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

[User]
RADIOLOGY NOTE:
A 41-year-old Caucasian female presented with a 2-day history of abdominal distention and generalized pain that was worsened with motion. These symptoms were accompanied by nausea, several episodes of nonbilious vomiting, and poor appetite. Her last bowel movement had been a week prior to admission. Her past medical history was significant for type 2 diabetes and vulvar lichen sclerosis, which was being treated with steroids since its diagnosis one year prior. She had a 15-pack-year history of tobacco use, as well as a distant history of intravenous heroin abuse with subsequent long-term dependence on methadone maintenance at 180 mg.
Vital signs were noted as temperature 98.7°F, blood pressure 121/68 mmHg, pulse 101 bpm, and respiratory rate 24. Physical examination revealed diffuse abdominal tenderness with maximal pain on the left side, as well as rebound tenderness, guarding, and hypoactive bowel sounds. A rectal exam revealed no masses, empty ampulla, and hemoccult negative stool. Laboratory studies revealed a white blood cell count of 22,200/mL with bandemia, glucose at 267 mg/dL, and lactic acid elevated at 4.7 mmol/L. Other laboratory values were all normal. A CT scan of the abdomen and pelvis with PO contrast revealed multiple foci of extraluminal air in the peritoneum, a large amount of fecal material in the colon, and extravasation of oral contrast consistent with perforation of the colon (Figures and ).
The patient was promptly taken to the operating room for an exploratory laparotomy with a provisional diagnosis of bowel perforation with peritonitis. She was found to have a large perforation in the sigmoid colon measuring approximately 8–10 cm. The remainder of the bowel was proximally dilated and filled with hard dry fecal material, with its widest point measuring 19 cm in circumference with a very thin bowel wall. Extensive purulent material with fibrinous exudates into the small and large bowel, as well as multiple large fecaliths of varying

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


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

[User]
RADIOLOGY NOTE:
A 38-year-old woman, who had undergone correction of congenital supravalvular aortic stenosis at 8 years of age, developed progressive exertional dyspnea and chest pain for more than a year prior to the current presentation. Electrocardiogram-gated contrast-enhanced computed tomography (CT) showed stenosis in the ascending aorta and highly dilated bilateral coronary arteries (Fig. ). Echocardiography showed normal left ventricular (LV) wall motion with an ejection fraction of 59%, prominent LV hypertrophy, mild aortic regurgitation, and flow acceleration of 5.2 m/s in the ascending aorta. Thallium myocardial scintigraphy did not detect myocardial ischemia. Catheter examination demonstrated a pressure drop of 110 mmHg at the stenosis site of the ascending aorta with high pressure in the sinus of Valsalva. Three-dimensional time-resolved cine phase contrast magnetic resonance imaging (4D flow MRI) demonstrated preserved LV wall motion and cardiac output but highly accelerated flow (> 5.0 m/s) in the ascending aorta. Release of stenosis was necessary to resolve the patient’s complaint and avoid LV functional deterioration due to excessive afterload; however, when we had performed simply aortic root replacement with the in situ coronary revascularization during surgery, reduction of the blood pressure in the sinus of Valsalva may have led to demand–supply mismatch in coronary flow due to heavily dilated and tortuous coronary artery and the highly thickened LV wall muscle. Moreover, we also suspected to harvest dense adhesion around the sinus of Valsalva due to the old patch material in this reoperation. Therefore, we had to examine whether CABG could be a candidate or alternative option for coronary reconstruction. However, we could not determine which strategy of revascularization could supply exactly more sufficient coronary perfusion, CABG or in situ reconstruction with the Carrel patch technique. Therefore, we performed computerized virtual surgery based on CFD comb

[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-day old male baby presented to the emergency department with fever, poor feeding, and abdominal distension which started 1 day ago. Initial lab findings showed CRP elevation, leukocytosis, and bowel distension on plain x-ray, suggesting possible congenital megacolon (Fig. ). He was admitted for treatment of enteritis and evaluation for megacolon including colon study. He had a previous history of neonatal intensive care unit admission after birth due to neonatal pneumonia and had received ventilator care. Congenital pharynx deformity was observed for which resection of pharyngeal polyp was done and also congenital ptosis of the right eye and mild sacral deformity was suspected. During neonatal intensive care unit care, the infant showed signs of repeated colon distension and colon study was done. However, other than mildly decreased bowel motility of the transverse megacolon, no specific findings were apparent and eventually normal defecation was observed. Oral feeding was gradually increased and 27 days after admission, the patient was discharged.
However, few days after discharge, the amount of oral feeding decreased to less than half, and the infant had extreme difficulty in defecating. Although rectal tube insertion was immediately done, decompression was ineffective and abdominal distension aggravated with worsening signs of shock. Patient was admitted to PICU where resuscitation with hydration, inotropics, mechanical ventilation, and combined antibiotic therapy with vancomycin, meropenem, and metronidazole was initiated. Emergency ultrasonography findings showed clear signs of toxic megacolon with marked distension of rectum and distal colon, diffuse bowel wall thickening and turbid fluid collection (Fig. A). During ultrasonography, foley catheter was inserted through the anus to enable simultaneous rectal decompression. However, the tip of the foley catheter was located in a separate narrower tubular lumen adjacent to the distended rectum, which explaine

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


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

[User]
RADIOLOGY NOTE:
A 48-year-old woman presented to the emergency department with a sharp, severe left lower quadrant pain. Ultrasound imaging of the abdomen and pelvis demonstrated an enlarged uterus with multiple masses (highly suggestive of leiomyoma), an 8.7 cm left adnexal complex mass, and minimal fluid in the pelvis. Subsequent computed tomography (CT) scan of the abdomen and pelvis confirmed the above findings.
Pelvic examination revealed a posterior cervix with an enlarged, boggy uterus, but no tenderness. The cervix could not be visualized on speculum exam due to a distorted uterus. No palpable inguinal lymph nodes were identified. The remainder of the physical exam was unremarkable. Laboratory workup was notable for an elevated CA-125 level (125.9 U/mL).
The patient's past medical history was significant for breast cancer status after lumpectomy, radiation therapy, and Tamoxifen therapy. Her past gynecologic history was remarkable for laparoscopic myomectomy (12 years prior to this encounter). She resumed having regular cycles every 30 days and denied any recent abnormal bleeding, weight loss, and gastrointestinal or genitourinary symptoms.
The patient was advised that the best approach would be to remove the uterus and ovaries and send them for intraoperative consultation during the surgery. Subsequently, the patient underwent a total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAH/BSO).
Exploration of the pelvis at the time of surgery revealed a large multilobated uterus that was about 16 weeks in size, as well as hemorrhagic cysts on both ovaries. The left ovary was no longer 8 to 9 cm, but was instead around 4 to 5 cm. Additionally, there was also some blood in the pelvis. Pelvic washings were obtained, and a representative section from the left ovary was submitted for frozen section examination. The diagnosis was reported as a benign hemorrhagic cyst. The surgery and the postoperative course proceeded without complication and the patient was discharged

[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 male patient was admitted to the hospital due to an irritating cough for more than 1 month. He had no recent history of chest trauma surgery or respiratory diseases. A chest CT scan showed anterior mediastinal space, and showed differential diagnosis of teratoma, thymoma and lymphomas, in order to clarify the relationship between the space-occupying lesions and blood vessels and surrounding tissues, a chest-enhanced CT examination was performed. After intravenous injection of contrast medium, a dual-phase scan was performed. It was found that there was a localized aneurysm-like expansion in the left brachiocephalic vein and its diameter was 5.2 cm with the smooth edge (Fig. ), which confirmed the diagnosis of venous aneurysm. After careful evaluation of the patient, surgery was performed.
A median sternum incision was selected in the surgery. During the operation, a huge aneurysm is found to be located in front of the left brachiocephalic vein. The aneurysm and surrounding tissues were carefully separated to prevent uncontrollable bleeding during the process, and to mechanical damage caused by extracorporeal circulation. We first performed heparinization of the whole body blood, and blocked both ends of the brachiocephalic vein, separated the fibrous membrane of the venous blood vessel, and found that the aneurysm wall was thin. The aneurysm was cystic expansion, and there as a larger aneurysm neck connected to it. After the aneurysm was removed, a double-layer continuous suture with 5–0 prolene thread was used to suture the brachiocephalic vein. We paid attention to the shape of the normal brachiocephalic vein during the suture process. To prevent vascular distortion and lumen stenosis, we carefully loosened the blocking bands at both ends before knotting, determined the shape of the formed blood vessel, and expelled the possible air (Fig. ). After confirming that there is no obvious active bleeding, heparin was neutralized with protamine, and the ope

