another institution.
The patient described his pain as intermittent and vague in nature, starting from the suprapubic area and spreading all over his abdomen, rated 6/10. The pain was not associated with fever, nausea, or vomiting. The patient had been having such episodes since his hernia repair but they increased in intensity over the past three weeks. He also had chronic diarrhea with a small amount of blood when he wipes. Physical exam showed a midline incision scar with bulging when coughing and diffuse tenderness all over the abdomen most prominently over the suprapubic/lower abdominal area. The patient looked ill in mild distress and had positive bowel sounds and tachycardia. Initial lab results showed mild normocytic anemia (HGB: 10.5, WBC: 9800, PLT: 579, HCT: 32, and MCV: 70). CT scan () showed thickening and stranding of the J-pouch and rectum, with obliteration of the rectal fat planes, along with mesenteric lymphadenopathy. There was proximal dilatation with partial air-fluid levels within the small bowel, concerning for partial obstruction. A flexible sigmoidoscopy () showed inflamed mucosa with ulceration and adherent mucus. Multiple biopsies were obtained. A large foreign object was visualized in the pouch. It had a rope-like lattice appearance on its outside; the inner contents were not well visualized. The foreign object was not removed then due to the uncertainty of its origin and extent. The patient was then taken to the operating room for pouch exam under anesthesia where the foreign body was removed in its entirety (). The object turned out to be a mesh with tacks and sutures from the original placement one year

[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 man received a renal transplantation from cadaver donor on October 1999, after one year spent on dialysis. The early clinical course was characterised by a delayed graft function and two clinical episodes of acute rejection, both treated with steroid pulse therapy. The immunosuppressive treatment consisted of basiliximab, methylprednisolone, cyclosporine, and azathioprine (AZA). At discharge, creatinine plasma concentration was 2.0 mg/dL and remained stable thereafter. On October 2002, AZA was replaced by sirolimus, and some months later cyclosporine was completely withdrawn. No rejection episode, nor infectious problems were observed during the following years.
In 2007 the patient, due to work problems, moved to a different hospital for his periodic followup. On October 2010, routine laboratory analysis showed the asymptomatic rise of plasma creatinine to 3.2 mg/dL. An abdominal ultrasonography (US) was performed, showing a hyperechoic solid renal mass that completely enveloped kidney structures. The nephrologist suspected a renal neoplasia and advised the patient to contact us for a deeper clinical evaluation.
At admission in our unit, the decline of GFR was confirmed (plasma creatinine: 4.2 mg/dL); palpation of the transplanted kidney evoked no pain, and diuresis was maintained. The US confirmed the alteration of renal structure due to the presence of a conspicuous nonvascularized mass (10.4 × 4.1 cm) that completely wrapped the kidney around, but had the characteristics of fat tissue, with a concomitant hydronephrosis (Figures and ). A RSL was hypothesized, and a computed tomography (CT) scan was performed, since magnetic resonance imaging (MRI) could not be performed due to the presence of abdominal metallic clips. CT (with no contrast medium) confirmed the presence of the extensive fat proliferation that completely covered renal pelvis; the ureter was not visualized, nor calculi could be demonstrated in any scan.
Three different diagnoses were co

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


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

[User]
RADIOLOGY NOTE:
A 28-year-old female with insignificant past medico surgical history presented with one day of acute onset pain in the periumbilical region that later migrated and confined to the RIF. She had associated intermittent fever, nausea, and loss of appetite. She did not have any urinary symptoms, bowel irregularities, or gynecological complaints. Abdominal examination was performed by two senior surgeons at two different occasions; the same day had findings of guarding and rebound tenderness at RIF. Hematological tests showed polymorphonuclear leukocytosis with left shift. Biochemical tests and urinalysis were normal. Urinary pregnancy test was negative. Abdominal radiographs were unremarkable. USG could not visualize appendix and was inconclusive except for probe tenderness in RIF. CT scan of the abdomen could not be done due to unavailability. A clinical diagnosis of acute appendicitis was made assigning an Alvarado score of 9/10. Laparotomy was performed using the Lanz incision in RIF. Intraoperatively appendix was found to be normal without evidence of inflammation or infection in RIF. In view of symptoms and signs, a possibility of other pathology was thought. Walking the bowel proximally up to 3 feet (1 m) did not show a Meckel's diverticulum or any other small bowel lesions. There were no obvious mesenteric lymph nodal enlargement and pelvic organs looked pristine. Approaching closure, just when the medial edge of the incision was retracted superomedially, a hemorrhagic lesion seemed to appear little deeper in the mid abdomen. Therefore, the incision was extended transversely from the medial edge to explore further. Entire bowel was explored and this revealed an ulcerated lesion measuring 7 × 5 cm arising from the antimesenteric border of the ileum 8 feet (2.5 m) from ICJ with localized interloop hemoperitoneum and inflammatory exudates as shown in . Resection of ileal segment containing the lesion was performed followed by restoration of bowel continuity and peri

