[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 66-year-old man was referred to our hospital with the diagnosis of a left ventricular mass detected incidentally during transthoracic echocardiography that was performed prior to a cholecystectomy. He had no cardiac symptoms or history of embolism. On physical examination, he had normal heart sounds without any cardiac murmurs. The results on chest radiography, electrocardiography, and blood examinations were normal. Transthoracic echocardiography revealed a mobile mass, 16 mm in diameter, originating from the anterolateral wall of the left ventricle. Its stalk was short, and the tumor was directly attached to the ventricular wall. The diameter of the left ventricle was 52 mm in the diastolic phase and 30 mm in the systolic phase. The ejection fraction (EF) of the left ventricle was estimated as 80 %. Computed tomography showed a homogeneous 20-mm-diameter tumor that originated from the anterolateral wall of the left ventricle with an extremely short stalk.
Under general anesthesia, the heart was exposed through a median thoracotomy. The pericardium was retracted by Lima suture []. The tumor was observed in detail via transesophageal echocardiography (TEE). Tumor location, its relation to the coronary arteries in particular, was estimated by gentle pressure placed on the left ventricular wall by the surgeon’s finger. The origin of the tumor was detected to be on the free wall of the left ventricle between the first diagonal and obtuse marginal branches (Fig. ). The incision line was carefully planned under echo-guidance and then cardiopulmonary bypass through bicaval and aortic cannulation was instituted. The heart was arrested with antegrade tepid blood cardioplegia. The final location of the incision was determined by epicardial echocardiography focused on the surgical margin. A 3-cm-long ventriculotomy was placed between the first diagonal and obtuse marginal branches along the planned incision line. A gelatinous 18-mm mass was directly visualized and found to

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


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

[User]
RADIOLOGY NOTE:
A 53-year-old female with poorly controlled diabetes mellitus (DM) was brought to the emergency department with focal motor clonic seizures induced by forced voluntary eye closure due to rubbing her eyes. During hospitalization it was observed that seizures began when she closed her eyes strongly. Every time she repeated the eye closure the seizures recurred. The seizures started two days previously and occurred with each forced voluntary eye closure. She had no seizure with spontaneous eye blinking or sleeping, or with horizontal, vertical or rotatory eye movements. The seizures occured in the left orbicularis oculi, and then spread to the ipsilateral angularis oris and upper extremity, turning to the left side of the head. They lasted 2 to 3 minutes. The patient did not lose consciousness during seizures. She had had type 2 DM for eight years and her past medical history revealed no other significant disease. She had no history of seizures or other neurological disorder. She was using only insulin as her medication. The physical examination, including the neurological examination of the patient, revealed no abnormality. Her visual acuity, pupil reactions to light and eye movements were normal. The laboratory tests showed an elevated blood glucose level of 550 mg/dL but no evidence of ketosis. Serum osmolarity was 279.8 mOsm/L. Her ictal electroencephalogram (EEG) showed discharges of high amplitude spike-waves and multiple spikes-waves which localized to the right temporoparietal electrodes involving to the adjacent area. (). The photoparoxysmal response was not observed during the photic stimulation. Brain magnetic resonance imaging (MRI) was normal. Functional MR and single photon emission computed tomography (SPECT) were not performed. Seizure control was achieved immediately after the glucose level fell to normal levels. When the blood glucose levels decreased slowly to about 150 mg/dL in five days, the seizures ended completely. No anticonvulsants were used.

[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 46-year-old Bahraini female diagnosed as premature ovarian failure at the age of 29 years treated with hormonal replacement therapy presented with a history of epigastric abdominal pain and vomiting at the age of 37 years. Biochemical and radiological assessment showed features of acute pancreatitis in terms of elevated pancreatic enzyme level, and CT abdomen finding showed edematous pancreas with normal ductal system. It was attributed to hormonal replacement therapy after thorough investigation. Although the patient had stopped the implicated medications, she still had recurrent attacks of acute pancreatitis.
Since there was no obvious cause found for her recurrent episodes of pancreatitis, autoimmune pancreatitis was suspected.
Then, she underwent endoscopic ultrasound in 2015 which revealed mass swelling at the duodenal ampulla, and biopsy was taken. The biopsy showed ampullary adenoma with high-grade dysplasia (Figures and ).
Then, the patient decided to go abroad for further assessment where she underwent Whipple's procedure and histopathology confirmed the presence of ampullary adenoma with high-grade dysplasia.
Unfortunately, she continued to have recurrent episodes of pancreatitis despite the removal of the ampullary adenoma.
In 2016, while she was admitted under care of a surgical team for another episode of pancreatitis, she was reviewed by the rheumatology team to rule out autoimmune condition. Therefore, IgG4 level was tested (1.49 g/L (149 mg/dl)). The biopsy was reassessed and found to have increased IgG4-positive plasma cells around 30–40 per high-power field with the background of adenoma with high-grade dysplasia. Accordingly, she was diagnosed to have both IgG4-related disease and ampullary adenoma.
She was started on oral prednisolone 0.5 mg/kg and rituximab therapy with significant improvement over 1 year of follow-up as the pancreatitis attacks have reduced from around once in every month to around once in every 3 to 4 months after 3 months o

[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 man was operated 3 years back at other center for traumatic fracture C6 vertebrae. As per the notes patient had presented with grade three power in both the upper and lower limbs, however, had not received any steroids. Using Cloward's anterior cervical approach-aC6 corpectomy, and fusion was attempted with fibular bone graft and buttress screw fixation. The postoperative period was uneventful, and he had received antibiotics and rehabilitation as per surgeon protocol. Patient was asymptomatic for 3 years during which he had recovered neurologically and was ambulatory. The patient presented to us with a 4 months discharging sinus over the posterior triangle of neck and fever on and off.
He had no complaints of neurological weakness, dysphagia, abnormal neck swelling, loss of appetite, loss of weight and any past history of tuberculosis or tuberculosis contact. A differential diagnosis of tuberculosis infection was made as a posterior triangle of the neck is the most common site for a cold abscess in the neck, also India being a tuberculous endemic country.[] Hematological investigations showed raised erythrocyte sedimentation rate (ESR) 45, C-reactive protein (CRP) positive and HIV negative. He was investigated with the plain radiograph of the cervical spine, sinogram for the sinus, and computerized tomography (CT) of the neck. Radiographs showed an unusual single screw fixation with evidence of fusion without any vertebral destruction or lysis which was confirmed with CT scan [Figures –]. The images showed prominent screw head anterior to the bodies supposedly irritating the esophagus, however, esophageal endoscopy was normal. Magnetic resonance imaging was not done as the patient had a metallic implant. Sinogram showed a prevertebral collection near the vicinity of the screw draining in the right posterior neck triangle through sinus track mostly posterior to vessels and sternocleidomastoid. Chest radiographs were normal, and there was no evidence of

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


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

[User]
RADIOLOGY NOTE:
We describe a case of a 40-year-old female nurse who presented in May 2003 with an 18-month history of pain in the left thumb. Clinical examination showed soft-tissue swelling around the left thumb metacarpal. Radiographs showed an expansile lesion occupying most of the metacarpal with periosteal reaction and cortical destruction. MR scan () showed extensive destruction with expansion of the shaft of the first metacarpal of the left hand, associated with a soft-tissue mass and an extraosseous component, primarily on the dorsal aspect. On T
1 weighted images, the lesion was of low signal; on fluid-sensitive sequences, the lesion showed high signal with a thin and irregular septae. Following contrast medium administration, inhomogeneous, multilobulated, peripheral enhancement of the lesion was noted but also areas of non-enhancement predominated centrally, consistent with a cartilaginous lesion.
The CT scan () demonstrated a lytic lesion involving virtually the entire shaft of the first metacarpal of the left hand and reaching the subchondral bone plate at both ends. The lesion demonstrated a significant expansion of the bone with small areas of punctuate calcification, significant thinning of the cortex circumferentially and a breach in the cortex with some new bone formation on the dorsal aspect. Some soft-tissue swelling was also seen. There was no evidence of pulmonary metastases on the CT scan () at initial diagnosis.
An open biopsy was performed in June 2003, the histology of which revealed a grade II chondrosarcoma with evidence of spread beyond the cortex into the periosteum. Vascular invasion was not identified. 1 month later, under general anaesthesia, a first ray amputation was performed with disarticulation of the thumb at the trapezioscaphoid joint. A tourniquet was used at the time of the surgery to exsanguinate the limb. Macroscopic examination revealed an expansion of the metacarpal bone due to a chondroid tumour measuring 35 × 25 mm, which eroded thro

