[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:
Written informed consent was obtained to report the case. A 34-year-old G2P1 pregnant woman diagnosed with AS presented at the obstetric outpatient clinic at 18 weeks of gestation. She experienced back pain when she was 25 years old; these symptoms made walking difficult during her first pregnancy at 31 years old. Following her first vaginal delivery, she was able to walk although pain persisted to a lesser degree than during pregnancy. Radiography revealed osteosclerosis of the posterior surface of cervical vertebrae and osteoarthritis of the right hip with joint space narrowing (Figure ). The initial diagnosis of AS was made at 33 years of age.
Pain was managed by the administration of nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen. After the present pregnancy was diagnosed, only acetaminophen continued to be administered, but pain increased during the present pregnancy. She complained of right hip pain, with a visual analog scale (VAS) score of 7/10. A dosage of 5 mg of oral prednisolone was administered daily from 18 weeks of gestation, and thereafter, the symptoms temporarily improved to 0/10 on the VAS. Unfortunately, the symptoms relapsed at 31 weeks of gestation. At 32 weeks of gestation, she complained of restricted neck mobility with difficulty gargling, restricted lumbar mobility that caused difficulties in bending her back, and restricted right hip joint mobility with a limitation of 10º of abduction, which also affected internal and external hip rotation. Peripartum management was discussed and planned by obstetricians and anesthesiologists. Given that only hip abduction and rotation, but not flexion, were limited, it was considered that an attempt of vaginal delivery would be possible when spontaneous labor occurred. However, if an emergency cesarean section (CS) was necessary during labor owing to other obstetric complications such as nonreassuring fetal status, special anesthesia management may be required because of the possible fai

[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 man presented to the neurosurgical clinic complaining of headache after a workplace accident. He was found to have a right calvarial mass with compression of the right frontal lobe on head computed tomography (CT). A magnetic resonance imaging (MRI) of the brain demonstrated a contrast enhancing calvarial mass with features consistent with meningioma. In the context of the patient’s unremarkable medical history, poorly controlled headaches and age, he was scheduled for elective resection. Aside from acetaminophen he took no additional medications for pain and was not started on any anti-inflammatory or steroid medications.
An MRI obtained three weeks later on the morning of surgery for use with intraoperative neuronavigation demonstrated a spontaneous reduction in the size of the lesion, raising the suspicion of an alternative diagnosis to meningioma (Figure ). In discussion with the patient it was decided that, because of the size of the lesion and associated mass effect, it would be prudent to proceed with a minimally invasive biopsy followed by resection depending on the preliminary pathologic diagnosis. A frozen section at the time of surgery was non-diagnostic and described as a cellular neoplasm that could be consistent with an atypical meningioma given the sheet-like architecture. Lymphoma was not suspected given the cell size and amount of cytoplasm, and a plasmacytoid morphology was not appreciated, hampered in part by frozen section artifact. A gross total resection was performed. The patient recovered well and had an unremarkable perioperative course.
After permanent processing, the tumor was identified as a plasmacytoma (CD138+, CD56+, Lambda+, Kappa-) with overall 30% Ki67 positivity, eight percent in the CD138+ population. The patient underwent a systemic evaluation postoperatively, which revealed multiple lytic lesions in the humerus, glenoid process, and ribs. Serum protein electrophoresis (SPEP) was positive for immunoglobulin G (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:
A 48-year-old, gravida 1, para 0 female was referred to the University of Minnesota Maternal-Fetal Medicine Center due to vaginal bleeding and uterine fibroids. Ultrasound findings revealed a viable gestation at 14 + 1 weeks' and an adjacent thickened, nonhomogeneous placenta with a diffuse multicystic appearance (see ). The adjacent placental mass was consistent with a coexisting molar gestation, and it was noted to be overlying the cervix. In addition, there were multiple intramural uterine myomas visualized, the largest of which measured 10.3 cm × 9.3 cm × 7.3 cm and 7.0 cm × 7.1 cm × 6.2 cm. A serum quantitative hCG was 290,000 iu/L. The patient reported persistent vaginal bleeding starting early in the first trimester, not associated with cramping. Given the diagnosis of a presumed molar gestation, the patient was counseled on the risks of continuing the pregnancy. An amniocentesis was performed at 16 weeks' gestation which returned as a normal 46, XY karyotype. Amniotic fluid AFP was 1.38 multiples of the median. After identifying a viable fetus, the parents opted to continue the pregnancy. Further evaluation included normal thyroid function tests, and in agreement with the patient, we proceeded with imaging studies, as the presence of any metastases may have resulted in her decision to terminate the pregnancy. MRI of the brain, abdomen, and pelvis were negative for evidence of metastatic choriocarcinoma, and the molar pregnancy measured 7.0 cm × 8.3 cm × 6.9 cm. We thoroughly reviewed the extremely low teratogenic and stochastic risks of radiation from a chest CT (<1 rad) prior to obtaining a pulmonary CT scan that revealed small incidental nodules not concerning for metastases.
At 17 weeks, the patient was admitted to the hospital for observation due to an increase in vaginal bleeding. Her hemoglobin was stable at 11.6 g/dL, and the remainder of her laboratory analysis was reassuring.

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


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

[User]
RADIOLOGY NOTE:
In 2009, a 25 year old man was referred to the Department of Conservative Dentistry at Gangnam Severance Dental Hospital for evaluation and further treatment because of an apical pathosis on a lower left first molar. Nonsurgical endodontic treatment was performed on the tooth by the referring dentist because of apical radiolucency on the tooth 5 years previously (in 2005), and the patient was informed that the size of the apical radiolucency had increased. The patient could not recall the initial root canal treatment and did not experience any discomfort.
A panoramic radiograph obtained during the first visit to our institution showed a large, radiolucent area around a mesial root of tooth #36 (). Root canal fillings were found, and a metallic obstruction in one canal was noticed (). A clinical examination showed no remarkable findings, including tooth mobility, sensitivity to percussion, or swelling. We informed the patient of a large periapical radiolucency and that the possible treatment options were nonsurgical retreatment, surgical treatment, or extraction. In addition, because of the size of the lesion, computed tomography (CT) was suggested to evaluate the proximity of the lesion to the mandibular canal. However, because the patient was asymptomatic, he did not want to perform further radiographic examinations and active treatment. The patient was recommended to undergo a routine check-up before a final decision. However, the patient did not come for a follow-up without any notice.
Five years later, the patient came back because of cold sensitivity in the lower left molars. He felt moderate cold sensitivity during outdoor activity a week before this visit, and the sensitivity disappeared thereafter. He recalled his appointment scheduled in 2009 and decided to return for a check-up. A large cystic lesion involving the left lower premolar and molars was found in a panoramic radiograph (). Tooth #36 was negative for percussion and showed a normal range of mobili

[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 90-year-old Caucasian woman with a past medical history significant for provoked upper extremity deep venous thrombosis and Clostridium difficile colitis with subsequent ileostomy was admitted to our orthopedic service for a planned left hip arthroplasty revision and correction of acetabular protrusion. Preoperatively our patient denied chest pain or shortness of breath. She was unable to achieve four metabolic equivalents secondary to hip pain. Past surgeries included left hip arthroplasty, bilateral total knee replacement, hysterectomy, appendectomy, and cholecystectomy without any cardiopulmonary complications. A preoperative examination was unremarkable with all vital signs within normal limits and no murmurs, gallops or rubs on cardiac auscultation. Her only medications were omeprazole and vitamin B12. Patient risk was stratified as average risk for an intermediate risk procedure. Intraoperatively our patient was given regional, spinal, and monitored anesthetic care (MAC), which were well tolerated. She initially received midazolam prior to morphine spinal anesthetic. Due to the procedure length, she was converted to general anesthesia using a laryngeal mask airway. Fentanyl, midazolam, and propofol were used to convert to general anesthesia. Shortly after the transition to general anesthesia, she converted from normal sinus rhythm to sinus tachycardia. Unexpected hypotension near the end of operation required 3200cc of crystalloid fluids, 500cc albumin, and two units of packed red blood cells. Postoperatively she was transferred to our surgical intensive care unit.On postoperative evaluation, our patient was alert, comfortable, and without any complaints. Her vital signs revealed a blood pressure of 89/46mmHg and a heart rate of 95 beats per minute on a phenylephrine drip. A physical examination was significant for a new-onset grade 4/6 systolic murmur at the apical area radiating to the axilla. She was breathing comfortably without accessory muscle use and

