[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 56-year-old male with no history of allergic symptoms reported to the department of periodontology for the removal of a well-placed implant with prosthesis in relation to upper left central incisor. The patient's history revealed implant placement in the left upper central incisor region 6 months back by private practitioner after which the patient noticed generalized eruptions involving almost all the surfaces of the body including axilla, groin, chest, shoulder, forearms, hands, within a week of dental implant placement [] with no obvious peri-oral signs and symptoms. Following this he first consulted a dermatologist after 10 days of implant placement, who considered this a skin problem and diagnosed it as generalized pruritus. Raised eosinophilic count was present in hematological reports after 2 weeks of implant placement. He was prescribed antihistaminic (H1 antagonists) as an anti-allergic, but the eczema did not resolve. Skin biopsy was advised to rule out dermatitis herpetiformis and gliadin antibody (IgG, IgA) along with tissue transglutaminase (Ttg) test after 2 months to rule out celiac disease after observing continuous eruptions without much relief with anti-allergic as well. All tests reported negative. There were no significant pathologic findings observed around the implants [], and radiographically, the surrounding bone appeared normal. The patient was systemically healthy, with no history of medications or other suggestive medical treatment. The patient went to numerous skin clinics and hospitals and had taken anti-allergic medication, local and systemic steroids, and obtained only symptomatic relief but complained of the eruptions again after stopping the medications. The patient had also reported back to the private clinic after 4 months and requested for implant removal for which dentist convince him not to get it removed considering no perioral signs and symptoms and placed the crown as well. With regular medications and consulting dentist an

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


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

[User]
RADIOLOGY NOTE:
A 62-year-old man with PL was found a right-side ureteral calculi by ultrasound in the routine health examination. Thirteen years ago, when he was diagnosed with PL, CT scan found a heavy hydronephrosis in the left side. So he had accepted an open surgery of uretero-vesical reimplantation in the left side, without necessary follow-up after the surgery. Three years ago, a severe hydronephrosis was observed in the left side and kidney stone in the right side in health examination, but he did not take any further treatment. This time, CT scan demonstrated a proliferation of adipose tissue predominantly in the pelvic space (Fig. ), a severe hydronephrosis in the left side and mild hydronephrosis along with a calculi in lower ureter in the right side (Fig. ). The intravenous urography showed that the upper urinary tract in left side was barely showed up, bladder was elevated and the upper urinary tract in right side was dilated slightly (Fig. ). Serum creatinine was 99 μmol/L, the count of white blood cell was 47 per microliter in urinalysis and the urine culture was negative.
During the surgery, patient in lithotomy position under general anesthesia, rigid ureteroscope was not able to reach into the bladder cavity due to the elongated bladder neck and elevated bladder base. So the cystoscopy was accomplished with flexible ureteroscope directly. However, the flexible ureteroscope failed to get into the right ureter with or without guidewire due to the stricture of uretero-vesical orifice. Finally, after several failed attempts of inserting a guidewire into kidney because of the tortuous lower ureter with calculi in right side and the difficulty to hold the position of flexible ureteroscope in bladder cavity, the guidewire passed the contortion of ureter and ureteral calculi. Then ureteral access sheath (UAS), in a size of 12/14Fr, was placed into the lower ureter in right side and the unbroken stone was basketed through UAS. The ureteral

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


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

[User]
RADIOLOGY NOTE:
A 38-year-old male patient with a 40-pack-year history of smoking initially presented with sudden-onset right-sided facial nerve palsy which was diagnosed as idiopathic Bell's palsy and was treated with prednisolone. Three weeks later, the patient developed a new left-sided facial palsy in addition to his unrecovered right-sided facial palsy. The patient denied any systemic symptoms except for a mild headache. His physical examination showed bilateral lower motor neuron facial nerve palsy. Outside of the facial nerve paralysis, he was neurologically intact, and his physical examination revealed no abnormalities. Further workup was carried out to rule out autoimmune, metabolic, infectious, and vasculitic causes and revealed no abnormality. A chest X-ray showed a right upper lobe opacity which prompted a computed tomography (CT) scan of the chest which showed a well-defined, suspected soft-tissue lesion in the right upper lobe with extensive hilar and ipsilateral mediastinal lymphadenopathy (Fig ).
At this point, the differential diagnosis included sarcoidosis and primary lung cancer given the presenting complaint was bilateral facial nerve paralysis. Because the intrapulmonary lesion was too distal to be reached by flexible bronchoscopy, video-assisted mediastinoscopy was performed and revealed gross right-sided mediastinal invasion. Multiple biopsies from lymph nodes were taken and revealed metastatic poorly differentiated adenocarcinoma of the lung. Accordingly, positron emission tomography (PET)/CT and magnetic resonance imaging (MRI) of the brain were performed to stage the cancer. Brain MRI with contrast showed normal enhancement of the seventh and eighth cranial nerves with neither brain metastasis nor leptomeningeal metastasis. The PET/CT showed a metabolically active right upper lobe lesion with extension into the mediastinum and active ipsilateral mediastinal lymph nodes but no distant metastasis. Due to our high clinical suspicion of leptomeningeal involvem

[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 woman came to the emergency room with fever for a month and pain in the left upper quadrants of the abdomen and lower left back pain. She had no other systemic symptoms or comorbidity. Routine blood tests were in the normal range with no evidence of infectious diseases. On clinical examination there were no signs of peritonitis but we found a palpable large mass in left flank. We performed a CT abdominal scan that demonstrated a voluminous solid oval mass (11.2 cm × 7.5 cm × 12 cm) in the left perirenal space with dislocation of the kidney and in continuity with the anterior renal fascia. After iodinated-contrast we observed a progressive, inhomogeneous enhancement of the lesion with peripheral vascularization () [,]. After a percutaneous CT-guided biopsy of the mass the histopathological diagnosis was a dedifferentiated retroperitoneal liposarcoma. Considering the site of the neoplasm in left renal loggia and the absence of others repetitive local or distant lesions our tumor board decided for surgical resection of the mass in block with kidney and left adrenal gland. We chose the possibility of laparoscopic approach with conversion to open surgery in case of muscle infiltration or vascular invasion. After preoperative clinical study [] the surgical procedure was carried out with a transperitoneal approach with the patient in right lateral decubitus position to obtain a large surgical field with well known anatomic landmarks and possibility of exploration of peritoneal organs. We used a laparoscopic 3D vision system [,] with three trocars in the left subcostal region, but during surgical procedure we positioned another 5-mm trocar for spleen retraction. We performed an adequate mobilization of the splenic-pancreatic block in order to identify infiltration of peritumor tissues. We found a well-capsulated mass. The dissection was done with Harmonic scalpel™ (Ethicon Endo Surgery INC – Johnson & Johnson, NJ, USA) from up-to-down until the left

[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 slim 46-year-old Japanese man was brought to the emergency room of the Chiba Emergency Medical Center because of intermittent epigastric pain. He had no history of abdominal surgery. His initial blood and urine examinations showed no abnormalities. However, the pain had been getting worse and signs of peritoneal irritation appeared within a few hours.
An abdominal enhanced MDCT scan without multiplanar reconstruction was then performed, which revealed small bowel loops with suspicious ischemic change in the right lateral part of the abdomen of our patient (Figure ). An internal hernia with strangulation was diagnosed, and emergency surgery was subsequently performed.
During surgery, a band between the mesentery near the cecum and the retroperitoneum was found. Part of his jejunum had been sliding under the band and had thus become necrotic. The necrotic bowel, which was 50 cm in length, was resected. Furthermore, one-quarter of the proximal small intestine was encapsulated in a peritoneal sac that was surrounded by transverse mesocolon. The bowel was entering the Waldeyer's fossa through an opening beside the ligament of Treitz (Figure ). A right paraduodenal hernia was then diagnosed.
The bowel was removed manually from the sac. There was no sign of ischemic change. The fossa was approximated tightly with no free space. Furthermore, there was no malrotation of our patient's bowel, and the cecum was located in the normal position without Ladd's band. On the third post-operative day, our patient complained of nausea and he started vomiting, thus a nasogastric tube was placed. After that, more than 2000 mL of bilious gastric juice was drained from him every day.
An upper gastrointestinal contrast series revealed dilatation of the right side of the duodenal third portion with a straight line cut-off sign. The contrast medium did not pass to the proximal side in supine position, although it did pass with postural change to the prone position (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:
The second case refers to a 48-year-old woman, a busy manager with a history of depression and sleep disturbance. She has had three terminations of pregnancy and one delivery by cesarean section. She smokes approximately ten cigarettes per day and has high cholesterol serum levels. She takes several medications: a selective serotonin reuptake inhibitor (escitalopram), two benzodiazepines (delorazepam and clonazepam), and a statin. She reports a four-year history of urinary symptoms: daily UUI episodes, mild stress urinary incontinence (SUI), and two episodes of nocturia per night. She wears pads every day. The urology consultation revealed some degree of pelvic pain, especially during vaginal examination. The urine dipstick was negative and there was no PVR. No specific causes of the symptoms such as urine tract infection were identified. The patient also complained of mild dyspareunia and occasional constipation. The urine culture turned out to be sterile, with no blood in urine, and the pelvic ultrasound scan and urine cytology were also negative. The cystoscopy, which was performed as a result of the presence of storage symptoms and to rule out a bladder tumor in this current smoker, was normal.
In OAB patients, it is of utmost importance to consider all comorbidities. Anxiety and depression may play a role, feeding a vicious circle. Moreover, medications to treat neurological or psychiatric disorders can influence OAB and be responsible for side effects [, ]. Gastrointestinal disorders are frequently associated with OAB, such as constipation in this case, but patients rarely raise the topic. An overlap exists between irritable bowel syndrome and OAB [].
The patient was prescribed a β3 agonist, pelvic floor muscle training (PFMT) and bladder retraining. Four months later, she noticed some degree of improvement, but had stopped the treatment as she felt that she had no time for PFMT. She was not compliant with the bladder drill either, and soon stopped

