[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 January 4th, 2018, a 57-year-old woman was hospitalized in the department of Psychiatry, Sir Run Run Shaw Hospital because of pain and acid bilge in multiple sites of her upper body for more than 1 year. Over a year ago, the patient started feeling pain and discomfort in the upper left abdomen, and the pain got worse when coughing but with no other discomfort. Two months later, the upper left abdomen pain and acid bilge extended to the front chest, back, abdomen, and upper limbs. The symptoms persisted for months, and aggravated when changing body posture. Test results including cervical MRI, chest CT, abdominal B ultrasound of upper abdomen in a local hospital showed no abnormalities. Treated with Chinese medicine for more than 3 months, there was no significant improvement. About 6 months ago, the patient came to our hospital, expressing the symptoms above and worries about them, with weight loss of about 1–1.5 kg, but denying continuous depression, anxiety, and other symptoms (the score of 24 items of Hamilton Rating Scale for Depression was 12, and Hamilton Anxiety Rating Scale score was 11), and was diagnosed as “somatic symptom disorder.” After 4 months of treatment with 60 mg of duloxetine enteric-coated capsules twice daily and hypnotic drugs, the symptoms were obviously alleviated but not completely relieved and there was a significant weight loss of about 5 kg. Therefore, medication was adjusted to escitalopram tablets 20 mg once daily. Two months later, the patient felt no further improvement.
With hypertension history of more than 10 years, the patient claimed that it's not necessary for her to take any antihypertensive drugs to control blood pressure in recent 1 year. She had bronchitis for 12 years but no medicine was needed. She denied any history of diabetes, heart disease and other diseases and claimed there was no history of surgery and trauma. Also, the patient denied long-term chemical substances, drug or poison

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


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

[User]
RADIOLOGY NOTE:
The patient was a 23-year-old woman charged with attempted manslaughter. She was ordered by the court to undergo a pre-trial forensic psychiatric examination which took place in a maximum security state mental hospital. The trial records and all available background information were reviewed. Both of her parents were alcoholics and she was taken to protective custody under the age of one year. Her grandmother suffered from schizophrenia and her mother had been in a psychiatric hospital after a suicide attempt. The patient used to shoplift before the age of 15 and later she stole money from time to time. She also worked as a prostitute to earn money. She started to abuse alcohol at the age of 15. She had several boyfriends but has never married and has no children. Her personality was noticed to change before the age of 17. She started to have obsessive-compulsive behaviour, paranoid thoughts as well as depressive symptoms. She tried to kill herself by hanging and by several drug intoxications. She brutally killed her own pet. She was never hospitalized before the forensic mental examination but she irregularly visited an outpatient clinic. Despite psychiatric treatment, she impulsively tried to kill her male friend with whom she was drinking. During the psychiatric examination the diagnoses – schizophrenia paranoid type, alcohol dependence and features of antisocial personality disorder – were made by a senior forensic psychiatrist using the structured clinical interview for DSM-IV, SCID I and II [,]. Neither waking EEG nor brain MRI (1.5T) disclosed any abnormality. She had no somatic disorders. She had finished high school and vocational school, and was within average intelligence (WAIS-IQ total 109). She was not sentenced, but was ordered by the Finnish National Board of Medico-Legal Affairs to stay in the state mental hospital as a criminally insane patient. The sleep recordings were performed during the psychiatric examination period and

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


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

[User]
RADIOLOGY NOTE:
A 48-year-old man with a history of alcohol abuse presented to the gastroenterology department for the first time in November 2006. He was suffering from severe epigastric pain and nausea for two days. Because the laboratory findings were suspicious for pancreatitis, the patient underwent computed tomography (CT) (Fig. ). The examination showed an edematous pancreas tail and fluid in the anterior prerenal space and in the anterior, posterior and lateroconal fascia. There were no signs of chronic pancreatitis or vascular complications. In the following months the patient had two similar episodes of acute tail pancreatitis.
In September 2009 he presented with vague epigastric pain of several weeks duration. Serum amylase and lipase levels were normal, however the cholestatic parameters were mildly elevated. Therefore, a magnetic resonance (MR) study was performed. The examination demonstrated moderate chronic pancreatitis of the tail with atrophy and irregular bording of the Wirsung’s duct. There were no other abnormalities. Further examinations also revealed a Helicobacter pylori gastritis.
In February 2012 the patient presented again to the gastroenterologist with epigastric and left upper quadrant pain. Laboratory findings were not suspect for acute pancreatitis. However, contrast-enhanced CT scan was performed in order to evaluate the known chronic pancreatitis and other causes of pain (Fig. ). This study surprisingly revealed a hypervascular lesion in the pancreatic tail consisting of a conglomeration of small hypervascular spots and blood vessels. Further examinations were performed in order to differentiate a vascular malformation from a hypervascular pancreatic tumor, especially an islet cell tumor or a hypervascular metastasis. Contrast-enhanced MR study showed a focal area of heterogeneous contrast enhancement without an apparent nodular component. The subsequent angiography showed two large feeding arteries in the early arterial phase, followed by a racemos

[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 59 year old woman with a 7 year history of recurrent nephrolithiasis and mild hypertension presented with a complaint of weakness and fatigue with associated bone and joint pain. Further history revealed that she had had five previous episodes of urinary calculi requiring surgery or lithotripsy. She was also discovered to have had a first degree atrioventricular block and was currently awaiting pacemaker insertion. There was no family history of thyroid/parathyroid disorders or history of previous radiation. Physical examination was unremarkable. Laboratory investigations revealed hypercalcemia (2.89 mmol/L), hypophosphatemia (0.78 mmol/L) and elevations in parathyroid hormone (PTH) (15.2 pmol/L). Bone mineral density studies revealed cortical bone osteoporosis.
A 99mTc-sestamibi scan did not reveal any abnormality. An exploratory parathyroidectomy was then arranged and the right and left superior parathyroid glands were removed, along with a localized biopsy of the left inferior parathyroid gland. The right upper gland was 1 cm in diameter and was thought to be an adenoma. No inferior right parathyroid gland was identifiable. She subsequently remained hyperparathyroid and underwent re-exploration and removal of the previously biopsied left inferior gland. Again, a right inferior gland was not identified and a right thyroid lobectomy to locate a possible intra-thyroid adenoma was performed. The final pathological analysis of the removed thyroid lobe did not identify any parathyroid tissue within the thyroid parenchyma, but there was normal parathyroid tissue in the paratracheal fat removed at the time. Parathyroid hormone levels continued to remain persistently elevated. Although subsequent MRI and CT scans remained negative, PET-CT scanning showed a 3 cm region of uptake in the right parapharyngeal region behind the thyroid cartilage at the level of the arytenoids. Selective venous sampling showed increased PTH levels in this area.
A third parathyroid exploration

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


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

[User]
RADIOLOGY NOTE:
A 70-year-old female, known case of gout, presented to our center through emergency department with 2 weeks history of right upper quadrate (RUQ) pain. The pain was sudden with no radiation, relieved by analgesia, not related to food. There was no fever, no vomiting, no change in bowel habit or stool color, and no jaundice. No history of trauma. No remarkable surgical history prior to her complaint. She was not a smoker. The physical examination disclosed only an abdominal tenderness in the RUQ.
Laboratory investigation revealed mild leukocytosis with normal liver enzymes, normal bilirubin level, and normal liver function panel. Also, the tumor marker tests were performed after awhile and revealed elevation in cancer antigen 19–9 (CA19-9) (291.6 U/mL).
Radiological studies and interventions were conducted. Abdominal ultrasound revealed distended gallbladder with stone and suspicion of soft tissue mass. Then, an enhanced computerized tomography (CT) scan of the chest, abdomen, and pelvis was performed and demonstrated an irregular enhancing diffuse wall thickening of the gallbladder mainly at the fundus with an exophytic mass lesion measuring about 5×6 cm abutting the hepatic flexure with fatty infiltration of the liver and hypodense hepatic lesions noted in the gallbladder bed with largest measuring about 1.3 cm in diameter. Also, the proximal transverse colon showed wall thickening with regional lymphadenopathy, ( and ). Then, the patient underwent positron emission tomography (PET) scan that also demonstrated intensely increased uptake involving the gallbladder wall as well as exophytic mass coming from the gallbladder strongly suspicious for primary malignancy. Also, there are multiple foci of increased uptake in the liver at the gallbladder bed representing direct invasion of the primary gallbladder tumor into liver. The multiple enlarged lymph nodes seen on CT images were hypermetabolic on PET scan which was consistent with metastatic lymphadenopathy, ).
While

