[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 58-year-old female presented to the emergency department with intermittent, crampy right-sided abdominal pain, nausea, and vomiting, which began approximately 18 hours previously. Her past medical history was significant for hypertension and her surgical history included a thyroidectomy for treatment of thyroid cancer and a Caesarean section. A contrast enhanced CT abdomen and pelvis was obtained, demonstrating multiple fluid-filled, dilated small bowel loops in the right abdomen, which were predominantly anterolateral to the ascending colon and cecum (). In addition, two transition points were identified in the right lower quadrant, with one transition point at the distal ileum just proximal to the cecum and a second transition point in the proximal ileum. The two transition points were in close proximity to each other, indicative of closed loop obstruction. Decreased wall enhancement of the dilated small bowel loops was concerning for ischemia. Mucosal hyperenhancement of the ileum at the proximal transition point was felt to relate to ischemia or decompressed state (). Given the patient's symptoms and findings of closed loop obstruction on CT, the patient was taken to operating room. In the operating room, an internal hernia with closed loop obstruction was confirmed and resulted from herniation of small bowel through an adhesion of a transverse colon epiploic appendage to the ascending colon mesentery. The herniated small bowel was nonviable and a total of 60 cm of small bowel was resected (). Retrospectively, kinking of the ascending and transverse colon could be seen on the initial abdominal CT and was felt to correspond with the site of adhesion ().
After resection, the patient's small bowel was left in discontinuity and an abdominal wound-vac was placed. The following day, the patient returned to the operating room, at which time the terminal ileum was also found to be nonviable. An ileocecectomy with enterocolonic anastomosis was performed.
The patient ha

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

[User]
RADIOLOGY NOTE:
22 years old male presented with acute pain and tenderness with deformity of right elbow joint with inability to move the elbow joint after he fell down due to episode of seizure, there was no neurovascular deficit. He was a known case of epilepsy on medical management. He had an history of injury to same elbow five years back following which immobilisation in a plaster cast was done for four weeks but any documentation regarding the injury was not available with the patient. Radiological examination (Fig.) confirmed anterior dislocation of elbow joint with a ununited medial epicondyle fracture.
Management One attempt of closed reduction was done in emergency but reduction could not be achieved. Another attempt of closed reduction was done in operating room under general anaesthesia and muscle relaxants was successful and elbow was stable during complete range of motion and no restrictions of motion was present. Reduction technique included distal traction on the wrist and backward pressure on the proximal forearm, a coupling was felt as the joint was reduced. care was taken not to hyperextend the elbow as it may lead to traction and potential injury to anterior neurovascular structures. A smooth K wire was used to transfix the ulno humeral joint (Fig.) along with application of long forearm slab as the patient was having epilepsy and another similar episode may happen. No attempt to fix the medial epicondyle was done in view of soft tissue stripping may compromise joint stability, also under fluoroscopic examination medial epicondyle appeared to be stable suggestive of fibrous union. K wire was removed after 2 week time and active and active assisted elbow mobilisation exercises were started. Patient regained complete range of elbow motion after 15 days of physiotherapy and was pain free. He again had episode of seizure after 2 months of injury but his elbow was not affected this time.

[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:
Herein, we report a case of a 71-year-old female patient hospitalized for anemia, motor incoordination, gait disturbance, weakness, and decline of her functional state. She was asymptomatic eight months prior to the day she was hospitalized, when she had asthenia, adynamia, hyporexia, symptoms of dizziness, and vertigo. Six months prior to admission, the symptoms increased, with onset of loss of balance, and postural instability. The patient also developed deterioration for walking, with repeated falls, which led her to stop walking for fear of falling, and limited her physical daily living activities to simply transferring from the chair to the bed. Likewise, it was noted that upon flexing her neck, she reported feeling an electrical discharge irradiating from her back to her legs. Two months before hospital admission, she noted lesions on the tongue, which produced a burning sensation and pain when swallowing foods - leading her to decreased intake of food and a loss of 5 kg coupled with increased feeling of weakness in her general state. She consulted with her local hospital, where she was diagnosed with paraparesis and anemia to continue studies.
As personal antecedents, she revealed hypertension managed with captopril 50 mg every 12 h. She did not report alcohol consumption, vegetarian nutritional habits, or other personal or family antecedents of importance.
Upon physical exam for admission, she was in poor general state, pale, and marked loss of muscle mass. Blood pressure was 130/80 mm/Hg, without orthostasis, respiratory rate 17 per min and heart rate 85 per min. Her weight before developing the diseasewas 70 kg; her current weight is 60 kg, height 1.65 m. The oral cavity showed smooth, shiny, reddish depapillated tongue with ulceration at lateral level ).
Neurological exam revealed that she was alert and oriented in all three spheres, no cranial nerve involvement, or abnormal movements. She had muscle weakness grade 3/5

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


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

[User]
RADIOLOGY NOTE:
A 38-year-old female patient presented with progressive dysarthria, dysphagia, nasal regurgitation and hyper nasal speech for 5 months duration. She had 4 episodes of partial seizures involving the right upper and the lower limb for the past 5 months and was not on any medications. There was weakness of the left upper limb for the past 15 days duration but there was no headache, vomiting or blurring of vision. She had emotional instability in the form of inappropriate crying. Neurological examination showed exaggerated jaw jerks and gag reflex with spastic dysarthria. She had both proximal and distal weakness in the left upper limb with power of 3/5. All the deep tendon reflexes were brisk with plantar response mute bilaterally and cortical sensory loss in the left upper limb. There was no atrophy or fasciculation of the affected muscles. The fundus and other system examination were normal.
Laboratory examination revealed positive neurocysticercosis serology. The peripheral smear was normal. The renal and liver function tests were normal. The MRI brain showed multiple small cysts with scolex in both the cerebral hemispheres and a giant intraparenchymal cyst measuring 5 × 4.3 cms in the right cerebral hemisphere [Figure and ].
Our patient presented with pseudobulbar palsy, partial seizures and weakness of the left upper limb. Her NCC serology was positive and diagnosis confirmed by MRI, which showed multiple cysts with scolex (in vesicular stage). She received the treatment with albendazole at 15 mg/kg/day along with steroids (for two weeks). She also received phenytoin for seizures. The patient remained seizure free and there were no significant events during her hospital stay. On follow-up six weeks after the completion of albendazole therapy she reported no recurrence of seizures and her right upper limb weakness recovered partially with power of 4/5. There was also improvement in her speech, emotional instability and was able to take food without nasal regurgitat

[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 34-year-old G4P3 Caucasian woman was followed up antenatally because of a stillbirth in her previous pregnancy. She had had mild pre-eclampsia in her first pregnancy and a Caesarean section was carried out after unsuccessful induction of labor. Her second pregnancy and delivery were uneventful. The reason for the stillbirth in her third pregnancy was found to be an umbilical cord knot.
In the pregnancy reported here, our patient had polymorphic eruption of pregnancy (PEP) from 26 weeks' gestation and had three separate courses of oral steroids. Anti-D-antibodies were also found to be increased but in quantitative analyses their concentration, however, remained low. She was hospitalized once for a short period in late pregnancy because of an abnormal fetal heart rate recording.
At 36 weeks' gestation, a hypoechoic, 3.6 × 4.2 cm rounded mass was noted within the placenta on ultrasound examination (Figure ). An ultrasound scan with umbilical artery Doppler measurement after 28 weeks' gestation was normal and it is likely that the leiomyoma had gone unnoticed probably because no special attention had been paid to the placenta on that occasion. Another explanation could be that the leiomyoma grew very rapidly in the third trimester of pregnancy and it was too small to draw appropriate attention in earlier scans.
She had induction of labor due to worsening of PEP at 38 weeks' gestation. A viable male infant weighing 3330 g was delivered with Apgar scores of 9 at one minute and 9 at five minutes. The placenta was removed without difficulty.
A round-shaped nodule was noted on the maternal surface of the otherwise normal placenta. The size of the nodule was 4 × 4 × 3 cm. It had a pale cut surface without hemorrhage, necrosis or calcification (Figure ).
Histologically, the nodule was composed of bundles of smooth muscle cells. Nuclei were round or oval shaped and there were no atypical features or mitotic activity (Figure ). No attached myometrium