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


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

[User]
RADIOLOGY NOTE:
A 10-year-old female child presented with a generalized diffuse swelling of the tongue since birth. The parents had noted her to have an apparently large tongue since birth which gradually increased in size. The child also developed multiple nodules over the tongue which spontaneously burst with watery discharge [ - Left picture]. This was associated with excessive salivation, inability to completely close the mouth, chewing and feeding difficulty, and slurring of speech over the past 5 years. There was no history of dyspnea. On examination, the child had diffuse nontender enlargement of the tongue with multiple vesicle-like projections over the dorsal aspect, giving it an irregular granular experience. She also had mandibular prognathism. The rest of the oral cavity and neck were normal.
With a clinical diagnosis of generalized lymphangioma of the tongue, a magnetic resonance imaging scan was done. This showed a large diffuse ill-defined altered signal intensity lesion involving tongue and sublingual regions on either side of the midline. There was no intracranial or intraorbital extension. In view of the symptoms, physical findings, and investigations, a partial glossectomy was planned to provide symptomatic relief to the child.
The area of excision was marked, which was middle one-third of dorsum to the junction of anterior two-third and posterior one-third including the tip and a portion of ventral surface. After nasal intubation, the tongue was infiltrated with 2% lignocaine with optimal dilution of adrenaline. Following excision, the tongue was reconstructed in layers with 3-0 and 4-0 polyglactin sutures []. The child was given nasogastric tube feeding for 10 days following surgery after which oral feeds were gradually introduced, which were tolerated well. Histopathology confirmed lymphangioma circumscriptum characterized by numerous channels filled with lymphatic fluid in the papillary dermis causing it to expand. Large caliber lymph filled vessels were also

[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 22-year-old female came with the chief complaint of swelling over the left front side of the face since 4 months []. Patient gave the history of extraction in the same region 1 year back. There was no significant contributing family and medical history. The patient gave a history of rapidly enlarging swelling which attained the present size of 3 cm × 4 cm. There was associated history of difficulty in speech and mastication. Extraorally, the swelling extended superoinferiorly from infraorbital margin to the upper lip and anteroposteriorly from midline to the corner of the mouth. Swelling was round to oval in shape with well-defined borders. Skin over the swelling was stretched but was normal in color. The swelling was firm and fixed to underlying structures. Intraorally, the swelling appeared to be arising from the labial vestibule extending up to the second premolar of the left side []. The buccal cortical plates were expanded but intact. There was displacement and Grade II mobility in relation to 21, 22 and 24.
The orthopantomography revealed unilocular radiolucency associated with 11, 12, 21, 22, 24 and root resorption in relation to 21, 22, 24 with missing 23 []. The computed tomography scan also revealed perforation of the cortical plates. Chest X-ray and hematological investigation were within the normal limits.
Informed consent was taken from the patient and surgical excision was done and the tissue was sent for the histopathological examination. The hematoxylin and eosin stained sections revealed the presence of parakeratinized stratified squamous epithelium overlying the connective tissue stroma. The connective tissue was fibrocellular in nature with numerous spindle-shaped cells. The cells were arranged in fascicular pattern with few areas showing herringbone pattern of arrangement []. The cells were dysplastic in nature with most of them showing cellular and nuclear pleomorphism. The cells showed immunoreactivity for vimentin []. There were few areas sh

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


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

[User]
RADIOLOGY NOTE:
Our patient was a 4-year-old Japanese female who underwent an urgent innominate artery transection under general anesthesia due to a suspected TIF. She was born at 37 weeks’ gestation with a natural delivery. Her birth weight was 2542 g and the APGAR scores were 7 and 8 at 1 and 5 min, respectively. At birth, the patient was immediately intubated due to forced breathing and hypoxemia. Her craniofacial anomalies including exophthalmos, prominent forehead, blue sclera, and micrognathia indicated the possibility of one or more complications of a genetic disease. Radiographic examinations demonstrated advanced skeletal maturation, and she was diagnosed MSS at 2 months old. She underwent tracheostomy for tracheomalacia at 3 months old, followed by gastrostomy at the age of 2 years, but not required ventilator support. Gastrostomy was performed under inhalation anesthesia via tracheostomy tube under spontaneous breathing in combination with regional anesthesia.
One month before the patient’s admission to our hospital, intermittent tracheal bleeding was observed and managed by a change in the smaller cannula size and shorter length. Two weeks later, the patient needed hospitalization at a primary medical clinic because of acute tonsillitis and pneumonia-induced hypoxemia. Intermittent tracheal bleeding reappeared, and granulation at the distal site of the cannula without bleeding was detected by bronchoscopy. Contrast-enhanced computed tomography revealed extremely thin connective tissue between the innominate artery and the trachea, suggesting TIF and she was transferred to our hospital (Fig. ).
After admission, the patient’s vital signs were stable; blood pressure 96/57 mmHg, heart rate 143 bpm, and SpO2 97% (room air attached with heat and moisture exchangers). Her height and body weight were 81 cm and 8 kg, respectively. A 4.0 mm ID uncuffed tracheostomy tube of a length that was customized for the patient was used, and air leakage during bag valve ventilation was limi

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


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

[User]
RADIOLOGY NOTE:
A 75-year-old male patient visited the hospital complaining of dysphagia and weight loss (as much as 5 kg) that had occurred 3 months prior to this visit. Twenty years earlier, he had a received craniotomy on the left frontal parietal region because of traumatic subdural hemorrhage from falling and had recovered without sequelae. He had taken drug treatment for hypertension, but has no difficulty in daily living activity. For his dysphagia, he complained of more difficulties in swallowing solid foods rather than liquid foods and this was gradually progressing. Seven months after the onset of dysphagia, he was hospitalized, at which time he could only take small amounts of liquid foods instead of regular meals and his weight loss during 10 months since the onset of dysphagia was approximately 10 kg. The patient did not complain of speech disturbance or dyspnea and both movements of the tongue and gag reflex were normal. On his brain MRI scan, partial encephalomalacia was observed on the lesion where the left frontal parietal craniotomy had performed and left inferior temporal gyrus; this was not different compared with a prior brain MRI scan, and any additional lesions which might induce dysphagia was not observed. An endoscopic examination was performed with suspicion of a pharyngolaryngeal tumor, but no abnormal findings were detected. There were also no abnormal results in routine blood and tumor marker tests. As excessive osteophytosis on the anterior part of the cervical vertebrae from C3rd to C6th levels were observed in the cervical plain radiograph, a 3D cervical CT was performed and the identified posterior part of the pharyngolaryngeal cavity was compressed and narrowed by osteophytes from C2nd to C7th vertebrae levels (). As the dysphagia by anterior cervical osteophytes was suspected, a VFSS (Video Fluroscopic Swallowing Study) was performed (). Findings revealed that a movement of the epiglottis displayed an abnormal recurvation by osteophytes, with at l