[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 11-month-old boy was referred to a tertiary center for failure to thrive, poor muscle tone, short neck, kyphosis, and unusual spacing between teeth. He was diagnosed with infantile HPP after repeated low ALP activity test results and radiographic assessment of severe rickets-like skeletal changes and tongue-like lucencies projecting into the metaphyses. He was hospitalized multiple times for pneumonia likely related to musculoskeletal manifestation of HPP, which required treatment with intravenous antibiotics. At age 9 years, he developed persistent headaches; a magnetic resonance imaging (MRI) cranial scan confirmed craniosynostosis with Chiari malformation and cerebellar tonsillar herniation. He underwent craniovertebral decompression, with removal of the posterior arch of C1; a ventriculoperitoneal shunt was inserted to relieve intracranial pressure. He subsequently underwent 2 shunt revisions.
The patient experienced multiple fractures, starting at age 17 years, when he sustained bilateral femoral fractures when jumping off a wall; this required bilateral intramedullary rod insertion. At age 18 years, he sustained a right tibial fracture while jumping. Bone healing was delayed, but the fracture eventually healed satisfactorily. At age 20 years, he sustained bilateral femoral fractures when he rolled off his bed during a seizure and required rehabilitation for approximately 8 months.
Over the first 18 years of life, the patient was hospitalized 8 times for a total of 43 days (Table ). Of these hospitalizations, 5 separate admissions required a stay of ≥5 days; the stay for insertion of a ventriculoperitoneal shunt was 14 days.
Outpatient specialist visits represented a significant proportion of the healthcare resource utilization by this patient (Fig. ). Most of the outpatient specialist visits required consultation with providers in 12 specialties, including pediatric dentist (38 visits), pediatric endocrinologist (32 visits), neurosurgeon (27 visits), and ge

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


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

[User]
RADIOLOGY NOTE:
A 24 year old Asian female presented to the surgical clinic with a goitre of eight months duration and recent onset of altered bowel habits (i.e., increased stool frequency) with features of anaemia. She was otherwise well and there was no family history of adenomatous polyposis, colorectal carcinoma or thyroid neoplasms. Physical examination revealed a multi nodular goitre. Ultrasonically both lobes of the thyroid gland were enlarged with multiple hyper-echoic nodules with central irregularity denoting necrosis. Fine needle aspiration cytology was compatible with a smear suspicious of papillary thyroid malignancy. The patient was biochemically euthyroid and antithyroid antibody status was negative.
Colonoscopy revealed multiple polyps (more than 100) of varying sizes from the caecum extending to the rectum. Histology showed adenomatous polyps with low grade dysplasia rendering the diagnosis of FAP.
She underwent a total thyroidectomy with level VI lymph node dissection and the recovery was uneventful. Macroscopy revealed multiple circumscribed whitish tumours of varying sizes in both thyroid lobes (Fig. ). There were 14 separate tumours in total, the largest measuring 18 × 17 × 14 mm in size. Some of the lesions contained areas of haemorrhages and cystic changes.
Microscopically, all the tumours showed predominant features of encapsulated PTC. However, unlike in the usual PTC, a variety of architectural growth patterns including cribriform, solid and trabecular with morule formation were noted along with the papillary structures (Fig. ). Constituent cells were cuboidal to columnar with amphophilic cytoplasm. Spindle shaped cells were noted in morular structures. Capsular invasion was seen in one tumour but there was no evidence of vascular invasion. The lymph nodes were free of metastases.
The patient was started on high dose thyroxine replacement and referred for radio iodine treatment. Disease involvement of the small bowel was excluded with capsule endoscopy 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 29-year-old, G2P2 mother was diagnosed with blue rubber bleb nevus syndrome more than five years ago and has had two pregnancies while being treated with sirolimus. These children were small for gestational age at birth and are the focus of this case report. Upon diagnosis of this rare disorder, the patient was treated with oral sirolimus 2mg twice daily. Her cutaneous lesions resolved significantly at 6 months follow up. She had a flare up of the lesions when she discontinued treatment before preconception. Her family history is unremarkable. She conceived naturally at one year of sirolimus therapy through a non-consanguineous marriage. Both the partners are of average built and denied tobacco, alcohol or substance use. In view of the previous flare up history following preconception planning, she was advised to continue sirolimus by the treating physician. Prenatal care for the first pregnancy included an ultrasound for determination of gestational age and routine monitoring of possible side effects of sirolimus. Regular blood investigation revealed normal complete blood count, liver and renal functions, sugar and lipid profile. Routine antenatal checkup done at the rural health care center by the Health Assistant were uneventful. Records maintained in the prenatal care book showed normal blood pressure, maternal weight gain, height of fundus corresponding to gestational age and normal hemoglobin level. Fetal ultrasound done at 36 weeks of gestation at the district hospital by a sonographer technician revealed a single live fetus with adequate amniotic fluid and expected fetal weight corresponding to 34 weeks. In view of maternal medical condition, sirolimus therapy and suspected fetal growth restriction, the mother was referred to the tertiary hospital. No gross anomalies were noted on limited anomaly examination and umbilical artery doppler study was within the normal range for the gestational age. At 40 weeks, she delivered a normal live male newborn weighing

[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 68-year-old man presented with a 4-month history of a painless swelling in both parotid area. The mass was multiple and fixed at the parotid region. He had no medical or operation history. Neither facial palsy nor tumor extension to oropharynx was seen.
Fine needle aspiration cytology revealed that the lesion was consistent with a few clusters of ductal epithelial cells and stromal cells. An enhanced CT scan showed multiple tumors within bilateral parotid gland. In view of these investigations and clinical presentation at that stage, the presumed diagnosis was the Warthin’s tumor.
We conducted a parotid duct preserving bilateral superficial parotidectomy by one-stage operation to remove the multiple tumors. A lazy S incision was made in both preauricular area and the peripheral branches of the facial nerve were identified using surgical landmark (main parotid duct and posterior facial vein without nerve stimulator). After dissecting the branches of the facial nerve and parotid duct, main parotid duct was preserved but only small fine ductules from the superficial lobe were ligated. Parotid gland was excised from its anterior aspect with about 1 cm of normal parotid tissue margin (). Histological examination of the specimen postoperatively confirmed 5×2×1.5 cm-sized Warthin’s tumor in right superficial parotid gland and five segments of Warthin’s tumors (1.5 cm in diameter of the largest one) in left superficial parotid gland.
Patient was followed up for 6 years to evaluate postoperative parotid gland function. The preoperative and postoperative photographs with the computed tomography scans were taken (). Patient was satisfied with no significant complication such as sunken changes in facial contour, facial nerve function.
However, increased sweating and mild edema on left preauricular area was noticed after 6 months of follow-up period, which was revealed as Frey’s syndrome after conducting Minor starch test. At the follow-up date of 6 years, the symptoms of swea

[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:
Herein, we describe a three-generation family of Italian origins. The proband is a 2 years old boy referred to our center for suspected Food-Protein induced Enterocolitis ().
The mother of the proband is a 31 years old woman. She reported allergic rhinoconjunctivitis and recurrent gastrointestinal complaints from a young age, described as frequent loose stools and abdominal pain, interpreted as food allergies. She also experienced dizzy spells, vertigo, and small skin rash. Laboratory findings included normal Ig levels, normal total IgE levels, and no specific Ig for known allergens, whereas increased basal serum tryptase was found. The maternal grandfather also reported non-specific gastrointestinal symptoms and elevated serum tryptase. The father of the proband had no relevant clinical history.
The proband was born at term via vaginal delivery from an uncomplicated pregnancy. The baby at birth weighed 2,750 g. He received mixed feeding for the first month and only breastfeeding in the following period. He then developed cradle cap and peri-auricular dermatitis. Gastroesophageal reflux was also diagnosed. The child started weaning at 6 months of age, and after the introduction of wheat at 8 months, he developed facial erythematous skin rash and diarrhea (5–6 episodes per day) starting 2 h after the aliment ingestion. After wheat reintroduction, the symptoms recurred, and so it was excluded from the diet. He then also experienced episodes of diarrhea after 3–4 h from the intake of milk derivatives and vomiting linked to the ingestion of egg yolk, which led to the exclusion of these two aliments. Skin prick test for alimentary allergens resulted negative. In the following weeks, reintroducing small quantities of wheat was attempted, but that prompted a severe episode of vomiting that required hospitalization. A diagnosis of Food-Protein induced Enterocolitis was therefore suspected. At 1 year of age, he presented atopic dermatitis and a maculopapular hyperchromic les

