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

[User]
RADIOLOGY NOTE:
A 73-year-old Chinese man was found a cervical mass for 1 month. He had a history of coronary heart disease for 2 years, but no relevant personal or family history of malignancy. Physical examination showed bilateral neck asymmetry, the trachea was deflected to the left, the carotid pulse was normal, approximately 6 × 5 cm solid masses were felt in the right lobe of the thyroid gland. The tumor mass border was unclear with smooth surface, and the tumor moved up and down with swallowing. The left lobe of the thyroid gland had no palpable mass and the neck had no palpable swollen lymph nodes. Accessory examination of neck color Doppler ultrasound at our hospital showed increase in size of the right lobe of the thyroid gland, which had abnormal shape. The upper right pole of the thyroid gland had an approximately 5.6 × 6.0 × 4.2 cm sized mass, with unclear margin, and multiple cystic nodules in the thyroid. The CT of thyroid showed increase in size of the right lobe of the thyroid gland, and an approximately 5.6 × 6.0 × 4.2 cm sized mass, the trachea was compressed and deflected to the left, the thyroid cartilage was compressed, deformed and reached the right subglottic region. The right thyroid lump had multiple calcifications, indicative of a tumor (Fig. ). Electronic laryngoscope examination showed ventricular bands thickening, the right ventricular bands compartment showed a rice-like projection, arytenoid region movement was poor (Fig. ). Thyroid function test was 5.07 mIU/L. The patient underwent subtotal thyroidectomy and excisional biopsy of neck mass under general anesthesia. Intraoperative findings indicated a hard mass in the thyroid gland area, the lateral border and the lower bound were closely related to the surrounding soft tissues, but there was an extremely close relationship between the medial border, the thyroid cartilage, and cricoid cartilage, with no gap between them. An ENT doctor was invited for intraoperative consultation, who suggested that so

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


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

[User]
RADIOLOGY NOTE:
A 50-year-old woman was referred by her dentist for the evaluation of mandibular swelling. The patient had osteoporosis treated with risedronate. Physical examination revealed swelling of the mandibular symphysis with chin deformation. The tumor did not seem to adhere to the skin but extended from the mandibular left first premolar to the mandibular right canine. The anterior buccal floor was deformed, and the inferior alveolar nerve was preserved. An excisional biopsy of the buccal mass was performed, confirming an initial diagnosis of chondrosarcoma. The histological plates were reinterpreted, leading to a final diagnosis of chondroblastic osteosarcoma. Cartilaginous tissue with chondroid matrix was observed in which chondrocytes with cytonuclear abnormalities were found (Figure ). Immunohistochemistry was not contributory, because it did not detect any IDH1 and IDH2 variants. Craniofacial computed tomography scan (Figure ) revealed a 32-mm-long axis lesion in the symphyseal region responsible for an osteolysis on both sides of the mandible. This scan did not reveal any suspicious lesions elsewhere. No suspected hypermetabolic focus or submandibular and cervical lymph node involvement was found in positron emission tomography imaging.
It was decided to implement neoadjuvant chemotherapy with doxorubicin 80 mg and cisplatin 140 mg over three cycles. Due to the lack of significant evolution in the tumor mass, an interrupted pelvi-mandibulectomy with bilateral lymph node dissection was performed along with reconstruction with a fibula free flap. The histological analysis after the tumor resection showed a lobulated architecture of the tumor, with pleomorphic cells associated with a predominantly cartilaginous matrix and a matrix in the form of thick immature bone areas (Figure ). The lymph nodes were free of malignant cells. The final diagnosis was conventional osteosarcoma with a chondroblastic predominance. The patient underwent 60-Gy adjuvant radiotherapy in 33 fr

[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 five-year-old typically developing female was referred by her primary care provider for evaluation of a rash reported to be sensitive to sunlight and had been reoccurring for the last 4 years. Cutaneous exam revealed fine scale on her trunk and extremities as well as small pink flat papules on lower left leg. She was diagnosed with ichthyosis vulgaris and provided with a treatment plan. She was subsequently referred to gastroenterology for decreased appetite. Two weeks later the child presented to the Emergency Department for right knee pain. Her mother reported her daughter had experienced bilateral lower extremity pain and had been limping. During the evaluation she was able to walk for the physician without reporting pain and no tenderness was reported with palpation. The mother reported her daughter was bitten by a tick about 1 year ago and that no workup or treatment was conducted. Radiographic scans of the right knee and leg showed no abnormalities. Laboratory testing for Lyme disease was conducted and found to be negative. She was discharged with the diagnosis of tenosynovitis. The child presented again to the Emergency Department the following week for left knee and ankle pain. She reported pain in her left calcaneus when asked to bear weight. Migratory arthralgia was noted and further laboratory testing, including a vitamin C level, was ordered. Her vitamin C level was found to be < 5 umol/L (reference range: 23 to 114 umol/L). Her prealbumin level was also low, 14 mg/dl (reference range: 17–36 mg/dl) as was both her ferritin 3.9 ng/ml (reference range: 6.2–137.0 ng/ml) and her iron saturation 15% (reference range: 20–55%). Both vitamin A and vitamin D were found to be within the normal reference range. With the diagnosis of the vitamin C deficiency, the child was started on ascorbic acid and referred to the feeding program.
The participant was the youngest of six

[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 60-year-old man was referred to the emergency department with a 2-day history of febrile sensation, nausea, and emesis. He also complained of occasional, tolerable, left-lower quadrant abdominal pain in the past three months. He had suffered from bacterial coxitis about 10 years ago and it was aggravated to severe ankylosis in both hip joints that had not been treated. His range of motion was only 20-30 degrees. He had no previous history of urinary tract stones. Plain film radiography showed an 18.1 mm calcification in the right ureteral course, an 18.5 mm calcification in the left ureteral course, and bilateral hip joint ankylosis (). The patient's initial serum creatinine level was 5.1 mg/dl and a nonenhanced computed tomography scan was checked to rule out other causes of obstructive nephropathy. The computed tomography scan revealed both ureteral stones to be in the area of both upper ureters with significant hydronephrosis (). Percutaneous nephrostomy tubes were inserted into the dilated pelvocaliceal system of both kidneys for the immediate relief of the obstructive nephropathy. After this intervention and adequate intravenous antibiotics, the patient's symptoms subsided and his serum creatinine level was normalized.
When the patient's condition became stable, we decided to perform elective surgical management to remove the bilateral ureteral stones rather than SWL because of the relatively large size of the stones. However, the patient could not be placed in the dorsal lithotomy or low lithotomy position to perform a retrograde ureteroscopy because of the severe hip joint ankylosis. In this situation, we decided to perform antegrade flexible ureteroscopy through a percutaneous trans-renal route to approach the ureteral stones. Before the start of the procedure, while the patient was under general anesthesia, the patient was placed in the prone position with appropriate padding and prepared and draped in a sterile fashion. A 0.035 inch guidewire was placed

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


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

[User]
RADIOLOGY NOTE:
A 55-year-old female patient reported to us in March 2009 with complaints of a slowly enlarging mass involving the lower jaw for the last 5 years. The swelling was asymptomatic. She was having difficulty in taking food with multiple malpositioned and mobile teeth. She had the history of a small swelling in the anterior region of the lower jaw that had been curetted 5 years back. Then she had noticed the slowly enlarging mass, which involved the whole of the lower jaw over time. On examination a firm multilobular mass was found with both buccal and lingual cortical expansion, more on the right side than the left side of mandible []. Intraoral examination showed diffuse swelling obliterating the buccal vestibule with multiple displaced and mobile teeth []. The overlying mucosa was normal and intact. No regional lymphadenopathy was found.
Radiographic study revealed an ill-defined, multilocular radiolucent lesion with massive cortical expansion and multiple displaced teeth (“floating teeth” appearance) [Figure and ]. Computerized tomography (CT) scan showed a large ill-defined homogenous mass measuring 124 × 77 mm involving the whole of the mandible and extending into the infratemporal fossa region, with no intracranial extension [].
On incisional biopsy, hematoxylin and eosin (H and E) stained sections revealed multiple islands of cartilage arranged in a lobular pattern, with cells that contained large, plump nuclei and were often binucleated or multinucleated. There was an increase in the number of cells, and each lacuna often contained two or more cells. Areas of hemorrhage and sheets of pleomorphic, hyperchromatic spindle cells were present [Figures and ]. A diagnosis of dedifferentiated CS was concluded.
Complete resection of the mandible was planned for the patient. Under general anesthesia, tracheostomy was done to prevent postoperative upper airway obstruction, and the tumor was exposed via apron incision over the bilateral submandibular region. Complete resect

