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

[User]
RADIOLOGY NOTE:
The patient was a 75-year-old woman, who had developed left shoulder pain five years earlier without any known precipitating factor. She presented to our department because of gradual difficulty in raising her left arm and worsening pain. Physical examination on presentation did not reveal any swelling or feeling of heat in the left shoulder. The range of motion of the left shoulder showed extremely severe restriction; namely, flexion 80°, abduction 60°, and external rotation 0°, and prominent impingement symptoms were found. On plain radiographs and computed tomography (CT), prominent shoulder arthropathic changes and numerous calcified lesions around the joint were found. On plain magnetic resonance imaging (MRI), around the shoulder an irregular hypointense region was identified in the center on T1-enhanced images and on T2-enhanced images (). Routine blood examinations did not reveal any obvious abnormalities. This patient was diagnosed with synovial osteochondromatosis associated with a massive tear of the rotator cuff and shoulder arthropathic changes, for which the treatment RSA was chosen.
Intraoperative findings: A delto-pectoral approach was used. Full-thickness tears of the supraspinatus and infraspinatus tendons were found. When the joint capsule was incised, synovial proliferation and a whitish mass-like lesion, seemingly adherent to the synovium, were found. The intraarticular mass was resected to the extent possible, but the cartilage in the humeral head was severely damaged, while that in the glenoid cavity had almost disappeared. After loose body resection, RSA was performed.
The postoperative course was uneventful, with the left shoulder pain disappearing from early in the postoperative period. At one year postoperatively, there was no recurrence of pain and the left shoulder range of motion showed improvement to flexion 140°, abduction 130°, and external rotation 30°. Moreover, no complications such as recurrence of osteochondromatosis, implant lo

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


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

[User]
RADIOLOGY NOTE:
A 67-year-old woman was referred to the Department of Maxillofacial Surgery of the Galeazzi Orthopedic Institute five years after the diagnosis and treatment of a mandibular carcinoma. The clinical history of the patient was rather complex.
In 2012, after a dental visit due to periodontal disease of frontal inferior teeth, the patient underwent a computerized tomography (CT) scan that revealed the presence of an osteolytic lesion in this site (). A preoperative histopathological examination revealed an intraosseous squamous cell carcinoma. The medical history data of the patient revealed no systemic diseases or smoking habits. The patient was treated with surgical removal of the lesion through subtotal mandibular resection, associated with a temporary tracheostomy, bilateral lymph node neck dissection and fibula free flap reconstruction (). After flap failure, a second fibula free flap was performed, but this again failed. Seven months later, a spontaneous internal jugular vein and external carotid artery laceration was treated by vessel ligation. The pectoralis flap was then used to supply soft tissue defects. Oncological follow-up observed a recurrence nineteen months after the first surgery. Multiple cycles of chemotherapy and monoclonal therapy were then administered. Radiotherapy was refused by the patient.
The first clinical evaluation in our department revealed an important deformity in the inferior third of the face associated with swallowing and language deficiency caused by tongue hypomobility and lower lip paralysis, incontinence, and incompetence. Feeding was possible only with percutaneous endoscopic gastrotomy. Further reconstructive treatment with free flaps was contraindicated. Therefore, it was decided to reconstruct the mandible with a CAD/CAM technique and with a custom-made DMLS titanium implant. The patient was informed about the procedure in full detail and signed an informed consent form dedicated to this therapy. The study protocol was approv

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


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

[User]
RADIOLOGY NOTE:
An 88 year-old Caucasian female was seen by the neurosurgical service with worsening pain between her scapula and difficulties ambulating. She had had upper back pain for several months. She underwent work up with plain films which did not show any abnormalities, and had been managed conservatively by pain management clinics. Over the past 4 weeks, she had developed progressive lower extremity weakness, requiring a walker for ambulation. She was admitted to hospital for medical management of her back pain and over the course of the next 48 hours, she had subjective worsening of her lower limb weakness. A review of systems was negative for malignancy or B-type symptoms.
Physical examination was negative for lymphadenopathy. Neurologic examination was significant for a positive Rhomberg’s sign and decreased pinprick sensation in both legs extending to the hip (approximately to the L2 distribution). She had loss of proprioception in all extremities. Rectal tone was normal. Toe responses were described as extensor on the left and equivocal on the right. Blood panel showed normal values apart from slight anaemia and mildly elevated platelets.
Since plain films had been normal, an MRI of the thoracic and lumbar spine was ordered, showing an epidural lesion from T2 to T4 levels (Figure A) with involvement of the posterior left T4 vertebral body (Figure B), posterior elements of T2 and T3, as well as extension through the left T2-3 and T3-4 neural foramina (Figures C & D). The lesion caused significant cord compression with evidence of mild cord edema.
The patient was taken urgently to the operating room for a decompressive laminectomy from T1-T4. The epidural mass was diligently resected to decompress the cord. Frozen tissue histology confirmed a malignant infiltrative tumor initially suggestive of a carcinoma, which prompted us to also excise the surrounding involved paraspinal tissues. Given her advanced age, extensive tumor burden, and preexisting comorbidities,

[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 woman presented with large palpable mass on the left side of the abdomen with dull aching pain in the flank and abdomen. Surprisingly, she had noticed the mass one month earlier on turning or bending forward. She had no haematuria, fever, or history of bowel disturbances. Previous medical history was not significant.
On examination, vitals were within normal limits. Physical examination revealed a firm multinodular, mildly tender mass in the left hypochondrium extending up to left iliac, left lumbar, and umbilical region. The mass moved with respiration. No other organomegaly was present. Laboratory investigations revealed normocytic hypochromic anaemia with a raised ESR. Serum chemistry levels were normal. Urinalysis showed 2–5 polymorphonuclear cells per high power field without any evidence of microscopic haematuria.
Abdominal ultrasonography showed a large heterogenous mass originating from lower half of left kidney and occupying more than three fourths of it. A portion of uninvolved left upper pole showed hydronephrotic changes. Computed tomographic scan revealed a large left renal mass without any vascular or hepatic metastasis. There was no calcification in the lesion. A provisional diagnosis of renal cell carcinoma was made. Left radical nephrectomy and left hemicolectomy revealed a renal mass adherent to descending colon. The tumor appeared to completely replace the kidney and was adherent to the colonic segments.
The excised mass measured 20 × 16 × 12 cms. Adherent colonic segments measured 12 cms in length. The tumor was bulky, had a nodular, lobulated external surface, and almost completely replaced the left kidney. Only a small portion of dilated appearing kidney measuring 3 × 4 cms was seen on cut section. Cut section also revealed a fleshy tan white mass with areas of necrosis, cystic degeneration, and haemorrhage []. The tumor was separated from the adjoining renal parenchyma by a capsule. The capsule was invaded at places by the tumor.

[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 man of Indian ethnicity, presented to the outpatient department of general surgery with lower abdominal distension for the past one and a half months and a continuous dull aching lower abdominal pain for past 15 days. Patient was a chronic smoker and gave no history of trauma, anorexia, weight loss, altered bowel habits, vomiting, fever, or any urinary symptoms such as hematuria. On examination, patient was moderately built, and abdominal fullness was apparent on inspection, more so in the left lower abdomen. A vague mass of approximate size of 20 × 15 cm was palpable, extending from left iliac and left hypogastrium to umbilical region, crossing the midline and reaching up to right midclavicular line at the level of iliac crest. The lump had a smooth surface, ill-defined margins and lower margin could not be reached on palpation. The lump was nontender with firm, cystic consistency, and restricted mobility in all the directions. There was no inguinal lymphadenopathy and digital rectal examination was unremarkable. Patient was further investigated for differential diagnoses of mesenteric cyst, pancreatic pseudocyst, duplication cyst, or cystic metastasis. Ultrasound abdomen showed a large cystic lesion with multiple septae, left to the urinary bladder in the pelvis. Liver, spleen, pancreas, and bilateral kidneys were within normal limits. A contrast enhanced computed tomography (CECT) scan of abdomen and pelvis showed a large 14.4 × 14.6 × 9.2 cm multilocular cystic mass with enhancing septations and lobulation, occupying the left side of abdominal cavity extending downwards into the pelvis and displacing the gut loops and the urinary bladder to the right side. Mass was encasing the left iliac artery and there were no enlarged lymph nodes in paraaortic and pelvic region. The attenuation coefficient of the mass was in the +10 to 15 HU range. There were no ascites and no evidence of small or large bowel obstruction ().
A fine needle aspiration cytology 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 29-year-old female patient with end stage renal failure was our recipient. She was considered for a pre-emptive transplant and the only viable living donor was her 59-year-old mother. Upon evaluation for the donor, all the criteria were met except for the detected horseshoe kidney by CT scan. Dynamic CT revealed one renal artery and one renal vein for each side, a long but thin isthmus connecting lower poles with no visible arterial supply (). Sizes of the left and right kidneys were 110 × 38 cm and 117 × 42 cm, respectively. Absence of a connecting caliceal system was established with a descending urography. We did not perform a dynamic renal perfusion scintigraphy to assess the split functions of the kidneys since their sizes, respective vasculature and measured GFR values indicated sufficient capacity for each kidney. Left portion of the kidney was considered for nephrectomy.
With a left subcostal incision transperitoneal exploration was performed. The left kidney had indeed one renal artery and one renal vein. There were two ureters for the left kidney. The vessels, ureters were prepared and the kidney was mobilized up to the isthmus. A temporary bulldog clamp was put on left renal artery to determine the demarcation zone and it was shown to form around isthmus (). The artery and vein were divided and the isthmus separation was performed with a 60-mm Endo GIA Black stapler (Medtronic, USA) (). After separation, no bleeding and no urine leakage were detected from transacted surface of the remaining kidney.
The graft was perfused with cold lactated ringer–prilocaine–heparin solution. There were no visible leaks (). It was transplanted to right iliac fossa of the recipient. Total cold ischemia duration was 21 min. Ureters were anastomosed to bladder separately side by side. Patient received tacrolimus, mycofenolic acid and methylprednisolone treatment. No collection was formed on the postoperative period, drain creatinine sampling