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


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

[User]
RADIOLOGY NOTE:
A 20-year-old Danish woman was referred with constant pain in the right proximal thigh that had progressed for 8 years. She had no other known medical conditions. Menarche was at age 13. There was no family history of sclerosing bone diseases. The limb pain was aggravated at night and was moderately relieved during physical activity and by cold baths. She was on daily analgesic medication with nonsteroidal anti-inflammatory drugs, paracetamol, and weak opioid agonists, and she was on sick leave from her university studies at the time of referral due to her symptoms. She was using shoe inserts because of leg length discrepancy.
At age 11 she had consulted a rheumatologist because of hip joint pain. Guided by ultrasound a hip joint puncture was performed due to fluid gathering; serology was negative. After the puncture, the joint pain ceased.
Six months prior to referral to our clinic, she was involved in a traffic accident and hit by a car from the right at knee level. She was discharged from an emergency room (ER) with no suspected fracture and a radiological examination was not performed. She reported that there was significant worsening of the femoral pain after the traffic accident.
A clinical examination revealed no skin lesions, café au lait spots, or redness; there was no increased temperature or swelling in her right thigh. Leg length was unequal but within normality.
She was instructed to fill out a diary with daily registration of pain on an analog scale from zero to 10, where increasing values were equivalent to more intensive pain. Orally administered analgesics were required when the pain exceeded a score of 6 or more, and the score 10 was reserved for symptoms that kept our patient from falling asleep and that did not respond adequately to orally administered analgesics.
Magnetic resonance (MR) and positron emission tomography-computed tomography (PET-CT) scans revealed significant increased cortical thickness in the right femoral diaphysis that partial

[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 Greek woman, presented in the General Hospital of Volos with a painless neck mass on the left (Fig. ). No previous operations were recorded in patient's medical history. She reported that the lesion appeared in the last year and had a slow growth. Fine needle aspiration biopsy (FNA) of the lesion revealed a small amount of inflammatory cells mainly lymphocytes and several neoplastic cells with malignant features advocating undifferentiating carcinoma. These cells were either scattered or aggregated with large, hyperdense nuclei, nuclear membrane grooves and several abnormal mitoses. Several neoplastic cells were spindle shaped with solid cytoplasm and multiple nuclei. Computed tomography with contrast of the neck region revealed a bi-lobe lesion of 3.2 × 2 × 4 cm dimensions with peripheral enhancement and hypodense necrotic center in the subcutaneous tissue of the posterior neck triangle with no involvement of the deeper muscle tissue (Fig. ). After a thorough clinical examination, including endoscopy of the nasopharynx, larynx, and hypopharynx, and with no signs of metastatic disease, the lesion was excised under topical anesthesia.
Histology showed a low grade nodular malignant mesenchymal neoplasm consisting of perpendicularly arranged fascicles of spindle cells with eosinophilic fibrillary cytoplasm, scattered pleomorphic nuclei and irregular mitosis with a rate of 6 to 8 per 10 high-power-fields (Fig. ). The lesion was localized in the subcutaneous tissue, while medially it was in contact with striated muscle without infiltrating it. On immunohistochemical staining, the tumor expressed focal smooth muscle actin (α-SMA) and vimentin, while a small number of tumor cells were also weakly positive to HHF-35, desmin and S-100 stains. According to the histopathology and immunohistochemistry, the final diagnosis was subcutaneous LMS of the neck and the specimen's surgical margins were negative. Brain magnetic resonance as well as computed tomography of l

