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

[User]
RADIOLOGY NOTE:
In June 2007, a 70-year-old non-smoking female was seen at our hospital because of a 3-month history of progressive dysponea at rest. CT scan revealed a mass at the right lower lobe and moderate pleural effusion on the right side. Metastasis to right adrenal gland was observed on abdominal CT. There was no evidence of extra thoracic metastasis on brain MRI and bone ECT scans. Lung needle aspiration revealed adenocarcinoma and the patient was diagnosed with NSCLC stage IV. She started 4 cycles of systemic chemotherapy with cisplatin and gemcitabine in Jul 2007. CT scan showed a stable disease of the carcinoma and marked clinical improvement was noted as dyspnoea disappeared and the patient reported a general feeling of wellness. The patient then received two cycles of docetaxel for maintenance therapy. In the following six months, the patient was well without any evidence of local or systemic recurrence. In June 2008 a routine follow-up bone ECT and brain MRI revealed bone and brain metastatic lesions, and the patient commenced erlotinib (150 mg daily ), which she tolerated well and only experienced grade 1 skin rash without requiring dose adjustment. After 4 weeks of erlotinib, the patient showed complete response in her intracranial disease and a partial response in her lung disease. After 12 months of erlotinib therapy, tumor at the right lower lobe progressed, and two cycles of carboplatin and paclitaxel were administered. CT imaging confirmed stable disease in the right lower lobe tumor. However, the patient refused further cytotoxic chemotherapy because of severe treatment-related diarrhea. She was re-challenged with erlotinib (150 mg daily ) in October 2009, and experienced grade 3 skin rash without dose modification. Fortunately, she improved clinically with her right lower lobe tumor showing partial response after 4 weeks of erlotinib treatment and the treatment was continued for eleven more months(CT scans were shown in Figure ).

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


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

[User]
RADIOLOGY NOTE:
A 51-year-old non-smoking woman was admitted to L. G. Sokolov Memorial Hospital 122 due to an area of consolidation in the middle lobe that was found on a chest computed tomography (CT) scan. Two years ago, chest CT was performed due to increasing dyspnea, and revealed a middle lobe neoplasm (). The lesion was solid, centrally located, measuring 16×15 mm, with smooth margins, and caused partial atelectasis of the middle lobe with no enlarged lymph nodes. During video-assisted thoracoscopic surgery (VATS) exploration performed at another institution, the neoplasm in the middle lobe was visualized, as well as multiple small yellowish foci on the parietal pleura, upon which basis pleural dissemination was suspected. Thus, wedge resection of the middle lobe with the entire lesion and biopsy of the parietal pleura were performed. According to the morphologic examination, an atypical carcinoid was verified, the resection margins were clear, and pleural carcinomatosis was confirmed. The patient was treated with octreotide (20 mg once in 28 days) since she had mild symptoms of carcinoid syndrome (the recurrent feeling of blood rushing to the face). Twelve months after surgery, local recurrence was suspected based on follow-up CT (). Significant consolidation was seen in the suture line area, and several small lesions were noted on the parietal pleura. No other signs of distant metastasis or lymph node involvement were found on chest and abdominal CT.
At the time of admission to our hospital, the patient had mild dyspnea. Her Charlson comorbidity index was 3. The level of chromogranin A was elevated. The patient was scheduled for VATS re-exploration of the pleural space to prove the presence of recurrence and to evaluate the volume of dissemination and the extent of the previous operation. During surgery, local recurrence in the remaining middle lobe and multiple miliary yellowish foci from 2 to 5 mm in diameter on the parietal pleura were visualized, but the visceral pleura

[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 physician of a 70-year-old Japanese woman noted the carbohydrate antigen 19-9 (CA-19-9) level, which was elevated to 112 U/mL, and CT revealed a tumor in the pancreatic body. She was referred to our hospital for further examination and treatment. She had diabetes mellitus and no family history of cancer. She had no smoking history or alcohol consumption.
On examination, her abdomen was soft and flat without any apparent mass or tenderness. Blood tests demonstrated elevated tumor markers (CA-19-9, 112 U/mL; Span-1, 41 U/mL). Abdominal enhanced CT revealed an 18-mm hypovascular tumor in the pancreatic body and a dilated main pancreatic duct in the tail side of this tumor (Figure ). The tumor was located next to the splenic vein. There was a 7-mm cystic lesion without a nodule in the pancreatic head. Endoscopic ultrasound showed an 18.5-mm low echoic heterogeneous tumor in the pancreatic body and a 10-mm branch duct intraductal papillary mucinous neoplasm (IPMN) in the uncinate process of the pancreas. The main pancreatic duct was narrowed at the pancreatic body and dilated in the tail side in endoscopic retrograde pancreatography (Figure ). We diagnosed PDAC in the pancreatic duct with a branch duct type IPMN in the pancreatic uncus and performed distal pancreatectomy, splenectomy, and lymph node dissection.
Macroscopic findings of the resected specimen showed a 32 mm × 20 mm tumor in the pancreatic body and a small lesion in the pancreatic tail, 15 mm away from the main tumor (Figure ). Pathological findings revealed a poorly differentiated tubular adenocarcinoma with invasion of the splenic vein at the main tumor (Figure ). Carcinoma in situ continued in the main pancreatic duct, in the range of 15 mm from the invasive cancer. A 1-mm poorly differentiated tubular adenocarcinoma was present in the pancreatic tail parenchyma, 20 mm away from the main invasive cancer (Figure ). There 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 45-year-old woman suffering from intraocular hemorrhage associated with chronic myeloid leukemia complicated by subdural hematoma was referred to our institution. Chronic myeloid leukemia had been diagnosed 10 years earlier and the patient’s comorbidities were treated arterial hypertension, hepatitis B virus positivity, and orally treated type 2 diabetes mellitus diagnosed 3 years earlier. At presentation, she was in blast crisis for the second time and the disease was rapidly progressing. She was hospitalized in the Hematology-Oncology Department, University of Turin, with a very low platelet count (8,000/mm3) and red cell count (2,000 mm3), asthenia, fever, and occipital headache radiating to the anterior parts. A severe subdural hematoma was discovered, with ventricular dilatation and signs of high intracranial pressure. She was treated with repeated platelet transfusions and conservative medical therapy. The patient’s condition improved slowly, with progressive reabsorption of the hematoma and normalization of ventricular morphology on brain computed tomography scan.
We followed up this patient for a year by assessment of visual acuity, fundus examination, color retinography, and A-scan and B-scan ultrasonography. The patient complained of visual impairment in the left eye since the onset of her neurological symptoms, and was referred to our clinic. At presentation, her best corrected visual acuity on the right was 20/63 and on the left was 20/320. Retinal examination of the right eye revealed blurring of the optic margins surrounded by retinal and preretinal hemorrhages, preretinal fibrosis starting from the optic disc and extending along the vascular arcades, and perivascular retinal infiltrates (). Massive fibrosis with hard exudates and severe preretinal hemorrhage were observed in the left eye at the posterior pole (). The optic disc was surrounded by retinal and preretinal hemorrhages. Roth spots and many circular and preretinal hemorrhages were noted at

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


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

[User]
RADIOLOGY NOTE:
A 62-year-old Caucasian man had a history of general malaise and recurrent fever. His general practitioner commissioned seven days of doxycycline therapy under the suspicion of Q fever, although the results of serological testing were negative. The patient still complained of general malaise and experienced progressive abdominal pain based on a symptomatic infrarenal aortic aneurysm of more than 6 cm, which was treated electively with an endovascular repair at another hospital. A bifurcated endograft was implanted without complications. The patient experienced a short episode of high fever early after the operation but remained free of symptoms for three months when he was readmitted to the hospital with increasing abdominal complaints and general malaise. On admission, he was afebrile. The results of a clinical examination were normal except for abdominal tenderness on deep palpation. Blood cultures were sterile in the absence of any recent antibiotic therapy. Laboratory results showed a white blood cell count of 11.5 × 109/L and a C-reactive protein level of 24 mg/L. A serological test showed the persistence of C. burnetii phase II antibodies (immunoglobulin G [IgG]: 4096) and the appearance of phase I antibodies (IgG: 2048). A computed tomography (CT) scan of the abdomen revealed several para-aneurysmal fluid collections (Figure ).
At that point, the patient was referred to our hospital for surgical treatment of his infected abdominal aortic aneurysm. Surgery was performed via midline laparotomy. A visual inspection showed huge abscesses in his abdominal aortic wall. The entire abdominal wall of his aneurysmal sac, including the abscesses, was removed. The vascular endoprosthesis showed no macroscopic signs of infection, and because of the severe cardiopulmonary comorbidities, the decision was made to leave the endograft in place to avoid suprarenal clamping and explantation of this device with venous reconstruction. The proximal part and distal parts of the endo

