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

[User]
RADIOLOGY NOTE:
A 24-year-old female patient presented to the Department of Oral and Maxillofacial Surgery at Homerton University Hospital in East London, UK, with a 4-week history of suspicious upper lip swelling. This patient was referred by her general practitioner on the urgent head and neck cancer referral pathway.
The patient's primary concern was the sudden onset of a large upper lip swelling with associated pain. The patient was not forthcoming and defensive when questioned regarding precipitating factors or possible trauma to the region. She was medically fit and healthy with no risk factors for oral cancer, such as smoking and alcohol consumption [].
On extraoral examination, the patient appeared to be well with no clinical signs of systemic illness. In general, the upper lip was disproportionately enlarged with an incompetent lip seal (). On close examination, a 2 cm × 1 cm firm, erythematous, swelling was noted in the upper right lip. The lesion was not encroaching on the midline and there was no associated cranial nerve deficit or lymphadenopathy. At the vermillion border, there was a puncture wound on a background of traumatised tissue adjacent to the firm swelling (). The lesion was painful on palpation with no suppuration, induration, or ulceration noted. Intraoral examination revealed a concurrent firm swelling within the labial sulcus. Dental health was unremarkable, and there were no signs of systemic infection.
Upon revision of the patient's electronic health-care record, it was noted that the patient had attended the Accident and Emergency Department at the Homerton University Hospital four weeks prior. The clinical clerking from this visit showed the main complaint to be swelling of the upper lip following self-injection of a dermal filler, purchased over the internet. When questioned again directly by the OMFS team regarding the true mode of injury, the patient revealed that she had purchased the filler material over the internet. The patient was uncertain 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 62-year-old female patient was recently referred to our hospital with a 3-months history of an episodic, but progressively worsening stridor, exertional dyspnoea and dry cough. Clinical examination of the right side of the neck revealed a hard 3 cm × 5 cm solitary thyroid nodule with ipsilateral level III and IV cervical lymphadenopathy. No neck tenderness or dilated veins could be identified. Serum thyroid function tests were within normal limits (TSH 1.8 Miu/L, Free T3 4 pmol/L, Free T4 16.3 pmol/L), but thyroglobulin level was >115 IU/ml. Subsequent neck ultrasonography (US) confirmed a solitary thyroid nodule showing cystic changes and calcification with cervical lymphadenopathy. The ipsilateral IJV was also noted to be distended but the ultrasonographer was not able to comment on any intravascular masses. Fine-needle aspiration cytology of the thyroid nodule revealed a papillary thyroid carcinoma, and papillary thyroid cells in the enlarged lymph nodes. A fibre-optic laryngeal examination revealed a narrow glottis area with a postnasal drip, the vocal cords appeared normal, but with diminished mobility. Computed tomography (CT) imaging showed a large hypo dense nodule with areas of cystic degeneration and calcification occupying the right lobe of the thyroid gland and invading the left lobe (a) and a large, well defined, heterogeneously enhancing mass in the right anterior jugulo-digastric region representing a pathological lymph node partially compressing the right IJV (b). Surgery was considered for treatment and a total thyroidectomy with right neck dissection revealed a locally advanced thyroid neoplasm with superficial invasion of the trachea. Intraoperative palpation of the distended right IJV showed a 2 cm × 3 cm hard intraluminal mass. Longitudinal venotomy revealed a tumour thrombus with no endothelial adhesion and was easily removed (). The vein was repaired using 6-0 prolene and the tracheal invasion was shaved successfully.
Histopathology and immu

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


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

[User]
RADIOLOGY NOTE:
In 2005, a 59-year-old male patient who suffered from occipital headache underwent complete surgical excision of a solitary cerebellar mass. Occipital transtentorial approach was done, and pathological diagnosis was confirmed to be hemangioblastoma (). He had no family history of VHL disease and no clinical stigmata to suggest the presence of VHL disease. VHL gene mutation was not detected in his peripheral blood sample. His symptom resolved after surgery, and the magnetic resonance image (MRI) of the brain showed no remnant lesion postoperatively. The patient was followed up with MRI, and no evidence of residual or recurrent lesion was observed until 2010.
In 2010, MRI of the brain showed a newly developed nodular mass at right medial edge of tentorium cerebelli suggesting dissemination of HB (). And in 2012, similar mass was observed at the posterior falx on the MRI (). There was no evidence of recurrence at the resected area and workup for VHL disease was also negative. He had no clinical symptom. He received cyberknife radiosurgery (total dose of 1,800 cGy/3 fx each) for each lesion in 2010 and 2012. After radiosurgery, the size of each lesion was reduced temporarily, but soon after the lesion at tentorium grew larger and other masses have newly developed around the pons and midbrain ().
Whole spine MRI revealed negative finding until 2012, but a intradural extramedullary mass was noted at T6-7 level in 2012 without any symptom (). In 2014, during follow-up of the thoracic lesion, he developed severe back pain at T9 dermatome, which correlated with the lesion. Spine MRI was done and it showed enlargement of the previously noted tumor mass at T6-7 level. Workup for VHL disease was done again, and the peripheral blood was analyzed for the presence of VHL gene mutations by direct sequencing method using ABI 3,730 sequencer. However, VHL gene mutation was not detected and

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


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

[User]
RADIOLOGY NOTE:
A 59-year-old right-handed woman presented with a one year history of involuntary abnormal right leg movements associated with ascending and descending stairs. The onset of the movements was rapid, but there had been no progression over the one year of her symptoms. She described the movements as a “hitch” or a feeling of getting stuck mid-stride. She felt unsteady but denied any falls or need for assistance. She denied pain or sensation of stiffness during these movements. She felt no urge or relief with movement. The movements occurred with every step on a staircase, regardless of step height. The movements occurred with no other activity. She is not aware of any alleviating maneuvers such as a sensory trick. Physical therapy has not been helpful. She has never tried medications for the movements. She has no history of leg trauma, weakness, or other neurologic symptoms. She has no family history of neurologic disease, including dystonia. MRI of the brain showed mild microvascular white matter changes that were not felt to be contributory to her symptoms. Serum studies of B12, thyroid stimulating hormone, ceruloplasmin, and copper levels were unremarkable prior to presentation to our office.
On exam, during performance of rapid movements of the hand, she had subtle mirrored movements seen in the inactive hand. She had no rigidity. Gait on a level surface was normal. The rest of her neurological exam was normal, including no cerebellar nor bradykinetic abnormalities. During stair descent, there was exaggeration of right hip flexion with external hip rotation and ankle dorsiflexion, consistent with previous reports of task-specific stair dystonia []. However, with ascending stairs, there was also exaggeration of right hip and knee flexion compared to the left leg, with a slight delay in the placement of the right foot on the next step ( in the online-only Data Supplement). These movements were not seen when she ascended 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 60-year-old man was admitted with cough. Chest computed tomography (CT) showed an 11-cm mass in the right upper lobe that was suspected of invading the right side of the superior vena cava (SVC) almost from the proximal end of the right internal jugular vein to the right atrium inflow (Fig. a, b). The patient did not present with signs or symptoms of SVC obstruction. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) showed leiomyosarcoma of the lung (Fig. a). 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET)-CT showed the high accumulation of FDG in the pulmonary tumor with a maximal standardized uptake value of 16.83; the absence of any other accumulation allowed us to exclude metastasis from another site. We diagnosed the patient with primary pulmonary leiomyosarcoma.
We considered complete resection of the tumor to be very difficult because of the tumor invasion, particularly that to the right atrium inflow of the superior vena cava, so we performed chemotherapy (doxorubicin monotherapy) for five cycles. We discussed the regimen for neoadjuvant treatment in a conference with orthopedic surgeons and medical oncologists. The recommended regimen for advanced soft tissue sarcoma is doxorubicin monotherapy or the combination of doxorubicin and ifosfamide. However, given that the combination therapy results in bone marrow toxicity more frequently than monotherapy, we selected doxorubicin monotherapy for neoadjuvant treatment. After chemotherapy, the tumor size shrank to 5.6 cm, and the distance of suspected invasion to the superior vena cava was reduced, rendering the tumor resectable with a sufficient surgical margin between the inflow of the atrium and the tumor (Fig. c, d).
We performed right upper lobectomy with combined resection of the superior vena cava and reconstructed the blood flow by an artificial vascular graft between the left brachiocephalic vein and right atrial appendage. We were able to remove the dense adhes