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


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

[User]
RADIOLOGY NOTE:
We describe the case of a premature Bahraini girl born at 29 weeks of gestation by spontaneous vaginal delivery, to a 39-year-old gravida 6 para 5 mother. She was born “flat” with an APGAR score of 4 and 9 at 1 and 5 minutes respectively and a birth weight of 910 g. Ventilatory support was required during her first 6 days of life, with a dose of surfactant. She had an uneventful Neonatal Intensive care stay, tolerating breast milk and was gaining weight at a steady pace. On her 47th day of life she developed sepsis and required repeated ventilator support for 3 days. At day 51 she weighed 1400 g, but developed abdominal distension and feed intolerance. She was referred to the pediatric surgeon on day 54 when pneumoperitoneum was detected by a shoot-through lateral plain abdominal film (Fig. ). Our examination showed her abdomen to be distended but soft with mild diffuse tenderness and no signs of peritonitis. There was no abdominal wall erythema or visible bowel loops. We did not find any hernias or abdominal masses. Her C-reactive protein (CRP) was 37 mg/L which is 12 times higher than the normal range. In view of pneumoperitoneum, she was taken for exploratory laparotomy. A classic right transverse upper abdominal incision was used to open her abdomen as the diagnosis was NEC. Her entire small and large bowel was healthy and normal in appearance (Fig. ). Her appendix measured approximately 2 cm in length and was acutely inflamed with a perforation at the tip. Except for the site of perforation, there was no other evidence of gangrene (Fig. ). The findings were consistent with a perforated appendix with no evidence of peritonitis or NEC. An appendectomy was performed. She had a smooth postoperative recovery where she was started on breast milk on the second postoperative day and her CRP was normal on the eighth postoperative day. Histology demonstrated mucosal ulceration of her appendiceal wall, marked acute transmural inflammation, and

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


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

[User]
RADIOLOGY NOTE:
A 72-year-old man, with a history of type 2 diabetes mellitus, underwent a colonoscopy with standard bowel preparation following a positive faecal occult blood test. He presented to the emergency department 2 days later with increasingly severe right upper quadrant abdominal pain. On questioning, he stated that the abdominal pain had started 3 h following his colonoscopy but he failed to present to hospital earlier as he lived on a rural property more than 2 h away from the nearest medical assistance.
On presentation to the emergency department, the patient was tachycardic and febrile and his serology showed a neutrophilia, elevated CRP and bilirubin with normal hepatic transaminases. On examination, he was focally tender with voluntary guarding in the right upper quadrant. A CT abdomen was performed which identified a distended gallbladder, with adjacent gas locules and fat stranding around the hepatic flexure. The differentials included a contained microperforation at the hepatic flexure or emphysematous cholecystitis. The patient was haemodynamically stable and therefore a period of non-operative treatment was pursued. The patient was commenced on IV ampicillin, metronidazole and gentamicin, strict fluid balance, nil by mouth with regular clinical reviews. On Day 3, the patient had shown minimal clinical improvement and a progress CT was obtained which revealed extensive gas within the gallbladder wall and adjacent-free fluid consistent with emphysematous cholecystitis ( and ).
The patient proceeded to theatre—at laparoscopy, the omentum was wrapped and densely adherent over a firm, thickened and palpable gallbladder. It was unsafe to proceed laparoscopically and the decision was made to convert to a laparotomy. A Kocher’s incision was performed, which revealed a necrotic, gangrenous gallbladder with surrounding seropurulent fluid in the right upper quadrant (). Due to necrosis and oedema of the surrounding anatomy, the cystic duct could not be confidently identi

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


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

[User]
RADIOLOGY NOTE:
A 51 year old female was admitted to our hospital with complaints of dyspnea on exertion and chest pain radiating towards the back and right arm for 3 months. She was a known case of hypertension and osteoarthritis of both knees, and had a positive family history for ischemic heart disease. On examination, the first and second heart sounds were normal and a III/VI systolic murmur was heard at the apex with radiation to the left axilla.
Upon investigating, a transthoracic echocardiogram (TTE) showed thickened rolled up and prolapsed anterior mitral leaflet with severe mitral regurgitation (MR). A Trans-Esophageal Echocardiography (TEE) revealed thickened anterior mitral valve leaflet with rolled up margins, forming an aneurysm, with severe mitral regurgitation but no rupture of sub-valvular apparatus (Figs. and ). The posterior leaflet was also thickened with rolled up tips with mild prolapse of P1/P3. Mitral valve annulus measured about 42 mm. A diagnosis of mitral valve aneurysm along with severe MR was made, with prolapse of both leaflets and a grade II left ventricular diastolic dysfunction.
Subsequently, an elective surgery was scheduled for mitral valve repair +/− replacement. Median sternotomy approach was taken. Cardiac arrest was achieved with antegrade cardioplegia, under cardiopulmonary bypass and the usual state of moderate hypothermia was maintained. Mitral valve was approached through the left atrium and the findings of anterior mitral leaflet aneurysm were confirmed. The severely thickened valve was grossly evaluated again and assessed for repair but it was not possible due to severely distorted leaflets, hence most of the anterior leaflet and part of the posterior leaflet had to be excised (Fig. ), and replaced with a Hancock II 29 mm valve. On histopathological examination, the valve tissue revealed nonspecific degenerative changes microscopically, with no significant inflammation, atypia or malignancy. Post-operative course of the patient was uneven

[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 88-year-old Causasian woman presented with a large mass at the left prescapular region that had progressed in size over several months. Two years prior, she had undergone surgical excision of a SCC at the same site but resection margins were inadequate. She refused further treatment, was lost to follow-up and has been on homeopathy since. She is otherwise healthy with no significant comorbidities and does not smoke tobacco or drink. In fact, she had no attending physician and suffered from no pathology. She was rather resistant to medical treatment and had consulted very few doctors during her lifetime. Thus, she did not take any treatment except homeopathy to keep her in good general shape. She had no other medical history other than the surgical cure of a bladder prolapse and a right native hip luxation which was reduced in an operating room a few months before our first consultation. Socially, she is a retiree from laboratory work, who has been widowed for 5 years, and lives alone with three adult children nearby. She had a normal neurological examination at the consultation. On physical examination, she appeared cachectic and had received food supplements during hospitalization and there were numerous dermatological lesions suspected of being skin tumors. She had a heart rate of 78 beats per minute; her blood pressure was 125 mmHg (systolic) and 75 mmHg (diastolic). Her temperature was normal (37.6 °C). No medication was prescribed prior to surgery. However, on this physical examination, there was a notable fungating mass (measuring 10 cm in its major axis) involving the deeper tissues with contact bleeding (Fig. ). SCC was confirmed on biopsy. Oncological work-up included ultrasonographic evaluation of draining lymph nodes in the axillae and groin bilaterally, and a staging thoracoabdominal computed tomography (CT) scan (Fig. ); these were negative. Final staging of the SCC was T3N0M0 according to the 8th edition of the American Joint Committee on Cancer

[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 male patient aged 42 years reported to the department of maxillofacial surgery with the chief complaint of painless huge growth over left eye and loss of vision. History revealed that the patient was apparently alright 2 years back, when he first noticed a small pea nut size ulcerative growth over left lower eyelid near medial canthus. The growth was painless and persistent in growth. It was not associated with any kind of pain or fever. Initially eye site was normal but as the growth increased his vision started to diminish from left eye due to the increase in the size of growth, approximately 1 year before patient completely loses his vision from left eye. Only due to his extremely poor economic conditions he could not seek any sort of medical treatment.
On clinical examination the growth extended superoinferiorly from supraorbital ridge to ipsilateral alae of nose and mesiodistally from right inner canthus of eye to left side of maxillary buttress crossing midline (). Personal history was negative for any detrimental habits. On palpation superficial cervical nodes were not palpable. The growth was ulcerative, exophytic, and fungating and exudates were present. It was approximately 6 × 5 cms in size. The vision from right eye was normal and ocular movements in all directions were intact. All other parameters were within normal range. HR-CT scan was advised. The axial and coronal sections showed large homogenous mass covering the whole left orbit involving the globe but no erosive damage was seen in any of the bony structures (). Correlating the clinical history, examination, and radiological findings a provisional diagnosis of carcinoma of left lower eyelid was suggested. Incisional biopsy was performed and histopathological report revealed dermal invasion by abnormal cells from the epidermis, pleomorphism of the tumour cells with presence of keratinization within the cells which give the cells abundant pink cytoplasm, and intraepithelial keratin in the shape of

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

[User]
RADIOLOGY NOTE:
A 20 year-old Caucasian male presented to our department with incomplete left abducens nerve palsy; neuroradiological examination documented three intracranial space occupying lesions, respectively in the left cavernous sinus, on the right frontal convexity and on the superior aspect of the right petrous pyramid (Figure ).
He presented with a two year history of diplopia, of subacute onset, due to a left sixth cranial nerve palsy. Neurological examination was otherwise normal at the time; he denied any pain and had no fever. Head CT scan documented a small space-occupying lesion in the left cavernous sinus, with well-defined margins and minimal contrast enhancement (Figure A). Brain MRI confirmed the lesion in the posterior compartment of the left cavernous sinus: its signal behaviour excluded both fatty and hemorrhagic content of the tumour, excluding the hypothesis of paramagnetic effect related to hemosiderin and blood degradation products (Figure ). Due to the high complication rate associate with surgery inside the cavernous sinus, specifically with respect to a very high risk of permanent diplopia, his treating doctors chose to manage him conservatively with low dose corticosteroids and surveillance imaging. His diplopia resolved and a new MRI, three months after the previous, documented a minimal volume reduction of the left cavernous sinus mass lesion. Unfortunately the patient experienced bilateral femoral head necrosis secondary to corticosteroid use that resulted in discontinuation of dexamethasone. Three months later a new brain MRI documented minimal growth of the lesion, which was confirmed in subsequent examinations and the patient remained asymptomatic. One year and a half after the first neuroradiological examination, a repeat brain MRI documented a contralateral extraaxial lesion, at the level of the right frontal convexity, with the same radiological features, characterized by hyper-intensity on un-enhanced T1-weighted images (Figure A); a smaller