[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 right-handed Caucasian man experienced an electrical burn after contact with a 440 volt line while working on a roof. Upon standing up from the squatted position, the right side of our patient’s head came into contact with an exposed wire, resulting in electrocution with a loss of consciousness. Witnesses called the emergency medical services, and our patient was intubated at the scene. He was transferred from a local community hospital to our institution’s burn unit for a higher level of care. Second and third degree burns covered 21% of his total body surface area. The entry wound was through his scalp, traversing through his neck and chest, into his groin, and exiting from his left foot. No spinal fractures were identified.
Initially, our patient was alert and able to move all four limbs. Over the ensuing days, he was observed to move his legs less than his arms. Two days after our patient received multiple skin grafts and a calvarial flap, sedation was held and he was noted to have absent limb movements during routine dressing changes. A neurological consultation was obtained on his 10th day of hospitalization because of his evolving weakness. On examination, our patient was intubated, and his head, chest, groin and bilateral lower extremities were covered by dressings. He was awake with eyes open, alert and able to follow simple commands. A cranial nerve examination revealed reactive pupils, intact extraocular movements and symmetrical facial movement to smile, eye closure and eyebrow elevation. Our patient indicated normal light touch sensation on his face with nodding. He was breathing over the ventilator and able to shrug his shoulders. A motor examination showed normal muscle bulk with flaccid tone and only intermittent, trace movement in his left fingers. Our patient acknowledged pain with nodding on light pressure to all limbs. His deep tendon reflexes were diminished and plantar responses were equivocal.
On admission, magnetic resonance ima

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


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

[User]
RADIOLOGY NOTE:
We report the case of a 69-year-old male with a past medical history of hypertension, coronary artery disease, ischemic cardiomyopathy, noninsulin dependent type 2 diabetes mellitus, and alcohol dependence who presented to our institution in cardiac arrest and underwent emergent cardiac catheterization. During admission, laboratory results were notable for anemia with a hemoglobin of 4.6 g/dL, compared to a baseline hemoglobin of 14.2 g/dL approximately four years prior, with mean corpuscular volume of 65 fL. Further workup revealed iron levels of less than 10 μg/dL and ferritin of 3.3 ng/mL, confirming a diagnosis of iron deficiency anemia. CT of the chest, abdomen, and pelvis with intravenous contrast was performed to evaluate for occult malignancy.
While chest CT did not show any findings of intrathoracic malignancy, abdomen and pelvis CT showed a 2.4 × 3.2 cm soft tissue mass at the tip of the appendix () as well as a 5.3 × 2.5 cm lobular perirectal mass () which were concerning for a malignancy. There were also borderline enlarged perirectal and pelvic lymph nodes. MRI of the pelvis was also performed again demonstrating an infiltrative rectal soft tissue mass which was nonspecific ().
A colonoscopy was performed with a normal appearing appendiceal orifice and normal rectal mucosa without any masses identified. The patient also underwent a flexible sigmoidoscopy with endoscopic ultrasound evaluation of the rectum. No rectal mass was seen on endoscopic ultrasound, and only small, benign appearing perirectal lymph nodes were identified and therefore, no biopsies were obtained.
Carcinoid tumor was in the differential in addition to malignancy. However, serologic studies showed normal gastrin (39 pg/mL), chromogranin A (2 nmol/L), and serotonin (86 ng/mL) levels. Given the presence of concurrent appendiceal and rectal masses, tissue sampling was further pursued for treatment planning. Three 18-gauge () core needle biopsies of the appendiceal mass were obtained and

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


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

[User]
RADIOLOGY NOTE:
A 54-year-old Caucasian female proceeded to our institution with epigastric pain, nausea and vomiting along with pain located around the lumbar area lasting for one week. No previous surgical history or commorbidities existed. Clinical examination did not reveal any palpable abdominal masses or abdominal tenderness and the patient’s vital signs were within the normal spectrum. Blood test detected hypercalcemia (serum calcium: 10.2 mg/dL) and parathyroid hormone level of 111.8 pg/mL. All the findings in conjunction with the clinical presentation lead to the assumption that the patient had primary hyperparathyroidism (PHPT).
Then, an ultrasound was performed but it was negative for any thyroid or parathyroid abnormalities. Subsequently, the thoracic and abdominal CT revealed a soft tissue in the anterior mediastinum 7 × 1 cm. Additional Tc-99m-MIBI scintigraphy followed, which detected an ectopic adenoma located in the lower anterior mediastinum, on the left of the median line (). Following these, a mid-sternal thoracotomy was finally scheduled.
During the operation, after the thoracotomy, surgeons attempted to detect deep into the mediastinum the parathyroid adenoma according to the preoparative localization. Indeed, the mediastinal mass was detected on the left of the median line, at the anterior mediastinum, in front of the anterior surface of the pericardium and close to the left pericardiophrenic vessels and the left phrenic nerve (). The adenoma was covered by a thin fibrous capsule. When surgeons removed the capsule, a dark red mass of 7 × 2.8 × 1 cm was finally revealed (). The detailful preoperative localization of the present mediastinal adenoma which was in close relation with various anatomical structures of the thorax, reduced effectively the difficulty of the mass excision and the potentiality of accidental surgical injuries which may lead to thoracic bleeding and subsequent obstructive symptoms.
Then, the operation continued in the usual fashion and a d

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


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

[User]
RADIOLOGY NOTE:
A healthy 35-year-old woman, gravida 3 para 1, was referred to our unit at 21 weeks and 5 days' gestation because of CMS. The course of the pregnancy had been uneventful until 16 weeks with no history of amniocentesis or abdominal trauma. The patient had two previous pregnancies. The first pregnancy had been uneventful, resulting in a caesarean delivery at term. The second pregnancy was terminated by dilatation and curettage because of a missed abortion at 8 weeks'
gestation.
An ultrasound examination revealed a single living fetus with an estimated weight of 419 g. However, the amniotic membrane appeared to be in a completely separated state from the chorion except the site where the umbilical cord was inserted into the placenta. The amount of amniotic fluid was decreased overall in the amniotic cavity, while the echogenicity of the amniotic fluid was increased. In contrast, the fluid between the separated amnion and chorion had low echogenicity (). We tried to perform a targeted ultrasound examination for fetal anomaly; however, it was difficult to scan the fetal structure in detail due to oligohydramnios.
After obtaining the patient's consent, we removed 20 mL of amniotic fluid for chromosome analysis and cytology and then slowly infused 230 mL of warm saline and 40 mg of Indigocarmine (United Pharm, Seoul, Korea) into the amniotic cavity with a 22-gauge spinal needle. After infusion, we could confirm the fetus had no evidence of fetal anomaly, including in its urinary system. About ten minutes later, the amniotic fluid in the amniotic cavity started to decrease to the previous size. In contrast, the space between the chorion and the amnion had enlarged. After removal of 200 mL of amniotic fluid from the space, we completed the procedure. There was no evidence of leakage of amniotic fluid into the vagina. Based on this outcome, our diagnosis was CMS with amniotic membrane rupture. Chromosome analysis revealed 46XX and cytology showed there was no no white blood c

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


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

[User]
RADIOLOGY NOTE:
A 19-year-old girl presented with complaints of three episodes which mimic seizures during sleep over the past 3 months, first episode was characterized by loss of consciousness, tonic-clonic movements of both upper and lower limb, upward rolling of eyeballs, and tongue bite with postictal confusion lasting for 10 minutes, and the subsequent episodes were characterized by tonic-clonic movements of both upper and lower limbs and chanting “om namashivaya,” followed by unresponsiveness lasting for 10 to 15 minutes. Patient would sleep after these episodes and did not have any memories of those episodes. Then, one morning while sleeping she developed myoclonic jerks and screamed out of her bed with acute confusion, psychomotor agitation, and irrelevant talk which lasted for three days and was then brought to psychiatry OPD. There was no history suggestive of fever, headache, vomiting, and focal neurological deficits during this period. Physical examination was unremarkable. On examination, patient was restless, disoriented, producing abnormal clicking sound, and not obeying verbal commands. Patient was admitted to psychiatric ward for diagnostic clarification and further management. Patient was started on oral benzodiazepines and her behaviour was closely monitored. Her sleep and communication remained poor and she required assistance for maintaining her personal hygiene. Routine lab examinations were within normal limits. Her EEG recording showed normal study, and ultrasound abdomen and MRI brain plain and contrast were reported to be normal. Over the next couple of days, she was noticed to be pacing around aimlessly and started exhibiting abnormal behaviours such as dancing and crawling like snake. These behaviours varied over the days and she developed posturing, echopraxia, echolalia, and ambivalence subsequently. For these symptoms patient was started on injectable lorazepam 6 mg per day in three divided doses. Since patient's status remained the same after few day