[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 76-year-old woman without histories of cardiovascular risks such as ischemic heart disease and heart failure and use of medications was referred to our hospital because of chest pain. Her chest pain was characterized by a squeezing sensation that was unrelated to exercise and lasted for less than half an hour. She denied any family history of heart disease. Her initial blood pressure was 110/60 mm Hg; heart rate was 68 beats per minute and regular. Auscultation revealed no evidence of cardiac murmur or crackle. On the chest radiograph, no remarkable findings such as cardiomegaly and pulmonary congestion were found. Electrocardiography revealed an ST depression in leads V5 and V6 and left ventricular hypertrophy (). Biochemical laboratory test results, including for cardiac enzyme and B-type natriuretic peptide, were within the reference range.
In order to exclude ischemic heart disease, invasive coronary angiography was performed. No significant luminal stenosis was observed in both the left and right coronary arteries. After contrast medium injection through the orifice of the left coronary artery, remarkable tortuosity of the left coronary artery and a plexiform network of vessels in the LV wall were observed (). The LV cavity directly communicated with the diagonal branch of the left anterior descending (LAD) artery through multiple microfistulas. After diastole, the LV was filled with contrast, enough for yielding findings on ventriculography (). The right coronary angiogram showed that the posterior descending artery of the right coronary artery was also directly drained into the LV ().
On two-dimensional echocardiography, the ratio of the apical lateral wall thickness (12 mm) to the left ventricular lateral free wall thickness (7 mm) was greater than 1.5 times (). Apical obliteration, aneurysmal change, or intraventricular pressure gradient was not found. Doppler echocardiography demonstrated that color signal of perpendicular to epicardium through multiple

[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:
CW is a 44-year-old female with four living children, who presented with an 8-month history of abnormal vaginal bleeding that started as intramenstrual spotting progressed to copious post-coital bleeding at presentation. She had occasional abdominal cramps and early satiety and no history of weight changes or constipation. No other systemic manifestations were elicited; she had a PAP smear test 6 years earlier that was normal. On clinical exam, the only positives were palpable abdominopelvic mass measuring 8 cm and a cervical tumour 3 cm with no evidence of parametrial, pelvic side wall or rectal involvement.
An ultrasound revealed a complex cystic mass with vascular mural nodules and ascites seen within the right adnexa ().
A bulky uterine cervix with a thickened endometrium that was heterogeneous in appearance was also noted. A staging MRI pelvis was also done (). A heterogeneous mass was seen arising from the cervix with endoluminal extension into the endometrial cavity. The mass was causing obliteration of the anterior fornix of the vagina with evidence of parametrial invasion anteriorly and on the left. The lower third of the vagina was normal and there was no evidence of bladder or rectal invasion. Also seen were complex masses with cystic and solid components arising from both ovaries. Moderate amount of ascites, peritoneal deposits and para-aortic lymphadenopathy were also seen. The rest of the solid and hollow abdominopelvic viscera including the visualized bone marrow signals were unremarkable. Provisional diagnosis at this stage was cervical malignancy with evidence of parametrial invasion (FIGO Stage IIb) and bilateral complex adnexal masses with ascites and peritoneal deposits suggestive of primary ovarian malignancy.
Biopsy of the cervix was SCC of the cervix and an ultrasound-guided biopsy of the ovarian mass was a SCC. The patient was stages as metastatic cervical cancer. Following tumour board discussion, the patient was started to systemic therapy

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


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

[User]
RADIOLOGY NOTE:
A 65-year-old gentleman with no comorbidities underwent elective laparoscopic cholecystectomy for symptomatic gallstones in 2013. His operation was complicated by intra-operative spillage of gallstones, which were retrieved. The patient remained well until 2017 when he developed a long-standing dry cough. Computed tomography (CT) scan chest showed a right lung base mass lesion with a large area of contact with diaphragmatic pleura, also abutting the right lobe of the liver. A small area of calcification was seen in the mass lesion thought to be part of the malignant process ().
Subsequent positron emission tomography scan and right pleural biopsies only showed inflammatory changes, and no evidence of malignancy was found. This mass lesion was followed up with a CT scan at 6 months interval that showed complete resolution.
Two years later, the patient developed fever and painful swelling over the back in the right paraspinal region. CT scan abdomen showed a large abscess in the right paraspinal region with no apparent cause demonstrated. This abscess was drained with a pigtail drain under ultrasound guidance.
A year later, the abscess recurred, and the patient required acute hospital admission. Inflammatory markers were observed to be elevated, C-reactive protein of 125 mg/L. His liver function test remained unremarkable. Abdomen was soft but tender in right flank.
A CT scan abdomen was performed, which demonstrated a large retroperitoneal abscess behind the liver tracking through a small intramuscular opening onto the skin over the upper aspect of the back ().
Because of previously identified calcification in the mass lesion and history of laparoscopic cholecystectomy, a non-contrast CT scan abdomen was obtained to ascertain if spilled gallstones were responsible for the recurrent abscess formation ().
Incision and drainage of the back abscess were performed under general anaesthesia. Almost 200 mL of frank pus were drained, and after a washout, a corrugated drain w

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


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

[User]
RADIOLOGY NOTE:
A 34-year-old man was admitted to our institution for chronic and intermittent abdominal wall pain localized in the right iliac fossa. This pain, evolving for the past one year, was not related to any particular position, oral feeding, or bowel movements. There was no history of weight loss or any gastrointestinal symptoms such as nausea-vomiting, diarrhea-constipation, or signs of gastrointestinal bleeding. He denied any abdominal trauma or past surgical operations.
On physical examination, a well-defined subcutaneous mass was palpable in the right iliac fossa. The mass was firm, non-tender, and not fixed to the skin or the muscular plane of the abdominal wall. It was sensitive to both light touch and deep pressure. No peritoneal signs or overlying skin changes were found. All routine laboratory tests including blood cell count, CRP (C-reactive protein), serum electrolytes, and hemostasis tests were completely unremarkable. Tumor markers including carcinoembryonic antigen and carbohydrate antigen (CA 19-9) were within the normal ranges.
An abdominal ultrasound examination was performed, which showed a solid and heterogeneous mass developed in the right abdominal wall. A basal computed tomography (CT) revealed a 7×5 cm well-circumscribed tissue-mass located in the subcutaneous plane of the right iliac fossa (). After intravenous administration of contrast media, the lesion showed a modest and homogeneous enhancement with a few scattered liquid chambers (). No lesions in the peritoneal cavity or parietal defects were identified.
Surgical resection of the mass was proposed and the patient was then operated under general anesthesia. The mass was easily enucleated after a direct anterior approach by a selective incision in the right iliac fossa ().
It was exclusively involving the subcutaneous plane without any connection to the musculofascial layer or the parietal peritoneum of the abdominal wall. Pathological examination of the resected specimen revealed an encapsulat

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


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

[User]
RADIOLOGY NOTE:
A 17-year-old Sardinian young woman underwent an initial examination at the dentist’s office during a routine checkup in 2010. After obtaining informed consent from her parents, clinical evaluation was performed, during which some caries were detected and also the need for an orthodontic consultation. The presence of an atrophy of filiform papillae with circinate erythematous ulcer-like lesions of the dorsum and the lateral border of the tongue was observed.
During the anamnesis, neither the patient nor her parents reported any history of systemic disease or, in particular, any gastrointestinal symptoms. Talking with the patient and her parents, it was possible to verify that the tongue affection had started when she was five years old with no other symptoms and with intermittence. During her past medical history, no one had ever investigated these tongue lesions.
With these elements, the clinician identified the tongue condition as an AG and started with a more detailed analysis of systemic and local conditions related to this pathology. The patient, as highlighted by the anamnesis, did not show any other symptoms or signs related to pathologies typically linked to an AG, apart from her short stature []. She was only 145 cm tall but this condition had previously gone unnoticed because her parents were also short. Considering the presence of short stature with an AG, the problems could be related to a nutritional dysfunction such as vitamin B12 deficiency. Given that Sardinia is an area with a high frequency of CD, gluten enteropathy became the first suspect as a possible cause for the eventual vitamin B12 deficiency.
As a first step, a blood sample was requested to determine the vitamin deficiency and to perform AGA and tTG antibody tests and the EmA test. Hematologic tests showed a vitamin deficiency with positive results for antibody tests (Table ) so a small intestine biopsy was performed during a gastroenterological consultation [].
A diagnosis of CD was made b

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


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

[User]
RADIOLOGY NOTE:
Cortical blindness followed successful surgical repair of two stab wounds in the heart in a 29-year old Libyan man, who was brought in a state of shock to the accident and emergency unit of our hospital following a fight. The patient was semi comatosed, with cold extremities, and with capillary filling more than 4 seconds. He was in sinus bradycardia with weakening pulse of 45 per minute, and his blood pressure was 70/50 mmHg. The pupil was dilated and sluggishly-reacting to light. Monitor ECG showed sinus bradycardia. Chest X Ray showed massive left haemothorax with left lung collapse. The patient didn't arrest but was in a pre arrest condition with low cardiac output status and progressively collapsing pulse and dropping blood pressure. We estimated a blood loss from the clothes of at least 2 litres. Cross matching for 5 units of whole blood was ordered, while left chest tube was immediately inserted with 850 ml of fresh arterial blood gushed out, and continued to drain at an estimated rate of more than 200 ml per hour into the water-seal reservoir. Urgent left anterior thoracotomy was performed under general anaesthesia. The heart was reached via pericariotomy. During this time, IV fluid infusion therapy was instituted with 1000 ml 5% dextrose saline and 1000 ml Ringers solution, and adrenaline 3 mg was given in the IV. Blood samples were sent urgently to the laboratory. Two profusely bleeding wounds were determined; one was at the ascending aortic root just above the aortic annulus, and the second was on the anterior surface of the left ventricle; a few millimetres to the left side of the proximal left anterior descending artery. The bleeding was completely stopped after repairing the 2 wounds with 4/0 pledgeted polypropylene sutures. By then, the cross matched blood arrived to theatre and was immediately given. Five units of whole blood were given over 24 hours, and were controlled by multiple Complete