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

[User]
RADIOLOGY NOTE:
Case: a 63-year-old male was presented with pain in the left proximal thigh. A tumor was suspected by X-ray and magnetic resonance imaging (MRI).
Imaging findings: X-ray showed slight uptake in the left acetabulum ().
Computed tomography showed bone destruction images mainly in the left acetabulum extending to femoral head ().
MRI revealed a multilocular lesion from left acetabulum to pubis (). There was a slight accumulation of joint fluid. A lesion having similar abnormal signal was detected in the femoral head. The tumorous cords were well circumscribed from the surroundings, and there were findings suggestive of the existence of ligament component in the center.
Clinical course: an incision biopsy was performed and a diagnosis of chondrogenic sarcoma, suspect of chondrogenic osteosarcoma, was established. Tumor cells were fusiform or round shaped with atypical nuclei, often binucleated and scattered mitotic figures, suggesting high-grade sarcoma (). After preoperative chemotherapy was started, a deterioration of renal function was observed, and therefore, the chemotherapy (cisplatin + doxorubicin) was stopped after one course. The surgery consisted of wide excision and femoral head replacement for tumor ().
Pathology: gross cut surface of the resected specimen revealed that the tumor in the acetabulum progressed through the round ligament to the femoral head side. The articular cartilage was not destructed by the tumor, neither on the acetabular side nor on the femoral head side. There was no tumor extending into the joint cavity (). Final diagnosis was chondroblastic osteosarcoma with slight osteoid formation and little therapeutic effect (). Histological findings were similar to the preoperative biopsied specimen. Microscopic examination confirmed the unique extension of tumor cells on the gross findings. The tumor invaded along to the ligament from the acetabular site to the femoral head (). The pathological assessment of preoperative chemotherapy was grade 1

[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 man with stage IV squamous cell carcinoma of the tonsil presented for evaluation ulcerated nodules on his neck and multiple erythematous papules and plaques on his proximal chest. The patient had no history of alcohol or tobacco use and was diagnosed with invasive squamous cell carcinoma of the right tonsil in September 2012. He was treated with three cycles of cisplatin along with radiation therapy to his neck and upper chest over two months with good response.
In 2014, recurrence of squamous cell carcinoma was discovered in his cervical lymph nodes. He was treated with bilateral selective neck dissection. In 2015, he developed severe dysphagia, and esophagogastroduodenoscopy with dilation was performed. Tracheostomy tube was placed due to airway compromise.
He underwent a second esophagogastroduodenoscopy with dilation three months later in July 2015 for continued dysphagia; during the procedure, an abnormal area on the posterior pharyngeal wall was noted. Subsequent direct laryngoscopy with biopsy revealed squamous cell carcinoma in-situ. However, the gross appearance of the lesion was suspicious for invasive disease; positron emission tomography–computed tomography (PET-CT) was consistent with local progression of his carcinoma.
In November 2015, he was treated with two cycles of carboplatin and paclitaxel chemotherapy. He was then transitioned to nivolumab; he received 16 cycles from December 2015 to July 2016. In August 2016, he was restarted on carboplatin and paclitaxel. After three cycles, the patient decided to discontinue chemotherapy in November 2016.
In January 2017, the patient presented to his otolaryngologist for routine tracheostomy tube change. He described a two-month history of a neck rash that was initially painful, had spread to his chest, and was vesicular in appearance. The otolaryngologist noted not only a malodorous discharge near the tracheostomy site, but also skin lesions that were suspicious for varicella zoster

[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 presented to the Department of Orthopedic Oncology of the First Affiliated Hospital of Nanchang University (Nanchang, China) with the chief complaint of a painless mass in the right lower limb that developed over a period of 16 years. The patient appeared projections without apparent inducement at the medial cutaneous right leg which was about 2 × 2 cm in size, fixed block, soft, clear boundary, all directions and passive activities were unlimited at the beginning. Physical examination did not reveal any abnormalities, and the results of routine laboratory tests, such as erythrocyte sedimentation rate, were within the normal range. Three years after the mass was first recognized, a biopsy conducted at the Jian City People’s Hospital, Jiangxi, China showed signs of NF. However, the patient did not report any obvious discomfort, and therefore, the physicians did not recommend further examination but only regular follow-up instead. By early 2012, the patient started to limp. The symptom relieved after walking for a long period; however, the patient subsequently experienced numbness over the skin of the right lower extremity. On July 9, 2013, the patient underwent debridement at a local hospital, wherein the pathology results showed inflammatory cell infiltrations along with ulcers. The treatment did not illicit a favorable response and the tumors were not completely removed. Multiple tumors extending from the right leg to the popliteal fossa, buttocks, and groin were observed, with the largest tumor measuring approximately 10 × 12 cm; knee function was acceptable and no localized tenderness was detected. On April 30, 2014, the patient underwent multiple suction lumpectomies. Postoperative pathological findings indicated multiple schwannomas. However, the patient was hospitalized again owing to a right thigh and groin mass that enlarged; the patient also reported discomfort and weakness in the right calf, and underwent multisite lumpectomy for the righ

[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 25-year-old woman reported to the outpatient department of our tertiary care hospital with lower abdominal pain, vaginal spotting, and severe nausea lasting 10 days. At the time of presentation, she was primigravid at 18 weeks and six days of gestation according to her last menstrual period. The pregnancy was a planned conception occurring within three months of marriage. The pregnancy was confirmed with a positive urine pregnancy test. Further questioning about menstrual history revealed cycles of four to five days every 28 to 30 days. Past medical, surgical or family history was unremarkable. On physical examination, she was alert and pale with a blood pressure of 150/90 mmHg and a pulse of 80 beats/minute. Her abdomen was soft, non-tender with a 32-week fundal height. A speculum examination revealed no active bleeding or discharge; the os was closed. Apart from the elicited anemic signs, the remainder of the physical examination findings were within normal limits. An ultrasound examination revealed a single live fetus of 18 weeks and two days in duration (Figures -). We also noted a partial mole indicated by mass resembling a bunch of grapes and measuring 19 cm by 8 cm. The molar vascularity was insignificant on the Doppler evaluation. We ordered additional investigations through our hospital’s designated laboratory.
At 20 weeks of gestation, a repeat ultrasound revealed a single live fetus of 20 weeks duration with no gross fetal anomaly. A large mass with multiple short cysts was noted in the fundal region at the site of the placenta. We also noted evidence of a partial mole in the anterior fundal region of the uterus measuring 19.7 cm by 10.9 cm, bulging into the amniotic cavity and compressing the fetus. Repeat serial measurement of β-hCG at this point of pregnancy was 561,771 mIU/mL. At 20 weeks and two days, she reported concerns of a passage of grape-like vesicles, and spontaneous abortion followed.

[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 12-year-old boy was hospitalized with complaints of a headache and high fever accompanied by psychosis, delirium, and indistinct consciousness. He was diagnosed with limbic encephalitis, which is an autoimmune disorder characterized by inflammation of the limbic area in the brain. His symptoms became exacerbated, and he required intensive therapies including high-dose steroid and catecholamine administration.
Despite the continuous therapeutic support mentioned above, he abruptly developed hypotension following diarrhea, fever, and abdominal distension on day 41 after admission. Metabolic acidosis (pH 7.34, base excess − 7.0 mmol/L) was confirmed by blood gas analysis, and highly elevated CPK 11800 U/L, AST 461 U/L, ALT 201 U/L, and LDH 1034 U/L values were revealed by a blood chemistry profile. An emergency CT scan revealed pneumatosis intestinalis localized in the ascending colon and rectum coexisting with portal venous gas (Fig. ). While the root of the SMA and the inferior mesenteric arterial (IMA) flow was maintained, the peripheral blood flow was attenuated adjacent to the non-contrast-enhanced ascending colon and rectum.
Although intraabdominal free air was not detected in the CT scan, the massive ascites and progressing peritoneal signs with muscular guarding required an emergency laparotomy for suspected mesenteric ischemia and bowel perforation. Intraoperatively, skip ischemic lesions were observed in the ascending colon close to the hepatic flexure and the rectum without bowel perforation. Although SMA and superior rectal arterial pulsations were present, the marginal perfusion near the two lesions could not be confirmed. The patient was diagnosed with NOMI based on these operative findings and the rapid progression of the symptoms, which are unlike other vascular disorders or necrotizing enterocolitis. The remaining colon, from the transverse to the sigmoid colon, appeared intact. The color of the unaffected intestinal wall was restored, which suggeste

