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

[User]
RADIOLOGY NOTE:
A 23-year-old male patient presented with a protruding neck mass. Six years prior to this presentation, the patient had undergone superficial parotidectomy for the removal of pleomorphic adenoma of the right parotid gland at our institution (). The patient experienced recurrence at 17 months after the initial resection, which required a total parotidectomy.
At physical examination, the 1.5 cm mass was located within the surgical scar on the upper portion of the sternocleidomastoid muscle. It was firm, indolent, and nontender. Computed tomography (CT) scan of the neck revealed a 5.1×3.2-cm multinodular mass at the site of initial tumor location, along the 1.5-cm subcutaneous mass in the surgical scar area ().
Under general anesthesia, the mass was excised with wide margins. At the site of cervical surgery scar, the mass was located in the subcutaneous layer and surrounded by fibrotic tissue, but no glandular tissue was observed. The multinodular mass deeply rooted in the trunk of facial nerve and expanded beyond the area occupied by the first tumor. Intraoperative frozen section confirmed both masses having benign histology. Therefore, both masses were resected along with all surrounding scar tissues. A portion of the frontal branch of facial nerve were sacrificed for complete resection of the parotid mass.
Histopathologic examination of the initial resection demonstrated solitary nodules containing a mixture of epithelial and mesenchymal structures. It was a typical pleomorphic adenoma with tubular or linear architecture of epithelial cells and hyaline and myxochondroid appearance of stromal components. Tissues obtained after the second surgery also comprised multiple nodules. Histopathologic findings indicated that the recurrent tumor was also a typical pleomorphic adenoma but composed of more than 80 large and small nodules. We observed both the presence of microscopic extensions or pseudopodia—finger-like expansions—protruding beyond pseudocapsule and capsular pe

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


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

[User]
RADIOLOGY NOTE:
A 57-year-old male was referred to our oral surgery clinic for the evaluation of a radiolucent image of his left mandible. Three weeks prior to being seen in our clinic, he visited a family dentist for the treatment of caries in his right maxillary tooth. At that time, a relatively large left mandibular radiolucent area, which was larger than that previously observed, was found. The patient's past history included hypertension, hemiplegia, dysarthria, and dysphagia. At the time of his initial examination, he was taking amlodipine besilate 2.5 mg/day. Radiographic examination showed impaction of the left mandibular wisdom tooth and a cystic radiolucent area spreading around the crown of the tooth (). Oral examination demonstrated that there was no gingival swelling or tenderness in the area corresponding to the cyst and wisdom teeth. The patient's oral hygiene and periodontal status were fair. The clinical diagnosis was a dentigerous cyst of the left mandibular wisdom tooth. As results suggested that further expansion of the cyst was possible, after the consultation with the attending physician, the patient, and his family, a surgical treatment was planned. Under general anesthesia, the wisdom tooth and cyst were removed. The surgical procedure was performed using a triangular flap. This involved an incision from the distobuccal edge of the left first molar, dropping at a slightly oblique angle into the mandibular vestibule. The second incision made was a relieving incision that ran from the ramus to the distobuccal aspect of the first molar []. The left second molar was extracted at the same time, as the root apex was contained in the cyst. No abnormal findings were observed in the excision cavity of the cyst, the extracted mandibular second molar, or their extraction sockets. The surgical wound was sutured without complication. The histopathological diagnosis of the specimen was a dentigerous cyst (). A follow-up was performed at approximately 1, 3, and

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


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

[User]
RADIOLOGY NOTE:
A 24 years old male motorcyclist with no significant past medical history was admitted after he collided with a car. He sustained a closed T-type acetabular fracture dislocation on the left, with sacroiliac joint diastasis (). He was also noted on presentation to have a dense ipsilateral lower limb sensorimotor deficit. He underwent immediate manipulation and reduction of the left hip with Steinman pin insertion into the distal femur for skeletal traction. Open reduction and internal fixation of left acetabulum was done semi-electively 6 days later. A posterior Kocher-Langenbeck approach was utilized with the patient in a prone position. Surgical stabilization was achieved with two posteriorly applied low profile pelvic reconstruction plates. The patient was mobilized on a wheel chair after surgery, and progressed to weight-bearing at six weeks after follow-up radiographs had shown evidence of fracture healing. In the meantime, the patient required a referral to a pain specialist for chronic neuropathic limb pain. An electromyographic study performed at six weeks after injury confirmed the presence of widespread left lumbosacral plexopathy involving the left femoral, sciatic, and gluteal nerves (). He was managed supportively for the neurological injury with physiotherapy, and a walking ankle foot orthosis for his left foot drop. Unfortunately due to progressive wasting of his hip abductor muscles which was evident on serial radiographs (), he experienced recurrent episodes of hip subluxation which were self-reducible. Radiograph showed lateral subluxation of the femoral head. The lumbosacral plexopathy continued to improve over the next two years with eventual full neurological recovery (). However by this time, there was symptomatic post-traumatic osteoarthritis of the left hip and he underwent an unconstrained total hip arthroplasty at two years after the initial injury (). No acetabular defect was seen at operation. Patient recovered uneventfully thereafter with