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


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

[User]
RADIOLOGY NOTE:
A 26-year-old female was admitted to the Department of General Surgery of Daping Hospital and Research Institute of Surgery (Chongqing, China), due to the presence of a painless mass in the left breast for three months. The patient indicated that the mass had recently grown rapidly. The patient had no notable medical history or family history of carcinoma. Clinical examination revealed a 3×2-cm firm irregular mass in the upper inner quadrant of the left breast. There was no change in the appearance of the local skin, no discharge from, or retraction of, the nipple. A small number of lymph nodes were palpated in the left axilla. The breast magnetic resonance imaging result indicated left breast cancer due to the presence of enlarged left axillary lymph nodes. A chest computed tomography (CT) scan demonstrated widespread lung and pleural nodules, indicating lung and pleural metastases. An emission CT whole body bone scintigraphy indicated destruction to multiple ribs, the cervical vertebrae and thoracic bone. A core needle biopsy of the breast mass and hematoxylin and eosin staining demonstrated that the mass tissue was comprised of a large distribution of diffuse small cells. Those cells were round or oval, with large nuclei and nucleoli, and abundant cytoplasm. No significant intracellular pigmentation was observed (). Immunohistochemistry demonstrated that the tumour cells were immunopositive for S-100, HMB-45 and melan-A (). However. a panel of markers that included epithelial markers, such as cytokeratin (CK) and epithelial membrane antigen (EMA), and mesenchymal markers, such as vimentin, smooth muscle antigen (SMA), estrogen receptor, progesterone receptor and HER2 were negative. The percentage of Ki-67-positive cells was 30%.
Based on the pathologic and immunohistochemical features, a diagnosis of malignant melanoma was proposed. Careful examination of the skin and mucous membranes failed to reveal a malignant melanoma. Therefore this patient was diagnosed wit

[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 first patient is a 58-year-old man who was a previous smoker who presented to an outside hospital with abdominal pain and was diagnosed with gallstone pancreatitis. However, despite having a laparoscopic cholecystectomy, he continued to have episodes of pancreatitis yearly for the next 3 years. Computed tomography (CT) scan demonstrated a pancreatic duct dilated throughout its course to a maximum size of 8 mm without a discrete pancreatic mass in the head of the pancreas. Endoscopic retrograde cholangiopancreatography confirmed a dilated pancreatic duct with a suspected filling defect of the common bile duct, after which the patient underwent sphincterotomy and stent placement.
He then presented to our institution for consultation. Further workup with endoscopic ultrasound (EUS) was performed, which also confirmed the dilated pancreatic duct, but noted irregular contour of the duct. In addition, free mucin was seen exiting the main papilla, and there was a papillary growth noted in the pancreatic duct in the head of the pancreas, all of which was consistent with a main duct IPMN (). Preoperative laboratory values, including CA19-9, were within normal limits. Of note, it was unclear if the dilatation of the pancreatic duct was secondary to obstruction from the mass in the pancreatic head or due to main duct IPMN involving the entirety of the duct.
He was scheduled for surgical resection after the stated workup. He was planned for a Whipple procedure (pancreaticoduodenectomy) with possible total pancreatectomy if intraoperatively the main duct was found to be involved by IPMN with high-grade dysplasia. Transection of the pancreatic neck identified cells of high-grade dysplasia free floating near the margin (although exclusive of the margin). In addition, upon probing the pancreatic duct in the tail of the pancreas, the probe did not slide smoothly, suggestive of additional growths in the duct. Due to his young age and high risk of developing pancreatic cancer, a 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 30-year-old pregnant patient at 14 weeks' gestation, who was in her second pregnancy with a previous cesarean delivery, went to her primary care physician with mild abdominal pain and nausea. After receiving fluids and endovenous analgesics, resulting in an improvement of symptoms, she was discharged. Twelve hours after the onset of pain, she came to the first-aid post with diffuse abdominal pain, malaise, and reports of syncope. On admission, she exhibited mucocutaneous pallor, tachycardia (108 bpm), mild hypotension (BP 90/60 mmHg), moderate hypogastric pain, decreased bowel sounds, and a positive rapid decompression test. The uterus was palpable 2 cm above the pubic symphysis and the fetal heartbeat was 140 bpm. Secondary exams showed hemoglobin at 5.3 g/dL and hematocrit level of 16.7%. An ultrasound revealed a large amount of free fluid in the abdomen, suggesting the presence of hemoperitoneum.
The patient was immediately taken to the operating room for a diagnostic laparoscopy. During the inventory of the abdominal cavity, about 2.5 liters of blood was aspirated (Figures and ) and after careful inspection, active arterial bleeding in the left uterine vessel topography was detected (). Due to the uterine size and technical difficulty, the most feasible surgical option was conversion to Pfannenstiel laparotomy, followed by dissection of the left retroperitoneal space with identification and isolation of the left iliac vessels and ureter. Rupture of the left uterine artery was observed, after which it was connected to its origin and to its distal portion (close to the uterus) obtaining full bleeding control.
Fetal viability was evaluated by obstetric ultrasound and remained preserved. After the transfusion of three units of packed red blood cells, the patient demonstrated an excellent recovery and was discharged two days after surgery.
The pregnancy continued without complications and childbirth occurred electively at 39 weeks of pregnancy via cesarean section.

[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 woman presented in July 2017 with extensive bleeding from her ileostomy site. Her history included locally advanced bladder cancer for which she had undergone pelvic exenteration and ileal conduit formation in November 2015. At that time, she had a known primary lung adenocarcinoma as well, but had no known liver metastases or other liver disease. Intravenous contrast-enhanced CT of the abdomen and pelvis performed in January 2016 raised the possibility of cirrhosis; however this was not biopsy-proven. In April 2016, she began to notice intermittent bleeding from her stoma which was initially thought to be mechanical tissue breakdown from the stomal flange. Concern for hepatic encephalopathy was raised when she had her first episode of confusion in December 2016. At that time CT of the abdomen and pelvis demonstrated strong radiographic suspicion for cirrhosis together with prominent vessels surrounding the urinary diversion site suspicious for portal hypertension. Despite not having a tissue biopsy, she was diagnosed clinically with cryptogenic cirrhosis in May 2017 during a hospitalization for fatigue, anasarca, and altered mental status. An upper endoscopy performed in June 2017 demonstrated portal hypertensive gastropathy but no esophageal varices.
Upon presentation to the Emergency Department in July 2017 she had significant hemorrhage from her stoma resulting in hemodynamic instability. She was anemic with a hemoglobin of 8.3 g/dL that improved to 9.4 g/dL after blood transfusion, but gradually fell to 8.2 g/dL by the time of the procedure. Her MELD score was retrospectively calculated to be 19 at presentation, with an INR of 1.5 and total bilirubin of 4.3 mg/dl. She was emergently taken to the interventional suite for embolization with or without portal venous decompression via portosystemic shunt formation. A review of intravenous contrast-enhanced CT imaging showed extensive venous varices around the stoma involving the abdominal wall with a 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:
A 10-year-old girl presented with a 2-day history of constant right-sided flank pain with intermittent episodes of increased intensity. Movement and laying supine exacerbated the pain, whereas some relief was found with paracetamol. There was no trauma to the area, but the patient reported playing netball shortly before the pain started. There was no associated nausea, vomiting, or change in bowel or urinary habit. There was no fever and no symptoms of cough or breathing difficulties.
The patient had no significant medical history and immunisations were up to date. On examination, she was apyrexial with a heart rate of 110 beats per minute, oxygen saturations of 99% on room air and respiratory rate of 22 breaths per minute. She was warm and well perfused with a central capillary refill time of <2 seconds. She appeared distressed when laying down reporting worsening pain; however, the abdomen was soft and non-tender to palpation. Systemic examination was otherwise unremarkable.
Urine analysis showed no evidence of infection and blood tests revealed a C-reactive protein (CRP) of 23 mg/L and a normal full blood count with white cells of 13.4 × 109 cells/L. Liver function tests, urea and electrolytes, and venous blood gas were also normal.
With normal observations, examination and investigation results and a good response to analgesia in the department, the patient was discharged with a planned review.
On re-assessment the following day, she continued to complain of significant pain on the right side of the abdomen with similar features on examination. Owing to the persistence of symptoms, chest radiography (Fig. ) and abdominal ultrasound were performed. Both were reported as normal. With no surgical or medical cause of the pain identified, it was deemed musculoskeletal in origin, associated with playing netball. She was discharged with advice to take regular analgesia and to return if symptoms were not settling.
The patient represented the following day looking unwell

