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

[User]
RADIOLOGY NOTE:
A 42-year-old female presented to the ED with left-sided back pain upon waking up in the morning. She reported that the pain was located in the left posterior lower ribs, about the inferior portion of the left scapula. The patient denied associated fevers, trauma, or rashes. She stated that her pain was worse with movement and taking a deep breath, and when reaching her left arm across the right side of the body. She denied any associated numbness or weakness. Her past medical history was notable for hypertension, but she could not recall the name of her anti-hypertensive medication. She had no allergies and had no other significant past medical or social history, although she did smoke e-cigarettes.
On examination, her vital signs were within normal limits. There was no hypoxia, tachypnea, or tachycardia. Pertinent physical exam findings revealed that the patient was experiencing moderate distress secondary to pain. She had a normal cardiac and pulmonary auscultation, and her skin was normal. Neurologically, her strength and sensation were intact in the upper and lower extremities. On musculoskeletal examination, the provider noted pain with forced adduction of the left arm across the body, and back exam was notable for tenderness in the left paravertebral muscles of the thoracic spine. The provider initially reported concern for pulmonary embolism, which was excluded with the Pulmonary Embolism Rule-out Criteria, as well as concern for pneumothorax and occult rib injury. A chest radiograph with dedicated left-sided rib views revealed no acute abnormality.
Given that the patient’s pain appeared to be myofascial in origin, a physical therapy consultation was obtained. The physical therapist was specifically trained in myofascial manipulation and trigger point release. The patient was diagnosed by the physical therapist with muscular spasm of the left quadratus lumborum muscle, and was treated with manual trigger point therapy, which completely released the spasm in

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


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

[User]
RADIOLOGY NOTE:
A 38-year-old woman, who had been treated for mental development delay and schizophrenia, was admitted to the intensive care unit of the Department of Traumatology and Critical Care Medicine after a fall during a suicide attempt 30 minutes previously.
She was alert on arrival and her extremities did not have any neurovascular deficits. On physical examination, she was unable to move her right arm and leg, and an approximately 3 cm open wound was noted in the anterolateral thigh region.
Radiographs showed fractured femoral neck and shaft, an acetabular fracture (Figures and ), and a humeral shaft fracture on the right side. Whole body computed tomography showed right pulmonary contusion, liver contusion, and type B3 acetabular fracture, according to the AO classification system (). Additionally, her injury severity score was 29.
She was transferred to the operating room 5 hours after the fall. First, she underwent antegrade intramedullary nailing for the right humerus fracture and retrograde intramedullary nailing for the right femoral shaft fracture simultaneously. Then, she was placed on a traction table and underwent multiple screw fixation with cannulated cancellous screws for the right femoral neck fracture (). The operating time was 5 hours, and the intraoperative blood loss was 500 mL.
Postoperatively, her condition stabilized and she recovered. Seven days after the initial operation, a second operation was performed for the acetabular fracture. First, the transverse fracture was exposed using the modified Stoppa approach and was anatomically reduced and fixed using a reconstruction plate. Then, using the Kocher-Langenbeck approach, posterior wall fixation was performed with a reconstruction plate (). The operating time was 5.5 hours and the intraoperative blood loss was 540 mL.
The early postoperative course was uneventful. Eight weeks after the second operation, partial weight-bearing was allowed. After partial weight-bearing, she complained of right hip 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 61-year-old woman presented to our hospital with low back pain. Trauma history was vague except for falling 40 cm from a bed a month earlier. She had a past history of eosinophilic granulomatosis with polyangiitis and was treated with prednisolone (40 mg/day) 3 months before presenting at our hospital. Her bone mineral density in the hip had a T-score of −4.7, and bisphosphonate and vitamin D were initiated to treat osteoporosis. She underwent computed tomography (CT) and was diagnosed as having a left vertical sacral fracture and treated conservatively. Three weeks after her initial diagnosis of sacral fracture, her low back pain worsened and she started to have radiating left posterior thigh pain with symptoms of stress urinary incontinence, constipation, and loss of anal sensation.
On examination, she had weakness of dorsiflexion of her left ankle and flexion of both great toes, in which the muscular power was grade 3/5 and 4/5, respectively, as measured with manual muscle testing (MMT). Sensation to pinprick on her S2 receptive field was impaired. Lumbosacral magnetic resonance imaging using a short inversion time inversion recovery (STIR) sequence revealed an H-shaped fracture in the sacrum, but there were no abnormal findings such as spinal stenosis in her lumbar spine potentially explaining for her neurological symptoms (). Repeated CT demonstrated slightly aggravated displacement of the sacral fracture compared with previous CT ().
We consulted a urologist, and the patient was diagnosed as having stress incontinence because of poor function of pelvic floor muscles or the sphincter. However, we speculate that both the weakness of dorsiflexion of the ankle and great toes and loss of anal sensation could be attributed to SIF and recommended that she undergo surgery. She underwent lumbopelvic fixation from L3 to the ilium using a minimally invasive technique with a percutaneous pedicle screw system () []. Her radiating leg pain, motor weakness in her ankles, a

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


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

[User]
RADIOLOGY NOTE:
A 75-year-old female visited the hospital with progressive severe dyspnea class III (New York Heart Association) for 1 year. She had a history of MVR and tricuspid annuloplasty (TAP) for mitral and tricuspid valve regurgitation 20 years ago. She had been taking warfarin, since the mechanical mitral valve was inserted. A chest X-ray showed marked cardiomegaly and evidence of a median sternotomy. Transthoracic echocardiography (TTE) revealed huge enlarged bi-atria without visible intracardiac thrombi, a mechanical mitral valve with mild paravalvular leakage, and severe tricuspid regurgitation (TR) due to coaptation failure with moderate pulmonary hypertension (Fig. ). Coronary angiography showed no significant stenosis of the coronary arteries. A chest CT also revealed marked cardiomegaly and bi-atrial enlargement, evidence of a median sternotomy, and a replaced mechanical mitral valve (Fig. ). No pulmonary abnormalities that cause dyspnea were detected on the chest CT. No abnormal laboratory findings were observed, including inflammatory markers. TVR was planned for severe TR under general anesthesia with cardiopulmonary bypass as an elective operation with heparin bridging therapy.
General anesthesia was induced uneventfully. The arterial line was inserted before induction of general anesthesia, and a Swan-Ganz catheter was inserted through the right internal jugular vein. We inserted the TEE probe to evaluate cardiac status preoperatively. We identified almost the same findings as with the previous TTE. However, a floating, 1-mm-diameter hyperechoic signal was found in the left atrium, which was not mentioned on the preoperative TTE (Fig. ). We discussed the existence of an intracardiac foreign body with the cardiac surgeon, and the surgeon performed an additional left atrial incision to identify the foreign material prior to the main operation.
A long thin foreign body was observed in the right pulmonary vein to the left atrium. It was tied at the right upper pulm

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


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

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

[Assistant]
ICD-10-CM Coding based on findings:
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 33-week gestation preterm male delivered through precipitous vaginal delivery in the emergency department to a 21-year-old G2P1 female presenting with acute onset of labor with rupture of membranes at home. Birth weight was 1870 g and Apgar scores were 7 at 1 min and 8 at 5 min. Due to immediate respiratory distress, the infant was intubated and mechanically ventilated. One dose of surfactant was given and he was transferred to the neonatal intensive care unit. Caffeine was administered for apnea of prematurity, and ampicillin and amikacin were initiated for concern of neonatal sepsis due to preterm labor and delivery. Within hours, the infant became hypotensive requiring normal saline boluses and a dobutamine drip, prompting an increased concern for sepsis and the addition of cefepime. However, after 3 days, blood cultures were negative, and the clinical condition had improved. Therefore, the antibiotics were discontinued.
On the day of life three, a routine cranial ultrasound was found to be normal. Echocardiogram was also normal with no structural abnormalities. The initial cranial circumference was 31 cm, and the neurological examination after resolution of hypotension was normal with no focal findings. On the day of life six, significant abdominal distention occurred with pain elicited on examination. Necrotizing enterocolitis was suspected, so empiric intravenous vancomycin and meropenem were initiated. However, pneumatosis intestinalis and portal venous gas were not observed on serial abdominal X-rays, and blood cultures never isolated a pathogen. Due to clinical severity, 2 weeks of antimicrobial treatment was given with clinical improvement and enteral feedings by nasogastric tube were started.
On the 18th day of life, the cranial circumference suddenly increased 34 cm. On examination, the anterior fontanelle was bulging, despite the child being alert and active with a normal neurological examination. Cefipime was initiated out of concern of neonatal seps