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


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

[User]
RADIOLOGY NOTE:
A 30-year old Indian woman presented with complaints of pain in the central abdomen for 3 days, with vomiting and loose stools. On examination, she had a pulse rate of 84/min, blood pressure of 110/84 mmHg, respiration rate of 15 breaths per minute and SpO2 of 98% at room air. The abdomen was soft, there was mild central distension, and bowel sounds were increased. Laboratory investigations were essentially normal. The patient had a history of two similar episodes over the preceding 6 months, both of which resolved spontaneously following treatment with a conservative regimen. Abdomen X-ray was suggestive of dilated jejunal and proximal ileal loops. In view of the previous two similar episodes, a computed tomography (CT) was done, with the results suggestive of an intraluminal fatty mass surrounded by a thick collar of soft tissue attenuation consistent with the target sign suggesting intussusception in the distal small bowel, along with dilated proximal small bowel loops. (Figs. , , ) The patient underwent laparoscopic procedure. Intra-operative findings were suggestive of an intussuscepted segment of ileum measuring 10 cm in length, about 75 cm proximal to the ileo-cecal junction, with dilated proximal ileal and jejunal loops. The segment was removed through a small midline incision at the umbilicus. A firm mass was palpable within the lumen; hence, an enterotomy was performed, revealing a tubular segment of 4 cm in length with a globular swelling at the end. The involved segment was resected, and an ileo-ileal anastomosis performed, then reposited back to the peritoneal cavity and the port sites closed. Further careful examination of the specimen revealed that it was a narrow-mouth, inverted diverticulum with lipoma at its end, leading to intussusception and obstruction and causing the recurrent episodes (Figs. , ). Histopathology investigations revealed a necrotic and hemorrhagic architecture of the resected bowel segment that was consistent with intussusception

[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 15-year-old female patient was first seen in our service in 2012 for a second opinion regarding the treatment of her cardiac arrhythmias. Her medical history includes mental retardation, delay of psychomotor development, and a progressive dorso-lumbar scoliosis (Figure ) for which she underwent an orthopedic correction at the age of 15 years, 5 months before she was first seen in our service. Her family's medical history is unremarkable. She was being followed in another institution for a sinus bradycardia discovered during the neonatal period. Since the age of 14 years old, she also presented paroxysmal atrial fibrillation. To allow an intensification of her antiarrhythmic treatment, a pacemaker implantation was one of the options proposed in the other institution.
Despite her mental retardation, the patient could express that she had no heart related symptoms such as dyspnea, palpitations, or chest pain, and had no limitations in her activities of daily living, such as walking or doing some indoor cycling. There was no history of syncope. This was confirmed by her parents, who were most of the time with her.
Her 12-lead electrocardiogram showed a junctional rhythm, with narrow QRS complexes (Figure ). A 6-day holter monitor revealed sinus bradycardia, junctional rhythm, sinus pauses, short episodes of Wenckebach atrioventricular block, 20% of atrial fibrillation, atrial flutter, and premature ventricular contractions with episodes of bigeminy (Figure A-F). Her echocardiography did not detect any abnormality, without left atrial dilatation. The patient supported a load of 120 Watt at her exercise test that allowed reaching a heart rate of 132 beats per minute (65% of the maximum heart rate).
An electrophysiological study was conducted in our institution, showing atrioventricular conduction abnormalities with episodes of Wenckebach atrioventricular block. AH interval was measured at 76 ms and HV interval at 53 ms. There was a duality of the atrioventricular conduc

[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 44-year-old male was admitted to a health institution complaining of severe colicky abdominal pain for 2 days. It started suddenly and was continuous and diffuse; however, it was mainly in the right lower quadrant and was increasing in severity. He had never experienced similar pain in the past. The pain was associated with nausea, vomiting, hiccoughs, anorexia and bloating sensation. He had passed his last stool and flatus in the morning on the same day of admission.
On admission, he was alert and his vital signs, chest and cardiovascular examination were normal. The abdomen was distended, free of scars, and tender all over mainly in the right iliac fossa with guarding and a palpable mass with absence of bowel sounds. The hernia orifices were intact. The rectum was empty on digital rectal examination. His complete blood count and basic biochemical parameters were also normal. Contrast enhanced abdominal computed tomography scan showed an intra-abdominal mass associated with small bowel obstruction and a small amount of intra-peritoneal free fluid. Following a brief period of resuscitation, the patient was taken to the operating room for exploration. Upon examination, a 4 × 4 cm mass was detected in the small bowel mesentery with multiple small bowel loops adherent to it, together with their mesentery. There was no evidence of liver or peritoneal metastasis. Approximately, 1 m of small bowel had to be resected to completely excise the mesenteric mass with clear margins together with the adherent bowel and mesentery ( and ). Then, primary anastomosis was performed. The final pathology result was a grade 2 gastrointestinal stromal tumor with clear margins, mitotic index less than 2/10 high power field, maximum tumor size of 4 cm, and tumor cells were positive for CD117 (C-kit) and CD34. Hence, the final diagnosis was primary gastrointestinal stromal tumor of the small bowel mesentery. The patient had an uneventful postoperative course and was disc

[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 19-year-old female sustained a closed spiral midshaft fracture of her right femur following a road traffic accident. The fracture was treated using a femoral intramedullary nail with one dynamic proximal screw and two lateral static distal locking screws. There were no intraoperative complications noted.
After six months, she complained of difficulty walking. On examination she was noted to have an internally rotated right leg with her patella pointing medially. She also walked with a painful in-toeing gait on the right. No leg length discrepancy was found. Her wounds had healed well and she complained of no rest pain. Radiographs of her femur showed signs of union of the fracture. A CT scan of her right femur revealed approximately 30 degrees of internal rotation distal to the fracture site (see ).
A decision was made to proceed with a derotational osteotomy, leaving the femoral nail in situ. At operation a lateral approach to the femur was performed. One K wire was inserted into the femur proximal to the fracture site and another inserted at 30 degrees of internal rotation distal to the fracture site. This angle was measured using a protractor normally used for the Maquet tibial osteotomy. A circumferential femoral osteotomy was made around the femoral intramedullary nail using a Gigli saw approximately 5 cm proximal to the distal interlocking screws. The bone was held above and below the osteotomy site using bone clamps. The lateral static distal interlocking screws were then removed and the malrotation was corrected. This brought the guidewires parallel, thereby correcting the malrotation deformity. Two antero-posterior static distal interlocking screws were used to secure the intramedullary nail and freeze-dried bone graft was inserted around the osteotomy site.
The patient went on to make a good postoperative recovery and at her six-month followup she had no pain and walked with a normal gait. The osteotomy site had united both clinically and radiologically

[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 girl presented with complaints of a progressively increasing swelling over the front of her left chest over the previous 5 months. The swelling was not painful, situated just adjacent to her left breast, with no associated shortness of breath. There was no history of trauma to the chest wall. She did not complain of an engorgement of the left breast, nipple discharge, or retraction. There was no family history of similar complaints. On examination, her vital signs were stable. There was a large, hard, non-tender mass, 25×30 cm in size, extending from just below the left clavicle to the 6th intercostal space and from the lateral border of the sternum to the mid-axillary line (). The mass itself was adherent to the chest wall although the overlying skin was not. The left breast had been lifted up by the mass and was not adherent to it. There was no palpable breast nodule, ulceration, nipple discharge, or retraction. There were no palpable lymph nodes. Breath sounds were equal and normal bilaterally. The systemic examination was unremarkable. Chest X-ray showed a diffuse opacification over the mid-lung field extending over to the lateral chest wall. Bronchovascular markings in the periphery were normal. A blood investigation revealed a raised lactate dehydrogenase and alkaline phosphatase, positive C-reactive protein, and normal total counts. Contrast-enhanced computed tomography (CT) of the thorax showed evidence of irregular destruction and periosteal reaction involving the left 3rd rib (). There was a large soft tissue component extending through the skin and the subcutaneous region, anterior mediastinum, and in the left upper lobe. This was causing compression of the left upper and lower lobe bronchus with a partial collapse of the underlying lung field. The lesion was also abutting the arch of the aorta and its branches and was found to be displacing the left brachiocephalic vein laterally. Magnetic resonance imaging (MRI) findings were similar 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 man aged 56 years presented to the emergency department with a 4-month history of right buttock pain radiating down the right leg treated as sciatica in the community. Two weeks prior to admission, the pain had worsened to the extent that he needed a walking stick to mobilise. He had also developed nocturnal pain and allodynia throughout the outer aspect of the right leg and noticed a tender lump in his right buttock. This had not been present on previous visits to his general practitioner, but on discovery, he was promptly referred to the emergency department for further assessment.
He developed myelodysplastic syndrome (RAEB-2) aged 49 and underwent chemotherapy (daunorubicin+cytarabine) and allogeneic bone marrow transplant. This subsequently failed and he required more chemotherapy (FLAG-Ida+cytarabine) and a second allogeneic bone marrow transplant. He had been in remission until the time of presentation.
On examination, a hard, smooth tender mass was palpable in the upper half of the right buttock. The posterolateral aspect of his right buttock and thigh were very painful to touch. He had weak right knee flexion with total loss of movement in the ankle and on knee extension. The right ankle reflex was absent. The left lower limb was neurologically normal. The SLR test was negative bilaterally. Admission blood test results are shown in .
An MRI of the lumbar spine performed 6 weeks prior to admission had shown mild lumbar disc protrusions at L3/4 and L5/S1 with a disc prolapse at L4/5. There was no evidence of significant neurological compromise or bone marrow abnormality. On admission, after detecting the buttock mass on clinical examination, an informal ultrasound scan was performed in the emergency department and showed a 4×10 cm heterogeneous hypoechoic mass in the right buttock (). Subsequent MRI of the right buttock revealed a heterogenous enhancing soft tissue mass lesion along the right lateral wall of the pelvis extending through