[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:
Woman 52 year old with severe grade III APLD came in consultation. She was also aware of her familiar condition. Liver transplantation was offered to her in another center but she refused. Previous MRI from another center showed multiple giants cysts compromising the whole abdominal cavity. Cysts reached hypogastric area and both inferior quadrants. Higher segments of the liver seemed to be respected. Globulous deformation of the abdomen was clearly observed. Despite aesthetic and mild abdominal pain symptoms were not as significant as they were in her two sister so she did not want to underwent liver resection too. However she kept coming to consultation every six months.
Two years later she came back presenting jaundice with serum levels of FAL>1700 mg/dl. Bilirrubin 9,8/7,9 mg/dl. New MRI showed cyst compression of the hepatic pedicle including common bile duct and portal vein ( A and 3B)
Surgery was soon programed and approach was discussed. We decided laparoscopic approach but being aware room will be very reduced even after pneumoperitoneum. We decided to start by performing aspiration and evacuation of the big lower and anterior cysts to intend reducing the mass and make new space for the laparoscopic procedure. By performing this gesture followed by several fenestration and partial cysts resections space was increased within the abdominal cavity so laparoscopic liver resection could be then performed. Once gallbladder was located, we then identified two cysts that seemed to be responsible for hepatic pedicle compression. Fenestration was done and, then, intra-operative cholangiogram showed no further compression of the common bile duct with adequate passage of contrast to duodenum. Standard cholecystectomy was completed and later laparoscopic left lateral sectionectomy was done in association with several more cyst fenestration. Post-operative course was un-eventful and patient was discharged at 6th day with decreasing levels of FAL and bilirubin. Late follo

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


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

[User]
RADIOLOGY NOTE:
A 57-year-old Chinese female was referred to National University Hospital, Singapore in February 2016 for management of a hard swelling over her right TMJ. This patient suffered from chronic right TMJ pain for more than 5 years. She had consulted several physicians over the past few years, but could not obtain a definitive diagnosis. There was no prior treatment provided. Her past medical history includes surgical excision of left breast fibro-adenoma, recurrent upper urinary tract infection, stress urinary incontinence and infective colitis. She was on active follow up with the Otolaryngology department for hoarseness of voice. She was a non-smoker and non-drinker. There was no known history of any genetic disorder. The patient denied any history of trauma or infection to the jaw area. There were no other family members with a history of temporomandibular joint or jaw swelling.
On examination, a localized swelling was palpable over the right pre-auricular region which measured 15 mm by 20 mm. It was tender upon palpation and had a bony hard texture. The swelling appeared distinct from the TMJ capsule as it did not move when the right mandibular condyle translated anteriorly during mouth opening. On maximal mouth opening, the condylar translation at both TMJs was similar. The maximal mouth opening was normal. The overlying skin was normal in consistency and was not fixed to the swelling.
A series of lab tests were ordered, including liver function test, renal function test and complete blood count. All results were being found to be within normal ranges. A dental panoramic tomogram (DPT) was taken (Fig. ), but no distinct lesion could be observed at the right TMJ. Unenhanced computed tomography (CT) was taken subsequently (Fig. a-b). It revealed a sharply defined hyper-dense benign-looking ovoid mass measuring 10 mm by 13 mm by 20 mm within the subcutaneous layer over the right pre-auricular region. It was closely associated with the lateral aspect

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


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

[User]
RADIOLOGY NOTE:
A 38-year-old woman, gravid 0, underwent freeze-thaw embryo transfer due to a male sterility complication. She became pregnant and had no complications other than a 4-cm diameter fibroid in the anterior wall of the uterus. Her pregnancy progressed uneventfully though posterior wall low-lying placentation, but not placenta previa was noted. She underwent routine examinations at 33 weeks of gestation, and transvaginal ultrasonography revealed abnormal blood flow at the cervical region. She underwent MRI (Figure ), which also revealed abnormal findings. She was estimated to have a high risk of massive obstetric hemorrhage though a precise diagnosis could not be obtained. She was transferred to the maternal-fetal intensive care unit in our hospital.
Radiologists in our hospital interpreted the MRI as either invasive placentation into the cervix or cervical vascular anomalies, though they had never seen images like these. An expert opinion of the transvaginal ultrasonography finding (Figure ) was as follows. The cervix was open. Placental parenchyma was low lying but not covering the internal os. The placental marginal sinus seemed to descend through the opened cervix to the external os. Vessels at the posterior cervix wall were enlarged, and no direct connection was found between the vessels and the descended marginal sinus.
The woman and her family consented to Cesarean hysterectomy if necessary. Late preterm cesarean delivery was performed at 36 weeks and 2 days of gestation to avoid emergent cesarean hysterectomy in case of invasive placentation with massive bleeding. A male neonate weighing 2774 g was delivered. Apgar scores were 7 (1 minutes) and 9 (5 minutes), and umbilical artery pH was 7.340. The placenta did not separate naturally 15 minutes after birth. Hysterectomy was conducted without manual removal of the placenta. Operating time was 2 hours 3 minutes and total blood loss amounted to 1412 g. The patient recovered smoothly after surgery.
In examining the re

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


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

[User]
RADIOLOGY NOTE:
The patient is now an 18-year-old. He was referred at 3 years of age with a complaint of a chronic wound in the medial region of the right thigh and systemic symptoms, including lethargy, weight loss, and intermittent fever since 2 months prior. The lesion was initially a small red ulcer, which rapidly progressed in size with yellowish nonpurulent bloody discharge. Initially, the patient was hospitalized and treated with topical and systemic antibiotics. Blood studies for systemic vasculitis and chronic granulomatous disease and all investigations to rule out any background conditions, such as inflammatory bowel disease, were normal. His skin lesion improved with local care and topical antibiotic for 2 months, and the patient was discharged without any specific diagnosis. However, after a few months he found new lesions on his right hand and abdomen. Biopsy of the lesions showed subacute necrotic dermatitis, and then prednisolone and azathioprine were started. Several months later, when his medications were tapering, a new lesion of 15×15 cm developed in the left thigh, and this time the patient was diagnosed with PG, based on the second biopsy. Reevaluation of the patient for systemic vasculitis and inflammatory bowel disease again were negative. With a final diagnosis of PG, he received cyclosporine and dapsone. However, despite treatment with these medications for consecutive years, he suffered a recurrent and relapsing course. We also tried different combination therapies, such as methotrexate, cyclophosphamide, and mycophenolate mofetil, for several courses, with unfavorable responses. Based on an unpublished report by Göknur Kalkan on the association of familial Mediterranean fever and PG in the Mediterranean area, we assessed MEFV gene mutations, which showed normal results. Because of refractory courses with different relapses and temporary recoveries, we decided to start infliximab as a biologic drug at 100 mg at weeks 0, 2 and 6 and then every 4 weeks. He