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


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

[User]
RADIOLOGY NOTE:
An 18-year-old male visited the clinic with complaints of constant dull ache located in the right shoulder girdle, associated with sudden difficulty with overhead activities and heavy lifting. There was no report of history of neck trauma or manipulation that would predispose the patient to injury. A week later, the pain was worsened. There were no associated episodes of headaches, nausea and vomiting or numbness in right upper extremity.
Physical examination revealed winging of the patient's right scapula and severe atrophy of the right trapezius muscle (). Moreover, there was weakness in contralateral rotation and ipsilateral flexion of the neck on the right side. Passive range of motion of his right shoulder joint was normal. Manual muscle test grade was poor plus in flexion and abduction; and normal in external and internal rotation on his right shoulder. The patient was unable to abduct and flex the right arm forwardly to more than 70 to 80 degrees (). There were normal muscle tone, normal sensory function and symmetrical upper extremity reflexes. Hawkins', Neer's, Roos', Wright's, and Adson's provocative tests were all negative.
The magnetic resonance imaging (MRI), nerve conduction study (NCS), and electromyography (EMG) on the right shoulder were performed to determine the cause of weakness and pain, on the basis of history and physical examination.
The MRI demonstrated increased signal intensity at the supraspinatus muscle. This finding was suggestive of partial tear of supraspinatus muscle on the articular surface. NCS and EMG were carried out almost 10 days after the onset of symptoms. NCS of the SANs showed low amplitude and prolonged latency of nerve potential of the right side when compared with the left side (). EMG studies revealed positive sharp waves at rest () and reduced recruitment, normal morphology, regular firing pattern, and stable stability on volition in the right upper trapezius and SCM muscle. The other examined muscles in both the upper

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


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

[User]
RADIOLOGY NOTE:
A 27-year-old male sustained penetrating trauma to his right eye as a child at 7 years of age, but unlike the other two cases had undergone primary repair. He developed sympathetic ophthalmia a few years later, and this was managed with oral steroids. He had also undergone cataract extraction to both eyes and used contact lenses to correct his aphakia. Like our other two cases, he too had undergone superficial keratectomy for band keratopathy in the sympathising eye. He was then offered and underwent a corneal graft, to the exciting right eye. This was performed under immunosuppressive cover of mycophenolate 1 g twice a day along with 40 mg of oral steroids which was then reduced to the dose 500 mg once a day and oral prednisolone 5 mg once a day. He developed glaucoma in his right eye, one year from the time of the graft and is on topical with brinzolamide and latanoprost. On examination, one year from the time of right corneal graft procedure, his BCVA was 3/60 in his right eye and 1/60 in his left eye. Anterior segment examination showed a clear right corneal graft and corneal degenerative changes in the form of band keratopathy and corneal decompensation in his left eye (). Ultrasound examination showed the retina to be attached and a single flash ERG showed a normal retinal response in his left eye. Penetrating keratoplasty was performed on the sympathizing eye, with the donor graft size of 7.50 mm and the host was 7.25 mm. Postoperatively the mycophenolate was increased to 1 g twice a day and was also on 30 mg oral prednisolone which was then tapered by 5 mg per week, and he is on the maintainance dose of 5 mg. He was also on topical steroids and antibiotics. At 10 months follow-up his BCVA was 6/36 and his graft was clear (). Fundus examination showed peripheral chorioretinal atrophy with scarring at the macula ().

[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 visited our outpatient clinic with a small palpable mass on the palmar side of her wrist; the mass moved concurrently up and down during wrist motion for roughly three years. The movements of mass in the carpal tunnel created momentary pain and snapping during usage of the finger. She complained of numbness on the thumb, index, and middle fingers worsened by usual activities of the hand and wrist, suggesting carpal tunnel syndrome.
Upon physical examination, the mass was palpated just proximal to the transverse carpal ligament. The direct carpal compression test and Phalen test were both positive. A snapping sound and pain around carpal tunnel was detected during flexion and extension of the index finger with moving mass. There was no tenderness on the A1 pulley area of index finger. In nerve conduction studies, median neuropathy at the wrist level was confirmed. There were no abnormal findings on plain X-rays (). Computed tomography scanning with gadolinium enhancement showed 11 mm × 8 mm × 12 mm sized, oval and well demarcated soft tissue mass at wrist level extended into the carpal tunnel ().
According to these findings, we suspected either a nodule or ganglion as a space occupying lesion which led to carpal tunnel syndrome. We performed surgical exploration to excise the palpable mass. Mild hypertrophic transverse carpal ligament and degeneration of median nerve were identified. The transverse carpal ligament was divided; however, there was no mass lesion within carpal tunnel. By exploration of flexor tendons in carpal tunnel and proximal wrist level, we found hypertrophied and anomalous muscle belly of FDS of index finger, more distally extended muscle belly than a normal condition (). Anomalous muscle belly made compression of median nerve and snapping around carpal tunnel during finger motion. After resection of abnormal muscle belly from FDS tendon (), snapping during finger motion was disappeared. Three months after the operation, patien

[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 our clinic with complaints of an enlarging lump in the throat. Her family history was significant for thyroid cancer of unknown type in her mother. She had history of right thyroid lobectomy for multiple right lobe nodules at age of 25; one of the nodules was found to be follicular adenoma. At age of 37 she was found to have three nodules in the left lobe. Specimen obtained from one out of three nodules by fine needle aspiration (FNA) at an outside institution was concerning for follicular lesion. Few months later left lobectomy was performed, and surgical pathology specimen review revealed a 6 mm papillary thyroid carcinoma with no evidence of vascular or capsular invasion.
Upon presentation to our institution she had palpable mass in the right side of the neck that corresponded to hypoechoic mass seen in the thyroid ultrasound. It demonstrated increased flow on color Doppler images and was measuring 1.5 × 1.1 × 2.2 cm. An FNA of the mass was performed, but sample obtained was nondiagnostic. The patient elected to proceed with completion thyroidectomy. The pathological diagnosis of this mass was reported as benign thyroid tissue. Given her maternal history of thyroid cancer and also personal history of micropapillary carcinoma, the patient wished to proceed with RAI ablation of remaining thyroid tissue.
The patient underwent a diagnostic WBS five weeks after her last surgery, when thyroid-stimulating hormone (TSH) was 75 mIU/L (0.4–4.5), thyroglobulin (TG) was 65.4 ng/mL (2–35) and the thyroglobulin antibodies (anti-TG) were <20 IU/mL. WBS revealed two focal areas of increased uptake within the left posterior lateral head and mid-portion of the head superiorly (). These areas persisted on spot views and repeat images after scrubbing and washing. Head CT with and without IV contrast was performed few days after the WBS and showed no abnormalities in these regions. RAI ablation 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 60-year-old female patient presented with complaints of pain in right upper abdomen and right lower chest during inspiration for 4 months. No history of fever and jaundice or any associated co-morbidities. Ultrasonography showed a 10 cm × 7 cm × 7 cm thick walled cyst in segment VIII of liver with multiple loculations, septations suggestive of daughter cysts and partially calcified cyst wall [].
Contrast enhanced computed tomography (CT) shows a multiloculated cyst in the segment VIII of liver with calcification at multiple sites in the wall and humping of the diaphragm []. The diagnosis being hydatid cyst WHO classification type 3 B.
As the hydatid cyst was WHO type 3B with solid matrix and few areas of calcification in the wall, PAIR was not possible. The location of the cyst was such that laparoscopic treatment was not feasible. The patient was already treated with albendazole tablet for 3 weeks.
We thought of an innovative technique, using a nephroscope for percutaneous evacuation of the cyst.
The procedure was done under general anaesthesia. Patient positioned with 45° with right side up, to gain an easy access to the cyst percutaneously. Ultrasonography [] was to identify the cyst and a 18 Fr spinal needle was used to puncture the hydatid wall through the midaxillary line. The cyst was punctured where it was closest to the parietal wall. After puncture intracystic position of the needle was confirmed by aspiration and a guide wire was introduced using Seldinger's technique.
Metal Dilators of increasing size from 9 to 27 were introduced over the guide wire. After sufficient dilation of tract, an Amplatz sheath was slided over the dilators and the metal dilators were then removed. As the dilators were removed there was a gush of clear fluid with white membranous material.
Through the Amplatz sheath suction was then introduced in the cavity and fluid with pieces of hydatid membrane were sucked out. 3% normal saline (