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


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

[User]
RADIOLOGY NOTE:
A 43-year-old Asian male was transferred to our hospital after undergoing a drainage procedure for a gluteal abscess at another hospital. He was known to have poorly controlled diabetes, and hyperlipidemia on treatment; he was also a heavy smoker for more than 20 years. The complaints started 3 weeks prior to presentation with fever and gluteal abscess which was drained surgically (). The fever persisted despite receiving a combination of gentamycin and penicillin. Two days later, the patient’s condition deteriorated with the onset of shortness of breath and orthopnea. Two sets of blood culture performed on 6 August 2017 grew CoNS, which was considered a contaminant. Further evaluation via transthoracic echocardiography revealed the presence of large vegetation on the aortic valve with severe regurgitation and moderate size vegetation on mitral and tricuspid valve with moderate regurgitation plus aortic root abscess. He was subsequently transferred to our hospital for cardiac surgery.
On arrival, his condition had worsened as evidenced by fever with a temperature of 38.9°C, tachycardia (142 beats/minute), hypotension (96/54 mm Hg), and blood oxygen saturation level of 91%. Laboratory tests revealed a white blood cell count of 14,000/mm3 with 81% neutrophils while kidney profile showed acute renal failure with urea 19.5 mmol/L and creatinine 533 µmol/L. His C-reactive protein level was 200 mg/L.
He was admitted to the intensive care unit and parenteral vancomycin was initiated based on the knowledge of a previous culture of CoNS from the referring hospital. The condition of the patient deteriorated further the next day with refractory heart failure and pulmonary edema due to the extensive valvular lesions and insufficiency with worse blood gas values and desaturation (SpO2, 84%). He was intubated and continuous renal replacement therapy was initiated with a good response as demonstrated by the normalization of his blood pressure and blood gases.
The microbiologist 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:
In June 1986, a 28-year old man sustained hemopneumothorax due to 3rd-6th costal fractures and brachial plexus injury in the left side during a motor cycle accident. He was referred to our clinic 2 months after initial trauma due to there has been no spontaneous recovery of the upper limb function. Upon physical examination, a positive Claude Bernard-Horner's sign was found. The function of the shoulder, elbow, wrist and hand was completely lost. Plain chest X-ray film also showed elevation of the left diaphragm. Electromyogram detected no SEP from C5-T1 nerve roots and NAP could be recorded. The diagnosis was preganglionic injury of the C5-T1 nerve roots, ie., total root avulsion injury of the brachial plexus. The EMG exam also suggested concomitant complete palsy of the accessory nerve and phrenic nerve. Based on our observation of over 1000 cases of brachial plexus injuries, no patient suffered functional loss from single C7 root injury, therefore we postulated that C7from the healthy limb may be sacrificed and used as a donor nerve to reconstruct the injured plexus. During surgical exploration of the affected plexus, C5-T1 nerve roots were found avulsed. Due to extensive scarring in the neck/shoulder region, the accessory nerve and motor branches of the cervical plexus could not be used. The phrenic nerve was found to be buried in the scarry tissue on the surface of the fibrosed anterior scalenus muscle and a neurolysis was performed.Upon electrical stimulation a strong contraction of the diaphragm could be induced which indicated the viability of phrenic nerve. It was then divided with its proximal stump transferred directly to the anterior division of the upper trunk (fascicles destined to the musculocutaneous nerve). Since there were no further donor nerves to be used in the injured side, the contralateral C7 nerve was decided to be used and therefore exposed and divided. In the injured side

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

[User]
RADIOLOGY NOTE:
A 70-year-old male was referred to our hospital complaining of left flank pain. At physical examination, nothing relevant was observed and laboratory findings were within normal limits. A CT examination of the abdomen and the pelvis was performed with a multidetector scanner, before and after contrast media administration. Portal phase images showed a large amount of solid tissue in the left perirenal space, infiltrating the renal capsule and the main renal vessels; the tissue did not show significant contrast enhancement. Similar findings were detected also in the right perirenal space (). CT images also revealed a partial stenosis of the common bile duct, with intrahepatic bile duct ectasia owing to hypervascular eccentric tissue (). Hence, a diagnostic integration with endoscopic retrograde cholangiopancreatography was performed to exclude an intraductal proliferation. A biopsy was also performed in the left perirenal space; the pathological samples were composed of connective and adipose tissues, revealing the histological features of a DT or abdominal fibromatosis and also showing immunohistochemical markers typical of muscular tissues, such as actine. The tumour was considered unresectable and medical therapy was started with tamoxifen (20 mg die–1); after an episode of thrombophlebitis, the patient asked to suspend tamoxifen and accepted a new therapeutic regimen (docetaxel 75 mg m−2 every 3 weeks); unfortunately, even this treatment was discontinued after only 4 weeks owing to neuropathy. A new CT examination was then performed to assess the results of the treatment. Unexpectedly, on venous phase images, the perirenal tissue showed a remarkable reduction on the left side and had almost disappeared on the right side (). The peribiliary tissue had equally decreased in size and thickness (). The treatment was then discontinued in accordance with the patient’s decision. 1 year later, both the left perirenal and peribiliary tissues demonstrated no progression and

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


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

[User]
RADIOLOGY NOTE:
We present a patient that underwent radical liver resection for intrahepatic CCA and then re-underwent radical liver resection for a first intrahepatic recurrence; nonetheless, he developed a second unresectable intrahepatic recurrence with PM and was referred to our institution where CRS, ECT with BLM, and HIPEC were performed ().
In July 2016, an otherwise healthy 47-year-old male patient underwent another institution liver resection of segments 4 and 5 and cholecystectomy for an intrahepatic CCA; the histologic examination of the specimen revealed a “mass forming” cholangiocarcinoma with gallbladder invasion and with one positive hilar lymph node of the eight sampled. The surgical margins were clear. After the operation, the patient received six cycles of adjuvant chemotherapy with gemcitabine and cisplatin.
In June 2017, the patient developed a massive intrahepatic recurrence with ten peripheral lesions surgically resected in the same hospital with multiple hepatic wedge resections (Wedge of segments 1–6–7, Wedge of segments 4–8, Wedge of segments 5–6, and a Wedge of segment 7). The margins were clear, and no vascular invasion nor perineural invasion was observed on the surgical specimen. After surgery, the patient received four cycles of adjuvant chemotherapy with capecitabine, followed by five chemotherapy cycles with folinic acid, fluorouracil, and irinotecan (FOLFIRI). Later on, considering the tumor progression with emergence at the radiological CT scan of lung metastasis and a new liver recurrence (), the patient received systemic therapy with TKI Pan-FGFR Derazantinib with limited effect on tumor progression.
In the same hospital in April 2019, the patient underwent another attempt of hepatic surgical resection. However, due to the burden of the hepatic disease and the intraoperative detection of PM presence on the pelvic floor and on the lower quadrants, no demolition procedures on the liver or on the abdominal cavity PM were carried.
In July 2019, 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:
We present the case of a 42-year-old man who presented to the emergency department with a complaint of abdominal pain and diarrhea for 3 days. The abdominal pain started in the periumbilical region and was shifted to the right lower quadrant of the abdomen. The pain started gradually and had been progressing in severity. He described the pain as a stabbing in nature. It was exacerbated by movement and food intake. The pain was partially relieved by oral analgesic medications like paracetamol. The pain was associated with low-grade fever and decreased appetite. The patient also complained of diarrhea with five bowel motions/day. The stools were watery with no mucus or blood. He reported that diarrhea developed after he received an oral antibiotic therapy (cefuroxime) for a recent upper respiratory tract infection.
The past medical history of the patient was remarkable for diabetes mellitus that was well-controlled with oral antidiabetic agents. He did not undergo any previous abdominal surgeries. He had a smoking history of 15 pack-years. He had never drunk alcohol before. He worked as a taxi driver. The family history was unremarkable for any inherited gastrointestinal disorders.
Upon examination, the patient appeared sick. He was not pale, jaundiced, or cyanosed. Vital signs revealed tachycardia (115 bpm), low-grade fever (37.5℃), normal respiratory rate (14 bpm), and maintained blood pressure (122/80 mmHg). The oxygen saturation was 99% on room air. Abdominal examination revealed a soft abdomen with diffuse tenderness. However, the tenderness was more pronounced in the right iliac fossa with a positive rebound sign. Further, the Rovsing sign was positive. Initial laboratory investigation revealed elevated leukocyte count and elevated inflammatory markers, including erythrocyte sedimentation rate and C-reactive protein. The renal and hepatic profiles were within the normal limits (Table ).
In light of the aforementioned clinical information, the patient was diagnos