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


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

[User]
RADIOLOGY NOTE:
A 65-year-old female weighing around 40 kg presented with swelling of the face, over the nasal bridge []. The mass was progressively increasing in size. The angiogram showed AV malformation which was partially thrombosed and calcified. The patient was planned for embolization of the malformation, under general anesthesia. We were informed to be careful while anesthetizing the patient as the swelling was fragile and there was a risk of rupture.
The preanesthetic evaluation was done. She was a diabetic and hypertensive on treatment and well controlled. On the evaluation, there was a swelling on the face which measured around 7 cm × 7 cm in size, adjoining the left medial canthus of eyes, extending to the nasal bridge, and alae nasae []. There were cracks and ooze from the surface. It was also observed that swelling could come in the way of direct laryngoscopy. Mouth opening was adequate, and Mallampati was Class 2. Neck extension was adequate. Investigations were normal. The patient was optimized and kept nil per orally for 8 h. Cath Laboratory was prepared with difficult airway cart including flexible fiberoptic scope and equipment for emergency cricothyrotomy. Our plan was to try normal intubation.
On the day of the procedure, the patient was shifted onto the table. Wide bore cannula was secured, and monitors were connected. Premedication was done with 1 mg midazolam and 50 μg fentanyl. Preoxygenation was tried with size 5 face mask by gently keeping the mask above the face to give oxygen enriched air, taking care not to pressurize on the swelling. Induction was done with 50 mg propofol. Mask ventilation was tried with size 5 face mask, with the view of taking the swelling inside the mask, but the swelling was too big to be included. Then, size 1 face mask and Rendell-Baker-Soucek (RBS) mask were used just to cover the mouth, but we

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


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

[User]
RADIOLOGY NOTE:
The patient was a 46-year-old man who presented with pain (2–4 NRS scores) and difficulty in moving his left lower limb after a fall. He was diagnosed with a left femoral neck fracture, and surgery for the fixation of the left lower extremity with an intramedullary nail was planned. Preoperative interview revealed a history of tuberculosis and a subsequent pulmonary CT revealed severe tuberculous damage in left lung and diffuse lesions in right lung (Fig. ). Echocardiography showed significant pulmonary arterial hypertension (109 mm Hg). The patient was classified as American Society of Anesthesiologists (ASA) class III. Ultimately, we performed an ultrasound-guided SIFI block combined with a sacral plexus block. After obtaining preoperative informed consent, sedation was initiated using an infusion of dexmedetomidine (1 μg/kg maintenance). Using all aseptic precautions, the anterior superior iliac spine (ASIS) was first palpated and a high frequency linear ultrasound transducer (UMT-400, Mindray, China) was placed over the inguinal ligament to identify the femoral artery. The probe was then moved laterally to identify the sartorius muscle and to place it at the center of the ultrasound field of vision. The probe was then rotated 30°, just perpendicular to inguinal ligament and moved towards the femoral head to identify the internal oblique muscle, iliacus muscle, and the ilium (Fig. ). Local anesthesia of puncture site was performed with 5 mL of 1% lidocaine, and a continuous plexus block needle (1000 mm × 20 G, Germany) for catheter placement was advanced in an in-plane technique, in the cephalad direction, to enter the superficial part of the fascia iliaca. The position of the needle tip was confirmed by injection of 2 mL of normal saline, and its depth was adjusted according to the diffusion of the solution. After reaching the target position, 0.375% ropivacaine was injected (20 mL), and the diffusion of the solution between the iliac fascia and iliac muscle was

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


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

[User]
RADIOLOGY NOTE:
A 54-year-old man came to the private dental clinic with complaint of difficulty in mastication and esthetical concern for his upper anterior teeth. He was a nonsmoker and was diagnosed with IgG-kappa type MM in November 2011. In the physical examination, he was diagnosed with MM. Bony metastasis was present at the time of diagnosis of the disease. A full radiographic skeletal survey showed multiple bony lesions at the ribs, femurs, and hip (Figures and ).
Panoramic view revealed bony lytic and punch out lesions at the right side of the mandible. This patient had no history of surgery. His weight had decreased by 7 kg, following 22 months of acute intravenous injection (IV) BP treatment after the last chemotherapy treatment session. His blood pressure was 130/80, and he had a normal breathing and pulse rate. Preoperative examination of his oral mucosa revealed no evidence of pathological lesions, and overall oral hygiene was good. The patient was felt healthy and was well nourished, alert, and cooperative. After thorough clinical examination, maxillary right first premolar was found missing.
After meticulous consulting sessions with the patient and discussing the advantages and disadvantages of all treatment options, he accepted to receive dental implant.
According to the patient's physician, the appropriate time for the surgery relied upon the patient's regular blood cell counts. This patient did not undergo any radiotherapy phases in the entire duration of his active IV BP treatment. He underwent chemotherapy for two separate sessions. After the last session of chemotherapy, the patient received monthly infusion of 3.5 mg of the IV BP drug zoledronate (Zometa; Novartis Pharmaceuticals Corporation) for a period of 22 months (from May 2014 to March 2016). As per the physician's recommendation, C-terminal cross-linking telopeptide (CTX) examination was carried out 6 months after stopping IV BP therapy. The CTX above of more than 150 was considered to be safe

[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 41-year-old female with metastatic breast cancer presented to the emergency department with chest pain of 1 day duration. The chest pain started gradually, and was relieved by rest and exacerbated by exertion. She was started on capecitabine therapy 3 days before the onset of chest pain. She denied shortness of breath, nausea, vomiting, diaphoresis, fever, syncope, heartburn, and peripheral edema. The patient did not have a history of CAD or had known risk factors for CAD. She denied the use of cocaine. The patient did not describe symptoms suggestive of panic attack. On examination, her heart rate was 100 bpm and regular. Her physical examination was otherwise unremarkable.
Five years before the current event, she underwent mastectomy and axillary lymph node dissection for a stage III (pT2N3) breast cancer. The tumor was ER+, PR+, HER2+, and she received adjuvant chemotherapy and trastuzumab, followed by tamoxifen. She was diagnosed with metastatic disease in the liver in 2014, and was started on trastuzumab, pertuzumab, and docetaxel. Fifteen months later, she had disease progression in the liver and was switched to trastuzumab-emtansine. Nine months later, she progressed again, and therapy was changed to lapatinib and capecitabine (1,500 mg b.i.d.). Three days after starting capecitabine, she experienced acute-onset chest pain.
Electrocardiogram (ECG) testing showed normal sinus rhythm and no changes suggestive of coronary ischemia. Cardiac enzymes were negative. Complete blood count and chemistry panel were within normal range. CT angiography of the chest did not reveal any evidence of pulmonary embolism. A transthoracic echocardiogram documented normal cardiac function and a left ventricular ejection fraction of 60%. Her chest pain resolved after aspirin and analgesics were administered upon admission in the ER. A cardiology opinion was sought for possible angiography, but was not undertaken because of the patient's improving condition. She was discharged fol

[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 41-year-old woman presented in 2012 to our office with history of secondary infertility for the past year. The patient and her partner were counseled for intracytoplasmic sperm injection (ICSI) due to combined male and tubal factor infertility. The patient underwent stimulation using a combination of 225 IU/day recombinant follicle stimulating hormone with gonadotropin-releasing hormone antagonist. Thirty-six hours following human chorionic gonadotropin (hCG) injection, 12 oocytes were retrieved, 11 oocytes were inseminated, and 8 were fertilized.
One day after egg retrieval, the patient presented to our office complaining of severe left lower quadrant pain, associated with nausea and vomiting. Her vital signs were stable and abdominal exam revealed mild left lower quadrant tenderness with no rebound or guarding. Transvaginal sonogram () showed left ovary measuring 75 × 55 mm, right ovary measuring 71 × 43 mm, mild free fluid, and normal Doppler blood flow to both ovaries. Her white blood cell count was 20.4 × 103 cells/μL with 90% neutrophils. Due to high suspicion of left ovarian torsion, the patient was transferred immediately to the hospital for diagnostic laparoscopy. At laparoscopy, left ovarian torsion with multiple small cysts was noted. The left ovary was found to be twisted 180° around the infundibulopelvic ligament and had a viable pinkish color. The left ovary was untwisted successfully and three small cysts were drained. The patient tolerated the procedure well and the postoperative recovery was uneventful.
The patient was informed about the unknown impact of ovarian torsion and detorsion on the implantation rate and pregnancy outcome as well as the absence of evidence supporting embryo cryopreservation versus fresh embryo transfer. She opted to proceed with fresh embryo transfer. On day five following egg retrieval, four blastocysts were transferred under transabdominal ultrasound guidance. Subsequent sonogram four weeks later confirmed a viable six-