[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 with a right cervical mass. She had undergone a subtotal thyroidectomy in 1986 for multinodular goiter, and the results of the histopathological studies revealed no malignancy. Twenty-four years after surgery, the patient complained about mass, pain, and swallowing difficulty. The only biochemical remaining sequela was subclinical hypothyroidism. Imaging studies that were performed (ultrasound——and CT scan—) revealed an enlarged right thyroid lobe and a right paratracheal mass displacing (but not invading) the carotid artery, the esophagus, and the trachea. A fine needle aspiration cytology (FNAC) was performed but no conclusion could be given according to the cytology found.
Surgery was performed, finding a thyroid gland strongly adhered to the carotid sheath and invading the posterolateral side of the esophagus. The recurrent laryngeal nerve was identified and respected. During the surgery, the patient suffered from bradycardia secondary to carotid manipulation, being reverted with atropine.
The first postoperative day, the physical exploration revealed right ptosis and miosis, being diagnosed with Horner's syndrome. Hematoma and seroma were ruled out as a cause after a careful exploration, and HSd was attributed to damage to the communication between the cervical sympathetic chain and the recurrent laryngeal nerve, associated to palsy of the right vocal cord (). Final histopathological analysis revealed poorly differentiated insular carcinoma of the thyroid, an infrequent finding usually related to a low survival rate (overall five-year survival rate near 20%). The patient was discharged from the hospital and followed a radioactive iodine protocol, without further complications during the followup. To this date (twenty-four months after surgery), she has not complained from additional cervical masses suggestive of recurrence, although the formerly described ptosis and miosis still remain. A stroboscopy has been performed and shows a

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


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

[User]
RADIOLOGY NOTE:
A previously healthy 45 year old Caucasian woman had a magnetic resonance scan for persistent mild hearing loss in her right ear. The cause for the hearing loss was not identified but the magnetic resonance imaging demonstrated multiple small parotid masses: a 9 mm diameter peripherally enhancing/T2 hyperintense lesion in anterolateral aspect of right parotid gland, a few additional smaller T1 hypointense nonenhancing lesions in right parotid gland and additional lesions in the superficial and deep lobes of the left parotid gland (Figure ). Fine needle aspiration biopsies revealed a mildly hypercellular collection of epithelial cells with oncocytic differentiation and associated lymphoid aggregates; the interpretation was: suspicious for oncocytic neoplasm, favor Warthin tumor. The differential diagnosis included the spectrum of oncocytic proliferations which includes Warthin tumors, nodular oncocytic hyperplasia (nodular oncocytosis), and multiple oncocytomas of the parotid glands. The presence of lymphoid aggregates favors the diagnosis of Warthin tumors. The histologic diagnosis could not be further refined based upon the tissues obtained. Given the FNA findings and the distribution of the lesions, the plan is for observation of the parotid nodules until bothersome (size, cosmesis) and the treatment will require surgery addressing both the superficial and deep lobes of the parotid gland given the diffuse distribution of the nodules. She reported no prior history of tumors but had had several “moles” removed from her face for cosmetic reasons which were labeled only as “benign”. There was no history of spontaneous pneumothorax.
The family history was notable for maternal grandfather with prostate cancer, maternal grandmother with a bladder cancer diagnosed in her 40s and a lung cancer diagnosed in her 50s (she had smoked). A maternal uncle had a throat cancer and died at 58. The paternal family history was negative for neoplasms. Her three siblings and two childre

[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:
Three years before initial presentation, a 19 year-old female experienced the first of seven spontaneous pneumothorax events. By that time, three first trimester miscarriages had occurred (etiology unknown) and she had already undergone an uncomplicated term vaginal delivery of a healthy male infant. The patient did not use alcohol but had a four pack-year smoking history; she had stopped smoking 10d before her first pneumothorax. In the sixth week of her fifth pregnancy, she "felt sharp right-sided chest pain" radiating posteriorly accompanied by right arm paraesthesia and dyspnea. This developed while driving her car home. There was no history of trauma, coughing or sneezing episodes. She was brought to the emergency room where she was admitted with the diagnosis of right pneumothorax and a chest tube was placed. Good re-expansion was noted on chest x-ray and the patient was discharged home 2d later.
Approximately two weeks later, a second pneumothorax occurred, this time following a prolonged "vomiting spell" secondary to hyperemesis of pregnancy. Evaluation in the emergency room identified a recurrent right pneumothorax. The patient's pulmonary symptoms were less pronounced and it was not considered large enough on chest x-ray to warrant treatment with a chest tube.
A third small right pneumothorax developed at the 10th gestational week that responded well to conservative management and, again, no chest tube was required.
However at ~19 weeks' gestation, the patient sustained a fourth pneumothorax with symptoms similar to that of the first. Chest x-ray revealed approximately 50% collapse of the right lung; she agreed to referral for definitive surgical management. Thoracoscopic excision of right apical lung blebs and mechanical pleurodesis proceeded without complication. The remainder of pregnancy was unremarkable and she was delivered (vaginally) of a viable female infant at term. Of note, the infant was diagnosed with postaxial polydactyly of both hands and on

[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 52-year-old Korean female visited Seoul Veterans Hospital with a complaint of acute pain and gingival swelling on the right mandibular molar region. The patient was systemically healthy and her physical examination showed no significant abnormality. Intraoral examination revealed completely edentulous state. The overlying gingiva of the right mandibular area showed swelling and inflammation clinically. On palpation, bilateral buccal bony expansion was noted on the posterior mandible and maxilla (). She had a complete denture, however her denture was out of use due to the gingival swelling and pain.
Panoramic radiograph showed diffuse, lobular, and irregularly shaped radiopacities or cotton-wool appearance throughout the alveolar process of both quadrants of the maxilla and mandible. Multiple sclerotic masses with radiolucent borders were found in the maxilla and mandible, confined within the alveoli at the level corresponding to the roots of the teeth, above the inferior alveolar canal (). Cone beam computed tomography (CBCT) (KaVo 3D eXam, KaVo, Biberach, Germany) images also revealed large radiopaque shadow extending into the mandible and maxilla. The bucco-lingual aspects of the lesions could be visualized on the CBCT images, which demonstrated the relationship of the bony lesions to the cortical plates in the bucco-lingual dimension. High density masses were surrounded by a low density layer. The superior border of the mandibular canal was intact (). Some lesions appeared larger and connected with the buccal and lingual cortical plates. On the parasagittal reformatted images at this level, bucco-lingual cortical expansion was observed (). The radiographic appearance varied from radiolucent to mixed lesions or rather radiopaque masses.
Under local anesthesia, incision and surgical curettage was performed on the right mandibular posterior area. Irregular bony defects and inflammatory fibrous tissue were seen in the operation field.
After curettage, the swelling

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


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

[User]
RADIOLOGY NOTE:
A 54-year-old woman with history of migraines presented to ER with worst headaches of life for the past few days. Although she had a history of migraines, this headache differed from her usual migraines. In the ER subarachnoid hemorrhage (SAH) was suspected and a noncontrast head CT was done which was negative for any hemorrhage. As she continued to have severe headache, a lumbar puncture (LP) was done which was negative for xanthochromia, and thus SAH was ruled out. She was sent home with recommendation for over-the-counter analgesics. Following discharge patient continued to experience worsening of headaches associated with nausea, and vomiting. Three days later she presented to the emergency department (ED) with worsening headaches, nausea and hiccups preceding vomiting. Two days later MRI of the brain was done which revealed subdural fluid collections over the bilateral convexities and SAH in the parietal and occipital lobes. There were prominent cortical veins but no obvious CVT. At this point the etiology of the headache was unclear as the head CT during the initial ED visit was negative for any subdural or SAH. Because of venous engorgement, a cerebral venogram was done and was negative for venous sinus thrombosis. A four-vessel angiogram was performed to investigate the cause of SAH which revealed a 1.8 × 1.6 mm right ophthalmic artery aneurysm (). Rupture of this ophthalmic artery aneurysm was presumed to be the cause of SAH and headaches. It was stented and coiled. However, the patient showed no improvement in symptoms over the next few days and a repeat magnetic resonance venogram (MRV) was done which revealed a cortical vein thrombosis on the left side with extension into the superior sagittal sinus. CVT was treated with anticoagulation therapy. The patient's headache, nausea, and vomiting continued. A repeat careful history revealed that she was comfortable lying down and headaches escalated upon standing. These headaches were different from usual migra

[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, a case of carcinoma right buccal mucosa, underwent excision and adjuvant radiotherapy in 2009. The patient was disease-free from 2010 to 2017. Disease recurred in the form of a nonhealing ulcer at the operated site. The patient underwent resurgery in July 2017, with excision and pectoralis major myocutaneous flap reconstruction. Postsurgery radiotherapy was given to face and neck and treatment was completed in October 2017. The patient was disease-free and was referred to pain clinic with complaints of pain on the right side of the face and right upper chest with an NRS of 6/10.
Pain may have been due to localized fibrosis and inflammation due to radiotherapy; also postsurgical tissue and nerve damage may have contributed to the pain. Keeping these two causes of pain in mind, the patient was started on flexon and gabapentin 300 mg. Tramadol 50 mg was added on the first follow-up visit after 1 week as there was no relief in pain. In view of the stable disease state, we decided to start scrambler therapy to avoid escalation of opioids.
Details of scrambler therapy are summarized in , and electrode placement around the area of pain is depicted in .
Scrambler machine (MC5-A Calmare®) produces 16 different electrical currents. Surface electrodes transmitting the impulses are placed on the area surrounding the pain. The electrical current and voltage delivered correspond to the setting of 10–70 on the dial of the machine representing the lowest and the highest current and voltage.
This intensity of voltage and current is altered on the dial by the operator till the pain sensation is replaced by a pleasant vibrating sensation. Classically, this therapy is given for 10 sessions on successive days, each session of 30–45 min. The expected duration of pain relief may be weeks to months after 10 sessions and booster sessions may be given if there is a relapse of pain.
Scramb

