[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 81-year-old Chinese woman was referred to our centre from a private medical centre for further management of intestinal obstruction and pneumonia. She presented with one week history of epigastric discomfort associated with vomiting and abdominal distension. Her bowel habit was mildly altered but there was no history of passing blood per rectally. She denied any loss of weight or appetite. Interestingly she gave a history of eating a large amount of Chinese mushroom a few days prior to her presentation. Medically she was being treated for hypertension and congestive cardiac failure. Her past surgical history consists of a laparotomy performed 26 years ago and a right nephrectomy for renal stone performed 20 years ago. She was however unable to ascertain the reason for the laparotomy.
On admission, her vital signs were stable with BP of 200/90 and HR of 100/m. Chest auscultation revealed reduced air entry and crepitation at the right lower lobe. Her abdomen was soft but slightly distended. A mobile vague mass was palpable at the left iliac fossa. Bowel sound was sluggish and per-rectal examination revealed an empty rectum with no palpable mass. Her hernia orifice were normal.
Chest radiograph was done and showed right lower lobe consolidation with evidence of chronic obstructive airway disease and cor pulmonale. Echocardiogram showed evidence of cor pulmonale with no acute ischaemic changes. Her blood investigation results were unremarkable. Blood culture was positive for coagulase negative Staphylococcus. Urine culture and sputum AFB were negative. Her amylase level was normal.
Prior to admission to our hospital, the patient had a barium meal and follow-through examination and CT scan of the abdomen done at the referring hospital. The barium studies showed proximal small bowel dilatation with an oval intraluminal filling defect seen at the end of the dilated segment which was about 1 foot from the duodeno-jejunal junction. Also present were ‘coil spring’ and ‘cla

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


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

[User]
RADIOLOGY NOTE:
The second case is a 7-year-old boy with right-sided submandibular lymphadenopathy who was transferred from a regional hospital to the Children's University Hospital where he remained for approximately two weeks. His body temperature during this period was normal; however, his parents reported that he had occasional fatigue and poor appetite. It was noted that he had signs of dysmorphism and mild growth delay. He was born at 40 weeks (mother's 5th pregnancy, 5th birth) with a weight of 3,680 g and a height of 53 cm; there were no complications during pregnancy/birth. He had had some mild viral infections after starting kindergarten and had received all his immunizations according to the immunization schedule. His parents did not detail any chronic diseases. He had two healthy brothers, one sister with a double kidney, and one sister that had died at 11 years of age due to some type of congenital pathology, possibly microcephaly (not enough information was available)—family tree shown in .
Ultrasound examination of the boy's cervical lymph nodes and abdominal cavity, thoracic CT scan, and abdominal MRI were performed, and they showed suspicions of lymphoproliferative disease. Consequently, lymph node biopsy, bone marrow aspiration, and trephine biopsy were performed; however, no evidence of lymphoproliferative disease was found, and the boy was discharged in a stable condition. At a follow-up visit, two months later, it was observed that the lymph node conglomerate in his neck area had increased in size. An MRI of the head and neck area was subsequently performed, and the following was reported: large abnormal formation in the cervical soft tissues on the right side, with extracranial parapharyngeal, carotid space with internal carotid artery (ACI), ACE overgrowth, intracranial proliferation through the foramen jugulare in the cerebral cortex with peripheral oedema, and 4th ventricle compression with initial 3rd and lateral ventricle extension. Trepanation, extirpati

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


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

[User]
RADIOLOGY NOTE:
A 55-year-old Caucasian male, with a past medical history significant for tobacco abuse (41 pack-years), presented with shortness of breath accompanied by chest and back pain for two months. Blood workup showed a WBC count of 68,400 cells/µL, with an AEC of 27,360 cells/µL. A computed tomography (CT) pulmonary angiogram was performed, as he was hypoxic, and revealed a 3.6-cm speculated mass within the anterior right upper lobe, partially invading the anterior chest wall. It also revealed mediastinal and hilar adenopathy, an extensive osseous lesion (including compression fracture at T7), and a small pericardial effusion (Figure ). A CT of the abdomen and pelvis with contrast was performed and revealed a diffuse metastatic disease involving the liver, adrenal glands, spleen, and the bones. Magnetic resonance imaging (MRI) of the thoracic spine did not reveal spinal cord compression, but it did show the compression fracture at T7 and multilevel thoracic spondylosis. An MRI of the brain revealed a 5-mm lesion in the left occipital lobe, without edema or mass effect.
The hematology-oncology team was consulted for an evaluation of the metastatic disease and the eosinophilia. A core needle biopsy was obtained from a liver lesion and the result came back as poorly differentiated adenocarcinoma of the lung (cytokeratin 7, TTF1, and napsin-A were positive, while cytokeratin 2 and CDX2 were negative). Given his functional status, the decision was made to hold on systemic therapy and start on palliative radiation to the spine for pain control. The plan was to complete radiation sessions and then evaluate his functional status before starting systemic therapy.
He continued to have a high WBC count during the admission (Figure ). Therefore, a bone marrow biopsy was performed to rule out a hematologic malignancy and it revealed metastatic adenocarcinoma of the lung with no evidence of a myeloproliferative disorder. The flow cytometry from the bone marrow showed

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

[User]
RADIOLOGY NOTE:
An 81-year-old Caucasian female underwent a CTC for colorectal cancer screening. She tested positive to a faecal occult blood stool test, and had experienced longstanding, infrequent, minimal and painless bright red rectal bleeding for a period of over twenty years. She gave no history of loss of weight, change in bowel habits, or family history of colorectal cancer. Past medical history was significant for atrial fibrillation requiring anticoagulation, diverticular disease and a hysterectomy 20 years prior with subsequent radiotherapy to the pelvis as histology had confirmed uterine cancer. In the last twenty years, four screening colonoscopies had been carried out, the last five years prior, and whilst clear of polyps, was significant for an asymptomatic narrowed segment of distal sigmoid which had to be traversed with a paediatric colonoscope. The patient underwent a CTC as, she had, earlier in the year, undergone a failed optical colonoscopy. CTC was carried out with manual air insufflation via a rectal soft tip Foley catheter until the patient felt slight discomfort, at which point a scout AP film was taken to ensure adequate bowel distension. It proceeded without complications. The official report noted a localized contained perforation demonstrated around the rectum (
,
). There was extensive diverticular disease demonstrated throughout the sigmoid colon, which was markedly narrowed throughout in keeping with stricture formation, which would be consistent with previous diverticulitis or radiation treatment (
). Further assessment of that region was difficult. The remainder of the large bowel had achieved excellent distension.
The patient was admitted to the ward and commenced on prophylactic antibiotics (Tazocin 4.5g tds), and bowel rest. She complained of mild discomfort in the lower abdominal region, and had a soft abdomen with no evidence of peritonism. During the first two days of admission, she passed a small amount of blood clot per rectum. She was disc

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

[User]
RADIOLOGY NOTE:
A 70 year old woman with a history of B-Cell Chronic Lymphocytic Leukemia (B-CLL) presented with a several week history of progressive right upper extremity weakness and increasing confusion. She had no prior history of cardiac surgery or cardiac abnormalities. Pertinent physical exam findings included a normal cardiac exam and 3/5 strength in the right arm. She was afebrile and her white cell count was at her baseline but markedly elevated (> 170 × 103/μL).
The initial workup was focused on the patient’s neurologic complaints. A brain MRI revealed multiple bilateral rim-enhancing brain lesions with surrounding vasogenic edema. The differential diagnosis included embolic or metastatic lesions, with a high suspicion for metastatic disease given the patient’s presentation and history. Workup for primary malignancy was negative, and the patient subsequently underwent a right craniotomy for biopsy. The resected lesion was found contain necrotic tissue with branching fungal hyphae suggestive of Aspergillus. Tissue cultures revealed Aspergillus Fumigatus species. IV Voraconazole (6 mg/kg every 12 h day 1 then 4 mg/kg every 12 h) and Micafungin (100 mg daily) were started. The Galactomannan assay was positive but all blood cultures were negative. A 2D echocardiogram was performed to evaluate for possible embolic source for the brain abscesses. This revealed a 1.3 × 1.1 cm pedunculated mass in the inferior wall of the left ventricle (Fig. ). There was no evidence of any cardiac dysfunction and the LV ejection fraction was measured at 55%. Cardiac surgery was consulted and the patient underwent median sternotomy with cardiopulmonary bypass for removal of the left ventricular mass using a left atriotomy incision. The mitral valve was first inspected through the atriotomy incision and demonstrated no vegetations. Subsequently, a retractor was placed through the mitral valve and the left ventricular mass was easily identified. A 1 cm soft, smooth appearing mass was found adhere