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


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

[User]
RADIOLOGY NOTE:
A 26-year-old female patient was transferred to the Samsung Medical Center from an outside institution due to severe refractory cardiogenic shock. The patient was diagnosed with non-Hodgkin’s lymphoma 2 years prior and underwent 6 cycles of chemotherapy, which included doxorubicin. After chemotherapy treatments were completed, the patient suffered from orthopnea and dyspnea, and an echocardiography revealed a severely depressed left ventricular (LV) ejection fraction (25%) and dilated LV. Due to complications from cancer treatments, she had an episode of acute decompensated heart failure and was referred to Samsung Medical Center.
On initial presentation, vital signs included arterial blood pressure of 79/27 mmHg, heart rate of 133 beats/min, respiratory rate of 28 breaths/min, and body temperature of 35.9°C. She had pulmonary edema with bilateral pulmonary congestion () and multiorgan failure with liver and kidney involvement. Despite the use of inotropes and vasopressors, we were unable to achieve stable vital signs.
Percutaneous extracorporeal life support (P-ECLS) was then placed using the left femoral artery and vein. However, the left leg became ischemic after several hours, and we decided to shift the cannulas to the right groin. The patient was brought to a hybrid operating room, and the groin was opened bilaterally. First, we removed the left femoral arterial cannula and performed a thrombectomy. Then, the arterial and venous cannulas were inserted through the common femoral artery and vein, and the catheter for the superficial femoral artery was inserted at the same time.
The following day, transthoracic echocardiography revealed a distended left ventricle, and the chest X-ray showed worsening pulmonary edema. In this case, we determined that an atrial septostomy was not a viable option since both the femoral veins were already cannulated or had been surgically repaired. Instead, we performed an emergency standard median sternotomy and inserted a vent cath

[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:
Mr. CD, a 45-year-old manual laborer, with no history of any medical illness, non-smoker, alleged motor vehicle accident (pedestrian vs. car) 1½ years back and sustained right-sided open comminuted fracture distal third tibia Gustilo type 3 A. The initial wound debridement and external fixation were done on day 0 of accident to manage the bony and soft-tissue damage. During the initial procedure, we carried out tests for the antibiotic sensitivity and the organism identification, the resultant organism being Staphylococcus aureus and the sensitive antibiotics were initiated and continued for around 6 weeks, post-trauma, the wound was healed up but the fracture was still undergoing union and only minimal callus formation was present. Diagnosed with osteomyelitis, the patient was taken up for right-sided tibia debridement, sequestrectomy, and resection of necrotic bone fragment (, ). 6 cm bone fragment was resected with oscillating saw at the distal tibial shaft site, up to the presumed healthy area during the operation (). After resection of necrotic bone fragment it was followed by proximal tibial metaphyseal corticotomy after passing an antibiotic coated intramedullary nail with local gentamycin beads insertion (). Four days later, Ilizarov ring fixator procedure was done over the antibiotic coated intramedullary nail (). Gradual compression and docking was planned after the 8th day of ring fixation as the bone loss at the initial measurement after debridement was 6 cm (). At the outset of the pandemic, the patient was discharged and instructed to follow up for check X-rays and monitoring for the compression distraction process. The patient himself made the distraction and compression regulations but failed to follow up during the lockdown period. When he returned back to us for follow-up, check X-ray was done ().
It revealed union at the fracture docking site. At this point, kindly note that check X-ray failed to reveal the proximal fibular head migration due to t

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


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

[User]
RADIOLOGY NOTE:
A 42-year-old male with underlying chronic obstructive airway disease and chronic rheumatic heart disease was diagnosed with severe mitral stenosis. The patient had symptoms of and shortness of breath despite optimal medical therapy. An echocardiogram revealed a mitral valve area of 0.9 cm2 and ejection fraction of 69%. The patient underwent an elective mitral valve replacement through a left arteriotomy. Before the start of surgery, a PAC was inserted by the cardiac anesthetist to aid in pulmonary artery pressure monitoring. Intraoperatively, the diseased and stenosed mitral valve was replaced with a mechanical stable type size 8 using interrupted pledgeted sutures. After closing the left atrium with 3/0 prolene sutures, there was bleeding at the superior edge of the arteriotomy site adjacent to the superior vena cava (SVC)-pulmonary artery junction. This was controlled using two pledgeted 4/0 prolene stitches. The sternum was closed in standard fashion using steel wires. Postoperatively, the patient was nursed in the cardiac intensive care unit and his recovery was uneventful. On the second postoperative day, attempts to remove the PAC were met with great resistance. A chest roentgenogram [] revealed a straight PAC without any kinks or knots. This led to the suspicion of a possible PAC entrapment secondary to suture piercing. A chest re-open through median sternotomy was decided for fear of risk from fatal bleeding due to further attempts at pulling on the PAC. After intubation, a TEE was performed which revealed that the PAC was adherent to the wall of the right atrium close to the SVC [].
The suspicion of the entrapment due to suture piercing was confirmed upon entering the chest and examining of the heart. The cardiac surgeons could feel a tug over the plegeted suture (which was previously sutured over the left atrial suture line for hemostasis) when the anesthetist tugged gently on the PAC [].
Incidentally, during digital palpation of 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:
A 72- year old male patient attended the department of oral pathology for evaluation of a painless gingival growth in the premolar region of the right mandible. This lesion has been growing over the last year. The patient referred the excision of a similar lesion 6 years before which was diagnosed as ameloblastoma, but unfortunately, he did not have the previous documentation. His past medical history also included the diagnosis of diabetes mellitus that was on regular control. The examination revealed an oval-shaped exophytic mass of 1×1 cm in the lingual gingiva of the right mandible at the first and second premolar region. The surface was pebbly, with a sessile base and firm on palpation. No local enlarged lymph nodes were identified ().
The Orthopantomography (OPG) showed no evidence of bone involvement. The initial working diagnosis was pyogenic granuloma though the suspicion of recurrence of ameloblastoma was not ruled out ().
An incisional biopsy was done, considering the previous history of ameloblastoma and upon the microscopic examination, the diagnosis of pseudo epitheliomatous hyperplasia was made (). However, complete excision was performed because the initial diagnosis was not convincing. The analysis of excisional biopsy showed numerous proliferating odontogenic epithelial islands spreading throughout the moderately dense connective tissue stroma. The odontogenic epithelial islands were mainly of follicular pattern with peripheral hyperchromatic palisaded columnar cells resembling ameloblasts. The center of the follicle disclosed stellate reticulum like cells. In some of the odontogenic epithelial islands, the central cells underwent squamous metaplasia with keratin formation.
The overlying stratified squamous epithelium was proliferative and was found to be in close association with the odontogenic epithelial islands in few areas. A moderate amount of chronic inflammation was depicted in the subepithelial zone. No inductive effect was noticed around

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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 24-year-old woman presented to our hospital with pain in her knee. At the age of seven, she developed nephrotic syndrome and was diagnosed with primary focal segmental glomerulosclerosis (FSGS) by renal biopsy (Fig. ). Nephrotic syndrome gradually worsened without symptoms such as edema. She was administered corticosteroids from the age of 18 years, but did not respond to this therapy. Cyclosporine was then administered, but was discontinued within one week due to the adverse effect of fatigue. Corticosteroids were tapered with proteinuria of 4 to 6 g per 24 hours.
When she presented to our hospital, she had poorly developed nails and small corneas. Intraocular pressure was normal. She gradually developed pain in her knee over 12 months. X-ray and computed tomography were performed to systemically evaluate the orthopedic morphology, and revealed hypoplastic patellas, dislocation of the elbows, and iliac horns in the pelvis (Fig. ). Laboratory data showed hypoalbuminemia and the excretion of a large amount of protein in the urine, indicating nephrotic syndrome with renal insufficiency. Other serological results revealed that the secondary causes of nephrotic syndrome such as autoimmune disease, hematological diseases, or infection were negative (Table ). Her clinical course of SRNS and orthopedic manifestations indicated NPS; therefore, we performed a genetic analysis, which showed a heterozygous mutation in the first base of the fifth intron of the LMX1B gene (c.819 + 1G > A) (Fig. ). Since this mutation was not detected in her parents, our case was considered to have a de novo mutation.
In a review of renal biopsy at the age of 7, light microscopy revealed focal glomerular lesions only (Fig. ). Immunofluorescence showed slightly positive staining for IgM and C3 within glomerular segmental lesions (Fig. ). Electron microscopy displayed mild irregular thickening of the glomerular basement membrane (GBM) and swollen podocytes with partial foot process effacement, wh

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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:
Patient 2, also a six year old boy, presented at the CDTUB with a 20×15 cm ulcerated lesion on the interior side of his right upper leg and knee. Undermined edges as well as ‘cotton wool’ appearance of necrotic tissue at the center of the lesion were characteristic for BU . Clinical diagnosis was confirmed by positive IS2404 PCR results and microscopic detection of AFB in swab samples. Surgical débridement was performed 29 days after start of standard R/S chemotherapy followed 10 days later by skin grafting. Twelve days after completion of antibiotic treatment, a nodule (nodule 1) 2×2 cm; had emerged about 5 cm proximal of the border of the primary lesion at the upper right leg and was excised 7 days later. The initial lesion as well as the lesion at the excision site had healed 39 days after completion of the antibiotic treatment (i. e 57 days after skin grafting) and the patient was discharged from hospital.
One week after discharge (46 days after completion of antibiotic treatment) the patient was readmitted with a second nodule (1,5×1,5 cm) located at the lower right leg about 15 cm distal of the border of the primary lesion. Again eight days later (54 days after completion of antibiotic treatment) a third nodule (nodule 3) (3×2 cm) had emerged at the upper right leg located 5 cm proximal of the initial wound. These two nodules were excised 93 days after completion of the antibiotic therapy. While AFB staining, as well as IS2404 PCR confirmed the presence of M. ulcerans, both nodules were culture negative.
After surgical excision and healing of the satellite lesions the patient was discharged, but re-admitted 176 days after completion of antibiotic treatment with a fourth nodule (nodule 4) 2×2 cm on the right foot. A minimal surgical intervention was performed and the patient was discharged 10 days later and no further relapses were