[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 58-year-old female was admitted to the emergency unit of our hospital suffering from acute dyspnoea, multiple episodes of vomiting, productive cough, and fever since 3 days. The patient reported a previous medical history of right mastectomy due to breast cancer followed by chemoradiotherapy and laparoscopic cholecystectomy for cholelithiasis ten months earlier. In the beginning of the operation after injection of anesthesia and endotracheal intubation, the patient developed pneumothorax which led to postponing the cholecystectomy. The pneumothorax was treated by inserting a thoracic drainage tube. After removing the thoracic drainage tube, chest X-ray and CT scan of the thorax were performed, but there was no evidence of diaphragm defect or herniation. Α laparoscopic cholecystectomy was performed four months later under general anesthesia with no complications. On admission to our department, the patient was febrile, pale, had considerable usage of accessory respiratory muscles, and had abdominal distention. On physical examination, the right lung presented decreased sounds during inspiration, while the abdomen was distended with diminished bowel sounds and peritonism. The blood exams were within normal values, while the arterial blood analysis demonstrated increased lactic acid levels and compromised pO2 values. Chest X-ray revealed that the right lung was totally suppressed by the intestine and suggested that due to intestinal transposition to the thoracic cavity, a functional right pneumonectomy had occurred (). CT scan of the thorax and abdomen detected a right diaphragm defect and herniation of the small intestine, which was also ischaemic due to venous circulation occlusion (). Urgent exploratory laparotomy was performed, and it revealed a diaphragm defect of 10 × 2 cm extending from the anterior side of the right diaphragm to the posterolateral side. Almost all the small intestine and part of the transverse colon were extending to the right thoracic cavity

[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 34-year-old Caucasian female, who had originally undergone an uneventful laparoscopic adjustable gastric band 4 years ago, presented to the bariatric surgery clinic with inability to tolerate solids. A work-up revealed that the laparoscopic band remained in good position but the patient had oesophagitis and gastritis, causing swelling of the mucosa at the band site. The fluid was removed from the reservoir, and the patient was treated conservatively with anti-reflux medication and a full liquid diet. After 2 weeks of treatment the patient’s symptoms improved. After careful consideration, she wished to undergo revisional surgery converting the laparoscopic adjustable gastric band to a laparoscopic vertical sleeve gastrectomy. The patient moved through the appropriate multidisciplinary team approach and was found to be an appropriate candidate for surgery. She underwent laparoscopic removal of the adjustable gastric band and conversion to a laparoscopic vertical sleeve gastrectomy without complications. Her post-operative course was uncomplicated and she was discharged on post-operative day 3.
On post-operative day 12, the patient was readmitted to an outside tertiary care hospital for lightheadedness and shortness of breath and was found to have leukocytosis, with white blood cell count of 18,000 cells μl–1. The work-up included a CT scan with intravenous contrast of the chest, abdomen and pelvis, and the patient was diagnosed with a pulmonary embolism. The patient was immediately transferred to our centre for definitive care. When the patient arrived at our centre, the CT films from the outside hospital were reviewed by our radiologists and there was concern that there was air and a faint suggestion of oral contrast outside of the suture line (). Given this finding, an UGI evaluation was ordered. During the early phase, no leak was observed, owing, in part, to the slow passage of 30 ml oral non-ionic contrast (). Some residual contrast from the outside hospital CT

[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 patient is a 54-year-old female with a past medical history of hypothyroidism and very severe obesity (BMI 48 kg/m2). She underwent laparoscopic gastric sleeve surgery in the year 2012. Results were non-satisfactory in terms of weight loss with a difference of 6 kg/m2 in BMI post-procedure. So after six years, she underwent a laparoscopic biliopancreatic diversion with a duodenal switch. She had an uneventful postoperative recovery period. An upper gastrointestinal (GI) study contrast post-procedure did not reveal any evidence of obstruction or leak. The patient was discharged home two days after the procedure. A few days later, she started experiencing three episodes of nausea with brown-colored vomitus. She was found to be septic, with a heart rate of 110 beats per minute and temperature of 100.2oF. Her white blood cells count was 12/mm3.The source of infection was presumed to be intraabdominal considering her symptoms. Computed tomography (CT) of the abdomen and pelvis showed mildly dilated proximal small bowel loops. The patient was started on empiric antibiotic therapy with ceftriaxone 1 gm intravenous (IV) daily and metronidazole 500 mg IV every eight hours. Symptoms did not improve, so she was taken back to the operating room for diagnostic laparoscopy. Partial small bowel obstruction was noted along with ischemia of a segment of the ileum that was part of the duodenoileostomy due to mesenteric dissection. She underwent an open revision of the small bowel anastomosis with resection and anastomosis for the obstruction revision of the duodenoileostomy. Her hospital stay post-surgery remained uneventful. Diet was advanced gradually throughout the hospital course and a week later, the patient was discharged home with outpatient follow-up. Three weeks after that procedure, she noticed a productive cough with thick, yellow, foul-smelling phlegm and shortness of breath. She saw her primary care physician. A chest X-ray performed showed a right lung infiltrate wi

[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 18-year-old male patient presented with symptoms of pain and swelling localized on the medial aspect of his right ankle joint, specifically at the medial malleolus. The patient noted a recent history of a twisting injury of his right ankle 6-months before presentation at our specialty orthopedic clinic. The injury occurred while playing football. Initially, he was treated by his general practitioner, who assumed it to be a severe sprain injury and had placed him on a course of ice compress and anti-inflammatory medication followed by a below knee plaster cast for a period of 3 weeks. Following this treatment protocol, the patient was able to walk but reported on-going pain while walking once the plaster cast was removed. No radiographic imaging was done at the time and was therefore not available for review and comparison.
On further examination, swelling was observed over the distal aspect of the medial malleolus, along with tenderness over deltoid ligament of the right ankle. There was no bone related tenderness at the distal tibia. Ankle joint movement was also observed to be normal. We proceeded with a thorough radiograph examination including standard X-rays and 3-dimensional computed tomography (CT) scanning of the right ankle, which revealed the presence of a small bone fragment located anterior and distal to the medial malleolus (, ). This fragment was not free floating and rather appeared to be attached to the distal tibia. Furthermore, it was a uni-lateral presentation as the patient’s left ankle anatomy did not reveal the presence of a similar bone fragment and was rather normal in appearance (). Based on our findings as well as the findings of previously published reports on this topic, a benefit of doubt was provided, and it was assumed to be a case of acute trauma, leading to a small fracture of the anterior aspect of the distal tibia.
At first consultation, the patient was explained of his diagnosis and offered a conservative treatment protocol tha

[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 patient was an 11-year-old Japanese boy (height 141 cm, weight 36.5 kg) with acute lymphocytic leukemia. Since the onset of acute lymphocytic leukemia, he had received early-stage intensive chemotherapy, remission therapy, and maintenance therapy; however, because he had a positive test result for minor breakpoint cluster region, umbilical cord blood transplantation was performed. After transplantation, he complained of abdominal and articular pain; his abdominal pain was accompanied by frequent diarrhea. These were considered to represent gastrointestinal symptoms of graft-versus-host disease (GVHD); thus, opioid therapy was initiated. For long-term opioid therapy, few opioid medications provide information on the label regarding the safety and effectiveness of the drug in pediatric patients []. We selected fentanyl because chemotherapy for leukemia predisposes the patient to renal dysfunction, and it is considered effective because it has high selectivity for mu 1 receptors in the treatment of mucosal pain [, ]. However, the dose of fentanyl was gradually increased for pain management, resulting in dose as high as 2300 μg/day, which required intervention from the palliative care team.
At the time of intervention, the patient was isolated in a sterilized room after transplantation. In addition to the major complaint of pain in the lower left abdomen, upon palpation, the patient complained of pressure pain throughout the abdomen; he also complained of joint pain in the legs when the abdominal pain intensified. Computed tomography revealed changes showing pancreatitis and mild intestinal edema, which was considered to be a sign of GVHD (Fig. ).
Given the intense acute pain caused by GVHD, the fentanyl dose was increased again to 2700 μg/day; however, the frequency of the rescue dose for pain (equivalent to 1-h dose of continuous infusion) did not decrease below 15 times per day, and continuously increasing the dose did not reduce the frequency of the rescue dose.