[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 otherwise healthy man presented to his primary care physician with complaints of bleeding per rectum for the past six days. He described the stools as dark in color and pasty in consistency. He also complained of colicky right lower quadrant abdominal pain. Physical examination was unremarkable except for mild generalized abdominal pain. He was found to have a hemoglobin of 9 mg/dl, and was referred to the emergency room for evaluation. Further lab studies revealed iron deficiency anemia, and fecal occult blood was positive. Further, the patient underwent a CT abdomen/pelvis with contrast, which showed a 3.7 x 3.7 x 3.2 cm mesenteric mass in the right mid-abdomen with associated desmoplastic reaction and thickening of the surrounding distal ileum, highly suspicious of carcinoid tumor. The patient's serotonin and chromogranin levels were also reported to be elevated.
The patient was then started on venofer for his anemia. To locate the source of bleeding, the patient underwent esophagogastroduodenoscopy and colonoscopy. However, both tests failed to demonstrate a source of an active or recent GI bleed. The options of attempted biopsy with interventional radiology versus surgical exploration with resection of affected area and mass were discussed with the patient. Considering the patient's symptoms and iron deficiency anemia, surgery was performed with the patient's informed consent. The patient completed the course of venofer and underwent explorative laparotomy with segmental ileal resection and primary reanastomosis. Gross findings were significant for a large abnormal mass of mesentery of distal ileum with dilated and thickened overlying small bowel. There was no evidence of peritoneal implants or liver masses. Resected mass and tissue were sent for pathology. The pathology report confirmed the presence of multiple foci of well-differentiated grade 1 (G1) NET extending to the serosa and involving the mesenteric margins (Figure ). Three out of ten lym

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


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

[User]
RADIOLOGY NOTE:
A 22-year-old woman visited our hospital with high-grade fever and low abdominal pain while urinating. Physical examination revealed low abdominal tenderness and pus discharging from skin near the pubic region. Urinary findings and urinalysis were normal. Routine hematological and chemical evaluation revealed a high level of white blood-cells and C-reactive protein. Abdominal ultrasound revealed no residual urine, but detected an isoechoic lesion in her prevesical space. Computed tomography (CT) with contrast medium also clearly revealed the prevesical abscess (). Although cystoscopical findings were relatively normal, the mucosa of the anterior wall was slightly reddish. During the first surgical procedure, yellowish tissue surrounded by a capsule in front of the bladder was found. We excised a portion of the inflammatory tissue and inserted a tube in this space for drainage. Pathological findings revealed fat necrosis with granulation surrounded by a cystic wall. Urachal remnants were not detected in the tissue. She was discharged from the hospital one week later after her general condition had improved. She was re-admitted three months later to undergo a second surgical procedure on the sinus. Before this radical operation, we examined the relationship between the sinus and urinary tract by using contrast medium from the catheter inserted to opening sinus. Fluoroscopy revealed that there is no connection between this congenital prepubic sinus (CPS) and lower urinary tract. Plain CT that performed immediately after this examination endorsed this fluoroscopic view (). Thus the sinus was diagnosed as an extremely rare anomaly that called CPS. In the operating room, we first injected indigo carmine into the opening of the CPS, inserted a catheter (0.7 mm in diameter) into the same opening, and then reached into the anterior area of the bladder using fluoroscopic monitoring in order to confirm the diagnosis. Excision of the CPS was performed using this catheter while

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


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

[User]
RADIOLOGY NOTE:
A 40-year-old woman was referred to us for salvage treatment. She was diagnosed in February 2005 with a 6.5 cm right occipital tumor with small millimetric parenchymal metastases and drop metastases throughout the neuraxis. She presented with clinical evidence of increased intra-crania pressure (ICP), mass effect with extensive vasogenic edema requiring urgent surgery. She underwent gross tumor resection and pathology reported an atypical choroid plexus papilloma. Her staging work up was obtained following her recovery including brain and full spine contrast enhanced magnetic resonance imaging (MRI) scans. This revealed small drop metastases in the posterior fossa and along the spinal cord. The patient received radiation therapy to the neuraxis (the CSI dose was 36 Gy and the total dose to the primary tumor bed or surgical cavity was 54 Gy). She remained clinically stable for two years, and was able to perform activities of daily living. Repeated contrast enhanced MRI scans of the brain and full spine reported stable appearance in size and enhancement of all drop metastases in the posterior fossa and the spinal canal.
At relapse, she presented with continuous headaches, neck stiffness, altered mental status, and severe ataxia. Imaging revealed metastasis to bilateral cerebello-pontine (CP) angles and intraparenchymal supratentorial lesions (left frontal, right thalamic, and right temporal). She received 2 cycles of nitrosourea without response and worsening symptoms. Hence this was changed to ifosfamide, carboplatin and etoposide based combination. Radiological and clinical stabilization were attained following three cycles, but second progression was documented after the fifth cycle. Further surgeries and performed for rapidly growing and symptomatic right CP angle metastasis and dorsal brain stem metastasis. Post-operative imaging revealed decrease size of the tumor. With remaining residual disease, the patient was referred to us for salvage treatment.
In this set

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

[User]
RADIOLOGY NOTE:
The patient was a previously healthy 19-year-old Caucasian female college student who presented to the hospital with pain and swelling of the thighs bilaterally. Three nights prior to admission, she had attended a spinning class at a local gym for the first time. She stated that the session was intense and lasted 45 minutes, and although she exercised daily, the intensity of this class was outside of her normal level of activity. After the class, she noted swelling and pain in her thighs but did not seek medical attention until three nights later when she noticed that her urine was dark in color. Alarmed by the changes in her urine, the patient presented to the student health center, where she was noted to have rapid progression of thigh swelling accompanied by increasing pain. As a result of these findings, the patient was immediately transferred to the emergency department for further evaluation.
Initial assessment revealed marked elevation of creatine kinase (CK) of 53,000 IU/L and leukocytosis of 11,260 white blood cells per microliter. The admitting team ordered an MRI of the lower extremities, which showed swelling in the anterior compartment with a feathery, high-intensity, fluid-sensitive signal within the vastus intermedius, lateralis, and medialis bilaterally (Figure ).
The pain grew worse overnight, and repeat labs showed a CK of 119,000 IU/L. Vascular surgery was consulted within 12 hours of admission for evaluation of possible compartment syndrome. The patient was found to have tight, painful thigh compartments with extreme tenderness on passive motion. She had normal distal pulses but had developed tingling and numbness in her right leg since admission. The compartment pressures of the right thigh were measured at the bedside and found to be 28 mmHg in the anterior compartment, 14 mmHg in the middle, and 8 mmHg in the posterior. Based on these findings, the patient was diagnosed with TCS.
Informed patient consent was obtained prior to treatment.

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

[User]
RADIOLOGY NOTE:
A 66-year-old woman presented with a non-tender mass of the right cheek, which slowly increased in its size over 3 years. Three years ago, she had visited with the same lesion. However, she had been lost to follow-up after computed tomography (CT), and the mass had gradually expanded over the time. Physical examination revealed a hard, mobile round mass with about 2 cm diameter. The overlying skin and cheek sensation was normal. She had a history of left frontal bone and orbital wall fracture due to traffic accident 7 years ago. Findings of fine needle aspiration biopsy showed clusters of epithelioid cells suggesting benign tumor such as salivary gland tumor or skin adnexal tumor. Nasal cavity was normal on endoscopic examination. Preoperative CT scan revealed a heterogenously enhanced mass in the subcutaneous fat layer of the right cheek, with well defined margin (). Tumor diameter has increased about 2 times compared to that of 3 years ago. There was no evidence of any intracranial mass lesion except encephalomalacia of the frontal lobe.
Under general anesthesia, she underwent complete mass excision via lateral rhinotomy incision. Intraoperative frozen biopsy was compatible with benign lesion. The tumor was surrounded by unclear and thin fibrous capsule, and tethered to the surrounding soft tissue. The relationships of the tumor with the infraorbital nerve was not identified. There was no postoperative morbidity such as cheek sensory defect. She was discharged three days after surgery. She had shown no signs of recurrence during a follow-up period of 18 months.
Microscopic examination revealed a poorly-defined tumor which is haphazardly admixed with mature adipose tissue and normal skeletal muscle. The tumor was composed of uniform, epithelioid cells showing delicate chromatin pattern, and characteristic meningothelial whorls were frequently observed (). There were several foci of psammoma bodies within meningothelial whorls. Neither mitotic figures nor significan

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

[User]
RADIOLOGY NOTE:
The 8-year-old boy first presented in January 2012, having been referred by the family dentist, to the Department of Orthodontics at the Medical Center of the University of Göttingen for a routine orthodontic control and evaluation of treatment need (). The clinical examination of the asymptomatic patient showed no extra- or intraoral pathological findings. The medical history of the boy included a mild pulmonary valve stenosis and a secundum atrial septal defect with a left-right shunt. He showed a good physical and cardiac fitness and a normal nutritional status. The family history was positive for maxillofacial anomalies: the boy's older sister had been previously diagnosed with a dysplastic fibroma, a rare benign fibrovascular defect in the mandible, and a resection of the affected area in the mandible had been performed. His father and paternal grandmother had a positive history of odontogenic cysts as well as basal cell carcinomas, although the family history of OKCs was negative. The radiological examination showed three suspicious hypomineralisations visible as radiolucencies in the panoramic radiograph associated with the retained teeth 13 and 23 and the ectopic tooth 27 (). The young patient was referred to the Department of Maxillofacial Surgery for a surgical examination of the radiologic anomalies.
The operation was performed under general anesthesia. The suspected pathological area around teeth 23 and 13 showed no visible intraoperative pathological signs. A bone and soft tissue biopsy for histological examination was taken. In the area of tooth 27, a well-marked membrane was revealed, filled with a viscid fluid and fully enclosing the dental crown. The clinical aspect was consistent with a follicular cyst. During the radical cystectomy, tooth 27 was removed due to massive attachment loss. The histopathological biopsy showed a fibroosseous lesion in the area of teeth 13 and 23. The biopsy from region 27 showed an odontogenic connective tissue cyst wall