[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 2 is a 55-year-old European man with a history of hypertension who presented to the emergency room with seizures in December 2013; Case 2 is summarized in Fig. . A brain CT scan and further MRI showed three tumors surrounded by cerebral edema. A left kidney tumor and two lung nodules were identified by CT scan and, finally, clinical examination found some hypervascularized lesions of his scalp. The cutaneous tumors were surgically removed and the pathological report identified metastases of a type 2 papillary renal tumor. This patient was classified in the favorable risk group according to the International Metastatic RCC Database Consortium (IMDC) []. Brain metastases were all treated by stereotaxic radiation. Pazopanib another TKI directed to VEGFr was initiated at 800 mg/day. This treatment induced a partial response in lung metastases and in the primary renal tumor; the three brain metastases were also reduced. The disease remained stable for 2.5 years under pazopanib, except in his brain. In fact, two new brain metastases appeared 12 months later and three others after 24 months. Stereotaxic radiation was performed on each new brain tumor and pazopanib at 800 mg per day was resumed. Some neurological symptoms appeared with several transient episodes of aphasia together with some degree of mental confusion, 4 months after the last radiation treatment. Pazopanib treatment was completed and brain MRI indicated a radionecrosis with surrounding cerebral edema in one of the recently irradiated brain metastases. Two months after pazopanib completion, a CT scan showed significant progression in all other metastatic sites including previously irradiated brain metastases. Cabozantinib was started after our patient gave consent. Neurological symptoms rapidly resolved and a brain MRI at 2.5 months evidenced tumor regression of the different brain metastases (Fig. ). Cabozantinib was ongoing for 6 months but had to be reduced to 40 mg/day due to grade 3 diarrhea. Seque

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


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

[User]
RADIOLOGY NOTE:
A 40 year old female, suffering from hypothyroidism for 6 years, presented to our outpatient department with a gradually progressing large abdominal lump for 1year associated with bilateral pedal edema and difficulty in breathing for 1 month. She had had a similar large lump in 2013 and 2017, and had twice undergone excision of the tumour elsewhere. Biopsy revealed a well differentiated liposarcoma. She received 6 cycles of chemotherapy after the second surgery and her last cycle was in March 2018. She had not had radiotherapy. She was well till November 2018 when she again noticed a lump in the lower abdomen which gradually increased in size occupying her entire abdomen. There were no symptoms suggestive of bowel or urinary bladder involvement and no history of jaundice, back pain or headache.
On examination, she was moderately built and nourished with weight of 83 kg, height of 161 cm and body mass index (BMI) of 32. She had a distended abdomen with a midline scar from a previous laparotomy. Firm non-tender mass felt all over abdomen with edema noted all over abdominal wall and bilateral lower limbs. Her bowel sounds were heard in the left upper quadrant of the abdomen. On digital rectal examination, a mass was felt anteriorly compressing the rectum. Her all lab parameters were within normal limits except for raised thyroid-stimulating hormone that was managed by increasing the dose of thyroxin from 25mcg to 50mcg once daily. She was evaluated with a PET CT () which showed a mildly FDG avid, large heterogeneously enhancing lesion with a predominantly fat component occupying almost the entire abdominopelvic cavity with displacement of the other intra-abdominal organs. No other significant FDG avid lesion was seen elsewhere in the body.
As it was a second recurrence of the tumour and the patient refused neo-adjuvant therapy, it was decided to relieve her symptoms by surgical excision. On exploration by a senior consultant in surgical gastroenterology and liver trans

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


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

[User]
RADIOLOGY NOTE:
A 39-year-old woman with hepatitis C was being seen by the gastroenterology service to monitor a liver nodule. Abdominal ultrasonography identified a visceral artery aneurysm as an incidental finding. Angiotomography revealed that it was a saccular aneurysm of the pancreaticoduodenal artery, with a diameter of 40 mm, and showed subocclusive stenosis of the celiac trunk compatible with extrinsic compression ( ).
The patient underwent laparoscopic relief of celiac trunk compression ( ), thereby averting the possibility of mesenteric ischemia, as the pancreaticoduodenal artery is an important collateral route between the celiac trunk and the superior mesenteric artery and an undiscovered occlusion of this artery can cause visceral ischemia. The laparoscopic procedure was performed using a 10 mm trocar for the camera, in an umbilical position, and a further four trocars; in the right and left hypochondrium, the left flank, and a subxiphoid position. The gastrohepatic ligament, phrenoesophageal membrane, esophagus, and crura of the diaphragmatic were dissected, with inferior sectioning of the crura to enable the arcuate ligament to be viewed. Relief of celiac trunk compression was achieved by sectioning the arcuate ligament by electrocautery and the crura were drawn back together to prevent gastroesophageal reflux. Doppler ultrasonography conducted before hospital discharge showed that there was no longer compression of the celiac trunk and revealed some residual stenosis and post-stenotic dilation (the pre-stenotic celiac trunk diameter was 10 mm and at the stenosis it was 3.5 mm) ( ).
The patient returned 2 months later for pancreaticoduodenal artery aneurysm repair, which was performed under local anesthesia and sedation, via a left brachial access with selective catheterization of the superior mesenteric artery and selective embolization of the aneurysm sac with microcoils, with no intercurrent conditions ( ). Four 20 mm to 25 mm x 50 cm Axium 3D microcoils and two 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 32 year old man who had recurrent episodes of epistaxis was seen in the ENT outpatient clinic. Flexible endoscopy revealed deviation of the nasal septum to the left. Arising from the posterior end of the left nasal septum was a pedunculated well-circumscribed lesion. Magnetic resonance imaging revealed no other abnormalities. At operation, a lobulated solid mass was seen. The mucosa anterior to the mass had become detached. The underlying bone was removed but did not look involved. Postoperative recovery was uneventful and he was discharged the next day. The lesion was suspected to be a haemangioma. Previous episodes of epistaxis were treated with silver nitrate cautery. The patient has no significant past medical history. He is a non-smoker, was not on any regular medication and had no relevant occupational history. Subsequently, the patient had two further operations. Firstly, removal of the posterior aspect of the nasal septum was performed four months after removal of this mass. Secondly, a biopsy of the nostril was undertaken. The former revealed mucosal fragments incorporating seromucinous glands with intervening chronic inflammation of the stroma but no evidence of residual adenocarcinoma. The latter showed inflammatory granulation tissue around suture granulomata from previous surgery. Since initial presentation over two years ago, the patient remains free of recurrence or metastatic disease and does not have any lesions in his lungs or thyroid gland.
Macroscopically, two yellow-white polypoid fragments of tissue, measuring 10 and 4 mm in maximum dimension were received. Histologically, these fragments were partly covered by focally ulcerated squamous epithelium. The underlying stroma was infiltrated by a neoplasm with a complex papillary and tubular configuration, lined by moderately dysplastic pale columnar epithelium with intervening spindle shaped cells(Figure and ).
Immunohistochemical labelling revealed diffuse positivity with antibodies to EMA, CAM

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


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

[User]
RADIOLOGY NOTE:
A 70-year-old female (weight, 42 kg; height 149 cm) was scheduled to undergo bladder hydrodistension therapy for interstitial cystitis []. She had a previous medical history of gastroesophageal reflux disease and lung cancer for which she had undergone a lobectomy 6 years previously and chemotherapy. Although she also had undergone hydrodistension of bladder under spinal anesthesia 2 years ago, she had a preference for general anesthesia this time. Routine preoperative laboratory investigations, electrocardiogram (ECG) () and chest X-ray showed no abnormalities. Preoperative evaluation revealed no remarkable risk factors. Thus, the patient was considered as ASA PS 1 at the preoperative consult and we planned that she would undergo ambulatory surgery under general anesthesia.
Anesthesia was induced with 80 mg of propofol and maintained with sevoflurane at 2-3% in 50% O2 with 50% air via laryngeal mask airway. BIS value was maintained between 50 and 60. 50 mg of flurbiprofen was administered for postoperative analgesia soon after anesthesia induction. Either opioids or muscular relaxants were not administered. The surgery proceeded uneventfully until the bladder was extended when her heart rate increased from 80 beats/min to 140 beats/min and her blood pressure raised from 100/50 mmHg to 190/120 mmHg. Inhalation bolus of sevoflurane (8% sevoflurane with 8 L fresh gas flow) was administered for about 5 minutes and her vital signs were stabilized. No ECG abnormality was observed. After the incident, the surgery proceeded without any particular events and she recovered from general anesthesia 10 minutes after the surgery. She was transferred to a post anesthesia care unit (PACU). On arrival in the PACU, she did not have any complaints. Two hours after the surgery she began to complain chest discomfort and lower abdominal pain in the PACU. ECG showed T wave change () compared to baseline ECG () taken 29 days before surgery. HR and BP were 110 beats/min and 95/62 mmHg resp