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


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

[User]
RADIOLOGY NOTE:
A 59-year-old man with a past medical history of nonischemic cardiomyopathy who initially underwent OHT in 1994 (biatrial anastomosis) was referred for pacemaker lead revision. His posttransplant course had been complicated by transplant vasculopathy, and he ultimately required a second heart transplant in 2002 (bicaval anastomosis). He also developed ESRD and underwent deceased donor kidney transplantation in 2004. He developed ehrlichiosis in 2011 in addition to cryptococcal pneumonia and histoplasmosis requiring chronic treatment with antifungals. In 2013, he had syncope leading to a subarachnoid hemorrhage and was diagnosed with sinus node dysfunction in the setting of intermittent sinus bradycardia to less than 20 beats per minute. He underwent dual chamber pacemaker placement in 2013 (Medtronic ADDRL1) with a Medtronic 5076 lead in the ventricular position and a Medtronic 5592 lead placed in the right atrial appendage after an active fixation lead was deemed to be unstable.
He was admitted for volume overload three years later, and pacemaker interrogation revealed undersensing on the atrial channel due to a gradual P wave amplitude decrease from 4.7 mV at implant to ~0.4 mV, leading to asynchronous ventricular pacing and failure to recognize atrial arrhythmias. No change in lead position was detectable on chest X-ray. An atrial lead addition was planned. However, the left subclavian vein was occluded. He underwent extraction of the atrial lead to obtain venous access. A 12 French Spectranetics SLS II laser sheath was advanced over the lead, and minimal application of laser energy was used to free adhesions. Countertraction using a snare was also employed from the femoral vein. The lead was removed, and subclavian access was retained. A Medtronic 3830 lead was implanted in the right atrium. The patient tolerated the procedure well, and he had no complications within the next 30 days. However, he was admitted with cryptogenic encephalopathy two months later whic

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


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

[User]
RADIOLOGY NOTE:
A 72-year-old male presented with a two-day history of right upper quadrant pain on a background of a metastatic, small bowel, well-differentiated NET diagnosed 5 years previously. The tumour was a low-grade mesenteric NET with a ki67 of 8% at diagnosis. He had multiple liver metastasis, which were stable. Carcinoid syndrome was well controlled on a long-acting, monthly dose of a somatostatin analogue with last dose being 28 days prior to presentation and due in three days. His comorbidities included hypertension, an infrarenal aortic aneurysm and chronic obstructive pulmonary disease. He presented with right upper quadrant tenderness and the liver edge was palpable 4 cm below the costal margin. Initial blood tests showed a white cell count of 18.9 × 109/L, C-reactive protein 212 mg/L and liver function tests within normal limits. Vital signs were reassuring, and an abdominal ultrasound described a thickened gallbladder wall, mobile sludge and an 8.5-mm common bile duct suggestive of cholecystitis (). Computerised tomography (CT) of the abdomen was noted to show multiple segment V liver masses with capsular deformity suggestive of central necrosis. He was initially managed with analgesia and intravenous piperacillin-tazobactam. After a discussion with the patient and consultation with his treating oncologist regarding his relatively stable disease burden and reasonable prognosis, a laparoscopic cholecystectomy was performed.
During cholecystectomy, extensive carcinoid metastases were encountered (). To perform the operation laparoscopically required retraction of the left liver lobe. However, the liver was stiff and inflamed making exposure of the biliary tree difficult. The gallbladder was mobilized, a critical view of safety and an unremarkable intraoperative cholangiogram was obtained. The length of the operation was 1 h and 35 min. Histopathology of the gallbladder showed benign, chronic outlet obstruction, patchy serosal mixed inflammation and one lymph node co

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


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

[User]
RADIOLOGY NOTE:
A 34-year-old male with past medical history of protein S deficiency presented to emergency room with a two-week history of worsening headaches and three-day history of subjective fevers, nausea, and vomiting. Over the counter medications did not relieve his symptoms. On the day of presentation, he experienced difficulty in walking and according to his friends he seemed to be mildly confused. He neither complained of any visual changes nor had any seizures. He is of Indian origin, professional, and married with a child. His history was negative for smoking, alcohol, and illicit drug use. He came to United States six months prior to onset of these symptoms for his job. He did not have any sick contacts with or exposure to wildlife. He did not receive any vaccination within the recent past.
On physical examination his vital signs are within normal limits. He was oriented to only person and place but he did not have any other focal neurological deficits. Other systems examinations were within normal limits. His initial basic labs were within normal limits. Computerized tomography (CT) scan of head did not reveal any acute intracranial process.
A spinal tap was performed and patient was started on empiric antibiotic therapy and Acyclovir. Cerebrospinal fluid (CSF) analysis was consistent with aseptic meningitis (White Blood Cell Count (WBC)-287 cells/mL with lymphocytic predominance, glucose at 30 mg/100 mL, and protein at 236 mg/100 mL) and did not reveal any albuminocytological dissociation. Based on CSF findings, antibiotics were discontinued, Acyclovir was continued, and its course was completed.
On the second day of admission, his mental status worsened; he developed seizure and went into respiratory failure which needed intubation. Magnetic resonance imaging (MRI) brain performed during that time course revealed symmetrical increased T-2 (Figures and ) signal in bilateral basal ganglia, thalami, and middle cerebellar peduncles and did not show any gross enhancemen

[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 48-year-old Asian woman presented, along with her relatives, to the outpatient department of our hospital complaining of unconsciousness of 4 minutes’ duration with fecal incontinence that had occurred 20 days earlier. The patient had difficulty with communication because of a history of encephalitis. Thus, the main narrator of her history was her cousin. We were told that the patient had a history of common cold diagnosed by her local doctor 3 months earlier and had been treated with antibiotics (including ribavirin, amoxicillin sodium and clavulanate potassium, cefoperazone sulbactam, and levofloxacin) for about 1 month because of repeated fever.
The patient’s temperature was normal during her hospitalization, but the results of her blood test showed elevations in the percentage of neutrophil granulocytes (78.7 %) and in her C-reactive protein level (13.2 mg/dl). Her chest x-ray showed two foreign bodies in her chest: one in the base of the left lower lobe and the other in the left ventricle (Fig. ). Her echocardiogram showed a 21 × 11–mm echogenic mass with some calcifications attached to the anterolateral papillary muscle in the left ventricle (Fig. ). Her chest computed tomographic (CT) scans confirmed the presence of the foreign bodies (Fig. ). According to her cousin, she had been pierced by a foreign body through her chest wall approximately 3 months or longer before presentation.
During the patient’s hospitalization, she had numbness in her left arm and drooping on the left side of her face. Serial cerebral CT scans revealed multiple new infarction areas in her brain (Fig. ). Because of the positional relationship to the ventricle and her recurrent cerebral infarctions, surgical treatment was necessary. However, the timing of the operation was argued among surgeons in our department. A consensus was ultimately made according to the special situation of the patient. Five days after the cerebral infarction, surgery was performed to remove the foreign