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


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

[User]
RADIOLOGY NOTE:
In June 1997, a 52-year-old man without any medical history was referred to the department of gastroenterology because of gastric subepithelial tumor. Esophagogastroduodenoscopy (EGD) demonstrated 1 cm sized subepithelial tumor on the proximal antrum anterial wall (). Biopsies showed chronic gastritis only. He was admitted and diagnostic endoscopic mucosal resection was done (). The pathologic finding was diffuse aggregation of monomorphic lymphoid cells without any large cell or small cell component in the submucosal layer (). Immunohistochemical staining showed atypical lymphoid cells that were positive for pan B and lamda, but negative for pan T, bcl-2 and kappa. Ki-67 labeling index was 5%. These findings suggested his diagnosis was low-grade MALT lymphoma. Abdomen and pelvic computed tomography (CT), chest CT, bilateral bone marrow examination and F-18-fluorodeoxyglucose positron emission tomography (PET) were done and there were no involvement of disease. Although rapid urease test (RUT), serologic test for H. pylori, urea breath test (UBT) and H. pylori culture of gastric mucosa were all negative, he took triple regimen of H. pylori eradication including clarythromycin, amoxicillin, and proton-pump inhibitor (PPI) for 14 days. After the H. pylori eradication was completed, subtotal gastrectomy was done. In the pathologic review of surgical specimen, there were no residual tumor cells. We performed esophagogastroscopy, abdomen and pelvic CT and PET every 6 months for 2 years and then we performed the same examination every 12 months for 4 years. He had been followed without evidence of disease recurrence for 6 years, after which he stopped visiting our hospital. In May 2007, he was referred to our hospital again complaining of throat pain and neck mass. Neck CT showed multiple enlarged lymph nodes in bilateral cervical nodes (). The largest diameter of the involved lymph node was 6 cm. Excisional biopsy showed diffuse infiltration of large atypical lymphoid ce

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


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

[User]
RADIOLOGY NOTE:
A 39-year-old female presented with a history of abdominal hysterectomy 10 years back followed by exploratory laparotomy and adhesiolysis for adhesive intestinal obstruction 5 years back, development of incisional hernia, and repair by open onlay mesh hernioplasty 2 years back. Physical examination showed a supra- and infraumbilical incisional hernia with a periumbilical midline scar (). She underwent ultrasonography of the abdomen; further radiological investigations could not be done. There was a defect 11 cm long and 6 cm wide around the umbilical region containing omentum. We decided to perform a laparoscopic e-TEP Rives repair in March 2018. The operative technique has been followed according to the technique put forward by Belyansky et al., except for the transfascial suture reconstruction of the linea alba []. The omentum was reduced, the midline defect was closed with interrupted transfascial 1-0 polypropylene sutures, and the defect in the posterior layer was closed with 2-0 polygalactin continuous without any tension. Then, a polypropylene mesh measuring 21 cm long and 14 cm wide was placed in the retrorectal space to ensure adequate overlap of the mesh edges. The previous onlay mesh did not need removal because it was in a completely different plane. She had an uneventful postoperative recovery and was discharged on the 4th postoperative day (). In 1-year follow-up, she is completely free of any complaints.
A 45-year-old female had a history of open cholecystectomy 19 years back and developed hernia in the medial part of the incision at the right subcostal region. She underwent an onlay mesh repair with a polypropylene mesh 8 years back which recurred after 2 years. She underwent intraperitoneal onlay (IPOM) mesh repair with a proceed composite mesh (Ethicon) tacked with a securestrap (Ethicon) and transfascial sutures 4 years back; after 6 months, it recurred again along with another infraumbilical port site hernia. She was subjected to a contrast-

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


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

[User]
RADIOLOGY NOTE:
An 18-year-old male worker was admitted to the emergency department due to pain, paresthesia, and coldness of the right lower limb. He has no history of cardiac disease or trauma and otherwise in good health. On physical examination, the right lower limb was cold and with cyanotic toes. The right femoral and popliteal pulses were undetectable. An urgent color-flow duplex scanning had been arranged which revealed a complete obstruction of the right external iliac artery blood flow by a rather big embolus. A trans-thoracic echocardiography showed an anechoic lesion of 36–40 mm originating from the left ventricle (LV). Since it was an endemic area of hydatid disease, a provisional diagnosis of (CHC) had been postulated. An urgent surgical embolectomy through the common femoral artery had been done. The obstruction has been opened with a Fogarty catheter. The catheter harvested a cruor thrombus with a white membrane from the common femoral artery, the histopathology of which was a hydatid tissue as it is shown in a and b. After immediate subsidence of symptoms and signs, and an uneventful post-operative night, a CT scan of thorax revealed a well-defined cystic lesion of 45 mm diameter was protruding into the LV, as shown in a, b, and c. A week later, the patient had been submitted to a standard a sternotomy and under cardiopulmonary bypass between the ascending aorta and the two-vena cava. The LV cavity showed an inside protruding mass, . The mass was incised and the cyst was removed, as shown in a and b). This has been followed by mopping of endocyst, as in , putting stay suture of LV as in , and enlarging of a cystic cavity as in . The perforated myocardium was sutured by prolene, and the cavity closure was achieved by a standard mattress suturing with gel foam, . The postoperative period was uneventful, and the patient was discharged after 9 days with no complications.

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


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

[User]
RADIOLOGY NOTE:
A 41-year-old Indian man presented with sudden onscet of chest pain in February 2011 and was diagnosed with an anterolateral myocardial infarction (MI); prior to the event, he was completely asymptomatic. The coronary angiogram revealed an occluded ostial and proximal left anterior descending (LAD) artery. After a failed percutaneous coronary intervention (PCI), he underwent emergency coronary artery bypass grafting (CABG) involving the left internal mammary artery (LIMA) to the LAD.
Post-operatively he developed progressively worsening symptoms of right heart failure with increasing abdominal distension and lower limb swelling. Clinically, the patient was in NYHA class 4 heart failure. The 2D echocardiogram revealed an ejection fraction of 10% and a pulmonary artery systolic pressure (PASP) of 40 mmHg.
He was admitted multiple times for the treatment of his heart failure, which was recalcitrant to diuretic therapy. He was eventually offered a heart-lung transplant to alleviate his symptoms.
In October 2011, he was admitted to another institution for further re-evaluation of his symptoms.
A repeat 2D echocardiogram revealed severe biventricular dysfunction with a left ventricular ejection fraction (LVEF) of 12%, a PASP of 38 mmHg as well as severe tricuspid regurgitation (TR). There was a thinned out ventricular septum with a possible left ventricular (LV) apical aneurysm.
Multiple attempts to further evaluate the apical aneurysm or additional intracardiac lesions with a cardiac MRI failed, as the patient was unable to lie supine because of his severe dyspnoea.
A decision was made to insert a peritoneal dialysis catheter to alleviate his abdominal distension.
He subsequently tolerated an MRI scan, which revealed near transmural myocardial infarction involving mainly the LAD and left circumflex (LCx) territories; the segments supplied by the right coronary artery (RCA) were viable. The right atrium and ventricle were grossly dilated, with moderate to severe right ven

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


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

[User]
RADIOLOGY NOTE:
In February 2014, an 11-year-old male presented with a history of recurrent respiratory tract infections and suspected tuberculosis following a case within his family. On physical examination, he appeared to be in good health. Chest auscultation did not reveal any specific pathological heart or lung sounds. Abdominal objectivity was negative. His parents did not refer any other relevant medical history about him. Tuberculin skin tests resulted positive and a chest X-ray showed a dishomogeneous parenchymal consolidation in the left lower lobe (). Suspecting active tuberculosis, a preliminary CT scan of the thorax was performed showing a heterogeneous consolidation with some cystic masses containing mixed fluid and air in the left lower lobe posterior segment, not in communication with the respiratory tract, and a probable expression of a dysplastic parenchymal area ( and ). These findings were suggestive of pulmonary sequestration, including a differential diagnosis of congenital pulmonary airway malformation, because of the presence of a cystic component within the consolidation. The injection of contrast medium showed an artery arising from the descending thoracic aorta that divided into two 1.2 cm after its exit, with both branches extending to the dysplastic area; therefore, a diagnosis of intralobar sequestration with associated aspects of bronchial atresia was made; superinfection and trapping of contiguous parenchyma coexisted. Just below the emergence of the previously anomalous vessel, another artery was detected that crossed the midline to achieve a healthy parenchyma in the right pulmonary base, configuring a pattern of aberrant systemic artery feeding a normal lung (–). Other congenital anomalies that appear to be related to pulmonary sequestration were absent; in particular, pulmonary venous drainage was regular through the pulmonary veins, there was no communication between the bronchus and the oesophagus, and no diaphragmatic defects or other gross pul