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


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

[User]
RADIOLOGY NOTE:
A 48-year-old man presented with right knee pain that had been ongoing for 10 years prior and had not been the result of trauma; He presented with difficulty in full extension or squatting. This right knee pain had been aggravated 4 years prior. The patient had received conservative treatment that included medication with non-steroidal anti-inflammatory drugs from other hospitals over the prior 2-3 years, but the symptoms had not improved. Physical examination revealed mild swelling, quadriceps atrophy, and a positive McMurray's test. There was no evidence of joint line tenderness. The Lachman test, anterior and posterior drawer and pivot shift tests, and maneuvers for rotator instability were all negative. The range of motion was a flexion contracture of 5° and a further flexion of 130° with mild pain exacerbated by full extension or full flexion at the posterior aspect of the knee joint. Plain radiograph of the right knee joint showed mild degenerative changes and the notch-width index of the femur was 0.213 (). Both ACL and PCL had inhomogeneous signal intensity and diffuse hypertrophic changes on the T1-weighted, proton-density and T2-weighted images of MRI (). The menisci were normal.
At arthroscopy, there was no meniscal pathology medially or laterally. There was no ligamentum mucosum. However, there were mild grade 1 or 2 articular surface changes in the medial tibial plateau and in the medial femoral condyle. Both ACL and PCL were intact, but which was no longer enveloped by the synovium, and showed yellowish, hypertrophic changes. The hypertrophic ACL and PCL filled the entire intercondylar notch and caused impingement. There was no gross evidence of cyst or ganglion formation within the ligament. The ligament demonstrated appropriate tension when probed and when an anterior or posterior drawer test was applied. A biopsy was performed on the hypertrophic portion of both the ACL and PCL. We performed a partial excision for normal appearing shape of ACL and P

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


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

[User]
RADIOLOGY NOTE:
This case is of a 55-year-old female who initially presented with a palpable left neck mass. The mass had been noted by the patient 8 years ago and had progressively grown in size. A computed tomography (CT) of the neck was obtained, which demonstrated a 3.5 × 2.3 × 4.6 cm lesion deep to the left sternocleidomastoid (SCM) muscle in addition to a smaller 1 × 1 × 1.8 cm left posterior neck-enhancing mass. A fine needle aspiration (FNA) had been performed 2 years prior at an outside hospital with pathology indicating a low-grade spindle cell proliferation. She was thus referred to our institution for further evaluation. At the time of initial presentation to our group, the patient had noted dysphagia, left ear ache and tinnitus, and neck pain localized to the two masses. A positron emission tomography (PET) CT was performed, which demonstrated increased fluoro-2-deoxy-
d
-glucose uptake in the high cervical mass and, to a lesser degree, in the mass located within the posterior triangle of the neck (
). The outside tissue blocks were reviewed at our institution and felt to be consistent with a peripheral nerve sheath tumor compatible with schwannoma from both lesions. Because of the patient's ongoing symptoms and because malignancy could not be completely excluded based on the results of the prior FNA, the decision was made to proceed with surgical excision of both lesions. Prior to proceeding, a magnetic resonance neurogram was obtained (
). Tractography demonstrated that the two lesions appeared to originate from the spinal accessory nerve and that apparent diffusion coefficient values were elevated in both masses, supporting the diagnosis of a less aggressive tumor (
).
The patient was taken to the operating room for surgical resection. The patient was positioned with her head turned slightly to the right with the neck extended (
). The smaller lesion was approached first through the posterior triangle of the neck. Stimulation mapping of the tumor was conducted.

[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 6-year-old boy reported to the Department of Pediatric Dentistry with a history of fall while playing 2 days ago. After the fall the child did not lose consciousness, had no history of vomiting or convulsions. There was a history of bleeding from gums, difficulty in the closing mouth and chewing food.
Clinical examination revealed a diffuse extraoral swelling in the right lower one-third of the face causing a asymmetry of the face, difficulty in opening and closing the mouth, and a cut on the chin and the lower lip. Intraoral examination revealed a vertical fracture line between right mandibular primary lateral incisor and primary canine associated with medially displaced left mandibular dentoalveolar segment with step deformity and altered occlusion leading to an open mouth appearance []. Preoperative orthopantamogram (OPG) was taken [], which confirmed right parasymphisis fracture. There was an associated fracture present on the left mandibular angle region.
Upper and lower arch alginate impressions were taken, and stone casts were poured. An acrylic splint was fabricated, and mandibular fracture was immobilized, fixed with the acrylic splint that was retained by circum mandibular wiring. Circummandibular wiring was done under general anesthesia by placing a small-stab incision on the inferior border of mandible on the right and left side 3–4 cm from the midline. The mandibular bone awl was used to enter lingually along the body of the mandible and piercing lingual mucosa the wire was fed and passed onto buccal sulcus along the body of the mandible. Wire held together and stent stabilized by winding wire in a clockwise direction at 83.84 region. The same procedure was repeated on the left side []. Another circum mandibular wire was placed at the left body region to stabilize the fractured fragment at the lower border of mandible. Postoperative OPG was taken with circum mandibular wires in place []. The patient was reviewed every week and on the fourth postoperat

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


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

[User]
RADIOLOGY NOTE:
A 30-year-old Caucasian woman was followed by a pneumologist due to an insidious dyspnea on exertion and even when resting. She had been a smoker for 18 years (30 pack-years) and had her first child at the age of 20 as a vaginal delivery. There was no history of any chronic medication intake or any prior drug or food allergies.
Her disease was monitored thoroughly and, initially, through a lung CT scan, several cysts were identified, suggesting bullous emphysema associated with fibrosis in the lower lobes. In the meantime, the patient developed polyuria and polydipsia (with the consumption of more than 5 liters of water per day), so, as her anti-diuretic hormone levels were low, LCH was considered a possible diagnosis, and intranasal desmopressin was administered with symptomatic improvement. A lung biopsy was performed without any complications, and LCH diagnosis was confirmed through the expression of CD1a and S100 protein.
As the patient had developed symptoms of a diabetes insipidus, a cranial magnetic resonance was performed that confirmed the existence of a lesion located in the posterior lobe of the pituitary gland. Finally, a positron emission tomography was performed, which revealed diffused liver and skeletal lesions besides the pulmonary and pituitary lesions. So, the patient was diagnosed with a disseminated LCH, and she was followed closely in the rare disease consultation and was started on cytarabine (5-day treatment every month for one year) with significant improvement in respiratory distress and dyspnea. Pulmonary function tests (PFT) were repeated yearly and showed a mixed pattern that remained stable during follow-up. Afterward, the patient manifested the will to have another child so, she was followed at the high-risk pregnancy consultation and became pregnant 14 months after the last treatment with cytarabine.
Her pregnancy progressed normally, without any complications or symptoms, and in terms of medication she was only taking iron and folic