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


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

[User]
RADIOLOGY NOTE:
An 84-year-old male presented with a 1-day history of abdominal pain in bilateral iliac fossae, associated with nausea, vomiting and last opening his bowels prior to the onset of abdominal pain. Background medical history included rheumatoid arthritis, a prior cardiac arrest, coronary artery bypass graft for ischaemic heart disease, asthma, gout, benign prostatic hypertrophy, atrial fibrillation and gastro-oesophageal reflux. Relevant surgical history included surgical repair of pyloric stenosis as a young child, open appendicectomy in early adulthood, laparoscopic cholecystectomy, placement of an automatic implantable cardioverter defibrillator (AICD) into the abdominal cavity in 2007, and a colonoscopy which identified diverticular disease.
The diagnosis of ASBO was made following a computed tomography (CT) scan of the abdomen and pelvis, which identified a transition point in the pelvis, beam hardening artefact from an AICD within the abdomen, with no underlying mass identified, reported as likely being caused by intra-abdominal adhesions. Conservative management with a nasogastric tube, making the patient nil by mouth and administering intravenous fluids was commenced. The patient opened his bowels and started passing flatus the following day, and then had this diet upgraded. The patient was discharged home after a short admission. A further episode of ASBO a few weeks later was again conservatively managed successfully.
A presentation 6 weeks later was once again diagnosed as ASBO, with multiple segments of dilated small bowel with a transition point identified in the right iliac fossa on CT scan ( and ). On this occasion, operative management was required, with the AICD identified to the left of the umbilicis with extensive matted adhesions to small bowel encountered. Extensive adhesiolysis was undertaken at this area, with the defibrillator removed from the intra-abdominal cavity and repositioned in a subrectus pocket. Following the procedure, the AICD was 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:
An 18-year-old male without any significant past medical history first presented to our facility with a traumatic skull fracture and severe eye injury. He required enucleation and subsequently underwent oculoplasty but had no other relevant surgeries or hospitalizations.
He presented to another hospital 5 years later complaining of headache, vomiting and decreased level of consciousness. Computed tomography (CT) scan revealed hydrocephalus and right thalamic hyperdense lesion with perifocal edema that was causing mass effect and some midline shift. A ventriculoperitoneal shunt (VPS) was inserted.
The patient was transferred to our institute for additional work-up. The patient was conscious on arrival to the hospital with a Glasgow coma scale of 15/15. His vital signs were stable with normal neurological examination. MRI revealed a large right thalamic lesion compressing the lateral ventricles (Fig. A).
The patient underwent stereotactic biopsy for the right thalamic lesion. The histopathological examination was inconclusive because of inadequate material for immunohistochemical staining, but it indicated possible high-grade glioma versus lymphoma. These differentials were suggested based on the morphological features, including discohesive pleomorphic cells, reactive lymphocytes, necrosis and vascular proliferation.
The patient underwent cerebrospinal fluid (CSF) cytological examination because of the suspicion of the differential diagnosis, and the results revealed benign mature lymphocytes with no malignant cells. Bone marrow biopsy also revealed no evidence of lymphoma.
The patient complain of worsening headache, progressive left side weakness, vomiting and a decreased level of consciousness. CT scan revealed active hydrocephalus with enlarged ventricles and the thalamic lesion, which appeared enlarged compared to the previous scan. The VP shunt was revised, after which he developed intraventricular hemorrhage. Therefore, an external ventricular drain was inserte

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

[User]
RADIOLOGY NOTE:
A 33-year-old man with no significant past medical history presented to the emergency department (ED) complaining of a 7-day history of constant, dull pain in his right shoulder with radiation to the ipsilateral neck and associated with slight decrease in sensation throughout the right upper extremity. With the exception of a pulse rate of 103 beats per minute, his vital signs were within normal limits. Examination of the neck and right shoulder was without abnormality. Plain radiographs of the right shoulder were obtained and were within normal limits. He was then given prescriptions for methylprednisolone, methocarbamol, and hydrocodone-acetaminophen and discharged home with a diagnosis of cervical radiculopathy.
Two days later, he returned to the ED complaining of worsening pain in the right shoulder with radiation from the right arm to the neck with associated paresthesias in the right arm. Review of systems revealed interval development of nausea associated with occasional vomiting. Physical examination was notable for normal vital signs, focal tenderness of the right trapezius muscle with no range-of-motion deficits involving the right shoulder, and the absence of focal neurologic deficits. A point-of-care troponin measurement was undetectable. He was then provided a referral to undergo MRI as an outpatient and discharged home.
Two days after his second presentation, the patient developed acute numbness of the right leg while waiting to be seen in an outpatient chiropractic clinic. He was instructed to immediately return to the ED, and no chiropractic manipulation was performed. However, by this time, the patient was unable to arise from a seated position and required transport to the ED by ambulance. Physical examination at the ED revealed diffuse muscle weakness and numbness distal to the neck, tachypnea, and mild diaphoresis. Vital signs were notable for pulse rate of 113 beats per minute, respiratory rate of 24, temperature of 99.5°F, pulse oximetry of 97%

[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 39-year-old woman was referred to our hospital because of a cystic lesion in the liver demonstrated by abdominal ultrasonography (US). Laboratory studies, including liver function tests, and tumor markers were also within the normal limits. Serological markers for hepatitis B or C viral infection were undetectable. Abdominal US revealed a well demarcated, heterogeneously low-echoic mass 170 mm in diameter in right lobe of the liver. Abdominal computed tomography (CT) during hepatic arteriography (CTHA) revealed early ring enhancement in the peripheral area in the arterial phase and slight internal heterogeneous enhancement in the delayed phase (Figures and ). Magnetic resonance imaging (MRI) showed that the tumor had low signal intensity on T1-weighted images and some foci of high signal intensity on T2-weighted images. Gadolinium ethoxybenzyl (Gd-EOB) MRI revealed no uptake in the corresponding area (Figures , , and ). Abdominal angiography demonstrated a large avascular region in the liver corresponding to the tumor, although no typical features of cavernous hemangioma were evident (). 18-Fluorodeoxyglucose positron emission tomography (FDG-PET) revealed no abnormal FDG uptake. With these radiological findings, malignant liver tumor could not be excluded, such as biliary cystadenocarcinoma, cholangiocarcinoma, mesenchymal tumors, and hepatocellular carcinoma associated with cystic formation.
The patient underwent posterior sectionectomy. Intraoperative examination revealed a relatively soft dark red tumor (); the resected specimen weighed 1.1 kg and measured as 170×100×80 mm. The cut surface of the tumor revealed a white, solid, and cystic mass that was elastic, soft, and homogeneous with a yellowish area considered to be myxoid degeneration (). Histological examination showed that the tumor mostly consisted of sclerotic area and cavernous hemangioma area is partly observed (). Sclerotic area presents diffuse fibrosis () and the typical histol

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


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

[User]
RADIOLOGY NOTE:
A 51-year-old male was referred to our hospital with dysphagia and recurrent upper abdominal discomfort. Apart from arterial hypertension, no significant medical history was reported. Endoscopy detected an ulcerous lesion dorsal at the GEJ (figure ), however, biopsies did not prove malignant disease. Deep biopsies lead to the histopathological diagnosis of a GIST in the GEJ. High-resolution multislice computerized tomography (CT) showed a solid tumor measuring 7.6 cm extending from the distal esophagus to the gastric cardia and fundus with extension into of the left diaphragmatic muscular column and the splenic hilus (figure ). Surgery with curative intent at this stage would have required a multivisceral resection by an abdomino-thoracic approach, including resection of the left diaphragmatic muscle as well as splenectomy. After thorough discussion of the treatment options, the patient consented to try to downstage the tumor first by neoadjuvant treatment with imatinib mesylate followed by surgery after three to six months.
Liver metastases were excluded by ultrasound and abdominal CT as were lung metastases by conventional chest x-ray and CT of the thorax. Before starting with drug treatment the patient underwent functional staging with 18F-FDG-PET demonstrating an increased tumor metabolism without signs of distant tumor spread. Imatinib mesylate at 400 mg per day was given orally. The patient suffered from mild diarrhoea and nausea during the treatment. The side effects were controlled by loperamide and metoclopramide. Follow-up 18FDG-PET examination two months after the beginning of the treatment showed a steep decline of 18FDG-uptake at the area of the tumor which by visual analysis of the PET could no longer be detected. This result documented response to treatment with imatinib mesylate which was continued for another four months. Follow-up CT at six months revealed a regression of the tumor diameter from 7.6 cm to 4.8 cm. The tumor margin showed a wash-out

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


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

[User]
RADIOLOGY NOTE:
A 61-year-old man with no remarkable history had never had a regular medical examination. He has been smoking about forty cigarettes per day for more than forty years. On the morning of the day before admission, he found that he was not able to read a book as his vision became suddenly distorted. He had additionally noticed weakness in his left leg during the daytime but went to bed without going to the hospital. The next morning, his weakness grew worse and he visited our hospital in a wheelchair due to gait disturbance. At this first admission, his NIH Stroke Scale (NIHSS) score was 4 points: hemiparesis 2, sensory disturbance 1, and dysarthria 1. He complained of diplopia when he looked to the right, but we could not observe his ocular deviation. His head MRI-DWI showed a scattered fresh infarction including the right occipital lobe, cerebral crus, and thalamus, and MRA showed occlusion of the P2 area of the right PCA and left SCA (). Carotid ultrasound (CUS) showed findings of moderate arteriosclerosis, and plaque accumulation in the carotid bifurcation was not observed. He was admitted to our hospital. Electrocardiogram (ECG) and monitoring data showed no findings of arrhythmia. We speculated that the cause of this stroke might be atherosclerotic change at first. We decided to begin injection of argatroban hydrate and edaravone, and administered oral aspirin 100 mg.
Early the next morning, a drop in consciousness level and aggravation of left hemiparesis presented. Emergency MRI was performed and showed enlargement of the lesion in the thalamus and additional cuneate fresh stroke on the right paramedian portion of the midbrain and small spotty fresh stroke on the left paramedian portion. MRA showed the extension of the occlusion of the PCA to the P1 portion (). At this point, we thought perforators branching from proximal part of PCA were occluded due to the progression of thrombosis in the PCA. We added cilostazol to avoid