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


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

[User]
RADIOLOGY NOTE:
A 25-year-old female with a known diagnosis of epilepsy presented to the emergency department with complaints of fever, anorexia, and uncontrolled convulsions for the last one month. The convulsions were generalized, tonic-clonic, and were associated with tongue biting, fecal and urinary incontinence as well as postictal confusion. The seizures lasted for about ten minutes. They were recurrent with episodes occurring on a monthly basis. The fever was of gradual onset, high grade, intermittent in pattern, relieved temporarily by medications and cold sponging. There were no associated rigors or chills. She was reported to be having poor appetite and sleep. She had a history of multiple previous admissions in different hospitals for the management of her seizures. However, no brain imaging had previously been done. Her past medical history was significant for delayed motor, language, and cognitive functions. She was bedridden and needed nursing care since childhood. She had a skin lesion on her face since her birth. There was no significant past surgical history. She was on anti-epileptic medications, but there was no available record.
On inspection, a young female of average height and build was lying in a drowsy state. She had a dark, pigmented skin lesion on the midline of her face. The lesion was dark brown in color, extending from the submental region to the lower lip and then extending from her nasal bridge to her forehead in the same midline plane (Figure ).
The lesion was greasy on touch. She was pale and dehydrated. Her temperature was 102o F, pulse was 106 bpm, and her BP was 90/60mm Hg. Her right eye showed many raised dark pigmented lesions on the temporal sides of the optic discs. Both the corneas were hazy in the periphery. She had poor oral hygiene with shallow oral ulcers. Her neurologic examination showed a GCS of 6/15. Her neck was supple with no signs of meningeal irritation. Her pupils were reactive to light.

[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:
Case 1 was a 63-year-old man who presented with a 4-month history of productive cough and started to deteriorate after having a fever for a week. The patient had an 8-year history of cigarette smoking, and his father had been diagnosed with lung cancer. Repeated antibiotic treatment had been used since he started coughing, which produced a small amount of yellow sputum, and on January 6, 2018, he was diagnosed with community-acquired pneumonia. Unfortunately, his condition did not improve, and he gradually developed persistent right chest pain and shortness of breath after activity. He was admitted to our hospital on March 19th, and chest computed tomography (CT) showed an irregular solid nodule in the anterior segment of the upper lobe of the right lung and lamellar density shadows in the lower lobe of the right lung ( and ). A bronchoscopic examination showed that the bronchi were unobstructed, slightly congested and had a mild amount of purulent exudate. A transbronchial lung biopsy (TBLB) was performed in the posterior basal segment and dorsal segment. Galactomannan (GM) of bronchoalveolar lavage fluid (BALF) was 1.068. No fungus, interstitial fibroblastic proliferation, incrassation or fibrosis was seen in the lung tissue biopsy, but acid-fast staining and PAS negativity suggested organizing pneumonia; the patient was then diagnosed with organizing pneumonia. The patient was started on prednisone 30 mg orally once a day on March 27, and he was discharged after his symptoms of cough, chest pain and shortness of breath had gradually improved. He took prednisone as prescribed after discharge. However, his condition worsened with a fever that developed on May 8, and he was admitted to the hospital on May 15. On examination, his body temperature was 39.6°C, and his superficial lymph nodes were not swollen. A small moist rale was detected in the lower right lung. Routine blood tests revealed a leukocyte count of 15.85×

[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 28-year-old female [para 2, living 2 (P2 L2)], had undergone an elective cesarean one month prior to her presentation in view of a previous cesarean section. The surgery had been uneventful, and she had been discharged on the sixth postoperative day. She came to the OPD after seven days with the complaint of bleeding per vaginum with a history of the passage of clots. On examination, bleeding was found to be more than average. The patient was medically managed, and the subsequent ultrasonography returned normal findings.
After transfusing one unit of blood and giving antibiotic coverage, the patient was discharged with bleeding per vaginum within the normal limit. The patient presented to the OPD again after 10 days with the same complaints. On PV examination, bleeding was still present. Intrauterine packing was done and kept for 24 hours. Packing was removed after 24 hours, and she was kept under observation for the next 48 hours with no bleeding PV. Again, after 10 days, the patient returned with the same complaint with ultrasound suggestive of a focal hypogenic mass devoid of any vascularity extending from endometrium to subserosa on the left side. The patient was referred to our center and the decision was taken to manage the case laparoscopically.
Intraoperative findings were as follows: bladder was found adhered to the anterior uterine wall, which was dissected down. A Hematoma was present at the right end of the cesarean scar, extending up to the broad ligament. Cesarean scar sutures had given away. Active bleeding was present from the right angle of the scar.
Retroperitoneal dissection was performed, and bilateral internal iliac arteries were ligated. The cesarean scar site was exposed, and older suture material was removed. Complete scar site was restored with Vicryl No. 1 after taking both angles separately. Hemostasis was confirmed. The patient had an uneventful recovery and was discharged on the day after surgery. Ultrasound performed at eight weeks po

[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 23-year-old male was feeding his horse, and while stroking the horse's hair, the animal chewed the fourth finger of his left hand causing violent pain and total functional impotence of the finger. Both the patient and the horse were up to date on their required vaccinations at the time of the incident. The patient was transferred to an emergency department and was admitted six hours after the incident. He was conscious, in good general condition, and apyretic. An examination revealed a crush injury of the fourth finger with tendons and bone exposed ().
Copious irrigation with normal saline (2 liters) at the injury site was performed along with injection of 0.5 ml tetanus toxoid and 500 IU of human tetanus immunoglobulin. Postexposure rabies prophylaxis (rabies immune globulin human 20 IU/kg) with the first-dose rabies vaccine was injected into the depth of the wound as well as around the wound. The remaining rabies immune globulin was injected into the deltoid muscle. The patient was also treated with prophylactic antibiotic therapy with intravenous amoxicillin-clavulanate, gentamicin, and metronidazole.
After this initial treatment, radiography revealed a fracture dislocation of the proximal interphalangeal joint of the fourth finger with a third fragment (), prompting the patient to undergo surgery. Surgical exploration under locoregional anesthesia found that the ulnar digital pedicle was sectioned and thrombosed, the radial digital pedicle was intact, the flexor and extensor tendons were sectioned and shredded, and the skin was irreparably shredded ().
Surgical procedures included removal of foreign bodies and excisional debridement of devitalized tissue, collection of bacteriological samples, copious irrigation with saline serum (3 liters), tendon striping, and finger amputation with coverage of the bone by the radial digital flap using separate stitches (). The surgery was followed by careful clinical and biological monitoring.
A clinical assessment of the p

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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 70-year-old female with no significant past medical history, Eastern Cooperative Oncology Group performance status 0 and no prior incidence of hypersensitivity reactions, was incidentally found to have a small nodule in the proximal right posterolateral vaginal wall after presenting with post-menopausal bleeding. Subsequent biopsy demonstrated a 9 mm invasive melanoma and the patient underwent wide local excision with confirmed negative margins. 4 months later, she developed a right periclitoral mass. Positron emission tomography/CT scan at that time demonstrated focal uptake in this area but no regional/distant metastases (). Excision demonstrated a large submucosal mass of atypical epithelioid cells with evidence of melanin synthesis, consistent with malignant melanoma. Breslow depth was 9 mm (3 mitoses/mm2) with a positive deep margin, and there was no evidence of lymphatic invasion. Her case was presented at a multidisciplinary tumour board and either additional surgery or radiation therapy was recommended to the patient. Owing to the significant morbidity anticipated with additional surgery, the patient opted for radiation therapy. Given the high risk of both local and regional/distant failure, concurrent chemotherapy was proposed. Owing to the historically poor response rates with standard chemotherapy, an immune pathway targeted agent was considered. This non-standard approach was actually initially proposed by the patient. After being thoroughly explained the current standard of care, in addition to the pros and cons of pursuing concurrent radiation and immunotherapy, the patient chose to proceed with combination immunotherapy and radiation treatment. Several studies have demonstrated that local radiotherapy primes and/or enhances an immune response through cytotoxic T lymphocytes. Concurrent immunotherapy may then further enhance the activity and/or duration of the downstream immune response. Given the historically low efficacy of our current treatment pa