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


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

[User]
RADIOLOGY NOTE:
A 76-year-old man presented with prolonged dull back pain for 3 months. One year prior to being referred to our hospital, he underwent BCG intravesical instillation therapy for bladder cancer. Computed tomography (CT) at a neighboring hospital revealed both thoracic and abdominal aortic aneurysms (AAAs). Follow-up CT at 4 weeks after the initial examination showed enlargement of both aneurysms. The saccular-shaped thoracic aneurysm enlarged from 39 × 35 mm to 52 × 47 mm, and the size of the abdominal aneurysm also increased from 26 × 23 mm to 41 × 34 mm. The surrounding tissue showed typical findings of inflammation, such as thickening of the adventitia and faint contrast effect (Fig. ). Although he had no symptom except for dull back pain, laboratory tests showed only a slight increase in the inflammatory response (C-reactive protein 4.95 mg/dl, procalcitonin 0.127 ng/ml), and blood culture was negative, he was diagnosed with an impending rupture of both infectious thoracic and AAAs and was referred to our hospital. Considering the risk of rupture and the possibility of infectious aneurysms, urgent surgical treatment was planned. Although open surgical resection of both aneurysms and vascular reconstruction were ideal, these operations were considered highly invasive for the patient who had a poor general condition due to prolonged dull back pain. Therefore, a hybrid operation consisting of simultaneous endovascular repair of the thoracic aneurysm and open surgery of the abdominal lesion was performed.
Under general anesthesia, the AAA was exposed through a midline abdominal incision. Prior to abdominal aortic replacement, a stent-graft (GORE C-TAG: W. L. Gore & Associates Inc. Flagstaff, AZ) was inserted via the left femoral artery and deployed at the level of the saccular TAA. After confirming the precise placement of the endograft and no endoleak, the abdominal aorta was clamped, and the aneurysmal sac was opened. The aneurysmal wall was quite thin and fragile.

[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 abdominal wall mass presented for excision of an anterior abdominal wall mass, adjacent tissue transfer, and flap graft under general anesthesia. His past medical history was significant for coronary artery disease status after three stents, hypertension, dyslipidemia, obstructive sleep apnea using home CPAP, and being a chronic smoker. His medication included clopidogrel (stopped 3 weeks before surgery), aspirin (stopped 5 days prior to the procedure), atorvastatin, hydrochlorothiazide-losartan, and metoprolol. He had no known allergies. His body mass index was 38 (height 183 cm and weight 129 kg). Intraoperative monitoring included continuous electrocardiograph (EKG), pulse oximetery, temperature, and automatic blood pressure monitoring with a large size adult blood pressure cuff (cuff size 16 cm width × 36 cm length and blood pressure monitor calibrated every 6–12 months) placed on his left upper arm, and possible pressure points were not found during a secondary survey. General anesthesia was induced through a 20 gauge intravenous catheter placed on the dorsum of the right hand. The patient was positioned supine with the head neutral and both arms placed neutrally alongside the body and secured on the arm board. Arm abduction was less than 90 degrees with padding of the pressure points. Intraoperatively, noninvasive blood pressure was measured every 5 minutes, and it ranged from 160 to 87 mm Hg systolic and from 104 to 51 mm Hg diastolic ( shows the trend of blood pressure measurements). Surgery lasted for about 9 hours (630 minutes). Throughout the surgery, the patient's temperature was maintained normothermic by using warm fluid, a forced air warming device, and maintaining the room temperature between 24°C and 26°C. At the end of the surgery, patient was extubated and transferred to the recovery room. In the recovery room, after two hours, the patient complained of left forearm swelling, pain, and wrist drop. Postoperatively, blood pre

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


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

[User]
RADIOLOGY NOTE:
A 69-year-old man, with a background of recurrent outbreaks of herpes labialis approximately once every 2 years and childhood varicella, noticed vesicles on the lower lips. Five days later, a skin eruption developed on the right side of his face. Although he had no history of atopic dermatitis, Kaposi varicelliform eruption with secondary bacterial infection was suspected at another hospital, so he was treated with oral acyclovir and levofloxacin for 2 days. The patient subsequently presented to our outpatient clinic for consultation after the lack of symptomatic improvement.
On examination, erythema and small vesicles were present on the right side of the face in the dermatome innervated by the maxillary branch of the trigeminal nerve; the dorsum nasi, philtrum and upper lip were also affected. Crusting of these lesions was observed, and the right eyelids were red and swollen. Small vesicles were also noted at the bottom of the lower lip (fig. ). Vesicles with red halos were scattered on the trunk and extremities. Laboratory investigations revealed an elevated level of C-reactive protein of 2.4 mg/dl, suggesting a mild inflammatory reaction; however, other blood tests, including immunoglobulin levels and HIV antibody results, were either normal or negative. No evidence of immunological dysfunction was seen. A small number of coagulase-negative staphylococci were identified on bacterial culture of a swab taken from a skin lesion.
The differential diagnosis included disseminated herpes zoster, varicella, herpes simplex and impetigo. We performed the LAMP assay (Eiken Chemical, Tokyo, Japan) using swab samples taken from the following areas: an erosion on the right cheek, vesicles on the upper and lower lips (fig. ; arrows 1, 2 and 3) and a vesicle with a red halo on the right thigh. HSV-1 and VZV were detected by LAMP in samples taken from all 3 sites on the face, and VZV was detected in the sample taken from the vesicle on the right

[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:
Case 1: Kidney trauma
An 11-year-old girl got injured during a fall with a bike. A day later, she started to experience abdominal pain and nausea. She has had a fever (38°C) and a sore throat for a few days before the injury. The inflammatory markers were increased [C-reactive protein (CRP) 133 mg/L]. The physical exam found tenderness in the costovertebral angle and the left upper quadrant of the abdomen. A therapy with co-amoxiclav was started. The B-mode US examination showed a hyperechogenic change in the left kidney located between the upper and middle thirds of the kidney (Figure ). A subcapsular hematoma was also described. Color Doppler showed blood flow only in the middle and lower thirds of the kidney (Figure ), pointing towards a laceration and infarction of the upper pole of the kidney.
A day after admission, the patient's inflammatory parameters began to rise (CRP 187 mg/L), and microscopic hematuria was detected. Chest radiograph and urine culture tests ruled out respiratory and urinary tract infections, and the focus of possible infection was not found. Co-amoxiclav was replaced with ceftriaxone. A control CEUS examination showed a devascularization of the upper third of the kidney parenchyma, which was confirmed by the MRI of the abdomen. Approximately 40% of the kidney parenchyma was affected, and the increase in CRP was presumed to be due to the ischemia/necrosis of the damaged part of the kidney. The patient was followed clinically and with US until discharge.
In this case, CEUS showed the extent of laceration a lot more clearly than B-mode and Doppler US. The approximate area of the injury was detectable by color Doppler, but CEUS demonstrated the lesion better and helped to evaluate the degree of organ injury (Figure ). Renal parenchyma has very high blood flow, and thus, large quantities of contrast are visible quickly []. Due to the absence of

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


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

[User]
RADIOLOGY NOTE:
The patient was born prematurely (34 weeks and 1 day of gestation) at an outside hospital to a 29-year-old woman by elective cesarean section. The pregnancy had been complicated by preterm premature rupture of the membranes at 28 weeks and 2 days of gestation as well as prenatal diagnoses of cystic hygroma, pericardial and pleural effusions, left renal artery duplication, and bilateral ventricular hypertrophy with worsening myocardial function. This conglomeration of symptoms was later confirmed to result from Noonan syndrome. Specifically, this patient was found to have a PTPN11 gene mutation (c.923A>C; p.N308T).
At 12 hours of life, the patient became hypotensive and did not respond well to fluid resuscitation. Given the constellation of complications, the decision was made to transfer her to the tertiary care children's hospital for genetic assessment and cardiologic consultation. Upon arrival, the patient remained in respiratory distress and was hemodynamically unstable, and the placement of an umbilical catheter was attempted. A portable chest radiograph demonstrated a caudal loop of the catheter prior to ascending to the superior abdomen, so the catheter was assumed to be within an umbilical artery. However, the tip of the line was ultimately located to the right of the vertebral column (). Given this unusual position of the catheter, a cross-table lateral radiograph was performed. This demonstrated the tip of the umbilical line projecting over the expected location of the right atrium, at the level of the lower thoracic spine, and anteriorly and to the right of the expected position of the aorta (). A subsequent portable radiograph was obtained the following morning, redemonstrating the atypical position.
An ultrasound with Doppler assessment was performed to accurately determine the positioning of the line. The aorta was found to be unremarkable and without an intraluminal catheter. Instead, the catheter was identified within the inferior vena cava, with 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 33-year-old male was diagnosed to have type I truncus arteriosus (TA) during infancy. He underwent palliative main PA banding at the age of four months. No following corrective surgery was performed at his family’s choice. He had an uneventful childhood. At 26, he presented with Streptococcal Gordonii endocarditis with severe truncal valve regurgitation. This was complicated with septic emboli to his lungs and kidneys. At the same time, he was found to have left sided pulmonary hypertension due to migration of the PA band to the right PA (RPA) on the computed tomography of the chest (Fig. ). He survived from a stormy hospital stay which required intubation and mechanical ventilation, and completed 5 weeks of antibiotics. A decision was made not for surgery at that point of time in view of the high surgical risk and uncertain surgical outcomes at this age [].
He remained relatively well in New York Heart Association (NYHA) functional class I for 3 years, subsequently, his functional class deteriorated to NYHA II. On annual echocardiographic follow up, there was evidence of increase in size and decrease in systolic function of the left ventricle (LV). At 32 years old, he was hospitalized for worsening heart failure. On physical examination, he was thinly built with pectus carinatum, finger clubbing, raised jugular venous pressure and pitting edema over bilateral lower limbs. He had displaced apex beat, first and second heart sounds were present. There were ejection systolic murmur and early diastolic murmur at the left parasternal edge. The oxygen saturation was 90 % on room air. Blood investigation were unremarkable except for elevated hemoglobin of 17.9 g/L and serum creatinine of 105 mmol/L. Electrocardiogram revealed right ventricular (RV) hypertrophy with strain pattern. Chest radiograph showed an enlarged heart with prominent pulmonary trunk.
Trans-thoracic echocardiogram showed type I TA (Fig. ). The LV was severely dilated with ejection fraction of