[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 with hepatitis C was being seen by the gastroenterology service to monitor a liver nodule. Abdominal ultrasonography identified a visceral artery aneurysm as an incidental finding. Angiotomography revealed that it was a saccular aneurysm of the pancreaticoduodenal artery, with a diameter of 40 mm, and showed subocclusive stenosis of the celiac trunk compatible with extrinsic compression ( ).
The patient underwent laparoscopic relief of celiac trunk compression ( ), thereby averting the possibility of mesenteric ischemia, as the pancreaticoduodenal artery is an important collateral route between the celiac trunk and the superior mesenteric artery and an undiscovered occlusion of this artery can cause visceral ischemia. The laparoscopic procedure was performed using a 10 mm trocar for the camera, in an umbilical position, and a further four trocars; in the right and left hypochondrium, the left flank, and a subxiphoid position. The gastrohepatic ligament, phrenoesophageal membrane, esophagus, and crura of the diaphragmatic were dissected, with inferior sectioning of the crura to enable the arcuate ligament to be viewed. Relief of celiac trunk compression was achieved by sectioning the arcuate ligament by electrocautery and the crura were drawn back together to prevent gastroesophageal reflux. Doppler ultrasonography conducted before hospital discharge showed that there was no longer compression of the celiac trunk and revealed some residual stenosis and post-stenotic dilation (the pre-stenotic celiac trunk diameter was 10 mm and at the stenosis it was 3.5 mm) ( ).
The patient returned 2 months later for pancreaticoduodenal artery aneurysm repair, which was performed under local anesthesia and sedation, via a left brachial access with selective catheterization of the superior mesenteric artery and selective embolization of the aneurysm sac with microcoils, with no intercurrent conditions ( ). Four 20 mm to 25 mm x 50 cm Axium 3D microcoils and two A

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


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

[User]
RADIOLOGY NOTE:
We describe a case of a 29-year-old lady who was referred to our hospital at the 40th gestational week of her first spontaneous pregnancy for counseling regarding an elective cesarean section due to a pelvic mass presenting as a tumor previa.
She was aware of an abdominal ultrasound examination performed at her childhood in which bilateral pelvic kidneys were diagnosed. Her renal function tests were always within normal limits.
On the transvaginal ultrasound examination performed at the 12th gestational week an intrauterine singleton pregnancy with a fetus appropriate for gestational age was found. On this scan the maternal left kidney was demonstrated in the pelvis behind the uterus attached to the sacral wall (see ).
Later in the pregnancy, the patient had two routine obstetrical sonographic scans at 15th and 24th gestational weeks. Both examinations were normal, concerning the fetal growth and anatomy. In both scans the bilateral pelvic kidneys were reported (see ). The kidneys had a normal sonographic appearance and showed no hydronephrosis. The patient was informed of the possibility that the ectopic kidneys may interfere with the vaginal birth and a near-term assessment was recommended. Lastly, she was examined at the 40th week gestation. The fetal heart monitoring and amniotic fluid index were normal and the estimated fetal weight was 3800 grams. On the digital vaginal examination the cervix was closed, 50% effaced, and posteriorly positioned. The fetal vertex was at the spina −5 station, floating outside the pelvic inlet. Below the fetal head, the left pelvic kidney was palpated as a large fixed mass bulging from the upper-posterior vaginal wall into the birth canal. A transvaginal sonogram showing the relation between the fetal vertex, pubis, pelvic walls, and left kidney is presented in . An anterior-posterior distance of 5.75 cm was measured between the most anterior margin of the kidney and the posterior aspect of the pubic symphysis, while the fetal bip

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


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

[User]
RADIOLOGY NOTE:
A 26-year-old male without any significant past medical history initially presented to an outlying facility for being struck by lightning while storm chasing. According to bystanders, he was standing on a concrete pylon when the lightning struck, and he was thrown an unknown distance from the pylon. He was next seen at the side of a bystander’s vehicle partially clothed and confused (). He was taken to the nearest emergency department (ED) immediately.
According to the medical record at the outlying ED, he arrived neurologically intact with stable vital signs. After receiving pain medication and 3 L of normal saline, he was transferred to a Level 1 trauma center via ambulance. On arrival, he was awake and alert with complaints of muscle cramping, bilateral ear pain, and amnesia to the actual event.
His initial vital signs were within normal limits and he was neurologically intact. He was found to have mild bilateral otorrhea with bilateral tympanic membrane ruptures. He also had superficial partial thickness cutaneous linear burns that extended from the sternal notch down the anterior chest and abdomen in the midline (), splitting to travel down the medial aspect of each thigh and calf, ending at the medial malleoli bilaterally (). It was determined that this burn was approximately 13% of his body surface area. The remainder of his physical examination was normal with no other evidence of traumatic injury.
Initial laboratory values were drawn and were unremarkable with the exception of an elevated creatine kinase (CK). An electrocardiogram was obtained and demonstrated normal sinus rhythm with a right bundle branch block. A chest X-ray showed no acute cardiopulmonary disease. Computed tomography (CT) scan of the head revealed no acute intracranial process; however, there was a small amount of fluid in the left mastoid air cells and middle ear without clear evidence for temporal bone fracture. CT of the facial bones, cervical spine, thoracic spine, and lumbar spine