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


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

[User]
RADIOLOGY NOTE:
A 30-year-old male presented to the outpatient department with the chief complaint of intractable hiccups for four months. There was a history of intermittent pain in the epigastrium for four months which was dull in nature and non-radiating. The patient had no history of nausea, vomiting, or loose stools. There was no history of jaundice. There was no history of fever. The patient had history of chronic alcohol abuse with the last intake six months back with a CAGE score (Cut down, Annoyed, Guilty, and Eye-opener) of two out of four. He was admitted two months back when he was diagnosed as a case of chronic pancreatitis on the basis of a CT scan and a gastroscopy was done which did not show any significant finding followed by an endoscopic retrograde cholangiopancreatography (ERCP) procedure revealing biliary stricture which was treated by a prosthesis placement. The patient had no history of hypertension, diabetes mellitus, or any other chronic illness in the past. On general examination, the patient's pulse was 98 beats per minute, regular in rhythm, blood pressure was 110/70 mmHg in right arm supine position, pallor was present, and spo2 was 98 percent on room air with a respiratory rate of 24 breaths/minute.
On systemic examination the patient had tenderness in the epigastrium, the heart sounds were normal, the chest was bilaterally clear, and the patient was conscious and oriented. Lab investigations revealed a normal electrolyte panel with normal liver and renal function tests. Serum amylase was 42 units/L and serum lipase was 46 units/L. A contrast-enhanced CT scan of the abdomen was carried out which was suggestive of chronic pancreatitis with pseudocyst of pancreas involving the tail of the pancreas (Figure ).
The patient was initially started on metoclopramide; however, he did not respond well and was then started on tablet gabapentin 100 mg BD with which there was a dramatic improvement 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:
The 54 year old Caucasian woman, who came to our clinic for the first time in September 2006, complained of pain, loss of function and weakness in her right shoulder. She had suffered from these symptoms for years. Conservative treatment by analgesics and physiotherapy showed little or no benefit. Her main reason for coming to our hospital was an increasing loss of function of her right shoulder. In addition she reported several unexplained falls but no feeling of waddling gait and hypotonia. She had osteoporotic vertebral compression fractures at thoracic level 5 and 6. The corresponding thoracic gibbus was compensated by hyperlordosis of the lumbar spine. After a traffic accident in 2004, she was treated conservatively for a fracture of the right scapula and the sternum. She sometimes felt dysaesthesia in both hands. She casually referred to progressive muscle atrophy in both shoulders and upper arms, which other doctors had assigned to previous trauma and inactivity. The familiar anamnesis of her two sons was negative, without signs of neurological or systemic diseases. There was no intellectual impairment or facial weakness.
The patient's clinical examination showed no signs of cardiac or pulmonary impairment. There was a frozen right shoulder, a pronounced isolated limb-muscle atrophy of the delta- und biceps-muscle on both sides and a rotator cuff tear of the supraspinatus and infraspinatus muscle on the right side , and . There were no signs of muscle impairment in the hip or thigh. The clinical neurological examination revealed a normal result. Walking analysis showed no waddling gait.
In view of the pronounced muscle atrophy of both shoulders, that was progressive over years, despite physiotherapy, a myopathy was suspected although it seemed unlikely in a middle-aged patient.
Contrary to the expected high increase of the level of serum creatinkinasis, the level of serum creatinkinasis was only slightly above normal (186 U/l). The exact pattern [] of muscle

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


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

[User]
RADIOLOGY NOTE:
A 36-year-old woman at 19+4 weeks of gestation was referred to Xinjiang Medical University affiliated First Hospital for abnormal thyroid function in August 2017. She was tested for thyroid function a week ago because of excessive sweating. There was no history of fatiguability, weakness, proptosis or diplopia, palpitations, unusual bowel habits, or recent changes in weight. Upon physical examination: height 152 cm, body weight 60 kg, normal development, moderate skin temperature and elasticity, negative eye symptoms; a diffuse goiter with several small nodules, no tenderness, tremor or vascular murmur; heart rate 88 beats/min, no arrhythmia; no hands shaking or edema in lower extremities. Laboratory findings: thyroid function is listed in Table . Thyroid ultrasound showed a normal thyroid gland with some nonspecific nodules. The patient refused to undergo magnetic resonance imaging of the pituitary. The results of complete blood count, routine urinalysis, blood glucose, and renal function were all within normal ranges. She had no family history of thyroid disease. Past history showed that the patient had been diagnosed with hyperthyroidism for 2 years. Two years ago, she visited the hospital for lower abdominal pain and was diagnosed with hyperthyroidism after related inspections. Previous medical records showed abnormal thyroid function indicated by increased serum FT3 and FT4 levels, whereas TSH levels remained normal or mild elevated (Table ). The radioiodine131 uptake test was completed in October 2015, which was 4.1% at 3 hours and 20.5% at 24 hours. A thyroid ultrasound showed a normal thyroid gland with several nonspecific nodules. She was treated with methimazole orally once per day for 10 mg. The proband visited the hospital several times and the methimazole dosage had been repeatedly adjusted (10–30 mg/d). However, thyroid function was not restored and medication was discontinued by herself because of pregnancy. During hospitalization, she was diagnosed w

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

[User]
RADIOLOGY NOTE:
An 80-year-old man presented with a severe headache of sudden onset and nausea. His medical history included the surgical clipping of a ruptured basilar tip aneurysm and unruptured right internal carotid-posterior communicating aneurysm through the right orbitozygomatic approach 14 years ago. On admission, he exhibited a mild disturbance of consciousness, with a Glasgow Coma Scale score of 14. Computed tomography (CT) revealed clots in all ventricles [ and ]. Three-dimensional CT angiography and digital subtraction angiography showed only a small bulge on the right side of the previously applied clip [-]; this could not be confirmed as the source of hemorrhage. We adopted a strategy of conservative therapy with subsequent radiographical imaging. Although repeated angiography on day 14 revealed no further information, the patient recovered well, and surgical repair was planned considering the desire of the patient and his family to proceed with the treatment of the possible source of bleeding.
Considering the shape of the small bulge and the lack of space into which the coil could be inserted, the use of coil embolization, even in conjunction with the stent-assisted technique, was precluded. Several microsurgical approaches including the pterional, subtemporal, temporopolar, and orbitozygomatic approaches were thought to be impractical due to the topography of the aneurysm and the previously applied clip. We selected the trans-lamina terminalis approach. To prepare for a premature rupture, we decided to incorporate the endovascular technique in the hybrid operation room (OR). Through bifrontal craniotomy, the interhemispheric fissure was widely dissected. Subsequently, a 4-Fr guiding sheath was inserted through the right femoral artery and was advanced to the left vertebral artery. A balloon microcatheter (HyperForm®, 7 mm × 7 mm) was placed at the basilar artery for proximal flow control. Opening of the third ventricle was performed through the trans-lamina terminal

[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 1.5-year-old female child was brought to the pediatric oncology department for evaluation of a residual mass on her left thigh. The mass had been present for several months and had progressively increased in size. The child had undergone excision of the swelling 2 months back in a remote area and there was no histopathological report or slides for review.
On physical examination, an 8 cm scar of the previous surgery was seen on the back of the left thigh. A diffuse mass was felt underneath the scar with indistinct borders. There was no tenderness, erythema, or warmth associated with the mass. Range of motion, motor and sensory examination of the left leg was normal. Rest of the systemic examination was normal.
Radiographic analysis of the mass revealed no bony pathology. Magnetic resonance imaging (MRI) of the thigh revealed a diffuse soft tissue swelling with postoperative changes.
Re-excision of the mass was planned. Because of the previous surgery, the residual mass was adherent to the scar. Complete excision of the residual mass and the previous surgical scar was done. The remaining skin defect was too large for the primary closure and hence a split skin graft was placed [].
Gross examination of the mass revealed poorly circumscribed, lobulated fragments of yellowish tissue measuring 2 × 1.5 × 0.5 cm. The mass was composed predominantly of whitish tissue of fibrous appearance intermixed with fat. Microscopically, the lesion showed a distinct organoid pattern, involving the dermis and subcutaneous fat. The lesion showed three distinct types of tissues: well differentiated fibrous tissue, mature adipose tissue and immature cellular area arranged in a whorl like pattern [], typical of fibrous hamartoma of infancy. There was superficial involvement of the underlying muscle fibers. Base of resection and surgical margins were free of the tumor.
The child is asymptomatic after 1 year of follow-up with a well-healed wound.