[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 20-year-old man with both upper limb disabilities admitted to our hospital for mandatory health screening before military service. He had no health complaints other than the skeletal disorder involving his upper limbs. In detailed questioning, he stated that he had four fingers in his left foot. He is the last of six children born to nonconsanguineous healthy parents. All of his brothers and sisters are completely healthy. There is no family history of any kind of congenital skeletal abnormalities in the extended family. His mother was at the age of 32 when she gave birth to our patient. There is no history of any drug, smoke, alcohol, or radiation exposure during pregnancy. Our patient was born uneventfully at full-term through normal vaginal delivery. No other significant health problem is present in the history of his childhood.
On physical examination, all skeletal elements beyond his left elbow and right wrist, and the fifth finger of his left foot were found to be absent (). He had oligodactyly of the left foot (). Anteroposterior radiograph of the right arm depicted the absence of the hand with well-developed radius and ulna. There was a rudimentary bone of about 1 cm in the medial neighborhood of the distal ulna (). Anteroposterior radiograph of the left arm demonstrated that the proximal forearm segment participating in the elbow joint structure was small but present, while the radius and ulna distal to this point were absent (). Anteroposterior, lateral oblique, and mediolateral radiographs of the left foot revealed absence of the fifth finger and the lateral cuneiform. The second to fourth fingers were short. The number, size, and joint relations of the other bones forming the foot were normal (). Magnified anteroposterior and lateral oblique radiographs of the left foot showed that the middle phalanges of the second and third fingers were shorter than the distal phalanges, and the middle phalanx of the fourth finger was absent ().
The patient was then

[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 31-year-old woman with a VNS implantation three years prior to her MEG recording presented for further evaluation. Since age 5, the patient had focal seizures that began with a “funny feeling,” flushing, and head turning to the right. Some seizures terminated at this point, while at other times her seizures progressed to impair awareness and/or evolved into a bilateral convulsive seizure. Treatment with several antiseizure medicines failed to improve the woman’s seizure frequency. An MRI did not demonstrate any structural brain abnormalities. An EMU evaluation captured seizures with a broad, right hemispheric onset. An initial MEG recording prior to VNS implantation captured epileptiform activity, which was originally and unsuccessfully analyzed using equivalent current dipole modeling (A). The interpretation at the time was that the MEG study did not provide localizing information. As the patient’s seizure focus was not localized with any modality, she received a VNS.
However, the patient continued to have seizures after the VNS implantation. Because we had subsequently implemented SAM(g2) as an alternative to dipole analyses, the patient returned for a second MEG scan. SAM(g2) was used to analyze this second MEG recording, as well as the previous recording performed prior to VNS implantation. Even though the second recording was separated from the first by six years and the raw MEG sensor data were strongly contaminated by artifact from the VNS during the second recording, an equivalent right frontal focus was identified on both recordings (A), a focus not revealed by dipole analysis previously. This indicates that SAM can reproducibly localize interictal epileptiform activity despite the presence of large artifacts due to the VNS implant. (The dipole localization in the presence of VNS artifact is shown in B for comparison. The dipole tails have been omitted for clarity.) Examination of the virtual electrodes reconstructed from the SAM(g2) focus demonstrated ME

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


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

[User]
RADIOLOGY NOTE:
A 5-year-old female child came to us with history of fever and loss of appetite since 2 weeks and right sided weakness since 4 days. She had history of generalized convulsion 3 months back and one more focal convulsion in right sided limbs 4 days back followed by same side limb weakness. She was lethargic and had preference to sleep but was easily arousable. There was history of headache that was holocranial and with morning exacerbation. On examination, her right sided limb power was 4/5. There was hypertonia and exaggerated reflexes in right sided limbs. Magnetic resonance imaging (MRI) showed a large heterogeneously enhancing space occupying lesion in the left parieto-occipital region causing significant mass effect and midline shift. The lesion was partly solid and partly cystic with rim enhancement and in close proximity to the occipital horn of the lateral ventricle [Figures and ].
The patient was operated in right lateral position. A parieto-occipital craniotomy was performed, and the brain was found to be extremely tense. A small cortisectomy was done in the posterior parietal region and tumor identified []. The tumor was grayish in color, firm in consistency and had a good plane of cleavage from surrounding brain parenchyma. The lesion was excised completely in piecemeal fashion. The choroid plexus with ependyma was found adherent to the capsule that was preserved. Histopathology was suggestive of the malignant spindle cell tumor with densely packed tumor cells. Immunohistochemistry (IHC) was performed which was IHC-negative for glial fibrillary acidic protein and S-100. MIB-1 labeling index at some areas was up to 40%.
Postoperatively patient improved in sensorium and right sided limb power. The power was Grade 5/5 by postoperative day 1. The wound healed well and suture removal was done on day 9. Postoperative MRI done was suggestive of complete excision of tumor []. The patient underwent concurrent chemoradiation of 60 Gy along with temozolomide 75

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

[User]
RADIOLOGY NOTE:
This is the child ‘GL’ 13-year-old, male, with no particular medical history, who was consulted with the Emergency Department of Pediatric Surgery at Aristide Le Dantec Hospital in Dakar for pain in the right thigh and lameness in the right lower limb.
The onset of these symptoms began about 1 month ago. During a football match, he had fallen down, causing pain and swelling in the inner side of the right thigh. The evolution was marked by a regression of the swelling and persistent mechanical pain. That motivated the parents to consult with our service for better management.
The admission examination found a good general and haemodynamic status, analgesic attitude (bent trunk on the right side), painful end proximal thigh on palpation, especially in the inner side. The amplitude of the hip motion was normal, except that the internal and external rotations, which were painful. The rest of the examination was normal.
To establish the diagnosis, a paraclinical examination was requested. Radiography showed an eccentric cystic lesion, multilocular with cavities that were separated by septa and thin cortical bone. The lesion was invading almost the entire femoral neck. The trochanters were not affected by this lesion and it did not cross the growth plate. The soft parts did not appear to be invaded [].
Ultrasound of the hip was normal as well as laboratory tests (complete blood count, C-reactive protein, blood sugar and haemostasis).
Before the patient's radiographic findings, the diagnosis of ABC was discussed, and the surgical indication was asked for and performed. After the anterior Hueter approach of the right hip joint, opening of the capsule and trepanation of the femoral neck, about 10cc were taken from a haematic fluid-filled cyst cavity. The lesion was curetted, cancellous graft from the ipsilateral iliac bone filled the cyst cavity. The gesture was completed by prophylactic screwing with a spongy screw and drainage of the joint

[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:
Male, 45 years old
Chest pain and myalgia
Not applicable
A 45-year-old male patient, who was a former radiologic oncologist, presented to the department of rehabilitation medicine at a university hospital with chief complaints of chest pain and myalgia on August 19, 2011. The case was suspected of having a hematological malignancy based on his blood test results, and subsequently underwent a bone marrow test on August 23, 2011. On August 30, 2011, The case was diagnosed with leukemia based on histological findings. The case received chemotherapy thereafter, but died during a chemotherapy session on January 6, 2012.
The case underwent surgery for cryptorchidism in 1990 and for L4/5 disc herniation in 2007. He also underwent treatment for acute gastric ulcers in 2004. In November 2000, while he was performing brachytherapy, The case experienced extreme fatigue, dramatic weight loss, and loss of appetite. In early December of the same year, he underwent extracorporeal shock wave lithotripsy after finding urinary calculi, but did not undergo any test related to excessive radiation exposure. The case started taking medicine for dyslipidemia, especially high triglyceride (TG = 473 g/dL) detected during a health examination in July 2011. No abnormal hematological findings were noted in the general health examinations recorded since 2003. The case did not have a history of any other disorders or a family history of leukemia.
A blood test was performed in August 2011 in response to the chief complaints mentioned previously. The test showed that the patient’s level of hemoglobin was 11.1 g, white blood cells were 41,490 μl, hematocrit was 31.8%, and platelets were 49,000 μl. Based on these results, The case was suspected of having acute lymphoblastic leukemia, and accordingly, he underwent a bone marrow biopsy. Based on the bone marrow test results, The case was diagnosed with B-precursor lymphoblastic leukemia with a BCR/ABL rearrangement. The FISH (Fluorescence in situ hybr

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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 51-year-old male came to our hospital with a year old history of gradual onset pain and swelling below his left knee and repeated episodes of fever. The swelling advanced gradually over the year and ulcerated 3 months ago. Patient could walk without any assistance. On examination, there was a firm mass of 30*18*12 cm at the upper part of tibia extending to the calves and a large discharging ulcer of 12 cm diameter anteriorly with necrotic areas. The discharge was yellow, thick in consistency. Range of motion of knee was reduced. Tenderness was present over the left knee and proximal tibia. Pulsations of dorsalis pediis, posterior tibial and popliteal arteries were present. A neurological examination of the lower limbs was within normal limits. Examination of other systems was unremarkable. A clinical blood examination and a chest X-ray at the time of presentation showed no abnormality. Plain radiograph showed a large lesion with soft tissue opacity involving the metadiaphysis of left tibia, causing erosion and destruction of tibia and adjacent fibula, with linear and ring like calcifications suggesting a tumor, possibly an enchondroma, osteosarcoma or chondrosarcoma, with extensions into the soft tissue of proximal leg.
Tc99m radio isotope bone scan showed increased tracer uptake in the shaft of left tibia and proximal soft tissue with no skeletal metastasis.
Due to financial constraint on the side of patient, a MRI was not done. Based on the presentation and radiographic appearance, differential diagnosis included osteosarcoma and chondrosarcoma of tibia.
On admission, patient was started on intravenous antibiotics and analgesics and counselled on different treatment options. Considering the preferences of the patient, including the cost factor of megaprosthesis, the size of the lesion, extend of infection and survival rate of the tumor, the patient opted for transfermoral amputation as treatment modality along with post-operative chemotherapy.
Post-surgery, the