[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 male patient was admitted to our Vascular Surgery Department.
In 2001, the patient was in a traffic accident, resulting in a blunt injury to the chest and pelvis. This, presumably, was the mechanism of development of an aneurysm of the aortic arch.
In 2012, on the plane X-ray of the chest, an abnormal mass lesion was found, but computed tomographic (CT) verification was not performed due to unknown reason.
In 2014, the patient was hospitalized in our department when we confirmed the diagnosis of the aortic arch pseudoaneurysm (
). CT imaging identified a giant pseudoaneurysm with maximum size 136 × 72 mm. The size of posterior aortic arch wall defect was 28 mm. There were no signs of aortic dissection.
We performed an operation—the elimination of the aortic arch pseudoaneurysm and posterior wall tear and false aneurysm in the mediastinum without the use of cardiopulmonary bypass.
The position of the patient was on hs back with his left hand fixed above the head.
Under total anesthesia, through the L-shaped median sternotomy and left 5th intercostal thoracotomy, we identified and extracted the ascending aorta, aortic arch, left common carotid and subclavian arteries and mid part of descending aorta (
).
The brachiocephalic trunk was unable to mobilize because it was intimately fused with the anterior wall of the false aneurysm. Therefore, the right subclavian artery was controlled. A temporary bypass (TB) shunt of 20 mm between the ascending and descending aorta was created. In addition, from this bypass an anastomosis with a bifurcation prosthesis for temporary blood supply to the brachiocephalic trunk and left common carotid artery was formed. The first branch of the bifurcated bypass was anastomosed to the right subclavian artery, and the second connected through cannulation to the left carotid artery. The bloodstream was allowed to run through all temporary shunts. The ascending aorta was clamped distal to the shunt, and the descending aorta was cla

[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 73-year-old woman was admitted to our hospital with a few days history of fever and diarrhoea. She reported a 3-month weight loss of about 4 kg and complained of a mild abdominal pain in the right iliac fossa. A colonoscopy revealed an adenocarcinoma of the ascending colon. Chest X-ray and abdominal ultrasonography showed no pulmonary or liver metastases. A right hemicolectomy was performed. Histological examination of surgical specimen revealed a poorly differentiated adenocarcinoma, 4 × 4 cm in diameter, with invasion of the serosa and metastases to mesenteric lymph nodes. A few days after discharge, the patient noted three nodules in her abdominal wall, chest, and back skin respectively. On physical examination, the nodules were indolent, elastic masses of about 2 × 2 cm in diameter, not freely movable, with normal appearance of the overlying skin. Excisional biopsy revealed cutaneous metastases from adenocarcinoma. The patient refused any adjuvant treatment. Six months later, she was readmitted for removal of a large, firm, flesh, coloured mass of her left arm, limiting the movements. By that moment, multiple nodules were present throughout the skin of the buttock, trunk, abdominal wall, and neck ().
The lesions were varying in size from few millimeters to 10 centimetres. The overlying skin was normal or violaceous. A nodule on the chest wall was ulcerated. Chest X-ray and bone scintigraphy showed no metastatic lesions. Abdominal ultrasonography revealed no sign of abdominal relapse, in particular no liver secondaries. In the following days, the patient developed a rapidly increasing mild dyspnoea. Indirect laryngoscopy showed incomplete paralysis of the vocal cords. A tracheostomy was performed as an emergency procedure for an asphyxial crisis. On gross appearance, the trachea was compressed and infiltrated by large subcutaneous masses. Results of histological examination revealed metastases from adenocarcinoma. The patient died of respiratory failure before

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


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

[User]
RADIOLOGY NOTE:
A 33-year-old man was involved in an automobile accident and was brought to our hospital by ambulance. He had been in the front passenger seat and had been wearing a three-point seatbelt. He reported severe back pain, but showed no neurological deficit.
Anteroposterior and lateral radiographs of the spine showed an increased gap between the 1st and 2nd lumbar spinous processes and 2nd lumbar vertebral fracture (figures not shown). Magnetic resonance imaging (MRI) of the spine also demonstrated an L2 vertebral fracture and disruptions of the posterior ligamentous complex between L1 and L2, in combination with extensive subcutaneous hematoma ().
Computed tomography (CT) of the spine in the sagittal orientation and 3-dimensional (3D) CT further revealed the involvement of the superior end plate of the L2 vertebra, comprising horizontal splitting from the left pedicle, through the left transverse process, and reaching the center of the neural arch (). The right-sided L2 pedicle was intact.
After checking the general condition of the patient and excluding intra-abdominal injury by enhanced CT and ultrasonography, the patient underwent L1-L2 single-level instrumented fusion using a posterior approach. Initially, monoaxial pedicle screws with conventional trajectory were placed at L1 and L2 pedicles on the right side (intact pedicle side). A rod slightly bent in lordosis was then introduced and connected with these pedicle screws with a compression force applied between screws. This procedure achieved reduction and the fracture gap at the left L2 pedicle and lamina was completely closed. Polyaxial pedicle screws were used on the left side. A pedicle screw with a conventional trajectory was placed at the left L1 pedicle. A CBT pedicle screw was then inserted through the fractured L2 pedicle under fluoroscopy. This CBT screw was used as an alternative to an osteosynthesis screw. A rod was introduced on the left side, bilateral facet fusion with local bones obtained from the

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


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

[User]
RADIOLOGY NOTE:
A 65-year-old Japanese woman was admitted to our hospital with a 1-month history of vomiting. She had undergone no medical examination for 10 years prior to admission. Nine months before admission, she was hospitalized at another hospital with dyspnea. She was diagnosed with acute heart failure and three-vessel coronary arteriosclerotic lesions by coronary angiography. She subsequently underwent coronary artery bypass grafting surgery. At that time, computed tomography (CT) revealed irregular soft tissue mass lesions with calcification in the abdominal aortic retroperitoneum and mesentery (Figures and ). Positron emission tomography (PET) showed that 18F-fluorodeoxy glucose mildly accumulated only in the irregular soft tissue mass lesions (standardized uptake value 3.35). Based on the PET result, the soft tissue mass lesions were considered unlikely to be cancerous, and she was followed up by regular imaging evaluation.
One month before admission to our hospital, the patient was readmitted to the previous hospital with persistent vomiting. Abdominal CT revealed enlargement of the abdominal aortic retroperitoneal and mesenteric soft tissue tumor masses. The masses were compressing her duodenum, leading to symptoms of bowel obstruction. She was clinically diagnosed with retroperitoneal fibrosis, and prednisolone was administered at a dose of 40 mg/day. After 3 weeks of treatment, however, the tumor masses did not reduce in size and her symptoms persisted.
She was transferred to our hospital at this point, and on admission she was afebrile (35.3°C), her body weight was 45.1 kg (no weight loss), and she had a performance status of 3. The palpebral conjunctiva appeared anemic, although we observed no marked hair loss, oral ulcers, tongue swelling, thyroid gland and lymph node enlargement, skin rash, arthritis, or Raynaud's phenomenon. The soft tissue masses were not palpable on the abdomen. In addition, there were no findings of syncope, dizziness on standing up, movemen

[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 male presented to the Emergency Department with a 2-hour history of intermittent left-sided lower chest pain, described as heaviness on the lower chest radiating to the upper abdomen. The intensity of the pain varied from 8/10 to 4/10 on the pain scale, associated with some shortness of breath. The patient reported experiencing similar discomfort intermittently over the previous few weeks before this particular presentation. He was known to have asthma, hypercholesterolaemia and a history of myocardial infarction 3 years earlier, which was treated with coronary angioplasty and stenting. The patient had been admitted to the hospital 10 times in the previous 2 years with similar symptoms and treated for angina given his cardiac history, despite unchanged electrocardiograms (ECGs), negative troponin testing and no evidence of recurrent ischaemia on follow-up cardiac perfusion scans. He had a repeated coronary angiogram a year before this presentation, which showed stable coronary artery disease. Constipation was also reported by the patient during this episode but he was able to pass flatus. The recording of vital signs showed blood pressure of 104/65 mmHg and a pulse rate of 61 bpm. Chest examination was unremarkable with a clear chest and normal heart sounds on auscultation. Abdominal examination revealed a soft non-tender abdomen with mild distension. Laboratory blood tests were grossly normal with negative troponin and D-dimer results. The ECG showed sinus rhythm (), with no acute changes compared to previous ECGs. Chest radiography showed an elevated left hemidiaphragm and dilation of the colon at the splenic flexure (). For this reason, an abdominal radiograph was requested, which revealed extensively dilated large bowel loops (). A computed tomography (CT) scan of the abdomen-pelvis was carried out (), confirming a diagnosis of large bowel dilation and no mechanical obstruction. The cardiology and surgical teams at the hospital were consulted, and