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


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

[User]
RADIOLOGY NOTE:
A 64-year-old male with a known VSD, who had not experienced any previous VSD-related complications, underwent a dental crown implantation without antibiotic prophylaxis in September 2016. Three months later he experienced fevers, sweats, and a dry cough, which spontaneously resolved after several weeks without antibiotic treatment. His symptoms recurred in June 2017 and at this time were associated with raised inflammatory markers. Further investigation, including a computed tomography (CT) chest, identified multiple peripheral lung lesions that were initially presumed to be malignant. Once again, his symptoms spontaneously resolved without any antibiotics. A follow-up CT chest in August 2017 identified resolution of the peripheral lung lesions, challenging the initial presumed diagnosis of malignancy.
A further CT chest was organized in November 2017, and on this occasion there was recurrence of lung lesions in new areas, suggestive of septic emboli with internal cavitation (Fig. A, B). At this time that patient complained of sweats and lethargy, and was consequentially hospitalized for further investigation of his relapsing remitting lung lesions.
On admission, four blood cultures all identified Streptococcus mutans. A transthoracic and transoesophageal echocardiogram was completed, which identified a perimembranous VSD but no endocardial vegetation (Fig. C). A CT pulmonary angiogram was performed to exclude a pulmonary embolus and to identify an appropriate lung lesion to biopsy.
A thoracoscopic lung biopsy was completed, which isolated S. mutans from the necrotizing lung abscesses. Furthermore, the patient complained of lower back pain, which was investigated with spinal magnetic resonance imaging and identified early L3-4 osteomyelitis without a complicating epidural abscess. As the patient was not haemodynamically compromised during admission, there was no need for urgent surgical repair of the VSD. The decision was made to treat the VSD-related IE medically,

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


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

[User]
RADIOLOGY NOTE:
This is the case of a 48-year-old G2P2002 who originally presented to our office in March 2016 with vaginal discharge, dysuria, and dyspareunia. She had previously been evaluated by her primary care physician (PCP) where a small cyst on the anterior vaginal wall was drained. She had received antibiotic treatment without relief of her symptoms. Her past medical history was significant for multiple sclerosis, Crohn's disease, and anxiety/depression. Her surgical history was significant for cesarean section × 2, bilateral tubal ligation, polypropylene midurethral sling procedure, and cholecystectomy. On physical examination, she was noted to have a small anterior vaginal wall fold near the urethra. MRI showed a cystic mass posterolateral to the urethra measuring 2.1 × 1.7 × 2.3 cm likely representing a urethral diverticulum. The mass had signs of infection/inflammation (Figures and ). Of note, the patient also had a long history of abnormal uterine bleeding and was found to have fibroids on MRI. She underwent hysterectomy with concurrent repair of the urethral diverticulum.
In June 2016, she underwent total abdominal hysterectomy, bilateral salpingectomy, and adhesiolysis. After the hysterectomy was complete, excision of her previous midurethral sling was also performed due to the patient's chronic groin pain and recurrent UTIs. Approximately 2 cm of the polypropylene mesh was freed from the periurethral space and partially excised to the inferior pubic rami bilaterally. At the time of excision, no diverticulum was able to be identified and only an area of inflammation was visualized. A 20 gauge spinal needle was passed through that area in an attempt to aspirate fluid, but no fluid was able to be retrieved. Cystoscopy was also performed and no ostia or communication suggestive of a diverticulum was visualized. Postoperatively, patient had no complications. Although the diverticulum was not able to be isolated and repaired, the patient initially had improvement of her

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


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

[User]
RADIOLOGY NOTE:
A 14-year-old girl presented with a port wine patch on the left side of face mainly over the lateral side of nose and nasolabial fold and malar area which was present since birth and was gradually increasing in size as the child grew. In the last 3 months period, she complained of appearance of a globular swelling on left lateral side of nose which rapidly increased in size resulting in bulky appearance of upper part of nose and slight deviation of nose to right side. Simultaneously two warty growths appeared on left ala and cheek which gradually increased in size []. There was no history of trauma to the area. There were no complain of pain or tenderness, or respiratory difficulty. Examination revealed a globular swelling of size 7 cm × 5 cm, with smooth surface, bony hard consistency, nonpulsatile, noncompressible, no palpable thrill or audible bruit, no fluctuation, not increasing in size with coughing, without local rise of temperature, with an area of port wine stain on the left side of nose and nasolabial fold area overlying the swelling.
CT scan showed an avidly enhancing soft tissue density lesion with bone density within it with “sun burst appearance” from left nasal bone [].
The lesion was approached through an incision along the nasolabial fold slightly extending over the dorsum of nose. A well circumscribed bony growth was found within the left nasal bone. The swelling was gently dissected of the nasal bone which had a vascular stalk attached to the nasal mucosa which was ligated. Then the lesion could be completely enucleated and had a honeycomb appearance []. Rest of the nearby bony growths was chisselled out and hemostasis achieved with electrocautery. Wound was closed with subcuticular suturing and pressure dressing applied.
Histopathology revealed large vascular spaces with endothelial lining giving the impression of venous channels, with scattered osteocytes surrounding the spaces []. The postoperative course was uneventful, 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:
The patient is a 59-year-old male with a postoperative union of a left tibial plateau fracture who, after open reduction and internal fixation, underwent surgery for implant removal at a local hospital (Fig. ). The first day after surgery, at approximately 9 a.m., he complained of severe pain in the wound region and developed a fever in which the highest temperature reached was 39 °C. Upon examination, the patient was conscious without chills and other discomfort, and the incision was severely swollen and filled with hemorrhagic content. Analgesic therapy was given, but the patient did not feel pain relief. Early on the second morning, the patient started to become irritable and apathetic and the incision was inflamed. The following afternoon, at approximately 3 p.m., the patient felt increasing pain out of proportion to the physical findings accompanied by progressive swelling, numbness, and weakness of the limb. The skin around the wound was darkened, and tension blisters were visible (Fig. ). The patient was delirious on the third morning after surgery, the systemic skin turned yellow, and there was a large amount of dark red, bloody discharge drainage from the incision with bubbles of gas, and a foul, sweetish, unpleasant odor was smelled in the incision. A physical examination revealed subcutaneous crepitus extending along the length of the limb, roentgenograms revealed the accumulation of gas in soft tissue (Fig. ), the lower limb skin temperature decreased, the dorsal artery of the foot could not be touched, and the patient had no response to pain in the lower extremities. Anaerobic infection gas gangrene was highly suspected, and the patient was transferred to our hospital at approximately 7 p.m.
Left lower extremity incision decompression was carried out immediately. Upon incision, the musculature was found to be extensively necrotic and crepitant, the appearance of the affected muscles was purplish red and brown with a characteristic foul odor,

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


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

[User]
RADIOLOGY NOTE:
A 23-year-old female patient with no notable medical and family history was referred to our department after the discovery of a radiolucent image which spans the entire left mandibular ramus. She first consulted her dentist after the sensation of discomfort and slight pain in the left retromolar region. The extraoral examination was without particularities (no facial asymmetry) (). The intraoral examination revealed insufficient hygiene, absence of swelling and deep decay in tooth 36 ().
The panoramic radiograph showed a well-defined, corticated radiolucent lesion extended over the ramus in relation to the impacted wisdom tooth 38 (). The computed tomography (CT) scan revealed that this unilocular osteolytic lesion was with tissue matrix, very slightly enhanced by the contrast agent and contained sparse millimetric calcifications. It was not very blowing, eroding the internal surface of the internal cortical without cortical rupture. This lesion measured 34 mm in the coronal plane and 10 × 25 mm in the axial plane (). Based on the clinical and radiological features, we made a diagnosis of a calcifying epithelial odontogenic tumour (Pindborg tumour) or ameloblastoma.
The patient was treated under general anaesthesia. After detachment of a full thickness flap, bone milling and resection of the coronoid process to facilitate direct access to the lesion, we performed the total enucleation, curettage and extraction of the impacted wisdom tooth. The immediate postoperative follow-up was straightforward without complications. The lesional tissue was submitted to the pathology department for histopathological evaluation. Macroscopically, the tumour consisted in a whitish-yellow mass of soft consistency related to the impacted tooth (). Microscopically, the lesion was essentially made of a tissue of fibrous appearance with cells having an abundant pale cytoplasm, with rounded or ovoid nucleus and fine chromatin. The cell density was moderate with the presence of a few hyalin