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


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

[User]
RADIOLOGY NOTE:
A 70-year-old man presented in 2017 after discovery of a hypervascular, expansile, 7 cm pancreatic body mass involving the splenic vein on routine surveillance CT scan (). He endorsed 1 year of diarrhea and steatorrhea that he had not sought medical care for but denied weight loss, appetite changes, fatigue, pain, or jaundice. He had a history of RCC and underwent a left nephrectomy and adrenalectomy in 2002. Additionally, he developed adenocarcinoma of the ampulla of Vater and was treated with pancreaticoduodenectomy in 2003.
He developed pulmonary metastases from the RCC and was treated with right lung segmentectomy in 2006 and three bilateral CyberKnife treatments in 2010, 2011, and 2013. He had surveillance CT scans roughly every 6 months from the discovery of the 2010 lung metastasis until 2015 and then yearly thereafter. He never received any chemotherapy for either the RCC or PDA. He is a former smoker.
Unfortunately, records of his prior malignancies, treatments, and surgeries were limited. His metastatic workup consisted of a CT scan of the head, chest, abdomen, and pelvis, which revealed no other sites of tumor except the 7 cm mass in the body of the pancreas, and testing his carcinoembryonic antigen (CEA) tumor marker level, which resulted as 0.9 ng/mL. The two main differential diagnoses were metastatic RCC versus recurrent PDA. Imaging characteristics, timeline of the mass development, and normal CEA level were the investigations used to determine that metastatic RCC was most likely and supported the decision to resect the mass.
The patient underwent completion pancreatectomy and splenectomy to resect his newly discovered pancreatic lesion. Surgical exploration and dissection revealed that the previous pancreaticoduodenectomy had been completed entirely antecolic. The gastrojejunostomy was able to be left intact throughout the duration of the procedure, whereas the hepaticojejunostomy was reconstructed due to its initial position being too far anterior

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


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

[User]
RADIOLOGY NOTE:
A 61-year-old female presented to the emergency room complaining of sharp lower right abdominal pain of 2 days duration; she also admitted to chronic intermittent abdominal pain over the past 2 months. She denied any fever, chills, nausea, vomiting, chest pain or shortness of breath. She did admit to cyclical episodes of diarrhea and constipation. Her past medical history was significant for antiphospholipid antibody with recent stroke and venous sinus thrombosis, lupus and hypothyroidism. Her past surgical history included: caesarian section, total abdominal hysterectomy, laparoscopic cholecystectomy and a total knee replacement. Her family history was negative for any types of inflammatory bowel disorder. Socially, she was married and denied any history of smoking, drug or alcohol use. She took the following medications daily: Coumadin 15 mg, Plaquenil 200 mg and Levothyroxine 25 mcg.
On physical exam, she was noted to be afebrile and normotensive. The abdomen was soft with tenderness to palpation in the right lower quadrant. There were normoactive bowel sounds. Laboratory data demonstrated a white blood count of 5300, a hemoglobin of 14.4 and a hematocrit of 43%. Renal function, electrolytes, liver function and urinalysis were all within normal ranges. Her international normalized ratio was 3.5.
A CT of the abdomen and pelvis without contrast was obtained on admission and revealed a dilated appendix up to 1.5 cm in size with no evidence of obvious appendicolith (). There was evidence of extensive mesenteric edema in the right lower quadrant of the abdomen. It was felt that these findings were consistent with appendicitis with possible early rupture pattern. Due to her history and likely early ruptured appendicitis, she was felt to be a high surgical risk and she was initially treated on the interval appendicitis pathway. This included IV antibiotic therapy and a repeat CT scan of the abdomen/pelvis 48 h after initial presentation. She was also placed on a heparin

[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 85-year-old woman with a past medical history of hypertension, hyperlipidemia, cerebrovascular accident (CVA), and left lower lung lobectomy presented to the ER due to intermittent abdominal pain, dysuria, and nausea for one day. Physical exam was significant for diffuse tenderness to palpation, worse in the suprapubic region. Her vitals were blood pressure of 167/78 mm Hg, respiratory rate of 16 per minute, pulse rate 87 beats per minute, and temperature of 95.9 °F. Relevant laboratory workup is mentioned in Table .
CT scan of the abdomen and pelvis with intravenous (IV) contrast was suggestive of proximal ureteral/ureteropelvic junction rupture and a large amount of fluid in the left retroperitoneum and surrounding the left kidney in the pelvis (Figure ). No clear obstructive etiology was identified on the CT scan. There was no evidence of stone or mass on the CT scan.
The patient received broad-spectrum antibiotics in ER. While the patient was in the ER, she was noted to have an atrial flutter with rapid ventricular rate and systolic blood pressure dropped to 89 mm Hg. She was given an amiodarone bolus and she reverted to normal sinus rhythm. Norepinephrine infusion was also planned to be given but once she reverted to sinus rhythm, her blood pressure was noted to improve. She was also noted to drop her oxygen saturation to 70% and was placed on two liters of oxygen through a nasal cannula.
Urology consultants were consulted and the recommendations were to admit the patient to the intensive care unit (ICU) and placement of percutaneous nephroureteral catheter tube (PNCT). This was done successfully (Figure ). The patient was monitored in ICU and continued on antibiotics.
Over the course of her stay, the patient clinically improved, and she was transferred out of ICU to medicine service. Due to persistent leukocytosis, a CT scan abdomen and pelvis with IV contrast was repeated, which did not show any clear infectious