[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:
On 16th March 2012, a 49-year-old female who experienced symptoms of exertional dyspnea and increased fatigue for 15 months presented at the Department of Cardiac Surgery, Xinqiao Hospital (Chongqing, China). The patient reported dyspnea, which developed following activity and sleeping in the supine position, which gradually worsened, without chest pain, heavy sweating and palpitations. The patient additionally reported poor sleep and a loss of appetite, although no marked weight loss. Two days prior to the the patient presenting at the hospital, the described symptoms worsened and the patient experienced bilateral edema in the lower limbs. Physical examination revealed cyanosis, an enlarged heart and a weakened cardiac sound. A transesophageal echocardiography demonstrated a right atrial mass originating in the inferior vena cava (IVC; size, 14×8 cm) that caused a tricuspid inflow obstruction and the abdomen ultrasonic examination demonstrated a mass in the lower right kidney. An emergency resection of the intra-atrial tumor thrombus was performed. Frozen sections obtained from the intra-atrial surgery revealed abundant necrosis with heterotypic cells. The intra-atrial tumor thrombus was tightly attached to the abdominal aorta, therefore, only a partial resection could be performed to relieve the tricuspid obstruction. Histological examination confirmed the diagnosis of a clear cell renal cell carcinoma, however, the patient’s symptoms had partially subsided following a month of recovery. The patient refused a right nephrectomy, and interleukin-2 and interferon-α therapy, as well as additional types of targeted therapy. The patient underwent intensity-modulated radiation therapy (56 Gy/24 fractions of one fraction per day, five days a week; from the IVC, where the mass initiated, to the iliac vein, which included the mass on the upper kidney). Following this, the patient refused further therapy. Six months following the radiation therapy, the symptoms had markedly

[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 male admitted in our institute with complaints of severe pain in the right index finger with inability to extend the DIP joint for 5 days. There was a history of fall from the bike before this complaint. Radiographs revealed a bony mallet fracture at the distal phalanx, with fracture fragment involving more than one-third of distal phalanx articular surface. The patient was then planned for delta wiring fixation of the fracture. The procedure was performed using an image intensifier under digital block anesthesia without a tourniquet. Appropriate reduction is confirmed on lateral X-ray with slight flexion with suspension. Insert a Kirschner wire 0.8 mm through the bony fracture fragment attached with extensor tendon from the dorsal side and make a hook on dorsal end of Kirschner wire and advance the Kirschner wire through the distal phalanx with counter force. Cut the Kirschner wire saving 2 cm length at plantar end which is now come out from the skin of plantar side penetrated through the fracture fragment, distal phalanx and make another hook. Insert another Kirschner wire 1 mm along the long axis of distal phalanx intrameduallry. Make an acute angle and another hook leaving 5mm of distance from the previous Kirschner wire. Hang the two hooks and apply dressing over them to prevent further injury (-), allowing the DIP joint to have free movement. The patient’s was discharged on the day of surgery and requested to return for weekly review. After clinical and radiological confirmation of union around 7 weeks, the Kirschner wires were removed. For removal, the first step is to untie the hook, then axial intramedullary wire pulled out easily, then the first wire was just push back slight dorsally, and the hook was cut, then from plantar side the first wire pulled out. Lateral and posteroanterior plain radiographs were taken pre-operative, intraoperative, and weekly postoperatively

[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 healthy Caucasian boy who was 11 years old presented with a spontaneous sudden pain that was localized in his right shoulder and unilateral upper arm (right hand was spared) in the absence of trauma. His family doctor prescribed paracetamol, but there was no relief of the pain. Therefore, he visited the emergency department where shoulder and upper arm radiographs show no fractures. However, an orthopedist recommended dressing and immobilization of the arm for 2 weeks. Ten days later, because of constant and persistent pain, the family doctor requested some laboratory tests. A blood cell count, levels of C-reactive protein, creatine-phosphokinase, and lactate dehydrogenase, urinalysis, and culture of a pharyngeal sample were normal. When the orthopedist removed the dressing, the boy presented with considerable weakness in the upper arm. The family doctor then recommended a pediatric rheumatological examination. There was pain to acupressure in the low cervical area with insertion and along the ridge of the right biceps with strength deficit of this muscle. This specialist doctor prescribed ex-juvantibus therapy with gabapentin 300 mg three times a day for 3 weeks as a neuroprotective action. The severe pain persisted and the muscle weakness worsened until appearance of paralysis. At this time, pain and muscle weakness also appeared on the right hand and his family doctor recommended hospitalization.
In our Pediatric Unit, the boy presented with an antalgic posture of the right arm that appeared adduct and outstretched with severe pain at acupressure of the right trapezium muscle, shoulder, and elbow. We gradually withdrew gabapentin because of problems of concentration as reported by the mother and we prescribed ibuprofen 10 mg/kg three times a day.
A neurological examination showed normal sensory function, no cranial nerve deficit, no neural sensitivity defects, no motor deficit in the lower limbs, normal tendon reflexes, and absence of Babinski sign. Muscle weak

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


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

[User]
RADIOLOGY NOTE:
A 45-year-old man was transferred to our facility for the management of recurrent cholangitis and pancreatitis due to impacted intrahepatic biliary stones. Approximately 15 years prior, the patient sustained a Grade III liver laceration while serving in combat for the US military and was managed nonoperatively.
Approximately 6 years after the initial liver injury, the patient developed right upper quadrant (RUQ) abdominal pain, nausea, and vomiting. A CT of the abdomen revealed intrahepatic ductal dilatation with intrahepatic bile stones in the right hepatic lobe, isolated to Couinaud segment 7 []. He was admitted for ascending cholangitis and gallstone pancreatitis, and underwent an open cholecystectomy with bile duct exploration and t-tube placement.
His recovery was uneventful until 2 years later, when he presented with RUQ abdominal pain and nausea, and was found to have choledocholithiasis and intrahepatic bile duct stones on CT. He was treated with an ERCP with stone extraction and sphincterotomy that cleared the common bile duct (CBD) stones. There was no report of intrahepatic stones identified or treated. A post-procedural magnetic resonance cholangiopancreatography was performed and reported no obvious obstructive stones remaining in the CBD.
Four years later, he presented again with RUQ pain and was diagnosed with recurrent ascending cholangitis and gallstone pancreatitis, and underwent repeat ERCP with stone extraction. Symptoms recurred 2 years later, and the patient underwent percutaneous transhepatic biliary drain (PTBD) placement by an interventional radiologist. Attempts to extract the stones at that time through percutaneous access using fluoroscopic guidance were unsuccessful.
Follow-up MRI of the abdomen after PTBD placement demonstrated diffuse biliary duct dilation with recurrent intrahepatic stone formation in the right posterior liver and in the CBD, complicated by acute pancreatitis []. He was transferred to our tertiary care center for furt

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


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

[User]
RADIOLOGY NOTE:
A 60-year-old male was referred to the Asan Medical Center for a nodule in the left lower lobe (LLL). The nodule was incidentally detected during the preoperative evaluation of gallstone, for which he underwent laparoscopic cholecystectomy at an outside hospital three months prior to his presentation to us. On his visit, he did not have any respiratory complaints such as productive cough or dyspnea. Medical history was unremarkable except hypertension. Further, the patient had been a non-smoker for 10 years although he used to smoke half a pack a day for 30 years before quitting.
We found that the patient's physical examination was unremarkable except decreased breath sounds over the left lower lung field. The laboratory data were all within normal limits. Chest X-ray and computed tomography scan revealed a mass having the following dimensions: 20×10×5 mm. The mass obstructed the secondary bronchus entering into the LLL, which resulted in a total collapse of LLL (). A flexible bronchoscopy showed an endobronchial mass filling the basal segments of the LLL (). Further, a biopsy indicated a granular cell tumor.
The patient underwent a left lower lobectomy via left posterolateral thoracotomy through the 5th intercostal space. The left thoracic cavity showed neither pleural adhesion nor seeding suggestive of malignancy. The LLL was heavily collapsed due to the obstruction by the endobronchial tumor. We divided the LLL bronchus at the level of the left upper lobe spur and performed a left lower lobectomy. The medial side of the left main bronchus was repaired using an interrupted anastomosis of 3-0 Vicryl. The resection margin of the bronchial stump was clear from the tumor on the frozen section. All five lymph nodes that were biopsied were tumor-free. The patient recovered well postoperatively and was discharged on postoperative day 5. Immunohistochemical staining demonstrated the positivity for S-100 protein, and the Ki-67 labeling index was low (1%), supporting the cu