[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 male patient reported with a complaint of mobile and broken teeth in the maxillary anterior region. He had suffered from trauma 2 days back. His medical history was noncontributory. On extra- and intra-oral examination, there was no apparent trauma to the soft tissues.
Intra-oral examination revealed a complicated crown root fracture of the maxillary left central incisor and uncomplicated crown fracture with maxillary right central incisor. The fracture line of 21 was supragingival on the labial side and subgingival on the palatal side. The fractured fragment of 21 was incompletely separated and mobile []. Palatal gingiva and interdental papilla were neither inflamed nor edematous. Evaluation of periodontal status of the patient revealed the absence of periodontitis. The intraoral periapical radiograph showed the fracture line. There was no evidence of periapical pathosis.
The adhesive reattachment of the coronal fractured fragment to the remaining tooth structure was planned for 21, to be followed by composite restoration of 11. To improve the tooth resistance and expand the bonding areas involved in the adhesive reattachment technique, placement of a translucent glass fiber post was also planned with 21. The patient accepted the treatment plan.
The gingiva was separated on the palatal side, and the fractured fragment was removed using a forceps without incurring any damage. The subgingival extent of fracture was confirmed on fragment removal. The surface of fragment and pulp chamber was debrided and cleaned. The fragment was preserved in saline until reattachment to avoid discoloration and dehydration. Since the patient reported 2 days after the trauma, preservation of the tooth vitality was not feasible. Hence, single visit root canal treatment was performed with 21. An enamel bevel was prepared all around the remaining tooth structure and the fractured margin of the fragment. An additional internal dentinal groove was also prepared within the denti

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


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

[User]
RADIOLOGY NOTE:
A 64-year-old male presented with gross hematuria. His past medical history was significant for coronary artery disease, obstructive sleep apnea, type 2 diabetes, hypertension, erectile dysfunction, and surgery for diverticulosis. Recent investigations revealed a creatinine level of 104 µmol/L and a glomerular filtration rate greater than 60 mL/min/1.73 m2. A computerized tomography urogram revealed a right-to-left CFRE, which roughly approximated a horseshoe kidney (Figure ). The urogram also identified a filling defect in the left upper pole of the fused kidney (Figure ). The renal tissue was biopsied using videoscopic ureteroscopy and pathology identified a high-grade pTa lesion. Given the stage and location of the lesion, the chosen treatment was nephrectomy of the left moiety with ureterectomy and bladder cuff excision.
The patient was positioned in the supine position with exposure of both the lower abdomen and the penis. A flexible cystoscope was introduced via the urethra and ureteral stents were placed inside both the left and right moieties of the kidney, allowing for accurate differentiation of the two collecting systems. Next, a large midline incision was made from the umbilicus to the pubic symphysis. The descending colon and small intestine were then mobilized and reflected to expose the fused kidney and the left renal vein.
Two branches from the left renal vein to the kidney were identified: one extending to the left moiety and the other to the right moiety. The left renal artery was then identified posterior to the renal vein. Accessory arterial branches were dissected, and ligation was placed just distal to the single branch supplying the right moiety of the kidney. The veins corresponding to the left moiety were then ligated and dissected. Finally, the portion of the artery distal to the ligation was dissected, providing full control of the left moiety vasculature. Next, the kidney was skeletonized until a clear area of demarcation emerged between

[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 6-year-old asian girl was referred to the Department of Pediatric Dentistry with a chief complaint of several missing teeth. The child was in good health and the health history did not reveal any systemic disease, child was born to non-consanguineous parents. Mother reported uneventful pregnancy and no significant family history. According to the mother no tooth had been lost due to trauma, extraction or exfoliation of teeth for this child. Extraoral examination revealed facial symmetry and no skeletal malocclusion. The child was examined with particular attention to hair, nail, eyes and ears, all of which appeared to be normal. No sweating abnormality was reported by the patient's mother. An intraoral examination revealed the presence of maxillary right and left primary second molars, mandibular right primary second molar, mandibular left primary canine, first and second molars. The teeth were of normal size, shape, and color. The alveolus present was very thin. There were no carious teeth and the patient has good oral hygiene. None of the teeth were mobile. Her oral range of motion was within normal limits. No temporomandibular joint sounds or masticatory muscle pain was noted. Panoramic radiograph revealed congenital absence of 14 primary teeth which included maxillary right and left central incisors, lateral incisors, canines (cuspids), and first primary molars. It also showed absence of right and left lower central incisors, lateral incisors, right canine and right first primary molar and also revealed the presence of all four first permanent molar tooth buds, lower left first and second premolar tooth buds and lower right and left second permanent molar tooth buds. Radiograph showed the beginning of calcification of cusp of lower right second premolar and probably early beginning of calcification of left mandibular second premolar (). The treatment plan included prosthesis in the form of simple acrylic partial dentures and oral health education. Maxillary an

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

[User]
RADIOLOGY NOTE:
A 25-year-old female presented to the Breast Physician in April 2007 with a 2-month history of a painless lump in the right breast. She had no associated nipple discharge or other constitutional symptoms. Physical examination revealed a 3 cm, non-mobile mass in the upper outer quadrant of the right breast. It was non-tender and the overlying skin was normal. There was no axillary lymphadenopathy. Prior to this presentation, the patient first presented to a private medical center with bilateral breast lumps in 2002. A few of these lumps were surgically removed and histologically proven to be fibroadenomas. During this period, her maternal aunt had developed breast cancer and was undergoing treatment.
Breast examination and ultrasound follow-up was performed every 12 months. She was symptom free until she developed a painful lump in the left breast in 2004. As this lesion clearly demonstrated typical benign features characteristic of a fibroadenoma, the lesion was followed up with ultrasound and had remained essentially unchanged for the next 3 years. She subsequently developed a new lump in the right breast for which she presented to us.
Ultrasound examination of the right breast demonstrated a well-circumscribed lobulated hypoechoic mass with smooth margins corresponding to the palpable lump at the 9 o’clock position (). There were inhomogeneous internal echoes associated with posterior enhancement which was suggestive of proteinaceous materials or internal haemorrhage. Colour Doppler imaging showed some demonstrable internal vascularity. On the basis of these morphological features, the lesion was categorized as suspicious finding BI-RADS 4. The previously known stable nodule in the left breast had remained unchanged in size and appearance; however two new benign looking lesions had been identified. Bilateral mammograms was subsequently performed which was of limited diagnostic value due to the dense breast parenchymal pattern (). No microcalcifications or axillary

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


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

[User]
RADIOLOGY NOTE:
The patient was a 13-year-old Caucasian girl who suffered from epilepsy in the form of salaam seizures that had begun at the age of 6 months. Aside from the seizures, clinical examination revealed hypopigmented skin lesions on the face and abdomen which were classified as peau chagrin. In addition, radiologic studies demonstrated the typical cortical tubers which led to the diagnosis of TSC. In the annual follow-up routine examinations, a large number of blurred coin lesions in both kidneys were found which were classified as multiple AMLs in the context of TSC. At the age of 13, one coin lesion showed an increase in size and magnetic resonance imaging (MRI) demonstrated a 3.5-cm tumor in the left kidney (Figure A and B), upon which the the patient underwent tumorectomy of that kidney. The postoperative period was uneventful and the patient was discharged 7 days after surgery. Four months postoperatively, a follow-up CT scan of the chest revealed multiple bilateral pulmonary nodules measuring 1–6 mm (Figure A). Due to the RCC diagnosis, and also to rule out lung metastases, follow-up chest CT scans were performed after 6 and 9 months, showing an unchanged status of the pulmonary nodules in terms of size and number, with CT-morphological appearances typical of MMPH.One year after the renal tumor resection, multiple open lung biopsies of both lungs were performed to obtain histological evidence. After an uneventful recovery the patient was discharged after 5 days.
Macroscopically, the tumorectomy revealed a 5 cm yellowish red tumor with multiple 1 to 2 mm yellow nodules in the adjacent kidney tissue.
The 5 cm tumor of the kidney showed a solid and nested, sometimes papillary architecture, and was composed of clear cells with voluminous cytoplasm, discrete cell borders, and vesicular chromatin. In addition, psammomatous calcification and hyaline nodules could be detected (Figure C). Immunohistochemical examinations revealed a weak to strong staining for vimentin

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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:
An 82-year-old female patient with a symptomatic gallstones disease and a recent weight loss was admitted to our hospital. The patient’s past medical history was free of other diseases and on physical examination, a Murphy sign was present. The abdominal ultrasound mentioned a large gallstone in the gallbladder and a hypoechoic liver mass. Liver blood tests, including tumor markers CEA and CA 19-9 were normal. Magnetic resonance imaging-magnetic resonance cholangiopancreatography (MRI-MRCP) revealed a liver tumor mass (4.5x3.5 cm) located mainly in segments IVa and VIII of the liver with an extent to segment I (Figure ).
The tumor displaced the adjacent hepatic veins and the inferior vena cava (IVC) without any signs of vessel invasion. There were no signs of liver cirrhosis and no dilated bile ducts or capsular retraction were noted. There was no associated lymphadenopathy. At this point, imaging characteristics were controversial regarding diagnosis. The differential diagnosis tilted in favor of ICC, mainly due to the enhancement characteristics and the absence of liver cirrhosis, as seen in Figure .
The patient was scheduled for exploratory laparotomy with a provisional diagnosis of an ICC. Intraoperatively, a cholecystectomy and lymph node sampling from the hepatoduodenal ligament were performed and both specimens were negative for malignancy on frozen section. Next, the liver was mobilized and the tumor was carefully dissected free of the hepatic veins, the IVC, and the rest of the liver parenchyma. The gross morphology of the liver specimen revealed a solid, grey-yellow liver lesion with a soft consistency. In the center, a light yellow region was noted, as can be seen in Figure .
The frozen section was negative for malignancy. Histologically, the tumor was characterized by a heavy inflammatory infiltrate in myxoid collagen stroma, consisting primarily of plasma cells, lymphocytes, and eosinophils. Fibroblast cells without significant fibrosis composed the str