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


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

[User]
RADIOLOGY NOTE:
The patient was a 44-year-old female craftswoman who had been suffering pain in the right upper limb for several months. The pain had increased progressively over the previous 3 months. She described pain at rest associated with coldness, pallor, and paresthesia of the limb. She had fallen from stairs when 9 months old, fracturing her clavicle, which was managed conservatively.
Physical examination revealed discrete deformity at the level of the mid third of the right clavicle. The right hand was cold and blue and ulnar, radial, brachial, and axillary pulses were all absent. Continuous wave Doppler detected no blood flow distally and monophasic flow in the brachial and axillary arteries. The chest X-ray showed a deformity of the mid third of the right clavicle, compatible with pseudarthrosis ( ).
Doppler ultrasonography demonstrated segmental occlusion of the subclavian artery with distal refilling via collateral vessels and very fine, threadlike flow in the axillary artery with occlusion of the brachial and radial arteries and refilling of the distal ulnar artery. Magnetic resonance angiography confirmed the Doppler ultrasonography findings ( ).
The pseudarthrosis was treated surgically, via a right supraclavicular incision, with resection of the mid segment of the clavicle ( ). The right subclavian artery was compressed and had thrombi with a chronic appearance inside. Thromboembolectomy of the subclavian artery was conducted with a 3F Fogarty catheter, followed by closure of the arteriotomy with a patch harvested from the saphenous vein in the thigh. Thromboembolectomy of the brachial, radial, and ulnar arteries was then conducted via an arteriotomy in the brachial artery, resulting in considerable improvement in terms of pain, temperature, color, and perfusion of the limb.
Throughout the examination, Doppler ultrasound of the hand showed triphasic flow in the radial and ulnar arteries. The patient was kept on clinical anticoagulant treatment with warfarin, maint

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


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

[User]
RADIOLOGY NOTE:
A 34-year-old male with no significant past medical history presented with generalized body pain and swelling of multiple joints. His symptoms slowly progressed and he developed severe backache and body pain which forced him to walk with support. Pain was so severe that someone had to help him get into his car. He had no history of trauma and was not on any medication. He did not have fever or other systemic symptoms. Initial clinical examinations were normal apart from generalized bone tenderness. The systemic examination did not reveal any features of Cushing’s syndrome.
The laboratory investigations showed elevated alkaline phosphatase, low serum phosphate, normal levels of parathyroid hormones (PTH), calcium, and vitamin D (Table ). His routine blood count, renal function, and serum protein electrophoresis were normal. The urine test was negative for Bence Jones protein.
X-ray of the cervical, thoracic and lumbar spine, shoulder, pelvis, and sacroiliac joint were also normal. Due to multiple joint pain and bone tenderness, a whole body MRI scan was done which was suggestive of osteoporosis with multiple insufficiency fractures of the sacrum, distal end of tibia and fibula, ribs, and acetabulum as well as multiple compression fractures of the vertebral body (Figures -). The bone densitometry showed a T score of -3.5 in the lumbar spine (Figure ).
A subsequent bone scan revealed multiple foci of increased radiotracer uptake likely from Looser's zones/pseudo fractures and costochondral beadings. Also increased uptake at proximal femoral and tibial growth plates likely from pseudo reactivation of growth plates. Multiple levels of increased vertebral uptake were noticed from compression fractures and at the sacroiliac joints from sacral insufficiency fracture. Findings were highly suggestive of osteomalacia. Left calcaneus three-phase bone scan revealed positive uptake suggestive of insufficiency type stress fracture. Delayed bone phase also showed bilateral distal t

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


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

[User]
RADIOLOGY NOTE:
A 44-year-old previously fit and well Caucasian man presented with a one-day history of severe, unremitting, and diffuse colicky abdominal pain with absolute constipation. He had a four-month history of similar but less severe pain, preceded by loose stools with mucus and frequent PR bleeds on a background of poor appetite and 7 kg weight loss over six months. Family history was notable for colorectal cancer in his uncle at 71 years of age. Social history was significant for 10 cigarettes a day, 70 units of alcohol a week, and extensive travel history to Thailand. On examination, the lower abdomen was distended and diffusely tender with tinkling bowel sounds but no guarding or rigidity.
A plain supine abdominal radiograph showed a hugely dilated caecum (maximum diameter: 15 cm) and transverse colon (maximum diameter: 10 cm) with paucity of gas in the descending colon (). A CT scan revealed apparent intussusception of a polypoid lead point into the distal descending colon () but no signs of bowel perforation as well as bilateral cavitating lesions in the lung apices ().
An urgent exploratory laparotomy revealed an irregular mass in the distal transverse colon and another adjacent mass in the splenic flexure with apparent spontaneous resolution of the intussusception seen on CT. Widespread lymphadenopathy was noted in the transverse colon mesentery. A left hemicolectomy was undertaken with excision of the left-sided omentum, followed by a side-to-side anastomosis with a defunctioning loop ileostomy.
A Mantoux test yielded 16 mm induration, albeit in the context of prior BCG vaccination 30 years ago. However, alcohol and acid-fast bacilli (AAFB) were not detected in sputum samples. HIV test was negative.
Histology sections from the colonic lesion showed an area of florid filiform polyposis () with no evidence of dysplasia but with adjacent ulceration of the colonic mucosa. The background colon showed areas of transmural chronic inflammation in the

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


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

[User]
RADIOLOGY NOTE:
A 35-year-old left-handed man who works as a mechanic and firefighter presented to our institution with hand pain and cold intolerance for 3 months. He was referred by a local vascular surgeon who had made the diagnosis of hypothenar hammer syndrome (HHS) following an angiogram of the right upper extremity showing complete occlusion of the ulnar artery (). On initial examination, Doppler signals of the ulnar artery, superficial palmar arch, and ring/small digital arteries were absent in the right hand. Subsequently, the patient developed an ulcer on his right long fingertip after minor trauma that had not healed over a 4-week period. He suffered ischemic hand pain and severe cold intolerance. After conservative management failed, the decision was made for operative intervention. We proposed using an arterial graft versus a venous graft in order to improve long-term patency. Our plan was to utilize the descending branch of the lateral circumflex femoral artery (DLCFA) as an arterial graft.
Intraoperatively, Doppler ultrasound revealed a segmental thrombotic defect extending from the superficial palmar arch, across the Guyon canal, extending 10 cm proximally in the forearm. The ulnar artery was resected back to healthy bleeding pulsatile flow, resulting in a segmental defect of 12 cm. Final pathology of the submitted ulnar artery segment revealed organizing thromboembolus in the lumen, which at the time of resection was adherent to the lumen.
The DLCFA was harvested, with care taken to prevent injury to the lateral femoral cutaneous nerve. A 12-cm segment of the artery was circumferentially dissected, as well as approximately 2 cm of 2 branching vessels at the distal end of the segment that would be used to reconstruct the superficial palmar arch and common digital arteries with one graft. With the arterial graft completely dissected, it was ligated both distally and proximally.
The arterial graft and recipient vessels were examined under the operative microscope. The

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


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

[User]
RADIOLOGY NOTE:
A 53 year old Pakistani lady presented to the Medicine clinic of a local hospital in 2004 with a history of heel pain and lower back pain for 5 months. In this period, the patient had sustained a rib fracture and left humeral fracture. There was no history of diabetes, hypertension or any other chronic disease. She had not been on any form of medication, including steroids and traditional drugs widely available and prescribed in the region, prior to the onset of pain. At the time of the fractures, she had been placed on non steroidal anti inflammatory agents, acetaminophen and tramadol. There was no history of illicit drug use and she was a non smoker. Family history was unremarkable, particularly in the context of bone disease, and malignancy.
Initial laboratory investigations had shown a mildly elevated total calcium level of 10.8 mg/dL {2.7 mmol/L}-(no albumin level result available from that time for correction). Parathormone levels (PTH) had not been determined. There was no vitamin d or renal function report available from that time. X-Ray pelvis revealed lytic lesions in the right iliac bone (Fig. ). A magnetic resonance imaging (MRI) of the lumbosacral spine showed some signal changes. The differentials based on the MRI were metastatic bone disease or multiple myeloma.
Serum protein electrophoresis was normal. The patient then got lost to follow-up. Her work up was resumed 4 years later when her bone pains had started flaring up. Bone marrow examinations done back in 2007, and later in 2009, were negative for multiple myeloma. A bone scan in November 2009 showed generalized increased tracer uptake over the skull and both the axial and appendicular skeletons- findings in favor of metabolic bone disease (Fig. a). An initial planar parathyroid sestamibi scan requested by a general practitioner in November 2009 was negative for any functioning parathyroid adenoma in the neck or superior mediastinum. No serum PTH report was available from this