[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 44-year-old female presented with a chief complaint of 3-year history of recurrent pain and intermittent swelling to the left mandibular region. The swelling was usually worsened by meals, extreme pain arising once a month. When the pain started, it lasted about 10 min, with an NRS (numeric rating scale) score of 10. She had recently begun to have pain every 4 h. On examination, there was a tense and sensitive submandibular salivary gland and visible swelling in the posterior part of the left side of submandibular area. No salivary flow was appreciated from the left submandibular duct. The radiograph showed an elongated radiopaque structure imposed on the left submandibular area (Fig. top). Computerized tomographic (CT) scan of the mandibular region showed the presence of multiple high attenuated materials and elongated sialolith located within the left Wharton’s duct. Also, very severe atrophic submandibular gland was found (Fig. bottom).
Preoperative technetium-99m pertechnetate salivary gland scintigraphy revealed that other salivary glands were within normal limits, but with no definite radiotracer excretion in the Lt. submandibular gland (Fig. ).
The patient was placed on the operating table in supine position and was induced with short-acting paralytics to allow for monitoring of the branches of the facial nerve during dissection. General anesthesia was obtained via oral endotracheal intubation. The neck was extended with the placement of a shoulder roll, and the head was turned to the opposite side of the involved parotid. The patient was prepared and draped in a sterile fashion. The ipsilateral commissure of the mouth was prepared as readily visible. The incision line was marked (standard modified facelift incision). 2% lidocaine with epinephrine was injected within the subcutaneous tissues of the proposed surgical incision, involving a standard preauricular curvilinear incision which begins at the tragus, going around the inferior border of the lobule 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:
An 89-year-old man underwent distal gastrectomy with lymph node dissection and concurrent resection of metastasis in the right axilla 6 years ago. The pathological diagnosis was T3N0M1 (skin), pStage IV. Immunohistochemistry of both the gastric cancer and right axillary metastasis tissues showed CK7 positivity, CK20 negativity, CDX-2 negativity, and a final diagnosis of solitary synchronous cutaneous metastasis originating from gastric cancer was made. The primary and metastatic tumors were resected with negative surgical margins. As adjuvant chemotherapy, seven courses of S-1 were administered. The patient was regularly followed up with laboratory tests and imaging studies with no signs of recurrence. After 6 years, the patient became aware of small, slowly growing reddish nodules on the scar of the primary surgery in his right axilla (Fig. ). On physical examination at the first visit, the vital signs were within normal limits, and the abdomen was soft and flat without tenderness, or rebound tenderness. The serum level of carcinoembryonic antigen was normal (4.8 ng/mL), and carbohydrate antigen 19-9 was slightly elevated (44 U/mL). Other laboratory data showed no abnormalities. Ultrasonography showed merged low echoic masses with a maximum size of 7 mm with high pulsation. Computed tomography revealed irregular thickening of the right axillary skin (Fig. ), and no other signs of recurrence including lungs and the abdomen were observed. Based on these findings, a diagnosis of late cutaneous metastasis from gastric cancer was made. For diagnosis confirmation and treatment, resection as a total biopsy was performed. The operation was performed with the local anesthesia without any complication. Histopathological examination revealed moderately to poorly differentiated adenocarcinoma with proliferation of atypical epithelium forming ductal and nest-like structures, and immunohistochemistry showed CK7 positivity, CK20 negativity, CDX-2 negativity (Fig. ). The histologi

[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 presented at the Neurology consultation with a six-week history of a severe, strictly left orbitotemporal headache, with a frequency of three attacks per week, occasionally more than one at the same day. Most of them occurred in the first half of the night, waking him up, and lasted between thirty minutes and one hour. He used to take ibuprofen as acute treatment, with unsatisfactory response, since he did not notice a significant difference between treated and untreated attacks in terms of duration and pain intensity. To relief the pain, he used to open the window to get some fresh air. The headache was always associated with ipsilateral conjunctival injection and lacrimation. Pain triggers were not identified by the patient. He had no personal or familial history of headaches. His medical history was remarkable for hypertension and asthma, with a past surgical history including septoplasty and bilateral middle turbinectomy and uncinectomy due to nasal respiratory insufficiency. By the time of medical evaluation he was asymptomatic and neurological exploration was unremarkable. The clinical picture was suggestive of a CH and the patient was medicated with verapamil 120 mg daily. A MRI scan was performed, which revealed a sphenoid sinus mucocele, without secure expansion of the sinus. Two weeks later the patient came to the Emergency Department with complaints of horizontal diplopia that he noted when he woke up in that morning. He maintained the headache attacks, with similar characteristics, despite prophylactic therapy. Neurological examination revealed left eye adduction palsy and ptosis. A brain CT scan was performed and excluded lesions other than the mucocele. Paranasal sinus MRI revealed molding of the medial wall of left cavernous sinus by the sphenoid mass (). A paranasal sinus CT scan was also performed to allow for a better characterization of the lesion, showing sclerosis and interruption of the roof and posterior wall of the left sphe

[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 77-year-old male patient visited our hospital with abnormal findings on his health screening examination. In September 2012, endoscopic examination showed a black-pigmented lesion at the cardia of the stomach and biopsy revealed melanoma, which presumed to be metastatic (). The advice from the pathologist was to find the primary lesion. Further examinations were performed to determine the primary origin. However, no other focus was found after physical evaluation. It was concluded that the origin of primary lesion was an unknown melanoma or the stomach was the primary lesion. In addition, abdominal ultrasonography detected the presence of a 2.4-cm sized gallbladder nodule (). Whole-body positron emission tomography-computed tomography (PET-CT) scan revealed only a hypermetabolic lesion in the gallbladder (). Surgical exploration was recommended for the gallbladder nodule and based on the possibility of primary gastric melanoma. However, the patient refused surgery and subsequent outpatient care. In February 2014, the patient returned and health screening examination showed that the gallbladder lesion had increased to 4.0 cm in size (). On endoscopic examination, the previously diagnosed melanoma of the stomach was not identified. CT scan confirmed findings observed on the ultrasonography. The radiologist indicated a possible diagnosis of gallbladder cancer and estimated a clinical staging of T3N1M0 (). Because of this possible diagnosis of gallbladder malignancy, open radical cholecystectomy including liver wedge resection was performed. Macroscopic evaluation found a dark-brown polypoid lesion measuring approximately 3.0 cm in diameter and two large lymph nodes (approximately 1.2 cm in size) adherent to the gallbladder (). Histopathologic examination of the gallbladder tumor revealed sheets of atypical cells with abundant melanin pigments in the cytoplasm that extended through the lamina propria to the subserosa (). A total of 28 lymph nodes were acquired, among

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


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

[User]
RADIOLOGY NOTE:
A 68-year-old man was referred to our pain management center from the department of neurology with motor weakness of the left leg following painful herpetic rash on his left lower extremity. Ten days before presentation, a herpetic rash occurred in his left L4 dermatome and 2 days after the onset of vesicular rash his diagnosis of HZ was made by a neurologist. He was managed with famciclovir 250 mg three times daily, tramadol 150 mg once daily, and pregabalin 75 mg twice daily. Even with these medications, his pain was rated as 7 on the visual analogue score (VAS) from 0 (no pain) to 10 (worst pain imaginable). He refused to take opioids due to side effects associated with opioids such as nausea and vomiting. Nine days after the onset of the rash, he noticed progressive motor weakness of his left lower limb. An MRI scan of his brain and lumbar spine was performed to explore the causes of weakness in his left lower extremity by the neurologist. But in the MRI scan there were no abnormalities. The neurological examination showed that the muscle strength of his left knee extension was 3/5 using the Medical Research Council muscle strength grading system [].
One year earlier he had been diagnosed with hypertension. Two month previous, he had received a cardiac stent insertion due to myocardial infarction and he was taking warfarin 2 mg and aspirin 100 mg once a day for prevention of thrombosis. His international normalized ratio was 2.2. On physical examination, herpetic rash was localized to his left L4 dermatome (). He suffered from intermittent, spontaneous, sore and throbbing pain over the left L4 dermatome, which was provoked by brushing. PCB was done with 0.5% lidocaine 15 ml and triamcinolone 40 mg under fluoroscopic guidance at the L4 transverse level (). The pain disappeared 3 days after the PCB. In addition, 6 days after the PCB, the motor weakness of his knee extension greatly improved 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:
An 88-year-old male presented in the outpatient surgical setting with a chief complaint of a right groin bulge that had been present for 6 weeks. He had sharp pain initially when he first developed the abnormality but had been asymptomatic ever since. He did not recall any inciting factors. He was concerned that a previously repaired right inguinal hernia had recurred from its original tissue repair in 1977. Details of the original right inguinal hernia repair were unknown to the patient, other than no implantation of mesh occurred. On physical examination, a 3 cm × 3 cm firm, nontender mass was palpable in the right groin just lateral to the pubic tubercle. A computed tomography scan of the abdomen and pelvis was performed to elucidate the cause of the mass in his groin (Figs. , , and ). The imaging was relevant for a right inguinal hernia with the appendix present within the sac. Preoperative laboratory testing revealed a white blood cell count of 4.7 × 109/L. The patient elected to proceed with surgical intervention for hernia repair.
The patient presented to the hospital setting for his elective right inguinal hernia repair. A classic oblique incision was made in the right groin using the anterior superior iliac spine and pubic tubercle as landmarks. The external oblique aponeurosis was opened and the hernia isolated and examined. The hernia was noted to be comprised of an extremely hard and dense amount of omentum that had a chronic, scarred appearance. The base of the appendix could be seen exiting the internal inguinal ring, but the densely adhered omentum prevented reduction of the appendix back into the peritoneal cavity. Initially, there was no indication to perform an appendectomy at the time of the procedure if the appendix could be successfully reduced into the abdominal cavity. However, the chronic appearing adhesions in the area prevented this step. In order to reduce the appendix at that point, a relaxing incision was then made in the typical transve