[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 25-year-old man was referred to vascular medicine clinic because of pain in the left calf while running, which had been occurring for the past 4 years.
This patient practiced almost daily physical activity that involved both combative and running (over 8 h per week), and he competed at a regional level (with a personal best of running of 36min12s/10000 m). In 2012, the patient had reported left calf pain when running, forcing him to stop. He described a calf swelling sensation that gradually increased with the intensity of running. While in the past he could easily run 15–20 km, the patient reported at that date that he could not run more than 2 km before having to stop. After stopping, the pain was deep and persisted for several minutes; it was also associated with swelling of the calf. This pain had led him to change his occupation to a less physically demanding job (military officer in the past, and now security officer). The consequences were a weight gain of 8 kg, and a cessation of all physical activity (running, fight sports). The patient also reported a loss of self-esteem.
Over a period of 4 years, the patient was seen by two general physicians, a rheumatologist, a neurologist, a sports physician and a vascular physician. Many explorations were carried out (spinal and pelvic x-ray, pelvic and lumbar spine scan, venous duplex scan, arterial duplex scan, and electromyography), all of which revealed no sign of dysfunction. The sports physician raised the possibility of diagnosis of a compartment syndrome, but the patient refused to submit to investigation of intramuscular pressure taken at rest and in immediately post exercise. Different therapies were proposed, including anti-inflammatory drugs, paracetamol and compression stockings (Class 2).
The patient interview revealed that a proximal deep vein thrombosis DVT (thrombosis in the iliac, femoral and popliteal veins) of the left lower limb had been diagnosed in 2012 and treated

[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 male patient presented with a history of trauma and subsequent avulsion of tooth number 11 and crown fracture at the neck of tooth number 21, previously extracted two weeks prior, at another dental facility. The patient requested an immediate fixed solution to the lost anterior teeth from our department. Clinical and radiological evaluation revealed adequate apico-occlusal alveolar bone, but extensive loss of the labial plate [Figure and ]. The soft tissue dimensions were, however, adequate for functional and aesthetic acceptability. It was decided to perform a single stage immediate loading implant placement with simultaneous augmentation of the lost facial plate using calcium phosphate bone substitute and collagen barrier.
After induction of local anaesthesia, full thickness flap was reflected in relation to number 11 and number 21. The sockets were debrided with curettes and two single piece implants (3.7 × 13 mm) were placed into the sockets. After checking for primary stability, which was achieved by wrenching the implant into the bone beyond the apex of the socket, calcium phosphate cement was mixed in sterile saline and injected into the spaces between the implant and the socket walls. Collagen membrane was trimmed to the appropriate size and shaped to cover the graft material. The flap was approximated and sutured with interrupted 3-0 Mersilk [Figure –]. The patient was instructed to discontinue tooth brushing and avoid trauma or pressure at the surgical site. A 0.2% chlorhexidine mouth rinse was prescribed two/three times daily for two-three weeks following surgery, and antibiotics and anti-inflammatory drugs were prescribed for five days. The sutures were removed after 10 days and the patient received temporary acrylic crowns on the same day. The patient was recalled for prophylaxis after two and four weeks and every three months. The clinical and radiographic appearances at six months and after one year show good aesthetic result and accepta

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


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

[User]
RADIOLOGY NOTE:
A 10-year-old boy presented to the Pediatric Clinic, Araraquara Dental School, Univ Estadual Paulista-UNESP with the main complaint of misaligned teeth. An intraoral examination revealed the absence of the left permanent upper lateral incisor (). The patient was submitted to panoramic radiograph that confirmed the hypothesis of the presence of the supernumerary tooth located near of the maxillary left central incisor (). Periapical radiograph was taken to confirm the location of the supernumerary tooth. After mother’s speech, it was verified that the patient presented healthy with positive dental and medical behavior prior and during the routine appointments. The need of the surgical procedure also the remotion of the tooth was explained to both the patient and mother.
Immediately after the surgical procedure, the region of the extracted supernumerary tooth received an irradiation of the GaAlAs diode low-level laser (Thera Lase, DMC, São Carlos, SP, Brazil) in the invisible wavelength (830 nm) in two different points aiming to increase bone formation. Each point was illuminated for 17 seconds and was delivered 3.4 J of energy with the fluence of 60 J/cm, and the mean output was adjusted to 100 mW (0.1 W). The region that received the sutures was also irradiated into four different points. To these applications, the laser device was adjusted in the red visible light wavelength and the parameters utilized were similar to the anterior case described above, since the reason for the irradiation was increase the quality repair of the soft tissue. This protocol was applied after 24 and 48 hours after the surgical procedure.
The pain recorded in the VAS of the patient showed that apart from the period of 12 hours in which the patient marked a number between 2 and 3 thus demonstrating an annoying sensation. The other periods evaluated it was demonstrated a mild to none pain sensation (between 1 and 0). Furthermore

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


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

[User]
RADIOLOGY NOTE:
A 23-year-old female patient presented to us with progressive deformity of her lower limbs towards the right side. It had started at two years of age and had continued until 14 years. She had then undergone corrective surgery for windswept deformity, following which there had been no further progression. At 16 years of age, she had sustained bilateral hip fractures after trivial trauma. She had consulted an orthopedic surgeon for her fractures and had been advised surgery. However, the family had not complied with the advice, and the patient had restricted her treatment to the intake of calcium and vitamin D supplements. Subsequently, for the past seven years until her current presentation, she had been bed-bound. Gradually, she had developed contracture deformity of bilateral lower limbs.
The patient also had diffuse musculoskeletal pain that was moderate to severe in intensity. In the past six months, her pain had worsened. Also, in the past two years, she had developed gradually worsening low backache and stiffness. She had also developed stiffness around bilateral hip joints, elbows, and shoulders.
She had a history suggestive of proximal and truncal muscle weakness. She could not get up from her bed without support. Neurological examination revealed a power of 3/5 in the proximal muscles of both lower limbs and the truncal muscles. There was also a history of dental abscesses that had started at the age of five years. When she presented to us, she was edentulous.
She had received multiple intermittent courses of calcium, vitamin D, and calcitriol supplements without phosphate. She was the shortest among all her peers. Her exact height and weight could not be measured as she was bed-bound and had contracture deformity of lower limbs.
Her brother, who was 18 years old, also had a similar history of windswept deformity of lower limbs, along with proximal myopathy and dental abscesses. His complaints had also started at an early age of four years. The windswept def

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


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

[User]
RADIOLOGY NOTE:
A 55-year-old diabetic hypertensive woman presented to the emergency department with acute retrosternal chest pain. Physical examination showed a heart rate of 110b.p.m., a blood pressure of 90/60 mmHg, and was otherwise unremarkable. Electrocardiography displayed non-specific ST-T wave changes, and cardiac troponin T was positive (2 ng/L). Upon admission, the haemodynamics of the patient continued to deteriorate, with a falling blood pressure of 75/50 mmHg and signs of poor peripheral perfusion. With a working diagnosis of non-ST-elevation myocardial infarction, emergency echocardiography was performed showing preserved left ventricular function and no pericardial effusion. The right ventricle could not be visualized due to acoustic window limitations. The suprasternal window (Figure ) was used to view the aortic arch, considering aortic dissection in the differential diagnosis. Unexpectedly, however, a mobile thrombus inside the right pulmonary artery was seen, establishing the diagnosis of pulmonary embolism. The patient received thrombolytic therapy, accelerated streptokinase regimen,with significant improvement in the haemodynamic status. Follow-up echocardiography revealed resolution of the thrombus. Further workup for hypercoagulable states is recommended.
Pulmonary embolism is sometimes a challenging diagnosis, with fatalities attributed to missed diagnosis rather than failure of therapy. Transthoracic echocardiography signs depend on the indirect detection of acute right ventricle pressure overload. Direct visualization of right-sided thrombi is possible in only <4% of cases.
High-risk pulmonary embolism in this case was diagnosed by direct thrombus visualization in an unusual echocardiographic view in a patient with limited acoustic windows and when computed tomography pulmonary angiography was not immediately available.
Although the detection of thrombi with echocardiography is uncommon in pulmonary embolism, their recognition can have significant impact