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


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

[User]
RADIOLOGY NOTE:
A 66-year-old man presented to the department of internal medicine with history of fever, cough, and difficulty in breathing and exertional chest pain. He had past history of hypertension, diabetes (diabetic nephropathy, estimated glomerular filtration rate 45 mL/min), and smoking. On admission, he was febrile and breathless. The chest had bilateral rhonchi and basal crepts. His blood sugar was 465 mg/dL and the ketone levels were high in urine. Arterial blood gas estimation showed metabolic acidosis. Other blood tests are summarized in . Chest X-ray showed increased bronchovascular markings in both the lower lobes (). Computed tomography (CT) scan chest showed bilateral pneumonic consolidation in the lower lobes (). He was managed with insulin, antibiotics, intravenous fluids, and the ketoacidosis was corrected. Reverse transcription–polymerase chain reaction for COVID-19 was negative.
On Day 3 of admission, he had severe chest pain and breathlessness with hypotension and the electrocardiogram (EKG) showed junctional rhythm with ST-elevation in inferior and lateral leads (). He was noted to be in acute left ventricular failure and required mechanical ventilation to maintain oxygen levels. Bedside echocardiogram showed that the patient had moderate to severe mitral regurgitation and severe left ventricular systolic dysfunction. He was given ticagrelor 180 mg and aspirin 325 mg orally and started on inotropes and diuretics and shifted to cardiac cath lab for primary angioplasty. The procedure was performed through the right femoral route (6F artery and 7F vein accessed). Additional 5F arterial sheath was introduced through the left side in preparation for need of emergent left ventricular support device. Coronary angiogram revealed a chronic total occlusion of right coronary artery. There was 30–40% stenosis in distal left main and 80% stenosis of osteoproximal left circumflex artery (Video 1). The left anterior descending artery was free of significant disease. Perc

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


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

[User]
RADIOLOGY NOTE:
A 25-year-old white male smoker patient was admitted to our hospital due to fever and right lower quadrant abdominal pain. Six years previously he suffered from perianal fistulas and underwent perianal surgery including drainage and fistulectomy. Two years later CD of the terminal ileum was diagnosed with an upper gastrointestinal barium contrast study and an endoscopic examination (colonoscopy with multiple biopsies). The patient was treated with mesalazine and was in clinical remission most of the time, except for occasional episodes of mild watery diarrhea without fever.
Two months prior to admission the patient had visited the outpatient clinic with abdominal pain and diarrhoea. A physical examination revealed a palpable mass in the right lower quadrant and laboratory analysis showed elevation of acute phase reactants. A gastrointestinal barium contrast was performed and confirmed the presence of a stenosis in the terminal ileum. The patient was treated with oral prednisone (0.5 mg/kg followed by a standard weaning strategy), to which he responded well.
Two months later the patient was attended to in the emergency department with a seven day history of abdominal pain, fever and malaise. At the time he was still taking 5 mg of prednisone by month per day. A physical examination showed a heart rate of 120/min, blood pressure of 130/65 mmHg and temperature of 39°C. His skin, chest and heart were normal. The abdomen was soft, non-distended, slightly tender in the right lower quadrant and with hypoactive bowel sounds. A rectal examination gave a normal result. Laboratory results on admission are listed in table . Thrombophilia studies were normal and included fasting plasma levels of protein C, protein S, anti-thrombin III, lupus anticoagulant, anti-cardiolipin and anti-phospholipid antibodies, antinuclear antibodies, and genetic testing for the factor V Leiden. Chest and abdominal X-rays were normal. An ultrasound abdominal examination revealed multiple hypoechoic n

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


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

[User]
RADIOLOGY NOTE:
A 17-year-old boy was admitted to the surgical ward for insertion of a FJ as his PEG tube was not functioning properly. He had been involved in a road traffic accident at the age of 12 and had suffered diffuse irreversible brain injury that had left him bed-ridden and in a vegetative state. Nutritional issues had been managed successfully for 5 years by means of a PEG tube, until the 'buried bumper' of the tube made feeding difficult. The PEG tube was removed and a FJ tube was inserted via a small laparotomy, 25 cm distal to the duodenojejunal flexure.
Twenty-four hours later the patient was restless and appeared to be distressed. Clinical assessment was limited due to his inability to communicate. A contrast study was performed into the jejunum to rule out any tube-related complications; this was reported as normal. Water infusion was subsequently commenced through the FJ as per protocol.
The patient became tachycardic and pyrexial over the next 24 hours and began to vomit. His white cell count was raised at 20 × 109/litre. Chest auscultation revealed right basal crepitations and a plain anterior-posterior chest X-ray showed right lower lobe consolidation. A diagnosis of aspiration pneumonia was made and he was commenced on intravenous antibiotics. The FJ was left on free drainage.
On the third postoperative day he remained septic in spite of the treatment. Clinical examination showed abdominal distension and tenderness. An urgent computed tomography scan was performed which confirmed right basal consolidation but no leak from the FJ tube and no other bowel abnormality.
As his condition did not improve the decision to explore the abdomen was made on clinical grounds. At laparotomy the tip of the feeding tube was found to be lying outside the jejunal lumen having eroded directly through the wall of the small bowel (Figure ). There was minimal spillage of bile in the peritoneum indicating recent perforation. The FJ 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 55-year-old woman with no notable medical and family history was referred to our department by her general practitioner following the appearance of multiple lesions of the oral mucosa. The intraoral clinical examination revealed poor oral hygiene, hypersialorrhea, and extensive mucosal damage affecting the entire oral cavity and causing discomfort, pain, and dysphagia. The lesions were located in the internal surfaces of the lips and cheeks, the dorsal and ventral surface of the tongue, and the soft palate mucosa (). There were epithelial erosions and postbullous ulcerations with a positive Nikolsky sign indicating acantholysis with dislocation of the epithelial layers (). Bulloerosive umbilical involvement was associated with the oral impairment without noting any other cutaneous lesions for four months ().
In front of these signs, we conducted an oral biopsy and prescribed topical prednisolone (20 mg; 3 times per day) and chlorhexidine-based (0.12%; 3 times per day) mouthwashes in order to reduce the oral pain awaiting the biopsy result. In a while, her condition worsened (). We referred her to the department of dermatology where she was hospitalized and an umbilical biopsy was performed.
On histopathological examinations, the oral biopsy concerned a squamous mucosa lined with a partially visualized coating, with disappearance of the superficial layers and the presence of cells of the basal layer which remain attached to the underlying chorion, drawing a “tapestry nail” appearance, surmounted by a few acantholytic cells. In the chorion, we noted the presence of a polymorphic inflammatory infiltrate rich in eosinophilic polynuclear cells. Direct immunofluorescent examination was negative (). As for the umbilical biopsy, the sample received was carried to the deep dermis. It was bordered by the basal layer of the epidermis, drawing the same “tapestry nail” appearance with extensive suprabasal acantholysis and separation of the overlying epidermal layers. The dermi

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


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

[User]
RADIOLOGY NOTE:
A 59-year-old woman presented with both knee pain and contracture of the left knee, which resulted in functional disability. She was not able to walk without 2 crutches preoperatively. Four years before presentation, she fell from a second-floor balcony due to epileptic attack and sustained open fracture of both knees. She was transported to the emergency room and underwent open reduction and internal fixation of both femurs. These fractures were healed without infection; however, there remained malunions in both femurs. Progressive pain in both knees leading to limping and stiffness developed gradually. She was referred to our hospital for surgery. Radiographs showed advanced degenerative arthritis of both knees, extra-articular deformity after supracondylar fracture and retained hardware (). The magnitude of angular deformity of the right femur was rather small (); however, there was a large cavity filled with fibrous tissue and partial defect of the anterior cortex in the distal femur (Figures , , , and ). On the other hand, the distal segment of the left femur was displaced laterally and posteriorly, and the overlap at the fracture site resulted in leg length discrepancy ().
Firstly, we performed right TKA because her right knee pain was more severe compared to her left knee. To avoid refracture due to partial defect of the anterior femoral cortex, we decided to place the femoral component without removing the hardware using navigation system. Preoperative planning confirmed that hardware was not likely to interfere with the femoral component.
After removal of the Herbert screws, distal femoral cut was performed perpendicular to the mechanical axis in the coronal plane and 3° flexion to the mechanical axis in the sagittal plane using navigation system. Cancerous bone chips made from resected bones were grafted into the cavity after clearing up the fibrous tissue.
Six months later, she underwent left TKA. Preoperative radiographs showed not only bone union but al

[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 male patient presented with a swelling on the posterolateral part of hard palate of 1 week duration. The swelling was of the size of a peanut when the parents of the patient first noticed it, but had grown rapidly over the past 1 week to attain the present size. The growth was asymptomatic. The patient's medical history was unremarkable apart from the cough he had since 4 days for which he was under medications prescribed at a general hospital.
The patient gave history of reddish purple pigmentation on the right middle third of face, extending from lower border of orbit to imaginary line joining corner of mouth and earlobe superoinferiorly and from lateral border of nose to temporal region 2 cm from outer canthus of eye anterosuperiorly, since birth []. Intraoral soft tissue examination revealed a solitary, peduncalated, spherical-shaped, reddish pink swelling with distinct border and irregular surface []. Surrounding palatal mucosa was normal and it was located in the posterior part of hard palate just lateral to the midline on right side in area between maxillary permanent first molar and maxillary second deciduous molar measuring 2 cm × 1.5 cm in size. On palpation the swelling was non-tender, soft to firm in consistency, blanching on pressure. Intraoral hard tissue examination showed over-retained left deciduous central incisor with erupting right permanent central incisor.
Occlusal and panoramic radiograph revealed no loss of bone in relation to the lesion [].
Based on its clinical signs and symptoms, a provisional diagnosis of pyogenic granuloma was established but as differential diagnosis consisted of capillary hemangioma excision under local anesthesia with all necessary emergency equipments at hand under the guidance of a trained anesthetist. The hemogram of the patient was within normal limits except for slightly prolonged clotting time and hence, he was taken for an excisional biopsy. Under local anesthesia, the growth was probed to check it