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


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

[User]
RADIOLOGY NOTE:
A 21-year-old woman was referred with an occasionally painful right loin mass, persistent microscopic haematuria and lower urinary tract symptoms of 3-month duration. She reported increasing breathlessness and felt dizzy whilst carrying out routine activities. Clinical examination revealed only a weak radial pulse and a palpable right renal mass with no ascites or peripheral oedema.
Ultrasound scan (USS) revealed a large 11 cm mass arising from the lower aspect of the right kidney, which extended along the right renal vein and into the inferior vena cava (IVC) and up to the diaphragm. Further radiological studies included magnetic resonance imaging (MRI) and computed tomography (CT) of the thorax and the abdomen. MRI of the kidney revealed a large 13 cm, right encapsulated, lower-aspect renal mass with tumour thrombus extending into the right renal vein, IVC and into the right atrium and occupying a significant proportion of the right atrial volume. The right atrium appeared largely distended with thrombus with a faint trickle of contrast just getting past its wall (Figures and ). There was a 12 mm paracaval lymph node and increased vascularity in the adjacent perinephric bed. Three nodules of less than 5 mm were identified within the lung parenchyma.
The patient underwent right radical nephrectomy and IVC and atrial tumour (level IV) thrombectomy with cardiopulmonary bypass in deep hypothermic circulatory arrest. The postoperative period was unremarkable apart from a pericardial effusion, which was aspirated.
Gross examination revealed a friable, greyish white, lobulated mass (125 mm × 90 mm), which replaced most of the kidney with only a small amount of uninvolved parenchyma at the lower pole. Haematoxylin and eosin staining showed the tumour to comprise cohesive sheets of small, uniform, primitive, blastema-like malignant cells separated by fibrous bands. Perivascular rosetting was noted, but there was no architectural arrangement. The malignant cells had only a

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


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

[User]
RADIOLOGY NOTE:
A 66-year-old woman was referred to our hospital with a 2-year history of painless swelling in her left cheek during mastication. The patient recalled no clear history of trauma to that region. The swelling was soft and unnoticeable in the resting state but became a round, smooth, protruding mass with a diameter of 3 cm when the patient clenched her teeth (). The mass was slightly compressible and movable on the anterior surface of the lateral mandibular body. No pulsation or bruits was noted. Ultrasonography showed a hypoechoic intramuscular mass with tubular extension and internal hypervascularity on Doppler study (). IMH of the masseter muscle was suggested.
Under a provisional diagnosis of masseteric IMH, an incision line was drawn on the left lateral neck about 10mm from the posterior border of the mandibular ramus. After sedation and local anesthesia (0.5% lidocaine and 1:200,000 epinephrine), an incision of less than 5 cm in length was made on the design from the inferior part of the earlobe to the mandibular angle; the incision was slightly curved anteriorly to follow the mandibular angle. Taking care not to disrupt the marginal mandibular branch of the facial nerve, the anterior skin flap was deeply undermined to expose the platysma muscle. The platysma muscle was cut along the mandibular border and the fibrous capsule of the mass was exposed on the anterior surface of the ramus. The fibrous capsule was separated from the covering tissue to isolate the mass from the muscle. During the separation procedure, a short incision was made on the capsule, which revealed a bulging of dark purple, soft tissue, but no bleeding from the mass. The extruded tissue was not pure hemangioma but looked like an unusual mixture of hematoma and multiple small fibers. The extruded mass with its fibrous capsule was completely removed from the muscle tissue after the pedicle was ligated. The soft mass was about 15 mm in diameter (

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


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

[User]
RADIOLOGY NOTE:
A 58-year-old male was admitted to our hospital in April 2007 with a suspected metastasis of a sigmoid cancer in the Couinaud segment (CS) 7 found during a follow-up examination using ultrasound. The patient had undergone a resection of the colon sigmoideum due to carcinoma in 2003. In addition to the liver metastasis, the patient suffered from mild hypertension and non-insulin-dependent diabetes mellitus. The only preoperative imaging was an abdominal ultrasound; thus, an additional CT scan of the abdomen was performed in preparation for the surgical intervention. The metastasis in the CS 7 had a size of 2.2 × 2.4 cm and was closely attached to the right hepatic vein (Figure ). After careful analysis of the CT scan, it became clear that the proximal part of the middle hepatic vein was completely missing, whereas its distal branches seemed to be open. In order to get more detailed information about the anatomical situation, an additional 3D imaging of this case was performed. It was evident that the middle hepatic vein was missing. Most likely this anatomical pattern was not tumour related because there was a close proximity of metastasis and right hepatic vein (Figure ) making the resection of the right hepatic vein inevitable. As the non-existence of a middle hepatic vein may have led to insufficient drainage of remnant hepatic parenchyma following a bisegmental resection of CS 6 and 7, it was decided to perform a right-sided hemihepatectomy. The pathologic examination confirmed the diagnosis of a colorectal liver metastasis. The surrounding liver parenchyma did not show any distinctive features, and in particular, no evidence of liver cirrhosis. The intra- and postoperative courses of the patient were uneventful. The patient was discharged on the eighth postoperative day.
The according CT scan was made available by the Radiology Department of the German Cancer Research Center, Heidelberg. The image data was acquired preoperatively during the routinely performed 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:
The present case is a 26-year-old woman. One year prior to the current admission, in an ultrasonography study, a well-defined lobular mass (78 × 28 × 33 mm in size) with a hypoechoic content in the posteroinferior of right kidney and a univesicular cyst of 105 × 98 × 73 mm in the lower pole of left kidney causing mild hydronephrosis had been reported (). The internal structure of the left mass was anechoic, and the cystic wall was thin and relatively regular. No alteration in the wall's structure, which could resemble a germinative membrane, was apparent.
In noncontrast CT-scan, the right mass had been hypodense and it was heterogeneously enhanced following contrast injection and a large cortical cyst in the lower pole of the left kidney with thin peripheral contrast enhancement without any other organ involvement ().
There had been no urinary symptom, gross hematuria, headache, sweating, flushing, or tachycardia. Physical exam had been normal, and abdominal masses had not been palpable.
Her medical history was also unremarkable, and no family history of hydatid disease was identified.
Medical laboratory tests including CBC, urinalysis, urine culture, and blood chemistries had been all in normal range. The patient had not been referred due to the lack of any symptom until feeling occasional mild and vague pain in her right flank from 2 to 3 months prior to the current admission.
In the second admission, no significant change in the masses was observed and all medical laboratory tests were normal. Histologic study following ultrasound-guided percutaneous core needle biopsy of the right retroperitoneal mass revealed benign schwannoma (). Open surgery with right subcostal flank approach was performed to remove the mass (). A well-encapsulated tumor in the right retroperitoneal region and anterior part of psoas muscle next to the inferior pole of the right kidney without any adhesion was observed. The tumor was enucleated and excised easily (Figures and ). There was

[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 14-year-old female was referred to emergency service with the symptoms of nausea and headache. In her oropharynx examination, only poor oral hygiene was seen by the pediatrician. There were no infection findings in her ear, nose, and throat. Her chest graphy was normal. Her urine tests and CBC were in normal limits. Analgesics were prescribed and control examination was suggested. After three days toothache started. Her parents took her to a dentist. It was said that there was a tooth abscess around right inferior first molar tooth decay. Amoxicillin and paracetamol were started and control examination was suggested. However, after two days with medication, the patient was getting worse. Submental swelling, dysphagia, and chest pain started. WBC was 20.700 per mm3, CRP was 35,7 mg/L, and her fever was 39°C. PA chest graphy was performed and a minimal increase in cardiothoracic index was detected. Neurological examination was normal. There were no pathology about eye movements, muscle strength, and tendon reflexes. Throat and blood cultures and antibiogram were performed. The patient was hospitalized in pediatrics clinic because of a lack of oral intake. Intravenous ceftriaxone and metronidazole medications were started at the first day of hospitalization. As the patient consulted otolaryngologist, in spite of impaired mouth opening abscess formation and purulent secretion from right inferior first molar tooth decay were seen. Impaired mouth opening is more likely because of the ache during the activity of the mandibula, not like trismus. Multiple lymph nodes were palpated in the submental region and bilateral submandibular and anterior cervical regions. There was tenderness in both cervical areas. Consultation by a dentist was suggested. In dental examination, abscess formation, an opening in periodontal tissue, and purulent secretion from right inferior first molar tooth decay were seen. Oral hygiene was poor but no other significant pathology was seen in oral ca