[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 68-year-old man was referred to our oncology clinic with the pathologic diagnosis of duodenal malignant melanoma. This patient had a history of controlled diabetes mellitus, controlled hypertension and myocardial infraction before admission. He had suffered from fatigue, weakness, lethargy and weight lost (more than 10%) since one month prior to admission. Physical examination revealed no additional clinical data.
A complete blood count (CBC) test showed an iron deficiency anemia. Thyroid function tests were normal. Moreover, he underwent an upper gastrointestinal endoscopy (GIE) and a colonoscopy that revealed some erosion around pylorus of stomach and a prominent papilla of duodenum along with an ulcerative lesion adjacent to D2. Several biopsies were taken from the antrum and D2 lesions.
Histopathologic evaluation showed a high-grade malignant neoplasm involving the bowel wall. Tumor was composed of sheets of loosely cohesive pleomorphic cells with prominent nucleoli and eosinophilic cytoplasm. There was no visible melanin pigment in tumoral cells. Necrosis was also noted. The tumor cells labeled for S100 protein and markers of melanocytic differentiation; Melan-A. As staining for CK, LCA, CD117, and CD34 were negative, the diagnoses of carcinoma, lymphoma and gastrointestinal stromal tumor were ruled out. Morphologic and immunohistochemical findings were consistent with malignant melanoma ( and ).
Subsequently, after confirming the diagnosis of malignant melanoma of duodenal mucosa, the patient underwent secondary full medical evaluation including detailed inspection of the eyes, skin and mucosal surface. These examinations did not show any clinically significant lesion. Moreover, he underwent anoscopy for any visible lesion that was negative. Abdominopelvic computed tomography (CT) scan with intravenous contrast revealed multiple abnormalities. CT scan exhibited an ovaloid mass in the gallbladder with washout in delayed phase that was suggestive of a tumoral

[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 female was admitted for progressive ascending spastic paraparesis and hypesthesia of 6 months’ duration extending from her feet to her buttocks. Neurologic examination revealed that light-touch sensation below T10 was impaired and that muscle strength was Medical Research Council grade 4 in both lower limbs. Additional myelopathy symptoms included bilateral extensor plantar response, intensified deep tendon reflexes in both knees and Achilles tendons, and fecal and urinary incontinence. A thoracic spinal lesion was suspected. Magnetic resonance imaging (MRI) was performed on the thoracic spine and showed a perimedullary vascular lesion []. Subsequent angiography showed a major feeding artery from the left L2 lumbar artery and another minor feeding artery from L1. Multiple fistulas drained by multiple perimedullary veins were present at the T12 level [], indicating a typical spinal vascular malformation of type IV, subtype B. After discussing her treatment choices with us, the patient chose transarterial embolization, which was performed by injecting the chemical agent Onyx (Covidien, Plymouth, MN, USA) via a coaxial microcatheter system. An angiogram taken, a transarterial embolization, showed complete occlusion of the fistulas with preservation of the parent artery [].
The symptoms improved immediately, and only residual foot numbness remained. To prevent spinal cord swelling, dexamethasone (4 mg every 8 h) was administered by intravenous drip for 1 week. Unfortunately, myelopathy symptoms came back gradually beginning 1 week after embolization and had returned to their pretreatment status 2 months later. Accordingly, we suggested follow-up catheter angiography to screen for vascular remodeling, but the patient refused it. Instead, we performed thoracic spine MRI to rule out the possibility that residual AV shunting was causing recurrent venous hypertension and cord hypoperfusion. The lesion still showed vascularity and edema, although more less than

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


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

[User]
RADIOLOGY NOTE:
An 85-year-old woman with a history of smoking presented with an abnormal shadow on chest X-ray, which was performed as part of a pre-operative evaluation for osteoarthritis of the knee in December 2012. A chest computed tomography (CT) scan revealed a 2.8 cm nodule in the right upper lung lobe (Fig ) and fluorodeoxyglucose–positron emission tomography (FDG-PET) showed uptake only within the nodule. Although transbronchial lung biopsy (TBLB) was negative, cytology of bronchoalveolar lavage fluid from the right upper bronchi showed atypical cells suspicious for malignancy.
The patient was referred to our hospital for curative pulmonary resection in March 2013. Her physical examination was unremarkable, and her blood examination, including tumor markers, showed anemia with a hemoglobin value of 10.2 mg/dL. The cause of the anemia was not clear despite scrutiny. In April 2013, the size of the tumor shadow decreased from 2.8 to 1.8 cm (Fig ). We strongly suspected the tumor was benign rather than malignant and planned to perform a follow-up imaging examination. The tumor shadow remained unchanged for the next three months (Fig ). In July 2013, the patient was diagnosed with rheumatoid arthritis and began to receive glucocorticoid treatment. In January 2014, the tumor increased from 1.8 to 4.8 cm (Fig ) and a TBLB of the tumor was performed with suspicions of inflammatory disease or malignancy; however results of the TBLB were inconclusive. A chest CT scan was repeated in June 2014 and showed that the tumor shadow had further enlarged to 8.6 cm, with swelling of the mediastinal lymph nodes and suspected invasion of the superior vena cava and chest wall (Fig ). FDG-PET showed uptake within the tumor with a maximal standard uptake value of 23.6, but did not show uptake within the mediastinal lymph nodes. An ultrasound-guided biopsy of the tumor revealed a proliferation of tumor cells with large and irregular nuclei (

[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 11-year-old girl was presented to the National University of Malaysia (UKM) Paediatric Dental Clinic with a referral for further management of pulp necrosis of an immature lower right second premolar (tooth 45), secondary to the fractured tubercle of dens evaginatus. Two weeks earlier, she had treatment at a general dental clinic for pain related to tooth 45. Tooth 45 had spontaneous and lingering pain following cold and thermal stimuli. The tooth was diagnosed to have symptomatic irreversible pulpitis, and root canal therapy was initiated. The canal was accessed, and pulp extirpation performed before the placement of intracanal nonsetting calcium hydroxide by the general dental practitioner (GDP).
At the time of current assessment, her tooth-related symptoms had completely resolved. General oral examination showed the presence of generalised mild gingivitis with a basic periodontal examination (BPE) score of 1 in all sextants. The patient's oral hygiene was fair with a plaque score of 30%. The patient is still in her mixed dentition with the presence of the primary maxillary canines. Her upper dental arch was well aligned, and mild crowding of anterior teeth was noted in the lower arch. Tooth 45 has an occlusal glass ionomer dressing of the access cavity made for the pulp extirpation earlier by the GDP (). Cold and electric pulp sensibility testings showed positive responses to all fully erupted premolars indicative of tooth vitality expect for tooth 45. Tooth 45 also has slight tenderness to percussion. Periapical radiograph of tooth 45 showed an immature root with convergent open apex and small periapical radiolucency. The pulp space of tooth 45 is of an even width from the coronal to the apical portion (). Based on the assessments, tooth 45 was diagnosed with pulp necrosis secondary to fractured dens evaginatus and symptomatic apical periodontitis.
On the day of initial assessment, tooth 45 was isolated with rubber dam after infiltration of local anaes

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


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

[User]
RADIOLOGY NOTE:
A 38-year-old female with no past medical history came to the hospital with complaints of episodic chest discomfort, mild dyspnea, and occasional non-productive cough. On physical examination, she was hemodynamically stable without any pathological finding. A chest x-ray was done and it showed mass-like opacities abutting the right heart (Figure ).
To have a better idea of the cause of opacity, a further assessment with computed tomography (CT) chest with contrast was ordered and it showed a large, well-circumscribed, heterogeneously enhancing mass of 10 cm with peripheral calcification in the right mediastinum. Also, there was a dilated vessel along the posteromedial and inferior of the mass (Figure ).
After the chest CT findings, the patient was admitted to the hospital for further evaluation and cardiac consult was called. In order to differentiate if the mass was due to some tumor or some anomaly of the coronary vessel, coronary CT angiography with contrast was ordered. A subsequent coronary CT angiography (CCTA) showed a 9.7 cm aneurysm and an anomalous vessel emanating from the left coronary artery and the proximal circumflex, fistulizing into the right atrial appendage. CCTA also showed a dilated right atrium likely due to fistula formation (Figures -).
When the right heart catheterization was performed, a rise in saturation was noted in the right side of the heart due to shunting of blood from the left side to the right side of the heart as a result of coronary cameral fistula formation between the right heart and the anomalous vessel originating from the left coronary artery and proximal circumflex artery. On transesophageal echocardiogram (TEE), an enlarged right atrial chamber was noted due to the fistulous tract draining into the right atrium. The cardiothoracic department then scheduled the patient for surgery. Sternotomy was performed to repair the coronary artery aneurysm with ligation and resection of the coronary cameral fistula and repair of the ri