[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 69 years old female patient was hospitalized for dyspnea, which was her chief complaint. The echocardiogram during the visit showed severe mitral stenosis (MVA = 0.8 cm2) and aortic stenosis (AVA = 0.7 cm2). Mild pulmonary hypertension (RVSP = 34 mmHg) and grade I tricuspid regurgitation were also present with a left ventricular ejection fraction of 43%. Left ventricular hypertrophy was present and the left ventricular wall motion was generalized hypokinetic, but no localized wall motion abnormality was found. According to the coronary artery angiogram, there was no stenosis of the coronary artery and the patient had no other significant medical history except for treatment for hypertension.
During the surgery, the aortic valve and mitral valve were replaced with Hancock® II (Medtronic) 23 mm and Hancock II (Medtronic) 27 mm, respectively, and then no postoperative complications were observed.
On the 8th postoperative day, sternal infection was noted and pseudomonas aeruginosa was cultured on the culture test. The patient experienced only mild fever, so wound care and ceftazidime IV were concurrently administered. Curettage and debridement of the infected sternum were scheduled and we continued observing the patient. On the 11th postoperative day, there was massive bleeding at the retrosternal area, so an emergency operation was performed. The bleeding site was around the aortic vent insertion site and the aortic adventitia was very weak due to infection. The weakened ascending aorta tissue was removed and patch repair was performed using a Hemashield® graft (Boston Scientific). She was continually given antibiotic medication for six weeks and there was no abnormal finding on the echocardiogram before discharge from the hospital. Two weeks after the discharge, the patient was hospitalized again from a 38°C fever and chills, and pseudomonas aeruginosa was cultured from her blood. Chest CT confirmed a large sized ascending aortic pseudoaneurysm (Figure ). The pseudo

[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 56-year-old male was admitted to our hospital for an increasing swelling mass at the root of his right neck (Figure ). He had an active smoking history, but no history of chest pain or trauma. Physical examination found a large pulsating mass on the right neck, without other significant clinical findings. Angio-CT scan revealed a large thrombosed aneurysm of 65 x 60 x 170 mm, originating from the innominate trunk; there was no involvement of the origin of the right carotid and subclavian arteries (Figure , Figure ). The electrocardiogram revealed a previous inferior wall myocardial infarction with negative T-waves in the inferior leads (Figure ). Transthoracic echocardiography showed severe depressed left ventricular function [ejection fraction (EF): 35%] (Figure ). Coronary angiography revealed atherosclerotic coronary disease with chronic occlusion of the right proximal coronary artery (RCA), severe stenosis of the main of the diagonal artery, and severe stenosis of the circumflex artery. Myocardial viability study confirmed the presence of viable myocardium in the lateral wall and the anterior wall with non-viable myocardium of the inferior wall. A CT angiogram scan of the cerebral arteries showed a permeable Willis polygon.
The decision was made to perform a simultaneous operation of the IAA resection and coronary artery bypass grafting (CABG).
Under general anesthesia, peripheral femoral arterial cannulation was performed along with the catheterization of the left carotid artery; a median sternotomy extending into the right side of the neck along with the medial edge of the sternocleidomastoid muscle was performed. Cardiopulmonary bypass (CPB) circuitry was completed with cannulation of the superior and inferior vena cava, and the patient was cooled to 25 °C. The myocardial arrest was achieved by cold crystalloid cardioplegia. The fragile part of the ascending aorta was clamped and resected over the coronary ostia at the level of the sinotubular junction (Fig

[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 8-year-old boy with severe mirror movements and impaired fine motor skills of both hands was treated. The patient had no specific perinatal event. He was born at 39 weeks + 4 days of gestational age and with birth weight of 3.2 kg. There were no definite abnormal signs such as prolonged rupture of membranes, asphyxia, pneumothorax or heart problem. There was no family history of mirror movements or neurological abnormality. His parents informed us that he had no definite sign of abnormal development, such as asymmetry or hand dominance at an early age (< 18 months), and no significant developmental delay. However, they pointed out that the patient suffered from manipulative inabilities, such as the handling of chopsticks and the use of a pencil, due to severe mirror movements. The patient had not been tested or treated for congenital mirror movements by any rehabilitative occupational or physical therapist. The patient's parents provided informed consent for his participation in this study.
MRI was performed during the first visit to determine the presence of any specific brain lesion. A pediatric neuroradiologist found no evidence of abnormal signal intensity. In addition, a physical evaluation by a pediatric neurologist revealed no definite abnormal pattern, such as weakness, asymmetric tone, pathologic reflex, or spasticity, although it was noted that his fine motor coordination was clumsy. His developmental milestones for language, examined by a speech therapist, were within normal range in both receptive and expressive language skills. Cognitive evaluation using the Korean Kaufman Assessment Battery for Children by a clinical neuropsychologist revealed an intelligence quotient of 102, in the normal range[]. Mirror movements were evaluated using the Woods and Teuber grading scale[] by two pediatric neurologists blinded to experimental design. Involuntary mirror movements of one hand during grip-release by the other were graded using a 0–5 scale: 0 = no clear

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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 male presented for an urgent biopsy of a lesion of Corpus Callosum on a background of clinically diagnosed intra-operative anaphylaxis for the same procedure 4 days prior, which was abandoned. Symptoms of the initial presentation, which brought the patient under the care of the Neurosurgical team, included impaired ability to self-care and mild cognitive dysfunction. Surgical and Medical teams deemed the histo-pathological diagnosis essential due to the need for tailored subsequent medical management including potential urgent administration of chemotherapy and radiation.
The specialised allergy testing was not feasible due to the brief 4 day timeline proposed between the two procedures. Decision was made to proceed with surgery due to the urgent need for the identification of the nature of the lesion.
Both patient and the prior care episode were evaluated. Patient had a background of treated hypertension, with no other underlying illnesses. Prior to this, he had undergone uneventful surgical procedures and anaesthesia.
History, records of the procedure, and tests for mast cell mediators, were reviewed by the attending anaesthetist. During the first care episode patient was given a single dose of midazolam, followed by remifentanil and propofol total intravenous anaesthesia, rocuronium and cephazolin in quick succession. The laryngoscopic view was a Grade 3 Cormack and Lehane, with direct laryngoscopy utilising a Macintosh 4 Blade. CMAC® Blade 4 Videolaryngoscope demonstrated an equivalent Grade 3 Cormack and Lehane view. Following successful airway management, patient developed intractable hypotension, concomitant bronchospasm and was diagnosed with clinical anaphylactic episode. The patient was treated with an adrenaline infusion, procedure was abandoned and he was admitted with an endotracheal tube in situ to Intensive Care Unit where he recovered uneventfully. The patient re-presented 4 days later for a repeat procedure. Specific allergen testing w

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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:
Our case treats of a 79-years-old man who has electively undergone aortic valve and ascending aorta replacement for degenerative aortic disease using a number 25 Edwards Lifesciences porcine stentless bioprosthesis (Edwards, California, USA). He was readmitted 4 months later with fever, intermittently painful and pulsatile swelling over the upper third of the sternum that appeared over a period of 15 days and had gradually increased in size to attain its present size of 6 × 4 cm (Fig. ).
A preoperative TEE showed a pseudoaneurysm with high flow velocity inside, developed between the prosthesis and the posterior surface of the sternum.
Moderate hypothermic bypass was instituted with cannulation of right axillary artery for antegrade cerebral perfusion and femoral artery with Estech® cannula for aorta endoclamping and perfusion of lower body districts [] (Fig. ). The chest was opened through the previous scar reducing the CPB flows and obtaining digital control over the defect on the aorta. Subsequently a vent cannula has been placed in the right superior pulmonary vein to decompress the left side of the heart. The extrathoracic component of the pseudoaneurysm was opened and the clots evacuated. Adhesions over the right ventricle were taken down, and both pleura were opened. Clots in front of the aorta were evacuated to reveal one main defect at the previous aortotomy site measuring 2 × 2 cm (Fig. ). The bioprosthesis was explored through the defect and was found to be normal. The defect was closed using 3 × 3 cm polytetrafluoroethylene patch.
After deairing the patient was rewarmed and the heart picked up after single electric shock in sinus rhythm. The weaning from the bypass was easy.
The patient remained hemodynamically stable on minimal inotropic support and was extubated in second postoperative day without neurologic complications.
The cause of the pseudoaneurysm appeared to be an infection at the previous aortotomy site; the cultures taken from adjacent tissues