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


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

[User]
RADIOLOGY NOTE:
A 44-year-old Japanese woman visited the dental clinic office of the Oral Care Center in Kagoshima University Hospital according to a suggestion by her gynecologist. She complained about pain and bleeding from gingiva by routine toothbrushing. She was diagnosed with ovarian cancer (stage IIIc) and received surgical therapy to remove all of the ovarian and surrounding lymph nodes, including the most malignant lesion. This was followed by chemotherapy to destroy the remaining cancer cells on the 15th day after the surgery. Anticancer drugs selected first were paclitaxel and carboplatin as a combination regimen. This administration was repeated six times approximately every 3 weeks. In addition, bevacizumab was also prescribed in the same day from the second to sixth course, and only bevacizumab was injected an additional 16 times after that. Finally, the total times of prescription during this chemotherapy were 21.
On the third day after the first injection, general adverse effects, which were urticarial, flare, and swelling in part, emerged, and she had strange feeling around the gingiva as an oral adverse effect as well. Although a combination regimen of docetaxel and carboplatin was administrated only in the third course, general adverse effects emerged similarly. Fortunately, these general effects have decreased gradually, but the oral problem was remaining and exacerbated gradually in contrast. During the whole period of chemotherapy, the patient did not experience hypertension, proteinuria, thrombosis, epistaxis, or gastrointestinal perforation as a major adverse effect of bevacizumab.
On the day of the 11th course of chemotherapy, which was the sixth course of only bevacizumab, the patient visited a dental office for the first time and complained about the oral disorder (Fig. ). Oral examination revealed followings: total number of tooth was 28; DMFT was 16 (16 filled teeth); gingival swelling was scored as grade 2–3 according to Gingival Index (GI); and edemat

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

[User]
RADIOLOGY NOTE:
We report the single clinical case of a 61-year-old right-handed male patient suffered a brainstem ischemic stroke caused by a thrombosis of the basilar artery and a dissection of the right vertebral artery at 55 years of age. He was treated with thrombolytic drugs, which proved ultimately ineffective and did not prevent the induction of irreversible stroke damage in several brain regions. T1 sequence magnetic resonance imaging (MRI) images acquired at the time of admission in the emergency room revealed a large lesion in the bulbo-pontine junction impinging on part of the left cerebral peduncle, and also small areas of ischemic damage in right cerebellar and left capsulo-thalamic structures. The patient was clinically diagnosed with an incomplete locked-in syndrome and tetra-paresia. Months following the stroke, the patient started several motor rehabilitation regimes aiming to preserve further functional loss and eventually improve the function of his four limbs, his face and trunk, favoring walking, equilibrium and allowing manual control of an automated wheelchair, ensuring for the patient a certain level of autonomy. After ~4 years of intense rehabilitation, the clinical status of the patient was characterized by a severe dysarthria and enduring tetra-paresia, impacting dramatically the left side of his body, including his left upper and lower limbs, and allowing only slight voluntary movements with his left fifth hand finger. In contrast, motion of his right hemibody parts was better preserved, allowing him to mobilize himself by operating an automated wheelchair with wrist flexion/extension movements. Regardless, his right hand opened incompletely and fine finger motor skills remained very limited, making manipulation of small items impossible. Additional rehabilitation regimes were implemented to improve swallowing difficulties (often conveying saliva and food to respiratory airways) and phonation disorders, which both endured regardless of the rehabilitatio

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


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

[User]
RADIOLOGY NOTE:
We report the case of a previously healthy 17-year-old Caucasian male with exercise-induced pain of the right foot that had deteriorated over the course of three months. During the last week prior to presentation at our emergency department, the symptoms had progressed from intermittent to constant calf pain. At clinical examination, the right foot was pale and cool with delayed capillary refill and absent pedal pulses consistent with the clinical picture of acute limb ischemia. The left foot was warm and well perfused with palpable pedal pulses.
Doppler ultrasound study of the right lower limb showed an occlusion at the proximal part of the right popliteal artery (PA). With magnetic resonance angiography the presence of a four-centimeter thrombus occluding this section of the PA was confirmed.
Furthermore, Doppler ultrasound study of the asymptomatic, contralateral (left) popliteal region revealed an occlusion of the PA with sufficient collateralization and unimpaired three-vessel runoff to the foot.
By conventional transfemoral angiography, the previously identified occlusion of the right PA and its aberrant course were demonstrated again (). An attempt of continuous intraarterial thrombolysis of the occluded right PA was undertaken by the use of actilyse and continuous heparin applied via a lysis catheter over 24 hours. The required therapeutic dose was controlled with aPTT between 60 and 80 seconds. This resulted in a significant reduction of thrombotic material within the PA, but the vessel was still considerably occluded (70-80%). After 24 hours of catheter-directed thrombolysis, low-molecular-weight heparin (LMWH) in therapeutic dosage and continuous infusion of iloprost (over 4h) were given daily. Further investigations were started to identify the already suspected extravascular cause of occlusion.
Indeed, in magnetic resonance imaging the anomalous origin of the MHGM lateral to the medial condyle of the femur was detected. The muscle's tendon and belly cro

[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 26-year-old chinese man was admitted to our hospital because of dysphagia for over one year. Results of his physical examination were normal. Gastroscopy revealed a giant esophageal submucosal protrusion with a smooth surface that was located 20 to 26 cm from the incisors. Ultrasonic gastroscopy revealed a giant mucous prominence of the esophagus located 23 cm from the incisors that originated from the muscularis propria and was suspected to be a leiomyoma because of its smooth surface and normal color (Figure ). Chest computed tomography (CT) showed a round high-density shadow on the right front edge of the esophagus at the level of the aortic arch to the inferior pulmonary vein, and this was suspected to be a leiomyoma of the middle esophagus. Upper gastrointestinal contrast radiography showed a leiomyoma of the middle esophagus and compensatory expansion of the upper esophagus (Figure ). After preoperative preparation, surgery was performed under single-lumen endotracheal intubation. The patient was placed in the left lateral position. An incision was made in the eighth intercostal space at the right posterior axillary line, and a thoracoscope was introduced through the incision. For the operation, one incision was made in the seventh intercostal space between the right scapular line and the posterior axillary line, and another incision was made in the fourth intercostal space between the auscultatory triangle and the anterior axillary line (Figure ). Exploration revealed that the tumor had spread to the entire length of the thoracic esophagus. The pleura mediastinalis was incised above the diaphragm to expose the lower segment of the esophagus. The muscularis of the esophagus was cut to expose the capsule of the tumor, and a well-defined solid tumor with an intact capsule and rich blood supply was revealed. The lower pole of the tumor along the capsule was gradually isolated. The lower pole of the tumor was sutured with thick silk to facilitate pulling up of t

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

[User]
RADIOLOGY NOTE:
A 26-year old man presented to the emergency department at Hamad Medical Corporation (HMC) in Doha, Qatar, with a three-day history of severe colicy epigastric and right upper quadrant abdominal pain, radiating to the back, associated with two episodes of vomiting and constipation. This was his first time to have such pain. He had past surgical history of open appendectomy during adolescence and was currently on oral medications for sciatica (prednisolone 5 mg BID for one-week, Naproxen 225 mg BID and Gabapentin 300 mg daily). Otherwise, he had no comorbidities, and the other systemic review was unremarkable. No recent travel or interaction with sick contacts was mentioned at the initial encounter at the emergency department.
The patient had normal vital signs. Abdominal examination revealed severe epigastric and right upper abdomen tenderness. Otherwise his examination was unremarkable at that time. Initial labs including CBC, complete metabolic panel were within normal range. Imaging including abdomen and chest x-rays, and CT angiogram abdomen were normal; however, US abdomen showed gallbladder sludge but with no signs of cholecystitis. Hence the patient was admitted by the surgical team with an initial diagnosis of possible persistent biliary colic.
During the night of admission day (day 0), the patient was still having severe colicy pain that required high doses of opioids, paracetamol and NSAIDs. Repeat set of all labs were undertaken and due to the colicy nature and persistent severe pain, a CT with oral contrast was done to exclude proximal bowel obstruction that might not have shown on the previous CT with IV contrast. The CT was normal, and the labs showed slightly rising transaminases (AST 94 IU, ALT 95 IU). The patient was kept nil per oral, on pain medications with IV hydration and a repeat set of labs were ordered to be done in 8 hours (early morning of day 1). During that time, the patient started to develop, for