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


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

[User]
RADIOLOGY NOTE:
A 35-year-old G4P1Ab2 refugee woman was referred to our perinatology clinic due to a suspected a fetal heart defect. There was no family history of congenital heart disease nor did she have any risk factors leading to congenital heart disease. The results of a fetal echocardiogram at 23 weeks of gestation showed the right aortic arch, malalignment ventricular septal defect, and overriding aorta in five-chamber view (). Further, DA could not be seen arising from the main PA and connecting to the descending aorta in the 3VT view and sagittal view, respectively (Samsung Ultrasound H60). Pulmonary valve, main PA, and the branches of the pulmonary valve were in the normal range. The diameters of the pulmonary annulus, right and LPA were 2.49 mm, 1.55 mm, and 1.87 mm, respectively (). Color Doppler confirmed the presence of an overriding aorta with blood draining from both ventricles into the aorta. The antegrade flow was seen in the main and branch of the PA but DA could not be demonstrated using color Doppler. After a prenatal genetic consultation, amniocentesis for karyotyping and analysis of 22q11 deletion was declined by the parents. The female fetus was delivered by CS due to previous CS at 38 weeks gestation. The neonate did not need any cardiac or respiratory support and weighed 3175 g. There were no findings suggesting any genetic anomaly in the phenotype of the newborn baby. A postnatal transthoracic echocardiogram revealed a normal four-chamber view; however, the aortic root was slightly shifted in the right ventricle and located to the right of the trachea, DA was absent as in the fetal findings. The diameters of the pulmonary annulus, right and LPA were 5.8 mm, 4.5 mm, and 4.8 mm, respectively. The peak pressure gradient at the level of the pulmonary valve was approximately 23 mm Hg at discharge from the hospital. She has remained uneventful for two months at the time of the writing.

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


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

[User]
RADIOLOGY NOTE:
A 40-year-old male patient presented with vision loss and headache of 2 months. Preoperative magnetic resonance images (MRI) revealed a large contrast-enhancing mass in sellar and suprasellar regions abutting bilateral internal carotid arteries []. This finding suggested a pituitary macroadenoma. The neurological examination revealed bilateral hemianopsia. Visual acuity was hand movement positive in the right eye and 6/12 on the left eye. The level of pituitary hormones was within the normal limits. He was diagnosed with a case of nonfunctional pituitary macroadenoma and underwent transsphenoidal resection of pituitary macroadenoma. There was no CSF leak during the surgery and it was confirmed with intraoperative Valsalva maneuver also. The sella and sphenoid sinus were packed with pieces of fat and surgicel. On day 1 after the surgery, patient reported significant subjective improvement in vision. Postoperatively, on day 2, the patient had CSF rhinorrhea and an external lumbar drain catheter was inserted to prevent CSF rhinorrhea. CSF was drained through the catheter at the rate of 5–10 ml/h. On the 3rd postoperative day, the patient complained of severe headache and decreased vision in both eyes to only perception of hand movements bilaterally. An emergent computed tomography (CT) scan was obtained. It revealed a large amount of air collection in the suprasellar region []. The patient underwent immediate reoperation through an endonasal endoscopic approach. After the trapped air was evacuated, the sella floor was subsequently repaired with fascia lata graft and muscle using fibrin glue. Examination of the cavity was performed with 0°and 30° nasal telescopes, and no residual tumor was appreciated. The pneumatocele was endoscopically decompressed using a transnasal approach guided by intraoperative fluoroscopy.
Skull lateral films which were obtained during surgery revealed a decrease in the air gradually [Figure and ]. A CT scan obtained after the second surgery sh

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


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

[User]
RADIOLOGY NOTE:
A 21-year-old Caucasian female gravida two parity one at 28 weeks presented to the dermatology clinic for evaluation of a large mass on her left lateral thigh (Figure ). The patient had an existing diagnosis of NF One, but no other medical conditions. Denied any use of regular medication besides prenatal vitamins. The mass had been present since early childhood and had been stable in size since 11 to 12 years of age.
Per the patient, the mass started to grow early in her first trimester and was noted to be more painful than in the past. The patient reported pain with minor trauma that lasted for days. No change in consistency of the mass was noted. No reported weakness or altered sensation in the leg, night sweats, fevers, chills, or weight loss by the patient. In her past pregnancy, the patient denied any change to the size of the mass or increase in pain like she was currently experiencing.
The physical exam was notable for multiple 2-3 mm hyperpigmented macules in the bilateral axilla. The upper extremities and back had large hyperpigmented tan macules and patches in various sizes consistent with Cafe au lait spots. The left thigh had a large 18 x 9 cm boggy hyperpigmented mass on the lateral side. It was pendulous and had multinodular consistency. The mass was moderately tender on palpation. The patient was noted to be able to ambulate without difficulty and had equal sensation and strength in both lower extremities.
After discussion with the patient, she was prepped for punch biopsy of the mass. Multiple biopsies were taken from different areas of the mass to ensure adequate sampling. The results of the biopsy revealed plexiform neurofibroma without any indications of malignant changes in any of the sites. The patient returned to the clinic a week later for suture removal and was informed that the mass was a plexiform neurofibroma, but did not appear to be malignant at the time of biopsy.
The

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


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

[User]
RADIOLOGY NOTE:
A 25-year-old male presented at our clinics for a right shoulder pain related to a dorsal scapular mass first observed 4 months earlier. The main symptom was a shoulder discomfort when lying on his back, sometimes compromising the sleep. The patient also complained of some weakness when using his right arm under the shoulder level. The medical history consisted in a unique kidney and past treatments for a nodular sclerosis-subtype Hodgkin lymphoma (chemotherapy and radiotherapy, last treatment twelve years ago and no recurrence).
The physical examination revealed a nonmobile 3 cm T × 3 cm AP × 2 cm CC hard mass on the posterior superomedial angle of the right scapula, sensitive to palpation (). Muscle trophicity was symmetrical. The right shoulder presented a full range of motion in all directions without scapulothoracic dyskinesis. Weakness and pain were observed when raising the right shoulder or during active abduction (at all levels).
A right shoulder radiological series including AP, lateral, and Neer views was described normal and conducted additional investigations. A thoracic computed tomography was performed and described a 2.6 cm T × 2.6 cm AP × 2.2 cm CC solid bone mass at the posterior aspect of the superomedial angle of the scapula. The diagnosis of an osteochondroma without signs of malignancy was stated (). No adenopathy or recurrence of the past Hodgkin lymphoma was observed. Retrospectively, the mass was apparent on the shoulder Neer view. A magnetic resonance imaging (MRI) including the right shoulder and scapula confirmed the benign character of the osteochondroma. The accessory nerve (XI) was compressed between the osteochondroma and the deep layer of the trapezius; no muscle atrophy was described ().
The osteochondroma was surgically removed under general anesthesia. The patient was prone, and a 10 cm incision was centered on the mass. The trapezius muscle was split at its superior part at the level of the scapula spine. The accessory nerve was