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


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

[User]
RADIOLOGY NOTE:
A 64-year-old right-handed retired male teacher was referred to our clinic with an inability to flex the interphalangeal (IP) joint of his left thumb. One week previously, he was gardening. He had flexed his thumb around the stem of a firmly embedded weed, and as he pulled hard, he felt a sudden pop in his left thumb and found he could not flex his left thumb. Although he often played saxophone, he could not recall any specific episode of pain or discomfort within the left thumb. There was no evidence of any history of rheumatoid or other inflammatory arthritis and his rheumatoid serology was normal.
Upon examination, no specific painful swelling in the left thumb was detected. However, the patient was unable to actively flex his thumb at the IP joint (Fig. ). He had full passive range of motion of IP joint.
Initial plain left thumb radiographs revealed no bony abnormalities resulting in secondary tendon rupture. Magnetic resonance imaging (MRI) revealed complete FPL tendon rupture at the level of the distal one-third of the proximal phalanx and the proximal end of the ruptured tendon was retracted to the level of the metacarpophalangeal (MP) joint (Fig. ).
With the patient under general anesthesia, the FPL tendon was explored through a volar zig-zag incision. During the operation, the FPL tendon was found to be ruptured completely. Gross examination revealed a slightly yellowish denaturated tissue at the distal end of the ruptured tendon and the gap of the ruptured ends was interposed by a fibrous tissue (Fig. ). No bony prominence was observed throughout the excursion of the tendon. We excised the denaturated tissue from the distal end of the ruptured tendon and sent it for histological examination. FPL tendon was repaired primarily via modified Becker method (Fig. ). Histopathological examination revealed normal vasculature in the tendon tissue and degenerative changes associated with lipid deposits in

[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 had no history of previous medical problem , but complained of acute upper gastrointestinal bleeding (hematemesis). A submucosal tumor located about 3 cm distal to the papilla of Vater was found by endoscopy. The lesion bulged beneath the mucosa with a central depressed ulceration, which was the origin of the massive bleeding. Following blood transfusion the bleeding spontaneously stopped ().
Magnetic resonance imaging (MRI) was remarkable for a homogenous tumor of the duodenum (). MRI and CT scans showed no metastases. The patient experienced another episode of bleeding for which a blood transfusion was performed due to a decreased hemoglobin level to 4g/dl. Fortunately the bleeding stopped again. Endoscopic ultrasonography showed a 12 x 10mm hypoechoic lesion that originated from the muscularis layer without any regional lymphadenopathy. The patient was diagnosed to have a duodenal GIST ( ).Surgery was recommended and a laparotomy was done. The submucosal tumor was located in the distal third portion of the duodenum, about 3 cm distal to the ampulla of Vater. No penetration of the pancreas or other adjacent organs was detected and there were no suspicious lymph nodes. The tumor was managed by a partial resection of the distal third and fourth portion of the duodenum with a 1cm safe margin on each side and an end-to-end anastomosis. His postoperative course passed without any problem and the patient was discharged on the fifth day after the operation. The diameter of the operated tumor was 3 cm (). Histopathology showed a GIST with a typical spindle tumor cell structure (). The overlying duodenal mucosa was ulcerated. The tumor had a thin fibrous capsule that reached the muscularis mucosae, but did not penetrate it. The tumor had a moderately malignant potential according to tumor grading and the excised margin was tumor-free. Immunohistochemistry was strongly positive for C- KIT and CD34 and DOG-1 and KI67(the pathologic tumor mitotic labeling i

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


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

[User]
RADIOLOGY NOTE:
A 47-year-old female presented with complaints of acute onset severe headache with nausea, vertigo, and gradually progressive weakness of the limbs (upper limb more than lower limb). There were no history of fever, seizures, loss of consciousness, and loss of vision. On examination, the patient was conscious, oriented, and blood pressure was 140/100 mmHg with no tachycardia. Cranial nerve examination was normal. Power in the right and left upper limb was 1/5 while 3/5 in bilateral lower limb. Investigations including complete blood count, renal function tests, coagulation studies, thyroid function test, urinalysis, and chest radiograph were not suggestive of any abnormality. MRI brain revealed multifocal acute infarcts in multiple vascular territories, predominantly in bilateral anterior cerebral arteries territories. Magnetic resonance cerebral angiography showed multifocal multisegmental areas of stenosis involving large- and medium-sized intracranial arteries likely due to CNS vasculitis. Computerized tomography (CT) cerebral angiography of the brain and neck revealed multifocal parenchymal hemorrhages along with areas of hypodensity suggestive of ischemia in the centrum semiovale with narrowing of bilateral terminal internal carotid artery and middle cerebral arteries [].
After identifying cerebral infarction as the cause of the weakness, she underwent detailed evaluation of connective tissue disorders and secondary vasculitis but was noncontributory. The patient was hence diagnosed and treated as primary CNS vasculitis. She was started on prednisolone pulse dosages and later continued on tapering dosages of prednisolone. Significant improvement in power and weakness was noted with steroid with near-normal recovery. She was further planned for cyclophosphamide monthly dosages but found to have grossly deranged liver enzymes. The ultrasonography abdomen during workup of raised liver enzymes revealed the right-sided suprarenal mass which on further evaluation with

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


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

[User]
RADIOLOGY NOTE:
A 42-yr-old man visited our hospital for management of liver masses. Two years earlier, he had undergone small bowel resection for removal of a 20 cm-sized mass, later shown to be a GIST. Following resection, he received postoperative adjuvant radiation therapy, at a total dose of 5,040 cGy. Upon presentation, multiple hepatic masses were revealed by computed tomography (CT). A paraffin block specimen of the previously resected small bowel mass was then reviewed. This tumor consisted of polygonal to spindle cells with moderate cellularity. The tumor cells showed pleomorphism, and necrosis was present. The mitotic figures were not frequent (2/50 high power fields). The tumor cells were immunohistochemically positive for c-Kit and focally positive for SMA, but negative for CD34 and S100, supporting the original diagnosis of GIST of interstitial cells of Cajal origin.
He was prescribed oral imatinib mesylate 400 mg daily. Just after starting drug treatment, the patient complained of periorbital swelling, but no dose reduction was required. Three months later, the hepatic lesions improved, showing a partial response, and nine months after his first visit to our hospital, CT scan and positron-emission tomography showed no evidence of disease. Treatment was discontinued after a further 5 months of imatinib mesylate, but a CT scan performed 3 months after finishing imatinib showed disease progression. A second period of imatinib treatment was started, at the same dose of 400 mg/day. One month later, the patient complained of breast pain and scrotal swelling. Physical examination revealed right gynecomastia and right painless scrotal swelling. A precise medical history was taken, at which point it was learned that left painful gynecomastia and scrotal swelling had developed during the first period of imatinib treatment, but that both had improved after stopping imatinib.
Pain in the right breast began on the 20th day of the second period of imatinib treatment. Decreased lib

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


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

[User]
RADIOLOGY NOTE:
A 17-year-old male with no history of medical illness and a previously usual state of health presented to King Fahd Hospital of the University with acute facial numbness along the distribution of the right V1 (ophthalmic division of the right trigeminal nerve), followed by weakness in the right eye abduction (i.e., right abducent nerve palsy). Magnetic resonance imaging (MRI) of the brain was performed and it showed a right parasellar mass (iso- to hypointense in T1 and hyperintense in T2) []. Surgery was offered to the patient and his family, but it was not performed owing to the family's socioeconomic concerns. Subsequently, the patient was lost to follow-up until he revisited the hospital a year later complaining of acute right-sided ptosis associated with dilated nonreactive right pupil (i.e., right oculomotor nerve palsy). MRI of the brain was performed and it showed expansion of the right parasellar mass []. The patient was admitted for workup and was prepared for surgery. After 5 days, he had complete right ophthalmoplegia. MRI of the brain was repeated and it showed an expanding right parasellar mass with interval development of T1 high-signal intensity and multiple fluid-fluid level on T2, suggestive of internal hemorrhage. It also showed multiple internal locules and septations with peripheral enhancement []. Radiology report suggested differential diagnosis of aneurysmal bone cyst versus cystic meningioma. Magnetic resonance angiogram was negative.
The right temporal craniotomy with gross total excision of the right parasellar mass was done, and the intraoperative frozen section showed spindle cell proliferation. The final histopathology showed a typical benign schwannoma appearance showing random nuclear pleomorphism along with short spindled cells. Most of the tissue was of the Antoni A type (dense and organized), with very few Antoni B type tissue. No Verocay bodies were seen. S-100 protein immunochemistry showed strong, dispersed cytoplasmic and nucle