[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 female presented with an asymptomatic gastric tumor found incidentally during screening upper gastrointestinal endoscopy. The lesion appeared as a flat protrusion in the lesser curvature of the lower third of the stomach (Fig. ). Endoscopic ultrasound (EUS) showed a 23 × 12-mm, hypovascular, heterogeneous lesion thickening the second and third gastric layers. The findings strongly suggested scirrhous gastric cancer (Fig. ). Although the lesion biopsy revealed no evidence of malignancy, our suspicion of scirrhous gastric carcinoma persisted due to the configuration of the tumor and our EUS findings. We performed an endoscopic open biopsy to make an accurate diagnosis. However, evaluation of the specimen revealed only slight chronic inflammatory cell invasion. Computed tomography (CT) scanning showed only gastric wall thickening at the angle of the stomach (Fig. ). Positron emission tomography-CT showed no evidence of metastasis or abnormal uptake in the tumor (Fig. ). The laboratory findings were normal as were levels of tumor markers (CEA, 1.6 ng/ml; CA19-9, 12 U/ml).
In spite of these findings, given our high level of suspicion, we decided to perform surgery to obtain a definitive diagnosis and treat the tumor. We chose gastric wedge resection using a combined laparoscopic and endoscopic method for several reasons. Firstly, the biopsy did not show cancer, but the tumor configuration strongly suggested malignancy; therefore, we selected a non-exposed method to prevent interoperative dissemination of tumor cells. Secondly, the tumor appeared to be a submucosal tumor (SMT), and gastric wedge resection using a combined laparoscopic and endoscopic method is among the safest procedures for resection of gastric SMTs [, ]. Lastly, we chose a wedge resection because if the tumor was not malignant, a distal gastrectomy could be considered excessive. We obtained an interoperative pathological diagnosis, and we planned to perform partial gastric resection 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 41-year-old Asian female patient reported to the Department of Oral and Maxillofacial Surgery with a 4-month history of a gradually increasing swelling on the right side of the face. The swelling was largely painless with no other associated functional symptoms. On local examination, a diffuse swelling was observed measuring about 6 cm × 5 cm on the right side infraorbital region with regional lymphadenitis of the submandibular region of that side. The skin over the swelling appeared normal with no signs of infection or inflammation [Figure 1 ( and )]. The lump was diffuse, firm, and mildly tender. Fixation to the underlying structures was not present. Intraoral findings were unremarkable with no foci of infection. No other distant lymphadenopathy was elicited clinically. All her hematological investigation parameters were within normal limits. Chest X-ray confirmed the absence of any pathology including hilar lymphadenopathy. The clinical differential diagnosis comprised a wide spectrum of conditions such as lymphoma, fibrosarcoma, and neuroma.
MRI scan of the head and neck showed a homogeneously enhancing infiltrative lesion seen involving the premaxillary space, buccal space, retromolar trigone, and lateral pterygoid in the masticator space on the right side. There was no significant bony destruction. Multiple enhancing solid lymph nodes were seen in the right submandibular, upper deep jugular group and the left submandibular group, largest measuring 18 mm × 12 mm in the right submandibular region. MRI report gave a differential diagnosis of neurofibroma [].
FNAC was performed initially, but the result was inconclusive. Therefore, we proceeded with examination under anesthesia and biopsy. The incisional biopsy report suggested a nonspecific type of lymphoid hyperplasia. Hence, definitive surgery was planned with complete excision of the lesion. Intraoperatively, it was observed that the mass was well defined, capsulated, and firm. The histopathology showed dens

[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 21-year-old healthy nulliparous female presented to a regional hospital in Australia in spontaneous labour at 39 weeks and 4 days of gestation. Her pregnancy was otherwise uncomplicated and she had no medical and surgical history of note.
The patient presented to the hospital with a cervical dilation of 4 cm. Her first stage of labour lasted 1 hr and 45 minutes and her second stage lasted 1 hr and 16 minutes, respectively. Analgesic treatment in the first stage included nitrogen oxide as required and 10 mg of intramuscular morphine. Analgesic used in the second stage was only nitrous oxide as required. An episiotomy was performed at delivery. She delivered a live born infant weighing 3690 g with APGAR scores of 9 and 10. The 3rd stage lasted 15 minutes with delivery of an intact placenta.
After delivery, she further requested nitrous oxide and had 10 mls of 1.0% lignocaine infiltrated into the perineum for an episiotomy repair.
Approximately 2 hours postpartum, the patient started complaining of sudden onset dyspnea and lower chest tightness. Her GCS was 15 at this time and her vital signs were oxygen saturation >95% on room air with a respiratory rate of 18 breaths per minute, pulse of 85 beats per minute, BP 130/78, and a temperature 37.2°C.
Physical examination at the time revealed swelling in the neck and jaw line and palpable crepitus in the anterior chest wall, neck, and jaw, consistent with subcutaneous emphysema.
Initial management included observation and pulse oximetry, as she was clinically stable and able to have a conversation without increase in chest pain or decrease in oxygen saturation.
Subsequently a chest X-ray (CXR) was obtained which demonstrated pneumomediastinum with air tracking superiorly into the pericardiac spaces (). Following telephone consultation with a cardiothoracic team at our major tertiary referral center, a computed tomography (CT) contrast study was ordered as recommended. CT

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


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

[User]
RADIOLOGY NOTE:
A 36-year-old healthy female presented to our Emergency Department with a progressive swelling on the left side of her neck that had started 2 days before presentation. There was no history of trauma, fever, cough, coagulopathies, recent medical procedures, medication intake or thyroid problems. The patient complained of pain and dysphagia on the side of the swelling.
The initial evaluation revealed a sick-looking nonetheless stable patient who was not in dyspnea or in respiratory distress. The neck examination revealed a well-defined soft cystic lesion confined to the left side of the neck anteriorly, measuring around 4 cm × 4 cm, extending from the left thyroid lobe levels III-IV. It was tender to the touch and moved with deglutition. Preliminary fiberoptic flexible scope examination of the larynx was normal.
Laboratory investigations showed a white blood cell count of 10.42 × 10 × 9/L, hemoglobin of 115 g/L and calcium levels of 2.32 mmol/L, which were all within the normal range. The thyroid function test was also within the normal range with elevated antithyroglobulin antibodies.
A preliminary ultrasound study of the neck showed posterior inferior left lobe hypoechoic thyroid nodule measuring 3 cm with ill-defined lateral border and echogenicity suggesting turbid fluid collection in the left neck spaces [].
A computer tomography scan showed diffused inflammatory changes of the superficial and deep facial planes mainly on the left side of the neck; however, they were confined to the infrathyroid region within the muscular and visceral facial planes of the intermediate deep cervical fascia [Figure and ].
Three hours after the initial assessment, the patient's condition suddenly changed. The swelling on the neck became engorged with increased tenderness. However, the patient remained clinically stable with no evidence of airway compromise or respiratory distress. Laryngeal flexible fiberoptic scope was repeated and revealed a left aryepiglottic submucosal hematoma

[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 3.5-year-old girl was referred to the Department of Pediatric Dentistry, Dental School, Islamic Azad University; Tehran, Iran. Her chief complaint was the abscess formation in the left maxillary region. The prenatal, natal conditions of the patient and the attained medical history revealed no explicit findings. Both parents did not report any previous history of tooth abnormalities or genetic anomalies on either maternal or paternal family part of the case. There was negative history concerning the delayed eruption of the maxillary left teeth compared to their counterparts. Based on her mother’s report, the abscess existed from six month ago and its size was reduced after administration of antibiotics.
The extra-oral examination revealed no swelling, no facial asymmetry and the lymph nodes were not palpable.
The intra-oral examination showed the occlusion type was mesial step on both sides and the oral hygiene was excellent. Oral mucosa was normal, except for an abscess on the gingiva above the maxillary left primary molar; which was fluctuant and about 0.5 x o.5 cm2 in size.
All the primary teeth on the left quadrant of the maxilla had abnormal crown, with a yellowish discoloration and hypoplastic enamel. The right maxillary central and lateral incisors as well as the canine had minor caries. The first primary molar was considerably hypoplastic with an obvious carious lesion. The abscess was considered to be related to the maxillary left first primary molar. The right maxillary and mandibular teeth were normal and caries-free ().
The periapical () and the panoramic radiographs were taken and the radiological images showed that the mandibular and the right maxillary teeth were normal. All the teeth in the left maxillary region were present, although they displayed a typical “ghost-like” appearance in the radiographs. The demarcation line between the enamel and the dentin of the affected teeth was not clear and the enamel was hypoplastic. All the involved teeth exh