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


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

[User]
RADIOLOGY NOTE:
The patient was a 74-year-old female; 152.9 cm in height and 56.0 kg in weight at the time of her initial examination; a housewife; and described as gentle in her personality. Her chief complaints were lack of motivation, irritability, loss of appetite, and weight loss. Her medical history included hypertension and dyslipidemia at the age of 68, and she had undergone a colectomy at the age of 73 in January X−1. She had no remarkable family medical history, but her husband had Lewy body dementia and was in need of long-term care. Regarding the history of here present illness, she came to our clinic in December X−1 for abnormal behavior based on amnesia and paranoia, such as buying too many vegetables that she could not use, rotting them in the refrigerator, being unable to clean her room, and repeatedly washing her clothes while saying “my husband is dirty.” She had high neuropsychological test scores of 28 on the MMSE and 16 on the FAB; and her ADLs were not abnormally rated low, as indicated by scores of 33 on the DASC-21, 7 on the Lawton IADL scale, and 2 on the level of support required. Neurological examination showed no tendon reflex, left-right hyperactivity, or pathological reflex; and no atrophy was observed in the medial temporal lobe on magnetic resonance imaging (MRI) with coronal transection imaging. However, cerebral blood flow SPECT showed significant blood flow reduction in the anterior part of the bilateral precuneus, which led to the diagnosis of Alzheimer's disease.
She was attending local clinics for internal medicine and orthopedic surgery, but her conditions were poorly controlled, with polypharmacy and a diastolic blood pressure of over 100 mmHg. In our hospital, the patient was not treated with anti-dementia medication and adjustments to her medication regimen were initiated. She was also diagnosed with colorectal cancer and underwent 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 72-year-old Caucasian man was admitted to our department with a pain in the left posterior mandible and periodontal hyperplasia associated with the left mandibular second molar tooth. He also complained about the ongoing pain for 2 months and spontaneous hemorrhage within the lesion region.
According to his medical history, the patient had suffered from coronary angioplasty 6 years ago. He also suffered from malaise and fatigue for last 1 year and also inappetence for last 6 months.
Extraoral examination of the patient showed no visible swelling, tenderness or pus discharge. Skin color and temperature were normal. In the intraoral examination of the relevant region, oral hygiene level was not good and gingival tissue around the second molar was hyperplastic and had a tendency to spontaneous bleeding.
On the other hand, the panoramic radiograph (PANO) showed a radiolucent lesion with irregular margins located the periapical area and also extended coronally that led into the serious mobility of mandibular left second molar tooth (Figure ).
Considering the patient's medical history and after an exhaustively clinical and radiographical examination, we decided to perform an incisional biopsy under local anesthesia. As expected, the result of the pathological examination was peripheral giant cell granuloma (PGCG). We did not consider to take an initial photography before the surgical procedures, however, with regard to the pathological results, we decided to perform another surgery under local anesthesia 1 week later, including extraction of the tooth and a wide curettage of the lesion in the left posterior mandible. Despite the anesthetic procedures were performed properly and adequately, the patient was still suffering from pain but no severe hemorrhage during the curettage was observed from the surgical area. After pathological assessment of the second biopsy, the lesion was diagnosed as DLBCL (Figure ).
Even though the patient was relieved and healing was uneventful

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


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

[User]
RADIOLOGY NOTE:
A 50-year-old male patient admitted to the emergency because of an electric shock which occurred 15 minutes before (alternative current, 50 Hz, 220 V). The patient indicated that as soon as he touched the wall plug to switch on light, he was shocked from his right hand and found himself lying on the floor of his home. He stated that he had lost his consciousness with the shock and after recovery he had found out he had a tightening chest pain radiating to his left arm. His pain had continued increasingly. Arterial blood pressure ratio was measured as 140/80 mmHg on examination of the patient. Pulse was arrhythmic and tachycardic. No lesion was observed regarding the electric shock entry and exit points. Sinus tachycardia, increase in the amplitude of the T-wave at inferior derivations, and ventricular premature beats were monitored in the performed ECG ().
After establishing a vascular access, routine blood tests were performed and the patient was monitored by connecting to a defibrillator. Nearly after ten minutes, atrial fibrillation developed with a sharpened chest pain. In the performed ECG, ST segment elevation in inferior derivations and ST segment depression in V1–V3 derivations were observed (). In order to maintain the ventricular rate under control, intravenous beta-blocker was applied to the patient whose blood pressure was stable. Due to continuous ST segment elevation, ASA 300 mg and clopidogrel 600 mg were given and enoxaparin 0.6 cc was applied subcutaneously. In an effort to exclude a potential Type 1 myocardial infarction, the patient was immediately transferred to a center where primary angioplasty could be performed in 120 minutes. Before coronary angiography in the hospital where he transferred, the patient's chest pain disappeared, ST segment descended to isoelectric line, and the patient returned to sinus rhythm approximately 100 minutes after the detection of symptom. In the performed coronary angiography, normal coronary arteries were determi

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


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

[User]
RADIOLOGY NOTE:
A 17-year-old male presented to the emergency department with a close-range gunshot wound to his right lower quadrant/groin area with an entry but no exit wound visible. He was haemodynamically stable on presentation. On initial clinical assessment in the trauma bay there was concern for an intra-abdominal injury, and emergency exploratory laparotomy was planned. A radiograph and a CT scan were performed as part of the preoperative workup. These revealed the bullet lodged in the femoral head, with associated fractures of the femoral head and the anterior lip of the acetabulum (Figures and ). Gas was seen within the soft tissues, right iliacus, and right inguinal region consistent with the bullet tract. There was no evidence of associated rupture of bowel or vasculature. The exploratory laparotomy was cancelled and orthopaedic surgery was consulted. The right lower extremity was neurovascularly intact, with no evidence of damage to the femoral neurovascular bundle. On CT imaging the femoral head fracture appeared to have multiple fragments (). In addition, the bullet appeared embedded inside the femoral head. Hence an open approach was chosen over an arthroscopic approach. The posterior location of the bullet made access appear difficult through an anterior Smith-Peterson approach and therefore the surgical dislocation approach with trochanteric osteotomy, as described by Ganz et al. [], was utilized.
Upon dislocation of the femoral head, the embedded bullet was noted to be in the posterosuperior region of the femoral head (). Other than the entry point of the bullet, there was no visible fragmentation of the femoral head. The bullet was carefully extracted using a narrow osteotome and the joint was thoroughly irrigated. Consideration was given to whether there were any osteochondral flaps that could be fixed back down to the femoral head to cover the remaining defect. However, the osteochondral fracture caused by the bullet was comminuted with no significant fragmen

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


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

[User]
RADIOLOGY NOTE:
A 31-year-old woman with no notable medical history, no usage of medications or tobacco, and fair oral hygiene was referred to a specialist unit with the chief complaint of a lingual gingival recession at the lower right central incisor (Figure ). She had orthodontic treatment while in her teens and later, in 2017, because of a relapse. Shortly after bonding the mandibular appliance in 2017, the patient became aware of an apical displacement of the gingival margin at the lingual surface of central incisor (Figure ). At the time of referral, the patient was diagnosed with a lingual recession measuring 4 mm vertically and 1.5 mm horizontally at the level of the CEJ. The phenotype was regarded as thin. The axial direction of the central incisor was characterized as neutral, without labial or lingual root torque. A definite labial frenal pull and a narrow zone of keratinized attached gingiva coronal to the fibrous attachment were diagnosed (Figure ). The lingual defect was classified according to Smith's classification (the only system that classifies both lingual and palatal recessions). Radiographs of mandibular central incisors showed short roots without loss of interdental bone, but with widened periodontal membrane apically. The incisors responded positively to cold test.
Clinical and radiographic findings in maxillary and mandibular jaws indicated a need for atraumatic oral hygiene instruction. The patient was therefore instructed in roll-brushing technique both lingually and labially. A grafting procedure to cover the lingual recession on the mandibular central incisor was not advocated due to a rather questionable prognosis for such a root coverage procedure.
The labial mandibular frenulum was associated with a decreased vestibular depth, a narrow zone of keratinized attached gingiva, and fiber pull (Figure ). To prophylactically reduce the risk of developing a labial recession on the left central incisor, a decision was made to perform a frenectomy with excisio

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


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

[User]
RADIOLOGY NOTE:
A 38-year-old man, with no significant past medical illness, was brought to the emergency department initially, after he sustained an episode of generalized tonic-clonic seizure. On further questioning after being recovered from seizure, he complained of suffering from generalized headache for a duration of 10 days prior to the presentation. He denied having any weakness or numbness and denied any complains of speech or swallowing difficulties. On arrival, he was hypertensive up to 170/101 mm Hg and was hemodynamically stable otherwise. Neurological examination did not reveal any cranial nerve or cerebellar deficits and had no focal deficits, with normal symmetrical reflexes overall. Other system examinations were within normal limits.
On further investigation, initial CT brain was done, which did not reveal any abnormalities, and so he was admitted to the neurology critical care unit for further management. As a workup for seizure, MRI brain was performed, which revealed a right cerebellar small acute ischemic infarct (Figures –). Subsequently, an MR angiography of the brain and neck was performed, which revealed filling defects causing focal narrowing in the origin of the internal carotid artery bilaterally. Routine brain EEG did not reveal any seizure activities.
Upon admission to the neurology unit, he was started on aspirin and atorvastatin for treatment of stroke. Carbamazepine was introduced in view of seizure due to focal organic cause. He was worked up thoroughly for his stroke considering his young age with complete collagen vascular disease and thrombophilia workup. He was initially found to have thrombocytopenia as low as 50,000 platelets per microliter. A transthoracic echocardiography revealed a pedunculated and lobular left atrial mass (Figures -), which was measuring around 1 × 1.5 cm and was freely mobile across the mitral valve, oscillating across the left ventricular inflow. This finding was subsequently confirmed by a transesophageal echocardiogr