[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 blind and painful right eye of a 38-year-old man was eviscerated in September 2016. The patient stated that his right eye had been blind since early childhood due to a unilateral congenital anomaly complicated by secondary glaucoma. He received the diagnosis of SO in January 2017 after he experienced visual loss in his only seeing (left) eye. At the time of diagnosis, the patient was admitted to the hospital and meticulously investigated for possible infectious and noninfectious causes to rule out other uveitic entities, but without any positive findings. At that time, his best-corrected visual acuity was 6/10. Slit-lamp examination yielded some vitreous cells in the left eye. Fundoscopy showed a few scattered pigmented chorioretinal scars and discrete yellowish round choroidal lesions throughout the left fundus (). Fluorescein angiogram delineated the active lesions as early hypofluorescent () with late staining. Left macular contour was normal on optical coherence tomography (OCT) examination (). He was started on oral prednisolone (64 mg) for 2 weeks with gradual tapering of 8 mg per week. Despite initial visual improvement, he experienced another episode of visual decline while taking 32 mg of prednisolone. His best-corrected visual acuity decreased to 2/10 and he had grade 4 vitreous haze according to the Miami grading. Fundus examination showed marked yellowish-white discoloration of the macula with some evidence of intraretinal hemorrhage ( and ). He was hospitalized and treated with pulse methylprednisolone 1 g (250 mg 4 times daily) for 3 days. Following pulse therapy, 64 mg oral prednisolone and 150 mg (50 mg 3 times daily) azathioprine were co-administered. Two weeks after the completion of pulse therapy, his visual acuity was still 2/10 despite a significant reduction in vitreous haze. Fluorescein angiogram and OCT demonstrated type 2 choroidal neovascularization (). Five intravitreal 2 mg aflibercept injections were given within a period of 8 months

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


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

[User]
RADIOLOGY NOTE:
The patient is a 53-year-old man with a history of hypertension. He sustained an out of hospital cardiac arrest secondary to an anterolateral ST elevation myocardial infarction (STEMI). He was loaded with Prasugrel and heparin and was treated with drug eluting stents in the LM, proximal left anterior descending (LAD) and left circumflex coronary arteries. Because of persistent cardiogenic shock, an intra-aortic balloon pump was placed. Transthoracic echocardiogram (TTE) revealed severe left ventricular (LV) dysfunction with an ejection fraction of 25%, moderately severe aortic regurgitation, aortic root dissection and he was subsequently transferred to our institution. Upon arrival, he was mechanically ventilated and required increasing doses of inotropes. He experienced frequent supraventricular and ventricular arrhythmias. CT scan of the thoracic aorta revealed a dilated aortic root (maximum transverse diameter of 5 cm) and a dissection flap involving the non-coronary and left coronary sinuses with concern of transmural hypoperfusion of LAD territory (Fig. ).
With the persistent hemodynamic instability, he suffered acute kidney and hepatic injury. Veno-arterial extracorporeal membrane oxygenator (ECMO) was inserted with restoration of satisfactory tissue perfusion.
The patient was presented to our heart transplant committee and was found to be a suitable candidate for implantation of total artificial heart (TAH) as a bridge to transplantation.
Upon pericardial entry; hematoma and ecchymosis involving the anterior aspect of both the aorta and pulmonary artery was noted (Fig. ) and this extended to the majority of the LV surface. Cardiopulmonary bypass was established with weaning off ECMO. As the tear was limited to the aortic root, the ascending aorta was cross clamped and aortotomy performed. A complex tear was noted, mainly in the left coronary sinus of Valsalva (Fig. ) and extending around the LM coronary ostia and which we believe was the cause of his STEMI. C

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


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

[User]
RADIOLOGY NOTE:
A 40-year-old previously healthy woman complaining of slight nausea, vomiting, and anorexia was referred to our hospital. Physical findings revealed a flat abdomen that was soft, not tender, and no palpable mass. CT and MRI examination showed a left abdominal lesion on the retroperitoneal side (, ). CT showed a lobule mass of 107 × 42 mm in size, with internal inhomogeneity and mild delayed enhancement on the retroperitoneal side of the left abdominal lesion. MRI showed a mass with low intensity and partial high intensity on T2WI·In addition, PET-CT detected slight FDG accumulation (SUV max: 3.01) in the same lesion ().
A retroperitoneal tumor, particularly a desmoid tumor, was suspected based on the abdominal MRI, abdominal CT, and PET-CT findings. A solitary fibrous tumor, malignant lymphoma, fatty tumor and neurogenic tumor were considered as differential diagnoses. Thus, total laparoscopic surgery was performed to resect the retroperitoneal tumor.
The operation was performed as follows. First, laparoscopic exploration was performed with five ports after inducing pneumoperitoneum (). Secondly, mobilization of the jejunum and the ileum was conducted in the right-head-ventral side position (). This mobilization was indicated to provide an optimal surgical view of the tumor. Dissection of the left side of the colon was performed using a medial-lateral retroperitoneal approach Thirdly, dissection of the tumor around the inferior mesenteric artery was performed. The tumor was adjacent to the left side of the aorta and the left lower vena cava, but no invasion was observed, and two feeding arteries were flowing into the tumor from the aorta and the IMA. Each artery was clipped (, ). In addition, two feeding veins flowing into the vena cava were clipped. The tumor specimen was removed via the umbilical wound.
The operative time was 124 min, and the operating blood loss was approximately 5 mL.
The size of resected tumor was 110 × 70 mm. A pathological examination of the

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


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

[User]
RADIOLOGY NOTE:
A 62-year-old man with a background history of diabetes mellitus presented with a five-month history of progressively enlarging, painless mass on the anteromedial aspect his left arm (Figure ). It was associated with constitutional symptoms, whereby patient claims to have lost 9 kg in the period of three months. He also noticed several areas of pigmented lesion over the mass which were painless. Over time, the swelling started to ulcerate with surrounding rashes, which prompted the patient to seek medical attention. There was no history of malignancy in his family. His occupation as an engineer in the Middle East caused him to have prolonged exposure to ultraviolet light. On examination, there was a large mass located on the anteromedial aspect of his left arm. The overlying skin has a bluish discoloration with several areas of pigmentation and presence of dilated veins. Firm in consistency with an ill-defined margin, it was adherent to the overlying skin and to the underlying muscle. No palpable thrill was detected to suggest a vascular in origin. Tinel test was also negative excluding that lesion arises from a nerve. A small subcutaneous nodule was located proximally to the lesion. Despite the size of the lesion, there was no limitation of movement at the elbow or shoulder. Distally the neurovascular bundle was not compromised. Proximally, a smaller mass was detected in the axilla which was suspicious of an enlarged lymph node. The presence of an enlarged lymph nodes led us to surmise that lymphoma was a more likely diagnosis than a soft tissue sarcoma.
With the above differential diagnosis, staging was next step in the management of this patient. Magnetic resonance imaging (MRI) illustrated a large heterogenous multilobulated left arm mass (Figure ). The fascia is breached, involving the subcutaneous layer and skin with presence of satellite nodules surrounding the mass. The neurovascular bundles were displaced laterally, however, displayed normal flow signal. Th

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


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

[User]
RADIOLOGY NOTE:
A 50-year-old female reported to nephrology outpatient department with complaints of the right upper abdominal discomfort of 6 months duration. The pain was dull aching type with no radiation elsewhere. There was a history of intermittent hematuria with the abdominal discomfort. There was no history of colicky abdominal pain, lithuria, weight loss, anorexia, or jaundice in the past. She was postmenopausal with none significant medical or surgical history. She hailed from a remote village in central India and was sheep rearer by occupation. She consumed mixed diet and belonged to low socioeconomic strata. General examination revealed palor while on abdominal examination right kidney was palpable with bosselated surface and was nontender. There was no renal angle tenderness or hepatosplenomegaly.
Complete hemogram showed anemia (hemoglobin - 6.5 g/dl) with normal leucocyte and platelet count. Her renal and liver function test was normal. An ultrasound examination of abdomen and pelvis showed a multiloculated cystic lesion of size 6 cm × 7 cm × 13 cm size with daughter cysts in the right kidney. Other viscera were found to be normal. The patient was hospitalized and transfused two units of blood. After adequate hydration, she was subjected to contrast-enhanced computed tomography of abdomen. It showed a well-defined multilocular peripherally enhancing cystic lesion with mixed internal attenuation and peripherally arranged daughter cysts and curvilinear calcification []. The cystic lesion replaced almost entire right kidney causing enlargement and architectural distortion measuring 5.5 cm × 7 cm × 13.5 cm with no contrast excretion. Rest of the examination was normal. Serology was not done due to nonavailability at our center. A final diagnosis of primary right renal hydatid cyst was arrived at.
The patient was started on tablet albendazole 10 mg/kg/day in two divided doses with fatty meal and hematinics. Urology consultation was sought, and the patient was explained ab