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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 62-year-old Caucasian male with a past medical history of hypertension and diabetes, presented with bilateral eye protrusion since 1 week. He had been experiencing double vision and throbbing frontal headaches for the past 2 weeks. Physical examination was remarkable only for bilateral exophthalmos [], without any palpable lymphadenopathy. Magnetic resonance imaging (MRI) of the orbit revealed 3.8 × 3.0 × 1.5 cm enhancing orbital mass involving the lateral and superolateral aspect of the peripheral right orbit as well as an irregular 1.1 × 1.1 × 2.4 cm mass along the inferior aspect of left orbit []. Also noted were abnormal signal enhancements within the lesser sphenoid wing and the anterior body of the mandible on the right. Given this constellation of findings, there was suspicion for lymphoma or other metastatic disease.
Biopsy of right eye mass was done that revealed extensive soft tissue involvement by two separate lymphomatous populations [ and ], comprising small and large neoplastic lymphocytes. The large cells were positive for CD20 B cells with co-expression of CD10 BCL6 and MUM-1. By corresponding flow cytometry, they were found to be kappa chain restricted. These features were consistent with high grade large B cell lymphoma. The small lymphoma cells were CD20+ B cells with co-expression of BCL2 and aberrant CD43 and partial CD5. Flow cytometry revealed lambda restriction. These morphological and phenotypic features were consistent with MALT lymphoma. B cell immunoglobulin gene rearrangement by polymerase chain reaction (PCR) was done to detect clonality. Peaks migrating at 318, 255, and 274 bases were present on B-cell immunoglobulin heavy chain (IgH). In addition, there were peaks present migrating at 195 and 273 bases on B-cell immunoglobulin kappa light chain (IgK). The intensities of these peaks were consistent with clonal neoplasm. Gene rearrangement studies were also done on the different aberrant lymphocyte population with diagnosis of MALT ly

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


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

[User]
RADIOLOGY NOTE:
A 32-year-old healthy Indian male presented with complaints of painful diminution of vision in his left eye for the past three days. The ocular evaluation revealed a best corrected visual acuity (BCVA) of 20/ 20 in the right eye and 20/ 80 in the left eye, with severe anterior chamber inflammation and hypopyon. There was a mild spillover inflammation seen in the vitreous cavity but third order vessels in the fundus could be visualized.
The patient was started on intense topical steroids and cycloplegics. All routine systemic investigations including HLA-B27, and X-ray sacroiliac joint were done. He was found to be HLA-B27 positive by deoxyribonucleic acid based molecular method: single specific primer- polymerase chain reaction (PCR). Over the next three days, the anterior segment inflammation considerably reduced, with the resolution of the hypopyon, but the patient noticed profound diminution of vision in the same eye, dropping to 20/ 400. The examination of the left eye revealed intense vitritis with media clarity decreased to Grade III, with the optic disc and vessels being faintly visible (), and optical coherence tomograph (OCT) showing macular fold and gross macular thickening. He was started on a high dose of oral steroids (1.5mg/ Kg body weight) in order to control the inflammation over the next one week, but the posterior segment inflammation persisted. In view of hypopyon at presentation and dense vitritis with no response to high dose oral steroids, a differential diagnosis of endogenous endophthalmitis was kept in mind and the patient was subjected to a diagnostic and therapeutic pars plana vitrectomy. The vitreous sample was negative for bacteria and fungi on smear as well as culture. The vitreous sample was negative for Mycobacterium tuberculosis (MTB) by PCR (Xpert MTB RIF assay G4).
There was a slight improvement in the posterior segment inflammation as well as media clarity after the surgical procedure, with examination revealing optic disc edema

[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 37-year-old male with known Down syndrome and epilepsy and taking carbamazepine was brought by his family to the emergency room with a large protruded tongue within 30 minutes of the incident ().
The patient was vitally stable; however, he was slightly agitated. The otolaryngology team had been consulted immediately for further evaluation of the patient's status. History from the patient's family showed that they believed the patient was engaging in aggressive behavior, and he has a history of multiple tongue tractions leading to sudden severe tongue swelling. The examination was unremarkable, except for a huge protruded swollen tongue, which was diffused with no confined collection or sign of hematoma. Fixable nasolaryngoscopy relieved bilateral vocal cord movement, and there was no laryngeal edema. The neurology team was consulted to rule out active seizure, and they cleared him. The decision was to intubate the patient to secure the upper airway and then admit him to the intensive care unit (ICU). The patient consented to endotracheal intubation and possible tracheostomy in case intubation failed. The patient was successfully undergoing orotracheal intubation in the operating room. Then, a CT scan was done, which revealed some artifacts due to endotracheal intubation, with evidence of an enlarged diffused edematous hypertrophic tongue muscle protruded outside the oral cavity and deviated to the left side due to tube insertion from the right side (Figures and ). In addition, the CT scan showed no evidence of mass lesions, collection, abnormal enhancement in postcontrast series, or sizable lymphadenopathy. Thereafter, he was transferred while intubated to the ICU, and he was connected to mechanical ventilation. He was kept on midazolam, fentanyl, and dexamethasone at 8 mg intravenously for Q6h to relieve swelling, as well as pantoprazole for 4 days. Furthermore, a removable bite block was placed on the teeth to prevent tongue biting, and wet gauze was applied to

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


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

[User]
RADIOLOGY NOTE:
A previously healthy 34-year-old Korean female was admitted to a regional hospital for fever, myalgia and severe headache that had started 2 weeks ago. Brain MRI showed a high T2 signal intensity change and diffuse swelling of the right temporal lobe, insula and hippocampus (Fig. ). Lumbar puncture showed lympho-dominant pleocytosis. The patient was started on intravenous (iv) dexamethasone and acyclovir under a high suspicion of viral encephalitis.
She was transferred to our institution 4 days later due to persistent headache despite treatment. A noncontrast computed tomography (CT) brain scan taken at our institution showed a hemorrhagic transformation of the right temporal lobe, which was not observed on the initial MRI (Fig. ). Follow-up lumbar puncture showed 510 white cells per mm3 (82% lymphocytes), 144 mg/dL protein and 61 mg/dL glucose. CSF culture studies were negative for bacteria, fungi and tuberculosis. PCR of the CSF confirmed the presence of HSV1. The patient was free of neurological symptoms, with a Glasgow Coma Scale of E4M6V5, and was admitted for close observation and continuation of iv acyclovir. Corticosteroid treatment was discontinued upon her admission. On day 3 of hospitalization, the patient presented with a sudden onset of vomiting and severe headache. Brain CT showed an increased amount of temporal lobe hemorrhage and a leftward shift in the midline (Fig. ). Mannitol was administered but did not seem to have a significant effect. The patient became increasingly drowsy, and her right pupil became dilated. She underwent emergency right decompressive craniectomy, expansile duraplasty and ICP monitor insertion. Postoperative brain CT showed alleviation of midline shifting (Fig. ). The patient recovered fully 5 days after the surgery. Apart from mild intermittent headache and dizziness, she did not show any other significant clinical symptoms, including neuropsychological problems. There were no significant neurologic deficits upon neurologica

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


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

[User]
RADIOLOGY NOTE:
Patient 2 is a 78-year-old male who was experiencing persistent lower urinary tract symptoms despite combined medical therapy with alpha blockade and 5-alpha reductase inhibitors. His medical history included coronary artery disease status post-coronary artery bypass grafting and percutaneous coronary intervention, and a history of pneumonia. Preoperative cystoscopy revealed enlarged median and lateral lobes, as well as severe trabeculations of the bladder with a TRUS measuring a 41 cc prostate. HoLEP was carried out utilizing a two-incision technique. Upon completion of morcellation, it was noted that the patient's abdomen was distended, but his peak airway pressures were normal, the abdomen was soft, and the catheter drainage was noted to be clear. In addition, there was no suspicion for a significant mismatch between irrigation used and fluid output collected in the drainage system.
Given the previous similar presentation in Case 1 with no suspicion of bladder injury, we suspected that the patient had extraperitoneal extravasation of the saline irrigation through a capsular perforation as occurred in Case 1. The decision was made for the patient to be awakened, extubated, and transferred to the recovery room where he was further monitored. A stat noncontrast abdominal CT scan was performed that revealed a moderate amount of free fluid in the pelvis and upper abdomen; the fluid in the pelvis and lower abdomen was distributed in the extraperitoneal region with no evidence of hematoma (). The patient remained hemodynamically stable and was transferred to the floor with continuous bladder irrigation. The patient was given a 40 mg dose of Lasix ∼8 hours after the operation was completed. Overnight, there were no acute events. On POD 1, the patient's abdomen was soft and significantly less distended. The Foley catheter drained 3950 cc of urine overnight without evidence of hematuria. The patient was discharged with a catheter on POD 1. The patient had his catheter remo