[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 32y old woman was referred to Yas hospital due to severe low abdominal pain and vomiting on May 2017. Ultrasonographic examination of her pelvis revealed bilateral ovarian cysts. During the 5 days before the admission, she had experienced severe right lower abdominal pain and vomiting especially after a meal. She had a long history of dysmenorrhea and, one cesarean delivery 3 years before. She was taking no medication. Her physical examination report included the temperature of 37°C, systolic blood pressure of 100 mmHg and heart rate of 120 beats per minute. The right lower quadrant of her abdomen was tender along with hypoactive bowel sounds. Laboratory data reported leukocytosis (16×109/L) with neutrophilia, C-reactive protein of 20 mg/dl and erythrocyte sedimentation rate of 60 mm/hr. Abdominal erect X-ray showed dilatation of small bowel segments. Colonoscopy was requested by gastroenterologist for finding the cause and excluding colon neoplasm. Diagnostic colonoscopy showed one small ulcer (8 mm) with the pressure effect of mass like lesion at cecum and scope couldn’t find the ileocecal valve. It was thought that a mass like lesion had caused the ileum obstruction. Colonoscopic biopsies were taken and histopathological examination revealed endometriosis. Afterwards, the patient was taken to the operating room for excision of the mass. At the exploration of the abdominal cavity, adequate exposure was attained by a vertical incision across the midline of the abdomen with a transverse extension to the right. The ileocecal part was covered by the omentum and was adherent to the abdominal wall. The ileocolic intussusception was seen without ischemic changes. Reduction of the intussusception was performed at first. After reduction, a firm mass was recognized at cecum, located close to the ileocecal valve. Then, the ileocecal resection was performed (). Pathological examination confirmed endometriosis.
The postoperative period was uneventful and she was discharged 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 50-year-old female was referred for evaluation of pain on #15, the upper left second premolar. She complained sharp pain on #15 when chewing that started 2 weeks ago. To resolve her discomfort, she visited her general dental practitioner and root canal therapy was started on this tooth. The patient was subsequently referred to the Department of Conservative Dentistry, Kyungpook National Dental Hospital when the pain was not resolved.
Clinical examination revealed that tooth #15 was restored with temporary filling material. The tooth was positive to percussion and periodontal probing depths on distopalatal area of was more than 7 mm. Pain could be elicited by bite test of the tooth. All adjacent teeth responded within normal limits to percussion, palpation and bite test and showed positive response to vitality tests with cold spray and electronic pulp tester. No noticeable pathologies were observed on the radiographs except alveolar bone resorption on distopalatal area of #15 (). On the basis of clinical findings and history of pain, a diagnosis of acute apical periodontitis was suspected. Root canal treatment was performed on this tooth ().
On follow-up 2 week later, the patient was still experiencing what she described as 'sharp pain' from her lower right tooth not from tooth #15. At this time she pointed to tooth #45 and insisted that sharp pain resulted when chewing. Tooth #45 was slightly sensitive to percussion and pain could be elicited by bite test of the tooth. Tooth #45 responded within normal limits when tested with cold and electronic pulp tester. A caries cavity was observed at the distal surface of #45 on the radiograph (). Intraligamental injection on #45 area resulted in relieving the pain. A definitive diagnosis could not be made from the clinical findings. Distal caries on #45 was removed and the tooth was restored with composite resin ().
On follow-up 1 week later, the patient informed us that the sharp

[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 is a 36-year-old female school teacher who was in her normal state of health until two years prior to the present admission when the patient started to feel occasional pressure-like chest discomfort and palpitation. The patient went to a local hospital for help. Mild mitral regurgitation was told, and the patient was then discharged with medical management as an outpatient. However, one month prior to the present admission, the patient's chest tightness, although still mild on onset, had increased in frequency. The patient went back to the same hospital for further evaluation. This time, a cardiac catheterization was performed and accidentally revealed anomalous drainage of left coronary artery (LCA), including all its branches (like the left anterior descending artery, left circumflex artery, and the left diagonal artery), into the main pulmonary artery. Single right coronary artery (RCA) originated from the aorta, and mild mitral regurgitation was seen concurrently in the cardiac catheterization. Upon recommendations from the patient's family, the patient came to our hospital and was admitted for surgical managements.
After the patient was admitted into our service, chest X-ray, ECG, carotid ultrasound, pulmonary function test, pressure volume recording, blood analysis, and viral check were done and all revealed normal findings. No fever, leukocytosis, or any sign that might reveal infectious process had been determined. The patient was clear for surgical correction ().
The patient received surgery on December 25, 2003 (Christmas Day). The operation consisted of closing the anomalous opening in the pulmonary trunk simply with a commercially available bovine pericardium patch; concurrently, a single coronary artery bypass utilizing the Left Internal Thoracic Artery was made to the patient's Left Interventricular Artery (left anterior descending artery). The patient tolerated the procedure well. The anastomosed artery was first perfused from both the ant