[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 68-year-old asymptomatic woman was referred to our hospital after an aortic valve mass was detected on transthoracic echocardiography after a heart murmur was found on routine auscultation. Her medical history was free. At transthoracic echocardiography, a mass 10.5 mm × 4.6 mm attached to the left coronary cusp was detected. The mass was a pedunculated, mobile, round, echo dense, and stipple in texture structure, with well-demarcated borders, features typical of a fibroelastoma. It projected into the arterial lumen of the aorta without causing any aortic insufficiency while the rest echocardiographic examination revealed an estimated left ventricular ejection fraction of 0.50 without other valvular abnormalities []. Because of the gross appearance and the location of the lesion, a working diagnosis of papillary fibroelastoma was made. On the basis of the potential embolic risk either of the mass itself or of associated thrombus and the possibility of further enlargement, the patient although asymptomatic at the time of diagnosis was referred for elective surgical excision of the mass in our department. This is confirmed by the international bibliography[] other than our experience. A median sternotomy and a standard cardiopulmonary bypass were established. After the aortotomy a pedunculated flower-like tumor was found []. A valve-sparing technique with simple shave excision of the tumor was undertaken with particular care in avoiding embolization and ensuring that no remnants from fragmentation of this friable tumor were left behind both locally on the cusp and in the vicinity of ascending aorta and left ventricle. The resected lesion had a flower-like appearance with frond-like projections deriving from the tumor. The lesion was histologically diagnosed as a papillary fibroelastoma []. The patient's postoperative course was uncomplicated. She discharged the 6th postoperative day in optimal clinical conditions. A follow-up echocardiogram at 2 weeks did not demons

[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 man presented to the Emergency Department after passing bright red blood mixed with dark clots per rectum. He had vague, crampy abdominal pains for the previous two days. Past medical history included hypertension, type 2 diabetes and ischaemic heart disease. One year previously, he was admitted to hospital with vague, intermittent central abdominal pain, which resolved following observation for 5 days.
On admission, he was tachycardic and hypotensive, with no abdominal tenderness or palpable masses. Rectal examination revealed bright red blood and clots on the glove. Admission haemoglobin was 8 g/dl. Serum ferritin was low at 19 μg/L. He was resuscitated and stabilised with intravenous fluids. Computed tomography (CT) scan demonstrated uncomplicated sigmoid diverticular disease and no other pathology to explain his symptoms. He underwent urgent upper gastrointestinal endoscopy, which was normal to the second part of the duodenum, with no signs of haemorrhage. Subsequent colonoscopy showed a colon full of fresh blood and clots up to the caecum, with no obvious bleeding source. Intubation of the small bowel and examination of the terminal ileum showed fresh blood filling the lumen, with a likely bleeding point in the proximal small bowel beyond the reach of the endoscope. At this stage, the patient became haemodynamically unstable and a decision was made to take the patient for an urgent exploratory laparotomy.
At laparotomy, blood was seen to fill the entire large intestine. The small bowel was filled with blood from the terminal ileum up to the proximal jejunum. The first 100 cm jejunum, after the ligament of Trietz, was fixed to the retroperitoneum with the rest of the proximal jejunum lying to the right of the midline (Figures &). There were no palpable masses or visible inflammatory pathology. The bleeding source was presumed to be in the proximal jejunum. The blood in the small bowel was emptied manually and a series of soft bowel clamps were appl

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


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

[User]
RADIOLOGY NOTE:
A 71-year-old Japanese postmenopausal woman was referred to us for evaluation of a tumor in the right breast. She had suffered from malignant lymphoma (diffuse, medium to large B-cell lymphoma) treated with chemotherapy consisting of eight cycles of R-CHOP and radiotherapy (total 46 Gy) to the head for the previous 3 years. She had undergone hysterectomy for myoma of the uterus at the age of 41 years. In addition, she had a medical history of hypertension and hyperlipidemia. There was no remarkable family history.
Physical examination demonstrated an elastic hard lump on palpation located in the lower lateral quadrant of the right breast. The tumor size was 2.0 cm in diameter, and the borderline was unclear. No skin change or dimpling was seen. Nipple charge was not evident. No axillary lymph node swelling was found. All laboratory data were unremarkable, and there was no increase of tumor markers such as CEA and CA15-3.
Mammography of the right breast showed an unclear mass with accumulation of calcification (Fig ). Ultrasonography showed a hyperechoic lesion within a hypoechoic area, with rough surface (Fig ). Enhanced magnetic resonance imaging revealed a mass of high intensity in the right breast (Fig ).
Histopathological evaluation of the core needle biopsy material revealed an invasive adenocarcinoma with metaplastic change, but definitive histological diagnosis could not be determined. There was no proliferation of atypical lymphocytes.
The patient underwent right mastectomy and sentinel lymph node biopsy. The frozen section of the sentinel lymph node was found to be free of disease by intraoperative diagnosis.
Macroscopically, cut sections revealed a white, solid, and well-circumscribed tumor measuring approximately 17 × 15 mm (Fig ). Histopathologically, the tumor was composed of cancer cells forming papillary or tubular structures with an abundant mucus cytoplasm, which was positive for periodic acid-Schiff staining, and accompanied by psammoma bodies (Fig

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


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

[User]
RADIOLOGY NOTE:
The patient was a 93-year-old man who presented with a several months history of an expanding lesion of the right temple (Figure ). Medical history was significant for ischemic heart disease and elevated cholesterol. The clinical evaluation demonstrated the lesion was greater than 5 cm in greatest dimension, ulcerative, non-mobile, and extended superiorly into the temporal region and anteriorly overlying the zygoma region. The sebaceous material could be expressed with pressure. Clinically, he had no adenopathy. Punch biopsy pathology demonstrated the presence of a proliferating trichilemmal cyst in the dermis. In focal areas, marked atypia and invasion into the stroma was also noted. The findings were consistent with a malignant proliferative trichilemmal tumor.
The patient was reviewed at a multidisciplinary tumor board. Given the relatively large nature of this unusual tumor, an immediate surgical intervention was not felt to be in keeping with optimal management. Given his advanced age and medical comorbidities, he was deemed to be high-risk for a general anesthetic, and the broad, thick lesion with margins would have necessitated a larger resection with skin graft reconstruction. The location of the temporal branch of the facial nerve would have necessitated a limited deep margin resection. The patient was consented for radiotherapy totaling 4,500 cGy over three weeks of 9 MeV electrons with a margin of 2 cm. A bolus of 1.5 cm was used to ensure a 95 – 100% dose to the lesion. Customized lead shielding was used to minimize radiation to healthy tissue (Figure ). Surgical reassessment and potential excision could then be arranged for a smaller resection, if needed.
The patient was reassessed five weeks following radiotherapy and near complete response of the tumor was noted. Only a small area of crusting 1.5 cm from the lateral canthus was observed. This area was in keeping with radiation-induced changes to the tissue. Further healing was noted at six months with

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


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

[User]
RADIOLOGY NOTE:
A 47-year-old Caucasian male with a past medical history of uncontrolled diabetes mellitus, hypertension, gastroesophageal reflux disease, and anxiety presented to the emergency department with a chief complaint of right foot swelling. The patient reported that the swelling started two weeks prior to the presentation but denied any associated pain. The patient denied injury or trauma to the foot. An X-ray of the right foot revealed old fracture deformities but no evidence of an acute osseous lesion. A lower extremity Doppler ultrasound was performed and ruled out the presence of deep vein thrombosis (DVT). The patient also endorsed dysuria, dribbling, and urinary retention over the previous day but adamantly refused placement of a catheter. When the patient was told that he would be discharged from the emergency department, he began complaining of chest tightness, shortness of breath, and nausea, all of which he denied on a review of symptoms during the initial evaluation. He stated that the chest discomfort had been present all day, was non-radiating, and rated at a 4/10 in severity. Electrocardiography (EKG) and cardiac enzymes were within normal limits. The patient was admitted for further evaluation.
During the hospitalization, the patient developed multiple additional complaints that after appropriate workup, ultimately did not lead to a specific diagnosis. The patient worked with physical therapy and occupational therapy, which established that the patient was difficult to assess, as his functional mobility issues were inconsistent. He was noted to have deficits in balance, endurance, and safety awareness, which affected the patient’s ability to perform the activities of daily living. Of note, one of the physical therapists documented that the patient was witnessed alone in his room, walking without difficulty while texting on his phone.
On hospital day four, the patient was displeased when told that he was being discharged, as he desired further workup for hi