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


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

[User]
RADIOLOGY NOTE:
A 70-year-old man with a past medical history of coronary artery disease, hypertension, hyperlipidemia, obstructive sleep apnea, and remote history of renal cell carcinoma with prior radical nephrectomy. During a surveillance scan for his prior renal cell carcinoma, an incidental pulmonary embolism was noted as well as a cystic lesion on the pancreas. He was referred to gastroenterology for further workup of the pancreatic cystic lesion. As part of the assessment, a chromogranin-A level was obtained. Chromogranin-A was elevated at >600 ng/mL with normal 5-hydroxyindoleacetic acid. Octreotide scan was negative and endoscopic ultrasound was negative for any solid component of the pancreatic lesion. It was postulated that the patient had elevated chromogranin-A levels related to his chronic kidney disease, recent thrombosis as well as being on a proton pump inhibitor (PPI). The patient was asymptomatic from the pancreatic lesion without complaints of diarrhea or flushing. A repeat chromogranin-A level a few months later decreased to 157 ng/mL after PPI was held but remained elevated beyond the upper limit of normal. Over the next several years he continued surveillance for the pancreatic cyst and elevated chromogranin-A level. On surveillance scans he was noted to have an increase in the size of cystic lesions on the pancreas as well as a peripancreatic lymph node enlargement. The chromogranin-A rose to 400 ng/mL.
After nearly 5 years of surveillance, a 68Ga-DOTATATE PET scan was obtained for a suspected NET. This showed an abnormal bifocal uptake in the left neck with a maximum SUV (standardized uptake value) 9, with an additional focus of abnormal uptake in the left neck more medially with a maximum SUV 7. Another abnormal focus of uptake was also appreciated in the right neck with maximum SUV 3.1 ( and ). Due to a high suspicion for metastatic NET, the patient was referred to a medical oncology specialist in gastrointestinal cancers. The patient was thought to

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


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

[User]
RADIOLOGY NOTE:
A 59-yr-old man with a history of pulmonary tuberculosis (TB) and no significant family history was diagnosed with idiopathic thrombocytopenia in June 2008. The patient was treated with corticosteroid therapy. In October 2008, he developed a cough, sputum, and rhinorrhea and five days later displayed fever and dyspnea. He was subsequently admitted to hospital. His chest radiography and computed tomography (CT) scan showed multifocal patchy ground-glass opacities (GGOs) in both lungs with underlying emphysema with large bullae in the left lower lobe and focal irregular nodular lesions in the right upper lobe that were presumed to be TB sequelae. He was assessed as having atypical pneumonia. Considering his immunocompromised status, antibiotic therapy was commenced empirically.
After five days, he was transferred to our hospital, a tertiary referral center, and admitted to the medical intensive care unit. At admission, he had tachypnea with a fever of 39℃. He had progressive bilateral diffuse infiltrations on his chest radiography. His initial SaO2 level was 75% and his PaO2/FiO2 (P/F) ratio was 166 mmHg. He was diagnosed with ARDS caused by atypical pneumonia. He then received mechanical ventilation (MV). We started a course of methylprednisolone at a dose of 40 mg twice a day to treat a possible Pneumocystis jiroveci pneumonia in conjunction with a continuing regimen of empirical antibiotics and an antiviral agent. However, no specific pathogen was identified in any specimen from this patient, including bronchoalveolar lavage, blood or sputum. Then, his chest radiography was stationary and his P/F ratio began to gradually improve.
On hospital day (HD) 7, he underwent tracheostomy to enable early weaning from MV. However, he then developed hospital-acquired pneumonia and hydropneumothorax due to a ruptured bullae with bronchopulmonary fistula (BPF). The repeated lung infections made him dependent on MV and weaning proved difficult. He was conscious during this time b

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


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

[User]
RADIOLOGY NOTE:
A 65-year-old woman presented with abdominal pain and hypophagia for 2 weeks. She had a medical history of alcoholic pancreatitis. A computed tomography (CT) scan of her abdomen and pelvis revealed thickening of the transverse colon wall. Colonoscopy showed an ulcerated tumor in the transverse colon, and histological analysis indicated moderately differentiated adenocarcinoma. Serum carcinoembryonic antigen (CEA) levels were normal, and no sites of distant metastasis were reported on preoperative examination. She underwent a laparoscopic extended right hemicolectomy using the non-touch isolation technique. Histopathological examination of the specimen revealed a moderately differentiated adenocarcinoma invading the subserosal layer with low venous invasion (v1) and no lymphatic invasion (ly0). The surgical margins were negative. A total of 92 lymph nodes were removed, of which none showed metastases. The tumor was diagnosed as stage IIA (T3, N0, M0) according to the International Union Against Cancer tumor, node, and metastasis (TNM) classification (7th edition) []. The patient had an uneventful recovery and was on regular follow-up every 3 months without adjuvant chemotherapy.
Fifteen months after her colectomy, a CT scan demonstrated a tumor in the antero-lateral rectal wall that was 20 mm in diameter, and a right ovarian tumor that was 25 mm in diameter (Fig. ). The ovarian tumor was a cystic mass with a solid component on magnetic resonance imaging (Fig. ). Colonoscopy revealed a superficial elevated lesion in the middle rectum that was shown by histological examination to be moderately differentiated adenocarcinoma (Fig. ). Serum CEA levels were normal. These findings were indicative of rectal cancer with ovarian metastasis, or double primary cancer of the rectum and ovary. A diagnostic and therapeutic laparoscopy detected no disseminated peritoneal metastases or liver metastases. Intraoperative cytological examination of the peritoneal lavage was negative for

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


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

[User]
RADIOLOGY NOTE:
An 87-year-old woman with history of rheumatoid arthritis presented with pain, decreased vision and injection in her right eye 10 days after excisional biopsy of a conjunctival lesion and placement of a conjunctival autograft. Per records, cryotherapy or antimetabolites were not used intraoperatively. The lesion was adjacent to a 1-year old cataract wound. Histopathology revealed poorly differentiated OSSN with positive surgical margins.
On initial exam, Snellen visual acuity in the right eye was 20/320. A membranous film covering the inferior half of an anterior chamber intraocular lens (ACIOL) and extending to the old cataract incision was seen on slit lamp examination of the right eye (Fig. a, b). The membrane was not attached to the posterior corneal surface. The membrane was biopsied in the operating room. Two paracentesis incisions were made superiorly, the membrane was grasped with micro forceps (MST, Redmond, WA), a small sample was cut with micro scissors (MST), and it was fixed in formalin for histopathological evaluation. Histopathology revealed dysplastic squamous epithelial cells of conjunctival origin. The patient and her family declined enucleation at that time given her age and comorbidities.
Ten days after initial presentation, her vision declined to light perception, and the membrane expanded to cover the entirety of the ACIOL and iris surface (Fig. c). Given the rapid progression, the patient was then amenable to surgery. A modified enucleation was performed using a no touch technique with wide margins and cryotherapy. A dermis fat graft was used instead of an implant given that a significant area of the conjunctiva was sacrificed to achieve clear margins, and the patient would be at risk for implant exposure. Histopathology revealed invasive squamous cell carcinoma extending deep to the ciliary body and laterally into the anterior chamber, with negative conjunctival margins. No mucoepidermoid or spindle cell characteristics were observed. The pat

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


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

[User]
RADIOLOGY NOTE:
A 45-year-old woman was admitted to our hospital with a chief complaint headache and dizziness. On initial neurologic examinations, the patient had no neurologic signs. A 3-dimensional computed tomography angiography scan on admission showed left vertebral artery stenosis. On day 5, the patient underwent magnetic resonance angiography at a follow-up, showing no interval change of left vertebral artery stenosis (). On day 10, the patient underwent transfemoral cerebral angiography (TFCA) showing complex vertebral dissecting aneurysm of long segment arising from the PICA (). These findings were suggestive of a sign of impending rupture of left vertebral artery dissecting aneurysm because a short-term follow-up radiography revealed a change in the vessel contour. In this patient, we decided on the segmental occlusion using a coil with stent insertion of contralateral vertebral artery after PICA-to-PICA bypass surgery because of the proximity and parallel course of the distal segments of the PICA (). Because simple stenting method had still risk for rupture of aneurysm after intervention and parent artery occlusion had risk for ipsilateral PICA territory infarction, we decided that.
After a midline suboccipital craniotomy, the cisterna magna was opened. After temporary clipping of proximal and distal PICA and perforating artery, a curved incision rather than a straight one along the PICA was done. To do this, the distal end of both PICA was stay-sutured. This was followed by the continuous suture from outside to inside of inner side of the vessel. Then, the final suture was done from inside to outside of the vessel. Following this, the proximal end was also stay-sutured on the external side and then tied with the final inner suture. Moreover, the continuous suture of outer side from outside to inside of the vessel was done in the same manner. After removal of temporary clips, a good patency was also seen on intraoperative indocyanine green angiography ().
On postoperati