[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 an intractable pain radiating over the left chest, suggestive of intercostal neuralgia, was referred to our spine center for further evaluation and management. Five weeks earlier, she experienced a ground-level fall, causing severe back pain. According to the initial evaluation conducted elsewhere, she was diagnosed as having OVF of the T10 vertebral body and managed conservatively with a brace and pain medication for one month. Her chief complaint gradually changed from bilateral back pain to an aching pain extending to the left thorax before her first visit to our hospital. What is noteworthy about the history of this case is that 8 years previously, she had had a painful OVF of the T12 vertebral body at the age of 79 years, which was treated with vertebroplasty using hydroxyapatite (HA) blocks and posterior pedicle screw instrumentation followed by iliac bone graft fusion from T11 to L1 at another hospital [].
On clinical examination at our hospital, the patient had no neurologic deficits, complaining of nothing but reporting a position-dependent severe chest pain on the left side, which intensified when sitting up from a supine position. Imaging studies revealed neither rib fractures nor abnormal findings of the chest cavity as a possible cause of the chest pain.
On the plain radiographs of the thoracic spine (), the anteroposterior (AP) views and the lateral views taken in the supine position showed the IVC within the T10 collapsed vertebral body as a gas-like radiolucent area, which disappeared on the lateral view obtained in the sitting position (i.e., the opening-closing phenomenon) most likely indicating an OVF of nonneoplastic and noninfectious origin [, ]. The lateral radiograph in the sitting position also demonstrated that the fracture line extended through the posterior fusion mass bone, grafted 8 years ago, indicating a potentially unstable flexion-distraction injury. Close observation of the AP radiograph obtained in the sup

[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 13-year-old male presented to us with fever (acute in onset, mild to moderate grade and associated with mild chills) since last 10 days followed by gradually progressive sensory motor paraparesis with urinary incontinence since last 4 days. He was then hospitalized with weakness remaining static for one day and then progressed and involved both upper limbs within 24 hours. Examination showed LMN type sensory motor quadriparesis with only flickering of contraction present in all the limbs; planter was downgoing bilaterally. The patient was febrile with other systemic and general examinations showing no significant abnormality. After one day of quadriparesis, patient developed acute onset altered sensorium preceded by drowsiness and headache which was diffuse and bursting in nature. No significant past and family history and similar episode were previous noted.
Now examination showed a Glasgow Coma Scale of E1M1V1 and patient was deeply comatose. On the basis of this history and examination we put the diagnosis of ascending myelitis of viral origin and did investigation accordingly. As the patient belongs to an endemic region, differential diagnosis of JE was kept too. All routine investigations were within normal limit. We did CSF which revealed total leucocyte count of 42 cells/cmm with lymphocytic predominance and slight elevation of protein and normal sugar along with elevated IgM titres against JE virus. Brain MRI showed bilateral basal ganglia that were grossly swollen with vasogenic edema tracking along internal capsule and midbrain. Adjacent ventrolateral thalamus and internal capsule also show mild abnormal intensities (Figures , , and ). Spinal screening shows abnormal cord intensities in entire cord with gross edema in cervical and conus region (Figures and ). Electrophysiological study was suggestive of preganglionic axonal involvement of upper limb and lower limb. Diagnosis of ascending myelitis and encephalitis due to JE virus was established. We start

[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 male with a past medical history of asthma, spastic paraplegia, hypertension, hyperlipidemia, peptic ulcer disease, and tibial osteomyelitis post-infected hardware removal was admitted for altered mental status. He was admitted to the orthopedic service for infected hardware removal one month prior to the current admission. He was subsequently started on IV cefepime 2g every eight hours for tibial osteomyelitis and then discharged to a skilled nursing facility for six weeks. Approximately 17 days later, the staff at the nursing facility reported that the patient was delirious, slurring his speech, and pulling out his peripherally inserted central catheter (PICC) line in the night. He was then hospitalized at an outside facility for four days where he had an extensive workup, including a CT head, MRI head, and EEG without any conclusive etiology for his altered mental status. The EEG showed generalized slowing and evidence of metabolic encephalopathy and he was discharged. He returned to an outside emergency department three days later for persistent neurological symptoms, where he was found to have acute kidney injury. Following administration of IV fluids, he was discharged to his skilled nursing facility. His mental status did not improve. After consultation with the infectious disease team, the patient was admitted to our hospital for further workup. Upon admission, his vitals were unremarkable and physical examination showed confusion and disorientation without any other focal neurological deficits. Laboratory results were unremarkable except for an elevated creatinine of 1.8mg/dL (baseline 1-1.2mg/dL) indicative of unresolved acute kidney injury. Cefepime was discontinued, and the patient’s mental status and speech improved over the next 72 hours. Nephrology was consulted. After extensive workup, acute kidney injury was presumed to be secondary to cefepime toxicity with a component of acute tubular necrosis given the hyaline and granular casts see

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


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

[User]
RADIOLOGY NOTE:
A 29-year-old gravida 1, para 0 woman was referred to our tertiary center at 24.4 weeks of gestation with a suspected cardiac anomaly. Her previous medical history was unremarkable, and she had no family history of congenital malformation. Quad tests and other prenatal laboratory findings were within normal ranges. A fetal echocardiography was performed and the four-chamber view of the heart revealed cardiomegaly with a right ventricular dilatation without definite contractility, but no obvious right atrial dilatation (). There were no discernible tricuspid leaflets (), indicating the absence of a tricuspid valve structure. Color Doppler imaging showed forward and backward flows from the right atrium to the right ventricle without evidence of tricuspid regurgitation (). Because the tricuspid valve structure was completely absent and also because there were communicating flows between right atrium and right ventricle, the fetus was thought to have a condition other than tricuspid atresia which is characterized with an absence of communication between right atrium and right ventricle. Functional pulmonary atresia was also associated. No other abnormalities were detected.
Following the counseling on the postnatal outcomes, the parents decided to continue the pregnancy, and did not want to undergo fetal karyotyping. Subsequent serial echocardiographic examinations showed no demonstrable changes. A follow-up evaluation at 35.5 weeks of gestation revealed newly developed skin edemas, pleural effusion, and ascites suggestive of fetal hydrops. An emergency cesarean section was therefore performed.
A male neonate of 2,160 g was delivered and was cyanotic with an Apgar score of 3 and 5 at 1 and 5 minutes, respectively, and an SaO2 level of 50%. An initial echocardiography indicated an Ebstein anomaly type-D, stenotic form with almost full atrialization of the right ventricle leaving only a very small functional portion of this ventricle (). A modified Starnes operation (right

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


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

[User]
RADIOLOGY NOTE:
A 76 year old male was presented to our department with a huge mass (20 × 15 cm) in his left posterior thoracic cage, extending between the medial edge of the scapula to the spine. The patient reported that the mass appeared 2 years ago and that it was slowly growing bigger ever since. From his past medical history, he had a myocardial infarction treated with angioplasty for which he was on a regime of acetyl-salicylic acid, with a dosage of 325 mg once per day. He also reported an ipsilateral chest wall injury after a fall 2 years ago for which he did not seek medical help. On examination the mass's texture was solid and fixed on the chest wall, inflicting pain to the patient who additionally complained of cosmetic discomfort. The patient was subjected to a thoracic computed tomography which revealed a huge extrathoracic tumor extending (medially) from the left side of the spine (laterally) to the tip of the scapula and (superiorly) below the scapula to the anterolateral thoracic wall (inferiorly). The mass did not seem to enter the thoracic cage or to invade the ribs and it had a tissue density (Housfield Units 40-50) of fat and muscle (Figure ). Based on a) the CT findings raising the suspicion of malignancy and ensuring total excision of the mass, b) the preference of the patient who did not consent to major surgery and c) the presenting symptoms (pain, cosmetic), a surgical removal - open biopsy of the lesion was decided.
Intra-operatively, the mass (Figure ) was dissected off the chest wall below the latissimus dorsi and trapezius muscles and was resected en bloc. Two broken ribs were palpated at the site where the mass was firmly attached to the thoracic cage. A drain was left in site. After the completion of the operation, the mass was opened and blood (fresh and organized) exited with

[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 48-year-old woman living in rural Maryland presented in early June with a two-week history of neck pain, fatigue, anorexia, nausea, and intermittent fevers and chills. She was concerned that she might have Lyme disease because of tick bites in the past and ongoing recreational exposure to ticks but did not recall a tick bite in the weeks preceding the onset of her illness. A tentative diagnosis of a viral illness, possibly mononucleosis, was made during an initial visit to her primary care physician. She presented to the emergency room the following day with worsening neck pain, stiffness, and myalgia and was admitted for dehydration and further evaluation. Physical exam showed a temperature of 101.1°F, pulse 101 beats per minute, and a new oval nonpainful red rash on her left hip which was attributed to a drug reaction (). Laboratory evaluation of complete blood count (CBC) showed a total white blood cell (WBC) count of 4.9·103 U/L with 8% lymphocytes and a low absolute lymphocyte count of 400 U/L. A comprehensive metabolic panel (CMP) showed an abnormal AST of 245 U/L, ALT of 218 U/L, and alkaline phosphatase of 215 U/L. A CT scan of the head without contrast was negative. A lumbar puncture showed one white blood cell, normal protein, a normal glucose level, negative bacterial culture, and negative Lyme antibodies in the CSF. Her blood cultures, hepatitis serology, and influenza A and B were also negative. The Epstein-Barr virus serology was interpreted as consistent with either late primary infection or reactivation of mononucleosis with a (+) IgG antibody, (−) IgM, and (+) EBNA. She was discharged with a diagnosis of mononucleosis due to EBV and recommendations for symptomatic care. A Lyme serology was sent with pending results at the time of discharge that subsequently showed no ELISA done, (+) IgM Western blot, and (−) IgG