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


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

[User]
RADIOLOGY NOTE:
The patient was a 54-year-old Italian Caucasian female. She was a non-smoker. She was evaluated in our hospital for recent onset of pain and tenderness in the left breast. She referred swelling of the breast, but denied nipple discharge. Her past medical history was not significant. Her family history was not significant for breast cancer; she denied oral contraceptives use in the past and she give birth to one child. Her most recent Pap smear had been negative for any squamous lesion. Physical examination revealed erythema, hyperaemia and tenderness to touch of the left breast. A palpable well circumscribed and firm mass measuring about 40 mm was present in the left inferior lateral quadrant. The right breast examination was normal. There was no evidence of lymphadenopathy on physical examination, including the axillary and supraclavicular regions.
She underwent an ultrasound examination of the left breast, which revealed a defined 29 mm mass with a thick rind and reduced central echogenicity, consistent with a cystic space. Mammography showed a round, high-density mass with almost regular but partially irregular margins, measuring approximately 30 mm.
Fine needle aspiration cytology revealed an infiltrative poorly differentiated squamous cell carcinoma.
Total body CT scan, bone scan, laboratory data (blood count, serum electrolytes, liver function tests, creatinine, prothrombin and partial thromboplastin time), tumors markers, including the levels of serum carcinoembryonic antigen, carbohydrate 15-3 and squamous cell carcinoma antigen were within normal range.
The patient underwent a wide local excision of the left breast with ipsilateral axillary lymph nodes dissection. Gross examination revealed a 4.7 cm tumor with central cystic space located in the center to lower outer quadrant of the left breast. There were no component of obvious invasive ductal carcinoma or other features of metaplastic carcinoma for example spindle cells, or osseous or cartilaginous metap

[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 32-year-old man undergoing treatment for a depression with serotonin–norepinephrine reuptake inhibitors (SNRIs) and with one prior admission to the hospital due to rightsided abdominal pain was admitted to our department after 4 h with severe abdominal pain. The pain was acute in onset, stabbing and located in the whole right side of the abdomen, radiating to the back and to the right groin. The pain was associated with nausea and restlessness, and could not be reduced with either NSAID or high doses of morphine. On presentation, he was ill looking, sweating, restless and in agony. He was ABC stable, his abdomen distended with generalized tenderness and in his upper right quadrant he had a 10 × 10-cm hard very sore mass, with positive rebound tenderness. There were normal bowel sounds.
Paraclinical tests showed leucocytosis (10,1 × 109/l) and normal serum lactate. A computed tomography (CT) scan showing gastric retention, encapsulated dilated small intestines in the right upper quadrant with pneumatosis intestinalis and collapsed small intestines distally from this area interpreted as intestinal obstruction (Figs and ).
An emergency laparotomy was performed 12 h after the first appearance of the symptoms and 7 h after admission to the hospital. This revealed severe small bowel obstruction. Approximately 1 m of small bowel was found distended, herniated and strangulated through a 2-cm defect in the mesentery of the transverse colon. Furthermore, it was capsuled in the mesenteric peritoneum, resembling a balloon ready to burst. The intestines were greyish in colour, but vital without signs of necrosis or ischaemia (Fig. ). The peritoneal capsule was then removed and the defect widened, before the herniated small bowel could be loosened and retracted back through the hernia. The defect was sutured. The postoperative course was smooth, and the patient was discharged 4 days later. The patient has not been readmitted to the hospital at

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


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

[User]
RADIOLOGY NOTE:
A 12-year-old girl was admitted with a several-weeks history of headache, vomiting, and abdominal pain. Neurological examination revealed slight ataxia but was otherwise normal. The past medical history as well as the family history was uneventful. Magnetic resonance imaging (MRI) of the brain revealed a large space-occupying lesion of the left posterior fossa measuring 5.4 × 5 × 3.9 cm. The lesion was based on the convexity of the left infratentorial space and extension into the posterior fossa with bone erosion extending towards the left occipital space. The intracranial tumor part consisted of two parts, enhanced gadolinium, and was accompanied by peritumoral edema mainly focused on the vermis and the contralateral white matter and dislocating the transverse sinus ().
The patient underwent total tumor resection via a left-sided suboccipital approach. First, an extracranial tumor layer overlying the left posterior fossa and infiltrating the muscle tissue was removed. The infiltrated bone segment extended from the posterior fossa to the left occipital region covering the occipital pole. All affected bone parts were removed. Then, an epidural tumor layer overlying the transverse sinus was removed. After decompressing the dura the transverse sinus was found to be intact. Intradural inspection at this site revealed no residual tumor. Then, the infratentorial intradural tumor was excised completely including the dura. The tumor was firm with only few small nutrition vessels originating from the leptomeninges. After tumor removal, the dural defects were covered with sutured Neuropatch. The resected bone was replaced with methyl-methacrylate pasty.
Histologically, the tumor consisted of small to ovoid cells with scanty cytoplasm. Nuclei were round and hyperchromatic. The cells were arranged in large sheets (Figures and ) with focal necrosis. Tumor cells infiltrated and destructed the bone trabeculae in the periphery (). PAS staining revealed a granular positivity (). Ret

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


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

[User]
RADIOLOGY NOTE:
The patient was a 60-year-old man who was the husband of the patient described above. He experienced lumbago on the same morning his wife was hospitalized. Fever and disturbance of consciousness occurred in the evening, and he visited the emergency room at another hospital. He had completed the course of neoadjuvant and adjuvant chemotherapy and radiation for glioblastoma 6 years ago, and was able to carry out his daily activities independently. He had no medical history of pneumonia or a history of pneumococcal vaccination. Although right lumbar pain was observed, the origin of fever was unknown; antimicrobial treatment was initiated with 4.5 g piperazine/tazobactam every 8 h. The results of the blood test taken at hospitalization are shown in Table . Pneumococcus was detected in his blood culture as well, and the regimen was changed to 2 g ABPC every 6 h. There were abnormal findings in the lumbar MRI scan taken on hospital day 2. Nonetheless, the results of the spinal fluid test, head MRI, thoracoabdominal contrast CT, transesophageal echocardiography, did not reveal presence of infection at other sites. Because lumbago persisted, MRI was performed again on hospital day 9; the consequent MRI results revealed purulent spondylitis (Fig. ). The patient was transferred to our hospital on hospital day 9. To normalize white blood cell count, CRP level, and blood sedimentation rate and to improve CT findings, antimicrobial drug treatment was carried out for a total of 9 weeks.
Both patients tolerated the antimicrobial treatment well, and recovered completely. A 13-valent pneumococcal conjugate vaccine was administered initially, and a 23-valent pneumococcal polysaccharide vaccine was administered 1 year later in both patients. More than 1 year has elapsed since the completion of treatment, and there has been no recurrence.
In the bacterial strain analysis (Table ) performed on the samples from both patients, the capsule serotype was 12F identified by the capsule quellin