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


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

[User]
RADIOLOGY NOTE:
A 25 year-old young man was injured in a motor vehicle accident (inability to control the vehicle due to violation of the speed limit). When his car reached the U-turn, it slid off the road and flipped over. Possible mechanism of injury was dorsiflexion pronation of the left side and dorsiflexion supination of the right side. The patient was brought in conscious and hemodynamically stable at the time of admission; he presented with severe bilateral ankle swelling, numerous bilateral ecchymoses and blisters without any open wounds. On physical exam, toe circulation was mildly delayed but the extremities were warm and no evidence of ischemia could be found. In the systemic review, no serious head, spinal or abdominal trauma requiring emergent measures could be noted. Ankle and plantar radiographs were obtained which demonstrated left ankle Hawkin type 4 open talar neck fracture with subtalar and talonavicular dislocation and a 3 cm open wound (). On the right side, Hawkin type 4 open and comminuted fracture of the right talar body and lateral process with subtalar and talonavicular dislocation, and 3 cm open wound was noted (, ). In spinal radiography there were T10 and T11 vertebral body fractures.
In the right lower extremity, multiple fragmented talar body fracture and posterior medial tubercle were opened via an anteromedial approach. Chevron osteotomy of the medial malleolus was performed. After intraarticular irrigation and minimal soft tissue manipulation, reduction was performed by three partial thread cannulated and cancellous screws (4 mm). Consequent intraarticular irrigation was performed and the location of malleolar osteotomy was fixed by 2 malleolar pins (). In the left extremity, the talus neck fracture with medial wall comminution and lateral malleolar tip avulsion was opened by simultaneous anteromedial and lateral approach for a better view, after which intraarticular irrigation and debridement took place. Neck reduction was performed using 2 cannul

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


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

[User]
RADIOLOGY NOTE:
A 50-year-old man was admitted for elective aortic valve replacement. The patient had severe aortic regurgitation; however, apart from hypertension, he had no other systemic diseases. The patient’s electrocardiogram showed a right bundle branch block with sinus bradycardia. Echocardiography revealed an ejection fraction of 45% to 55%, severe aortic valve regurgitation, and a dilated left ventricle. He had a normal preoperative coronary angiogram.
Immediately after routine induction of anesthesia, the patient developed intraoperative cardiac arrest. Cardiopulmonary resuscitation was started by performing emergency cardiopulmonary bypass, and the aortic valve was replaced with a mechanical valve. Postoperatively, the patient’s hemodynamic parameters were unstable and he was transferred to the ICU on inotropic support, atrioventricular sequential pacing, and an intra-aortic balloon pump. During the ICU stay, the patient developed acute kidney injury with hepatic dysfunction and deranged coagulation requiring massive transfusion of blood and blood products in the first 48Â hours postoperatively. Regular hemodialysis was initiated from the first postoperative day. By the fourth postoperative day, his renal, hepatic, and coagulation profiles had improved toward the reference ranges. An anticoagulation regimen of heparin and oral warfarin was started. Because of his depressed level of consciousness and inability to be weaned off mechanical ventilation, the patient underwent percutaneous tracheostomy on the seventh postoperative day. He gradually recovered in the ICU. On the 16th postoperative day, however, he developed fresh rectal bleeding. Urgent colonoscopy revealed multiple ischemic ulcers in the colon and a large hematoma in the right colon (FiguresÂ and ). The anticoagulants were stopped and consultation was requested with a gastrointestinal surgeon. The surgeon felt that in light of the patient’s poor general condition, extensive disease, and likely dismal outcome o

[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 86-year-old Caucasian man with a history of coronary artery disease, coronary artery bypass surgery in 1999, hyperlipidemia and hypertension, came to the out-patient laboratory of the hospital to check the results of his blood tests. His home medications included 40 mg daily of lisinopril, 40 mg daily of furosemide, and 80 mg daily of simvastatin. He complained of sudden pressure-like chest discomfort and collapsed in the waiting area. The "code blue" emergency call was given. The team responding to the call applied an automated external defibrillator and delivered a shock. The recorded rhythm indicated ventricular tachycardia. Consequently, the patient was given 300 mg of amiodarone, which resulted in the restoration of his normal sinus rhythm. The ventricular tachycardia was immediately restarted. For the next 16 minutes, ventricular tachycardia and ventricular fibrillation were treated with additional shocks and multiple doses of epinephrine, amiodarone and lidocaine.
After 16 minutes of resuscitation, the patient's normal sinus rhythm was restored, and he was transferred to the medical intensive care unit, intubated and started on mechanical ventilation. He was unconscious, and his BP was 98/58. The laboratory tests drawn at this time showed his white blood cells at 16.6 G/L, hemoglobin 10.2 G/dL and platelets 175 G/L. His coagulation test results and chemistry were normal.
After 15 minutes of normal rhythm, the patient again developed ventricular tachycardia. Following the advanced cardiac life support protocol, resuscitation efforts continued for 50 more minutes, using epinephrine, vasopressin, amiodarone, lidocaine, magnesium and bicarbonate. Eventually, the monitor recorded asystole and the patient had no spontaneous respirations, pulse, BP, or heart sounds. Based on previous experience with a patient, we gave him 4 mg of NTG intravenously as a bolus as a last resort. After three minutes of chest compressions the patient was pronounced dead and all resusc

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

[User]
RADIOLOGY NOTE:
A 63-year-old woman with metastatic breast carcinoma presented to the ophthalmology clinic with diplopia in right gaze and head turn to the right. Medical history revealed that she was diagnosed with estrogen receptor (ER)-positive and progesterone receptor (PR)-positive invasive ductal carcinoma 1 year earlier with mediastinal lymph node and bone metastasis at the time of diagnosis. She was treated with zoledronic acid 4 mg monthly and paclitaxel 80 mg/m2 weekly for 12 weeks, followed by endocrine therapy with letrozole.
On ophthalmological examination, best corrected visual acuity was 20/25 in both eyes. Slit-lamp examination of the anterior segment and fundus was unremarkable other than bilateral posterior chamber intraocular lenses. On motility exam, abduction was totally limited in the right eye with globe retraction and narrowing of the palpebral fissure on attempted abduction (). Abnormal head position towards the right side was noted. Magnetic resonance imaging (MRI) revealed isolated enlargement of the right medial rectus muscle (). Clinical evaluation and laboratory studies were carried out for differential diagnosis. There were no clinical findings suggestive of thyroid eye disease and thyroid function tests were normal. Rheumatologic assessment for inflammatory and vasculitic diseases was not contributory. Biopsy of the right medial rectus muscle was performed to establish a definite diagnosis and initiate appropriate treatment.
Hematoxylin and eosin staining of the biopsy specimen revealed large, round to polygonal epithelioid tumor cells arranged in loosely cohesive clusters and sheets infiltrating fibrocollagenous tissue and muscle fibers (). Immunohistochemical analyses using streptavidin-biotin peroxidase complex method revealed panCytokeratin and cytokeratin 7 positivity (). ER, PR and human epidermal growth factor receptor 2 (HER2/neu) were negative (triple-negative). Based on the patient’s clinical history and the morphological and immunohistoche

[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, now 16 years old, was born to a 23-year-old G4, P3→4 mother and 30-year-old father. During the pregnancy there was concern for decreased fetal movement. Labor was induced due to fetal distress at 36 weeks' gestation. Birth weight was 2614 g (<3%) and birth length was 44.5 cm (<3%). She had a positive toxicology screen for barbiturates and was noted to have large open fontanels. The patient remained in the hospital for 5 days after birth due to feeding difficulties.
The patient came to attention again around 6 months of age due to developmental delay and was evaluated by neurology. At around one year of age, the patient also began having seizure activity. EEG results were normal; a brain MRI at 14 months of age showed prominent CSF space posterior to cerebellar vermis, most likely representing large cisterna magna. A karyotype revealed abnormal results, 46,XX,del (7)(q32-q34). The patient's mother had a normal karyotype and her father remains unavailable for testing but is not known to have any features similar to the patient; her deletion is presumed to be de novo based on its large size. Her seizures resolved by 2.5 years of age.
The patient has had multiple recurrent infections throughout her life; by 28 months of age, she had been hospitalized for pneumonia 3 times. The patient has continued to experience multiple upper respiratory infections, recurrent otitis media, and urinary tract infections. Immunology work-up was normal; therefore the patient is not suspected of having a primary immunodeficiency. The patient has a history of chronic otitis media and abnormal tympanometry and audiology examinations; she had ear tubes placed at 30 months of age. An audiogram performed at age 8 showed right moderate conductive hearing loss and left borderline to mild hearing loss, and hearing aids were recommended. The patient was first evaluated by ophthalmology at 33 months and noted to have hyperopia and bilateral