[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:
Here we report a case of a 13-years-old boy who presented in a medical emergency with complaints of generalized tonic-clonic seizures and right hemiparesis. The hemiparesis was non-progressive and started at the age of ten years. He also had some behavioral changes that started at the age of six years, along with frequent episodes of mild headache. The behavioral changes included disturbed sleep, irrelevant talks, and irritability. There was no history of similar presentations in any other sibling or family member.
On general physical examination, there was emaciation with decreased cognitive functioning; 13/30 on the Mini-Mental State Examination. On neurological examination, the power was 3/5 on the left side of the body with decreased sensations, hypertonia, and brisk reflexes. We also observed mild left-sided facial angle deviation. The rest of the systemic examination was unremarkable. Laboratory workup included baseline investigations and a thorough workup for young stroke along with an autoimmune profile. All laboratory investigations were within a normal range.
We did a CT scan brain without contrast, which revealed atrophy of the right cerebral hemisphere, with the prominence of extra-axial cerebrospinal fluid (CSF) spaces and dilatation of the ipsilateral right lateral ventricle. It also revealed low attenuation areas in the right frontal and right parietal lobes depicting possible subacute infarct in the right frontal and acute infarct in the right parietal region (Figure ).
We also did magnetic resonance imaging (MRI), which revealed an atrophic right cerebral hemisphere, with dilatation of the right lateral ventricle and extra-axial CSF spaces with mild asymmetry in the calvarial thickness of both hemispheres (Figure ).
MRI also showed a prominent right frontal sinus as compared to the left one depicting hyperpneumatization. We also observed various areas of encephalomalacia with surrounding gliosis in the left frontal region that is suggestive of previ

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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 six-month-old Caucasian male with no significant past medical history presented to the pediatric emergency department for a chief complaint of frequent unusual eye movements as reported by the parents. The patient began having intermittent rotary nystagmus approximately three weeks ago, and since then it progressed and became more continuous, worsened by changes in position or flashing lights from toys brought in his visual field. The parents also noticed the patient sleeping more than usual, only staying awake for an hour at a time, and had a subsequent severe regression in milestones, with an inability to roll over or sit unsupported.
Initial workup in the emergency department included a CT brain without contrast, which showed evidence of thickening of the bilateral optic nerves with associated masses and diffuse bilateral ventriculomegaly (Figure ). This finding was concerning for possible bilateral optic pathway gliomas, at which point a dedicated MRI of the brain and orbits was recommended, along with further genetic workup for possible neurofibromatosis I.
MRI of the brain and orbits confirmed these findings, showing diffuse enlargement of the optic tracts extending from the lateral geniculate nuclei to the optic chiasm and into the bilateral optic nerves, with a mass demonstrating 270º encasement of the bilateral supraclinoid internal carotid arteries and near circumferential encasement of the bilateral A1 segments of the anterior cerebral arteries (Figures , ).
These imaging findings confirmed the suspicion of bilateral optic pathway glioma, and as a result, the patient was admitted to the hospital and evaluated by both neurosurgery and pediatric hematology-oncology. Neurosurgery did not recommend any surgical intervention at the time, and the hematology-oncology team recommended proceeding with chemotherapy. His genetic testing results showed no evidence of clinically significant variants of neurofibromatosis I or II, suggesting a sporadic bilateral optic

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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 male, 11 years old, suffered from pain in the left ankle joint after trauma and limitation of motion for 10 years, and the symptoms aggravated with claudication for 1 year. Physical examination showed swelling of the left ankle joint, extensive tenderness, normal skin temperature, and limited range of motion for ankle plantar flexion and dorsi flexion. Venous blood test showed no abnormalities in ESR, CRP, and blood routine. Radiograph and MRI suggested hyperplasia of synovial tissue in the articular cavity and epiphyseal injury of the distal tibia. Ankle arthrocentesis was conducted, and a small amount of turbid liquid was drained. No diagnosis of ankle TB was suggested. Preoperative diagnoses were (1) traumatic ankle synovitis and (2) epiphyseal injury of the left distal tibia. We initially planned to perform articular cavity debridement; however, when we conducted the surgery, we saw obvious hyperplasia of synovial tissue and the cartilage was obviously damaged; TB was highly suspected. Considering that the patient was still a child, ankle arthrodesis was not suitable in this case. Therefore, we only performed articular cavity debridement after obtaining the tissue sample for biopsy. Pathological examination confirmed ankle TB, and the result was also positive for TB-PCR. The patient was prevented from weight bearing for 6 weeks postoperatively; anti-TB treatment of rifampicin, isoniazid, and pyrazinamide were given orally; his nutrition was strengthened. Regular follow-ups were conducted. The swelling of the posterior malleolus was gradually relieved. After the reexamination at 6 months postoperatively, his anti-TB therapy was adjusted and only rifampicin and isoniazid were continued for maintenance treatment of 12 months. At the last follow-up at 5 years postoperatively, the patient’s left ankle swelling and pain disappeared, and the range of motion for ankle plantar flexion and dorsi flexion was basically normal. The AOFAS score improved from 57 points preop

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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:
An 81-year-old lady presented for further evaluation of progressive dysphagia with associated weight loss. The patient reported a 4-month history of unintentional weight loss of 5 kg. She is a life-long nonsmoker with no past medical history other than hypertension and hypercholesterolaemia, for which she takes a statin and an amlodipine/valsartan combination. Bloods were all within normal limits except for a mildly elevated creatinine at 105 umol/l (Hb 13.5 g/dl, MCV 87.9 fl). Physical exam was noncontributory. In particular, there was no evidence of secondary metastatic disease.
An oesophagogastroduodenoscopy (OGD) was carried out which was significant for two distinct oesophageal tumours. The first was found at 30–35 cms with an appearance of bulging mucosa (). A second tight stricture was seen at 40–46 cm abutting the oesophagogastric junction with extensive mass lesion extending into the fundus of the stomach (). The intervening oesophagus from 35 to 40 cm was normal in appearance as was the remainder of the OGD with the scope passing without difficulty to the second part of the duodenum. There was no endoscopic evidence of Barrett's oesophagus.
Multiple biopsies were taken and a staging CT of thorax, abdomen, and pelvis was performed. This confirmed the two separate tumours along with celiac adenopathy suggesting locoregional spread.
PET/CT showed that diffuse metabolic activity to a maximum of 14.2 SUV was evident at both tumour sites and there was associated gastric wall thickening compatible with extensive local spread of the distal mass. Large metabolically active lymph nodes at the level of the celiac axis measuring up to 15 mm were evident with a maximum SUV of 4.5 ().
Analysis from the biopsies confirmed the presence of two histologically distinct masses. Specimen A from the mid-oesophagus showed high grade carcinoma with some features suggesting neuroendocrine differentiation (). Overlying squamous mucosa shows moderate to severe dysplasia. Immunohisto

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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 23-year-old girl was admitted to hospital with sudden onset of loss of vision in both her eyes. Studying the details of the patient's history revealed episodes of weakness and dizziness since two years ago. She also experienced temporary clouding of sensorium and falling down on several occasions especially in the upright position just after a slight physical activity.
The patient's personal history was significant regarding the opium addiction. On admission, physical examination revealed an oral temperature of 37.2°C, a heart rate of 100 beats per minute, a respiratory rate of 18 breaths per minute, blood pressure in right upper arm was 150/100 mmHg and in left upper arm 170/100 mmHg, very weak pulses of the upper extremities and normal pulses of the lower ones. In neurological examination, the abnormal findings were decreased visual acuity and optic atrophy of left fundus. MRI of the brain with contrast agent showed bilateral abnormal T2 signals in white matter. Visual evoked potential (VEP) showed prolonged P100 latency in both eyes and electroencephalography (EEG) was reported normal. Findings of performed hematological laboratory tests on patient are listed in . Optic neuritis (ON) caused by multiple sclerosis (MS) was diagnosed and she received IV methyprednisolone 1 gr/day for 3 days. Her vision became better but attention on history of dizzy spell, physical findings of very weak pulses of upper limbs and difference between blood pressure of left and right arms made us investigate more on it. Radiological and sonographic findings of patient are listed in . As noted in , CT and conventional angiographies of chest and cervical arteries were the most diagnostic ones ().
So diagnosis of TA was established and due to rheumatologic consultation, she received 1 gr/day IV methyprednisolone for 5 days, 500 mg IV cyclophosphamide in the next day and oral antiplatelet clopidogrel bisulphate (Plavix 75 mg/day).
This patient was a candidate for the stenting of the right