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


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

[User]
RADIOLOGY NOTE:
A 68-year-old male patient was referred to our department from neurosurgery due to the occurrence of diplopia 10 days after a head surgery that was performed following a pedestrian traffic accident. On the day of the initial trauma, the patient was admitted to the intensive care unit after neurosurgical evaluation, because of a compound comminuted depressed fracture of the right temporal bone. In the initial ophthalmologic examination, there were no ocular symptoms. On day 4 after trauma, an open reduction and internal fixation were performed on the temporal bone fracture by the neurosurgeon. On day 2 after neurosurgery, the patient complained of diplopia and orbital computed tomography (CT) revealed bilateral orbital superior wall fractures. In contrast to the fact that a herniation of the brain parenchyma was unclear on the initial facial CT scan (Fig. a), the fracture fragment and the brain parenchyma were downwardly moved into the orbit, observed on CT scans taken when diplopia occurred (Fig. b). Upon physical examination at the time of admission to the department of oral and maxillofacial surgery, right eye movement limitation and right eye protrusion were observed (Fig. a, c). The surgical plan was to reconstruct the bilateral medial orbital wall using a titanium mesh via coronal approach. For better fitness of the titanium mesh, the mesh was contoured preoperatively on a model of the patient’s skull that included the orbital wall defect. The defect on the model was restored using a plate wax (Fig. ); following pre-operative manipulations, the mesh was sterilized.
The reconstruction of the orbital wall was performed 1 month after trauma. A bicoronal approach was attempted in order to easily access the tissue on the right orbital wall. Due to severe tissue adhesion, a craniotomy was performed on the frontal bone to approach the anterior cranial base, even though this is a more invasive approach. Despite utilizing this approach through the anterior cranial base,

[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 47-year-old woman presented to our clinic and complained of a left upper eyelid lesion that had increased slowly in size over the past three years. The lesion was 1.0 cm in size. It was round shaped, circumscribed elevated and had brown pigmented color (Figure 1 ). The appearance was typical of a seborrheic keratosis. Her visual acuity and eyelid movements were normal.
The procedure is performed under local anesthesia with intravenous sedation and magnification. Upper eyelid tumor is marked with 2 mm margin. A line is drawn on the eyelid at the level of the lid crease. Then, the advancement flap of the anterior lamella is outlined with two Burow’s triangles marked for excision, one triangle medial or lateral to the defect and the second diagonal to the first, above the lid crease (Figure 2 ). An incision is then made through the skin and the subcutaneous tissue of the lesion. The lesion was excised with a 2 mm free margin. The triangles’ boundaries are cut with a scalpel, dissected, and mobilized with blunt scissors (Figure 3A ). The subcutaneous tissue at the edges of the defect is undermined in the subdermal plane to minimize the tension at the suture lines. An advancement flap of the skin and orbicularis of the upper eyelid was undermined, elevated, and advanced inferiorly over the defect (Figure 3B ). Interrupted buried 6/0 nylon sutures are used to approximate the dermis and subcutaneous tissue and close the defect completely (Figure 4 ). Topical antibiotic ointment is applied twice daily for 7 days. The sutures are removed in 10 days. Histopathological examination of the tumor revealed seborrheic keratosis and confirmed that the margin was free of tumor. The patient has been followed up for six months with no evidence of recurrence and has no concerns with eyelid function. Moreover, this treatment produces good aesthetic

[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 47-year-old right hand dominant male working as a stable hand presented to the emergency department of a tertiary trauma and orthopedic referral center following a crush injury to the left hand. The injury had occurred while the patient had been assisting a friend to park a 4 × 4 vehicle. The vehicle had been reversing slowly towards a wall with the patient's hand behind the vehicle. The mechanism of injury suggested axial loading of the thumb between the vehicle and the wall. He presented directly to the emergency department with severe pain, swelling, and an obvious deformity at the wrist. The patient had no background medical or surgical history of note and reported no previous injuries to the affected limb. He was an active smoker of 30 cigarettes per day.
On examination in the emergency department, he had significant pain and swelling in the left wrist and forearm. There was a superficial abrasion over the dorsal aspect of the affected hand; however, this was considered to be a closed injury. There was significant tenderness over the carpals, particularly at the trapezium, with associated reduced range of motion at the wrist and thumb. There was no neurovascular compromise or associated tendon injury.
The AP radiograph reveals disruption of the continuation of arc I between the proximal border of the triquetrum and the proximal border of the trapezium, with the trapezium displaced in a radial direction (). This represents a volar dislocation of the trapezium. There was no associated fracture of the trapezium or any other associated bony injuries.
The patient subsequently underwent closed manipulation under general anesthesia. The surgeon achieved anatomical reduction by gripping the patient's thumb in one hand and applying a distracting force, while simultaneously applying pressure on the radial aspect of the trapezium with the thumb of the surgeon's other hand. The trapezium was stabilized with three 1.6 mm Kirschner wires percutaneously inserted from the ra

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


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

[User]
RADIOLOGY NOTE:
A 56-year-old male presented to a hospital in Togo, West Africa, with a long-standing swelling on the left lower leg, which progressively increased in size over time. He had a wide local excision done following a confirmatory biopsy for dermatofibrosarcoma protuberans (DFSP). No adjuvant therapy was recommended on account of clear surgical margins and the absence of distant metastases. The lesion recurred after two years and re-excision was performed. A second recurrence occurred in a year, which involved the knee joint, necessitating a transfemoral amputation. The surgical margin was clear and there was no evidence of distance metastases. He was rehabilitated and started walking with a prosthetic limb.
Two years after the second recurrence, the disease recurred in the left lower limb stump. At this point, a re-biopsy was done and DFSP was confirmed (Figure ). There was no fibrosarcomatous transformation. Immunohistochemistry was positive for CD34 (Figure ), focally positive for actin, and negative for desmin and S100 protein. Metastatic workup, consisting of chest X-ray and abdominal ultrasound, was negative. He commenced imatinib mesylate at a recommended dose of 400 mg twice daily. The recurrent lesion on the left lower limb stump gradually progressed in size after five months of imatinib mesylate treatment, and he eventually developed multiple lesions on the posterior torso.
He was then referred to the National Radiotherapy Oncology and Nuclear Medicine Centre, Korle-Bu Teaching Hospital in Accra. Physical examination showed a 15 x 12 cm mobile mass on the left lower limb stump and two palpable, firm, and fixed lesions on the posterior torso; the largest measuring 9 x 7 cm in size. There was no other clinical or radiological evidence of distance metastases. The decision was made to treat him with palliative radiotherapy to relieve pain in the left lower limb stump and to enable him to use the prosthetic limb.
Six months after stopping imatinib mesylate, he recei

[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 male with hypertension presented to emergency room with light headedness and hypotension. Initial blood pressure was 80/50 mmHg and heart rate was 70 beats/minute. Electrocardiogram revealed evidence of tall R waves in lead V1-2 []. Troponin I level was 11.9 ng/mL. An emergent echocardiogram revealed a large pericardial effusion with fibrinous material []. Patient denied any other complaints including chest pain or dyspnea and wished to be discharged home. He did mention that he had an episode of chest pain 1 week earlier that resolved spontaneously and he did not seek medical care. Based on electrocardiogram and echocardiogram findings, we suspected patient suffered a posterior myocardial infarction which was complicated by contained free wall rupture and pericardial effusion. Based on the high index of suspicion, patient was taken for emergent coronary angiography which revealed 100% circumflex occlusion and right heart catheterization was consistent with tamponade physiology. Left ventriculogram showed an ejection fraction of 40% with staining of postero-basal wall suggestive of possible cardiac rupture. Patient underwent emergent percutaneous coronary intervention to the left circumflex along with placement of an intraaortic balloon pump, and emergent pericardiocentesis with removal of 50cc of hemorrhagic fluid. This led to hemodynamic stabilization. Limited pericardiocentesis was done to prevent dislodgement of the clot which may be tamponading the ruptured site. Patient was then taken to operating room immediately. Intraoperative a large amount of hemorrhagic fluid with clot was removed. The infarcted posterior myocardium showed necrosis and hemorrhage with multiple puncture sites leaking/oozing blood. A large patch was created with combination of Bio Glue and patient's own pericardium. This was glued onto the posterior wall and then sewn with a running 5-0 Prolene reinforced with multiple pledgeted 5-0 Prolene circumferentially around the poster