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

[User]
RADIOLOGY NOTE:
An 80-year-old female underwent a Hartmann's procedure with intraoperative radiation therapy in 2008. A metastasectomy for liver metastasis was done before the Hartmann's procedure in a separate operation. Neoadjuvant therapy included radiation therapy with a dose of 5 × 5 Gy and chemotherapy with 6 cycles of capecitabine, oxaliplatin, and bevacizumab. Since December 2009 JJ-stents were placed for ureteral stricture and functional obstruction with regularly bilateral replacement afterwards. In November 2010, extensive abscess drainage from the Douglas Cavity was needed after occluded ureteral stents with Candida glabrata infection. Furthermore she was diagnosed with Type 2 (noninsulin-dependent) diabetes mellitus and angina pectoris.
In January 2011, she presented at the emergency room with intermittent macroscopic hematuria. An irrigation catheter was placed and manual irrigation was continued to remove all clots out of the bladder. Laboratory findings at admission included a hemoglobin level of 7,2 mmol/L and a creatinine level of 370 μmol/L. Ultrasound of the kidney showed bilateral hydronephrosis. One day after admission a cystoscopy and ureteral stent exchange was performed in the operation room because of persistent hematuria and suspected occlusion of the ureteral stents. Removal of the right double-J catheter revealed a pulsatile arterial bleeding from the right ureteral orifice. The ureteral stent was quickly changed and the bleeding subsided. An emergency peroperative hemoglobin was 3,4 mmol/L (norm >7,5 mmol/L). The patient was stabilized and 4 Packed Cells were given at the OR. Open surgery was primarily not considered an option because of the patients extensive abdominal surgical history. At the radiologist intervention department, computed tomography angiography (CTA) was performed for further diagnosis (see ).
An active hemorrhage was suspected at the level of the right pyelum and clots were seen in the pyelocaliceal system. Since the patient was hemo

[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 woman underwent left lower lobectomy for a pulmonary carcinoid tumor (pT1bN0M0-stage IA). Postoperatively, there was no pulmonary fistula or bronchial stump fistula, and her clinical course was favorable. She had been doing well for 8 years after completing therapy until 42 years of age when she visited a clinic with the chief complaints of fever and sputum. Chest plain radiography showed left-sided pneumonia, for which antibiotic treatment was initiated. Although the blood test result showed improvement of inflammatory markers, chest plain radiography showed no improvement in pneumonia; therefore, she was referred to our hospital.
Chest computed tomography (CT) showed a tumorous lesion nearly obstructing the bronchial lumen and the extension of pneumonia into the residual left lung (Fig. ). Recurrence of the bronchial stump was suspected based on her medical history. Subsequently, flexible bronchoscopy was performed and showed the presence of a mass, a fibrous suture material, that was completely obstructing the left second carina. Results of the biopsy revealed only fiber without evidence of malignancy (Fig. a). The sputum, blood, granuloma, and biopsy fiber cultures were negative.
Considering the risk of hemoptysis and bronchial stump fistula, the suture material obstructing the bronchial lumen was removed using a flexible bronchoscope with the patient under general anesthesia 1 week later (Fig. b). Little granulation tissue was observed at the site of the removal. Although there was some minor oozing of blood from the same site, hemostasis was achieved with argon plasma coagulation therapy. The procedure was completed without removing the small amount of granulation tissue because the bronchial lumen opened after removal of the suture material.
According to a copy of the 2010 operating report, the bronchial stump was sutured with five stitches using an absorbable monofilament suture (4–0 polydioxanone suture [PDS]). However, the left lower bronchus

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


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

[User]
RADIOLOGY NOTE:
A 32-year-old woman with a recent diagnosis of transient ischemic attack (TIA) presented to the emergency department 2.5 hours after awakening from sleep with sudden onset, thunderclap headache described as the worst headache of her life. Her headache was frontal, pressure-like, exacerbated by supine positioning, and was associated with nausea, vomiting, and photophobia. The headache reached maximal intensity within 60 seconds of onset. She denied prior history of headaches and migraines and denied recent viral illness and/or infectious symptoms. On exam, her vitals were normal and she had no focal neurologic deficits. A noncontrast CT of the head was negative for subarachnoid hemorrhage (SAH) and intracerebral hemorrhage (ICH). MRI brain revealed no evidence of stroke or blood products, but was notable for hydrocephalus and mega cisterna magna, presumed to be chronic given normal head circumference and the absence of transependymal flow. MR angiography of head and neck was negative for findings to support reversible cerebral vasoconstriction syndrome (RCVS) or dissection, and MR venogram was negative for cerebral venous sinus thrombosis (CVST). Intravenous normal saline, magnesium, and metoclopramide provided relief of headache.
She reported an admission to an outside hospital five days prior for a progressive syndrome of migratory paresthesias followed by global aphasia and right hemiparesis. During that admission, she was treated with tissue plasminogen activator given her aphasia and right hemiparesis. While in the intensive care unit, her neurological deficits resolved within 6 hours of symptom onset, but she developed a moderate intensity migrainous headache with mild photophobia and nausea. This headache resolved by the next day. Brain MRI was negative for stroke and MR angiography of head and neck was unrevealing for a dissection or other vessel pathology. Additional workup was also negative including 24 hours of video EEG monitoring, a transesophageal echoc

[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 woman with a history of voiding difficulty visited a nearby hospital, where she was prescribed urapidil. However, her symptom worsened, and, therefore, clean intermittent catheterization was initiated. For further examination, magnetic resonance imaging (MRI) was performed, which revealed a periurethral diverticulum (). The diverticulum was punctured, and a drainage catheter was inserted for 3 days.
Three months later, transvaginal ultrasonography showed that the size of the diverticulum had not reduced. Subsequently, she was transferred to our department for further examination and treatment. In order to assess the diverticulum, MRI was performed, which revealed a periurethral tumor (). The tumor had low signal intensity on a T1-weighted image and high signal intensity on a T2-weighted image. It was suspected to be malignant and appeared to invade the vagina. Laboratory data showed elevated carcinoembryonic antigen levels (22.8 ng/mL; normal range, 0–5 ng/mL).
The patient underwent transperineal needle biopsy of the tumor using transvaginal ultrasonography. The pathologic diagnosis was adenocarcinoma, and immunohistochemistry revealed CK7 positivity and CK20 negativity. The tumor cells did not express the estrogen receptor or progesterone receptor. Owing to lack of CDX2 expression, the gastrointestinal region was excluded as a possible site of origin of the tumor. The tumor had smooth muscle tissue and prostate-like tissue and was therefore diagnosed as a urethral cancer.
We conducted radical cystectomy and urethrectomy with combined resection of the uterus and vagina. The patient's urinary tract was reconstructed using an ileal conduit. She was discharged from our hospital after 3 weeks without any severe complications. Pathological examination of a resected specimen revealed adenocarcinoma of the urethral diverticulum (). The urethra demonstrated squamous metaplasia owing to the urethral catheter or clean intermittent catheterization. The adenocarci

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


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

[User]
RADIOLOGY NOTE:
This case report presents a 51-year-old female with no significant past medical history with complains of weight loss, vomiting, and right upper quadrant discomfort for several months. Laboratory tests showed elevated liver enzymes with a Alanine transaminase (ALT) level of 47 U/L, aspartate aminotransferase (AST) level of 47 U/L and an alkaline phosphatase level of 274 U/L. The patient's CA-19-9 level was also elevated at 105 U/mL. Computer tomography (CT) of her abdomen and pelvis revealed biliary dilatation with a small soft tissue bulge at the ampulla. Magnetic resonance imaging (MRI) of abdomen revealed a common bile duct dilatation with narrowing just proximal to the ampulla suggestive of malignancy. It also showed local adenopathy of the para-aortic and para-celiac lymph nodes suspicious for metastasis. EUS-FNA was performed to obtain a sample of the patient's celiac lymph node for evaluation of possible metastatic tumor.
A 17 mm oval, hypoechoic structure with distinct margins was seen in the para-aortic, celiac axis region. Color Doppler was used to ensure absence of major vessels. A 22 G needle was used to make two passes, followed by four passes made with a 25 G needle without suction. An attending cytopathologist was present during the procedure. The aspirate revealed 0.9 cc's of sanguinous material.
The cytological features of the FNA biopsy in this patient are presented in Figures and . The cytologic examination revealed paucicellular smears consisting of few clusters of large cells with abundant dense granular cytoplasm and round nuclei with prominent nucleoli. At a first glance, this was very alarming because they resembled malignant cells metastatic to the celiac lymph nodes. However, no lymphoid cells were identified and there was no evidence of inflammation, edema, or fibrosis. Some of these cells were seen in association with spindled stroma. These findings are representative of a benign celiac ganglion rather than a malignant metastatic

[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 girl underwent application of a humeral lengthening frame of her right humerus to correct severe humeral shortening gradually. The shortening was secondary to osteomyelitis of the right proximal humerus aged 10 weeks. This had left her with a 10-cm discrepancy between the lengths of the right and left humeri, resulting in significant functional difficulties. The lengthening frame was applied with the elbow extended without any intra-operative complications. In recovery, her right hand was warm and well perfused with full sensation and movement of the wrist and small hand joints. On the first post-operative day, however, she complained of severe burning pain in her right arm and hand requiring significant opiates for relief and a pain team review. Examination revealed evidence of a partial right radial nerve palsy; weakness of right wrist extension, an inability to extend the fingers and diminished sensation on the dorsum of the first webspace. She displayed evidence of hyperalgesia with an exaggerated response to pin-prick on the dorsum of the first webspace. There was no mechanical allodynia. All other hand and wrist movements and sensation were intact.
An ultrasound scan of the right arm was performed. This revealed no haematoma or collection. The radial nerve was not visualised.
On the second post-operative day, her symptoms decreased slightly. However, on the third post-operative day, her symptoms did not settle further and the patient was taken back to theatre for exploration of the radial nerve due to ongoing severe pain. The radial nerve was found to be in continuity without any bruising or contusion. Distally, it was found to pass tightly against the most distal external fixator pin such that, with the elbow flexed the nerve became tightly pressed against the pin. The distal pin was removed and re-sited slightly proximal.
Post-operatively, there was complete resolution of the right arm pain and hyperalgesia. Sensation to the first webspace reco