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


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

[User]
RADIOLOGY NOTE:
A 38-year-old man presented with multiple nodular lesions over the pubic region with ulceration and excoriation over the penile skin for the previous 2 months []. The lesions had been increasing in size and number over a period of time. The patient first consulted a dermatologist who referred him to a surgeon, given the history of malignancy in this patient with suspicion of cutaneous metastases. He had complaints of severe and intractable pain over the lesions. He had a 2-year history of carcinoma of the rectum with liver metastases. According to the American Joint Committee on Cancer Tumor-Node-Metastasis Staging System, the disease was Stage 4, so surgery was not feasible. A colonoscopy performed 9 months previously had revealed an ulceroproliferative lesion in the rectum 8 cm from the anal verge. Since a biopsy proved it to be an adenocarcinoma, a repeat biopsy was not performed. He underwent a colostomy 9 months previously because of obstructive symptoms. He received chemotherapy with three series of combinations of irinotecan, oxaliplatin, 5-fluorouracil (5 FU), and leucovorin (LV) (FOLFOX). A positron emission tomography-computed tomography scan revealed liver metastases, and he was encouraged to receive further chemotherapy, which he refused. Two months later, the patient returned to the surgery department and was found to have extensive new skin lesions involving the pubic region and external genital area. The cutaneous lesions were not close to the colostomy wound. His vital signs and laboratory investigations were normal. A hard, ulcerated lesion was felt on rectal examination. Histopathological examination of a biopsy from the skin nodules and the penile region revealed metastatic adenocarcinoma []. The tumor was assessed to identify histological features suggestive of high-frequency microsatellite instability which was negative in the index case. Palliative radiation therapy was advised, but the patient refused any further treatment. He also did not rec

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


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

[User]
RADIOLOGY NOTE:
A 48- year-old Chinese woman, gravida 4, para 2, was admitted to our hospital due to abdominal pain for 1 month. The clinical features of the patient at baseline were summarized in Table . The patient had a history of tubal ligation and denied asbestos exposure.
Fifteen years ago, the patient was diagnosed with a uterine myoma, which was about 8 cm in diameter. Instead of undergoing surgery, she opted for regular check-ups. One month ago, she developed abdominal pain and ultrasonography showed a 12 × 11.4 × 9.8 cm heterogeneous mass behind the uterus, with a cystic dark area of 3.4 × 2.3 cm (Fig. ). Ultrasound suspected as degeneration of uterine myoma. A further CT examination also considered it as a myoma fatty degeneration (Fig. ). Therefore, the patient underwent exploratory laparotomy.
Intraoperative observations were described as below: There was a small amount of viscous fluid in the pelvic cavity. The uterus was enlarged to the size of 2 months gestation. There was a mass about 12 cm in diameter behind the uterus with a pedicle attached to the uterus. The mass was multilocular cystic with myxoid fluid. The surface of the left ovary was dotted with minute neoplasms. No obvious metastatic lesions were observed elsewhere.
The mass was removed and a quick-freezing examination was performed. The results indicated that it was a mesenchymal tumor and adenomatoid tumor was possible. We treated her with a total hysterectomy and bilateral adnexectomy. The final pathology of paraffin confirmed it as localized well-differentiated benign mesothelioma (Fig. A). The results of immunohistochemistry showed that the 3 molecules Calretinin, D2–40, CK were positive, while p53, EMA were negative (Table ). The tiny neoplasm on the surface of the ovary was also thought to be mesothelioma involvement. In addition, a small nodule with a diameter of about 2 cm was found in the myometrium, and the pathological

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


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

[User]
RADIOLOGY NOTE:
The patient was a 35-year-old male presented to the ER with right craniofacial trauma due to an occupational injury caused by falling of a plastic pipe on his head. He was awake and aware at the time of arrival. The initial assessment revealed a GCS level of 14. Signs of traumatic injuries in the right side of his face included swollen eyelids due to trauma to the soft tissue of the right periorbital and frontal area along with right superior eyelid laceration, redness, and tenderness. The visual acuity in his right eye was almost no light perception. Right optic neuropathy was evident with a relative afferent pupillary defect (RAPD) of 4+. The eye movements of the right eye were restricted in all directions, but the other side was normal. Other examinations revealed no further abnormal findings.
CT-Scan depicted a small focus at the level of the right Sylvian fissure in favor of a pneumocephalus and a hyperdense structure in the right orbital cavity, posterior to the globe, suggestive of a bony material (Figs. , , and ). As we were not sure about the origin and material of hyperdense structure demonstrated on CT-Scan, use of MRI was waived in order to prevent subsequent complications in case of metal object foreign body. However, initial assessments of patient’s images amplified the suspicion of skull base fracture, regarding the foci of pneumocephalus, especially at the region of the right superior orbital wall. Based on these findings, the patient was admitted to the trauma section of the neurosurgery ward and received initial necessary supportive care. Antibiotic therapy was commenced for surgery preparation and preventing probable meningitis, with Cefepime and Vancomycin. A consult with ophthalmologists was performed, and regarding their evaluation, both ophthalmologists and neurosurgeons were agreeing with choosing a craniotomy approach. The procedure was performed by using the method of “extra-dural orbitocranial approach to the anterior cranial fossa” cranio

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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 25-year-old nulliparous woman presented with 24 h of increasing left lower quadrant pain, worsened with movement and temporarily relieved with narcotic medications given by the emergency room provider. She had a past medical history of PCOS and a surgical history of a right salpingectomy secondary to a right paraovarian cyst resulting in an isolated necrotic torsed fallopian tube at 13 years of age.
Physical exam revealed an obese female with normal vital signs. Abdominal exam was significant for left lower quadrant pain on deep palpation, with no rebound or guarding present. Bimanual examination revealed similar pain at left adnexa but otherwise benign with no vaginal bleeding, cervical motion tenderness or otherwise palpable masses. Of note, the physical examination was performed after patient had already received 975 mg of acetaminophen, 600 mg of ibuprofen and three doses of 2 mg morphine by emergency room providers.
Laboratory evaluation was significant only for a white blood cell (WBC) count of 12.85 × 109/l with an otherwise normal complete blood count, comprehensive metabolic profile and urinalysis. Transvaginal and transabdominal ultrasound revealed a simple left adnexal cyst 1.5 × 1.2 × 1.4 cm and a 4 × 3.8 × 4.1 cm mildly complex cyst, both of which appeared to be extraovarian. Arterial and venous waveforms were documented for both ovaries. Fluid in the endocervical canal was also noted.
The patient's surgical history was significant for a similar presentation to the emergency department at 13 years of age. Upon review of the medical record that was available, a nurse at triage noted the patient was complaining of right lower quadrant pain that worsened over the day and stated that the patient was “doubled over in triage”. Unfortunately, no provider note could be found regarding physical examination and history of presenting illness. A CT examination of the abdomen and pelvis had revealed a 5.1 × 4.4 cm right ovarian cyst with trace