[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 man with severe chronic obstructive pulmonary disease (COPD) presented with a feeling of fatigue, weight loss, and reduced physical activities. He was diagnosed with COPD at the age of 69 years and had retired from work the following year. His smoking history included 40 cigarettes per day between the age of 14 and 69 years; his airflow limitation was classified as severe by the Global initiative for Chronic Obstructive Lung Disease; and a chest computed tomography (CT) scan showed severe emphysema. He had started long-term oxygen therapy at the age of 72 years and is currently inhaling 3 L/min of oxygen. Medical and family histories were otherwise unremarkable. Cardiac ultrasound excluded comorbid congestive heart failure or pulmonary hypertension, and CT pulmonary arteriography also excluded chronic pulmonary thromboembolism. As the patient had a history of acute exacerbations of COPD more than twice a year with extreme respiratory symptoms, he was prescribed a combination of inhaled long-acting antimuscarinic antagonist, long-acting beta2-agonist, corticosteroid, and oral carbocysteine, ambroxol, and theophylline. He reported symptoms of dyspnea on exertion, depression and anxiety, and a decrease in physical activity. He also experienced anorexia with a weight loss of more than 5 kg in a year, and no other possible causes of weight loss, such as tuberculosis and malignant tumor, were observed. Therefore, in addition to respiratory pharmacotherapy, we prescribed an antianxiety drug and provided nutritional supplement therapy, patient education, and pulmonary rehabilitation. However, the patient's mental and physical symptoms did not improve after 4 months. Furthermore, he exhibited deterioration in activities of daily living as well as physical and mental weakness; hospital visits were difficult and therefore, he considered home care. Persistent weight loss, poor endurance and energy, and low physical activity levels led to the diagnosis of physical

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


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

[User]
RADIOLOGY NOTE:
A 69-year-old male visited the emergency room due to chest tightness and dyspnea that had occurred 3 days prior. Four years before this visit, the patient had undergone aortic valve replacement, ring mitral annuloplasty, and reconstruction of an aortic annular defect due to infective endocarditis using bovine pericardium.
He showed the symptoms of cardiac tamponade. Echocardiography and computed tomography revealed a large amount of pericardial effusion and a 16-mm cavity at the anterolateral wall of the left ventricle. The cavity had no communication with the nearby pericardial space and had the continuity of parietal pericardium. The myocardial wall motion around the cavity was normal. To stabilize vital signs, we performed pericardial centesis. The old bloody pericardial effusion was drained and there was no progressive bleeding.
Coronary angiography showed 30% tubular stenosis in the left anterior descending artery and 40% focal stenosis in the proximal left circumflex artery. Magnetic resonance imaging (MRI) showed an aneurysmal change of the left ventricle from the base to the middle and anterior wall. Considering the surrounding myocardium of pseudoaneurysm was normal, pseudo-pseudoaneurysm or intramyocardial abscess was suspected ().
Surgery was performed under cardiopulmonary bypass and cardiac arrest. In gross, we couldn't indentify the site of the pseudo-pseudoaneurysm, so we palpated the ventricular base between the left anterior descending artery and the ramus intermedius to identify the thinnest ventricle wall and incised it. After removing the inner thrombus, we identified a defect 1 cm in diameter in the endocardium and a 3×2-cm defect in the epicardium. There was no evidence of infection, so it was diagnosed as a pseudo-pseudoaneurysm. We performed patch closure of the defect using a prosthetic bypass graft in horizontal mattress sutures with pledgets (). The patient's postoperative vital signs were stable, and postoperative echocardiography showed

[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 man was admitted to the Department of Surgery at our hospital for complaints of fever and anorexia. There was no abdominal pain, nausea, or abdominal distension. He had a high fever, anorexia, tachycardia, and tachypnea. He had no comorbidities or surgical history. The white blood cell count, liver enzymes, and C-reactive protein level were elevated. Abdominal ultrasonography showed a hypoechoic lesion with a maximum diameter of 40 mm in the left lobe of the liver (Fig. ). Abdominal contrast-enhanced computed tomography (CT) revealed a lesion with coexisting low- and high-density areas in segment III of the liver. The lesion was adjacent to the stomach antrum and had a maximum diameter of 55 mm, with enhancement at the edge. The lesion contained air and a high-density linear object measuring about 24 mm (Fig. a, b). We suspected a liver abscess secondary to gastric perforation caused by a foreign body. The patient underwent abscess drainage and removal of the foreign body using five-port laparoscopic surgery. Adhesions had formed between the liver and reticulum due to inflammation (Fig. a). We confirmed pus leakage, performed lysis of adhesions, and found a fish bone inside the reticulum (Fig. b–d). The fish bone was removed laparoscopically. We lavaged the abscess cavity with saline. The operation was completed with the insertion of a drain inferior to the left lobe of the liver. There was no bile leakage from the abscess cavity. The total operative time was 62 min, and the total intraoperative blood loss was 20 ml. The pus culture showed the presence of Streptococcus anginosus, which matched the result of the blood culture. We used meropenem until postoperative day 10. The clinical course was uneventful, and the patient was discharged on postoperative day 11. When the patient was discharged, we changed the antibiotic treatment from meropenem to a combination of potassium clavulanate and amoxicillin hydrate according to the indications

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


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

[User]
RADIOLOGY NOTE:
A 14 year old Caucasian female presented to our pediatric scleroderma clinic with a 4 year history of progressive mixed morphea, a combination of generalized plaque morphea and linear scleroderma of the trunk/ extremities. Her condition started as a single bruise-like lesion over the right flank, and despite systemic therapy, had advanced to cover approximately 80% of her body surface area.
A deep punch biopsy of the initial lesion demonstrated histologic findings consistent with LS (morphea), including full thickness dermal fibrosis with a superficial and deep perivascular lymphohistiocytic infiltrate. In addition, there was thickening of the fibrous septa in the panniculus with aggregates of plasma cells at the edges, supporting deeper involvement. An eosinophilic infiltrate was not present in the subcutis. She was initially treated with topical corticosteroids, but these were discontinued due to their ineffectiveness to halt disease with expansion of lesions noted. Oral treatment was initiated, though not considered as standard therapy, with penicillin VK and hydroxychloroquine (400mg daily) (Fig. ). Approximately 1 year later she was started on more traditional steroid and methotrexate therapy, initially with oral prednisone, followed by IV methylprednisolone administered per Toronto protocol (1000 mg IV daily three consecutive days) []. Due to intolerability of the methotrexate (maximal dose 17.5 mg subcutaneous weekly), she was switched to mycophenolate mofetil (MMF) and continued on it for another year at a maximum dose of 1500 mg twice daily. She started to complain of odd side effects with MMF, including migraine headache and short term memory loss, leading to its eventual discontinuation. She received another course of monthly three consecutive days of 1000 mg daily IV methylprednisolone for 3 months prior to our evaluation in clinic (Fig. ).
The history obtained from the patient and documentation from the treating physician at the time of our initial cons

[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 woman presented with epigastric pain, intermittent nausea, frequent vomiting, and loss of appetite over the last seven days. She denied weight loss. She could pass gas but had not passed stool over the last four days. She was able to tolerate a full meal the night before presenting to the hospital, but nausea and vomiting had resumed within several hours.
Her medical history was significant only for laparoscopic oophorectomy for a left ovarian cyst almost 20 years prior. She was taking no medications, herbal remedies, or nutritional supplements. She admitted to chronic alcohol abuse with frequent visits to the emergency department due to alcohol intoxication, but had never smoked cigarettes. She denied any recent sexual contact, overseas travel, raw food ingestion, or sick contacts.
Upon presentation, the patient appeared to be in moderate distress. Her respiratory rate was 24 breaths per minute, but vital signs were otherwise stable. She complained of discomfort on palpation of the epigastric region. The upper abdomen was soft but mildly distended. No mass was palpated. Small scars from previous laparoscopy were noted.
Laboratory results were only remarkable for a mildly elevated C-reactive protein of 0.44 mg/dL. Esophagogastroduodenoscopy (EGD) performed 20 hours after the patient's last meal revealed a mildly distended stomach with significant food residue in the esophagus and stomach (). The patient vomited copious food residue during the procedure, precluding a thorough examination for fear of aspiration. No gross abnormalities were found up to the third part of the duodenum. Food residue and intraluminal air were suctioned to the extent possible at the end of the examination.
Despite the patient's ability to pass gas, an emergency computed tomography (CT) scan was conducted to rule out small bowel obstruction. CT without contract was largely unremarkable, with no visible signs of tumor or bowel obstruction (). However, CT with contrast taken seve

[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 female was admitted to our university hospital with an obstructing tumor of the proximal jejunum for a curative surgical approach. Her past medical history included a severe three-vessel CAD with myocardial infarction (MI), complex coronary artery bypass surgery and reconstruction of the mitral and tricuspid valve 6 month prior to admission.
During the preoperative evaluation, she reported intermittent chest discomfort during exercise or stress. Thus, percutaneous transluminal coronary angiography was performed to evaluate further interventional options. The angiography showed a global hypokinesis of the left ventricle (LV) and akinesis of the posterior wall with a LV ejection fraction (EF) of 33%. Whereas the aorto-coronary vein bypass to the right coronary artery showed no pathology, the left internal mammary artery (LIMA) to left anterior descending (LAD) bypass was compromised by a 70% stenosis of the subclavian artery proximal the bypass graft. This stenosis was technically intractable for revascularization [Figures and ].
As she developed symptoms of an upper intestinal obstruction due to tumor progression, the operation could not be postponed. To stabilize LV function and diastolic blood flow via the crucial LIMA to LAD bypass graft the perioperative use of an IABP was advocated.
To minimize perioperative cardiac stress and to obtain a sufficient postoperative analgesia a combined epidural and general anesthesia was attempted under invasive hemodynamic monitoring. General anesthesia was induced with midazolam, sufentanil, and propofol. Balanced Anesthesia was maintained with sevofluran continuous infusion of sufentanil. After placing a transesophageal echocardiography (TEE) probe, the IABP was inserted via the right femoral artery. The first TEE examination showed a severely reduced LV function (EF 30%), an akinesis of the posterior wall and an II° insufficiencies of the mitral and the tricuspid valve. With an augmentation rate of 1:1 and modera