[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 2010, a 48-years-old male patient arrived at the Emergency Department (ED) with a self-inserted FB in the rectum that he tried to remove without success. The patient had no symptoms, apart from a mild discomfort. Physical exploration revealed no signs of peritonism and a slight tenderness at palpation of the abdomen. Rectal exploration demonstrated the FB 6 cm proximally from the anal verge. An abdominal X-ray was performed, giving details about object's characteristics: a long silicone penis, reaching the splenic flexure ().
No signs of perforation were identified. Laboratory exams were in range. The patient underwent a colonoscopy, in order to remove the object, but every attempt failed. The maximum diameter of endoscopic loop available in our institute was 32 mm. The endoscopist tried to catch the object with this instrument, but it resulted unsuccessful due to the large diameter of the object. Moreover, its slipping surface and the elastic and smooth consistence prevented from catching it with a grasp. The instrument cannot get over the frictional resistance of the FB due to its length, and the endoscopist succeeded in tearing out just a little piece of it. Besides its diameter, the endoscopic loop resulted too flexible to reach our purpose. The patient was therefore transferred to our service and sent to the operating room (OR). Under deep sedation, many unsuccessful attempts to remove the FB with round and Kocher clamps were made. We decided to try the extraction with Endobag, a well-known laparoscopic surgical device. We first removed the plastic bag from the device, using the metallic ring as a noose, particularly useful for the shape of the object, composed by a larger part at both extremities. The metallic ring diameter after removing the plastic bag was 60 mm. After catching the object transanally with the noose on finger guide, we successfully pulled the object out (). It resulted to be 400 mm long and 44

[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:
We report the case of a previously healthy 17-year-old Caucasian male with exercise-induced pain of the right foot that had deteriorated over the course of three months. During the last week prior to presentation at our emergency department, the symptoms had progressed from intermittent to constant calf pain. At clinical examination, the right foot was pale and cool with delayed capillary refill and absent pedal pulses consistent with the clinical picture of acute limb ischemia. The left foot was warm and well perfused with palpable pedal pulses.
Doppler ultrasound study of the right lower limb showed an occlusion at the proximal part of the right popliteal artery (PA). With magnetic resonance angiography the presence of a four-centimeter thrombus occluding this section of the PA was confirmed.
Furthermore, Doppler ultrasound study of the asymptomatic, contralateral (left) popliteal region revealed an occlusion of the PA with sufficient collateralization and unimpaired three-vessel runoff to the foot.
By conventional transfemoral angiography, the previously identified occlusion of the right PA and its aberrant course were demonstrated again (). An attempt of continuous intraarterial thrombolysis of the occluded right PA was undertaken by the use of actilyse and continuous heparin applied via a lysis catheter over 24 hours. The required therapeutic dose was controlled with aPTT between 60 and 80 seconds. This resulted in a significant reduction of thrombotic material within the PA, but the vessel was still considerably occluded (70-80%). After 24 hours of catheter-directed thrombolysis, low-molecular-weight heparin (LMWH) in therapeutic dosage and continuous infusion of iloprost (over 4h) were given daily. Further investigations were started to identify the already suspected extravascular cause of occlusion.
Indeed, in magnetic resonance imaging the anomalous origin of the MHGM lateral to the medial condyle of the femur was detected. The muscle's tendon and belly cro

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


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

[User]
RADIOLOGY NOTE:
A 50 year-old male, with a history of coronary arterial bypass grafting 14 years back, presented with shortness of breath and dry cough. An X-ray revealed a large mass in the left hemithorax adjacent to the heart silhouette. A chest CT demonstrated the presence of a mass with smooth edges, in middle mediastinum next to the heart and partially intrapericardial (Fig. ). The mass was of heterogeneous density and of 11 cm size. Presence of atelectasis at the left lower lobe abating the mass was clearly seen. Based on clinical and radiologic evidence, we did proceed with CT guided FNA of the mass. The cytology findings revealed inflammatory lesion. Laboratory tests were normal. Based on patient symptoms, history and the presence of a mass potentially compressing the cardiopulmonary structures in vicinity, we decided to offer exploratory surgery for diagnosis and treatment.
Standard hemodynamic monitoring and general anesthesia were followed by positioning, prepping and draping patient in left lateral decubitus position. An anterolateral left thoracotomy was carried out and entrance in the hemithorax was made without any challenge. The mass was assessed and found to be leaning medially on the surface of the lateral wall of the left ventricle, including the pericardial layer and had smooth edges which didn’t infiltrate the lung (Fig. ). We started dissecting the mass from its smooth capsule, making it through all its layers. An old and degraded piece of surgical swap was visualized (Fig. ). The surgical swap was removed along with the capsular layer of this mass. Patient tolerated the procedure very well and blood loss was minimal. A chest tube was inserted in the left hemithorax and chest wall was closed following standard procedures.
In the immediate post-operative phase, patient improved steadily and on day four was discharged home symptom-free. In the long-term follow -up, patient was found to remain without symptoms.