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


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

[User]
RADIOLOGY NOTE:
A 70-year-old male patient presented to our emergency department due to dark tarry stool of 3 days with a change towards dark red stool in the last hours prior to his admission. He had also general weakness, dizziness, and palpitations. His past medical history included epilepsy.
On his admission, his vital signs revealed tachycardia of 126/min and blood pressure of 100/60. On abdominal examination, the abdomen was soft and not tender. No abdominal mass was palpated. Digital rectal exam revealed cherry red stool mixed with blood clots. Complete blood count showed hemoglobin level of 6.5 g/dL. Coagulation tests and liver and kidney function test were within normal limits. A computed tomography angiography revealed a lobular mass of 8 cm diameter, with calcifications at the pelvis, attached to the distal ileum, with intraluminal blush of contrast material (). He was admitted with a hemorrhagic shock due to gastrointestinal bleeding.
Due to these findings, the patient underwent an emergency laparotomy. At surgery, a hypervascular mass of 8 cm diameter at the right pelvis was found. The mass was partly calcified and seemed to rise from the distal ileum (). Additional findings were intraluminal blood in the small and large bowel with multiple small masses along the small bowel, mesentery and sigmoid colon. En bloc resection of the mass along with a 20 cm of ileum and primary side-to-side anastomosis was performed. Wound protector was used during specimen extraction as is paramount in these cases. Multiple biopsies were taken from the different masses. His postoperative course was uneventful, and the patient was discharged home on day 8.
The histopathological exam revealed a GIST, epithelioid type of 9 cm diameter, arising in the muscularis propria and extending to the pericolonic adventitia, reaching the serosa. 25 mitotic figures per 50 high power fields were counted, corresponding to tumor risk group 6A.
Immunohistochemically, the tumor cells were strongly positive for

[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 woman was referred to our hospital complaining of a huge swelling in the left side of her face and neck. She stated that this mass had begun to develop 15 years ago at which it was only the size of a small almond at the left side of her neck. The mass was painless and gradually increasing in size but the patient refused to get medical consultation throughout these years till she started to feel serious difficulty in breathing.
Clinical examinations revealed a huge firm mass in the left side of the face and neck crossing the midline reaching the right side of the neck and inferiorly till reaching below the left inframammary sulcus. The mass itself was not tender, with nodular bosselated outer surface and the surrounding skin was congested in some areas (, ).
The origin of the mass couldn’t be determined clinically whether it arised from parotid, submandibular or even thyroid gland. A core-needle biopsy suggested a salivary glandular origin.
CT scan with contrast of the neck was done and revealed a huge mass (34 × 20 × 26 cm) arising from left side of the neck and extended to parapharyngeal and sublingual spaces with displacement of trachea to the right side. It was found separated from thyroid gland and surrounding structures. CT angiography was also done and showed that the main arterial supply was from the facial branch of the left external carotid artery, common, external and internal carotid arteries on both sided which were patent and of normal shape (, ).
The patient was prepared for surgery. Anesthesia team used fibreoptic intubation. We started with a left inferolateral incision to separate the tumor from the neck great vessels. After securing them, we continued the dissection both superiorly and inferiorly in the medial direction to the right side (, ). There was no evidence of surrounding tissue infiltration. We were able to remove the tumor completely which weighed 8.1 kg (). The tumor

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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 7-year-old spayed female mixed-breed dog was admitted for surgical consultation due to an extensive facial defect. The patient was a mildly thin rescue dog (BCS 4/9) with an unknown history and lesion etiology. Approximately 80% of the maxillary region of the dog was destroyed with severe inflammation. The nasal planum, skin, bone, turbinates and upper lip were largely missing. Both the nasal cavities and the remaining turbinates were exposed. Soft tissue swelling of the right submandibular region, limited jaw range of motion accompanied by severe drooling and frequent sneezing were similarly observed (Figures and ). The tongue protruded to the left side but had no lesions. Despite these abnormalities, the patient was clinically healthy. The results of routine blood work, including complete blood count and a biochemistry panel, were generally unremarkable.
Computed tomography was performed to evaluate the severity of tissue damage and its possible etiology. The images revealed extensive destruction of the nasal and maxillary structures, extensive soft tissue inflammation of the right neck region, including the right submandibular salivary gland and enlargement of the submandibular and retropharyngeal lymph nodes (Figure ). No foreign bodies were detected.
An incisional biopsy, which was performed to investigate the nature of the tissue reaction and exclude possible neoplasm, revealed severe, chronic, and active necropurulent myositis, dermatitis, and sialadenitis, with myocyte degeneration, necrosis, and granulation tissue formation. The remnant soft tissues of the nasal cavity showed chronic active and proliferative rhinitis with granulation. Aerobic and anaerobic bacterial cultures of the submandibular discharge were negative. The tentative diagnosis was facial destruction and deformation caused by earlier trauma, chemical injury and possible secondary bacterial infection.
Despite the negative findings in the bacterial culture, the inflammation of the right subm

[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 23-year-old Asian man was referred to the ER of Xiamen Chang Gung Memorial Hospital with a 1-day history of right-sided chest pain that had been aggravated for 1 hour. He had no known medical illnesses and was well until the evening prior to presentation, at which time he developed obvious right-sided chest pain radiating to his ipsilateral shoulder with persistent chest tightness. This tightness was described as sticking in nature, significantly worse on deep inspiration and with movement, and relieved by leaning forward or lying down. There was an associated dry cough but no hemoptysis. There was no history of trauma, injury, difficulty in breathing, or palpitations. He was tall and thin and described himself as otherwise quite healthy. He had never previously been admitted to a hospital. He reported no significant chronic medical history, such as primary hypertension, any type of heart disease, disturbed microcirculation, peripheral neuropathy, diabetes mellitus, an impaired immune system, malignancies, leukemia, the long-term administration of corticosteroids, liver cirrhosis, renal failure, urinary tract infection, or hemodialysis. He also reported no history of infection, such as tuberculosis, any type of hepatitis, or acquired immunodeficiency syndrome (AIDS). There was no prior history of traumas, blood transfusions, surgical procedures, or other serious events in his medical history. He had not lived in an epidemic area and had no history of toxin or radioactive exposure. He denied a personal or family history of bleeding diathesis but reported a 10-year history of smoking 8–10 cigarettes per day. He was an office worker by occupation. He had experienced similar symptoms on one occasion 4 years previously. No abnormalities were detected at that time, and his symptoms resolved.
A physical examination (PE) revealed a young man who was awake and alert but in mild to moderate painful distress. His respiratory rate was 22–26 breaths/minute with an oxygen satur

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


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

[User]
RADIOLOGY NOTE:
A 49-year-old female Chinese patient was presented to our hospital with upper abdominal distension for 3 months. Marked abdominal distension had been observed more frequently for 10 days. Physical examination and lab test results were unremarkable.
Routine ultrasonography revealed a retroperitoneal tumor of 5.0 × 3.7 × 4.1 cm with a clear edge, located between stomach and pancreas and adjacent to the posterior stomach surface. Notably, gastric tissue adjacent to the tumor showed an intact structure of five layers of the stomach wall (). And the diagnosis from the ultrasonographist was a benign tumor, possibly schwannoma, derived from retroperitoneum or mesentera rather than from stomach.
On the contrary, a contrasted computed tomography (CT) was unable to rule out that the tumor was originated from the stomach wall due to tight tumor-stomach adjacency (). Further magnetic resonance imaging (MRI) suggested that the tumor was close to the stomach wall with gastric mucosa uninvolved (). We also observed uniformly progressive enhancement with several low-density areas inside the tumor. The radiologist suggested a diagnosis of gastrointestinal mesenchymal tumor but preferred stromal tumor rather than schwannoma.
The tumor board, therefore, suggested laparoscopic radical resection of the peritoneal tumor. Intraoperative dissection showed the tumor was strongly adjacent to the posterior stomach wall and free from the retroperitoneum. The initial frozen section indicated a pathological diagnosis of spindle cell tumor, which might be gastric schwannoma. However, the final pathology via paraffin section showed that the tumor is a gastric stromal tumor originated from the serosa layer of the stomach wall, with a mitotic rate of over 5 per 50 high power field. Immunohistochemistry results also supported the characteristic marker expression as gastric stromal tumor, including positive CD117, positive DOG-1, negative S100, 5% positive Ki67, negative SMA, negative CKpan, 8% positi

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


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

[User]
RADIOLOGY NOTE:
A 33-year-old female presented to the oral medicine service with a chief complaint of severe gingival pain and lesions for 1 month. The patient was a nonsmoker and had no significant medical history or known allergies.
The clinical examination revealed erythematous and ulcerative gingiva localized at the buccal side from teeth 15 to 17 and 24 to 27 (Federation Dentaire Internationale tooth numbering system), and oral hygiene was good (Fig. a, b). X-ray examination showed marginal alveolar bone loss in the involved teeth, and periodontal resorption of alveolar bone in teeth 15, 16, 25, and 26 was obvious (Fig. c, d). The laboratory tests performed included a complete blood count, autoantibody detection, syphilis serology and anti-HIV antibody detection, and the results were all normal. The diagnosis of necrotizing ulcerative periodontitis (NUP) was made.
Ten volumes of diluted hydrogen peroxide were administered to the necrotic lesions with a sterile cotton roll in conjunction with topical administration of metronidazole every other day. The patient was prescribed an oral mouth rinse (0.2% chlorhexidine twice daily for 5 days). Five days later, the clinical examination showed an improvement in symptoms, with resolution of the ulcerated pseudomembranous area, and then scaling and root planing with local anesthesia was performed. The patient showed obvious relief of pain. However, 10 days later, the condition relapsed. In addition to the therapy above, the patient received 500 mg of amoxicillin twice per day for 5 days, but the lesions did not completely heal, and she made no further visits.
Five months later, the patient presented to the department with a complaint of aggravated pain of the gingiva and movable teeth. The clinical examination revealed ulcerative and obviously recessed gingiva (Fig. e, f), and teeth 15, 16, 25, and 26 had different degrees of mobility. To further confirm the diagnosis, after obtaining informed consent from the patient, a