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


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

[User]
RADIOLOGY NOTE:
A 63-year-old female patient was admitted to our hospital with intermittent epigastric abdominal pain for the past three months. Results of the physical examination on admission indicated no icteric sclera. The abdomen was soft with no palpable abdominal mass. The patient had experienced a weight loss of about five kg in the past two months and had no history of hepatitis B or C. She had been exposed to dogs and sheep and denied any history of exposure to infected cases from the epidemic area. After admission, CA19-9 was measured and was 796.20 U/mL. No serological examination for echinococcosis was performed because of the limited conditions of our hospital. Test results from pelvic ultrasound indicated menopausal uterus and uterine fibroids. Test results from gastroscopy showed chronic non atrophic gastritis. Colonoscopy revealed multiple polyps in the large intestine (basically removed); intestinal histopathology (cecum, biopsy) showed severe chronic inflammation of the mucosa and adenomatous hyperplasia of the individual glands. Contrast-enhanced computed tomography of the upper abdomen (Fig. A) revealed a more homogeneous thickening of the gastric wall in the antrum. Round unenhanced low-density foci with a diameter of 4.6 cm was seen in the S7 segment of the liver. Nodular calcifications were also observed. No significant dilatation was noted in the intrahepatic and extrahepatic bile ducts. The size and shape of the gallbladder were normal, the wall was not thick, and no significant abnormal density was observed in the cavity. The pancreas, spleen, and adrenal glands showed no significant abnormalities. Test results from computed tomography indicated liver cyst and intrahepatic calcifications. Contrast-enhanced magnetic resonance imaging of the liver and gallbladder (Fig. B, ) revealed a normal size and shape of the liver and proportion of each lobe, and the intrahepatic and extrahepatic bile ducts and flow vessels ran naturally. A long T1 and long T2 cystic s

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


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

[User]
RADIOLOGY NOTE:
A 57-year-old man with cough and minimal whitish expectoration was diagnosed with adenocarcinoma after a biopsy was conducted on the upper lobe mass of his left lung on March 4, 2016. Mutational analysis revealed that he lacked EGFR mutations or ALK gene rearrangements. CT scans showed that this patient had developed multiple metastases, including mediastinal and hilar lymph nodes, and also to the right intrapulmonary lymph nodes. He received 6 cycles of Pem-Cis chemotherapy, followed by thoracic radiation. Review of the CT scan at completion of sequential chemoradiotherapy treatment resulted in a significant shrinkage in the primary tumor in his left lung, while simultaneously resulting in a slight increase in metastatic lymph nodes (Fig. ). In February 6, 2017, CT scans showed that the tumor progressed rapidly. He was then scheduled to receive gemcitabine plus nedaplatin (Gem-Ndp) chemotherapy. However, the patient had to discontinue the planned 2nd cycle of this regimen as he developed moderate pneumonia. After systemic antibiotic treatment, the patient improved symptomatically and became increasingly energetic. However, CT scans on March 29 revealed that his tumors had progressed further. Owing to his poor physical condition after Gem-Ndp treatment, the chemotherapy regimen was changed to Pem-Cis. However, CT scans on May 11 failed to detect any shrinkage in his tumor. In addition, lymph node metastases increased post-treatment. The patient subsequently started standard of care pembrolizumab treatment at 2 mg/kg intravenously every 3 weeks for 6 cycles. During hospitalization, the general condition of the patient was good, with signs of fatigue only present at the first 2 days after each pembrolizumab infusion. The treatment failed to result in an anti-tumor response. The patient then received 2 cycles of initially used chemotherapy regimen Pem-Cis. Interestingly, we detected a significant shrinkage in the enlarged mediastinal and hilar lymph node metastases, wi

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


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

[User]
RADIOLOGY NOTE:
A 54-year-old gentleman with cervical compressive spondylotic myelopathy and multiple congenital anomalies of the cervical spine such as cranio-vertebral junction anomaly with occipit-C1 synostosis and C4-C5 fused vertebrae [] underwent C3 median corpectomy, gardening, iliac crest graft placement, and stabilization using titanium plate and screws from C2 to C4 vertebral bodies []. Postoperatively, he had improvement in his symptomatology. He reviewed after 8 years with complaint that a screw had expelled through his mouth while having food. There was history of progressive difficulty in swallowing with occasional regurgitation of feeds of 2 months duration. He had no history of recent trauma or worsening of power in his limbs. He was conscious and his neurological examination was normal except for exaggerated deep tendon reflexes. On oral examination, there was a defect in the posterior pharyngeal wall, through which cervical plate along with a missed fixation screw and intact self-locking screw was seen []. X-ray cervical spine lateral view showed anterior dislodgement and migration of the plate with a missing screw socket []. Oral culture was taken, and he was started on intravenous antibiotics, betadine oral gargles, and was fed through a nasogastric tube. At resurgery, no abnormal movement was seen, but the plate and screw system was loose and had migrated, with no evidence of fracture of the plate system. The plate was removed in toto after removing the screws []. As the patient had no new neurological deterioration and no abnormal movement was seen intraoperatively, no further instrumentation was done. He was planned for posterior fusion in case he developed new neurological deficits or signs of instability. Postoperatively there was no injury to the peripheral nerves or cranial nerves. Since the posterior pharyngeal wall defect was small, it was expected to close over a period of time; hence, no attempt was made to close it. Postoperatively he was continued o

[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 Japanese male with no significant medical history other than migraines presented to a primary care clinic with 10 days of right neck pain that was not alleviated by treatment with 60 mg of loxoprofen sodium taken three times a day. He had had six episodes of this neck pain in the previous 5 years but had not visited his doctor because it had disappeared within a week each time. He had no history of chronic disease.
On physical examination, the patient was not pale, and his body temperature was 36.6°C. His initial blood pressure was 113/72 mmHg, his heart rate was 72 beats/min, his respiratory rate was 18/min, and his oxygen saturation was 99%. He had severe tenderness over his right carotid bifurcation but had no vascular bruit. The pain was constant and moderate in intensity and occasionally radiated to the inside of his ipsilateral ear and lower jaw. The pain was not made worse by swallowing, but it was exacerbated when he rotated his neck and opened his mouth widely. There was no tenderness over his thyroid or neck muscles. He had no pain elsewhere in his body, and there was no skin rash, lymphadenopathy, or inflammatory changes to his throat. His mucous membranes were moist, heart sounds were normal, lungs were clear, and abdomen was soft and nondistended. He had no peripheral edema.
The patient's laboratory values were within normal limits without any inflammatory findings (Table ). His blood cell count, liver and renal function tests, lipid tests, blood glucose, glycohemoglobin, and electrolytes were also in the normal ranges. There were negative findings for auto-nuclear antibodies and antineutrophil cytoplasmic antibodies. An ultrasound revealed a hypoechoic change of the outside wall of the carotid artery (Fig. ), slight outward extension of the vessel, mild thickening of the carotid wall, and mild narrowing of the vessel lumen (Fig. ). The maximum intima-media thickness of the right carotid bifurcation decreased in 2 weeks (

[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 94-year-old Caucasian woman presented urgently to the retina clinic for changes in her left vision. She was being regularly followed for neovascular age-related macular degeneration in both eyes with OCT-guided management. Her left eye had last received intravitreal anti-vascular endothelial growth factor (anti-VEGF) injection in 2016. Her other ocular history included dense asteroid hyalosis, making direct visualization of the retina difficult. She had a significant prior medical history of hypertension and on presentation had systolic blood pressures in the 200s. She had no relevant family medical history. The day prior to presentation, the patient described a “shadow” over her left vision that had progressed. The following day, she had nearly complete loss of vision in this eye other than a preserved inferior island. She denied headache or jaw claudication. Upon presentation to the clinic, her visual acuity was counting fingers. Confrontational visual fields showed loss throughout all quadrants other than her inferonasal quadrant. She had a left afferent pupillary defect (APD). Her vision in the affected eye was 20/40 at her appointment approximately 1 month earlier.
The differential for vision loss was broad and ranged from significant retinal pathology to a neurologic event given the profound vision loss with APD. As it was known that her dilated fundus exam was limited by dense asteroid hyalosis, multimodal imaging was performed to evaluate the patient’s vision loss. During dilation, a B-scan was performed to rule out retinal detachment. After dilation, OCT was obtained, which demonstrated slightly thickened and hyperreflective inner retinal layers that were more prominent superiorly and inferiorly in the macula and likely represented acute ischemia (Fig. ). At this point, a retinal vascular event was of highest concern, and preparations were made to transfer the patient to the emergency room for urgent stroke workup. A FANG was undertaken to definitively di