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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 21-year-old female patient reported to us with the chief compliant of swelling in gums in the upper and lower anterior tooth region. These swellings were increasing in size for the past 15 days and were associated with bleeding gums, purulent discharge, and intermittent pain that were increased on chewing food. She had also noticed increase in gaps between her front upper teeth with slight mobility with the same. The patient was concerned for her compromised esthetics. Her medical history was suggestive of abnormal menstrual cycles and her drug history revealed that she was on hormonal supplements for reducing her body weight. She had a waist circumference of 102 cm and weighed 91 kg. All her vitals were within normal limits.
The patient was cooperative and had no reported tissue abuse habits. No abnormality was detected during her extraoral examination. Her intraoral clinical examination revealed soft and edematous gingiva which bled spontaneously on probing. It was associated with purulent discharge with a marked halitosis. There were multiple reddish granulomatous swellings in relation to tooth no. 12, 11, and 21 in the upper arch and 31, 41, and 42 in the lower arch []. There was an associated localized gingival overgrowth covering at least one-third of the clinical crown height on the labial surfaces of teeth. Lesions had pedunculated base, varying from 4 mm × 3.5 mm in 11 and 21 regions to 5 mm × 4 mm in 12 region. A provisional diagnosis of PG was made. The differential diagnosis of the lesion included fibroma, irritational fibroma, peripheral ossifying fibroma, peripheral giant cell granuloma, and hemangioma.
The gingiva was painful to touch and the associated teeth were tender on percussion. Periodontal probing was done after administration of local anesthesia. Anterior teeth revealed deeper probing depth measuring around 9–10 mm []. Grade I mobility was also seen with 11 and 21. Radiograph showed presence of angular bone loss in all anterior teeth []. Th

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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:
16-year-old girl presented in the orthopedic clinic with a swollen right middle finger associated with occasional pain of one month duration. There was progressive increase in size. The middle phalanx was diffusely swollen, with mild tenderness. She did not have any lesions over the skin. Plain films of the right middle finger showed an expansile lesion with thinning of the cortex and intralesional calcifications. []
Her complete blood count was normal. Considering her age and the radiological features a diagnosis of enchondroma was made. Computerized tomographic scan[CT scan] showed a central oval round area of geographic destruction in the medullary canal at the metaphyseal region of the middle phalanx of the right middle finger. There were dystrophic calcifications with bulbous expansion of the bone with cortical thinning. There was no soft tissue involvement. As shown in the plain films and the CT scan. []
With a provisional diagnosis of enchondroma she was operated under general anesthesia. The mass was approached through a curvilinear dorsolateral approach under tourniquet. Dark- brown jelly like contents of the tumor was curetted out. There was break in the volar cortex. The defect in the bone was packed with cancellous grafts harvested from the proximal tibia.
Histopathology showed grey and dark brown tissue, with sections showing fragments of tissue composed of many perforating capillary sized blood vessels that are lined by plump endothelial cells with abundant cytoplasm and vesicular nuclei. Some cells showed vacuoles. At places there was hobnail appearance of the endothelial cells. These were admixed with numerous eosinophils, lymphocytes and few plasma cells. Occasional scattered giant cells also were seen. Immunohistochemistry for vascular markers showed CD31 positive in cords of cells and cells lining blood vessels, many CD 68 positive cells were also seen. Features were consistent with epitheloid hemangioma. [ & ]
At one-year follow up, there was no

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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 73-year-old man was referred to our hospital complaining of having had bloody stools five to seven times/day for 1 month. He had no noteworthy medical or familial history, including inflammatory bowel diseases. Colonoscopy showed moderate mucosal inflammation throughout the rectum to the sigmoid colon and multiple erosions from the sigmoid colon to the cecum. The findings also included a well-circumscribed raised tumor, which was revealed to have a type IV to VI pit pattern, 15 mm in diameter, in the sigmoid colon (Figure ). Step biopsying was performed at 18 points from the rectum to the terminal ileum, there being no findings of dysplasia lesions microscopically. The pathological findings revealed UC Matts’ grades 3 to 4 in the rectum to the sigmoid colon and Matts’ grades 1 to 2 in the left-sided colon to the cecum. He was given mesalazine (2,400 mg/day) as the initial medical treatment. Endoscopic mucosal resection was also performed to remove the sigmoid colon tumor at 1 month after the initial diagnosis. Histological examination showed a 15 × 10-mm well-differentiated adenocarcinoma with submucosal deep invasion (4,000 μm) that detect diffusely p53 protein accumulation in immunostaining. There was no intravenous or lymphatic invasion microscopically, and the horizontal and vertical margins were negative. The circumference mucosa around the cancer lesion did not show dysplasia, and the circumference and unaffected UC mucosa were considered negative for the p53 protein overexpression because only a few weakly positive cells were detected (Figure ).
For this case, additional surgical resection with lymphadenectomy was required because of the submucosal deep invasion. At 3 months after the initial diagnosis of UC, the bloody stools had disappeared, and clinical improvement was attained with mesalazine (3,600 mg/day) and prednisolone (15 mg/day). Also, an endoscopic examination showed improvement and Matts’ grade was 2 to 3 in the rectum to the sigmoid colon path

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


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

[User]
RADIOLOGY NOTE:
A forty-four year old woman presented to us with a five days history of multiple painful papulo vesicular lesions distributed along the right D9 dermatome. She had no known co-morbidities prior to the onset of the skin lesions. She was clinically diagnosed a case of HZ. Tzanck smear performed from the lesions revealed multinucleated giant cells confirming the diagnosis. Other investigations were found within normal limits. Acyclovir therapy was deferred as she had presented on the fifth day after the onset of the lesions. She was managed symptomatically with analgesics and topical soothing agents. Lesions started healing with crusting and post inflammatory pigmentary changes.
Two days later, she reported again with multiple erythematous itchy papules all over the body. In view of dissemination of lesions, the possibility of HZ with dissemination was kept. However, on closer examination, it was observed that some of the lesions were targetoid papules and plaques with central hyper pigmentation and at places fluid filled vesicles ().
Therefore, in view of morphology of lesions, provisional diagnosis of EM secondary to HZ was kept. She was in good health without any sign and symptom of immunosuppression. There was no mucosal involvement or lymphadenopathy. She was clinically suspected to have EM secondary to HZ. Tzanck smear prepared from new lesions did not reveal any multinucleated giant cell. Other Investigations revealed leukocytosis of 10,000/mm3 with 70% neutrophils, 1% eosinophils, and 29% lymphocytes. The C-reactive protein was of 5.9 mg/dl. Her liver function test and urine analysis were within normal limits. Her serology for Human immunodeficiency Virus, cytomegalovirus and mycoplasma were found negative. Antinuclear antibodies were also found negative. Histological examination of a skin biopsy showed a sub epidermal bulla with eosinophilic necrosis in the epidermis. A few inflammatory cells were present in the necrotic epidermis. There was a slight perivascu

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

[User]
RADIOLOGY NOTE:
An elderly lady in her late fifties, was referred to the endodontic department of a private dental clinic with her chief complain being dull tight pain on the left side of her face. She stated that she had been experiencing this sensation of pain for the past two weeks. On clinical inspection no facial discrepancy and swelling was noticed. Oral examination revealed a maxillary first molar on the left side that had an extensive amalgam filling and was extremely sensitive to percussion and palpation of the periradicular area. She mentioned previous root canal therapy of this tooth five weeks earlier. Radiography was indicated and revealed a phenomenon that was supposed to be the cause of all these discomforts (). The mesiobuccal root was perforated in many zones and the perforation sites were over obturated with gutta-percha. Surprisingly she was told that her tooth had five canals and was extra-charged for these canals.
The situation was discussed with the patient and extraction/implant placement was indicated. Patient had too much anxiety and refused to accept the situation stating that she could not take that due to recent complications in her personal life. She insisted on an alternative approach. Thus, she was referred to another endodontist for evaluation of possibility of intentional replantation. It was later decided to approach through trial and error; if the replantation was not successful the tooth would be extracted. On the very same session the procedure was initiated. Unfortunately, the mesial root was separated during extraction and the clinician had to extract the tooth.
One week later, she appeared with persisting pain on the left side of her face. This time she mentioned that this pain worsened when she became more stressful. She was not satisfied because she expected the pain would vanish after losing one tooth. As she was explaining her disapproval, it was observed that her face was blushing and she was sweating allover. The patient also mentioned