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


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

[User]
RADIOLOGY NOTE:
A 53-year-old man with major complaints of a sudden onset of headache and mental deterioration came to the emergency center of the hospital. On admission, he was drowsy and his Glasgow Coma Scale (GCS) score was 14, and no focal neurologic signs were detected. He had no medical history of diabetes mellitus, hypertension, tuberculosis, and hepatitis, and as for family history, his mother had suffered from cerebral hemorrhage.
Brain computed tomography (CT) and CT angiography carried out on admission showed a subarachnoid hemorrhage (SAH), intraventricular hemorrhage (IVH) with hydrocephalus, and a tortuous vascular structure that was observed around the brain stem and upper cervical spinal cord (). Cerebral angiography was performed when vital signs had been stabilized and headache had been controlled through conservative treatments. The cerebral angiogram on the left vertebral artery revealed multiple vascular structures around the V4 segment of the left vertebral artery, which were drained to both sides of the sigmoid sinus and vertebral venous plexus. A cerebral angiogram on the external carotid artery showed multiple vascular structures around the occipital artery, which were connected to the drained vein observed via the left vertebral artery angiogram. Embolization was attempted on the left occipital artery and the distal V2 segment of the left vertebral artery, but the treatment was halted due to reflux. Another embolization was performed from the V4 and V3 segment to some of the distal V2 segment of the left vertebral artery. The treatment was terminated after partial occlusion was identified (). As mental deterioration and left hemiplegia were observed after the embolization, cerebral angiography and brain CT were conducted. However, new lesions such as cerebral hemorrhages or vascular occlusions were not found. One week after the embolization, follow-up brain CT displayed subacute cerebral infarction on the left cerebellum and thalamus, and a mild mass effe

[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:
Our patient was a 60-year-old woman who had undergone bilateral MG II (Zimmer) total knee arthroplasty for rheumatoid arthritis of the knee (Larsen grade IV) in our department 16 years earlier (). She had no other relevant medical history. Body weight was 45.8 kg, height 158 cm, and body mass index 18.3 kg/m2. Weight and height were approximately the same as when the primary surgery was performed. After the initial procedure, she had been followed up every 3 months for 16 years and follow-up plain radiographs were regularly checked once a year. Nine years after the initial arthroplasty, she underwent surgery and chemotherapy for endometrial cancer; this treatment was successful and she experienced no recurrence or metastasis.
A follow-up plain radiograph taken 15 years after arthroplasty revealed a deterioration of the varus malalignment of the tibia (). However, the patient had no complaints about the left knee at this point, and we considered the problem was related to polyethylene wear. However, 16 years after arthroplasty, she presented to our department with a 3-month history of severe pain in the left knee. Clinically, she walked with a limp and a varus thrust. Examination of the left knee indicated joint effusion and tenderness along the medial joint line with localized warmth. There was a well-healed anterior skin incision over the left knee with no evidence of skin infection. Active and passive motions of the knee caused pain in the medial part of the knee. Plain radiographs taken at this time showed further distortion of the tibial component of the left knee with obvious fracture of the tibial baseplate and osteolysis under the broken component (). She had not consulted us about the problem immediately because she had been undergoing conservative treatment for Graves's disease for 3 months. At the time of presentation, rheumatoid arthritis and Graves' disease were well controlled and all other laboratory values were in the normal range.
The patient underwe

[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 73-year-old Chinese woman with osteoarthritis in both knees. In the recent half year, she had been suffering from intractable right knee pain with failed conservative treatment and prepared for right side TKA. She had a 27-year history of hypertension and her blood pressure was controlled well by medication. She had no other medical history, including smoking history. Her BMI was 24. The physical examination showed a limited range of motion (ROM) of 0°–120° without varus or valgus deformity. Preoperative X-ray showed narrow medial knee joint space and osteophyte formation without vascular calcification (Fig. ). The peripheral pulses and capillary refill were normal, although the preoperative Doppler ultrasound showed arteriosclerosis with plaque formation in the arteries in both legs.
The right side TKA with a posterior stabilized design (LPS, NexGen, Zimmer, Warsaw, USA) was performed under general anesthesia. A tourniquet was applied for 70 min at a pressure of 250 mmHg. The whole surgery was completed without any complications and there was normal intraoperative bleeding at the surgical site. The postoperative X-ray showed successful implantation for the right knee (Fig. ).
However, immediately after the surgery, routine peripheral pulse check in the operating room found absent dorsalis pedis artery pulse in the right foot. The patient was closely monitored in the recovery room. After approximately 2 h, there was no improvement in peripheral pulses, capillary refill, and oxygen saturation. In consideration of the high possibility of arterial occlusion, the vascular consultant recommended using 1000 U heparin for anticoagulation and immediate evaluation by arteriography for diagnosis. An emergency arteriography under local anesthesia showed that there was a short segmental occlusion of the popliteal artery (Fig. ). Then the angioplasty was performed with a balloon with a diameter of 5 mm for 3 min. Follow-up imaging showed excellent blood flow al

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


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

[User]
RADIOLOGY NOTE:
A 50-year-old male patient reported to the dental hospital with a complaint of painless swelling in the lower left body of the mandible since 25 days following the extraction of left lower 1st and 2nd molar teeth. The patient had a history of enlarged submandibular lymph node and fever since 15 days which was earlier thought to be due to infection after extraction. The swelling was insidious in onset and gradually increased in size causing facial asymmetry []. Examination revealed a nontender, solitary diffuse swelling measuring 3.5 cm × 3.5 cm in the lower left body of the mandible. The swelling was fixed, firm to hard in consistency. Intraorally, the swelling extended from left premolar till left ascending ramus of mandible obliterating the buccal vestibule, with buccal cortical plate expansion [].
Orthopantomogram of the patient was done to evaluate the invasion of the lesion and pathological fracture of lower left body of mandible [] was seen.
Fine-needle aspiration cytology was done, but no aspirate was obtained. The hematological tests (complete blood count, fasting blood glucose, prothrombin time, partial thromboplastin time, erythrocyte sedimentation rate) were normal and the patient was HIV negative. The incisional biopsy of the lesion was performed. Correlating the history and clinical features, a provisional diagnosis of squamous cell carcinoma was made.
Histopathological picture showed the lesion to be composed of dysplastic parakeratinized stratified squamous epithelium overlying connective tissue stroma. Basement membrane is indistinct at few places with infiltrating epithelial cells seen in the connective tissue. The connective tissue stroma is highly cellular in nature. There are diffuse proliferations of large atypical lymphoid cells showing dysplastic features such as nuclear and cellular pleomorphism, nuclear hyperchromatism, increased number of nucleoli and abnormal mitotic figures. Some areas show invasion of neurovascular bundles. Cells are hig

[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 female was transferred to our hospital with asymptomatic non-ST-elevation myocardial infarction (). Cardiac troponin T was elevated (0.32 μg/L), and normal coronary angiography suggested embolic infarction (Figures –).
Six weeks earlier the patient had been admitted to a stroke unit at an external hospital with hemiparesis of the right upper extremity, bilateral paraparesis, and dysphagia. A cerebral CT scan revealed acute posterior circulation territory ischemia. On the next day, the patient displayed pulselessness and cyanosis of lower extremities and elevated creatinine kinase (4,000 Units/L). An abdominal CT scan revealed embolism of the abdominal aorta, splenic and bilateral renal artery infarction, and multiple additional emboli in bilateral common and superficial femoral artery, left common iliac artery, and left popliteal artery. Emergency percutaneous embolectomy of aorta, bilateral iliac artery, right renal artery, and bilateral femoral artery was performed. Lysis catheters were placed in right and left popliteal arteries, and treatment with unfractionated heparin and urokinase was started and continued for one week. One day after initiation of local lysis, selective embolectomy of bilateral dorsal pedis and posterior tibial arteries was performed due to ongoing signs of lower extremity ischemia. Despite these efforts, the right lower leg had to be amputated one week later owing to irreversible ischemia. Ten days later, the patient developed right paraparesis due to acute media infarction confirmed by cranial CT scan. Three weeks prior to myocardial infarction, she was diagnosed with paralytic ileus, and ischemic segments of the small intestine were resected. Histological examination of embolic material removed from the right lower leg showed polygonal cells with eosinophilic cytoplasm and myxoid matrix, consistent with atrial myxoma. Transesophageal echocardiography (TEE) revealed an echogenic structure (1.0 × 0.5 × 0.5 cm) with a villous su