[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 79-year-old woman presented to the emergency department following an episode of syncope. She had undergone a total hysterectomy with adnexectomy and a Wells procedure for complete rectal prolapse 2 weeks before and had history of resting dyspnea in the previous week.
Upon examination she was hypotensive (85/49 mmHg), tachycardiac (110 bpm), and tachypneic (25 bpm). Oxygen saturation was 98% on room air. The electrocardiogram demonstrated sinus tachycardia with no other changes. Fluid therapy was promptly initiated and the patient rapidly became normotensive.
Urgent computed tomography angiography revealed bilateral PE () and dilatation of the right ventricle and suggested the presence of a long thrombus on the right atrium ().
Transthoracic echocardiography documented a big worm-like mass floating in the right atrium, protruding through the tricuspid valve into the right ventricle in diastole (see video 1 in Supplementary Material available online at ). Severe dilatation of the right heart chambers (right ventricle: 41 mm), significant tricuspid regurgitation, and moderate pulmonary hypertension (estimated pulmonary artery systolic pressure: 58 mmHg) were also documented (Figures and ).
Considering the high risk of hemorrhage with the recent surgery and the patient's clinical stability, conservative treatment was decided with no thrombolytic therapy or surgical embolectomy. Anticoagulation with intravenous unfractionated heparin was started immediately with a 5000 IU bolus, followed by an infusion of 18 IU/Kg targeting a therapeutic aPTT level between 46 and 70 seconds. At admission in the cardiac intensive care unit she presented mild dyspnea at rest with no other symptom and her blood pressure was stable (systolic BP > 100 mmHg).
The following day the patient's symptoms had improved, with no resting dyspnea, although the echocardiography assessment showed no improvements. On the third day the patient became completely asymptomatic. The echocardiographic evaluati

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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:
We report the case of a 75-year-old man with presumed history of high-grade urothelial cancer of the bladder, treated with transurethral resection and Bacille Calmette-Guérin (BCG) in 2004 by an outside urologist. The patient was followed up with regular cystoscopies and showed no evidence of recurrent disease. Then, six years after treatment of the bladder cancer, the patient presented with a partial small bowel obstruction and diffuse abdominal pain. Suspicious lesions within the stomach and duodenum were found on CAT scan at that time. Subsequent endoscopy showed an extensive, thickened lesion in the body and antrum of the stomach. Biopsy of this lesion was thought to be consistent with poorly differentiated gastric carcinoma. After receiving 6 cycles of neoadjuvant chemotherapy (epirubicin, oxaliplatin, capecitabine), the lesions responded well and the patient underwent a complete gastrectomy with jejunoesophageal anastomosis. Of note, peritoneal or hepatic metastatic disease were not detected on palpation during abdominal inspection. No evidence of malignancy was found on the gastric specimen removed at that time.
The patient was disease free on follow-up PET CT scans for approximately one year, at which time the patient began to have the flank pain, increased frequency, along with fatigue, weight loss, and diarrhea. Repeat PET CT scan at that time showed lesions in liver, peritoneal carcinomatosis, and right-sided hydronephrosis extending into the ureter down to the diffusely thickened bladder (). At this point, the patient was referred to our urology department and subsequently underwent cystoscopy to investigate the right hydronephrosis.
Grossly, cystoscopy revealed a diffusely thickened and erythematous bladder wall with bullous lesions throughout and extensive mucosal oozing. Other than these bullous lesions, there was no apparent bladder tumor. The right ureteral orifice was highly stenotic and was the likely cause of the hydronephrosis. Random biopsies o

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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 63-year-old woman presented to the emergency room with lower abdominal pain associated with nausea and vomiting for 3 days. She described the pain as dull, involving the right lower quadrant, non-radiating and constant. She also reported multiple episodes of non-bloody and nonbilious vomiting. Her prior medical problems included osteoarthritis requiring right-sided total knee replacement 5 years prior to this episode. She had been taking ibuprofen 400 mg for knee pain on as needed basis for the past 8 years. She had no family history of inflammatory bowel disease, colon cancer or any other GI-related disorder. She denied smoking, using alcohol and she reported no illicit drug use. She did not have any known drug allergies.
On initial examination in the emergency department, she was afebrile, hemodynamically stable and was not in any distress. Physical examination, including the abdominal examination, was unremarkable. Her laboratory investigations did not reveal any leukocytosis, but CRP was elevated to 55 mg/L. Computed tomography (CT) of the abdomen with intravenous contrast (Fig. ) showed focal mucosal thickening in the cecum which was highly suspicious for colonic malignancy. Subsequently, the patient underwent a colonoscopy which showed a frond-like/villous, infiltrative, ulcerated, large partially obstructing mass in the ascending colon in close proximity to the cecum (about 4 cm from the cecum) (Fig. ) and a large, ulcerated mass in the cecum. Biopsy samples were taken from both masses and pathology showed fragments of colonic mucosa with focal minimal hyperplastic changes, ulceration, mild acute and chronic inflammation and no malignancy. She was evaluated by both surgery and oncology and gastroenterology recommended to repeat colonoscopy with biopsy, but she refused and proceeded with right hemicolectomy, due to a suspicion of colonic malignancy in view of a colonic mass. Examination of the specimen after surgery showed an ascending colon mass measuring 3

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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 67-year-old male patient diagnosed with stage IV pulmonary adenocarcinoma was first treated with 6 cycles of carboplatin and pemetrexed followed by a maintenance regimen. Progression occurred within fourteen month after the start of the initial treatment. Consequently, second-line nivolumab was initiated at a dose of 3 mg/kg every two weeks.
After thirteen doses of nivolumab, the patient complained of irritated red eyes without visual impairment. He did not exhibit skin involvement, arthralgia or urinary tract or digestive symptoms. The conjunctiva swab test was negative, and no improvement was observed with antibiotic ocular drops. The ophthalmologist’s examination revealed bilateral sterile conjunctivitis with no signs of uveitis or retinal lesions (Fig. a). The patient was treated with topical steroids with partial improvement.
A few days later, he developed fatigue and progressive dysphagia which became severe after two months followed by rapid 10-kg weight loss without symptoms of associated colitis or gastritis. At that point, the main differential diagnosis was esophageal infection, tumor progression with gastrointestinal (GI) upper tract involvement, paraneoplastic syndrome [] or an atypical checkpoint inhibitor-related adverse event. Of note, the patient had no history of personal or familial autoimmune disease, conjunctivitis or upper digestive tract abnormality prior to nivolumab treatment. The oral examination initially revealed evidence for oral candidiasis, but treatment with a 7-day course of fluconazole did not improve dysphagia despite the resolution of the stomatitis. Bacterial culture of the oropharyngeal swab was negative, and PCR results for herpes simplex 1 and 2 infection were also negative. A blood sample revealed a discrete increase in the erythrocyte sedimentation rate (ESR) with no eosinophilia or leukocytosis. Liver and kidney function panel tests were normal. Thoracoabdominal CT scan reported no evidence of disease recurrence. Due to p

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

[User]
RADIOLOGY NOTE:
A 52-year-old man presented to the emergency department with LBP. The patient fell from approximately 2 m-container box to the ground 2 hours previously. He complained of no pain and no numbness in either leg. A neurological examination revealed grade 5/5 muscle strength and no sensory changes in the lower extremity. Normal rectal tone was present and there was no saddle anesthesia. Plain lateral radiography and computed tomography (CT) scan showed a burst fracture with spinous process fracture at L3 with more than 50% of the vertebral body height loss measured on Picture Archiving and Communication System (π-ViewSTAR, INFINITT Healthcare Co., Seoul, Korea) (). Spinal canal diameter was estimated at the level of the fracture on the axial CT image that traversing the level of the pedicle and was defined as the distance between the midsagittal border of the posteriorly dislocated bone fragment and the lamina. The normal size of the canal was estimated by the average midsagittal diameter of the levels adjacent to the fracture. Spinal canal diameter at the fractured level was 7.92 mm using this method and about 55% narrowing of the spinal canal was observed compared to the normal level (). Magnetic resonance imaging (MRI) revealed findings suspicious of injury in the supraspinous ligament (). Initially, we thought the patient had no neurological deficits, so internal fixation and posterior fusion without decompression of the thecal sac were planned under the impression of an unstable burst fracture.
He underwent pedicle screw fixation from L1 to L4 and posterior fusion the next day, with internal distraction to reduce the fragment away from the spinal canal. Motor strength and sense in his legs were intact postoperatively. Pain was tolerable 3 days postoperatively, and the patient began to ambulate without difficulty. The Foley catheter was removed. He did not feel the desire to urinate. He was able to expel only a few drops of urine by applying pressure