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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 74-year-old female patient presented with a locally advanced tumor of the proximal pancreatic body. The patient showed no signs of obstructive jaundice and did not require biliary stenting. Initially, her tumor was noted to involve the major visceral vessels, including the celiac artery, portal vein, and splenic artery and vein (). The tumor was deemed unresectable and the patient underwent extensive chemotherapy with multiple cycles of gemcitabine, Abraxane, 5-fluorouracil, Alloxantin, Avastin, and Xeloda. After showing a favorable response, she was referred for surgical re-evaluation. The post neoadjuvant chemotherapy CT scan () showed a poorly defined infiltrative pancreatic neck and body mass measuring ∼25 × 15 mm with ill-defined soft tissue encasing the proximal splenic artery, common hepatic artery (CHA), distal celiac axis, and superior mesenteric artery (SMA). The mass also partially encased the portal vein and superior mesenteric vein (SMV). There was no radiologic evidence of hepatic metastasis and there was mild pancreatic duct dilatation. Pre-treatment and post-treatment serum CA 19–9 levels were 46 and 9, respectively. The patient did not receive any additional studies to assess GDA flow or the need for preoperative coiling/embolization. The absolute need for resection of the celiac axis was not determined until the time of the operation. The patient's functional status, perioperative risk, and likelihood of response were weighed and she was determined to be a candidate for an attempt at a modified Appleby procedure. After being properly informed of her various treatment options, she elected to undergo the operation.
Exploration of the duodenum and pancreas revealed a firm mass in the body of the pancreas with a soft pancreatic neck. No gross evidence of metastatic disease was present. There was a benign appearing lesion in the superior aspect of liver segment II, which was excised in its entirety and confirmed to be benign. Cholecystectomy was perfo

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


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

[User]
RADIOLOGY NOTE:
A 64-year-old Han Chinese male patient presented with primary multi-HCC. He had tumors located in Couinaud’s segments III and V, which were treated with local resection. After surgery, he received transcatheter arterial chemoembolization (TACE). After 10 months, he was referred to our hospital in September 2012 with right upper abdominal pain and an abdominal wall mass (Figure ). He tested negative for the hepatitis B virus but was positive for hepatitis B core antibody. A physical examination revealed the abdominal wall mass to be 7×8cm. Results from routine blood chemistry tests were normal. Levels of tumor markers, such as alpha-fetoprotein, carcinoembryonic antigen and carbohydrate antigen 19–9, were all within the normal range. The functional status of his liver was assessed as class A on the Child-Pugh scale. Abdominal computed tomography and magnetic resonance imaging scans demonstrated a mass with ill-defined borders in the left lobe of his liver and revealed abdominal wall invasion (Figure ). The maximum diameter of the lesion was 10cm. Because of the extrahepatic tumor invasion and the recurrence of the HCC directly invading his abdominal wall, a hepatectomy and surgical resectioning of his abdominal wall were considered as the procedure of choice.
The second surgery was performed in July 2013. An incision was made between the original incisions, over a colored mass in the abdominal wall (Figure ). Intra-operative findings included a 10cm tumor involving the left lobe (Couinaud’s segment IV) of his liver. The tumor was invading his abdominal wall. The trunk of his left portal vein, left hepatic artery and left bile duct were divided and ligated. The common venous trunk of his left and middle hepatic veins were then divided and ligated. A liver parenchymal transection was performed without using Pringle’s maneuver. Liver resection was carried out by a clamp-crushing method. Great care was taken to protect his stomach and intestinal wall. Subsequently, a lef

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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 65-year-old woman with controlled dyslipidemia and hypertension and a previous history of CABG 9 years previously was referred to our center because of the PSA. She had undergone coronary angiography due to symptoms which were suspected to be of ischemic origin in another hospital and during aortic root injection, the PSA was revealed. Coronary angiography showed that the left anterior descending artery and the right coronary artery were occluded at the proximal part; the left internal mammary on the left anterior descending artery was patent and the right coronary artery was filled retrogradely via the left coronary artery system. There was mild left ventricular systolic dysfunction. In addition, a large saccular aneurysm (25 × 55 mm) was detected in the ascending aorta (). These findings were confirmed by multidetector computed tomographic (MDCT) angiography, which illustrated a large pseudoaneurysm in the tubular part of the ascending aorta (maximum aneurysm diameter and PSA neck were 60 mm and 24 mm, respectively) with a calcified wall and without evidence of leak or pericardial effusion (). The diameters of the ascending aorta, arch, and descending aorta were 27, 20, and 17 mm, respectively, and the arch had 3 patent branches. In transesophageal echocardiography, the distance between the PSA and the aortic valve was 30 mm and the diameter of the oval-shaped orifice of the PSA was 20 × 29 mm. In addition, a thin layered clot was visible in the pseudoaneurysm cavity (). Cardiac surgery consultation was done, but the patient refused open repair owing to the high risk of surgery. At this point, we arrived at the decision to use an ASD occluder device in off-label way so as to seal the PSA orifice. Written informed consent, after explanation, was obtained from the patient.
In a hybrid operating room setting, under general anesthesia and with transesophageal echocardiography guidance, after open arteriotomy, a 30-mm Amplatzer-like ASD occluder device (Cardi-O-Fix,

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


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

[User]
RADIOLOGY NOTE:
A 42-year-old gentleman approached the emergency department with complaints of bleeding from his gums for 5 days and coughing of blood for a day. He coughed up a spoon-full size of frank blood three times. He denied any preceding fever or symptoms of upper respiratory tract infection. He did not have any recent productive cough or shortness of breath. He had normal bowel and bladder habits. There was no history of red urine or dark stool. He did not notice any joint swellings or skin rash. He did not complain of any bruises and did not remember any recent trauma. He denied any unintentional weight loss in the recent past. He had an episode of bleeding from gums 2 years back, for which he did not seek any medical help as it self-resolved in a couple of days.
His past history was significant for an episode of abdominal distention 20 years back in Pakistan. He was found to have splenomegaly and underwent splenectomy at a local medical facility. However, the etiology of splenomegaly was undetermined, and he had no medical records available. He was also found to have thrombocytosis at that point and was started on hydroxyurea, which he continued for several years until stopping it a year back, without medical advice. He had bilateral pulmonary embolism 7 years ago and was started on rivaroxaban since then. He did not report any abnormal bleeding manifestations in the last 7 years, except for the gum bleeding 2 years back, and did not have any regular follow-ups. Family history was negative for easy bruising, bleeding, or clotting disorders. He was a smoker with 20 pack-years of smoking history.
The physical examination was unremarkable. There were no bruises or bleeding in any extremities. The chest and abdomen were grossly normal. Lab tests at the time of presentation showed leukocytosis, erythrocytosis, and marked thrombocytosis. Manual platelet count

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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 61-year-old male was diagnosed with renal cell carcinoma of the right kidney, which was resected in 1994. In 2005, a single 2 cm hypervascular tumor was detected in the head of the pancreas on computed tomography (CT). We suspected that the lesion was the result of pancreatic metastasis of the renal cell carcinoma and performed pancreatoduodenectomy with pancreaticogastrostomy reconstruction. Informed consent was obtained prior to operation. A pathological examination showed that the resected tumor was a metastatic lesion of renal cell carcinoma (data not shown). In April 2011, another single 2 cm hypervascular tumor was detected in the tail of the pancreas on follow-up CT (). Fluorodeoxyglucose-positron emission tomography (FDG-PET) showed no significant FDG accumulation in the tumor of the pancreas compared to the normal pancreatic tissue and no accumulation was detected in other organs (data not shown). The patient had no past history other than that described above and no abnormalities were detected on regular preoperative examinations, including blood tests of the fasting blood sugar and hemoglobin A1c (HbA1c 5.7%) levels. The patient was diagnosed with recurrent pancreatic metastasis of renal cell carcinoma based mostly on his clinical course and preoperative images.
The tumor was located 5 cm away from the site of anastomosis of the previous pancreaticogastrostomy. Therefore, we planned to perform distal pancreatectomy in order to preserve the middle portion of the remnant pancreas. The preservation of the spleen was also considered. However the splenic vein was close to the tumor as shown in the CT (); we decided to remove the spleen together. In June 2011, we performed laparotomy with an upper median incision and the adhesion was first dissected. The tumor was located 5 cm from the site of anastomosis in the pancreas and stomach; therefore, we decided to preserve the body of the remnant pancreas as planned (). After the spleen and tail of the pancreas wer

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