[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 16-year-old Bangladeshi girl presented to our hospital with hoarseness of voice which had been gradually worsening over the past 4 months. She was treated earlier by the local physician with antibiotics. On evaluation with a fiberoptic endoscopy, she was found to have a polyp in the anterior 2/3 of the right vocal cord with impaired right vocal cord mobility. She underwent excision of the polyp, and subsequent histopathology showed well-differentiated squamous cell carcinoma. She was then referred to the oncology clinic for further management.
She had no history of using tobacco or consuming alcohol. She had a history of exposure to passive smoke. She did not have a past history of any laryngeal surgery or exposure to radiation/carcinogenic agents; there was no family history of malignancy either. A computed tomography scan of the neck showed an irregularity of the right vocal cord, and no neck nodes were seen. Her biopsy slides were reviewed, and the diagnosis of carcinoma was confirmed (fig. ). Her disease was staged as T2N0M0 well-differentiated squamous cell carcinoma of the larynx.
She was planned for radical radiotherapy. The treatment fields were as per the standard guidelines for a T2 vocal cord. The superior border was 1 cm above the thyroid cartilage, the inferior border at the lower edge of cricoid cartilage, anteriorly in air, and the posterior border was kept at the anterior border of vertebral bodies (fig. ). Neck nodes were not prophylactically treated as the incidence of nodal positivity is <2% in T2 lesions. The organs at risk that were taken into consideration were the parotids and spinal cord. The dose received by breasts and thyroid glands was also estimated for documentation purposes. She did not receive any concurrent chemotherapy in view of early disease. She was then treated with radical radiotherapy (66 Gy in 33 fractions, 2 Gy per fraction, 5 days a week over 6 1/2 weeks) using 6 MV photons in a linear acceler

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


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

[User]
RADIOLOGY NOTE:
A 45-year-old woman presented to our hospital with multiple lung nodules. She had a history of poorly differentiated thyroid carcinoma, diagnosed 7 months prior to admission, at an outside hospital. The patient was healthy otherwise and reported no radiation exposure or any family history of thyroid cancer. The initial work-up at the time of discovery of the right thyroid nodule included fine needle aspiration and core biopsy, with findings consistent with poorly differentiated thyroid carcinoma. The patient then underwent a total thyroidectomy and central neck lymph node dissection. The pathologic diagnosis from the outside hospital reported a 2.8 × 2.4 × 1.1 cm tumor in the right thyroid without extrathyroidal extension or lymph node metastasis. However, both capsular invasion and extensive vascular space invasion were noted. Based on the tumor size, tumor extension and lymph node status, the tumor was designated as Stage II (pT2 pN0 pMx). IHC staining showed that the tumor cells were positive for thyroglobulin and thyroid transcription factor 1 (TTF1). An immunostain for p53 was also performed at the outside hospital and showed a small focus (< 1 cm) with p53 positivity, suggesting a diagnosis of anaplastic thyroid carcinoma.
At our institution, the diagnosis was revised, based on review of both the primary thyroid tumor and the current lung metastases. Both tumors were remarkable for biphasic malignant components: the carcinoma and the sarcoma. The carcinoma component showed a poorly differentiated microfollicular type thyroid carcinoma, composed of sheets and islands of tightly packed thyroid follicles with dense colloid. The tumor nuclei were small and round with vesicular chromatin, resembling those of typical poorly differentiated follicular thyroid carcinoma. Admixed with the epithelial component were malignant spindle cells with small round blue cell type morphology. Focally, rhabdomyosarcoma-like cells with eosinophilic cytoplasm were appreciated. No hete

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


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

[User]
RADIOLOGY NOTE:
The patient was a 63-year-old man who presented with the chief complaints of swallowing difficulty, heartburn, and vomiting. Although he had begun to notice those symptoms 10 years previously, the condition had been followed up conservatively. He had noticed worsening of the swallowing difficulty, had also developed vomiting, and therefore visited a hospital near his home. Upper gastrointestinal endoscopy revealed two lower esophageal diverticula on the right and left walls, and he was finally referred to our hospital in December 2014. His medical history included hypertension and bronchial asthma; there was no history of smoking or drinking.
Upon admission, physical examination of the patient was completely normal. Laboratory findings, including complete blood count, erythrocyte sedimentation rate, and biochemical tests, were all within normal limits. An upper gastrointestinal contrast study revealed two diverticula with diameters of 7.5 × 5.5 cm and 3 × 3 cm on the right and left walls, respectively. The entrances of the diverticula were located in the lower esophagus, and the lower esophagus was sigmoid-shaped, and pooling of barium in the diverticulum, delayed passage into the stomach, and dilation of the esophagus were seen (Fig. ). Upper gastrointestinal endoscopy revealed the inlet of the diverticulum on the right wall of the lower esophagus at a distance of 34 cm from the incisors and another diverticulum immediately above the esophagogastric junction at a distance of 40 cm from the incisors (Fig. ). The esophagogastric junction was not well opened by air supply (Fig. ). A chest computed tomography (CT) scan showed food debris and fluid collection within the diverticula (Fig. , ). Intra-esophageal pressure measurement showed a high lower esophageal sphincter (LES) pressure of 98.6 mmHg, with a length of 29 mm, a vector volume of 23,972 mmHg2 cm, and normal peristaltic waves (Fig. , ). In addition, LES relaxation was not noted during the manometry test, but i

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


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

[User]
RADIOLOGY NOTE:
We present the case of a 53-year-old Caucasian male who was admitted to the hospital owing to fatigue and black stools. His vital signs on the admission were: temperature 36.8 °C, heart rate 70 beats per minute, respiratory rate 17 breaths per minute, and blood pressure 120/80 mmHg.
The patient was pale but with good nutrition status [body mass index (BMI) 23.1 kg/m2]. He did not consume alcohol or tobacco. He was married and had two children aged 15 and 19 years.
He was taking no medication and had no other underlying disease. Moreover, his medical history was free of any previous surgical interventions. During the clinical examination, there was no sensitivity or tenderness in the abdomen and the bowel sounds were normal. Digital rectal examination revealed the presence of black stools. Clinical examination of cardiopulmonary and urogenital systems showed no abnormal signs. Apart from fatigue, there were no other findings on physical and neurological examination.
The blood tests depicted anemia (hemoglobin 6.0 g/dl with normal values between 13.4 and 17.4 g/dl, and hematocrit 20% with normal values between 41% and 53.8%). The results of all other markers were within normal range (Table ).
During his admission to the hospital, the patient was transfused with 4 units of blood and 1 unit of fresh frozen plasma, and a Computerized Tomography (CT) scan of the abdomen was performed. The CT scan of the abdomen revealed a mass with vague limits (dimensions 6.8 × 5.7 cm) between the pylorus of the stomach and the first part of the duodenum. Around that mass, there were several lymph nodes with diameter up to 1.6 cm. Furthermore, the presence of appendiceal mucocele was indicated as an incidental finding.
On the third day of his hospital stay, the patient underwent EUS and upper gastrointestinal endoscopy, in which the biopsies showed morphologic and immunochemical features

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


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

[User]
RADIOLOGY NOTE:
A 45-year-old female was admitted to the hospital after complaining of an orthostatic headache and cervical pain the day before. The headache occurred whenever the patient was in a sitting or standing position, but not in a supine position. She did not have a history of trauma. She was alert and did not have other neurological symptoms. There were no abnormal findings in the brain MRI.
The day after the patient's hospital admission, she had sudden quadriplegia and paraesthesia. The motor grade of her lower extremities was 0, and that of her upper extremities was I. The pain and high temperature on both sides were reduced, and the patient recovered with a motor grade of 3 in her upper and lower extremities. C-spine MRI was taken, and SEDH was suspected because isointensity was observed in the T1-weighted image of the epidural space from C2 to T2 while hyperintensity was observed in the T2-weighted image of the same ().
Angiography was performed to rule out any vascular abnormality, such as arteriovenous malformation. Its result was normal. An emergency left hemilaminectomy from C4 to T1 was performed to remove the hematoma, and controlled the bleeding. During the operation, engorged epidural veins were observed, and the dura was not damaged during the operation. After the operation, the patient recovered completely from motor and sensory deficits. 6 day after surgery, myelography and computed tomography (CT) were performed due to the CSF leakage in the wound. As a high density was observed from C3 to T3 (), lumbar drainage was performed. During the lumbar puncture, the opening pressure was too low to be measured, and the lumbar drainage was minimal. The patient was treated for two weeks, for stabilization. There was increased epidural fluid collection at C2 to T3 in the spinal CT(). Second operation was thus performed, and there was no leakage at the dorsal part of the dura but there was some leakage at the

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


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

[User]
RADIOLOGY NOTE:
A 39-year-old male was transferred to our hospital from another hospital. He had mild tenderness, an obvious bowel pattern and hyperactive bowel sounds; he was able to pass gas occasionally. Before admission, he suffered progressive abdominal distention and gradual deterioration, and he developed malnutrition for two months. A total alimentary tract angiography showed partial enlargement of the ascending colon and transverse colon and partial dilation of the distal small intestine (Fig. ). He was diagnosed with “adult megacolon” and recommended for surgical treatment. However, the operation was not performed because of a significant decrease in platelets (with a minimum of 19 × 109/L) and severe malnutrition. He had been in a car accident 2 years previously. He was the driver and was wearing a seat belt at the time of the accident. During that admission, he was always conscious and was found to have left clavicle fractures and multiple rib fractures. Abdominal examination showed seat belt marks and mild localized tenderness at the site of the abrasions. An abdominal CT scan showed a small amount of fluid (approximately 150 ml) in the abdominal cavity with no solid organ abnormalities. He was hemodynamically stable and was able to pass gas and defecate. He improved rapidly with conservative treatment, was discharged after several days and was asymptomatic. Two months after discharge, he started to have episodes of abdominal distension and intermittent mild tenderness, and he passed gas less frequently than before. However, he improved rapidly again after receiving treatment with traditional Chinese medicine.
After admission, we first tried to improve the general condition of the patient by strengthening parenteral nutrition and correcting electrolyte imbalances. Then, a series of additional examinations were performed to explore the possible reasons for these problems. An abdominal CT scan showed an abrupt narrowing zone at the jejunum (Fig. ). Small balloon colonosc