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


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

[User]
RADIOLOGY NOTE:
A 35-year-old male patient presented with a slow-growing painless mass on the left lower one-third region of the face. The mass was noted 6 months before the first visit. The tumor mass was hard in consistency, immobile, was fixed to the underlying tissue, approximately 3 cm × 2 cm in size, and located at the left lower border of the mandible at the body region []. There was no history of trauma; the mass was not tender and was deep with no skin changes. No enlarged local lymph nodes were noted and also no abdominal organ or mass was palpable. Systemic examination was unremarkable.
Routine blood investigations were normal. Chest X-ray was normal. Aspiration biopsy showed features suggestive of granulomatous inflammation. A high-resolution 12 MHz transducer ultrasound scan showed an ill-defined hyperechoic mass lesion in the left mandibular region abutting the body of the mandible. Computed tomography scan showed a well-defined encapsulated fusiform soft-tissue density mass of HU 20–30 measuring 3.0 cm × 1.7 cm × 2.8 cm noted adjacent to the left side of the body of the mandible with minimal appreciable enhancement causing scalloping of adjacent bone with thinning of the cortex. Trucut biopsy of the tumor mass suggested a diagnosis of possible benign nerve sheath tumor. The clinical and radiological impressions were those of possible intramuscular myxoma, myxoid liposarcoma, or a benign nerve sheath tumor. We performed an excisional biopsy to confirm the diagnosis []. A complete excision of the mass with its extension was done and at surgery, about 2 cm × 2 cm lobulated tumor mass, intramuscular and adherent to muscle fibers and underlying bone, was evident []. The lump was excised along with the attached muscle bundles of fibers and the wound was irrigated and closed in layers [].
On gross examination, the resected specimen consisted of an open ovoid mass of 2 cm × 2 × cm 1 cm. Light microscopy revealed well-circ

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


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

[User]
RADIOLOGY NOTE:
An 18-year-old man in otherwise good health presented complaining of the right midfoot pain and swelling for 7 months, worsening over the preceding 3 months. He stated that he could walk, but this was associated with pain. A 2 × 3 cm firm, tender mass was palpated on the medial aspect of his right midfoot ().
He had full range of motion at his ankle and limited inversion and eversion secondary to pain. A roentgenogram () showed an expansile, lytic lesion in the navicular bone. Magnetic resonance imaging (-) shows altered signal intensity over navicular bone of size 2.1 × 2.8 cm with mild edema and infiltration over surrounding soft tissues.
No other associated lesions were seen. Under strict aseptic precautions, biopsy was taken, it was a thick column of blood aspirate, and results () were consistent with ABC. In view of high recurrence rate after curettage of ABC, the primary procedure of intralesional sclerotherapy was planned. Under the aseptic condition, hypodermic needle inserted into the lesion with the help of image intensifier, aspirated to confirm the site followed by intralesional injection of polidocanol, a sclerotherapy agent at a dosage of 2 mg/kg, with the patient being 60 kg a total of 120 mg, was given. It was performed as a daycare procedure and carried out under local anesthesia. Early rehabilitation was performed with no mode of immobilization. Four such doses were given periodically at an interval of 1 month under aseptic precautions using the same aspiration and injection technique. The response was regularly observed with roentgenograms in each visit. The outcome seems to be markedly appreciable since the first injection and at the end of all the four injections, lesion found to be remitted completely and the patient improved greatly in view of symptoms. No complications were reported. At 3 months post-therapy (, ), roentgenogram was done and the patient was able to walk without pain and range of movements was full and painless

[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 gravida 2 para 2 Japanese woman visited her local hospital, complaining of fever and left vulvar pain over a 2-month period. She had a past medical history of appendicitis at 13 years of age, erythema nodosum at 20 years of age, and hypertension diagnosed at 50 years of age. Her menopause occurred at 53 years of age. The initial examination revealed a 10 × 6 mm, firm, ulcerative mass on the inner side of the left labium minorum (Fig. ). A vulvar abscess was suspected at the initial visit, but treatment with antibiotics was not effective. SCC was strongly suspected by a subsequent needle biopsy, and she was referred to our hospital for further treatment. Upon admission, her physical examination revealed an ulcerative mass on the left side of the vulva that had increased in size to 31 × 24 mm. Our patient underwent a diagnostic workup that included magnetic resonance imaging, revealing that the primary lesion did not involve the urethra or anus (Fig. ). Neither inguinal lymphadenopathy nor distant metastases were seen on computed tomography (CT). With a preoperative diagnosis of vulvar SCC, our patient underwent radical local excision and bilateral inguinal lymphadenectomy. Histopathological examination found eccrine porocarcinoma with a depth of invasion of more than 20 mm; marked vascular invasion was present. The inguinal lymph nodes were negative for metastatic disease, and the surgical margins of the resected lesion were also negative. Our patient was diagnosed with stage IB disease (T1bN0M0; International Federation of Gynecology and Obstetrics 2008). To prevent local recurrence, she underwent adjuvant radiation therapy for the pelvis, bilateral inguinal area, and vulva (50.4 Gy/28 Fr) with concurrent administration of weekly cisplatin (40 mg/m2) for five cycles. One month after her treatment was completed, positron emission tomography CT revealed metastases to the sacrum (Fig. ) and multiple small nodes in both lungs. She received three further co

[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 85-year-old woman originally presented to her primary care physician with vague pain in her left upper quadrant. She described it as a sharp, intermittent pain, not associated with meals. The pain was exacerbated by different body positions and by activity. She experienced loss of appetite and five pounds of weight loss. She had no significant past medical history, but had recently had both upper and lower endoscopies, which were normal.
Physical exam revealed tenderness in her left upper quadrant. No organomegaly was identified, and no other tenderness or palpable masses were present on examination. A computed tomography (CT) scan of her abdomen was ordered by her primary care physician, and this showed multiple masses within the spleen which were suspicious for malignancy (Figure ). Because of the CT findings and the patient's complaint of pain, she was referred for splenectomy.
Pre-operatively, a complete blood count and electrolytes were within normal limits. A laparoscopic splenectomy was initiated but due to extensive adhesions and multiple tumor implants, the procedure was converted to an open approach. On exploration, numerous omental, mesenteric, peritoneal, and diaphragmatic implants were identified. The splenic capsule, however, appeared to be uninvolved. A splenectomy, omentectomy, removal of peritoneal nodules, and right oophorectomy were performed. The left ovary was not identifiable due to the dense adhesions and implants matted in that area.
Pathologic examination of the gross specimen (Figure ) revealed intraparenchymal splenic lesions. Representative sections from the ovary (Figure ) and spleen (Figure ) are shown here. The tumor at both sites showed a similar morphology of a poorly differentiated adenocarcinoma consisting of irregular nests of large anaplastic polygonal cells with an ill-defined cribriform pattern (Figure , inset). The ovary was almost completely replaced by tumor. There were multiple splenic nodules showing invasive growth. Sp

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


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

[User]
RADIOLOGY NOTE:
A 61-year-old man referred from the emergency department to the ear, nose, and throat (ENT) clinic in Al Wakra Hospital because of vertigo and left ear discharge. The vertigo is rotatory in nature and is associated with hearing impairment and tinnitus as well as nausea and vomiting. Ear discharge was purulent, odorless, and intermittent for the last few years, but it became profuse and continuous for the last few days. The described symptoms were associated with severe left-sided headache and diplopia, and there were associated medical comorbidities (diabetic and hypertensive patient). On examination, the patient was conscious, oriented, and not feverish. Left ear examination showed pulsating purulent discharge with granulation tissue filling the middle ear cavity, the tympanic membrane was perforated, and the fistula test was negative. There was left beating nystagmus with left sixth cranial nerve palsy. Other ENT and neurological examinations were not remarkable. Pure tone audiometry showed left-sided severe mixed deafness, and left ear swab for microbiological study for culture and sensitivity was negative. Urgent CT scan was done to rule out intracranial complications, and it showed features of tympanomastoiditis and soft tissue shadow involving the middle ear and attic areas (Figures and ).
MRI with contrast showed asymmetrical signal changes in the bilateral petrous bone with reduced enhancement on the left with high suspicion of petrositis, in the context of chronic tympanomastoiditis ().
In addition to the mentioned pathology, there was a 10 × 4 mm enhancing lesion in the internal auditory meatus involving the 7th-8th nerve complex most likely acoustic neuroma, and there was no extension to the cerebellopontine angle (). Conservative treatment started with local and parenteral antimicrobial agents with labyrinthine sedative drugs. After ten-day treatment with good monitoring of blood sugar, the patient had satisfactory response and improvement regarding symp

[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 brought to the emergency room with a stab wound on the left side of the upper posterior neck (). He was intoxicated, with an initial blood ethanol level of 255 mg/mL. He was not able to communicate and was not cooperative on neurologic examination. The initial blood pressure was 143/90 mmHg, pulse rate was 109 beats/minute, and respiratory rate was 15 times/minute. Hemoglobin was 13.8 g/mL and the platelet count was 324,000/µL. Other laboratory findings were within normal range. There was no massive hemorrhage in the head or neck on three-dimensional high-resolution computed tomography (HRCT) and the cervical spine, trachea, and esophagus were intact. The knife had pierced the paraspinal muscles and the base of the occipital bone behind the stylomastoid foramen (). The tip of the knife lay on the roof of the fourth ventricle. The patency of the left cervical carotid artery was suspected to be intact because there was no perivascular hematoma or leakage of blood around the vessel (). No signs of tearing were seen in the basilar artery or its major vessels, including the posterior inferior cerebellar artery. However, because of the metal artifact, we could not guarantee that there were no combined vascular injuries. Computed tomography (CT) revealed no intraventricular hemorrhage in the fourth ventricle. We then performed digital subtraction angiography (DSA) to further investigate possible damage to the vascular structures. On injection of the left carotid artery, the blood flow was intact and showed no signs of arterial damage (). On injection of the left vertebral artery, the arterial and venous phases indicated normal patency ().
Based on these imaging findings, we proceeded to surgery to remove the knife and explore the penetrating wound using a microscope with simultaneous preparation for open craniotomy. The knife was gently removed without much difficulty under general anesthesia. There was minimal bleeding from the stabbing canal and the