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


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

[User]
RADIOLOGY NOTE:
A 15-year-old female patient was referred to the dental hospital for endodontic management of a maxillary left central incisor with an immature apex. She had no history of allergy or medication. The patient was healthy. Her chief complaint was a toothache at the apical area of the maxillary left central incisor. The patient reported a yellowish secretion with a foul odor coming from the left nostril every morning. The tooth showed history of trauma. Clinical examination showed that the tooth had a large mesiobuccal composite restoration that has been lasting >5 years. The patient reported pain and swelling with recurrent exudates during those 5 years. A sinus tract was found in the left nostril above the apical area of the left maxillary central incisor. Radiographic examination using a gutta-percha point to trace the sinus tract revealed that the origin of the sinus tract was the root apex of the left maxillary central incisor (). The tooth did not respond to thermal and electric pulp tests.
On radiographic examination, the maxillary left central incisor showed an immature root apex with a diameter of >2.0 mm. Radiographic examination showed an incomplete root formation associated with a 6×8 mm circumscribed radiolucency around the root apex. The diameter of the apical foramen was approximately 3 mm mesiodistally. The maxillary left lateral incisor and right central incisors had intact crowns, normal root canals, and an intact lamina dura.
The soft tissue swelling at the apical area of the left maxillary central incisor was treated by opening the canal for drainage. A cone beam computed tomography (CBCT) scan (DentiiScan; NSTDA, NECTEC, Phahon Yothin, Thailand) was performed to examine the sagittal cross-section of the affected left central incisor. The CBCT scan showed a perforation of the buccal bone plate related to the tooth (). Based on clinical and radiographic findings, necrotic pulp with chronic apical abscess was diagnosed. After a comprehensive discussion

[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 82-year-old female patient with a symptomatic gallstones disease and a recent weight loss was admitted to our hospital. The patient’s past medical history was free of other diseases and on physical examination, a Murphy sign was present. The abdominal ultrasound mentioned a large gallstone in the gallbladder and a hypoechoic liver mass. Liver blood tests, including tumor markers CEA and CA 19-9 were normal. Magnetic resonance imaging-magnetic resonance cholangiopancreatography (MRI-MRCP) revealed a liver tumor mass (4.5x3.5 cm) located mainly in segments IVa and VIII of the liver with an extent to segment I (Figure ).
The tumor displaced the adjacent hepatic veins and the inferior vena cava (IVC) without any signs of vessel invasion. There were no signs of liver cirrhosis and no dilated bile ducts or capsular retraction were noted. There was no associated lymphadenopathy. At this point, imaging characteristics were controversial regarding diagnosis. The differential diagnosis tilted in favor of ICC, mainly due to the enhancement characteristics and the absence of liver cirrhosis, as seen in Figure .
The patient was scheduled for exploratory laparotomy with a provisional diagnosis of an ICC. Intraoperatively, a cholecystectomy and lymph node sampling from the hepatoduodenal ligament were performed and both specimens were negative for malignancy on frozen section. Next, the liver was mobilized and the tumor was carefully dissected free of the hepatic veins, the IVC, and the rest of the liver parenchyma. The gross morphology of the liver specimen revealed a solid, grey-yellow liver lesion with a soft consistency. In the center, a light yellow region was noted, as can be seen in Figure .
The frozen section was negative for malignancy. Histologically, the tumor was characterized by a heavy inflammatory infiltrate in myxoid collagen stroma, consisting primarily of plasma cells, lymphocytes, and eosinophils. Fibroblast cells without significant fibrosis composed the str

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


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

[User]
RADIOLOGY NOTE:
A 44-year-old nulliparous woman was transferred to an Australian tertiary maternity centre with severe acute onset abdominal pain at gestation of 32 weeks and 2 days. Maternal observations on admission were within normal limits and a fetal CTG demonstrated a reactive trace. Following admission, the pain intensified and a bedside ultrasound demonstrated oligohydramnios and a fetus in breech presentation. The patient was commenced on oral antibiotics and received intramuscular corticosteroids for presumed premature prolonged prelabour rupture of membranes.
The patients past medical history included a laparoscopic fundal myomectomy performed eight years ago at a private health care facility. In addition to this her medical history included a laparoscopic ovarian dermoid cystectomy, gastric band insertion, and a provoked deep vein thrombosis (DVT), for which the patient no longer required anticoagulation.
The pain intensified during the night and a formal ultrasound was performed early the next morning. This ultrasound confirmed anhydramnios and uterine rupture with the right fetal arm seen intra-abdominally (). Fetal growth parameters were within normal limits with the estimated fetal weight plotted on the 50th centile.
The patient was transferred to theatre for an urgent caesarean section at gestation of 32 weeks and 3 days. A midline laparotomy was performed and the right fetal arm was seen protruding through a ruptured anterior myomectomy scar to the level of the fetal shoulder ().
The fetal right arm and hand were oedematous and bruised but otherwise uncompromised (). The neonate was delivered via a classical caesarean section, which extended the uterine rupture into an inverted “J” shape and allowed for delivery without additional trauma to the neonate or mother. This classical incision was then closed in two layers with mass closure of the abdominal wall (). As the site of the rupture was at the avascular uterine scar, there was minimal blood loss from the uterus

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


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

[User]
RADIOLOGY NOTE:
A 30-year-old female was referred to the urology clinic for severe lower urinary tract symptoms (LUTS) in addition to suspicion of a urethral mass. Her symptoms started two years earlier after the indwelling urethral catheter was removed following her Caesarian section. She noticed that a vestibular mass protruded at the level of her urethra and she reported increasing need to strain to void. In addition, this vestibular mass was very painful, and it required manual reduction to allow for her to void. LUTS got progressively worse over the course of the two years. In addition to the dysuria, she had intermittent hematuria, frequency of every hour as well as nocturia 3 to 4 times per night. Her personal past medical history was only positive for a remote appendectomy and a caesarean section. The patient had been previously worked up by her obstetrician since the LUTS appeared after her caesarean delivery. She had repeated urine analyses and cultures that were negative. Abdominal ultrasonography demonstrated the presence of two cystic lesions in the bladder of 2.5cm and 9mm in diameter. The kidneys did not show any hydronephrosis nor hydroureter. Her blood work, including renal function, was unremarkable.
Examination in lithotomy position revealed a very sensitive erythematous mucosa protruding from the urethra. Patient had to manually reduce the vestibular mass in the sitting position so that she could undergo cystoscopic examination under local anesthesia. Otherwise, it was too painful for the patient. Once reduced, cystoscopy was performed and demonstrated the presence of two large ureteroceles. The left ureterocele, which was significantly larger than the right side, demonstrated erythematous and edematous mucosa indicating that the vestibular mass previously noted by the patient and on examination was likely the wall of the left ureterocele. To rule out duplex system, a triphasic CT-urogram was ordered and it confirmed the patient's bilateral single-system uretero

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


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

[User]
RADIOLOGY NOTE:
A 57-year-old woman presented with chronic temporal headache and right tinnitus, and the symptoms gradually aggravated. Conservative treatment continued at the local Otolaryngology Clinic based on a diagnosis of otitis media. Slight consciousness disturbance, slight fever and auditory disturbance were noted 1 year after the initial symptoms, and the patient was referred to our department. Neurological findings showed slight consciousness disturbance, and an audiometric hearing test demonstrated 30 dB in the right ear, diagnosed as a mild hearing impairment. Magnetic resonance imaging (MRI) showed edematous brain swelling in the right temporal lobe and right tentorium and dural enhancement around the transverse sinus (fig. ). Digital subtraction angiography demonstrated occlusion of the right transverse sinus (fig. ). No marked venous cortical reflux was shown. MRI showed a heterogeneous mass lesion in the right middle ear and mastoid air cells with dural enhancement around the lesion (fig. ). She was diagnosed with recalcitrant otitis media invading the mastoid associated with transverse sinus thrombosis and was treated with antibiotics, hyperosmotic fluids, steroids and repeated external drainage of the middle ear. Consciousness disturbance gradually improved. Symptoms of temporal headache, auditory disturbance, slight fever and radiological findings of brain swelling did not disappear, and remission and exacerbation of these symptoms occurred repeatedly.
Consciousness disturbance occurred again, and chronic temporal headache gradually aggravated 5 years after the first examination in our department. MRI revealed enlargement of the edematous swelling around the right transverse sinus, and the enhanced lesion was also enlarged (fig. ). Open drainage of the middle ear with mastoidectomy was performed 6 years after the initial symptoms. Granulation had invaded the eardrum and stapes, and the auditory tube was also filled with granulation (fig. ). Infectious granulatio