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


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

[User]
RADIOLOGY NOTE:
A 10-year-old boy reported to private dental clinic due to missing upper front teeth following self-fall (). The time lapsed following the trauma was 4 days. Dental examination revealed clinically missing 21 and 22. 11 was extruded, palatally displaced and mobile. The avulsed permanent teeth (21 and 22) were stored in dry condition for 4 days and were brought to the hospital in a match box (). Clinical and radiographic maxillofacial examination revealed that there was no fracture of the maxilla, mandible or other facial bones. However, the radiograph confirmed the diagnosis done during the clinical examination. He had no other injuries and his medical records were uneventful. Poor prognosis was expected if the avulsed teeth were reimplanted, since there was prolonged extra oral dry storage time and conditions in which the teeth were stored was also not favorable. Considering the above factors decision was made not to reimplant the avulsed teeth. The treatment plan was to reposition the extruded 11 followed by splinting for stabilization. However, conventional splinting was not favorable in this case as 21 and 22 were avulsed. Hence a modified splint was planned. After administration of local anesthesia, the extruded 11 was repositioned using axial finger pressure on the incisal edge of the tooth (). Splinting was done with acrylic anterior teeth placed in the region of the missing 21 and 22 (). Glass ionomer cement bite plane was given on 36 and 46 to relieve occlusion. Patient was advised to consume soft diet and was instructed to maintain meticulous oral hygiene. This splint served the purpose of esthetics as well could help in the stabilization of the extruded 11. Post-operative phase () was uneventful with subsequent reduction in the pocket depth both labially and lingually indicating successful reattachment of periodontal ligament fibers. After 3 weeks radiographs were repeated to evaluate the pulpal and periodontal status. There was neither any periapical radi

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


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

[User]
RADIOLOGY NOTE:
A 24-year-old Asian Indian male presented to our uvea clinic with a complaint of difficulty in vision since 1 month. Systemic history was unremarkable. His best corrected visual acuity in right eye was 6/24 for distance and N8 for near and in the left eye was counting fingers at 1 m with near vision less than N36. Anterior segment was unremarkable in both eyes. He had bilateral vitreous haze and fundus examination revealed necrotizing hemorrhagic retinitis in the right eye and acute retinitis in the left eye []. Fluorescein angiogram showed early blockage of background fluorescence, followed by late staining of the retinitis lesions []. SD-OCT showed thinning of inner retinal layers with hyporeflective spaces in outer retinal layers with increased reflectivity of retinal layers, more in right eye than left eye []. Aqueous tap analysis was negative for cytomegalovirus, varicella zoster virus, herpes simplex virus, and chikungunya virus. With a working diagnosis of necrotizing herpetic retinopathy, he was empirically started on oral valacyclovir (1 gm thrice/day) and oral prednisolone (60 mg/day) in a weekly tapering dose. He was regularly followed up and at 1 year of presentation his vision improved with best corrected vision of 6/18, N6 in right eye and 3/60, N36 in left eye, with retina showing healed lesions, however he had developed disc pallor in the left eye. Eighteen months after initial presentation, the patient returned with sudden deterioration of vision in the left eye. On evaluation, right eye vision was same but left eye vision had dropped to hand motion close to face. On ocular examination, right eye was quiet with healed retinal lesions as before. Left eye had developed a subtotal retinal detachment with nasal thinned out retina with breaks []. Patient underwent pars plana vitrectomy with silicon oil injection. Surgery, and postoperative period were uneventful. At 6 weeks postop, his vision in left eye had improved to 2/60

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


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

[User]
RADIOLOGY NOTE:
A 34-year-old female was seen in the emergency department for abdominal pain. Her workup included a CT abdomen where she was found to have bilateral renal masses: 2.4cm on the right and 7.6 cm on the left (). Also noted were multiple small cysts in the lung bases. The rest of the workup was unremarkable and her abdominal pain resolved with conservative management alone. She was referred to urology where it was recommended that her left kidney tumor be resected and to defer the right pending pathology results. Notably, she had no prior medical history and no relevant surgical history and had otherwise been healthy and well. She has two siblings without lung, skin, or kidney symptoms and her parents are likewise healthy. She has a 15-year-old son who is healthy. There were no consistent skin findings on exam.
Pulmonary evaluation with a CT of chest identified basilar predominant multiple lung cysts with the largest cysts measuring approximately 1.6cm. Several <6mm partially solid nodules were noted as well. Spirometry, diffusion capacity, and plethysmography were all within normal limits. She did complain of mild dyspnea, but that this was intermittent and had a significant anxiety component.
She eventually underwent resection of the left kidney mass with a partial nephrectomy and a final pathologic diagnosis of an oncocytoma, which is a typical tumor type for Birt-Hogg-Dubé syndrome. Her postoperative course was unremarkable with a planned sequential right nephrectomy pending further evaluation.
Birt-Hogg-Dubé syndrome was suspected given this patient's basilar predominant multiple lung cysts and bilateral renal masses, but without skin findings the diagnosis was in question. There are no universally accepted diagnostic criteria, but typically either skin findings or a pathologic mutation must accompany the lung and kidney pathology to solidify the diagnosis. Genetic testing was thus obtained via a blood sample. The FLCN gene of the patient was sequenced with any del

[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 female patient reported to the Department of Periodontics, CSI College of dental Science, Madurai, with a chief complaint of the mobile upper front teeth. The patient also complains of spacing between upper and lower anteriors that keep increasing over a period of 6 months. All teeth were present with root stump in relation to 16 and 26. Her oral hygiene status was fair. No familial history could be elicited.
Her gingival examination revealed reddish discoloration in the upper and lower anterior region, with rounded margins in the anteriors. The gingiva in the anterior region was soft and edematous, with loss of stippling. There was generalized bleeding on probing evident. The gingival margin was apically placed in relation to the upper and lower anteriors.
A full-mouth periodontal charting revealed generalized periodontal pockets and clinical attachment loss. Pocket depths were deeper in the molar and incisor region with recession evident in the upper and lower incisor region. Clinical attachment loss ranged from 7 to 10 mm in the incisor region and 5–7 mm in the molar region. Most of the teeth were Grade I mobile, with Grade II mobility in 12, 22, 24, 31, 32, 41, 42 and Grade III mobile 11, 21.
An orthopantomogram and a full-mouth intraoral radiograph were taken. Radiographic findings revealed generalized horizontal bone loss with severe bone loss in the anterior region. There was a typical arch-shaped bone loss in relation to the first molar region []. A routine blood investigation revealed no abnormal findings.
Based on the patient's history, clinical findings, and radiographic findings, it was diagnosed as generalized aggressive periodontitis, according to AAP 1999 classification.
A through supragingival scaling was done, and oral hygiene instruction was given to the patient. Modified bass method was advised and chlorhexidine mouthwash was prescribed. Amoxicillin 500 mg and metronidazole 400 mg were prescribed for 7 days

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

[User]
RADIOLOGY NOTE:
A 17-year-old male with complete transposition of the great arteries, ventricular septal defect, and pulmonary stenosis had previously undergone a Rastelli repair with placement of a 16 mm pulmonary homograft in infancy. He subsequently underwent conduit replacement with a 20 mm aortic homograft at 7 years of age that was then balloon dilated at 12 years of age. A transcatheter Melody valve was placed within this homograft soon after balloon dilatation. He did well for 5 years following Melody valve implantation with minimal gradient across the conduit and no more than mild regurgitation. He presented with a 2 days history of fever, diarrhea, vomiting, and an episode of syncope. On examination, he was pale, febrile, icteric, tachycardic, and hypotensive. Two sets of blood cultures grew methicillin-sensitive staphylococcus aureus. He was admitted to the intensive care unit and resuscitated with intravenous fluids and inotropes (dopamine 5 μg/kg/min). He was commenced on intravenous vancomycin (1 g every 12 h), rifampicin (300 mg every 8 h) and gentamicin (62 mg every 12 h). Subsequently, vancomycin was stopped and intravenous oxacillin (2 g every 4th h) was started based on the sensitivity results. Right ventricular pressure estimates on echocardiography were initially normal, and increased over the 1st 48 h of hospitalization to near-systemic pressure. The stent within which the valve was mounted precluded direct visualization of the Melody valve leaflets to assess their motion or examine for vegetations. Cardiac magnetic resonance (CMR) imaging did not reveal perivalvular abscess and was also suboptimal for evaluating the internal anatomy of the pulmonary valve. Computed tomography (CT) of the chest showed multiple cavitary nodules of varying sizes throughout both the lungs, most pronounced at the apices, and associated with pulmonary vasculature, suggestive of septic emboli []. His condition stabilized over the next 48 h and he was discharged from the intensive ca