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


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

[User]
RADIOLOGY NOTE:
A 73-year-old male had a traffic accident while riding his bicycle and hit his left knee on the ground. He presented at our hospital 4 days after the accident. He could walk without crutches but could not extend his knee against gravity. We palpated a subcutaneous depression in the left knee.
The patient was 165.5 cm tall, weighed 63.8 kg, and had a BMI of 23.3 kg/m2. He had previously experienced a comminuted left patellar fracture and underwent a total patellectomy when he was 20 years old. After the patellectomy, he had no complaints and had a full range of movement in the left knee. The preinjury Lysholm knee score was 90 []. At 57 years of age, the patient had received mitral valve replacement for regurgitation at another hospital and had been on anticoagulant therapy since then.
Plain radiographic examination did not show any fracture of the left knee but detected the absence of the patella and a small heterotopic calcification at the distal side of the quadriceps tendon (). Ultrasound examination showed a loose left patellar tendon compared with the contralateral side (), although it could not identify the rupture site. Magnetic resonance imaging (MRI) revealed subcutaneous edema and tendon disruption at the proximal side of the left patellar tendon, which indicated patellar tendon rupture (). We immediately immobilized the left knee with a splint and changed his anticoagulant therapy from warfarin to intravenous heparin.
Surgery to reconstruct the ruptured left patellar tendon was performed 12 days after the accident. We made a midline incision instead of an oblique incision along the previous scar and found a complete patellar tendon rupture with both medial and lateral patellar retinaculum rupture with about a 2.0 cm gap filled with a hematoma (). These ruptures were at the proximal side of the patellar tendon. We first washed and removed the hematoma and refreshed the ruptured tendon edge with scissors. The length of remained patellar tendon was about 5 c

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


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

[User]
RADIOLOGY NOTE:
A 50-year-old male with a past medical history of chronic cocaine abuse was found unresponsive in the field. He was given multiple doses of naloxone in the field without any improvement in mental status. On presentation in the emergency department (ED), the patient was found unresponsive to questions and unable to follow commands but withdrawing to painful stimuli, with a Glasgow Coma Score of 8, and tachypneic. Vital signs were significant for a respiratory rate of 38 breaths per minute and oxygen saturation of 90% on 6 liters nasal cannula. Physical exam appreciated no tracheal deviation and no jugular venous distention but exhibited an uneven rise and fall of his chest on the right side compared to the left. On cardiopulmonary auscultation, absent breath sounds of the right lung fields were noted with normal cardiac heart sounds. The patient was emergently intubated for airway protection in the ED, and further evaluation was initiated. Immediate imaging with portable chest X-ray was obtained which showed extensive lucency in the right hemithorax suggestive of large pneumothorax or an air-filled cyst (). A CT scan of the chest was performed which suggested extensive pneumothorax of the right lung without a mediastinal shift ().
For this reason, an emergent 24 French chest tube was placed in the right 6th intercostal space but failed to expand the lung. In response, the chest tube was then exchanged for a 32 French tube under the assumption that a larger size may be required, but it too failed to expand the lung. There was no air drainage from either tube placed suggesting lack of a pneumothorax. He was stabilized and admitted to the intensive care unit for further management. A few hours after admission, he underwent bronchoscopy with a right chest VATS which revealed a giant bulla encasing the entire right pleural cavity with its origin in the right upper lobe beginning at the apex. The bulla was extracted, and pleurodesis was performed by mechanical and chemical