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


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

[User]
RADIOLOGY NOTE:
A 70-year-old male presented with severe dyspnea and general weakness on March 8, 2013. He was referred from a local hospital for pericardiocentesis and further work-up due to a large pericardial effusion. He had a past medical history of ischemic stroke 15 years prior to his visit to the hospital and of syncope a day before his visit to the hospital.
The vital signs of the patient in the Emergency Room (ER) were as follows: blood pressure of 163/93, heart rate of 135 beats per minute, respiratory rate of 30 breaths per minute, body temperature of 37.0°C, and oxygen saturation of 91%. The patient had distended neck veins and muffled heart sounds but did not have low blood pressure. Echocardiography was performed by an emergency physician, and a right ventricle (RV) free wall collapse in was observed in the diastolic phase. An emergency pericardiocentesis was indicated, and it was performed by a subxiphoid approach. Approximately 700 mL of serous effusion was drained through a catheter; the patient’s heart rate dropped to 110 and his blood pressure was maintained above 130. The follow-up echocardiography showed the absence of RV wall diastolic collapse. A water-sealed chest tube bottle was connected at the end of the catheter for further drainage.
The patient was transferred to a computerized tomography (CT) room for a chest CT to examine the cause of his pericardial effusion. Before he left the ER, his vital signs were stable and he was alert. After the patient returned to the ER from the CT room, his heart rate fell to 30, and he exhibited impending cardiac arrest. An intravenous dose of 0.5 mg atropine was given, and the patient was hydrated with crystalloid solution. The patient’s chest CT confirmed tension pneumopericardium, and imaging showed that pericardial air was compressing the right ventricle and that the catheter tip was placed behind the left ventricle (LV) (). Approximated

[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 32-year-old woman presented with 8 years of progressive right-sided subscapular thoracic pain incited by lifting her arm above her head. This pain became more frequent and began to occur spontaneously, disrupting her sleep and causing her significant difficulties. Two MRI studies were performed during this time, the first in 2004 and the second in 2009, and she was told that the findings were unremarkable. When she presented to our institution, she had severe, mechanically reproducible pain located several inches to the right of her mid-thoracic spine. The pain also radiated both up to the axilla as well as down the right leg. A review of outside MRI studies revealed a lobulated, T1 isointense, mildly T2 hyperintense, 3 cm enhancing mass involving the right T5 nerve root through the foramen with extension into the paraspinal muscles []. These imaging characteristics were most consistent with a schwannoma or another nerve sheath tumor since there was little change on interval exams that were 5 years apart.
As it was felt that this symptomatic lesion was likely benign and easily accessible, resection was advised. Intraoperatively, the mass was identified in the erector spinae muscles of the T4-7 region on the right side. The tumor was mobilized and gross total resection achieved, including the foraminal component. However, intraoperative pathology revealed a spindle cell sarcoma rather than a benign process, necessitating extension of the surgical resection. A T5-6 laminectomy was then performed, the dura incised, and the entire nerve root in the foramen of presumed origin was resected until negative dural margins were achieved. After the dural closure, all grossly visible tumor appeared to have been removed from the region and surrounding tissues. Final pathology showed a high-grade, fibrous-type, monophasic SS. The patient tolerated the surgery well and was neurologically intact.
Concern for residual tumor remained as postoperative imaging studies demonstrated

[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 anuric 60-year-old woman with diabetic nephropathy had been treated for four months by continuous ambulatory peritoneal dialysis (CAPD) with four daily exchanges and 2.0 L fill volume. She had a history of coronary artery disease with an anterior myocardial infarction seven months prior to the start of CAPD, followed by severe congestive heart failure with an ejection fraction of 23%. Her dry weight, documented one month after the start of CAPD by absence of both edema and hypertension, was 41.2 kg. Her height was 149 cm. She had not been seen by her CAPD providers for three months because of transportation difficulties when she was admitted with grand mal seizures followed by coma. One week prior to this admission, she communicated by telephone call with one provider. At that time, she reported total body swelling, moderate dyspnea and a body weight exceeding 70 kg. She was advised to use exclusively hypertonic dextrose (4.25%) CAPD dialysate and add two exchanges per day with short (1 hour) dwell times. Information obtained from relatives revealed that in the two days prior to this admission she had omitted her insulin dose because of anorexia and greatly decreased food intake.
On admission, she was comatose with a blood pressure of 180/74 mm Hg, regular pulse rhythm with a rate of 110 beats per minute, and temperature of 36.5 degrees Celsius. Her weight was 63.6 kg. Remarkable findings on physical examination included anasarca detected even in her scalp, a ventricular gallop, and crackles in both lung fields. Chest X-ray confirmed the presence of pulmonary edema and electrocardiogram was unchanged from recent tracings, which were consistent with old transmural myocardial infarction. Laboratory tests on admission revealed extreme hyperglycemia, severe hypertonicity, hypokalemia and respiratory acidosis.
Over the next 30 hours, she received insulin boluses and had frequent (every 2-4 hours) determinations of serum glucose and potassium concentrations. Serum gluc

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


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

[User]
RADIOLOGY NOTE:
In June 2017, a 15-year-old boy was admitted to the emergency department following blunt abdominal trauma after being hit by a car while he was observing a car race.
The patient was intubated and was haemodynamically stable (blood pressure 100/60 mmHg, pulse rate 88/min); therefore, laboratory tests and CT-scan were performed.
The computed tomographic scan of the thorax and abdomen showed bilateral pleural effusions with rib fractures and a large haemoperitoneum associated with a traumatic rupture of the spleen with multiple injuries (grade III of the Organ Injury Scale, of AAST []) and a 7-cm mass at the left side of the retroperitoneal space (Fig. ). A thoracic drain was inserted on the left side of the thorax, and non-operative management for the spleen started.
Haemoglobin decreased from 14.4 to 8.9 g/L during hospitalization with four hours of conservative treatment, with appearance of haemodynamic instability that was considered an indication for surgery.
An incision was made on the midline. The abdomen was packed and explored. The operation began with clearance of the haemoperitoneum. The spleen appeared with multiple longitudinal lesions in the visceral aspect. It was gently grasped and displaced medially towards the incision. The avascular peritoneal attachments and ligaments are incised with by electrocautery, followed by dissection of the splenogastric ligament and ligation of the short gastric vessels near the spleen to avoid injury or late necrosis of the gastric wall. The splenorenal, splenocolic and splenophrenic ligaments were divided. To avoid pancreatic injuries, dissection was carried out in close proximity to the hilum of the spleen, where the splenic artery and veins were identified, carefully dissected, doubly ligated and fixed with suture ligatures. After removal of the spleen, haemostasis was obtained and confirmed in a systematic fashion through careful inspection of the left subphrenic area, the greater curvature of the stomach and the shor

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


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

[User]
RADIOLOGY NOTE:
A 58-year-old designated female at birth with a past medical history of insomnia and depression who presented to clinic requesting HIV pre-exposure prophylaxis (PrEP), because he anticipate having new sexual partners soon. He is not currently sexually active. He is open to multiple types of sexual encounters, but has no planned partner and is not sure yet what sexual practices he will participate in. He achieved appropriate developmental milestones as a child. The patient wanted to transition 16 years back but a lack of awareness of medical and surgical interventions available and resources held him back. He came through with his decision to transition 15 months ago with a good support system around him. The patient has no prior history of cerebrovascular accidents, thromboembolism, myocardial infarction, seizures, or fractures. He is currently using three pumps of topical 1.62% 20.25 mg testosterone per day and has been on testosterone for 15 months. He is tolerating it well without any side effects. He denies any alcohol use and smokes half a pack per day of cigarettes. Current medications apart from testosterone include vitamin D supplements, melatonin, folic acid, and magnesium oxide.
His hemoglobin was 14.7 g/dL and hematocrit was 44%. The patient’s creatinine increased since the initiation of testosterone therapy. Creatinine before starting hormonal therapy was 0.9 mg/dL, and the recent laboratory findings showed creatinine of 1.2 mg/dL. Liver function tests were all within a normal range. The HIV antibody test, gonorrhea, chlamydia, and syphilis screen were negative. The urinalysis showed that the urine culture was negative and renal ultrasound showed normal size kidneys with no hydronephrosis.
Given the patient’s age of 58, the weight of 147 pounds, and using the birth gender, the estimated creatinine clearance of 48 mL/min was calculated per Modification of Diet in Renal Disease (MDRD) and 52 mL/min per Chronic Kidney Disease Epidemiology Collaboration (CKD

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


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

[User]
RADIOLOGY NOTE:
A 68-year-old man was referred to our institution with a diagnosis of rectosigmoid colon cancer. Colonoscopy revealed a type 2 tumor at the rectosigmoid colon (Fig. a). Right hemiparesis was present as a result of two cerebral infarctions that had occurred during the 2 months prior to his first admission. After consultation with a neurologist, we considered that it was necessary to wait several months before performing a major operation due to the risk of inducing another cerebral infarction. However, advanced cancer would be expected to grow during the waiting period. We therefore considered that it was necessary to administer systemic chemotherapy to suppress tumor growth. We initially administered five courses of preoperative chemotherapy (mFOLFOX6). No cerebral events or severe adverse events occurred during the chemotherapy. Stable disease, according to the RESIST criteria, was achieved with the preoperative chemotherapy. A laparoscopic Hartmann’s operation with D3 lymph node dissection was performed at 4 weeks after the last course of chemotherapy. The patient’s postoperative course was good without any complications. The final diagnosis of the rectal cancer was Dukes B with well-differentiated tubular adenocarcinoma and rectal tumor invasion to the subserosa (T3) without lymphatic or venous invasion (Fig. b). The resected specimen was free from cancer cells. The patient had complained of a perianal abscess for 5 years before his first admission. However, we gave priority to treating the rectal cancer. Although his anal symptoms did not worsen during chemotherapy, at 1 month after the Hartmann’s operation for rectal cancer, his perianal abscess worsened and induration with two secondary open lesions was detected on physical examination (Fig. a). The pathological examination of the biopsied perianal tissue revealed adenocarcinoma. Because the perianal tumor was localized without invasion of the neighboring tissue on magnetic resonance imaging findings (Fig. b),