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


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

[User]
RADIOLOGY NOTE:
In March 2004 a 51-year-old male patient was referred to our outpatient's department because of oropharyngeal pain of the right tonsillar region. The complaints had started one year before with a right sided feeling of pressure in the oral cavity and the neck. In 1966, 38 years before the patient presented to our department, he had been treated for a squamous cell carcinoma of the left tonsil in the territory of the former Soviet Union. At that time, the then 13-year-old boy underwent radical surgery followed by adjuvant radiotherapy with a cumulative radiation dose of 101 Gray. Although the patient was only 13 years old at the time when the diagnosis of a squamous cell carcinoma of the left tonsil was made, the presented documents left no doubt about the initial histological diagnosis. When the 51-year-old patient presented to our department in 2004, the otorhinolaryngological examination showed a smooth bounded neoformation in the region of the right-sided tonsillar fossa and soft palate with a diameter of about 2.5 cm (Fig. ). The tumor's palpation was dense. Computed tomography (CT) of the oropharynx confirmed the neoformation to be smooth bounded and well separated from the surrounding tissue (Fig. ). Computed tomography and ultrasonic examination of the neck did not reveal enlarged cervical lymph nodes that might have indicated lymphogenic metastatic spread. No indication for hematogenous metastatic spread was found on plain x-rays of the chest, ultrasonographic examination of the abdomen and positron emission tomography imaging studies.
An endoscopic examination of the larynx and hypopharynx was performed in general anesthesia and revealed these regions to be without pathological findings. Tumor-resection was then carried out by a transoral approach in combination with a mapping of the oropharyngeal mucous membrane. Histological examination of the tumor revealed spindle cells with marked polymorphism implicating a storiform growthpattern (Fig. ). Via immunohi

[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 patient presented to our emergency department with weakness in bilateral lower extremities of 3-hour duration without any pain in body part after waking up in the morning. Blood pressure was 120/60 mm Hg. There was no recent medical history of trauma, infection, surgery, or drug use. The initial laboratory tests of blood, such as blood routine test, liver function test, blood creatinine, electrolytes, the activated partial thromboplastin time, and the international normalized ratio, were within normal limits. The neurological examinations revealed loss of strength of both lower extremities and the muscle strength was grade 0/5. The loss of skin sensation was below the T4 vertebral level with saddle anesthesia. Babinski reflex of bilateral lower extremities was positive and the anal sphincter tone and bilateral tendon reflex were reduced. Magnetic resonance imaging (MRI) of the cervical and dorsal spines revealed a posterior epidural hematoma from T4 to T7 level with spinal cord compression. The mass had isointensity to the spinal cord on T1-weighted images and hyperintensity on T2-weighted images (Fig. ). The patient was hospitalized in the orthopedic department after diagnosis of SSEH and an operation was planned. Posterior approach decompression laminectomy and hematoma evacuation was performed on the patient. A bilateral laminectomy from T4 to T7 was performed. Thick, clotted blood, and prominent epidural hematoma were seen, but no obvious vascular malformation was found during operation. The hematoma was evacuated, the cord adequately decompressed, and tissue was sent for histology. The pathologic report described a hematoma without neoplasm or vessel malformation.
After the healing of the incision, the patient was transferred to the department of rehabilitation medicine. Preoperative spinal cord status assessment was AIS A scale. A detailed rehabilitation schedule was established for the early rehabilitation program, which included passive

[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 a case of a 4-year-old male child who presented in the casualty with the history of a fall into a gutter while walking on the road; when he fell, an iron rod penetrated into his head []. There was no history of loss of consciousness or convulsions. At the hospital, the patient was conscious and oriented and responding to verbal commands. His vitals were stable (pulse rate: 100/min, blood pressure: 100/60 mm Hg, and respiratory rate: 18–20/min). The pupils were equal in size and reacting normally to light. The Glasgow coma score (GCS) was 15/15. There was no motor or sensory deficit. Brainstem reflexes were normal. No associated systemic injuries were found.
After primary and secondary evaluation, basic blood investigations and X-ray studies were done of the skull [], cervical spine, and chest. Imaging showed that the iron rod (12 mm in diameter) had penetrated approximately 3.5 cm into the brain parenchyma of the right frontoparietal region. A CT scan of the head was not possible immediately because the scanner was out of order. To avoid any delay and aggravation of the injury, the patient was shifted to the operation theater after obtaining written consent []. Circumferential craniectomy was performed and the iron rod was removed along with a bone flap. The tip of the rod was seen to be 3.5 cm inside the brain parenchyma of the right cerebral hemisphere in the region of the precentral gyrus. There was no vascular injury. Necrotic brain tissue, the hematoma, and bone fragments were removed. The wound was closed after debridement of the track. The patient had an uneventful recovery and was able to walk about on day 4. There was no motor or sensory loss and he was able to communicate verbally in a coherent manner.
The absence of major neurological deficits was possible because the patient was right-handed, with left cerebral dominance. CT

[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 baby female, aged 4 months, was referred to our Orthodontics and Paediatric Dentistry Unit. The patient was receiving breast-feeding since birth. Her parents reported, during the first months of life, the spontaneous formation of a pink oblong vesicle in the left internal part of the lower lip (). The color [], the localization [], and the shape [] have been considered coherent with a mucocele lesion; however, a conclusive diagnosis requires histopathological examination. As spontaneous regression of these oral lesions has been reported [], the parents planned only a further control.
After a month, the patient returned, and the lesion had a significant growth with a shape modification and appeared as a more regular bulla (). Therefore, the excision intervention was planned. The size of lesion in the moment of surgery was about 10 mm × 6 mm.
The objective of the treatment was mucocele treatment with topic anesthesia and laser-assisted excision.
The first possible alternative to the treatment was the delay of the intervention, thus planning only further controls, with the risk of lesion growth and feeding problems. Another alternative consisted in a conventional lancet surgical approach, with the consequent risks of intra- and postoperative bleeding and potential difficulties in wound healing. The last option was marsupialization that would allow lesion drainage without excision, but this technique is more fitted for larger lesions.
Written informed consent was obtained from the patient's parents to proceed with lesion excision with laser surgery. The patient and the whole staff wore protective glasses to prevent eye damage []. Local topic anesthesia was performed with lidocaine gel local application for one minute. Diode laser (Diode Laser, DMT Lissone, Italy) at 810 nm wavelength, continuous wave mode with a power output of 3 watt, and a 0.4 mm diameter fiber optic were set for excising the lesion. The tip was directed at an angle of 10 to 15°, moving around the b

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


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

[User]
RADIOLOGY NOTE:
A 31-year-old woman, of Indian origin and known to have TA, was booked for an antenatal care appointment at the 11th week of her third gestation in April 2017. Her earlier two pregnancies in 2008 and 2010 resulted in the normal vaginal delivery of a full term and healthy singleton each. However, her second pregnancy was complicated by pre-eclampsia. The patient was incidentally diagnosed through a routine chest X-ray, which revealed a widened superior mediastinum (Figure ) in June 2014.
Further physical examination revealed an absent left radial pulse. Subsequently, a computed tomography (CT) pulmonary angiogram confirmed the presence of a dissecting aortic aneurysm, which measured 7 cm in length and was inferior to the origin of the left subclavian artery (occluded) (Figure ). The CT scan also revealed an atrophic right kidney and a hypertrophied left one. Thus, the patient was placed on prednisone as well as methotrexate and booked for endovascular repair surgery. The woman later successfully underwent endovascular stent grafting of the thoracic aorta in April 2015. After developing pneumonia, the patient was switched from methotrexate to azathioprine (AZA) and maintained on amlodipine (5 mg), aspirin, and prednisone.
The lady's antenatal care was under the feto-maternal unit (FMU) at the Women’s Hospital. Simultaneously, the patient was regularly followed by her rheumatologist and vascular surgeon. The patient resumed her medication during pregnancy; and serial ultrasound scans revealed a normally developing fetus. The antenatal period was uneventful except for gestational diabetes mellitus. In November 2017, the patient presented at 38+ weeks gestation for an elective cesarean section and bilateral tubal ligation as advised by the multidisciplinary team. Thus, the patient delivered a healthy baby girl, weighing 2279 g, and her postpartum period was uneventful. The patient was counselled about breastfeeding while on AZA and told that the current evidence does not