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

[User]
RADIOLOGY NOTE:
A healthy 42-year-old man visited the Department of Prosthodontics of Dar Aluloom University seeking a replacement for his missing mandibular right first molar which had been extracted several years ago after unsuccessful endodontic treatment (). His dental history also included orthodontic treatment for about two years to correct malocclusion (crowding in some areas and spacing in other areas because of his missing four first molars). The orthodontist referred him to the prosthodontic clinic to restore the narrow space in the mandibular right first molar area, which had not been closed by the orthodontic treatment. The clinical investigation revealed a narrow mandibular first molar space that contraindicated for implant placement (). In addition, the mandibular right second molar had an occlusal amalgam restoration with occlusal recurrent caries (). The majority of teeth were vital, and the oral hygiene was good. A periapical radiograph revealed a deep existing amalgam restoration in the mandibular right second molar, with no periapical abscesses or other significant findings. After making primary impressions for diagnostic casts and consultation with other specialists, a treatment plan was formulated to replace the missing tooth with a minimally invasive resin-bonded IRCFDP []. The patient was informed about the risk of the proposed treatment and its alternatives, including a conventional cantilever FDP and IRFDP. After rubber dam placement, the existing amalgam restoration on the second right molar and the caries were removed, providing a cavity for the inlay retainer, which followed the preparation principles for ceramic inlay restorations []. The inlay cavity was prepared without bevels with fine-grit diamond rotary instruments by removing sharp margins, smoothing the pulpal floor, and preparing two retainer-wings buccally and lingually. The enamel surface was reduced by approximately 0.5 mm to provide a 3 × 4 mm enamel area for bonding (). The reduction was pa

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


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

[User]
RADIOLOGY NOTE:
A 39-year old male presented with left sided pelvic pain for 1 year. He was evaluated elsewhere where MRI pelvis was suggestive of a soft tissue lesion in left pubic bone involving the body, superior and inferior rami, extending into ischiopubic rami, ischial tuberosity and sub-articular margin of anterior pillar of acetabulum with dimension 10 × 6.5 × 10.3 cm consistent with chondrosarcoma in view of chondroid pattern of matrix mineralization (Fig. a, b). His distant metastatic work up was negative. He underwent type II plus type III pelvic margin-free resection with histopathologic diagnosis of mesenchymal chondrosarcoma at a different hospital with pathological staging of pT2N0M0 (Stage IB) in April 2014. A follow up scan showed normal post-operative changes with no evidence of residual disease or distant metastases and was kept on observation by treating physician. In November 2014 after disease free intevral (DFI) of 7 months, he developed asymptomatic bilateral pulmonary metastases for which pulmonary metastatectomy was planned. After a course of 3 cycles of ifosfamide-adriamycin based chemotherapy, re-assessment in January 2015 revealed marked improvement in lung nodules but there was new evidence of gross local recurrence in form of left iliac bone and acetabular soft tissue lesion with irregular destruction of residual bone; the lesion was encasing the femoral head and infiltrating adjoining soft tissue. The patient underwent repeat pelvic resection in March 2015 but pulmonary metastatecomy was deferred in view of good response of pulmonary lesions to chemotherapy. In January 2016 after progression-free survival (PFS) of 11 months, the patient was found to have ill-defined soft tissue mass at left iliac bone and left hip along with another mass 7.5 × 6.5 cm dimension, at left hemipelvis suggestive of residual disease in left iliac lesion and progression of ischial lesion and multiple bilateral lung metastases. He underwent repeat local resection in February

[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 70-year-old man who presented with exertional dyspnea, which had persisted for one week and aggravated dyspnea, which had persisted for two weeks. He had been diagnosed with asthma two years previously and had regularly used inhaled corticosteroids since then. He had a 48 pack-year smoking history. On admission the patient had decreased breath sounds and coarse crackles in the left lower lung field. A laboratory test showed a normal blood leukocyte count and abnormal partial pressure of oxygen (59%) and oxygen saturation (88%) values. Chest radiography revealed an area of high density in the left lower lung, which led to a diagnosis of obstructive pneumonia and atelectasis (Fig. A). Computed tomography (CT) revealed a mass of 20-mm in diameter with smooth edges and a uniform density in the left main bronchus (Fig. B). Magnetic resonance imaging (MRI) revealed water signal intensity with low signal intensity on T1-weighted imaging (Fig. C) and high signal intensity on T2-weighted imaging (Fig. D), further suggesting a cystic lesion.
Flexible bronchoscopy revealed a shiny mass with a smooth surface and abundant blood vessels blocking the left main bronchus (Fig. A). When grasped by forceps, the cyst wall was easily broken and a sticky transparent secretion flowed out of the cyst. Polypectomy through bronchoscopy was finally performed. Histopathology confirmed a cystic lesion that consisted of ciliated columnar epithelium lining cells covering the lumen and collagenous fibres with a bronchial gland covering the wall (Fig. B). The cyst was not infected and nor malignant. The patient underwent follow-up examinations at six and 16 months after polypectomy. The remaining part did not grow in size. The detailed examination of the lesion by CT showed the oesophagus running on the dorsal side of the rear wall of the left main bronchus, which was the site of occurrence. We understood that the lesion was entering the gap between the two.

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


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

[User]
RADIOLOGY NOTE:
A 14-year-old 3.5 kg female spayed strictly indoor domestic shorthair cat was admitted to the Small animal clinic, Veterinary faculty Ljubljana, Slovenia, for evaluation of a facial skin lesion of approximately two weeks duration. The history and general physical examination were unremarkable, except for a small superficial autotraumatic skin lesion in the right mandibular region (ventrally at the level of the right mandibular canine tooth). A brief dermatologic examination of the cat revealed no other abnormalities of the skin or coat and no evidence of ectoparasites. The right rostral mandible appeared swollen. On a brief oral examination, several missing teeth, a severely mobile right mandibular canine tooth and moderate generalized plaque, calculus and gingivitis affecting the remaining of the teeth were noted.
Informed consent was obtained from the client to perform a detailed oral and dental examination under general anesthesia with dental radiographs and biopsy, as indicated. A basic preanesthetic bloodwork panel was within normal limits (Table ). The three-view thoracic radiographs were unremarkable and other diagnostic imaging procedures (e.g., CT scan) were declined by the owner. The detailed oral and dental examination revealed swelling and palpable instability of the rostral mandibles with severe mobility of all of the mandibular incisor teeth and the right mandibular canine tooth. No excessive probing depth, gingival recession or any other soft tissue lesions were diagnosed for any of the teeth (Fig. ). Several teeth were missing, gingivitis was present on all of the remaining teeth and tooth resorption of various stages was diagnosed at several of the remaining teeth. The dental radiographs of the rostral mandibles are presented in Fig. . The mandibular lymph nodes were palpably within normal limits.
Based on the clinical and radiographic features, an aggressive process, such as osteomyelitis or cancer, was suspected, and a biopsy was recommended. 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 47-year-old housewife presented with 2 days history of foreign body sensation and reduced vision over the left eye (). There was no history of trauma. She has never used glasses or contact lens in the past as she claimed that her visual acuity on each eye was equally good. On examination, her visual acuity was 6/9 in the right eye and counting finger in the left eye. The conjunctiva of the left eye was injected. There was no foreign body. There was a stromal abscess at the centre of the cornea measuring 2.8 mm × 2.5 mm with overlying cornea epithelial defect of 2.0 mm size in diameter. The edge of the abscess was well defined. There was no endothelial plaque or satellite lesion to suggest fungal keratitis. The left eye anterior chamber filled with inflammatory cells and a level of hypopyon (0.8 mm). Cornea sensation on the left eye was slightly reduced compared to the right eye. The left eye posterior segment was hazy in view. Both eyes have similar intraocular pressure ranging from 14 mmHg to 16 mmHg. The right eye was entirely normal.
Topical Ceftazidime 1% and Gentamicin 0.3% eye drops were commenced after cornea scrapping. She was admitted the same day for intensive treatment of the left cornea ulcer. Later that day, fungal hyphae were seen on cornea sample under the microscope. Gram stain for bacteria was negative. She was started on eye drop of Amphotericin B 0.15% while Gentamicin eye drop was changed to Ciprofloxacin eye drop. On the day of admission, her random capillary blood sugar was found out to be 30.6 mmol/L. She is only known to suffer from hypertension for the past 4 years. Her blood sugar was subsequently well controlled with two types of oral hypoglycaemic agent and comanagement with dietician. The hypopyon in the left eye has completely disappeared after 3 days on treatment.
However, 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 72-year-old female presented to the emergency room with the complaint of left thigh pain and the inability to walk after tumbling. She had been suffering from osteoarthritis of the left hip but was able to walk with a cane and sit on a couch. She had also received the diagnosis of osteoporosis and had been taking alendronate 35 mg weekly for six years. The initial radiograph in the emergency room showed a non-comminuted subtrochanteric fracture of the left femur with cortical thickness and the beaking of the lateral cortex at the fracture site. The fracture line was transverse on the lateral side and oblique on the medial side. The radiographic findings and the weakness of the force that caused the fracture satisfied the criteria for an atypical fracture of the femur. The radiograph showed Kellgren-Lawrence grade 4 osteoarthritis of the left hip as well, with superomedial migration, the external rotation of the femoral head, and the shortening of the femoral neck (Figure ).
Osteosynthesis with intramedullary nailing was planned. However, the deformity of the hip joint appeared to preclude correct nail insertion. Furthermore, whenever we used a fracture table in the past, we often observed that the perineal post of the fracture table impeded the adduction of the proximal fragment of the subtrochanteric fracture while the whole leg was being adducted, resulting in varus malalignment. On the other hand, we were aware of easy access to the entry point via the standard lateral decubitus position without using the perineal post. For these reasons, we decided to fix the fracture with a nail in the lateral decubitus position. Total hip arthroplasty with fracture fixation was not chosen because of its invasiveness, which was inappropriate for the rather mild, pre-injury symptoms due to osteoarthritis, and because of the patient’s wish to preserve the femoral head.
In surgery, a flat, radiolucent operating table was used. The whole injured leg was sterilized and draped,