[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 present a case of a 55-year-old female that presented with a 3-week history of shortness of breath, cough, and right-sided pleuritic chest pain. The patient was a nonsmoker and had a significant past medical history of complete hysterectomy 7 years prior for bleeding uterine fibroids. Pathology at that time had shown the fibroids to be leiomyomas. On current presentation, her chest X-ray showed multiple pulmonary nodules with a large right-sided pleural effusion. Subsequently, a computed tomography scan of the chest, abdomen, and pelvis revealed numerous bilateral pulmonary nodules with a large pleural effusion, and near complete collapse of the right middle and right lower lobes (). The sizes of the nodules was not documented but had borders that were circular and distinct. There were no abnormal lesions seen under the diaphragm. Two thoracenteses revealed bloody, exudative, pleural fluid but cytology failed to reveal any evidence of malignancy. Bronchoscopy of the right lung revealed extrinsic compression of the airways in the right middle and right lower lobe with no intrabronchial lesions. However, there was a large nonendobronchial mass on the right side causing atelectasis and collapse. Being the focus of the bronchoscopy, the left lung revealed 2 endobronchial lesions: one in the apicoposterior segment of the left upper lobe and one within the basilar segments of the left lower lobe. The lesions were smooth, round, and freely mobile with the patient’s inspiratory and expiratory effort. Each was anchored to the inside of the airways by thin stalks (). Biopsy of one of these lesions showed the lesions to be very friable. Histopathology revealed proliferating spindle cells that were highlighted with smooth muscle actin and desmin (). With the pleural effusion returning, the patient subsequently underwent a video-assisted thoracoscopic surgery (VATS) procedure to obtain more tissue for further histologic investigation and symptomatic relief. Pathology results

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


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

[User]
RADIOLOGY NOTE:
A 30-year-old Brazilian male was brought to our ED from a local jail because of agitation. He had been arrested by Swiss authorities because of suspected internal concealment of drugs of abuse (body packing), which had been confirmed by abdominal CT scan in our hospital approximately 12 h before (Fig. ). During this first visit, the patient had presented asymptomatic and had admitted to carrying cocaine-containing body packets. In addition, he had reported recreational use of marijuana and cocaine. It was also noted that the patient was transsexual; he had breast implants. The patient’s past medical history was unknown. Standard operating procedure in such a case is to perform a CT scan without a consultation at the ED. During the second visit approximately 12 h later, the patient presented with psychomotor agitation, mydriasis and tachycardia. His heart rate was 116 bpm, blood pressure was 116/68 mmHg, respiratory rate was 40/min, oxygen saturation by pulse oximetry was 99% on ambient air and auricular temperature was 38.0° Celsius. Communication with the patient was impossible because of his altered mental status and because he spoke a foreign language. The physical examination of heart, lungs and abdomen revealed no pathologies. Neurological examination showed symmetrical spontaneous movement of all extremities and symmetrical gaze to both sides prompted by speech or touch. Glasgow coma scale was 11. An electrocardiogram showed sinus tachycardia without signs of ischemia. Due to our knowledge of the ingested body packets, we first suspected cocaine intoxication because of package rupture. We treated the patient with repeated doses of intravenous midazolam and performed an emergency abdominal CT scan to guide potential emergency surgical decontamination. The CT scan showed 60–70 packets in the gastrointestinal tract without signs of gastrointestinal obstruction or perforation. Laboratory results showed an increased C-reactive protein (CRP) level (231 mg/l, norm <

[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:
Our patient is a 40-year-old Asian man with complaints of bleeding and discomfort in his anus of 2 months’ duration. He was an employee with average income who did not smoke tobacco or drink alcohol. He had no weight loss or urinary symptoms, and no substantial family history. He denied any significant medical or surgical history. His abdomen was soft, non-tender, and non-distended, with normoactive bowel sounds. In examination, a mass could be touched by finger tips. The mass was large and bleeding. In subsequent examinations, blood was detected in a stool sample. His vital signs were: blood pressure, 130.77 mm Hg; respiratory rate, 18 breaths/minute; heart rate, 83 beats/minute; and temperature within normal limits. Oxygen saturation was 98% on room air on admission. In colonoscopy, a large lobular tumor was diagnosed at 4 cm above the dentate line, which was suspicious for malignancy. Various samples were taken from the tumor. The rest of his large intestine did not show a clear pathologic lesion in the colonoscopy.
High-grade adenocarcinoma was reported in pathological examinations. In subsequent diagnostic procedures, his carcinoembryonic antigen (CEA) level was normal. Computed tomography (CT) scans revealed that metastatic lesions were not detected in his liver, abdominal viscera, and chest. In CT scans with or without contrast, and magnetic resonance imaging (MRI) scanning, an ectopic kidney was detected incidentally on his right pelvis without any prior urinary symptoms. The left kidney was in its original location, and both kidneys were functional. Renal function tests provided normal results.
In subsequent investigations done by MRI scanning for staging the tumor, a pelvic rectum tumor was reported to be interfering with the T3 N1 mesorectal lymph nodes (Figs. , ). The case was discussed in a multidisciplinary cancer team; afterward, our patient was regarded as a candidate for neoadjuvant radiotherapy. He underwent 45 GY radiation in 25 fractions to the p

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


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

[User]
RADIOLOGY NOTE:
A 65 years old male with history of colitis ulcerosa, and advanced sarcoidosis diagnosed 10 years before, on oral steroids was admitted to our department due to exertional dyspnea and right ventricular (RV) heart failure progressing since last 12 months to functional class IV. Two years earlier, he experienced the first severe decompensation of right heart function. At that time PH was diagnosed on echocardiography. RV to left ventricle (LV) ratio exceeded one (RV:LV - 39/32 mm); peak systolic tricuspid regurgitation gradient (TRPG) was 75 mmHg, and decreased tricuspid annular plane systolic excursion (TAPSE) 15 mm indicated significant pressure overload and RV systolic dysfunction. Chest computed tomography (CT) revealed sarcoidosis progression, however no pulmonary thromboemboli were detected. After typical heart failure treatment with diuretics, ACE inhibitors, and steroid dose increase the patient improved and he was discharged home in a good clinical condition in WHO functional class II, with the diagnosis of PH due to sarcoidosis stage IV. One year later, due to acute dyspnea, worsening of RV function and unilateral leg swelling he underwent another chest CT, which this time showed fresh thrombi in the left segmental upper lobe pulmonary artery. Moreover, acute deep vein thrombosis was detected with lower limb compression ultrasound. Long term oral anticoagulation with rivaroxaban was started. Two years later the patient was referred to our center due to progressive functional deterioration. On admission he was in WHO functional class IV, saturation on room air was 85%, blood pressure 120/80 mmHg, heart rate 90 beats per minute. Mild peripheral edema was present. Distance covered in 6 min walk test (6MWT) was 100 m with desaturation to 77%. Plasma natriuretic peptide (NT-pro-BNP) concentration was elevated to 6239 pg/ml (normal range < 125 pg/ml). Echocardiography showed severe RV pressure overload with TRPG 95 mmHg, dilatation of both right atrium and ventric

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


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

[User]
RADIOLOGY NOTE:
A 42-year-old man presented to our clinic with complaints of pain and limited movement in his left shoulder. The patient’s complaints began after he experienced a fall 7 months ago. At that time, radiography of his shoulder revealed soft tissue trauma, which was treated. However, his complaints showed no improvement, and he visited another hospital 3 days later. After radiography, the patient was administered a sling and analgesic, following soft tissue trauma diagnosis. The patient applied to our clinic approximately 7 months after the initial trauma. Subsequently, his left shoulder was fixed in internal rotation, but his passive shoulder movements were extremely limited and painful. Notably, the patient’s neurovascular examination was normal. Therefore, the patient was believed to have experienced posterior shoulder dislocation, and the clinical diagnosis was confirmed by radiological imaging (). Computed tomography (CT) revealed a reverse Hill-Sachs lesion on the humeral head and on approximately 25% of the joint surface. In addition, no associated fractures were noted. The patient was scheduled for the McLaughlin surgical procedure. Open reduction was performed through a deltopectoral approach. When the posteriorly locked humeral head was difficult to reduce, a small Darrach retractor was used. However, during this procedure, because the osteoporotic humerus showed a collapse of approximately 30% on the posterior articular surface, an iatrogenic Hill-Sachs lesion was added to the reverse Hill-Sachs lesion at the beginning of the humeral head (). When the glenoid was examined intraoperatively, there was minimal cartilaginous damage on the anterior and posterior glenoid rim cartilage. The patient was intraoperatively reevaluated, and previously, planned surgical procedure was performed. The subscapular is tendon was transferred to the anterior defective area of the humeral head with three anchor sutures, and stability was tested with shoulder movements. In externa