[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 56-yr-old woman was transferred to emergency room of our hospital because of suspected PTE on October fifth, 2010. When she arrived, mental state was clear and she complained dyspnea and chest discomfort. Initial systolic blood pressure (BP) was 90mmHg and heart rate was 116 bpm. Chest X-ray revealed no remarkable finding. Transthoracic echocardiography demonstrated decreased contractility of dilated right ventricle (RV) with D-shaped left ventricle on parasternal short axis view (). Also it showed a huge echogenic mass in dilated pulmonary trunk and a whip-like moving mass in right atrium (RA) (). The right atrial mass moved through tricuspid valve to right ventricle. Estimated pulmonary artery systolic pressure was about 70 mmHg. Computed tomography (CT) finding also showed heavy thrombus in main pulmonary artery which extended into lobar branches of pulmonary system and deep vein thrombosis of left external iliac vein ().We diagnosed PTE with huge thrombus on RA clinically. Because the patient had stable vital sign, we selected thrombolytic therapy with tissue plasminogen activator (t-PA) infusion (100 mg over 2 hr). After one hour from t-PA infusion, the patient suddenly became unconscious. Her peripheral oxygen saturation was 76%, systolic BP 50 mmHg, and heart rate decreased to 33 bpm. Shortly afterward, the patient arrested and we started cardiopulmonary resuscitation (CPR). During CPR, our team made a critical decision to apply percutaneous cardiopulmonary support (PCPS) system for hemodynamic stabilization before surgical embolectomy. PCPS was inserted via right femoral artery and left femoral vein under fluoroscopic guidance and local anesthesia. The Capiox (Terumo, Tokyo, Japan) emergent bypass system was used. Thereafter, hemodynamic state of patient was stabilized at the PCPS flow rate of 3-3.5 L/min. We revised our plan to continue thrombolytic therapy and anticoagulation with PCPS support in consideration of stable vital sign and high bleeding risk

[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 23-year-old gravida 1, para 0 patient visited the emergency department of our tertiary center because of high fever (up to 39.4°C) and chills with myalgia and headache for 1 day. At the initial visit, her vital signs were stable except for the fever, and her history was unremarkable. She strongly refused possibility of pregnancy, so was not done urine pregnancy test. Computed tomography revealed no focus for a fever, but a 4.5-cm cystic lesion was detected in the intrauterine cavity, suggesting early intrauterine pregnancy (). She was referred to our obstetrics department immediately.
She had a normal menstrual cycle with subsequent amenorrhea for 8 weeks. Transvaginal ultrasonography identified a gestational sac in the uterine cavity. The fetal crown-rump length was consistent with the gestational age of 8 weeks, 6 days. The fetal heart rate was 200 per minute. The fetus, uterus, and ovaries showed no gross abnormalities. The patient had no vaginal bleeding or abnormal discharge. A speculum examination showed a very small, salmon-colored patch on the surface of anterior lip of cervix.
Intravenous antibiotics was administered because of high fever, and her fever improved. Two days after the first obstetric examination, sudden vaginal bleeding developed and persisted without abdominal pain. We repeated the physical examination and found that the cervix was severely edematous and dark red in color, suggesting ischemic change, and bled easily on contact. The vaginal bleeding was not from the cervical os, but from an edematous cervical lip. Transvaginal color Doppler ultrasonography showed a dilated venous plexus with abundant blood flow in the uterine cervix, suggesting a cervical varix ().
Three days after the first episode of vaginal bleeding, no fetal heart sound was detected; hence, enhanced pelvic magnetic resonance imaging (MRI) was performed to verify the cervical varix and evaluate cervical varix status for treatment of a missed abortion. MRI revealed a diffu

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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 69-year-old woman with a history of hypertension was identified to have an incidental renal tumor on computed tomography (CT). She denied hematuria, lower urinary tract symptoms, pain, fever, fatigue, or weight loss. Her medical history was significant for hypertension and obstructive sleep apnea. Family history and social history were noncontributory. Physical exam at the time of presentation was normal.
On CT, the tumor was an exophytic, enhancing mass (3.0 × 2.0 × 3.5 cm), arising from the lower lateral pole of the left kidney with areas of low attenuation at its inferior aspect. The remainder of the urinary system was normal. No adenopathy or sign of metastasis was detected. An imaging obtained later the same year demonstrated no interval change in the size of the lesion. Biopsy was positive for an oncocytic neoplasm, which at the time was classified as an onocytoma. The patient was managed conservatively and presented 2 years later for repeat imaging.
A repeat CT was significant for an interval increase in the size of the mass from 3.5 to 5.6 cm in the greatest dimension. Tumor compressed the lower pole calyces without ureteral obstruction. There was no radiologic evidence of tumor calcification, fat, or infiltration into the adjacent tissues. Fine needle aspiration and the biopsies of the mass were again consistent with an oncocytic neoplasm.
Comparative radiologic images are provided (); the top images are radiographs with a smaller tumor from 2 years ago, while the bottom radiographs are from the patient's recent CT with a larger tumor. Given the unusual clinical features and behavior of the tumor, the patient was referred for a radical nephrectomy.
The specimen received at the pathology lab was composed of an intact kidney and perinephric adipose tissue (205g, 8.5 × 8.0 × 4.2 cm). At the midlower pole of the kidney, there was a circumscribed, cystic, and focally solid mass (6.0 ×

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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 4 month-old-male patient presenting weakness and decreased movement of the left lower extremity was transferred to our institute. He was born from an uneventful pregnancy and delivery. He was in good health until 1 month before the visit when his parents noticed weakness of left lower extremity. He received OPV with DTaP at local health center 1 month before presenting those symptoms. Making the diagnosis in this case was somewhat delayed because his parents hesitated to seek a proper medical help initially and took him to an orthopedics clinic where he was evaluated and treated under a misdiagnosis. His family history and past medical history of perinatal period were unremarkable.
His body weight was 8.1 kg, length 66 cm, and head circumference 41.2 cm and those growth indexes measurements continued to be in the 50-90th percentile at the time of this report (2 yr old). Vital signs were not remarkable. The physical examination revealed alert mental status, and cranial nerve function tests were all normal. Neurologic examination revealed markedly decreased spontaneous movement and flaccid paralysis on the left lower extremity (GI/V) with knee jerk (+/-), biceps tendon reflex (+/+), and ankle clonus (-/-). The response to painful stimuli on the left lower extremity was markedly reduced, but there was normal in other part of his body. He had no history of intramuscular injection or trauma on the left side buttock area. Laboratory evaluation, simple skeletal radiography, hip joint sonogram, and 3-phase bone scan were all within normal ranges. Brain and spinal MRI showed no abnormalities. Electrodiagnostic evaluations showed normal sensory nerve action potentials and low amplitudes in left tibial and deep peroneal nerve.
Up to the time of this presentation, he was able to sit alone at 10 months old and walk unaided (left side heel walking) at 16 months of age. His development quotients (by Korean developmental screening test) of gross motor, fine motor, personal-social

[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 4-year-old girl was referred to our institution with a mass and partial extrusion of a foreign body in the neck. Symptoms started 4 days ago with a redness and swelling on the right neck, followed by partial extrusion of a red, blunt foreign body. A computed tomography (CT) scan revealed a foreign body with prominent margins anterior to sternocleidomastoid and infrahyoid muscles, half being embedded in the skin and the other half being outside (). No fistula was found with the deeper tissues. The family remembered that the girl swallowed the plastic top piece of a knitting needle approximately one year ago. She had been asymptomatic until the present time.
Physical examination revealed a partially extruded red, plastic foreign body about 1 cm diameter in the right neck. The patient did not have fever. There was no any tenderness or pain in the affected region. The rest of the head and neck examination did not reveal any abnormalities. A blood sample examination revealed a normal white blood cell count (7,640/mm3) and a slightly elevated C-reactive protein level (2.2 mg/dL).
The patient was hospitalized after the initial examination and CT scan. An oral prophylactic antibiotic was administered (Clarithromycin 500 mg/day). The foreign body was held only with skin and subcutaneous fatty tissue. Also lateral neck X-rays and esophagography with barium swallow were obtained. Esophagography did not reveal any fistula tract between the foreign body and the upper aerodigestive tract. Direct laryngoscopy was performed under general anesthesia the next day. Larynx, cervical esophagus, and pyriform sinuses were found normal. The foreign body was removed easily (Figures and ). The foreign body had a rectangular shape, was made from hard plastic, and was 13 mm in length. The cavity was filled with granulation tissue. The examination did not reveal any pus or presence of a fistula tract with deeper tissues. Primary suturation was applied to