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


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

[User]
RADIOLOGY NOTE:
A 12-year-old male child patient born out of nonconsanguineous marriage was brought to the Department of Pedodontics and Preventive Dentistry, with the chief complaint of unaesthetic appearance due to irregular placement of teeth by the parents. The clinical examination revealed retained mandibular deciduous second molars. A panoramic radiograph revealed two radiopaque irregular structures in the mandible bone similar to crowns of teeth in relation to distal roots of the left and right second deciduous molars and in distal aspect relation to the crown of the second premolars slightly []. Intraoral periapical radiographs showed the calcifications in relation to the distal root of the second deciduous molars with a slight lingual orientation and resorption of the distal roots. A provisional diagnosis of complex odontoma was considered and management included extraction of the deciduous second molars to allow the permanent premolars to erupt, followed by exposure of the complex odontoma through the socket itself [] while carefully preserving the permanent second premolar. The excisions were planned 2 days apart starting with the right side, and both procedures were done under local anesthesia with pathology being removed conservatively through the extraction socket itself following which the surgical sites were sutured with 3-0 Vicryl suture material and the patient was advised review after 1 week. Both the right and left odontomas were elevated through the sockets and the tissue covering them were curetted and sent for histopathological examination []. Histopathology of the calcified structures under ×40 magnification revealed poorly formed dentin matrix [] and cementoid areas with lacunae containing cementocytes [], consistent with complex odontoma. The excised surrounding soft tissue with the odontoma showed a poorly differentiated benign lesion composed of irregularly arranged fibrocollagenous tissue, with the cellular fibrous matrix that was containing fibroblasts

[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 spayed female golden retriever was referred to the medical oncology service for evaluation of a biopsy-confirmed FSA involving the left rostral maxilla and dorsolateral muzzle. Absence of metastasis had been confirmed via lymph node aspiration and thoracic radiography by the rDVM before referral. A 3.4 cm, firm swelling was present on the dorsolateral aspect of the left rostral muzzle. Head CT revealed an ill-defined 2.7 cm × 1.8 cm × 2.8 cm soft tissue attenuating mass in the left dorsolateral maxilla extending from the mesial aspect of the left maxillary canine tooth to the mesial aspect of the left maxillary second premolar tooth. The dorsal extent of the mass was 0.6 cm from dorsal midline of muzzle and ventrally involved the alveolar margin of left maxillary canine tooth.
The case was referred to the dentistry and oral surgery service for surgical treatment. A composite resection with a combined intra- and extraoral approach was performed. The soft tissue resection extended from 3 cm rostral to the medial canthus of the left eye to <1.0 cm from the nasal planum. From dorsal to ventral, the resection extended from the dorsal midline of the muzzle to approximately 7 cm from the mucocutaneous junction of the left lip. The osseous resection extended from the mesial aspect of the left maxillary third incisor tooth to the distal root of the left maxillary second premolar tooth. The palatal extent of the resection was approximately 1 cm palatal to the dental arch. Following resection, the distal root of left maxillary second premolar tooth was extracted, and the wound was closed as described earlier.
Histopathological evaluation of the resected tissue confirmed the diagnosis of FSA and tumor-free margins. The dog recovered uneventfully from general anesthesia and was managed overnight in the critical care unit on an intravenous (IV) CRI of fentanyl (3 µg/kg/h), lidocaine (13 µg/min/h), and ketamine (5 µg

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


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

[User]
RADIOLOGY NOTE:
A 6-year-old girl with a history of multiple IgE-mediated food allergies, atopic dermatitis, and a remote history of asthma presented to the emergency department with urticaria, coughing, and wheezing. Symptoms began minutes after entering a ginseng store that was selling powdered American ginseng products. She did not have any respiratory symptoms or ingest anything prior to entering the store. Parents suspected she inhaled some powdered ginseng. This was her first known exposure to ginseng. On physical examination, she was afebrile with normal blood pressure for age. Respiratory examination confirmed increased work of breathing and decreased air entry with wheezing bilaterally. On dermatologic examination, she had urticaria on her chest. She was treated in the emergency department with salbutamol, dexamethasone and diphenhydramine. Symptoms resolved shortly after treatment, and the patient was referred to our Allergy Clinic.
In the Allergy Clinic, parents provided a history of wheezing with viral infections between ages two and four, with intermittent inhaled corticosteroid and salbutamol use. There had been no exacerbation of respiratory symptoms in over a year. She had confirmed food allergies to peanuts, tree nuts and fish, and had outgrown egg and wheat allergies. She was found to be sensitized to tree pollen.
Skin prick testing (SPT) with American ginseng powder dissolved in water was positive with a 13 × 12 mm wheal. Spirometry was normal (FEV1 107% predicted). The family declined an oral challenge to ginseng, given the severity of her initial reaction. Basophil activation test (BAT) showed a dose-dependent increase in expression of CD63 on basophils in response to American ginseng extract, but not Korean ginseng extract (Fig. ). No changes were observed in a non-atopic control, and minimal changes were observed in an atopic control that was tested with American ginseng extract.
It was concluded that this patient had an anaphylactic reaction to American gins

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


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

[User]
RADIOLOGY NOTE:
A 75-year-old female patient reported to the Department of Oral Pathology with complaints of burning sensation in the oral cavity and difficulty in swallowing for the past 2 years. The patient was weak and of thin built with no declared previous history of systemic illness, although she did give a history of viral fever 2 years before and was hospitalized briefly for the same. The patient had a history of betelnut chewing along with tobacco for the past 50 years and reportedly quit the habit 3 years ago.
On extra oral examination, multiple nodules of 0.5 mm were seen distributed over the face and neck region. There were papular lesions on the neck which seemed to have ruptured and healed with scarring. The eyes were noticeably reddish in color and there was visible scarring in bulbar conjunctiva of the right eye [Figures and ]. Patient also reported a history of recurrent genital vesicles and ulceration, but none was noticed during medical examination by dermatologist during the present visit. Submandibular lymph nodes were palpable bilaterally, tender and freely movable.
On intraoral examination, irregular erythematous ulcerations of hard palate, soft palate and alveolar mucosa were seen; which were covered by a greyish white pseudomembranous slough. Multiple, intact, translucent vesicles of size ranging from 3 and 5 mm in diameter were present in the anterior hard palate region []. On the right buccal mucosa, an irregular ulceration with erythematous halo, covered by a greyish white slough was seen in relation to 16 and 17 [Figures and ]. The oral hygiene of the patient was poor, with significant calculus and plaque deposition over the teeth and the gingiva showed generalized erythematous changes.
The clinical features of this case with classical intact vesicles and bullae accompanied with generalized irregular ulceration and symblepharon (scar formation) in right eye led to a provisional diagnosis of cicatricial pemphigoid. Differential diagnoses of LAD and pemph

[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 36-year-old female patient reported to the Department of Oral and Maxillofacial Surgery with a complaint of pain and purulent discharge on the left side of the face since 3 years. She gave a history of extraction of mandibular first molar, multiple fractures of lower limbs since two decades for which she was conservatively manage data primary health center. Clinical examination revealed short stature [height-122.4 cm, ], underweight (29 kg), prominent nose, accentuated nasolabial fold [], stubby fingers [] and blue sclera []. Intra-orally a mucosal defect with bone exposure measuring 8 mm × 4 mm in relation to the left posterior mandibular ridge was observed []. Purulent discharge was evident through an extra-oral draining sinus in the mandibular left body region []. Radiographic examination showed evidence of the generalized diffuse osteosclerosis and acro-osteolysis []. Antero-posterior and lateral views of the skull indicated straightening of the mandibular angle and widened coronal suture with persistence of the anterior fontanelle. Multiple healed old fractures of the femur, tibia and fibula were also observed in the radiographs. The orthopantomograph showed asequestrum in relation to the left body of the mandible []. The computed tomography scan revealed a sinus tract arising from the sequestrum to the skin surface suggesting osteomyelitis. It also showed evidence of root remnants of the molar ankylosed within the sequestrum []. Routine blood investigations, urine analysis and specific diagnostic tests for calcium, phosphorous and alkaline phosphatase levels revealed no significant alterations. Following thorough investigations and clinical correlations the patient was diagnosed to be a case of Pycnodysostosis with chronic suppurative osteomyelitis secondary to extraction of the left mandibular first molar.
All the treatment options were explained to the patient, but her persistent refusal for any surgical therapy necessitated conservative management to cont

[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 7-year-old boy was referred to the Pediatric Dentistry Department of Mashhad University of Medical Sciences with the chief complaint of severe rotation of the upper anterior tooth. There was no relevant and remarkable medical history reported. The clinical examination showed good facial symmetry and competent lips at rest. Intraoral examination showed Class П molar relationship with about 90° rotation of left maxillary central incisor. The rotated tooth was not fully erupted [Figure and ]. Class I skeletal pattern with no vertical problems was confirmed by cephalometric analysis and there were no transverse problems. Radiographic examination confirmed severe rotation of left maxillary central incisor and early stage of root development []. Space analysis on the study models shows a lack of space in both jaws. At the first visit, an alginate impression was taken from upper arch and a removable appliance consisting of acrylic base plate, circumferential clasps on the maxillary primary canine and Adams clasp on the maxillary permanent premolar and first molars was made. In the later appointment, a bonded mandibular first molar buccal tube (Dentaurum, Germany) was placed on the labial surface of the rotated central incisor. Whip spring was constructed with a segment of 0.4 mm stainless steel orthodontic wire (0.0016 inches) (Dentaurum, Germany) ligated into place. In order to protect buccal mucosa and gingiva from irritation the patient was instructed to wear the appliance fulltime and only to remove the appliance for tooth brushing after eating.
In every follow-up appointment, with a month interval, a new whip spring was fabricated. After 5 times replacement of the spring, rotation was almost corrected []. At the end of treatment, supracrestal fiberotomy was performed and alginate impression was taken of the upper jaw in order to construct a removable appliance for retention. This appliance was made of acrylic base plate, labial bow on anterior segment and Adams clas