[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 27-year-old Caucasian male with a noncontributory medical history and no previous trauma was referred from the maxillofacial department of the hospital for the endodontic evaluation of the mandibular right first and second molars, which were connected to an extensive asymptomatic osteolytic lesion incidentally discovered on a routine panoramic radiograph and scheduled to be treated surgically under general anesthesia. The patient reported that he had experienced pain and swelling in the right mandible months before, while the first molar had a history of caries, extensive amalgam restoration, and incongruous endodontic treatment performed ten years earlier. The clinical examination showed no sign of buccal or lingual bone expansion, no lymph node involvement, and intact overlaying mucosa. The first mandibular molar was asymptomatic. The right second mandibular molar was asymptomatic with an intact crown, and it responded normally to the sensitivity tests at the time of our examination. The panoramic radiograph showed a well-defined unilocular osteolytic lesion with sclerotic margins located between the two molar teeth and superimposed on the alveolar inferior nerve with a slight displacement of the second molar. The first molar showed inadequate root canal treatment with signs of resorption in the apical third of the distal root involved in the osteolytic lesion. A preoperative periapical radiograph taken using the paralleling technique confirmed these findings (). Cone beam computed tomography (CBCT) revealed a well-defined unilocular lesion, with considerable expansion toward the lingual wall and consequent thinning of the lingual plate. From the axial and sagittal sections, it was possible to diagnose a perforation both in the distal and lingual aspects of the apical third of the distal root of the right first molar (). To assess the content and vascularity of the lesion, a real-time ultrasound examination with the application of color-power-Doppler (CPD) 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.


[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 53-year old man visited the emergency room with suddenly developed mental deepening. On past history, he had an uncontrolled hypertension with left hemiparesis due to head injury of traffic accident 20 years ago. On neurological examination, he showed semi-comatose mental status. Glasgow Coma Scale was 5. He could not open his eyes. He was withdrawal to pain. He was in intubated state. The pupil size was 8 mm on right eye and 3 mm on left. The light reflex was absent on both pupils. The corneal reflex was present. Brain CT showed 8.6-cm-sized solid and cystic mass on right temporal lobe that was associated with hemorrhage (). Solid lesion showed a strong enhancement after an administration of contrast media (). The mass effect was severe with 1.8 cm-midline shift from right side to left. The provisional diagnosis was high grade glioma associated with acute hemorrhage. Because of his poor neurological status and severe mass effect, emergency craniotomy and tumor removal were performed. Intraoperatively, the mass was an intraparenchymal lesion without dural attachment (). The lesion had a cyst with yellowish fluid and myxoid change. It was acute hematoma and firm solid lesion. The solid hemorrhagic lesion contained many vasculatures that were relatively well-circumscribed from normal white mater. The mass was totally resected. Postoperative MRI showed no enhancing lesion on right temporal lobe. Postoperative 3 weeks later, he was recovered to confused mental status with dysarthria.
Pathologically, tumors showed a patternless arrangement. Both the hypocellular area and the hypercellular area appeared. The hyalinized band divided the boundary between hypocellular and hypercellular areas. It was surrounded by thin walled staghorn-like vasculatures (). Other portions consisted of tissues arranged very tightly which meant solid portion, which had more cellularity and much more dense structures. In random arrangement, stromal surrounding cells were much less while mitosis

[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 71-year-old male visited our hospital because of melena. He was suffering from diabetes mellitus and the sequelae of a cerebral infarction. He has been receiving oral diabetic drugs and an anti-coagulation drug, ticlopidine hydrochloride for 10 years. His blood pressure was 150/83 mmHg and the pulse rate was 105/minute. A blood examination revealed a high level of blood sugar at 162 mg/dL, and hemoglobin A1c of 6.6%, but neither a decrease in red blood cells nor hemoglobin. A computed tomography scan in the abdomen detected a high density fluid of ascites, but no inflammatory changes in any organs, including the intestinal tract. By an emergency colonoscopy, the fresh blood in the entire colon, but not in the ileum, and the blood and coagula in the orifice of the appendix were observed (Figure A). After washing the orifice with water, a hemorrhage was detected in the appendix (Figure B), and the lesion responsible for bleeding was regarded to exist in the appendix. After obtaining the patient’s informed consent, 200 ml of 50 W/V% barium was sprayed into the orifice of the appendix using a spraying tube (Figure C), because a therapeutic barium enema has been shown to be a useful procedure to control bleeding from a diverticulum [,]. The bleeding could be immediately stopped, and a radiological examination revealed the accumulation of barium at the cecum and the orifice of the appendix (Figure A). The barium accumulation disappeared by the next day (Figure B) and no obvious anal bleeding was observed in the patient. Two weeks after stopping the bleeding from the appendix, an appendectomy was performed to prevent further refractory hemorrhage from the appendix. A gross specimen showed ulceration, but no tumorous lesions, at the tip of the appendix (Figure A). A severe infiltration of neutrophils and lymphocytes within a shallow ulcer was histologically observed (Figure B). The administration of the anti

[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 54-year-old man was referred to the Department of Prosthodontics at Kyung Hee University to restore the mandibular left missing area. The patient had been in a motor vehicle accident about 20 years ago and had received a number of reconstruction surgeries due to the mandibular traumatic defect of the left side.
Comprehensive intraoral and radiographic examination revealed significant bone loss of the mandibular left side. The floor of the mouth was firm, and lingual vestibule of left side was very shallow. The patient also presented shallow mandibular buccal vestibule and insufficient amount of keratinized tissue. The premolars and molars on the left mandible were missing. Mandibular central, lateral incisor and canine on the left side were shown to be hopeless (, ).
Hard and soft tissue loss was needed to be restored by prosthetic rehabilitation. Several treatment options were suggested and discussed with the patient. Removable dental prosthesis was not considered as a treatment option because of poor tissue condition and lack of support. In spite of alveolar bone loss, inserting dental implants in the alveolar ridge was possible. Also the patient was expecting fixed restoration. Therefore, implant-supported fixed prosthesis was planned. A treatment plan was designed for fabrication of a fixed prosthesis supported by 4 dental implants.
Prior to implant surgery, a split-thickness skin graft combined with vestibuloplasty at the defect site was planned due to lack of keratinized tissue and shallow vestibule. To improve graft adherence, an intraoral stent was fabricated. Preliminary cast of type III stone (New Plaston; GC Co., Tokyo, Japan) of the mandible was prepared, and the left buccal vestibule was trimmed to the expected depth (). The stent was processed in clear acrylic resin (Vertex Rapid Simplified; Vertex Dental, Zeist, Netherlands), which was extended to the expected vestibular depth ().
One month after the extraction of mandibular lateral incisor and cani

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


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

[User]
RADIOLOGY NOTE:
A 17-year-old male patient reported to the Department of conservative dentistry and endodontics, PGIDS Rohtak with pain in the upper left lateral incisor for about 1 week. The patient recalled a history of trauma of the tooth 8 years before due to the accidental fall and he went to nearby clinic for treatment. The patient was explained to come for three visits to complete the treatment, but he missed two visits as the patient was relieved from pain in the first appointment. On clinical examination, there is Ellis Class III fracture in 22. Tooth mobility was within the normal limits and tenderness on percussion was present. Intraoral periapical radiography (IOPA) showed that there is a radioopaque foreign body present inside the root canal which resembles like broken file or wire. The apex was open and the foreign body was extending beyond the apex. Periapical radiolucency was seen at the apex []. Informed consent was obtained. After local infiltration anesthesia with 1.8 mL of 2% lidocaine with 1:80,000 epinephrine, wire was immediately removed from the root canal using H files [].
The patient was explained about treatment options and alternatives and was given time to decide. The patient was willing for revascularization procedure. In the first visit, after local infiltration anesthesia with 1.8 mL of 2% lidocaine with 1:80,000 epinephrine, the working length determination was done and periapical radiograph was taken with master file to ensure not to violate the open apex []. The root canal irrigation was done with 20 mL of 5.25% NaOCl followed by saline. The canal was dried with sterile paper point and calcium hydroxide medicament was filled. The cavity opening was closed with cotton pellet and temporary restoration was done.
After 3 weeks in the second visit, when the patient was asymptomatic, revascularization procedure was performed under local infiltration with 1.8 mL of 2% lidocaine without vasoconstrictor to facilitate bleeding.[] The access cavity was opene

[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.