[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 man presented to the emergency department, following exposure to a bomb blast injury. He had a patent airway, but he was tachypneic, agitated, confused, and pale. His blood pressure was 70/30 mm Hg and pulse rate 120 per minute. The right radial pulse was impalpable due to a compound fracture of the arm. There was a 4-cm wound in the right sixth intercostal space in the midclavicular line. The abdomen was tense and tender all over. Abdominal ultrasonography was positive for hemoperitoneum. A right-sided intercostal drainage tube was inserted for hemopneumothorax.
Exploratory laparotomy was carried out. Two liters of blood were found in the peritoneal cavity. The liver was lacerated and actively bleeding. The gallbladder was found injured; cholecystectomy was done. Suturing of the liver did not control the bleeding. Thus, a decision was made to insert perihepatic packs. Two gastric perforations were repaired. A 6 cm × 3 cm × 2 cm shrapnel was found anterior to the first part of the duodenum (). A drain was left near the Morrison's pouch.
The vascular surgeon explored the lacerated wound of the right arm and found that the ulnar artery was completely transected at the bifurcation of the brachial artery. Reconstruction was accomplished using a brachio-ulnar reversed saphenous vein graft.
On the first postoperative day one liter of blood was recovered from the abdominal drain. On the third postoperative day and before shifting the patient to the operating theatre for packs removal, CT of the abdomen was done; showed a 3 cm × 1.8 cm IHPA of the left hepatic artery (). Hepatic angiography confirmed the presence of the IHPA emerging from a side branch of the left hepatic artery (). Microcoil embolization of both afferent and efferent loops of the aneurysm was done (). The perihepatic packs were removed on the same day. There was mild oozing

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


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

[User]
RADIOLOGY NOTE:
A 64-year-old male patient presented to his primary care physician complaining of a dry cough and recurrent bouts of bronchitis as well as frequent orthostatic dizziness. At the age of 20 years, he had undergone repair of CO-A through a left thoracotomy using an interposition Dacron graft between the left SCA and the mid thoracic aorta. His chest radiograph raised suspicion of AN of the thoracic aorta. Computed tomographic angiogram then confirmed the presence of two large anastomotic PANs at both ends of the graft (
) as well as an occluded right SCA, stenosis of the left vertebral artery, and bovine origin of the carotid arteries (
).
In view of this complex anatomy, the decision was made to use a hybrid approach to address these findings. In a first stage, a right carotid artery to right SCA bypass was done using a short segment of Goretex graft (
). Next, using single lung ventilation, a right posterolateral thoracotomy was performed and the chest entered through the fifth intercostal space. With the diaphragm retracted inferiorly, the pericardium, posterior to the phrenic nerve, was gently lifted with a long clamp, thus allowing exposure of the distal most portion of the thoracic aorta, medial to the inferior vena cava (IVC). After heparinization, the aorta was partially clamped and a 22 mm Hemashield graft anastomosed in an end-to-side fashion to an appropriate aortotomy using a continuous suture of 5–0 Prolene (
). The graft was then brought posteriorly to the IVC and anteriorly to the right hilum, then anastomosed in an end-to-side similar fashion to the partially occluded ascending aorta through a vertical pericardial opening (
,
).
The immediate postoperative course was uneventful, and 5 days later, the patient was brought to the hybrid operating room for completion angiogram. This confirmed patency of the extra-anatomic graft as well as the presence of a 4 cm proximal left SCA anastomotic PAN with close extension

[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 is a 51-year-old man of North African origin with a history of hypertension who had been diagnosed as having a right kidney tumor associated with one bulky pleural metastasis and some smaller metastatic lesions of the lung; Case 1 is summarized in Fig. . No bone or brain metastases were observed at initial work up; he was classified in the poor risk group according to the International Metastatic RCC Database Consortium (IMDC) []. A radical nephrectomy was performed in July 2012. A pathological report indicated a renal cell carcinoma (RCC) of 16 cm with a clear cell component and some degree of a more aggressive cellular component, giving a Fuhrman grade of 4, pT3a pN0 M1 according to the Union for International Cancer Control (UICC) classification. Sunitinib, 50 mg/day, then reduced to 37.5 mg due to side effects, was administered during 6 months. Because of the painful progression of the pleural metastasis in the upper part of his left lung, radiation therapy was delivered to this tumor. Systemic treatment was further modified for the approved second-line treatment everolimus. This latter treatment induced a significant tumor response in most metastatic sites for 15 months before re-progression. In March 2014, our patient complained of persistent headaches and brain magnetic resonance imaging (MRI) identified a single right frontal metastasis. Stereotactic radiotherapy was performed and a treatment with axitinib, a second-line TKI directed against VEGFrs, was started. Axitinib induced significant tumor shrinkage in the pleural and lung metastases; the brain metastasis was much improved because a brain MRI was considered almost normal. Axitinib was maintained for 18 months, but had to be completed because of a severe episode of angina pectoris. A coronary stent that required dual anti-platelet therapy for 6 months was indicated. Due to an increased hemorrhagic risk with this treatment together with a VEGFr inhibitor, axitinib was not resumed; nivolumab, a pr

[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:
Patient 1 was a 45-year-old man who presented with left flank pain. His medical history indicated that he had renal stone. His physical examination was positive for tenderness upon palpation of his left flank. The initial laboratory evaluation showed normal. The computed tomography (CT) scan of abdomen and pelvis showed left moderate hydronephrosis and an upper ureteral stone was measured at 1.3 cm. Our patient was diagnosed with left upper ureteral stone with moderate hydronephrosis. The procedure of PCNL was carried out. A ureteral catheter was inserted retrogradely into the left pelvic under ureteroscopy. The puncture target calix was the middle posterior calix. The puncture site of the target calyceal fornix was localized under C-arm radiological monitoring using contrast agent injected through ureteral catheter, producing a retrograde pyelography (RP). An 18 gauge, 2 piece entry needle was used. Clear urine was seen when the needle stylet was removed. When we injected the contrast agent into his left collecting system through the puncture needle, we were able to see his left renal vein (Fig. ). Moreover, we could identify that the location of the puncture needle tip was not optimal, the reason was that the puncture needle tip was located outside the collecting system near the calyceal infundibulum. At the moment, the patient had a hemodynamic stability and the puncture needle was maintained in its original place. Additional lower pole calix puncture was performed under radiological monitoring. Clear urine was also seen when the needle stylet was removed. Injection of contrast agent in his left collecting system through the later puncture needle showed the collecting system, without visualization of the renal vein (Fig. ). In the process of injecting saline into his left collecting system by ureteral catheter, we were able to see the light red drips through the former puncture needle, and the clear drips through the latter puncture needle. The former puncture ne

[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 16-year-old boy visited an orthopedic hospital for pain in the right inguinal area that occurred after he fell down while standing on his hand during a physical exercise class, but as the simple X-ray did not show abnormal findings, the patient was observed with conservative management. Two days after the onset of symptoms, the patient had muscular weakness and hypesthesia on the right lower leg, so he underwent lumbar spine computed tomography (CT) at a general hospital, was hospitalized and treated conservatively under suspicion of spinal cord injury. Fourteen days after the onset of symptoms, since there was no improvement in his symptoms, the patient was transferred to the Department of Orthopedic Surgery in our hospital. He had no significant medical or trauma history before injury.
The simple X-ray of lumbar vertebrae and pelvic bone did not show abnormal findings. There was no abnormality on the thoracolumbar spine MRI except a mild herniated intervertebral disc between L5 and S1 and unilateral spondylolysis accompanied by spina bifida occulta.
Seventeen days after the onset of symptoms, the patient was referred to our Department of Rehabilitation Medicine for the assessment of muscular weakness in the right lower extremity. On physical examination, muscular atrophy was observed as the circumference of the right thigh measured at 10 cm proximal to the patellar upper margin was 40 cm while that of the left thigh was 46 cm (), and severe tenderness along with ecchymosis was observed in the right inguinal area. According to the results of the manual muscle test (MRC, Medical Research Council), the left lower extremities were normal but the right lower extremities showed hip flexion 3/5, knee extension 2/5, ankle dorsiflexion 5/5, great toe extension 5/5 and ankle plantar flexion 5/5. On sensory tests, hypesthesia and paresthesia were observed in the right anteromedial and anterolateral thigh, and the medial side of the lower leg (). The deep tendon reflex of t

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