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


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

[User]
RADIOLOGY NOTE:
A 14-year-old male patient was referred to our pediatric pneumology clinic with recurrent asthma attacks and laryngotracheitis with inspiratory stridor that did not respond to medical therapy. He had a history of recurrent asthma attacks since the age of 4 year, and recurrent laryngotracheitis attacks had supervened for the last two years. Two months previously he was admitted to hospital and chest computed tomography (CT) revealed calcification in the tracheal cartilage and bronchi. We also learned that his respiratory episodes became more frequent after he started his education at boarding school last year. He also had adenoidectomy four years ago in which there had been difficulty in intubation due to mild subglottic stenosis.
He was born to consanguineous parents who were second-degree cousins and he has 3 healthy siblings. He was born at term by spontaneous vaginal birth without any known complications. From the age of one he had hoarseness in his voice, and at age 4, he started to receive inhaler therapy. His family reported that he did not benefit from beta-agonists such as salbutamol. He had received immunotherapy for four years, which also did not reduce his attacks. He had a history of recurrent ear infections and hearing loss.
In his physical examination, mid-facial hypoplasia and depressed nasal bridge, and palpable nodules in bilateral auricula were detected. A respiratory examination revealed bilateral diffuse wheezing; while other systems were normal. His weight was at the 50-75th percentile, whereas his height was at the 10-25th percentile. Chest radiography showed a normal-sized heart with tracheal and bronchial calcifications. CT revealed diffuse calcification in all laryngeal cartilages and epiglottis, thickening in the cricoid cartilage and narrowing of the airway at that level, and calcification and segmentary stenosis in the anterior and lateral walls of the trachea (). There was also calcification in the main and bilateral segmentary bronchi (

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


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

[User]
RADIOLOGY NOTE:
A 30-year-old man sustained an anterior dislocation of the right shoulder along with a GT fracture () in the last week of April 2020 after being hit on the shoulder by a stick in a local street fight in a town located 150 kilometers from the main city. This region was served by general primary physicians in primary health services who are only equipped to treat common diseases; as a result, the local doctors provided the patient with a sling, no X-ray imaging or further management for the dislocation was performed. The patient was unable to travel because of the lockdown restrictions and sought our opinion only after a delay of 3 months with symptoms of severe pain with a visual analog scale (VAS) score of 8 points (out of a maximum of 10 points) and restricted use of the affected limb. His functional ability to use the injured limb was limited because he had severe pain and a restricted shoulder range of motion of −10° of external rotation, L4 vertebral level of internal rotation, and 50° of forward flexion. Computed tomography imaging did not reveal any glenoid bone loss. He was operated on after his COVID-19 status was confirmed to be negative under full personal protective equipment precautions as was the protocol for all surgeries. He underwent open reduction through a deltopectoral approach. During surgery, the following difficulties were encountered: (1) reduction of the GT was not possible without debulking the lateral part of the proximal metaphysis of the proximal humerus as ossification and fibrosis restricted the anterior reduction of the GT and (2) the lesser tuberosity (LT) was not visible even with a medial retraction of the conjoint tendon because of severe medial displacement of the proximal humerus. Hence, a coracoid osteotomy was performed that enabled the conjoint tendon to be retracted further medially and allowed the exposure of the LT and the attached subscapularis. The entire subscapularis had to be detached (later repaired) to allow the

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


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

[User]
RADIOLOGY NOTE:
A 71 year old man with signs of syncope and haemorrhagic shock secondary to massive haemetemesis was referred for emergency treatment and investigation to the 1st Department of Surgery, University of Athens Medical School in 2009. Eight years earlier the same patient, who had a known history of gastric ulcers, presented with a similar clinical picture to a different surgical unit. On admission he showed signs of haemorrhagic shock with a haemoglobin level (Hg) of 7 g dL. Emergency upper GI endoscopy was unable to identify the source of bleeding due to large volumes of blood in the stomach. Surgical treatment with a laparotomy was decided and the intraoperative findings demonstrated an acute gastric hemorrhage secondary to a massive propyloric ulcerative lesion. Resection of the lesion was decided and a distal gastrectomy and Billroth II reconstruction performed. The subsequent histology revealed a <2 cm gastrointestinal stromal tumour, with a mitotic rate of < 5 mitosis/50 per HPF, lacking necrosis and localized to the gastric mucosa. The patient made an uneventful recovery and was discharged eleven days post surgery. The patient was reviewed over the following two years and repeat endoscopies failed to reveal any signs of recurrence. The patient subsequently declined further surveillance and follow up.
At his readmission in 2009 the patient was primarily treated conservatively due to his hemodynamic instability. After successful resuscitation, an emergency upper GI endoscopy was performed which revealed an irregularly shaped elevated lesion on the gastrojejunostomy line and a thrombus at the center of the lesion. The hemorrhagic lesion was situated along the posterior anastomotic suture line. Multiple biopsies were performed and a definitive endoscopic haemostasis was obtained.
Preoperative staging computed tomography (CT) showed no lymphadenopathy or hepatic metastasis and as the patient's performance status was otherwise excellent, the decision for a second opera

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

[User]
RADIOLOGY NOTE:
A 53-year-old Caucasian man with a past medical history of recurrent pancreatitis for the last 18 months, depression, alcohol and tobacco abuse, was referred to our hospital after a 10-day hospitalization in a pulmonary clinic, where he was admitted due to dyspnea and two episodes of hemoptysis. An extensive workup had already been performed, including bronchoscopy, gastroscopy, chest and upper abdomen computed tomography (CT) scans. A diagnostic paracentesis had already been carried out and fluid samples were sent for further analysis. His upper gastrointestinal endoscopy and bronchoscopy did not show any remarkable findings, and his pleural fluid was plenteous in protein and amylase. His cytology reports were negative for malignancy and his pleural fluid adenosine deaminase levels showed no evidence of mycobacterial infection (Table ). He had a good clinical status, except for a mild shortness of breath on exertion. He reported no fever or chills and, despite having a good appetite the last six months, he noted a weight loss of 25kg. Additionally, he mentioned that over the last four months he had experienced difficulty in swallowing solid food. On admission, his physical examination revealed bilateral diminished breath sounds at the lung basis and a firm liver edge 5cm below the right costal margin. His laboratory results showed anemia, malnutrition and slightly elevated serum amylase (360U/L) (Table ). His chest CT scan revealed bilateral pleural effusions and a mass in the lower mediastinum (Figure ); these radiological findings were not present on his previous examinations nine months ago (Figure ). After a successful chest drainage clinical improvement was noticed, however, further chest CT imaging showed a longitudinal fluid collection in the mediastinum, along the lower esophagus, measuring 3×8cm (Figure A, B). This collection extended beyond the diaphragm and seemed to be connected with a small pseudocyst at the pancreatic tail (Figure ). He was on a speci

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

[User]
RADIOLOGY NOTE:
The patient involved provided written consent for reporting of this case.
A 63-year-old woman with medical history of super morbid obesity (BMI 54) and atrial fibrillation for which she was anticoagulated with apixaban presented for an open reduction internal fixation (ORIF) of an ankle fracture. Significant medical history included diabetes mellitus type 2, obstructive sleep apnea, chronic obstructive pulmonary disease, and diastolic heart failure. The patient's last dose of apixaban was 48 hours prior to surgery. Other than moderate anemia (hemoglobin 8.8 g/dL), all laboratory studies, including a coagulation profile, were normal.
Prior to surgery, the patient was offered a sciatic nerve catheter and an adductor canal block as part of a multimodal postoperative analgesia strategy. Because of her many, serious medical conditions, we concluded that a peripheral nerve block offered the best opportunity to provide satisfactory postoperative analgesia. Specifically, we were concerned that the postoperative pain management primarily with opioid medications would pose increased cardiopulmonary risk to the patient. We were careful to explain the risks associated with peripheral nerve blocks, including the risk of bleeding and hematoma formation, and verbal consent was obtained.
The surgery was performed under general anesthesia and her intraoperative course was uncomplicated. Upon arrival to the recovery room, our acute pain service was contacted to evaluate her for peripheral nerve blockade. We positioned the patient in the lateral decubitus position and placed a sciatic nerve catheter. Though technically challenging due to body habitus, this sciatic nerve block was performed successfully and without any complication. The patient was then positioned supine for the adductor canal block. The leg was externally rotated and the knee slightly flexed for optimal positioning. A high-frequency linear array ultrasound transducer was applied to the mid-thigh in short-axis and the

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

[User]
RADIOLOGY NOTE:
In February 1996, a 40-year-old Caucasian woman consulted an orthopaedic surgeon because of persistent pain in the right foot. On radiograms, a lytic tumoral process was discovered in the right os naviculare. Curettage was performed, and anatomopathological revision of the obtained tissue at the Mayo Clinic Rochester (Dr. Unni) confirmed the diagnosis of a clear cell chondrosarcoma (). In June 1996, local progression of the disease was discovered and an amputation of the right lower leg was performed. Subsequently, she was followed with annual chest X-ray examination and clinical examination by her treating orthopaedic surgeon.
In April 2016, her chest radiogram showed a new dense opacity in the left upper lung lobe. On CT scan, two opacities in the left upper lobe were detected, with a diameter of 6 mm and 3 mm, respectively (). After multidisciplinary consultation, close follow-up was advised given the aspecific and small diameter of the lesions. Three months later, only one lesion remained on CT scan. Further follow-up with annual radiograms was organised. In December 2019, a slight increase in diameter in the nodule in the left upper lobe was seen. Subsequently, a new CT scan was performed, which showed a single nodule of 13.5 mm. Apart from a dry cough, the patient was asymptomatic at the time of this finding. A lung function examination was performed and showed no abnormalities. Further staging with an abdominal CT showed no other lesions suspected for metastases. There was no history of smoking. A CT-guided lung biopsy was performed, and the patient was referred to our tertiary sarcoma centre for further diagnostic examination and treatment because of the probable diagnosis of a chondrosarcoma metastasis.
At the time of referral, the patient was in good health and had no symptoms other than a transient dry cough. She did not have complaints of weight loss or exhaustion. Clinical examination showed no abnormalities besides the lower right leg amputation after