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


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

[User]
RADIOLOGY NOTE:
A 79-year-old female with a past medical history of coronary artery disease (CAD) and coronary artery bypass grafts (CABG), bioprosthetic mitral valve replacement (MVR), hypertension, hyperlipidemia, obstructive sleep apnea, and atrial fibrillation presented to the clinic for the evaluation of worsening dyspnea. She underwent transthoracic echocardiogram (TTE) that revealed mild left ventricular hypertrophy, interventricular septum about 1.4-cm thick and normal left ventricular ejection fraction. In addition, she was found to have severe AS at outside hospital, thought to be causing her symptoms and was referred to us for TAVR evaluation.
After she underwent a comprehensive evaluation and reviewing her treatment options by the heart team, TAVR was recommended as preferred treatment. She had preprocedural computed tomography of chest/abdomen/pelvis for evaluation of access sites and for procedural planning. Her preprocedural transesophageal echocardiogram (TEE) revealed no thrombus in left atrial appendage and normally functioning mitral valve prosthesis and severe AS with peak/mean gradients of 67/44 mm Hg respectively, across her aortic valve (Figure ).
She subsequently was scheduled for and underwent transfemoral TAVR using a 26-mm Edwards Sapien S3 TAVR valve. Bilateral femoral arterial access was obtained and TAVR valve prepared, aortic valve crossed with a wire in usual fashion and TAVR valve positioned across the native aortic valve without any difficulty. Rapid ventricular pacing was initiated and after confirming no loss of capture and no premature ventricular contractions (PVCs) with adequate reduction in systolic blood pressure to 45-50 mm Hg range, the valve inflation was done. During the slow inflation of balloon expandable TAVR valve, the valve appeared to move a little (Video ).
Shortly after the withdrawal of valve delivery system and balloon into the descending thoracic aorta, the implanted TAVR valve embolized into ascending aorta. All the available

[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 woman with a history of idiopathic hemochromatosis and treatment with phlebotomies was admitted to our emergency department with a 2-day history of right abdominal pain, which she described as colicky, and clinical characteristics of intestinal obstruction. She complained of acute retention of gas and flatus and she had no bowel movements in the previous 3 days. She also complained of nausea, vomiting and no food intake. The patient reported anorexia, severe weakness and weight loss of 12 kg over a period of 6 months. On physical examination, her abdomen was markedly tender at the right iliac fossa and a vague mass was palpated. Her bowel sounds were of obstructive type. The biochemical evaluation tests were within normal limits. The most important laboratory findings were elevated α-fetoprotein (> 800 ng/ml) and cancer antigen 125 (51.2 U/ml). HBV and HCV serum blood tests investigated in the past were negative. Abdominal X-ray showed opacity in the right upper abdomen, displacing the small bowel loops, and a few radiological signs of intestinal obstruction. The patient had clinically abdominal distention and features of intestinal obstruction on physical examination therefore, ultrasound was not performed. She also reported a history of liver hemangioma that was diagnosed 10 years previously. Following computed tomography (CT) and magnetic resonance imaging (MRI), without administration of intravenous contrast agent, a large (14 × 12.5 cm) well-defined, heterogeneous mass of unclear origin and nature was detected between the right hepatic lobe and the colon. The mass appeared hyper-dense on T1- and T2- weighted images compared with the surrounding lower-signal-intensity liver tissue. No invasion into the liver or adjacent organs was demonstrated (Figure ).
With a possible diagnosis of giant liver hemangioma causing acute abdominal discomfort and intestinal obstruction, surgery followed. During the operation, an enormous pedunculated tumor with exophy

[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 2007, a 61-year old male was referred by his local dentist for the chief complaint of a swelling at site of tooth 14, where an implant was present. In December 2002, the patient’s maxillary right first premolar was extracted. A Nobel Biocare TiUnite dental implant was used to replace the missing tooth in February 2003. Since the time of implant placement, the patient noted swelling in the buccal gingival area where the implant was placed. He could feel it with his tongue and fingers. He had always been slightly uncomfortable with this. He preferred that his gingival tissue be returned to its previous form.
Intraoral clinical examination revealed an implant supported porcelain fused to metal crown replacing the maxillary right first premolar. A peri-apical radiograph of the implant revealed no signs of peri-implant bone loss or radiolucency. Periodontal examination revealed stability of the implant with probing depths ranging from 2-3 mm. There were no clinical signs of peri-implantitis. There was, however, a 5 × 5 mm raised area in the non-keratinized soft tissue facial to the implant []. There were no signs of erythema or infection. Upon digital palpation, there was no soft tissue drainage and the raised area was found to be firm and screw threads could be detected. The patient did not experience any discomfort upon percussion. Hard and soft tissue examination of the rest of the mouth was normal. We recommended surgical exploration and modification of the protruding implant. The patient consented to the treatment plan
The surgery was performed under local anesthesia. Sulcular incisions were made extending from the mesio-buccal of the right maxillary first molar distally to the mesio-labial of the right maxillary canine. A vertical releasing incision was also made at the mesio-labial aspect of the right maxillary canine. A full thickness buccal flap was raised. The area of the implant and