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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 28-year-old woman, para 1-0-0-1, was diagnosed with invasive squamous cell carcinoma of the cervix at 12 weeks of gestation and she was referred to the University of the Ryukyus Hospital. Specular examination showed a sessile tumor measuring approximately 2 cm in diameter on the anterior lip of the cervix. At 15 weeks of gestation, magnetic resonance imaging showed a lesion consistent with cervical carcinoma FIGO stage IB1. Both the patient and her husband were informed about the treatment options and the possible consequences of such treatments on the pregnancy. The couple was also informed about the option to perform radical abdominal trachelectomy (RAT) as a relatively new surgical procedure and all the possible consequences were discussed. The patient was told that the outcome of this procedure could not be guaranteed because not enough procedures had been globally performed to yield reliable conclusions. The patient wished to maintain the pregnancy, and both parents signed a written consent agreeing to RAT. The institutional review board of our university approved this treatment.
The patient underwent RAT with pelvic lymphadenectomy under general anesthesia in August 2013 at 17 weeks of gestation. To prevent uterine contraction, 50 mg of indometacin sodium rectal suppository was administered on the morning of the surgery; 25 mg of indometacin sodium rectal suppository was immediately administered after surgery and every 6 h thereafter (4 times in total). In addition, 250 mg of 17-alpha-hydroxyprogesterone caproate was intramuscularly administered 60 min immediately before the surgery and administered once a week thereafter until 36 weeks of gestation. An enlarged pregnant uterus prevented the operative field; therefore it was secured by manually putting aside the uterus because indomethacin sodium and sevoflurane were effective enough for the softening of the uterine muscle.
In our case, pelvic lymphadenectomy was performed. The frozen section of the lymph no

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


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

[User]
RADIOLOGY NOTE:
A 40-year-old man was referred to gastrointestinal surgeons for pancreatic mass pointed out by an abdominal ultrasonography in a medical check-up. The patient did not show any symptoms. Abdominal contrast-enhanced computed tomography (CT) revealed dissection from the CA (), DPA, and splenic artery (SA). This aneurysm was not seen on an abdominal unenhanced CT taken 6 years ago in a medical check-up. The enhancing inner lumen of the DPA was derived from false lumen and that of the SA was derived from true lumen. The stenosis of proximal side of SA, an aneurysm measuring 2.5 cm on DPAA with unenhanced mural thrombus, and the connection of the distal side of the DPAA to transverse pancreatic artery (TPA) with stenotic change were confirmed (). A connection with DPA and the superior mesenteric artery (SMA) was undetermined. The current diagnosis was the dissection of the CA to DPA and SA, resulting in DPAA and SA stenosis. After the diagnosis was made, the patient was referred to the department of radiology by a vascular surgeon for the consultation of endovascular surgery to prevent aneurysm rupture because open surgery was thought to be quite invasive as it required distal pancreatectomy with splenectomy and CA repair. He had received medications for hypertension. There were no remarkable findings in his initial laboratory data. We planned to embolize DPAA, SA, and dissected area of CA that allow to preserve vascular supply to hepatic artery from SMA via peripancreatic arcade and to distal side of SA via gastroduodenal artery (GDA) to TPA. An angiography from the CA revealed the enhancing inner lumen of DPAA from false lumen of dissected CA connecting to TPA (). TPA was revealed between the peripancreatic arcade from GDA and pancreatic tail artery that connected to the distal side of SA. A 4.5 Fr. Shepherd hook–type guiding sheath (Parent Plus 45: Medikit, Tokyo, Japan), carrying a triple coaxial system, consisted of a

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


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

[User]
RADIOLOGY NOTE:
A 23-year-old female was referred to our medicine dental department in UHC Sahloul, Sousse, for treatment of tooth #46. She suffered from major coronal destruction and needed to have her first molar restored. The medical history was noncontributory. Radiographic and clinical examinations were performed initially, and an extensive glass ionomer cement restoration of a nonvital tooth (46) was identified (Figures and ). The tooth was treated endodontically. The patient had an acceptable oral hygiene and a favorable occlusion. After removing the restoration, an endocrown restoration was recommended because of the amount of remaining tooth structure and the thickness of the walls (). The prosthetic decision was to restore tooth (46) with an endocrown fabricated from lithium disilicate ceramic (IPS e.Max CAD). The preparation for the endocrown is different from the conventional complete crown. This monolithic, ceramic adhesive restoration requires specific preparation techniques to be suitable for especial biomechanical needs.
This is aimed at achieving achieve an overall reduction in the height of the occlusal surface of at least 2 mm in the axial direction and to get a cervical margin or “cervical sidewalk” in the form of a butt joint. The cervical margin has to be supragingival and enamel walls less than 2 mm have to be eliminated.
Differences in levels between the various parts of the cervical margin should be linked by a slope of no more than 60° to escape a staircase effect. We used a cylindrical-conical diamond bur held parallel to the occlusal plane, to reduce the occlusal surface. Then we used a diamond wheel bur to control the orientation of the reduction and to guarantee a flat surface thanks to its shape.
We used a cylindrical-conical diamond bur with a total occlusal convergence of 7° to create continuity between the coronal pulp chamber and endodontic access cavity. The bur was orientated along the long axis of the tooth; the

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


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

[User]
RADIOLOGY NOTE:
A 32-year-old man was admitted to our hospital because of a bulge in the left inguinal region. He had no pain and no urinary symptoms. Physical examination revealed a non-tender, reducible bulge in the left inguinal region. His body mass index (BMI) was 19.0 kg/m2. Laboratory data were all within the normal range. Computed tomography (CT) performed 5 years before admission for other disease showed a left indirect inguinal hernia. In addition, a small protrusion of the adipose tissue into the left femoral canal and a portion of the bladder pulled to the left femoral ring were observed retrospectively (Fig. ). Preoperative imaging studies were not performed. Based on a diagnosis of left indirect inguinal hernia, we planned for TAPP.
The patient was placed in the supine position under general anesthesia. A urinary catheter was inserted before the operation. A 10-mm port was placed for the laparoscope at the umbilicus and two 5-mm ports were placed at each flank. Laparoscopy and intraperitoneal observation revealed a left indirect inguinal hernia with sliding of the surrounding tissue. There were no other peritoneal indentations (Fig. a). We incised the peritoneum and dissected the preperitoneal space toward the Retzius space along the vesicohypogastric fascia. We found a mass covered with the vesicohypogastric fascia that was pulled into the femoral ring (Fig. b). The mass was confirmed to be a portion of the bladder; the mass expanded when we injected saline through the urinary catheter (Fig. c). We first dissected the protruding bladder all around from the preperitoneal tissue sliding with the bladder because the protruding bladder had developed severe adhesion to the hernial orifice. Then we reduced the protruding bladder carefully without causing injury. The length of the herniated bladder in the femoral canal was about 1 cm. The diameter of the femoral ring was 1 cm. An aberrant obturator artery was

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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 56-year-old male patient visited our emergency room due to melena of duration one week. History taking revealed no particular issues other than antihypertensive medication after a diagnosis of hypertension five years previously. He did no smoke, but consumed a small amount of alcohol regularly. No specific features arose from his family or social history. He did not experience nausea or vomiting at the time of hospitalization, and only complained of mild indigestion. Furthermore, he showed no epigastric soreness, abdominal pain, or weight loss, and his vital signs at hospitalization were stable. His physical examination was uneventful. His hemoglobin was 10.4 g/dL, and renal and liver function, as determined by blood tests, were also normal. No lesions were found in the esophagus or stomach by esophagogastroduodenoscopy. However, an exophytic tumor with a bleeding surface ulcer was observed luminally in the ampulla of Vater in the second portion of the duodenum (Figure ). An endoscopic biopsy was performed on the tumor and bleeding from the ulcer was controlled endoscopically. And abdominal computer tomography (CT) and magnetic resonance imaging (MRI) revealed a hypoattenuating mass of diameter 1.6 cm in the second portion of the duodenum. The pathological result later revealed atypical chronic inflammation and regenerative atypia. Although no malignant cells were observed, surgery was performed based on the judgment that gross findings indicated that the possibility of malignancy was high. During surgery, a papillary 2.5 × 2.0 × 0.7 cm sized mass was found in the ampulla of Vater. Distant metastasis or any of lymph node enlargement were not observed. Pylorus preserving pancreaticoduodenectomy (PPPD) was performed. The pathological result of the excised specimen showed that the tumor was limited to the mucosa and proper muscle layer and had not invaded the pancreas or common bile duct. Furthermore, no lymph node metastasis was detected. The submucosal tumor was fo