[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 presented with a one-month history of cough. She had no complaints of sputum, chest pain, or dyspnea, but she had a suspicious history of hemoptysis. She had never smoked. She had a dog in her childhood and she also lived in the rural area. Her physical examination was normal. No abnormal signs were observed on her chest radiograph. Pulmonary function tests and laboratory test results were within normal limits except for eosinophilia and minimally elevated D-dimer in the blood test. D-dimer level of the patient was 600 ng/mL, while normal limits are 0-500. A negative D-dimer result may exclude pulmonary embolism, but there are many reasons that cause D-dimer elevation such as infection, trauma, deep venous thrombosis, and disseminated intravascular coagulation. In this case, the reason of elevated D-dimer was parasitic infection. The patient was treated with 250-mg fluticasone dry powder twice daily in an inhaler and montelukast once daily under a suspicious diagnosis of allergic asthma; she asked for a control examination 2 weeks later. At the control examination, she still complained of coughing. Thoracic computed tomography (CT) was performed to investigate the etiology of cough and her minimally elevated D-dimer level. Filling defects were observed inside the left main pulmonary artery, upper segmental branch of the lingular artery, and segmental and subsegmental branches of the lower lobe artery on her thoracic CT angiogram (-). This finding at the main and superior branch of the lingular artery showed continuity with an 18 × 16 mm nodular opacity considered likely to be a cystic embolism. The right pulmonary artery and its branches were clear. Subcutaneous low-molecular-weight heparin anticoagulant therapy was administered on the basis of the suspicious diagnosis of pulmonary thromboembolism. Left and right ventricular parameters on echocardiographic evaluation were normal. Systolic pulmonary artery pressure was 25 mm Hg. No intracardiac th

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


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

[User]
RADIOLOGY NOTE:
A 67-year-old man with underlying ischemic heart disease and dyslipidemia presented to the emergency department with spontaneous left leg swelling for a week. There were no complaints of any calf pain or bleeding tendency elsewhere. The patient had no history of preceding trauma or consumption of traditional supplements. Clinical examination revealed a hematoma measuring 10 cm×6 cm in the left calf; however, there was no evidence of hepatosplenomegaly. No other signs of bleeding were noted. The patient did not report of any personal or family history of bleeding disorders. He was compliant with his medications, which included Tab Ramipril (5 mg daily) and Tab Atorvastatin (40 mg, taken at night).
He was initially suspected to have lower left limb deep vein thrombosis; however, the results of D-dimer and ultrasound Doppler tests of the affected limb were found to be negative. The prothrombin ratio and platelet counts were normal but the aPTT was prolonged (55.8 seconds) relative to control (30–45 seconds). Following his recovery, he was discharged from casualty and referred to primary care for a follow-up examination of the swelling.
During subsequent visits to the clinic, the patient was attended by different doctors; however, his condition remained the same with prolonged isolated aPTT ranging between 51–59 seconds. Several years ago, the patient had been tested for anemia and presented a normal coagulation profile at the time. In the absence of extensive hematoma and other bruises, no further investigation was carried out for the abnormally prolonged aPTT.
During the 4th week of the illness, he developed new bruises on both of his hands. There was bleeding from venepuncture site, which did not stop spontaneously. However, there were no changes in the leg hematoma, and the repeated aPTT values still remained high.
On family medicine specialist review, he was referred to hematological team based on clinical suspicion of acquired hemophilia. Upon admission, the patie

[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 43-year old man with a sudden onset of headache, nausea and vomiting visited the emergency room at our institution. He had a history of hypertension that was being controlled with medication and smoking. His aunt suffered from moyamoya disease, but he had not undergone diagnostic work-up for familial cerebrovascular diseases because he had not experienced neurological deficits such as ischemic attacks, including dysarthria, dizziness and gait disturbances. Mentally alert, the patient had meningismus, experiencing neck stiffness on admission.
A brain computed tomography (CT) scan demonstrated diffuse and thick subarachnoid hemorrhage (SAH) in the bilateral sylvian fissures, the anterior interhemispheric fissure, the basal cistern and the posterior fossa, including the perimesencephalic region (). Subsequent carotid angiography showed complete occlusion of both ICAs, the so called 'bottle neck appearance' or 'beak shape,' at the level of the carotid bulb without appreciable intracranial filling and there were small collaterals from both external carotid arteries through the middle meningeal arteries to the anterior cranial fossa (). Vertebral artery angiography demonstrated that both hemispheres were seen filling in an antegrade fashion from the upper basilar artery and both posterior cerebral arteries through an extensive network of collateral vessels to the ICA bifurcations. A 6 × 4 mm aneurysm was also observed at the basilar artery bifurcation (). Perfusion CT scans revealed no reduction of cerebral blood flow and normal cerebrovascular reactivity to acetazolamide (). The abdominal CT aortograms did not demonstrate any other extracranial pathological vascular findings, including renal artery stenosis and fibromuscular dysplasia (figures not shown).
The patient underwent endovascular coiling under general anesthesia for the ruptured basilar tip aneurysm. Two Guglielmi electrically detachable platinum coils and two hydrosoft helical coils were successfully deploye

[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 49-year-old female experiencing untreated hypertension for several years presented with severe chest and back pain. A CT scan was performed and revealed an aortic dissection (Stanford type B) and an intimal flap was noted immediately distal from the origin of the left subclavian artery. After 4 days of medical management, her urine output decreased and both femoral pulses were weakened. Another CT scan was performed, showing that the aortic dissection had worsened and there was nearly total occlusion of the mid-aorta (). We recommended aortic repair operation, which the patient and her family refused. TEVAR was recommended as another treatment option to cover the intimal flap of the dissection. To acquire the proper proximal landing zone, her left subclavian artery and two thirds of the origin of the left common carotid artery would be covered by the stent graft. For the occluded left subclavian artery, revascularization can then be selectively considered in a staged approach if left arm pain, claudication and subclavian steal syndrome develop. The modified chimney technique was planned to preserve the blood flow of the left common carotid artery. The patient was taken to the cardiac catheterization laboratory and a left femoral arteriotomy was performed under general anesthesia. The 035 inch wire was placed in the ascending aorta and the left subclavian artery through the left radial artery approach. This wire is important to rescue the left carotid artery flow. If an aortic stent graft totally covers the left carotid artery or if it is difficult to select the left carotid artery with a catheter, then we can perform emergency balloon dilatation and place a chimney graft stent from the left subclavian artery to the aorta via this wire. The deployment of a 38×150 mm SEAL aortic stent graft (S&G Biotech, Seongnam, Korea) was performed so that the proximal part of the stent graft covered two thirds of the ostium of the left common carotid artery. After selection of t

[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 63-year-old Caucasian man was admitted to our hospital for further workup of a solitary pulmonary lesion. A simultaneous diagnosis of stage I renal cell carcinoma of the left kidney and adenocarcinoma of the rectum had been made in March 2005 which was treated by left nephrectomy, total mesorectal resection, and adjuvant radiochemotherapy according to the AIO protocol. Postoperative tumor staging and grading of the rectal carcinoma was pT3, pN0 (0/15), G2, R0, and M0. Regular followup until July 2010 was without pathological findings and the carcinoembryonic antigen (CEA) and CA19-9 serum concentrations were normal. A computed-tomography-guided core biopsy of the pulmonary lesion was performed; histological and immunohistochemical analysis showed an adenocarcinoma consistent with metastatic colon cancer. On further workup, an abdominal ultrasound showed a 25 mm polypoid lesion within the gallbladder (). Contrast enhanced ultrasound was performed for further characterization. Imaging in low mechanical index (MI) technique after intravenous injection of 5 mL sulphur hexafluoride microbubbles (SonoVue) showed an intense homogenous contrast signal within the gallbladder mass. Contrast enhancement was detected after 20 seconds and preceded the appearance of contrast in the adjacent liver tissue by approximately 20 seconds. The contrast signal decreased over time but no complete washout phenomenon was observed (see and Supplementary Video Sequence in Supplementary Material available online at ). The diagnostic and therapeutic options were discussed by the multidisciplinary tumor board and a decision was made to resect the pulmonary metastasis and to perform a cholecystectomy. While the pulmonary tumor was confirmed to represent metastatic colon cancer, an intramucosal metastasis of a clear cell renal cell carcinoma was found in the gallbladder (). After successful complete resection of both metastatic lesions, the patient remained without recurrent disease for more than