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


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

[User]
RADIOLOGY NOTE:
A 57-year-old male patient was admitted to our hand surgery department complaining of a progressive swelling located on the dorsoulnar side of the right wrist joint. The patient reported that the mass was started to grow for the past three months. On physical examination, there was no tenderness or erythema around the mass. The range of motion of the wrist joint was within the normal range. Neurovascular examination findings were normal. The patient was not diagnosed with any chronic disease previously, including gout or not under any medication. He had a history of an occupational injury 33 years ago in which he lost extensor muscles and tendons on the right forearm. Thus, the patient underwent a tendon transfer surgery in which the FCU tendon was transferred to EDC tendon (Figure 1). The patient’s family history was unremarkable for gout.
Magnetic resonance imaging (MRI) revealed an iso/hypointense mass at proton density-weighted and fat-suppressed T1 images (Figure 2). We decided to perform excisional biopsy. A written informed consent was obtained from the patient. During surgery, it was confirmed that the FCU tendon was transferred to EDC tendon. The tumor was located within the junction where the FCU tendon was transferred to EDC tendon. Non-absorbable suture materials were observed within the tendon transferred region (Figure 3). A caseous material was reached following the opening of the paratenon suggestive of tendon necrosis, tuberculosis, or a foreign body reaction. An excisional biopsy was performed, and the specimens were sent for histopathological and microbiological evaluation. The weakened tendon was repaired with eight-strand and epitendinous sutures.
No organism was seen in the initial Gram staining, and there was no bacterial growth in the microbiology cultures. His preoperative blood laboratory test results were within normal ranges for complete blood count, complete metabolic panel, and uric acid levels. Microscopic examination revealed typical

[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 9-year-old girl was presented to our hospital on referral from a peripheral hospital with a one-week history of darkish discoloration of both feet and her left hand and a six-day history of a purulent feculent discharge from an exploratory laparotomy wound. She had presented to the referring hospital eight days earlier, with a two-week history of high-grade fever and a one-week history of a generalized abdominal pain and diarrhea. She had an exploratory laparotomy at the referring hospital. Intraoperative findings include a feculent intraperitoneal collection and a single perforation on the antimesenteric border of the terminal ileum. An intraoperative diagnosis of perforated typhoid enteritis was made, and the perforation was closed in two layers. One unit of blood was transfused postoperatively. On the first day of postsurgery, the patient developed darkish discoloration of the left hand and both feet which were associated with pain. She was not a known sickle cell disease patient and had no past histories suggestive of intermittent claudication. On the second day of postoperation, a purulent discharge from the lower aspect of the laparotomy wound was noted, and there was darkening of the feet and duskiness of the distal one-third of both legs. Due to the progressive worsening of the patient's condition, she was referred to our hospital on the seventh day of postoperation.
At presentation to our unit, she was acutely ill looking, febrile with a temperature of 38.1°C, dehydrated, not pale, and anicteric. Her respiratory rate was 30/minute with reduced air entry and coarse crepitations in both lower lung fields. She had a pulse rate of 130/minute, which was regular and of moderate volume. Only first and second heart sounds were heard. Her abdomen was full, and did not move with respiration, and had a midline dressing soaked with a feculent fluid. There was a complete wound dehiscence of the abdominal wound, with both edges being necrotic

[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. XY is a 33-year-old man who was referred to the psychiatric service by his rheumatologist for a severe weight loss associated with complete food refusal. He was admitted to the psychiatric inpatient unit, and detailed information about the case history was collected.
Mr. XY was first diagnosed with a BS in 2003, over twelve years before the first psychiatric admission. BS is a disease featuring a chronic vasculitis with a multisystemic involvement of both arteries and veins []. Orogenital and ocular lesions are common in BS, but it may show a wide range of clinical manifestations, including involvement of the central nervous system (CNS) [, ].
BS is supposed to have a strong genetic vulnerability and, although its pathogenesis is still not clear, it was associated with an alteration of the immune and inflammatory response [, ]. Soon after, Mr. XY underwent a genetic examination, showing a HLA-B51 carrier status (an allele associated with the presence of BS) []; moreover, a brain magnetic resonance imaging (MRI) highlighted a diffuse signal intensity alteration of the right cerebellar hemisphere. He was first prescribed glucocorticoids (often employed in the treatment of the acute involvement of the CNS in BS) and colchicine, an alkaloid with anti-inflammatory and immune-modulatory properties used with beneficial effects in different kinds of diseases, from BS from gout [, ]. It was also prescribed cyclosporine, an immunosuppressive agent that interferes with the transcription of several cytokines []; however, cyclosporine intake was discontinued by Mr. XY in a few months because of gastrointestinal side effects. Since two years from the first diagnosis, he had started to show signs of neuromuscular damage (including tremors, muscle weakness with recurrent falls, dyspnea with reduced exercise tolerance, and evidence of restrictive ventilatory defect with no diffusion impairment). During 2009, he reported recurrent headaches, and as a consequence, a new brain MRI

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


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

[User]
RADIOLOGY NOTE:
A 57-year-old Ukranian male with a 45-year history of smoking but no other medical history presented in August 2008 complaining of months of intermittent abdominal pain, diarrhea, and a 40 lb weight loss. His symptoms presented over the course of 1 year. His diarrhea was initially evaluated and attributed to gastroenteritis. Routine studies were sent, including a stool culture. S. arizonae (subtype III), which is associated with osteomyelitis and gastroenteritis in reptile handlers, was isolated and the patient reported contact with a pet iguana. Computed tomography of the abdomen and pelvis was ordered and revealed a 1.5 × 1.7 cm speculated pulmonary nodule in the right upper lobe and thickening of the duodenal, jejunal, and colonic wall with scattered surrounding lymphadenopathy.
The patient was placed on antibiotics and continued to suffer from continued diarrhea and weight loss, so inflammatory bowel disease was suspected. In September 2008 he underwent endoscopic studies which revealed a hiatal hernia, old blood in the stomach, mucosal swelling near the gastric antrum, and three areas of circumferential ulceration and inflammation with mucosal pigmentation/erythema (see ). The areas were biopsied, and the biopsy showed reported duodenitis and jejunitis with acute on chronic inflammation. There were no signs of architectural distortion or cryptitis/crypt abscesses, Helicobacter pylori stains were negative, and no bacteria were apparent on biopsy. Given that the biopsies did not show any findings consistent with the suspected diagnosis of inflammatory bowel disease, his symptoms were attributed to S. arizonae gastroenteritis.
Fine needle aspiration of his pulmonary nodule was nondiagnostic, showing only clustered atypical epithelial cells. A positron emission tomography scan was obtained and showed a focus of hypermetabolic activity in the right upper lobe which was read as probable granulomatous disease.
He continued to have recurrent episodes of abdominal pain

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


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

[User]
RADIOLOGY NOTE:
A 51-year-old lady with recent history of laparoscopic abdominal surgery presented to our emergency department with watery diarrhea and generalized abdominal pain for four-day duration without vomiting, fever, or any other systemic complaints. She denied recent travel and was unable to relate any food that could have triggered her symptomatology. Four weeks earlier she was found to have small bowel obstruction secondary to incarcerated incisional hernia with trapped bowel loop in the hernial sac. She has a history of caesarean section with midline incision. Patient had laparoscopic small bowel resection and primary anastomosis with ventral incisional hernia repair. During her surgery there was no mechanical injury to the portal and mesenteric veins and standard pressure of pneumoperitoneum was utilized. She was perioperatively anticoagulated with prophylactic dose of heparin. Her postoperative period was uneventful with no abdominal sepsis and she was discharged home. Histology of the small bowel revealed submucosal congestion and serosal granulation. Her other medical problems were hypertension, diabetes mellitus, peripheral vascular disease, and meningioma, abnormal mammogram with BI-RADS score of 5 (Breast Imaging-Reporting and Data System) awaiting biopsy. There was no personal or family history of clotting disorders. Physical examination was positive for generalized abdominal tenderness without guarding or rigidity. All other system examination was unremarkable. Initial labs revealed mild neutrophil leukocytosis with a white blood cell count of 12 200/μL and 75% of neutrophils. She also had normochromic normocytic anemia with hemoglobin of 10.2 g/dL and normal platelet count. Chemistry showed normal electrolytes and renal function. Aspartate aminotransferase (AST) was mildly elevated to 84 IU/L (normal range 15–41) and other liver enzymes were normal. Bilirubin, total protein, albumin, and coagulation profile was normal.
A computed tomography of the abdomen was

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