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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:
In January 2010, a 51-year-old female presented to a rural hospital with a one month history of left lower and upper abdominal quadrant pain. The patient was admitted to the hospital with the preliminary diagnosis of pancreatitis. After admission, the patient developed gross hematuria. It was discovered that the patient had a past medical history significant for a stab injury in 1998 to her left kidney with involvement of the left renal artery. At that time, the patient underwent a transabdominal/transperitoneal partial nephrectomy. Due to the patient's complicated past medical history and her present gross hematuria, the decision was made to transfer the patient to our service for a higher level of care.
After admission to our hospital, a transurethral catheter was placed, which showed gross hematuria. Upon further evaluation, the decision was made to perform a cystoscopy and evacuation of blood clots. The urethrocystoscopy showed no gross pathology in the urethra and bladder. The left and right orifice were normal in size, place, and configuration. In order to locate the source of bleeding, bilateral ureteroscopy was performed. The right ureter and renal pelvis were found to be unremarkable. The left ureter also appeared to be free of pathology. However, at approximately the level of the ureteropelvic junction, a papillary mass was noted that appeared to extend into the left renal pelvis. A biopsy was unable to be obtained due to significant bleeding. After the blood clots were evacuated, and taking into account the past history of hematuria with a small, atretic kidney, it was deemed necessary to pass a stent into the left ureteral pelvis. The patient tolerated the procedure well. The results of the cystoscopy were discussed with the patient, and a nephrectomy was being considered to remove the tumor. However, after cystoscopy the patient developed an ileus. She was also very malnourished. Once her bleeding and ileus resolved, the decision was made to allow her t

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

[User]
RADIOLOGY NOTE:
A 27-year-old man visited another hospital with chief complaints of generalised weakness, pallor and intermittent rectal bleeding for 2 years prior to his presentation. Physical examination was unremarkable. His haematological profile showed low haemoglobin levels (8.5 g/dl). The rest of the laboratory parameters including total serum protein and erythrocyte sedimentation rate were within normal limits. Stool culture was negative for pathogenic organisms. Colonoscopy revealed pseudopolyps along with multiple erythematous and eroded mucosal lesions in the rectum []. He was diagnosed clinically as ulcerative colitis for which he received oral aminosalicylic acid followed by prednisolone for 6 months. However, the patient was non-responsive to this medical therapy. He was also transfused blood on two separate occasions along with hematenimics because of persistently low hemoglobin. One year after the initial treatment he was admitted to our hospital because of worsening of symptoms, which were now accompanied by mucous diarrhoea, straining at defecation and rectal prolapse (feeling of mass protruding out from rectum). Laboratory data at the time of present admission also revealed low hemoglobin (8.0 g/dl) however, remaining hematological investigations were within normal limits. On digital rectal examination, multiple soft elevated lesions were palpable. Contrast enhanced computed tomography of the lower abdomen and pelvis showed multiple rectal polyps and thickening of the rectal wall with a maximum wall thickness of 12 mm along with its abnormal inferior descent [].
As the patient was non-responsive to medical therapy, low anterior resection of the rectum was done. Intra-operatively, multiple sessile polyps were noted in the rectum along with erythema of the surrounding mucosa. An intra-operative diagnosis of inflammatory polyposis was considered. The post operative course of the patient was uneventful.
Gross examination of the resected specimen revealed multiple ses

[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 patient presented to his primary care physician complaining of a dry cough and recurrent bouts of bronchitis as well as frequent orthostatic dizziness. At the age of 20 years, he had undergone repair of CO-A through a left thoracotomy using an interposition Dacron graft between the left SCA and the mid thoracic aorta. His chest radiograph raised suspicion of AN of the thoracic aorta. Computed tomographic angiogram then confirmed the presence of two large anastomotic PANs at both ends of the graft (
) as well as an occluded right SCA, stenosis of the left vertebral artery, and bovine origin of the carotid arteries (
).
In view of this complex anatomy, the decision was made to use a hybrid approach to address these findings. In a first stage, a right carotid artery to right SCA bypass was done using a short segment of Goretex graft (
). Next, using single lung ventilation, a right posterolateral thoracotomy was performed and the chest entered through the fifth intercostal space. With the diaphragm retracted inferiorly, the pericardium, posterior to the phrenic nerve, was gently lifted with a long clamp, thus allowing exposure of the distal most portion of the thoracic aorta, medial to the inferior vena cava (IVC). After heparinization, the aorta was partially clamped and a 22 mm Hemashield graft anastomosed in an end-to-side fashion to an appropriate aortotomy using a continuous suture of 5–0 Prolene (
). The graft was then brought posteriorly to the IVC and anteriorly to the right hilum, then anastomosed in an end-to-side similar fashion to the partially occluded ascending aorta through a vertical pericardial opening (
,
).
The immediate postoperative course was uneventful, and 5 days later, the patient was brought to the hybrid operating room for completion angiogram. This confirmed patency of the extra-anatomic graft as well as the presence of a 4 cm proximal left SCA anastomotic PAN with close extension

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

[User]
RADIOLOGY NOTE:
A 17-year-old girl was referred to the Department of Periodontics with the chief complaint of gingival overgrowth and mobility in her teeth for the last 2 years. She reported that the problem has begun in lower anterior and progressed involving both the arches. Patient appeared fit and indicated no current or previous systemic disease during her medical history interview.
Intraorally, severe diffuse gingival enlargement of both the arcades (more pronounced on the right side) was observed covering almost all the surfaces of teeth and projecting into the vestibule [Figure –]. Gingiva was bright red, friable, fibrous as well as edematous in consistency. The erythema was disproportionate to the amount of plaque and calculus remaining on the dentition panoramic radiograph demonstrated generalized alveolar bone loss []. Probing depth ranged from 10 mm to 12 mm with an attachment loss of 7-9 mm and was more in the right molar region. Grade 2 mobility was present around the mandibular and maxillary first and second molars and grade 1 around the mandibular right premolars.
Laboratory tests revealed no evidence of any systemic disease such as leukemia, scurvy and hormonal disorders.
Internal bevel gingivectomy was performed in the maxillary arch and left mandibular region[]. Adjunctive amoxicillin (500 mg, 3 × 1) plus metronidazole (400 mg, 3 × 1) for 7 days was prescribed to treat AgP. Patient could not continue her treatment for personal reasons and when she reported after 1 year, the recurrence of gingival enlargement was noticed [Figure –]. Periodic panoramic radiographic examination revealed progressive alveolar bone loss, which was more pronounced on the right lower molars []. Biopsy showed hyperplastic stratified squamous epithelium along with ulceration of epithelium at places. Sub-epithelial tissue revealed a large number of normal plasma cells, few eosinophils and inflammatory granulation tissue [Figure and ]. A diagnosis consistent with PCG was made. To clarify whe

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


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

[User]
RADIOLOGY NOTE:
A 23-year-old female gravida 2 para 1 was referred to our hospital with a 1-week history of mild vaginal bleeding. She had already been diagnosed with a cesarean scar pregnancy via transvaginal ultrasonography and magnetic resonance imaging (MRI) that showed the pregnancy 2.5 mm from the bladder wall. Two years prior to presentation, the patient had had a cesarean delivery for macrosomia without complications. Repeat ultrasound at the current presentation showed a single viable gestational sac corresponding to 7 weeks’ gestation at the cesarean scar site (). Endometrial thickness was 12 mm, and blood was seen in the uterine cavity at the level of the fundus. Abdominal examination was unremarkable. Speculum examination revealed minimal blood in the vagina. Laboratory workup showed normal hemoglobin level, platelet count, white blood count, and C-reactive protein. After the risks of cesarean scar pregnancy and benefits of treatment were explained, the couple chose termination of pregnancy; informed consent was obtained.
The patient was positioned similarly to infertility patients for office-based ovum pickup. A transvaginal probe fitted with a suction double lumen needle (Kitazato Corp) was introduced into the vagina, and the sac content was aspirated until no cardiac activity was detected. Methotrexate 50 mg was injected into the sac, and a 25-mg methotrexate injection was administered intramuscularly. The patient was hospitalized for 1 week after the procedure. During the first 2 days postoperatively, the patient had minimal vaginal spotting associated with mild lower abdominal pain. Her vital signs were stable throughout her hospital stay, and she was discharged on postoperative day 7.
One week after the procedure, transvaginal ultrasound showed a well-defined soft tissue mass that was inhomogeneous in texture with surrounding vascularity at the site of the cesarean scar and a small collapsed gestational sac without a yolk sac or embryo (). Beta human chorionic gon