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


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

[User]
RADIOLOGY NOTE:
A 38 year-old man presented to the outpatient clinic of our centre with mild pain and redness in the right eye for the past two days. He also complained of gradually progressive decrease in vision in the right eye for the past one year. He had sustained a penetrating injury in the right eye six years ago, and had undergone surgical repair of the wound at another centre.
The vision in the right eye was hand movements with accurate projection of rays in all four quadrants. Apart from minimal circumcorneal congestion, there were no signs of ocular inflammation. An irregular scleral scar was noted at the superior limbus at twelve o’ clock position, extending about two millimeters posteriorly, with extension into the cornea just within the limbus. A cyst of the iris was seen in the superonasal quadrant, extending from twelve to two o’ clock position, associated with epithelial downgrowth and extensive peripheral anterior synechiae from ten to two o’ clock position (Fig. ). A total cataract obscured the view to the fundus. The intraocular pressure was normal and there was no relative afferent pupillary defect. The left eye was normal.
Ultrasound biomicroscopy of the right eye showed a thin-walled iris cyst with internal echolucency. There was no evidence of a foreign body (Fig. ). B scan ultrasonography of the right eye showed a clear vitreous with no evidence of a foreign body or retinal detachment. The patient underwent surgical excision of the iris cyst with cataract surgery under cover of topical corticosteroids. The cyst wall and peripheral anterior synechiae were separated from the corneal endothelium by gentle viscodissection. Posterior synechiae under the iris cyst were also released by viscodissection, aided by mechanical separation with the cannula used for injection of the viscoelastic agent. After conjunctival peritomy, a limbal incision was made from ten to two o’ clock position. The iris cyst was excised in toto, with excision of a one-

[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 premenopausal multiparous woman was admitted to our hospital's outpatient gynecology clinic with complaints of lower abdominal pain and abdominal distension for the last 6 months. On detailed anamnesis, the patient had noticed a mass in her abdomen for 3 months and a gradually increasing pain with easy tiredness. She had four previous vaginal deliveries with no abdominal surgical operation. Her medical history was remarkable for 10 years of type II diabetes and hypercholesterolemia and had no history for family member with genital malignancy. She had no complaints related with menstrual bleeding. On physical examination, her vital signs were normal and abdominal palpation revealed a distended abdomen with palpable hard, solid mass filling whole abdominal cavity which cannot be lateralized. No abdominal rebound or tenderness was observed. The speculum examination showed a normal uterine cervix and vagina but fornices were full on pelvic examination. Initially, a transvaginal ultrasound was applied and showed a large, solid, and complex mass in pelvic cavity which extended to subdiaphragmatic area and its origin could not be found. An MRI scan of abdomen showed that a large solid mass with somewhere in cystic and fatty content, approximately 33 × 17 × 25 cm in size, which could not be separated from uterus was noticed (Figures and ). No normal ovaries were detected.
Laboratory examinations for whole blood count, liver function tests, coagulation parameters, urea, creatinine, and serum electrolytes were in normal limits. Blood glucose, HgA1c level, and cholesterol levels were higher than normal limits. The serum level of cancer antigen-125 was detected to be high as 210 mIU/ml. So in the light of these clinical findings from ultrasound, MRI examinations and laboratory findings, we thought that leiomyosarcoma is the most likely diagnosis. We planned surgery for the patient and a midline xiphopubic vertical incision was made. At laparotomy, on inspection, a

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


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

[User]
RADIOLOGY NOTE:
Our patient, a 42-year-old, right hand dominated female was brought to the trauma center after a history of a fall from the first floor of a building. She presented with pain in the left arm and elbow. On examination, there was swelling and tenderness at the left mid-arm and left elbow and the neurovascular status was normal. Examination of the spine and lower limbs did not reveal any abnormality. A radiograph of the left upper extremity showed a transverse fracture of the mid-middle third-diaphyseal fracture of the humerus with a concomitant distal humerus fracture. A CT scan done for the elbow showed a comminuted fracture of the distal humerus (OTA/AO-13-C2) with a Type III capitellar fracture (Figure ). The arm was immobilized in a splint, and the patient was shifted to the ward.
Surgical technique
The rotation of the right arm was checked and recorded. The patient was positioned in a right lateral decubitus position following the administration of general anesthesia. The operative arm was placed at 90 degrees of forward elevation and internal rotation over a padded post such that the forearm could be flexed beyond 100 degrees. A 5 cm posterior incision was marked, starting 5 cm distal to the posterolateral acromion in line with the triceps. While approaching the olecranon, another incision starting 5 cm proximal to the tip of the olecranon was marked, curving around the olecranon over the medial aspect and ended up 5 cm distal to the tip of the olecranon over the subcutaneous border of the ulna. The incision was made along the marked line, and a full-thickness fasciocutaneous flap was developed (Figure ). Dissection was carried out between the middle and posterior bands of the deltoid muscle along the posterior deltoid raphe. Blunt dissection was carried out in between the two heads, and the radial nerve was located. The nerve was released from the proximal to the

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


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

[User]
RADIOLOGY NOTE:
A 69-year-old woman patient, under a routine, three times a week hemodialysis programme for 8 years, with a history of polycystic kidney disease accompanied by chronic renal failure (CRF) and chronic obstructive pulmonary disease (COPD), complained of a chest pain and dyspnea while being evaluated during one of her dialysis sessions. In the physical examination, her blood pressure (BP) in the right upper extremity was found to be 140/80 mmHg and heart rate 78/min, and heart and breath sounds were normal. Her electrocardiogram showed sinus rhythm. Cardiac enzymes observed for the purpose of excluding the diagnosis of acute coronary syndrome are found within the normal range. Echocardiographic evaluation showed left ventricular hypertrophy, dilatation in the right heart cavities, pulmonary hypertension, 2-3° tricuspid regurgitation, 1° aortic regurgitation, and minimal pericardial effusion. In BP measurements, while blood pressures in both upper extremities were found to be at the hypertension level (BP: 150/90 mmHg), the lower extremity pressures were found to be at low levels (BP: 110/70). Hence, spiral thorax CT angiography was applied to the patient, who was suspected to have aortic coarctation. It was seen in her report that the descending aorta was interrupted in a 1 cm segment starting from the subclavian arterial exit. It was observed that the distal of the descending aorta was being filled with internal mammarian and paravertebral collaterals (Figures and ). Coronary arteries were also evaluated in CT angiography, and no critic lesions were observed. The patient was diagnosed with interrupted aortic arch type A, and with the decision of a common meeting of cardiology and cardiovascular surgery, it was agreed to keep the patient under control with medical treatment (metoprolol 1 × 50 mg, ramipril 1 × 5 mg, and acetylsalicylic acid 1 × 100 mg). The patient, whose complaints have been considerably reduced, is still getting hemodialysis treatment in our center.

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


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

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

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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 male was referred to sarcoma clinic on 11/9/2017 with a painless swelling in his right forearm. He had a previous history of primary retro-peritoneal leiomyosarcoma surgery in 2011 with subsequent liver and lung metastases for which he underwent surgical resection in January 2017. His other past medical history included benign prostatic hypertrophy (controlled with medication), otherwise he was fully mobile, fit and well. This right-hand dominant male described a gradual 3-month history of increasing painless swelling to the volar aspect of the right forearm with full function of the arm and no neurological deficit. On clinical examination, there was a soft 5 × 4 cm swelling, 5 cm proximal to wrist crease in the volar compartment of the right forearm. The swelling was fixed, non-tender with no distal neurovascular deficit and or regional lymphadenopathy. Magnetic resonance imaging (MRI) of the right forearm demonstrated a 45 × 33 × 19 mm mass in the volar aspect in close relation to the median nerve (Fig. ). Ultrasound-guided needle core biopsy was consistent with LMS and the histology was similar to the previous LMS suggesting the possibility of metastatic LMS. Staging studies did not show any other metastatic deposits. Following multidisciplinary team discussion, he underwent planned marginal excision of the metastatic sarcoma with preservation of the median nerve. Histology confirmed LMS composed of spindle cells with eosinophilic cytoplasm with mild pleomorphism confined within the perimysium with no necrosis or vascular invasion (trojani grade 1). The patient recovered well post operatively with no neurological deficit only complicated with a mild episode of cellulitis to the wound site which fully resolved with a short course of oral antibiotics. One year after surgery, the patient has full function and use of his right hand and there is no evidence of LMS recurrence or further metastatic spread both clinically and radiologically on recent CT sca

[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.