[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 11-year-old boy was the second child of healthy unrelated parents. At the time of birth, his father and mother were 30 and 25 years old, respectively. He was a term newborn and his prenatal as well as perinatal period history were uncomplicated, except for mild hyperbilirubinemia (15 mg/dl of total bilirubin) at day 4 probably due to breast milk which improved with simple phototherapy. His early psychomotor development was normal. He completed the first and second level of elementary school with good scores. He developed one episode of generalized tonic-clonic seizure at age eight. It was repeated several days later; therefore, he was admitted to our hospital and phenytoin was started and the seizures were controlled. At this time precise physical and neurological examination unfolded clinical features of ODDD. Examination of the face revealed a long and thin nose with hypoplasia of nasal alae and anteverted nostrils (). Ophthalmic examination revealed microphthalmos with microcornea (), decreased visual acuity and glaucoma. Hearing assessment was normal. Oral cavity examination revealed yellowish color of the teeth with carries and smaller than normal and atypically-shaped teeth with arrested development appearance (). On skeletal examination, his hand revealed evidence of webbing of the skin (syndactyly) between the fourth and fifth fingers. There was also evidence of camptodactyly and hypoplasia of the mid phalanx of the fifth fingers (). Both parents were carefully examined and showed no stigmata suggestive of ODDD. His school performance was gradually deteriorated after the episode of seizure at age eight. One year later he complained of gait problem that has progressively worsened. There was spasticity of both legs with hyper-reflexia and extensor plantar responses. Gait examination showed spastic paraparesis.
On brain magnetic resonance imaging (MRI), symmetrical confluent hypersignal areas of subcortical white matter were evident with decreased signal o

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


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

[User]
RADIOLOGY NOTE:
A 60-year-old female came to the diagnosis of the oral disease department of Shahed Dental School for dental treatment with a chief complaint of lack of masticatory capability and poor esthetic for the past 20 years. Her medical history was significant for osteoporosis and congenital heart disease (CHD). Her current medication was the daily use of ASA as an antithrombotic, Digoxin for CHD, Enalapril for her hypertension, and vit D. Also, she had been medicating with Famotidine and Omeprazole for the last two years due to her masticatory hypofunction and digestive problems. Her medical practitioner advised that her dental treatment should be limited to noninvasive dental procedures with minimal trauma. The patient revealed that there was an absence of the lower and upper anterior teeth after exfoliation of deciduous teeth and the history of mandibular fractures 25 years ago in a motor vehicle collision. In extraoral examination, the prominent frontal and parietal, hypertelorism, depressed nasal bridge, mandibular prognathism, and maxillary hypoplasia were observed (). Also, the patient was able to move shoulders in front of the chest associated with underdeveloped or absent collarbone ().
Intraoral examination revealed a long span bridge in maxilla from tooth #15 to #25 and multiple missing permanent teeth in the anterior and posterior regions of the mandible. A panoramic radiograph and CBCT were captured (Figures and ).
Radiographic findings revealed multiple impacted permanent teeth in the anterior region of maxilla and anterior and posterior regions of the mandible as well as the fracture of the left angle of the mandible which had been fixed with wire. The patient was diagnosed with cleidocranial dysplasia evidenced by clinical and radiographic findings. After consulting with a maxillofacial surgeon, the extraction of all teeth (erupted and unerupted) and replacement by implants was not suggested due to the medical conditions of the patient including osteoporosis

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


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

[User]
RADIOLOGY NOTE:
A 39-year-old woman, who had been taking medication of quetiapine as an antipsychotics for depression, experienced mild dysarthria and visited the department of neurology in our hospital. Her symptom was diagnosed as drug-induced lip dyskinesia, which disappeared in a week. Screening head magnetic resonance imaging (MRI) at this time revealed stenosis of the left MCA with no brain parenchymal lesions (), why she was consulted to our department. We performed angiography, confirming moderate M1 portion stenosis (Figures and ). SPECT showed no apparent laterality in CBF, thereby we decided to observe her with no treatment.
Seven months later, the patient experienced mild weakness and numbness in her right hand and visited our department. Although MRI showed no apparent ischemic change in her brain, arterial spin labelling (ASL) of MRI detected the decrease of CBF in the left cerebrum (), which was thought to well correspond for her symptoms. She was admitted and treated with an antiplatelet agent. Two weeks later, she still complained of numbness in her right hand; thereby, we decided to perform left STA-MCA anastomosis to prevent deterioration of her symptoms. Preoperative SPECT showed no apparent laterality in CBF (). On operation, left temporal craniotomy was performed, and the parietal branch of the STA was anastomosed with the M4 portion on the temporal lobe (Figures and ). The intraoperative course was uneventful, and the patient recovered from anesthesia without any new neurological symptoms
Postoperatively, her speech was normal until postoperative day 1 (POD1). On POD2, she exhibited mild speech disturbance, which worsened day by day finally resulting in complete motor aphasia on POD6. Her comprehension was kept normal. On POD3, generalized convulsion occurred, which ceased quickly by diazepam, and levetiracetam was initiated. On the same day, she presented with mild weakness of right upper extremity, which improved gradually and disappeared on POD7. MRI and C