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

[User]
RADIOLOGY NOTE:
A 30-year-old woman first noticed double vision 2 years prior to hospitalization. It had been present periodically, mostly in the evenings, and did not disturb the patient sufficiently to seek medical attention. Three months later she noticed leg weakness with walking difficulties, especially when climbing and walking down stairs, and walking instability resulting in consecutive falls. Six months later weakness of the arms appeared that caused difficulties in washing and combing her hair. After seven months she noticed difficulties in swallowing and nasal speech after prolonged talking. All of these symptoms had a fluctuating course and were more pronounced in the evenings.
A neurological examination revealed diplopia due to the weakness and fatiguability of the rectus superior and rectus lateralis muscles of the left eye as well as of the rectus inferior of the right eye, moderate weakness of the facial muscles, mild dysphagia with nasal speech, mild weakness of neck muscles, and weakness and fatiguability of proximal limb muscles. Very mild active and percussion myotonia were observed, but the patients had not been aware of it prior to hospitalization. The patient's mother had been diagnosed with DM2 at the age of 48 years and her maternal grandfather had cataracts.
A diagnosis of MG was confirmed in our patient by clear positive results in the neostigmine test and decremental responses in the repetitive nerve stimulation test (RNST) (); these were 43% and 26% in the deltoid and nasal muscles, respectively. Anti-acetylcholine receptor (AChR) antibody titer was elevated (8.8 nmol/L, normal <0.2 nmol/L). A chest CT scan showed a persistent thymic tissue in the upper anterior mediastinum, and a pathohistological examination of the thymus after thymectomy revealed thymic hyperplasia. Electromyography during relaxation demonstrated diffuse episodes of myotonic discharges () in multiple muscles, while during voluntary muscle activity a mild myopathic lesion was revealed

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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 34-year-old Japanese woman in her second spontaneous pregnancy was referred to Takeda General Hospital at 17 weeks of gestation and diagnosed with a MCDA twin pregnancy. She was admitted to our hospital at 30 weeks' for management of potential premature delivery. She was regularly monitored by conventional ultrasound to assess growth and amniotic fluid volume, and by Doppler ultrasound of the umbilical artery (Table ). No TTTS complications were observed during hospitalization. The final routine monitoring before delivery was performed at 35 weeks and 5 days of gestation; and the maximum vertical pockets of the MCDA twins were observed to be 4.2 and 3.6 cm, respectively, with cardiotocography showing reassuring fetal status patterns for both. However, she complained of diminished fetal movement at 35 weeks and 6 days of gestation (approximately 12 h later; at the final confirmation of normal cardiac sound for both twins by fetal Doppler ultrasonography), and the IUD of one fetus was confirmed by ultrasonography. Emergency cesarean section was performed, and the patient delivered a 2306 g surviving twin male infant, and a 1994 g dead twin male infant without any definite anomalies. No autopsy was performed as consent could not be obtained from the parents. The surviving infant's hemoglobin was 13.9 g/dL, and ultrasonography of the head revealed no abnormal findings at birth. Although he showed no cardiac or renal dysfunction after birth, he was diagnosed with large cystic periventricular leukomalacia (PVL) on the basis of magnetic resonance imaging findings at 13 days after birth (Fig. ). His placenta was peculiar in that both UCIs were observed to be centrally located and in close proximity on the placenta (Fig. A). We did not observe any specific placental and umbilical cord findings during the fetal period. The placenta was 24 × 19 cm and weighed 778 g. The umbilical cords were found to be of unusual thickness and of 45 and 48 cm in length, respectively. Both um

[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 84-year-old woman (5′6″; 144 lb) was referred to a cardiologist by her primary care practitioner for evaluation of exertional dyspnea and chest pain upon walking a few feet. Her medical history included hypertension, hypothyroidism, and osteoarthritis. Her medications included nebivolol, levothyroxine, aspirin, and citalopram. Cardiolite stress test revealed no ischemia, and a 2-dimensional echocardiogram demonstrated normal left ventricular systolic function with no wall motion abnormalities, no significant valvular heart disease, and no pericardial effusion. An electrocardiogram showed normal sinus rhythm, and no acute changes were noted.
Based on her history of continued symptoms, the patient underwent 2 cardiac catheterizations. The first catheterization revealed normal right-sided heart pressures and 80% stenosis of the left circumflex artery and was followed by percutaneous coronary intervention. The second catheterization occurred 2 months after the first and revealed a patent left circumflex artery stent, but 70% stenosis of the right coronary artery, for which the patient again received percutaneous coronary intervention.
The patient continued to experience exertional dyspnea and chest pain, and she subsequently developed dysphagia to solid foods and episodic dizziness. Consultations with a pulmonologist, gastroenterologist, and otolaryngologist revealed no underlying cause for these symptoms apart from evidence of esophageal dysmotility. Her dysphagia persisted despite treatment with a proton pump inhibitor and a histamine H2 receptor blocker. A cardiac event monitor showed no evidence of significant bradycardia or tachycardia, although the patient reported 1 episode of low heart rate (35 beats per min).
She was subsequently referred to an electrophysiologist for evaluation of presumed bradycardia. Orthostatic evaluation found a supine blood pressure of 150/80 mmHg with a heart rate of 70 beats per min. Upon standing for 3 min, the patient’s blood press

[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 girl with a previous diagnosis of MFS was admitted in our Pediatric Surgery Unit with sudden onset of chest pain and shortness of breath after sneezing. Her past medical history revealed two previous left spontaneous pneumothorax (two and three months prior to this hospital admission), managed with conservative measures and pleural drainage.
Upon examination, both physical and radiographic findings were compatible with a pneumothorax recurrence on the left side. A thoracic CT scan showed bullous pulmonary dysplasia (). Thoracoscopic treatment included resection of the pneumopleural adhesions and bullae. The procedure was performed with the patient in a lateral decubitus position. Three valved ports, ranging in size from 3 to 5 mm, were used. The first port was placed in the mid to the anterior axillary line in the fifth interspace to determine the position of the major fissure and evaluate the lung parenchyma. The position of the fissure dictates the placement of the other ports. The working ports were placed in the anterior axillary line above and below the camera port. Lung resection, including the parenchymal area involved in the lesion, was performed using the LigaSure® device. A lung specimen was removed using a protective specimen endobag through a 5 mm port. No postsurgical drainage tubes were positioned. The patient was discharged on the eighth postoperative day.
One week later, a pneumothorax recurrence necessitated a second thoracoscopic intervention. Further pulmonary resection of the atypical upper left lobe was performed using a stapling device. Two patches (9.5 × 4.8 cm) were cut from the adhesive/foam complex (TachoSil®), rolled and inserted into the 5 mm trocar, and subsequently stretched over the sutures. No drainage tubes were inserted. The postoperative period was uneventful, and the patient was discharged one week later. Gross findings showed severe emphysematous involvement in the upper lobe with marked bulla formation (). Microsco

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


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

[User]
RADIOLOGY NOTE:
A 67-year-old female, with a typical presentation of carpal tunnel syndrome in the right hand, presented initially with numbness in digit IV and V a year later. A few months later, she developed numbness in all five fingers on the left side. Furthermore, the patient mentioned that she had had a burning sensation in both feet for a few years. Another few months later she complained of weakness in all four limbs and was sent for a neurological consultation with electromyography. Clinical examination revealed a Hoffmann-Trömner reflex on the left side, mild loss of strength in both hands, loss of vibratory sense and hypoesthesia in the distal end of all four limbs and loss of proprioception in both legs. The electromyography showed disturbed sensorimotor signals in the left hand and mildly disturbed sensorimotor signals in the right hand. The disturbed electromyography was attributed to carpal tunnel syndrome, which was presumably less severe on the right side due to treatment with long acting corticosteroid injections. The paresthesia in digit IV, digit V and both feet, however, could not be explained with the diagnosis of carpal tunnel syndrome. Therefore, magnetic resonance imaging (MRI) of the cervical spine was performed. Imaging showed an extra-dural soft tissue mass posterior to the odontoid process of the axis. The mass extruded through the transverse ligament of the atlas with severe compression of the myelum and myelomalacia at the level of C1 (Figures , and ).
A plain radiograph of the cervical spine was performed to check for atlanto-axial instability. The radiograph during flexion shows a slightly widened atlantodental interval, measuring 4 mm (normal value: <3 mm) (Figure and ).
Pre-operative imaging of the cervical spine also revealed an anatomical variant of the craniocervical junction, atlanto-occipital assimilation of the massa lateralis bilaterally (Figure ).
The patient was treated with laminectomy of C1 to decompress the spinal canal 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 five-month-old boy of Caucasian ethnicity presented at our pediatric emergency unit. He had suffered acute paroxysmal abdominal pain and bilious vomiting for nine hours. His general condition and vital signs were normal.
During physical examination, an abdominal mass was noted in the upper right quadrant - there was no blood in stools in the rectum. Biological examinations did not yield significant results, but an ultrasound scan revealed a target sign in the form of an opaque mass under the liver. An air enema reduction was performed and identified a loop in the transverse colon that was refluxing under air pressure. This procedure did not result in a complete reduction of the assumed intussusception even after two attempts under midazolam infusion. An ileocolic intussusception of 2 cm was diagnosed during the laparoscopic exploration and a reduction was carried out by applying gentle traction. The adjacent small intestine and the ascending colon had a normal color and the child had normal peristalsis. The procedure was finished on these reassuring signs. During the night, the boy suffered repeated episodes of vomiting and had blood in his stools. An ultrasound scan performed in the morning revealed an intussusception, a swelling of the distal small intestine and the presence of a mass in the pouch of Douglas. It was difficult to determine with confidence whether the intussusception was ileocolic or ileoileal.
A second laparoscopic procedure determined that the intussusception was not ileocolic. The cecum was in its usual location, and there was no inflammation of the appendix. The small intestine was examined more closely and an intussusception was found, located 40 cm above the ileocolic junction. A reduction attempt failed even with the help of a third forceps. A right hemitransverse abdominal incision was performed but the reduction attempt failed. Palpating the ascending colon revealed a diffuse induration with no signs of wall necrosis. The small intestine