[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 42-year-old female patient was admitted to our hospital on September 18, 2015. She had a 4-year history of recurrent oral ulcer, a 1-year history of right abdominal pain, a 6-month history of perineal ulcer, and a 4-month history of abdominal mass. She was diagnosed with an appendiceal abscess with cecum rupture and perforation in 2014 at a local county hospital. She received a partial cecum ileocecal resection and intestinal anastomosis. Then, an abscess incision and drainage were performed twice at that hospital. Fecal fluid discharge was observed during each procedure. Six months prior, she underwent an excision of a perineal ulcer at the local county hospital.
A CT scan of the intestinal tract at our hospital indicated that her CD was multi-series. There were perforation of intestines and formation of a local abscess near the original surgical incision on the anterior abdominal wall. Her colonoscopy showed polypoid change. The pathologic biopsy indicated severe chronic active inflammation of mucosa.
Laboratory tests revealed that HB was 99 g/L, ALB was 30.1 g/L, and ESR was 113 mm/h. Her admission diagnosis was CD with possible intestinal fistula.
On October 13, 2015, she underwent several surgical procedures at our hospital. These procedures included exploratory laparotomy, resection of the diseased small intestine, ileum end ostomy, and right lower abdominal sinus clean-up. She also received nutritional therapy during the perioperative period, which will be discussed below. Due to her poor economic status, 1 month after surgery, she had to choose azathioprine instead of infliximab (IFX).
This patient had a weight loss of 15 kg prior to this hospitalization. Her admission body weight was 34 kg and her body mass index (BMI) was 14.2 kg/m2. Our gastrointestinal surgeons removed her diseased small intestine and made a temporary ileostomy. This was done to remove the irritation of antigens from food and to optimize the “full rest”

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


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

[User]
RADIOLOGY NOTE:
A 35-year-old male presented with complaints of painful restriction of the right shoulder motion for the last 3 months. The pain was insidious in onset, dull-aching to pricking in character, occurring only while attempting extreme motions of the joint, more so in activities that involved raising the arm in an overhead position, e.g. bowling during the sport of cricket, reaching for articles placed high on the shelf or while sleeping on the affected side where it used to wake the patient in the night. There was no history of trauma, massage, morning stiffness, involvement of any other joint or any other medical or surgical history of illness. There was no history of any other lump in the body. On examination, the right shoulder appeared normal on inspection. There was no tenderness over the anterior, posterior or superior aspects of the shoulder as well as in the subacromion region. A mass was palpated in the right axilla, which was tender on deep palpation, well circumscribed, of the size of a small orange, firm in consistency and adherent to the underlying structures but not to the overlying skin. The mass became prominent on full abduction and used to move with the movement of the scapula. The mass was nonpulsatile and no bruit was heard on auscultation. The range of movement (ROM) was 0–160 degrees of abduction, with pain starting on 120 degrees and partially relieved on abduction beyond. Flexion, extension and internal rotation were comparable to the other (normal) side. There was 30 degrees of painful restriction of external rotation on the right side as compared with normal. The patient on further questioning revealed that this mass started as a small nodule observed while playing cricket 20 years back. The mass increased in size gradually but the patient ignored it till such time that he developed restriction of right shoulder movements, abnormal fullness and discomfort in the right axilla. Thorough clinical

[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 78 year old man with a history of atrial fibrillation, significant weight loss, and hypertension sustained a posterior dislocation of his right shoulder following a fall whilst getting off a bus. He did not have a history of any previous injury or symptoms regarding his shoulders. Following unsuccessful attempts to reduce his shoulder under sedation in the accident and emergency department, he underwent a closed reduction under general anesthesia. The shoulder joint, on examination, was found to be unstable on internal rotation beyond 10 degrees. Two weeks following a closed reduction, he sustained a recurrence of dislocation whilst putting on his shirt. X-rays demonstrated the presence of a large reverse Hill Sachs defect (Fig. , ). While performing a closed reduction under general anaesthesia with fluoroscopic screening, this defect was seen engaging the glenoid on internal rotation beyond 10 degrees. Screening was performed in all degrees of rotation, both in the reduced and unreduced positions to assess the maximum volume of this defect. A decision was taken to surgically repair the defect over the anteromedial humeral head without the need for further CT scans as fluoroscopic screening suggested the defect to be of sufficient size to contribute to a recurrent dislocation. Pre-operative x-rays and intraoperative screening confirmed an arthritic acromioclavicular joint. Excision of the lateral 1cm of the clavicle is a well described procedure in the management of acromioclavicular joint arthritis []. The size of the excised fragment was estimated to be of sufficient size to cover the reverse Hill Sachs defect as determined using fluoroscopy. An open reduction, bone grafting and shoulder stabilization was performed.
With the patient in a beach chair position, the shoulder joint was approached anteriorly through a standard deltopectoral approach. The subscapularis was divided in Z-lengthening pattern, and carefully dissected medial to the glenoid neck. A 3 cm X 4

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


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

[User]
RADIOLOGY NOTE:
A three-year-old male bear (bear-02), which was managed by the reintroduction program of ABB, was rescued from a traffic accident on the May 11, 2018 (bear-02 moved to the mountains after the collision with a bus on the 5th of May and we were able to capture him on the 11th of May). When captured, the animal weighed 110 kg and seemed to have a fracture of the left humerus. This bear was transferred to the same veterinary team and a non-reducible comminuted fracture of the left humerus was confirmed radiographically (Fig. a). Blood examinations revealed increased white blood cells, AST, and C-reactive protein. On the 17th of May (12 days after the accident), preoperative radiographs of both the injured and the contralateral humerus were obtained. From these radiographs, a plate of the appropriate length was selected in an attempt to span the entire length of the humerus. Immobilization and monitoring of vital signs were followed by the same procedures used for bear-01. Bear-02 was placed in a supine position and we approached laterally for the surgery. A longitudinal skin incision was made from the center of the deltoid insertion to the lateral epicondyle, and the lateral head of the triceps was exposed by the insertion of the brachial fascia. The humerus was exposed by elevation of the brachialis and triceps from the lateral intramuscular septum. We tried to remove a bone fragment that was lodged in the deep medial head of the triceps and repair the alignment of the humerus; however, it was impossible because of the exuberant granulations and muscular contraction. Thus, we only cut the sharp edge of the broken humerus using an electric surgical saw (BH 100S, IMEDICOM, Gunpo, South Korea) without removal of the bone fragment and then we repaired the alignment of the humerus. Then, a 10 holes’ 5.0 locking compression plate (L

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


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

[User]
RADIOLOGY NOTE:
To our knowledge, this is the first reported case of an index finger MCP joint dislocation surgically treated by a lateral approach.
The authors describe a case of a 16-year-old male who suffered a fall onto his outstretched right hand during a soccer game. The patient presented to the ER with pain and deformity of the index finger MCP joint. Volarly, the prominence of the second metacarpal head was evident ().
Radiographs confirmed a dorsal index finger MCP joint dislocation and showed a small dorsal osteochondral fragment (Figures and ).
After multiple unsuccessful reduction attempts under ring block by different physicians, the patient was referred to surgery.
Under general anesthesia, a lateral surgical approach () was performed on the MCP joint. A straight longitudinal incision was made over the lateral aspect of the MCP joint; the volar neurovascular bundle and the dorsal branch of the digital nerve were identified and retracted with Farabeufs.
Interposition of the volar plate () preventing the reduction was observed. Applying gentle traction and flexion, the MCP joint was reduced, and proximal volar plate reinsertion with a 4-0 Vicryl suture was performed.
The posterior joint capsule was identified and split longitudinally, above the collateral ligament. Once adequately exposed, a small osteochondral fragment was found (). Reduction and retrograde fixation of the osteochondral fragment with a 1.7 mm screw were performed, burying the screw head in the cartilage.
The joint capsule, subcutaneous layer, and skin were closed using appropriate sutures. Reduction was confirmed by intraoperative fluoroscopy.
The patient was placed in a volar splint with approximately 45° of flexion and discharged on postoperative day zero without any complications.
Immobilization was removed by week 3. Radiographic control revealed joint congruence, and the patient was encouraged to actively mobilize the finger.
At week 6, the fracture was consolidated (Figures and ). The joint was p

[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.