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


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

[User]
RADIOLOGY NOTE:
Our first patient was a 67-year-old male with a medical history of diabetes mellitus type II, hypertension, and benign polyps in the colon (three polypectomies). The patient had a history of tobacco use during the last 50 years; at the time of reference, he smoked 10 cigarettes daily. He had no alcohol overconsumption. When referred, the patient had suffered from dysphagia for 2 months, and he only consumed fluids. Besides a weight loss of 8 kg (weight at referral 83 kg, weight loss corresponding to 9% of initial body weight), the first physical examination was unremarkable, as were the initial blood tests. The primary endoscopy revealed a mucosa covered with white plaques spreading from 30 to 40 cm from the incisors. In the distal part of the affected area, the mucosa protruded and covered almost 2/3 of the lumen and involved the entire circumference (fig. ). The finding was thought to be a candida infection. Biopsies showed severe acute inflammation with reactive changes but without dysplasia or malignancy. A computed tomography (CT) scan showed a thickened wall in the distal part of the esophagus. Since no malignancy was found, the patient was discharged.
Four months later, the patient was referred again due to a further massive weight loss of 25 kg; at this time he weighed only 58 kg (weight loss corresponding to 36% of initial body weight). Gastroscopy and blood test were performed again, and human immunodeficiency virus, herpes, and HPV infection were ruled out. To rule out achalasia of the esophagus and gastroesophageal junction, a high-resolution impedance manometry examination was performed followed by a positron emission tomography (PET)-CT scan, but neither could explain the condition the patient suffered from. During this period of approximately 4 months, the patient was hospitalized at the Department of Infectious Diseases.
Six months after the first visit, another gastroscopy was performed showing ulceration and a process protruding into the lumen. 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:
Patient A.N. is an 83-year-old woman who was living in Iran in January of 2015 when she presented to a local hospital with painless jaundice and dark urine. A CT scan showed a pancreatic head mass compressing the common bile duct. For palliation of hyperbilirubinemia, a palliative stent was placed in the common bile duct. A fine needle aspirate obtained through an endoscopic ultrasound (EUS) revealed a poorly differentiated adenocarcinoma. A follow-up CT scan performed on February 13, 2015 revealed a 3.6 × 2.7 cm pancreatic head mass that abutted the superior mesenteric artery and one of its proximal branches. There were suspicious peripancreatic and retroperitoneal nodes and no evidence of distant disease. At the beginning of March, she began taking 50,000 U vitamin D3 (cholecalciferol) daily, ordered directly from the Internet and not under the direction of a healthcare practitioner. Repeat EUS and biopsy on March 3, 2015 again confirmed adenocarcinoma with papillary features. She was referred to an oncologist and surgeon for evaluation. A triple phase CT was done on March 16, 2015 that showed a stable mass without any evidence of involvement of the celiac axis or superior mesenteric artery. Upfront chemotherapy was recommended, with consideration of surgery in the future.
She received gemcitabine/protein nanoparticle-bound paclitaxel in March. On day 10 of cycle 1, she developed neutropenic fever complicated by atrial fibrillation with rapid ventricular response. She was intubated for a brief time who then recovered to her baseline functional status. She was discharged on April 19. Based on her frailty, she was deemed to be a poor candidate for surgery and chemotherapy was not resumed.
She was referred to radiation oncology for consideration of stereotactic body radiotherapy, but she decided to first pursue alternative therapies. She visited an alternative care clinic in April and began taking chelodium, curcumin, community mushroom blend, viscosin, and naltrexon

[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.