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


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

[User]
RADIOLOGY NOTE:
A 17-year-old female presented to our department with progressive blurring of vision in the left eye. She had been diagnosed with chronic inflammatory bowel disease 3 years earlier and was in remission on azathioprine and mesalazine. The patient underwent best-corrected visual acuity testing, full ophthalmic slit-lamp examination of the anterior and posterior segments, spectral-domain optical coherence tomography (SD-OCT), and fluorescein angiography at baseline. A complete serologic search was performed to detect an infectious cause, and active toxoplasma retinochoroiditis was diagnosed. A classic treatment regimen of pyrimethamine and sulfadiazine plus steroids was started.
During the ensuing observation period, the patient was evaluated every 2 months and underwent the same examinations performed at baseline except for fluorescein angiography. When the clinical course suddenly evolved toward a significant vitreoretinal traction due to retraction of the retinal scar, pars plana vitrectomy was considered. After written informed consent was obtained from the patient’s parents, a three-port pars plana vitrectomy was performed with a 23-gauge transconjunctival approach. The posterior hyaloid was removed intraoperatively using forceps and no attempt was made to remove the inner limiting membrane.
On presentation, visual acuity was 20/20 in the right eye and 1/20 in the left eye, with a mild relative afferent pupillary defect in the second one. No other neurologic signs or symptoms were detected. Anterior segment examination in both eyes was unremarkable and intraocular pressure was 16 mmHg. On biomicroscopic examination, the vitreous of the right eye was clear whereas the left eye exhibited mild inflammation. Fundus examination of the left eye showed a whitish yellow inflammatory lesion temporal to the macula surrounded by retinal edema with foveal involvement (). The lesion was apparently located under the retinal pigment epithelium and there was mild dilation 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 17-year-old male sustained high-voltage electrical injury to his left forearm due to contact with a live wire hanging from a generator van. He also sustained a laceration over the site of contact of the wire while untangling the wire. He gave no history of head injury or fall. No entry or exit wound was found. On exploration of the forearm laceration, soft tissue structures were normal. A distal third minimally displaced radius fracture was noted and fixed by percutaneous nailing. No other proximal fractures were found. The patient complained of loss of shoulder abduction, elbow flexion and extension and inability to extend his wrist and use his fingers, suggestive of a brachial plexopathy. Conservative management with rest to the affected shoulder and arm was instituted and patient followed up at 1 month. No corticosteroids were given. Physiotherapy was initiated and an electromyography was done which was suggestive of axonal degeneration involving median, axillary, musculocutaneous and radial nerves. Serial electromyography was performed at 8 weeks which reported no axonal regeneration. However, the patient had started regaining partial shoulder abduction, ulnar deviation of wrist and finger flexion at approximately 4 months after injury. He was posted for brachial plexus exploration at 6 months as his elbow flexion did not recover. On exploration, there was extensive damage with multiple thickened lobulations to long sections of median, musculocutaneous and radial nerves extending from their origins at the cords up to mid arm []. Rest of the plexus exploration was unremarkable []. No perineural fibrosis was noted. The surrounding tissue was surprisingly well preserved. Histopathology of the affected nerve segments showed fibrous tissue.
Long Sural nerve cable grafts were harvested. A single 13 cm long nerve graft was placed between anterior division of C7 root and radial nerve at the cranial end of sternal head of pectoralis major []. Lateral cord to musculocut

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


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

[User]
RADIOLOGY NOTE:
A 55-year-old female came with complaints of on and off right lower quadrant abdominal pain for 1-year. The patient also had urinary complaints such as intermittency, burning, and frequency. She denied any episodes of fever, chills, gross hematuria, or dysuria. Her past medical and surgical history were insignificant. The per abdominal examination was normal, but on bimanual pelvic examination a mass on the right side near the bladder neck area was palpable.
Ultrasonography (USG) suggested a well-circumscribed polypoidal soft tissue lesion projecting in urinary bladder lumen and attached to the posterior wall and base of the bladder with no internal vascularity []. Intravenous pyelography demonstrated a large filling defect in the bladder and normal functioning kidneys []. To know the detailed anatomy, magnetic resonance imaging (MRI) was done, which showed a large, well-defined rounded, soft tissue lesion of size 67.6 mm ×51 mm at posteroinferior aspect of urinary bladder, close to anterior surface of the cervix and vagina. The mass was isointense to the skeletal muscles on T1 and T2 images. It also showed small focal irregular cystic areas of necrosis []. The finding was suggestive of a benign lesion, probably leiomyoma. The urine cytology smear showed large numbers of squamous cells; few degenerated cells and bacteria, but atypical cells were not seen.
On cystoscopy, a large smooth sessile growth arising from the right posterolateral wall was noted []. The right ureteric orifice was not visualized. Transurethral resection (TUR) of the lesion was performed, and resected specimens were sent for histopathological examination. At the completion of the resection, the previously palpable pelvic mass could no longer be appreciated by bimanual examination.
On postoperative day 1, the patient's urine was clear, the Foley catheter was removed, and the patient was discharged on oral antibiotics. The histopathological examination showed spindle cells in sheets and fascicles

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


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

[User]
RADIOLOGY NOTE:
A 24-year old male with chronic rhinosinusitis was admitted for an elective Functional endoscopic sinus surgery (FESS) procedure under general anesthesia. During the operation, the surgeon applied several tampons soaked in 1:1000 dilution epinephrine to the nasal mucosa. Ninety minutes into the surgery, unexpectedly, blood pressure rose to 210/130 mmHg followed by pulseless electrical activity. CPR was initiated, with the administration of 2 mg of IV epinephrine in consecutive doses, leading to the return of spontaneous circulation. ECG showed sinus tachycardia and a prolonged QTc interval of 486 ms, Inverted T waves in leads I and aVL, and no signs of acute ischemic changes (Fig. ). A chest x-ray demonstrated pulmonary edema and a borderline enlarged cardiac silhouette (Fig. ).
The patient was placed on mechanical ventilation. Transthoracic echocardiogram showed a dilated left ventricle with an increased end-diastolic dimension (124% of normal value) with a mild reduction in LV mass, a severe reduction in systolic function, apical akinesis, and hyperdynamic base. The estimated systolic left ventricular ejection fraction was 30% (Fig. ). Cardiac troponin and CPK were elevated. NT or NT pro-BNP were not taken. A head CT was performed and demonstrated mild global cerebral edema, with multiple maxillary sinus fractures (Fig. ).
Medical information gathered from family members indicated no family history of heart diseases. The patient did not smoke, use illegal drugs nor consumed alcohol on daily basis. The patient was diagnosed with dilated cardiomyopathy and admitted to the intensive cardiac care unit. Upon arrival, upload titration of ACE inhibitors, β-blockers, and diuretics initiated. The following ECG strips indicate normal sinus rhythm, QTc interval of 420 ms, and normal T wave in lateral leads. We decided not to perform a diagnostic coronary catheterization since the patient's risk profile for ischemic cardiomyopathy was low. Objectively, there were no ischemic

[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, C. C., was a 91-year-old female, suffering from chronic heart failure and osteoarthrosis with subsequent functional impairment. She was a retired teacher and lived alone without any external caregiving support. She came to our department presenting painful skin ulcers of the lower extremities with inflammatory signs and alarming initial gangrene. They arose from accidental wounds 6 months before and increased in size despite wound care performed by the patient herself (washing, disinfection, dressing with topical silver sulfadiazine, etc.). No history of diabetes was reported.
At admission, she presented in poor general condition and was malnourished, while cognitive functions were intact. A skin examination was performed at the time of admission and showed extensive right leg ulcers. These lesions had a necrotic appearance, without granulation tissue, and were covered by purulent exudates ().
Blood sample showed increased levels of CRP and ESR. Main clinical data are shown in . A Doppler ultrasound of the lower limbs showed distally an initial decrease of arterial signal with normal venous axis. The ankle brachial index was 0.9, so that arterial insufficiency was not causing or contributing to the nonhealing wound [].
Consultation from the vascular surgery department proposed a demolitive surgical approach that was refused. Given the lack of response, risk of amputation, and general deterioration in the patient, EBS stimulation was proposed and started on a compassionate use basis, with informed consent, 2 days after her hospitalization. She parallel underwent standard medication with washing, enzymatic debridement, dressing, and parenteral antibiotics (amoxicillin/clavulanic acid 3 grams daily).
After 7 days of therapy, the wide ulcers of the lower limb started to present some granulation tissue with irregular edges and discrete fibrinous exudate (). Following a two-week EBS treatment period, all wide ulcers of the lower limb had improved with remarka

[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 man presented with a 3-month history of increasing pain in his left groin, and numbness and radiating pain in the anterior and medial thigh without any injury. He reported that he was in constant pain and that his pain continued during sleeping hours. The pain and numbness were markedly increased when he was in a sitting position. Although he had opportunities to sit in his job as a factory manager, he was unable to do so due to the increased pain and numbness that he experienced while sitting. At the medical examination, he was unable to sit on the chair in the consultation room. A physical examination revealed tenderness in the femoral triangle and radiating pain and numbness. There was no palpable mass or muscle atrophy. The patient was observed to limp from the time of start of walking. His range of motion was observed to be restricted to 100 of flexion, 10 of extension, and 10 of internal rotation due to an increase in the radiating thigh pain and numbness. Plain radiographs showed no osteoarthritic changes (, ). Computed tomography showed a bump and bone cyst in the anterolateral aspect of the femoral neck (, ). The presence of cam type femoroacetabular impingement was indicated. Magnetic resonance imaging (MRI) showed a cyst situated at the medial side of iliopsoas muscle and tendon. Its dimensions were 56 mm in the coronal view and 22×24 mm in the axial view. The mass, which was compressing the neurovascular bundle, was continuous with the hip joint (, , ). Based on these findings, a ganglion cyst arising from the hip joint and femoral nerve palsy associated with the ganglion were diagnosed. Initially, the patient was treated conservatively for 2 months with a nonsteroidal anti-inflammatory drug. However, his pain and numbness worsened, leading us to perform surgery. Hip arthroscopy was performed under general anesthesia in thesupine position with traction. Three portals (anterior: A-portal, mid-anterior: MA