[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 White man, having previously undergone right hemicolectomy for colon cancer and with no chronic drug use or any other comorbidities, was admitted to the emergency department of a level-2 hospital for bowel obstruction and was immediately referred to the operating theater to undergo laparoscopic viscerolysis. The postoperative course was complicated on the sixth postoperative day by obstructive cholangitis with jaundice in the presence of bile sand and suspected choledocholithiasis; accordingly, antibiotics were prescribed, and endoscopic retrograde cholangiopancreatography (ERCP) was scheduled to be performed a few days later. Nine days after surgery, he was in good clinical condition. ERCP was performed using a conscious sedation technique; however, during the procedure, the patient suddenly experienced hypoxemia, tachycardia, and hypotension. Because aspiration of gastric contents was diagnosed, tracheal intubation was performed immediately, fluid resuscitation and continuous infusion of norepinephrine was initiated, and the patient was promptly transferred to the intensive care unit (ICU). For the sudden onset of severe ARDS, the patient was sedated and paralyzed to start lung-protective ventilation (LPV). A few hours after ICU admission, the patient experienced further worsening of MOF, and ICU medical staff decided to refer the patient to a level-1 hospital with an ECMO facility. Approximately 6 hours after massive aspiration, the patient was admitted to the authors’ level-1 trauma center hospital, and the ECMO team provided a consultation service in accordance with institutional criteria.
The patient arrived at the first evaluation with the ECMO team having undergone maximal medical treatment including deep sedation with neuromuscular blockers, mechanical ventilation over the limits of LPV [], and continuous infusion of vasoactive and inotropic drugs to support circulation. Blood gas analysis revealed a pH of 6.9, a base excess of −11.4 mmol/L, 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 55-year-old, postmenopausal hypertensive woman presented with pelvic pain in surgery outpatient department. Her history dated back to year 2002 when she had a total hysterectomy with bilateral salpingo-oophorectomy for uterine fibroid at a private hospital. Her follow up was uneventful until next 3 years when she was operated for a pelvic tumor in a private hospital, which was locally adherent and was resected with sleeve resection of rectum, bladder, and vaginal vault. On histopathology, gross inspection revealed 3 well encapsulated masses largest measuring 17 cm, and the other two measuring 2 cm in diameter. Cut section was partly solid and partly cystic with solid areas revealing areas of whorling while the cystic component was filled with mucoid material. The histopathological impression was leiomyomata in pelvic cavity, with focal cystic and hyaline degeneration. She was again disease free for the next 3 years, then she was diagnosed with and operated for infiltrating duct carcinoma breast, positive for hormone receptors, estrogen and progesterone, while negative for Her 2/neu. In 2011 she again presented with lower abdominal pain. Her ultrasonography abdomen showed hypoechoic lesions of 3.77 × 2.43 cm in size in right iliac fossa and 2.04 × 1.28 cm in left iliac fossa. Another hypoechoic lesion 3.21 × 1.81 cm anterior to urinary bladder was also seen. On contrast enhanced computed tomography (CECT) two enlarged lymph nodes were seen in right pelvis, one anterior to bladder and one in left pelvis measuring 28 × 20 mm and 31 × 30 mm in size, respectively. Liver revealed mild fatty change. Gall bladder, pancreas, spleen, and bilateral kidneys were normal. No free fluid was present. Uterus was not visible. Her coagulation profile, liver function test, serum biochemistry, and bone scan were normal. She was nonreactive for HCV, HIV, and HBsAg. Her CA 125 level was raised to about 4 times (170 units/mL). An abdominal laparotomy was done

[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 case involves a 15-year-old male patient with no pertinent orthopaedic past medical or surgical history. He sustained an initial injury to his left hip six weeks prior to presentation following a direct lateral impact during a lacrosse match. The patient felt pain but was able to return to play. Two weeks later, he was running in a lacrosse match and sustained a non-contact left hip injury. He was unable to ambulate and was taken by ambulance to the emergency room, where he was diagnosed with a posterior hip dislocation. He underwent uncomplicated closed reduction within two hours of the injury and was referred for follow-up to the senior author’s practice. Upon examination, his left hip had good range of motion, demonstrated no joint laxity and had a negative dial test. There was no laxity in his elbows, wrist, hands or knees. His hip range of motion was symmetric to his contralateral side with internal rotation to 10 degrees and external rotation to 65 degrees. His radiographs showed a concentric reduction with no fracture (). He was instructed to limit weight bearing to 30% for 4 weeks, and to start a physical therapy program focusing primarily on hip stabilization and gluteus medius activation. He was also given standard instructions for posterior hip precautions to limit flexion to 90 degrees, adduction to neutral and to limit internal rotation. He was not braced, and the risks of avascular necrosis were discussed. He was instructed to follow-up with our clinic in 6–8 weeks.
Approximately 4 weeks after his clinical evaluation, he dislocated his hip in his sleep. He was evaluated in the Emergency Room where a magnetic resonance imaging (MRI) scan was ordered due to the lack of clinical suspicion for hip dislocation. It showed the left hip to be dislocated posteriorly with the ligamentum teres absent (). The hip was reduced with closed reduction techniques, and he was instructed to follow-up with our clinic. Radiographic evaluation in our clinic showed

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


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

[User]
RADIOLOGY NOTE:
A 23-year-old male presented to our oral health center with the complaint of unpleasant smile. He had an accident 8 years ago while he was playing a basketball, which caused his upper front teeth to be intruded and discolored. The patient was referred for diagnostic intraoral periapical radiograph. The X-ray showed that both the upper left central and right lateral incisor teeth were treated with root canal therapy. Furthermore, the upper left central tooth suffered a major external root resorption []. Using digital smile system software DSS (DSS v1.9.4, Just digital company, Italy), the smile has been analyzed. Moreover, digital mock-up was designed to assess the space availability and the need for ridge augmentation []. After a multidisciplinary discussion, a decision was made to extract the upper right central incisor, augment the defected socket as well as compensating the expected deficient soft tissue with PRF, and then provide the patient with a layered zirconia dental bridge incorporating into design an ovate pontic.
Teeth preparations were carried out for both the upper left central and right lateral incisor teeth adjacent to the tooth to be extracted. An irreversible hydrocolloid impression of the maxillary arch including both the teeth prepared and the tooth to be extracted was made. The upper right central was scored off from the poured cast making 3 mm depression simulating the postextraction socket. Moreover, to simulate the gingival volume expected to be gained postplacement of PRF membrane, plaster of Paris has been added to the labial gingival margins. Provisional dental bridge was fabricated using Protemp™ 4 Temporization and RelyXTM [].
A volume of 20 cc of the patient's own blood was drawn to prepare the PRF before the extraction of the indicated tooth. The upper right central was extracted atraumatically taking great care to preserve both buccal and lingual plates. The extracted socket was debrided from the remnant granulation tissue

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


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

[User]
RADIOLOGY NOTE:
An 81-year-old female with a medical history of CAD with stents, hyperlipidemia, hypothyroidism, GERD, recent UTI, pancreatic cyst, constipation, anemia and leukopenia presented to the ED with a 1 day history of mild, diffuse and cramping abdominal pain. The patient was unable to give an accurate history, but the son at bedside supplemented this reporting that for several years the patient had been experiencing ill-defined abdominal discomfort. Physical exam showed a soft abdomen with mild tenderness and no evidence of peritonitis. A CT scan of the abdomen and pelvis with IV and PO contrast (Fig. ) showed edematous changes to the mesentery of the small and large bowel with swirling of vessels indicative of internal hernia. The stomach was also noted to be distended with both air and fluid as a consequence of posterior compression by the hernia contents (Fig. ). A surgical consult was obtained, a nasogastric tube and Foley catheter were placed, antibiotics were started, and the patient was taken for an exploratory laparotomy. Upon entering the abdomen through a vertical midline incision, 1.5 l of ascites was drained revealing a diffusely edematous mesentery. A large portion of the small bowel was seen to be herniated through the Foramen of Winslow (Fig. ). A Kocher maneuver and division of the gastrocolic ligament were then performed to allow release of the herniated small bowel. It was at this time that, in addition to small bowel, a large portion of the ascending and transverse colon was noted to be herniated through the foramen of Winslow. The small bowel was also seen to be torsed about its own mesentery. Normal anatomy was restored and the bowel noted to be healthy and viable with peristalsis (Fig. ). Due to the large size of the foramen after reduction and enlargement, it was deemed best to leave it open to prevent any further incarceration or strangulation. The abdomen was closed and 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.