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


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

[User]
RADIOLOGY NOTE:
A 33-year-old woman was sent to the general surgery department due to upper-right abdominal pain for 2 weeks. A physical examination showed that the skin color and sclera of the patient were normal; however, a mass could be felt in the upper-right abdomen. The patient had received no relevant interventions prior. Laboratory findings revealed that the liver transaminase of the patient was slightly increased: alanine aminotransferase was 120 U/L, aspartate aminotransferase was 109 U/L, and r-glutamyl transpeptidase was 180 U/L, with the levels of tumor markers and serum total bilirubin (7 μmol/L) within the normal limits. CT found a liquid dark area of about 4 × 3 × 3 cm in the theoretical location of the pancreatic segment of the common bile duct with no enhancement found in the cystic wall by the enhanced CT scan. An aspherical expansion of the cystic dilatation was detected by both MRI and magnetic resonance cholangiopancreatography (MRCP). Therefore, the patient was diagnosed with a choledochal cyst based on the results of the radiological images preoperatively ().
Subsequently, the patient signed the informed consent and took a laparoscopic choledochal cyst resection. Under the laparoscopy, the gallbladder was found extremely dropsical with an unclear structure in the Calot's triangle. The gallbladder was resected as a routine operation, and the specimen was examined for pathology analysis. The stump of the cystic duct was lifted and separated medially along the cystic duct. The isolated cystic dilatation was found in the middle part of the cystic duct, and the caudal portion was found behind the head of the pancreas and converged into the common bile duct at an acute angle and low insertion. The surgery was converted to a laparotomy for the unclear structure and the possibility of anatomic variation of the bile duct. Because the drainage to the bile duct was through a narrow neck and the extrahepatic bile duct was not cystic, the cystic duct was eventually remov

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


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

[User]
RADIOLOGY NOTE:
A 24-year-old male presented with persistent, severe abdominal pain and gangrene of his toes for 6 months. His history dated back to 1999 when he was 8-year old and he had tender macular lesions over legs, abdominal pain, weight loss, testicular pain, persistent fever and right ulnar palsy. There was no past history of any comorbid illness. Serum inflammatory markers were raised and HIV and hepatitis B surface antigen (HbsAg) were negative. Orchidopexy was performed for suspected torsion of right testis which failed to relieve the pain. PAN was suspected on clinical grounds by a pediatrician and conventional angiography of abdominal vessels and CT scan of abdomen was normal. After treatment with prednisolone and oral cyclophosphamide, his symptoms subsided and after four months he stopped the treatment. He had a long remission until February 2003, when abdominal pain recurred. This was managed conservatively and disease went into remission after a few days.
In February 2007, disease relapsed with left testicular pain. Orchidopexy was done on the left side and testicular biopsy showed left testicular atrophy and acute orchitis without arteritis. It was managed conservatively and symptoms remitted after a few weeks. Diagnosis of PAN was not suspected due to lack of objective findings and spontaneous resolution of symptoms.
In November 2014, 6 months before presenting to us, he had fourth relapse with abdominal pain and pain in toes of both feet. This time the abdominal pain was very severe with marked anorexia and progressive loss of weight. Video colonoscopy, jejunal biopsy and CT angiography of abdomen was normal and capsule endoscopy revealed jejunal and ileal ulcers. PAN was reconsidered and treatment with prednisolone and azathioprine was started. Symptoms showed no response and abdominal pain continued unabated. Thereafter dry gangrene of toes of both feet developed. Anti-nuclear antibody (ANA), Anti-neutrophil Cytoplasmic antibody (ANCA), anti-ENA and HbsAg wer

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


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

[User]
RADIOLOGY NOTE:
The patient was a 65-year-old woman who presented with a 1-month history of bloody stool. A digital colonoscopy with biopsies revealed adenocarcinoma in the sigmoid colon. The patient elected to undergo primary laparoscopic colon resection, and the procedure was reported to be uneventful. However, on the 6th postoperative day, the patient noticed a large amount of yellow fluid coming out of a left side abdominal drain. The fluid appeared to be urine. An abdominal ultrasonography showed a collection of fluid in the patient's pelvis. A contrasted computed tomography (CT) scan showed contrast extravasation in the pelvis and around the descending colon (). The patient had decreased serum protein and albumin; however, complete blood count, creatinine, liver functions, and urine analysis were normal. On the 8th postoperative day, the patient was taken to the operating room for a ureteroscopy. The ureteroscopy revealed that the left ureter was completely severed about 4 to 5 cm from the ureteral orifice (, transected distal end of the ureter). The bowels could be seen through the ureteroscope (, intraabdominal cavity with bowels seen through the distal end of the transected ureter). No other obvious injury was identified. With patience, persistence, and some difficulty, the severed upper end of the ureter was identified and entered (, the proximal end of the transected ureter). We estimated that there was a 3- to 4-cm gap between the two ends of the ureter. Two 0.035″ guidewires were first passed, followed by the placement of two 4.5F Double-J ureteral stents. After placing the Double-J stents, the abdominal drainage quickly subsided. An abdominal ultrasonography 6 days after tube placement showed complete resolution of the abdominal fluid collection. The abdominal drain was removed and the patient was discharged. At the 3-month follow-up, a repeat CT scan showed no hydronephrosis, no abdominal fluid collection, and no contrast extravasation. The patient, however, had an 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 45-year-old woman presented to our hospital with multiple lung nodules. She had a history of poorly differentiated thyroid carcinoma, diagnosed 7 months prior to admission, at an outside hospital. The patient was healthy otherwise and reported no radiation exposure or any family history of thyroid cancer. The initial work-up at the time of discovery of the right thyroid nodule included fine needle aspiration and core biopsy, with findings consistent with poorly differentiated thyroid carcinoma. The patient then underwent a total thyroidectomy and central neck lymph node dissection. The pathologic diagnosis from the outside hospital reported a 2.8 × 2.4 × 1.1 cm tumor in the right thyroid without extrathyroidal extension or lymph node metastasis. However, both capsular invasion and extensive vascular space invasion were noted. Based on the tumor size, tumor extension and lymph node status, the tumor was designated as Stage II (pT2 pN0 pMx). IHC staining showed that the tumor cells were positive for thyroglobulin and thyroid transcription factor 1 (TTF1). An immunostain for p53 was also performed at the outside hospital and showed a small focus (< 1 cm) with p53 positivity, suggesting a diagnosis of anaplastic thyroid carcinoma.
At our institution, the diagnosis was revised, based on review of both the primary thyroid tumor and the current lung metastases. Both tumors were remarkable for biphasic malignant components: the carcinoma and the sarcoma. The carcinoma component showed a poorly differentiated microfollicular type thyroid carcinoma, composed of sheets and islands of tightly packed thyroid follicles with dense colloid. The tumor nuclei were small and round with vesicular chromatin, resembling those of typical poorly differentiated follicular thyroid carcinoma. Admixed with the epithelial component were malignant spindle cells with small round blue cell type morphology. Focally, rhabdomyosarcoma-like cells with eosinophilic cytoplasm were appreciated. No hete

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


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

[User]
RADIOLOGY NOTE:
A 39-year-old female presented to the emergency department with acute onset of right retroorbital and temporal headache associated with left-sided weakness and numbness following sexual intercourse. She was otherwise healthy without cerebrovascular risk factors, tobacco use, or illicit drug use. She was taking oral contraceptives. There was no family history of premature coronary artery disease or stroke. Initial general examination was notable for a blood pressure of 158/98. Neurologic examination revealed a left lower facial droop and hemiparesis. Brain MRI revealed an acute stroke in the right cerebral hemisphere in a watershed distribution (). Head MRA demonstrated no flow-related enhancement within the petrous and cavernous segments of the right ICA with reconstitution of the ICA at the ophthalmic artery level. Axial fat-saturated T1-weighted MRI through the skull base demonstrated a distortion of the lumen of the petrous and cavernous segments of the right ICA by a rounded region of increased signal abnormality consistent with a dissection (). Conventional 4-vessel cerebral angiography demonstrated 360-degree loops in both cervical ICAs (). At the apex of the loop involving the proximal right internal carotid artery, there was a fusiform aneurysm filled with a subintimal thrombus resulting in poor antegrade flow into the distal ICA and cerebral circulation. The 360-degree loop in the mid-cervical portion of the left internal carotid artery was not associated with outflow obstruction. The 360-degree loop in the distal right ICA was not felt to be amenable to surgical intervention by vascular surgery due to the distal nature of the vascular anomaly. She was anticoagulated with warfarin for 7 months followed by treatment with extended-release dipyridamole plus aspirin daily. Her left hemiparesis progressively improved following discharge and she had no residual weakness after 1 month. Eight years later, she presented with acute onset of right hemiplegia associate

[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.