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

[User]
RADIOLOGY NOTE:
A 42-year-old woman with a severe lower abdominal and pelvic pain due to advanced cervical uterine cancer was referred to our pain clinic. Cancer had been diagnosed five months ago. The patient had used many pain killers and the pain was intractable to many analgesic modalities. She was a candidate for a superior hypogastric plexus block. In a uterine cervix biopsy, moderately differentiated non-keratinizing squamous cell carcinoma was reported. She had five sessions of chemotherapy and 25 sessions of radiotherapy in the past three months. She was receiving methadone 5 - 7.5 mg every eight hours, gabapentin, and acetaminophen for pain management during these three months. This medical treatment was administered by the palliative care service but in spite of this medical management, she was suffering from severe pain in lower abdominal and pelvic areas. Then, she was referred to our pain clinic. The pain was evaluated by the Brief Pain Inventory and the overall pain intensity was 8 out of 10 on the 11-point NRS scale ().
In an MRI study, a heterogenous enhancing lobulated mass (9 × 8.5 cm) was reported involving lower uterine cervix and upper vagina suggestive for a cervical tumoral lesion. There were numerous enhancing masses (adenopathies) in both iliac and para-aortic regions, as well. Moreover, enhancing adnexal masses (4 - 5 cm) were observed in the right and left sides. The liver, spleen, pancreas, and both kidneys did not show any mass or abnormality.
On the physical exam, she had severe deep tenderness and pain in the lower abdominal and pelvic areas. Organomegaly was felt in the lower abdomen. She did not have any abdominal rebound tenderness; therefore, peritonitis was ruled out. There were radiotherapy-induced blisters on the lumbar skin. A dermatological consultation was requested. No infection or important lesion was reported over the skin of the lumbar area.
The origin of the pain was a pelvic malignancy. Consequently, we decided to perform the superior

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


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

[User]
RADIOLOGY NOTE:
An 18-year-old male presented to department of oral medicine and radiology with the chief complaint of malformed tooth in his upper front region. The patient was apparently healthy and there was no history of medical or family problem. There was no previous history of trauma to the teeth or jaws. An intraoral clinical examination revealed an anomalous tooth present in area of left maxillary central incisor (). There was mild pain which was intermittent but no swelling or mobility was observed. The tooth did not respond to an electric pulp test and was tender on percussion. A supernumerary tooth was observed palatally in relation to permanent maxillary lateral incisor region (). The patient was advised intraoral periapical radiograph that revealed the presence of impacted permanent maxillary left central incisor (). The supernumerary tooth showed an oval radiolucent interior delineated by a well-defined radiopaque border. Patient was advised anterior maxillary occlusal radiograph that showed periapical changes in relation to anomalous supernumerary tooth (). The panoramic radiograph further confirmed the presence of impacted maxillary central incisor and supernumerary teeth in anterior maxillary region (). Cone beam computerized tomography (CBCT) confirmed the presence of dilated odontoma (Figures and ). Based on the clinical and radiographic findings, the patient was diagnosed with dilated invaginated odontoma in supernumerary tooth in anterior maxillary region associated with periapical pathology. The diagnosis of supernumerary tooth in palatal region and impacted permanent maxillary central incisor was also done. The supernumerary tooth was subsequently extracted under local anaesthesia with written informed consent from the patient.
Impacted central incisor was surgically exposed using a full thickness mucoperiosteal flap and an attachment was bonded along with looped ligature wire on the labial surface of tooth. Flap was repositioned and a closed eruption was in

[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 meso-Rex shunt with transposition of the coronary vein was performed in a 20-year-old man. The patient had a previous clinical history of increased abdominal volume and five episodes of gastrointestinal bleeding, and was diagnosed with idiopathic portal vein obstruction at 5 years of age. Hypercoagulability studies were performed at the time of thediagnosis. Antithrombin III level was 58% of normal, but other parameters were all unremarkable. One month before the shunt operation, an endoscopy identified aggravated esophageal and paraesophageal varices and hypertensive gastropathy. The size and patency of the umbilical portion of the intrahepatic left portal vein were assessed by preoperative Doppler ultrasonography and computed tomography; there was massive splenomegaly and no detectable intrahepatic left portal vein (). A preoperative percutaneous transhepatic liver needle biopsy showed a noncirrhotic liver without fibrosis, and hepatic venous pressure gradient was 28 mmHg (pressure in the inferior vena cava 7 mmHg, wedged hepatic venous pressure 35 mmHg).
After laparotomy, the round ligament was dissected toward the distal part of the left portal vein at the level of the Rex recessus. The left portal vein was then approached, and its ventral and lateral aspects were dissected over a length of 3-4 cm. The intrahepatic left portal vein was evaluated by surgical exploration, and its diameter was approximately 3 mm. Splenectomy was performed because of massive splenomegaly. There was a nest of peripancreatic collaterals with flow toward the gastroesophageal junction through a series of large varices, which included the coronary vein with an adequate diameter and flow in the hepatopetal direction. This vein was fully mobilized, divided, and then transposed across the mesocolon and behind the pylorus to the intrahepatic left portal vein to which it was anastomosed end-to-side using nonabsorbable monofilament interrupted sutures (). Unclamping of the meso-Rex shunt imm

[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 man with neurofibromatosis type 1 (NF1) underwent a chest X-ray following a three-week history of cough productive of white sputum. He was otherwise asymptomatic but had a 30-pack-year smoking history. The radiograph revealed a solitary coin lesion of the right lower lobe. The patient underwent a CT scan which demonstrated a 3.3 cm right lower lobe lesion, separate to the pleura and suspicious for primary lung carcinoma (). A CT guided biopsy of the mass was obtained and histological examination demonstrated a deposit of large nucleolated epithelioid cells with pigment, positive for S100 and Melan A (). The patient was discussed at a multidisciplinary meeting and a provisional diagnosis of metastatic melanoma was made.
Physical examination to establish the primary lesion was complicated by the presence of numerous neurofibromas and hyperpigmented café au lait spots, and the search ultimately proved unsuccessful. A PET/CT demonstrated a focal nodule in the right lung and several other masses with poor radiotracer uptake consistent with neurofibromas. Crucially the scan did not elicit a primary melanoma. The patient's ECOG performance status was 0 and therefore VATS metastasectomy with clear histological margins was performed. The tissue was stained for the BRAF V600 mutation but was negative and thus, the prescription of Vemurafenib was not deemed beneficial. Because the risk of systemic relapse was extremely high, the patient was followed with active surveillance.
The patient had undergone two surgical resections of large superficial plexiform neurofibromas 20 years ago. After the PET scan had proved negative, the possibility that these operations had removed the primary melanoma was considered. While attending the plastic surgery department 2 months after his VATS procedure for removal of an elbow neurofibroma, a pigmented lesion of the patient's skin, buried within his beard, was noted (). Histologic analysis following excision demonstrated a superfi

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


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

[User]
RADIOLOGY NOTE:
A 49-year-old male presented with a history of bomb blast injury to his left elbow 25 years back, when he had sustained an open and comminuted fracture of left distal humerus with extension into the elbow joint. The injury was treated with wound debridement and cast application for 6 weeks. Distal humerus progressed to atrophic non-union, with severe deformity and stiffness of the elbow. He also had partial involvement of radial and ulnar nerves with stiffness and deformities of the fingers of the left hand. He presented to us for correction of the elbow deformity and to gain reasonable elbow and hand function.
On local examination, there were multiple scars present medially, laterally and posteriorly around his left elbow suggestive of healed wounds by secondary intention after compound injury. There was fixed flexion deformity of the elbow of 900 with further flexion up to 120 degree was possible (, ). There was partial sensory loss in the little and ring fingers and the muscle power (as per MRC grading) of the finger flexors was 3/5; wrist and those of elbow flexors was 2/5. The motor power of left fingers, wrist and elbow extensors were 1/5.
Plain radiographs revealed atrophic non-union of the supracondylar fracture along with the deformity at the distal humerus due to malunited distal humeral fracture (, ). CT scan confirmed these radiographic findings and demonstrated a significant gap at the fracture site with grossly rotated distal humeral condylar fragments and marked disuse osteopenia.
In view of grossly distorted anatomy of the distal humerus, poor bone stock, bone gap at the non-united fracture, severe elbow deformity and stiffness we preferred to go for a mega prosthetic replacement of the left elbow. Under general anaesthesia, elbow was approached posteriorly by ’Wadsworth approach’ and the fracture site was exposed. Severe fibrosis was encountered between the fractured ends of the bone, which was excised. The distal humeral condylar fragments were fou

[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.