[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 31-year-old primigravida woman with a history of pulmonary embolism and multiple deep venous thrombosis during the index pregnancy was admitted to the obstetric department with pre-eclampsia with severe hypertension of 160/100 mm Hg at 26 weeks of pregnancy. She had been taking vitamin K antagonists, which were switched to low-molecular-weight heparin, and she was treated with magnesium sulfate and intravenous antihypertensive drugs. A primary caesarean section under general anaesthesia was performed at 30 weeks of pregnancy due to fetal distress, delivering a growth-restricted, premature girl of 920 g. Postsurgery the mother developed severe postpartum haemorrhage with a total of 5000 mL blood loss, and treatment was complicated by her anticoagulation therapy. She received blood transfusions and was discharged from the hospital with a haemoglobin level of 77.3 g/L. Three days later she was readmitted with complaints of fatigue, severe dyspnoea and fever. She had pleural effusion and thrombocytopaenia. She was later transferred to the cardiac intensive care unit (ICU) due to deterioration of her condition, and echocardiographic examination revealed severe left ventricular dysfunction with mild dilatation of the ventricles. ECG showed a sinus tachycardia with low voltages in the extremity leads and a QS pattern in V1–V3 (). Coronary angiography showed normal coronary arteries and she was diagnosed with PPCM. She soon went into cardiogenic shock with high lactate levels, and when high dosages of inotropes could not stabilise her extracorporeal membrane oxygenation (ECMO) was started. Heart failure medication was started, which stabilised her condition, and after 15 days the ECMO could be removed. ECMO was complicated by cannula-related severe ischaemia of her right foot, which had to be amputated. She was transferred to a rehabilitation clinic after hospital discharge.
Because of the combination of multiple venous emboli, pre-eclampsia with proteinuria, pleural e

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


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

[User]
RADIOLOGY NOTE:
In this report, we present a case of a 57-year-old female patient with a 10 × 15 cm2 mesenteric cyst of the sigmoid colon that was excised laparoscopically and histopathology reported a cystadenoma. A 57-year-old female attended rapid access clinic complaining of left iliac fossa pain and swelling for ten months. She was reviewed by the Obsteric and Gynaecology team and an ultrasound scan of the pelvis was arranged which found a 116 × 94 × 76 mm3 cystic lesion probably from the left ovary. Following further investigations, (which were all normal) the patient was listed and consented for laparoscopic assisted vaginal hysterectomy, bilateral salpingo-oopherectomy and peritoneal washing. During the operation the Gynaecologist found a large 10 × 15 cm2 cyst attached to the mesentery of the sigmoid colon free from the ovaries. The operation was suspended and the on call general surgical team were called into theatre. A diagnostic laparoscopy was performed; all other organs were normal, however, due to the size it was difficult to assess the anatomy of the cyst and which other organs were involved, the only thing that was certain was this was not an ovarian cyst, therefore proceeding to operate would be risky. The on call consultant general surgeon did not see this as an emergency and suggested that the operation should be aborted and further investigations were required before proceeding with an operation on the cystic mass. An outpatient CT abdomen and pelvis scan plus a flexible sigmoidoscopy was arranged with an outpatient follow up appointment with the general surgeons. The flexible sigmoidoscopy came back as normal and the abdomino-pelvic CT scan revealed an 11 × 10 × 8 cm3 likely benign cyst but could not determine its origin (Figs and ).
Due to the persisting discomfort the patient was booked and consented for an elective laparoscopic removal of cyst with possibility of converting it to an open procedure due to the size of the mass. The operation was approached la

[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 70-year-old male patient was admitted to the Department of Neurology with isolated left upper extremity weakness and clumsiness. He had wrist drop and was unable to grip with the fingers. He complained of no sensory loss or numbness. His past medical history included long-term oral anticoagulation due to recurrent lower extremity deep vein thrombosis, glaucoma, and a non-significant aortic valve stenosis, with vascular risk factors including a 5-year history of treated hypertension, hypercholesterolemia, and a history of non-significant stenosis of the left anterior descendent coronary artery. On admission, no abnormality could be detected by physical examination, apart from the neurological signs, which included a wrist drop on the left side with decreased grip strength (Fig. ). Pronation and wrist dorsiflection were lost, as well as the ability to form a ring with the thumb and the index. The reflexes of the left upper extremity were slightly brisk, with not pathological reflexes present and no sensory deficits. Laboratory parameters were without abnormal findings except for a slightly elevated fasting blood glucose level. Cranial CT revealed contrast-enhancing, irregularly shaped lesions with diameters of 7, 10, and 9 mm (in the temporal, parietal, and frontal lobes, respectively), surrounded by perifocal edema. Carotid duplex ultrasonography did not demonstrate signs of focal atherosclerotic plaques, circulatory disturbance or stenosis on either side. In accordance with the findings of the CT scan, the cranial MRI confirmed the tumor in the right precentral gyrus, corresponding to the ‘hand knob’, accompanied by further similar lesions posteriorly in the parietal and the temporal lobes, and in the left frontal lobe (Fig. ). Electromyography and nerve conduction studies did not support a peripheral origin underlying the paresis. The neuropsychological examination revealed a deficit in the Luria three-step test as a single alteration, which performance could,

[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 79-year-old female on a ventilator was transferred to our ICU from another hospital due to biliary sepsis. Previously, the patient had been treated for about 1 week with combined antibiotics and another supportive treatment. The patient looked severely ill and jaundiced. The patient also has comorbidities such as heart problems, hypothyroidism, and diabetes mellitus. The total and direct bilirubin levels were high (10.94 and 9.67 mg/dL), with a very high CRP level (269.48 mg/L). The abdominal ultrasound (US) and MRI evaluation from the previous hospital showed a large cyst 14.7 × 6.2 cm in size suspected from the left liver lobe which caused gastric compression, and there was also evidence of bile duct obstruction with a large stone in the distal common bile duct (CBD) area (Fig. ).
The main treatment given during admission was as follows: a combination of the antibiotics piperacillin-tazobactam with amikacin, levothyroxine, insulin therapy, and other supportive treatments. Then an abdominal MRI was blindly reviewed by our senior radiologist, and it was concluded that there was a large cyst possibly arising from the pancreas (possible pancreatic pseudocyst [PPC]). After discussion with the family, it was decided to do biliary drainage. The bedside biliary drainage procedure was performed in the ICU without any fluoroscopy guidance, only transabdominal US guidance. After the dilated bile duct was seen on the US image, an 18-G Chiba needle was used to puncture the dilated bile duct, followed by bile fluid aspiration and guide wire insertion. The distance between the tip of the needle inside the bile duct and the area of the US probe was measured for length guidance marked on the PTBD pigtail catheter (DIALL abdominal drainage catheter, China). Then, slowly, the needle was pulled out with maintenance of the guide wire inside the bile duct. The final step was PTBD pigtail catheter insertion into the bile duct, after which,

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


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

[User]
RADIOLOGY NOTE:
A 26-year-old man with a history of 3 years of excessive alcohol intake was admitted to the emergency department for 48 h of abdominal pain, mainly in the left hypochondrium associated with fever and vomiting. He had a history of 1 year of intermittent abdominal pain that intensified over the last month, which led him to stop alcohol consumption. He was hemodynamically stable upon admission. Laboratory test showed C-reactive protein 176 mg/dl, white cell count 16.7 × 109/L, platelet count 617 × 109/L and serum amylase level 109 U/L. The computed tomography (CT) showed a cystic lesion in the pancreatic tail of 5.7 × 9 cm in size and significant splenomegaly with hypodense areas consistent with a pseudocyst with splenic extension and rupture ().
Due to patient stability, conservative management was decided. This included analgesics, antibiotics and nutritional optimization. During the first 48 h, the patient was stable, with little pain and without fever. On the fourth day of hospitalization, he developed tachycardia and severe pain. The abdominal examination showed signs of peritoneal irritation and laboratory tests with a white cell count of 41 × 109/L. Ultrasound assessment showed diffuse abdominal free fluid. An emergency laparotomy was performed, finding 1.5 L of dark serohematic and purulent fluid in the peritoneal cavity. The amylase level of this fluid was 3000 U/L. A large pancreatic tail pseudocyst was identified in addition to abundant clots in the left subphrenic space because of a ruptured spleen (). Due to extensive peripancreatic inflammation, dissection was difficult. Splenectomy was performed, extracting the shattered splenic parenchyma (). The amylase level of pancreatic cystic fluid was 13 000 U/L, confirming the diagnosis of a pseudocyst. We performed a double layer hand-sewn gastrocystic anastomosis with silk 2.0. One drain was located close to the anastomosis and two in the splenic bed. The patient had a satisfactory recovery, with drains

[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.