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


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

[User]
RADIOLOGY NOTE:
A 49-year-old woman patient presented a significant dissatisfaction with the aesthetics due to the gingival recession of a tooth located in the anterior region of the mouth. Dental history revealed that the patient had received orthodontic treatment seven years before. During and after the treatment, she perceived her longer canine tooth.
Clinical examination of tooth 23 revealed the presence of a 12 mm deep and 6 mm wide GR and keratinized tissue of 1 mm width on the buccal surface (). Probing depth (PD), GR and clinical attachment level (CAL) were recorded on six aspects of the tooth (). Bleeding on probing, slight supragingival calculus deposits, grade III mobility, and GR Class III, according to Miller [], were also recorded. The initial radiographic image revealed extensive periapical and lateral radiolucency ().
The patient was referred to an endodontist for evaluation. The tooth responded negatively to the cold test, and endodontic treatment was indicated. The tooth was diagnosed as a primary endodontic lesion with secondary periodontal involvement. The patient was informed that the tooth had a poor to guarded prognosis due to severe periodontal attachment loss. Following a discussion of the benefits, risks, and alternative treatment options, she decided to keep her tooth. She approved dental treatment through written informed consent.
The first phase of the treatment consisted of oral hygiene instructions and generalized scaling and root planing. A temporary splint was made to control tooth mobility and improves the patient’s comfort and function. After that, root canal therapy was performed. Four months later, the PD of all sites was within 3 mm, and the periapical radiograph showed a slight decrease in lateral and periapical radiolucency (). At that time, it was decided to perform root coverage with a laterally positioned flap (LPF) with subepithelial connective tissue graft (SCTG) on tooth 23. After local anesthesia was provided, an intrasulcular incision

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


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

[User]
RADIOLOGY NOTE:
A 60-year-old white male was admitted to our Department in January 2003 because of dysphagia and odinophagia. The patient's medical history included perforated benign gastric ulcer treated in 1965 by means of distal gastrectomy and ante colic end to side gastrojejejunostomy (Polya anastomosis). An esophagoscopy confirmed an ulcerated tumour of the lower third esophagus with the upper margin located at 35 cm from dental arcade; a squamous cell carcinoma was identified on biopsies. The interval between previous distal gastrectomy and esophagectomy was 38 years. Barium meal showed a capacious residual stomach with efficient emptying function through a wide gastrojejunostomy. The size of the residual stomach was measured before operation with contrast barium meal x-ray: 8 cm in length at the lesser curvature and 11 cm at the transection of the body (Figure ). Because of no evidence of metastatic disease and satisfactory general health conditions the patient was scheduled for resection of the oesophageal cancer.
Two-phase subtotal esophagectomy via abdominal (bilateral subcostal incision) associated with 5th right thoracotomy with two field lymph node dissection was carried out. In the right upper abdomen the duodenum stump, transverse colon, and lower surface of the liver were tightly adherent. Exploration of the thorax and abdomen excluded presence of distant metastases and confirmed wide gastrojejunal anastomosis. The right gastroepiploic arcade was divided at the time of previous gastrectomy. The residual stomach, afferent and efferent loops of jejunum were fully mobilized from peripheral cohesions. Short gastric vessels were not preserved and the left gastric artery was divided; no jejunal vessel was sacrified. The afferent loop was transected very close to the gastrojejunal anastomosis and the gastric end was closed. The other end was covered with gauze and closed. The prepared stomach roll was pulled up in continuity with the efferent loop through the posterior me

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


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

[User]
RADIOLOGY NOTE:
A 35-year-old male with a history of hyperlipidemia and seizure disorder presented to an outside hospital following a breakthrough seizure, where he was incidentally also found to have punctate areas of acute cerebral infarcts in multiple vascular territories. Additional workup revealed the presence of a left atrial thrombus and newly diagnosed atrial fibrillation. He was ultimately discharged to home on apixaban. The patient then re-presented a month later for evaluation of transient diplopia, expressive aphasia, daily right temporal headaches, and right facial and left leg weakness. MRI of the brain showed new areas of diffusion restriction in the left cerebellar hemisphere and left medial occipital lobe (Figure ). CTA showed no signs of carotid occlusion or stenosis. The etiology of his multifocal strokes was thought to be related to his newly diagnosed atrial fibrillation and left atrial thrombus.
The patient was then transferred to our hospital for further evaluation. His initial NIH stroke scale was 8 (primary deficits were including unilateral facial palsy, bilateral lower extremity pronator drift and ataxia). Stroke labs, including lipid panel and hemoglobin A1C, were unremarkable. MRI of the brain with contrast showed a new infarct in the splenium of the corpus callosum in addition to prominent generalized meningeal enhancement (Figure ). MRI of the spine with contrast showed possible meningeal enhancement as well as punctate areas of encephalomalacia in the C3-4, C7, and T3 spinal levels. A bedside LP revealed a mildly elevated opening pressure of 24 cm H20, lymphocytic pleocytosis (WBC 150 K/cumm, 61% lymphocytes), protein 170 mg/dl, hypoglycorrhachia of 15 mg/dl, and presence of cryptococcal antigen. Other notable CSF labs included the presence of 11 oligoclonal bands. He was diagnosed with cryptococcal meningoencephalitis and started on a four-week course of amphotericin B and flucytosine. A repeat LP after several days of treatment showed a normal open

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


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

[User]
RADIOLOGY NOTE:
A 60-year-old male presented to the Bay Regional Medical Center with a history of fatigue lasting for several days, a 20-lb weight loss over the past 2 months, one episode of painless hematuria, and persistent headache for the past several weeks. He denied any diplopia, blurry vision, nausea, emesis, weakness, abdominal pain, blood in stool, cough, shortness of breath, alcohol use, drug use, or tobacco use. On physical examination, there was a slight bony defect noted on the lateral aspect of his right supraorbital ridge consistent with the prior resection of a temporal teratoma. His past medical history includes the surgical removal of a benign temporal teratoma and a teratoma in the right knee at the ages of 2 and 30 years, respectively. He has a family history of breast cancer in his mother and maternal grandmother. CT imaging of the head with contrast showed multiple lesions in the right frontal lobe suspicious for malignancy. CT scans of the chest, abdomen, and pelvis were negative for any primary tumor source. The patient was subsequently admitted to St. Mary's of Michigan, where laboratory testing were done including comprehensive metabolic panel, complete blood count, and liver function tests which were all within normal limits.
An MRI with contrast was obtained to further characterize the brain lesions and showed 4 lesions with diameters of 2.6, 1.0, 1.8, and 0.9 cm as well as vasogenic edema and an anterior midline shift of 9 mm (Fig. ). Bone scan, scrotal duplex ultrasound, urine cytology, and diagnostic cystoscopy were all negative for any evidence of malignant processes. Three days after admission, the patient underwent diagnostic and therapeutic right frontal craniotomy for the resection of the largest mass (2.6 cm in diameter) in the right frontal lobe. The operation was successful in obtaining a gross total resection, and his recovery from surgery was uneventful. Pathologic analysis revealed the mass to be a moderately differentiated adenocarcinoma s

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


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

[User]
RADIOLOGY NOTE:
A 36-year-old male patient sought medical attention complaining of epigastric pain, constipation, and vomiting for about 10 days. He denied past similar episodes, peritoneal dialysis, chronic use of medications, or other comorbidities. On clinical examination, he looked well but the abdomen was distended, diffusely tender on deep palpation, and showed defense and dullness in the left hypochondrium and flank. There were no signs of enlarged viscera, Giordano and rebound signs were negative, and bowel sounds were reduced. Blood cell count on admission showed hemoglobin of 15.6 g/dL and leukocytes of 11,700/mL (86% segmented, without shift to the left). Abdominal ultrasound and laboratory workup were unremarkable. Abdominal computed tomography (CT) showed conglomerate of the small bowel in the central portion of the abdomen, with some loops exhibiting air–fluid level enclosed by a thick fibrous membrane associated with slight enhancement of the contrast media within the intestinal wall. Slight parietal engorgement of the mesenteric vessels, as well as a small amount of free liquid in the abdominal cavity, were also observed (, and ). The patient underwent an exploratory laparotomy. Surgical findings included segments of the small bowel entrapped by white fibrous tissue forming sacculations, and some inter-loop adhesions without signs of vascular loop suffering. No definite point of obstruction was evident, but free liquid was observed in the abdominal cavity. Partial resection of the fibrous membrane and lysis of the adhesions were undertaken.
The product of surgical excision consisted of multiple irregular fragments of membranous tissue measuring 10.0 × 8.0 × 4.0 cm. Histological findings showed that this membrane mainly consisted of a thin capsular fibrous tissue containing scattered fibroblasts ( and ) with a deposition of fibrin on the peritoneal surface ( and ). The thicker areas showed enlarged peritoneal fibroblasts containing large nuclei and increased cellular

[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.