[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 woman with a past medical history of sarcoidosis underwent an endoscopic examination owing to dysphagia. The endoscopic examination revealed a circumferential tumor with ulceration in the cervical esophagus. Biopsies obtained during the endoscopy indicated squamous cell carcinoma. Contrast-enhanced CT showed extensive tumor growth with suspected tracheal invasion and enlarged lymph nodes extending from the cervical region to the upper mediastinum. FDG-PET/CT revealed abnormal FDG accumulation in the primary lesion (SUV max: 23.1) and lymph nodes (SUV max: 5.45) from the cervical to upper mediastinal region (Fig. ). However, it was difficult to determine whether the multiple lymphadenopathy was benign or metastatic because of her past medical history of sarcoidosis. Therefore, and also for the purpose of preserving the larynx, we initiated definitive chemoradiotherapy. The patient was administered 2 cycles of 45 mg cisplatin and 700 mg 5-fluorouracil with 60 Gy/30 fr radiation therapy over 2 months. In each cycle, 8 mg dexamethasone was administered to prevent side effects of chemotherapy. After completing the chemoradiotherapy, we observed complete disappearance of FDG uptake in the primary cancer in the esophagus, and only a slight reduction in FDG uptake in the mediastinal lymph nodes (SUV max: 3.26; Fig. ), which indicated that the lymph nodes were affected by sarcoidosis. The primary lesion of the esophagus relapsed 3 months later. Then, the patient underwent thoracoscopic and laparoscopic total laryngopharyngoesophagectomy with gastric tube reconstruction via the posterior mediastinal route. The pathological diagnosis was moderately differentiated squamous cell carcinoma in the cervical esophagus. The resected lymph nodes demonstrated no tumor metastasis. However, some lymph nodes showed granulomatous reactions and contained several small epithelioid cell granulomas (Fig. ), suggesting the presence of sarcoidosis. The final stage was determined as

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


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

[User]
RADIOLOGY NOTE:
A 29-year-old gentleman complained of swelling and progressive pain in his left big toe after falling foot first into a drain. From his description of the fall, it seemed like the big toe suffered from an axial loading and hyperdorsiflexion injury. He visited the emergency department of another institution where he was given symptomatic treatment and had dorsoposterior (DP) and oblique radiographs of the left great toe performed (). He was told that the radiographs did not reveal any acute fracture and was advised to rest and to attend at the Orthopaedic Surgery Specialist Outpatient Clinic 2 weeks later. The patient felt symptomatically better after a few days and had returned to running and playing field hockey. Three weeks from the initial injury, there was recurrence of pain and swelling in the left great toe and this was limiting the function of the patient. This prompted him to seek attention at our Specialist Outpatient Clinic.
On examination, the affected big toe was shortened and dorsally dislocated as compared with the contralateral side. There was tenderness and swelling at the IP joint. While walking, the plantar side of the great toe did not touch the floor. There was lack of active movement of the affected IP joint. The IP joint could not be maneuvered passively too. Normal motion was maintained over the left metatarsophalangeal joint. Plain radiography was repeated and showed obliquity of the IP joint line with an interposed sesamoid bone (). Dislocation of the IP joint of the left big toe was suspected based on the clinical presentation as well as subtle features appreciable on the radiographs as discussed with our radiologists. Manual reduction was attempted but was unsuccessful. In spite of advice for surgical reduction, patient was not keen initially as the prescribed analgesics were efficacious in treating the pain and patient was still able to walk and jog without severe symptoms. However, the patient returned 1 week later (4 weeks from initial

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


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

[User]
RADIOLOGY NOTE:
A 20-year-old woman with a history of root canal treatment of the upper maxillary (left) central incisor was referred to our department from a private clinic. The root canal treatment had been initiated 4 months prior but could not be finished. A clinical examination revealed a temporary filling on the palatal surface. The coronal part of the tooth was discolored, and multiple visible cracks were present on the buccal surface (). The tooth was asymptomatic; the mobility was normal, and the probing depth at all sites was ≤ 3 mm. A periapical radiograph revealed a lesion around the apex and an enlarged and clearly irregular root canal (). When specifically asked, the patient denied knowledge of any previous dental trauma. Upon checking the electronic documentation of the faculty of the institution, we found that the patient had visited the department 2 years prior for other reasons, and X-rays were taken at that appointment. From a comparison of the periapical X-rays, it was clear that something must have happened since her last visit (). After gaining her confidence, the patient and her mother admitted that the patient had suffered from domestic abuse at the hands of her boyfriend, but that had been taken care of by the police. At this point, a small-field-of-view high-resolution cone-beam computed tomography (CBCT) scan was taken to investigate the extent and irregularity of the lesion. The scan confirmed the presence of a periapical lesion, which had destroyed most of the buccal bony wall around the root. The scan also showed massive internal resorption inside the root canal (). The patient was informed of the findings and the poor prognosis of the tooth, but since she desperately wanted to keep her tooth, she provided consent for endodontic treatment, which was initialized at a later appointment. The patient was also informed that due to the irregular nature and more pronounced buccolingual extent of the resorptive lesion and the massive destruction of the buccal

[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 one-and-a-half-month-old boy of Caucasian origins was referred to our hospital for an assessment of his feet. He was born with talipes equinovarus, or clubfoot, on his right foot. Figure shows his right foot postoperatively, after the correction to his clubfoot. On his left foot he had developed pes cavus and he had curly toes on both feet (Figure ). He had also been treated for a left hip dislocation.
There is no information with regard to the pregnancy itself but the birth was troublesome because he was lying in a lateral position and had to be born with vacuum extraction.
He was born to nonconsanguineous parents and has an older sister who is healthy.
It was found necessary to operate on his right foot and the operation, which went as planned, took place when he was just three months old. It was noted that there was an eczematous rash corresponding to the medial-dorsal skin furrow, which was exactly where the intended incision was to be made. The eczema was described as exuding, with fluid slowly seeping out, but not as a complete epidermis lesion. He was subsequently prescribed peri-operative antibiotics (dicloxacillin) two times per day for the course of one week after the operation, and the eczema was not considered an issue for the success of the operation and healing process.
Ten days after the surgery he was admitted urgently to our hospital because the bandages were foul-smelling and he had failed to thrive for the previous two days. Necrosis was seen around the cicatrix and it was found necessary to revise the wound under general anesthesia. Afterward, he was monitored for a month every other day when he had his bandages changed and the wound healed well. He was fitted with a dynamic splint to support his right foot.
A week after the last control, he was referred from

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


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

[User]
RADIOLOGY NOTE:
This is a case report of a 41 year old male patient who suffered a knife inflicted injury to the face. He was referred to our department 20 months after the incidence complaining of persistent discomfort with downward gaze of the left eye. He reported being agitated and feared a possible sight-threatening condition after the alleged assault. He was transferred to an emergency department where he was examined by an ophthalmologist who reassured him that his globe was intact and sutured the deep cut wounds related to his upper and lower eyelids. He was reassured that the facial edema would subside and the neurosensory deficit he was suffering from would eventually recover. Empirical antibiotics, Analgesia and tetanus prophylaxis were prescribed and the patient was discharged from the emergency department. He was unsatisfied with the resultant scar in his left eyelids and six months later was re-examined by a plastic surgeon that performed blepharoplasty. The persistent complaint of discomfort related to his left eye led him to seek medical advice again before being referred to our department.
Systematic thorough clinical and radiographic examination was performed. Upon inspection, it was noted that the left globe was displaced superiorly with increased scleral show (a). Bimanual palpation was done and a hard object could be felt behind the orbital rim of the left eye; although it was not visible externally. No evidence of diplopia was noted by ophthalmological examination. Plain radiography (Paranasal sinuses view (P.N.S) and lateral skull view) revealed a radiopaque foreign body (FB) lodged inside the orbital floor and directed downward & posteriorly (b and c). Computed tomography (CT) scan was ordered to precisely localize the foreign body and its relation to the surrounding structures. The foreign body was found penetrating the facial skeleton at the level of the orbital floor and transgressed the maxillary antrum and its tip reaching the pterygoid plates of maxill

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