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


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

[User]
RADIOLOGY NOTE:
The patient was a 64-year-old man with destructive injury of both lower extremities due to a machine accident. His left ankle and heel bone, along with the soft tissue, were torn off, and the peripheral blood supply and sensation to the toes of the left foot were lost. We amputated his left leg below the knee. The left fibular head was retained after the left foot operation. Two months later, the patient came to our hospital for additional treatment after debridement of necrotic tissue operations twice. There was still approximately a 20 ×10-cm area on the right foot and right external ankle exposing the distal fibula fractures. X-ray showed that the right external ankle bony defect and the right medial ankle mortise widened; fortunately, the left fibular head was retained after left foot amputation (Fig. ). We reconstructed the right ankle using vascular anastomosis of the fibular head and a flap taken from the left stump. The Ethics Committee of the Second Affiliated Hospital of Soochow University approved the study.
We used an ultrasonic Doppler instrument (Model: ES-1000SPM Hayashi Denki Co., Ltd, Hong Kong China) to find the perforating branch of the peroneal artery before surgery, and near that location we created a flap approximately 20 × 10 cm in size according to the right foot wound (Fig. ). Surgery was performed with the patient under general anesthesia. The patient was placed in the supine position on the operating table with the left knee joint slightly bent and the left lower limb stump in internal torsion. The incision began in the popliteal space, swept down to the fibular head, and continued along the lateral peroneus muscles to the stump extremity. We cut the skin and subcutaneous tissue, then separated the peroneus longus and soleus muscles. We found the nervus peroneus communis on the inner posterior margin of the biceps femoris tendon and dissociated it for protection. The peroneal perforator was located 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:
Approximately 6 months before presentation to our institution, a 67-year-old white woman had undergone placement of an IVC filter for bilateral pulmonary embolism after anticoagulation was contraindicated due to groin hematoma. She presented to our hospital with a 2-day history of fever, chills, and right upper quadrant abdominal pain. Her physical examination was normal except for mild right upper quadrant tenderness. Her blood cultures came back positive for methicillin-sensitive Staphylococcus aureus. No external source of infection was found during a detailed physical examination. She had intact skin with no ulcers or abscesses. She denied ever using intravenous drugs. The results of echocardiography were normal with no valvular vegetation. A computed tomographic scan of her abdomen and pelvis was ordered to rule out an intraabdominal infection source. Interestingly, the scan showed four struts of filter penetrating the wall of the IVC by approximately 1.5 cm. The anterior two struts extended into the lumen of the third portion of the duodenum, with the rest extending into the retroperitoneum, abutting the third lumbar vertebra and right ureter (as shown in Figs. and ). The gastroenterology team deferred upper endoscopy due to risk of barotrauma.
The cause of the patient’s abdominal pain was explained by the IVC filter penetrating the duodenum; however, the source of bacteremia could not be ascertained. The duodenum is a sterile part of the gastrointestinal tract and was unlikely to be the source of bacteremia. It was unclear if the bacteremia was a mere coincidence or whether it contributed to this complication by any means. Hopefully, more cases such as this one will clarify this in the future. A vascular surgeon and an interventional radiologist were consulted. The patient underwent successful retrieval of the IVC filter using a superior vena caval approach with a minimally invasive technique. She experienced no complications. She was discharged on an intrave

[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:
This 14-year-old Turkish male patient from Azerbaijan had a history of right focal seizures that began when he was 3 years of age. His previous examination and therapy was significant in that he experienced episodes of focal seizure until 6 years of age. He was treated with antiepileptic medicine (Phenobarbital), and a cranial MR image showed a left frontal mass. He underwent a craniotomy, and a biopsy was done during the first operation. Histopathological examination revealed a Dysembryoplastic Neuroepithelial Tumor (DNET). His seizures decreased over one year (Phenobarbital was continued for one year), then were lost without treatment of antiepileptic medicine until 12 years of age. He had experienced medically refractory complex partial seizures to sodium valproate with loss of consciousness. His neurological examination found no significant deficits. Magnetic resonance (MR) imaging of the brain showed a cystic mass in the left frontal lobe, directly adjacent to the pre motor area gyrus without gadolinium enhancement (). An electroencephalography (EEG) showed an epileptic wave focus on the left frontal lobe. Meanwhile, the patient's coagulation parameters, such as prothrombin time, activated partial thromboplastin time, international normalized ratio and thrombosit count, were within normal limits. The patient underwent a craniotomy for a left frontal tumor resection. Perioperative dehydration was achieved by a diuretic agent (Furosemide, 20 mg/2ml) and the infusion of 20% mannitol (250 ml). The brain was shrunken by the administration of the above agent. The aggressive anti-edema procedure caused the brain to become very slack.
Surgery was completed without complications. An epidural or a subgaleal drainage tube was not used. During surgery, the patient's mean arterial pressure ranged between 60 and 105 mm Hg. Histopathological examination of the surgical specimen yielded findings consistent with Dysembryoplastic neuroepithelial tumor.
Postoperative Course: 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 57-year-old Albanian man admitted to the emergency department presented with a 10-day history of right-sided epigastric and chest pain, together with a mild cough, distension of the abdomen, and constipation. The pain had been treated with analgesics. The patient had had a traffic accident seven years previously. After the accident, in the emergency room, he had undergone drainage to the right side of the thorax because of pleural effusion and the splinting of his upper arm due to a humerus fracture on the same side. An abdominal ultrasound examination, at that time, had confirmed no evidence of organ injury.
On arrival at the emergency department, the presence of gallstones was suspected, but none of the preclinical results supported this diagnosis. He was afebrile; his abdomen was inflated and insensitive to palpation. All laboratory results were within normal limits except for leucocytosis. The initial chest X-ray showed elevation of the right hemidiaphragm, an infiltrative shadow in the basal lobe of his right lung, and multiple radiolucencies over his right hemithorax (Figure ). The stones in the gallbladder were invisible. Black pigment or mixed gallstones may contain sufficient calcium to appear radiopaque on plain films. Only 15 to 20 percent of gallstones are visible on simple radiographs [].
The definite diagnosis was made through a thoracic-abdominal computed tomography (CT) scan, which revealed intrathoracic displacement of his liver and part of the colon, and his gallbladder with regular walls and with three 17mm stones around its neck (Figures and ).
The patient underwent surgical intervention via an abdominal approach. Intraoperative findings confirmed that the omentum, colon, gallbladder and 70 percent of his liver had herniated into the thoracic cavity. The organs were placed back into the abdominal cavity. The omentum was dissected off its adhesions and retrieved. A cholecystectomy was performed, and three stones were found in the gallbladder. Th

[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 37-year-old female patient reported to us expressing concern over the mobility of her teeth, the presence of a recurrent fistula, and overall displeasure with the height of her gingival smile line (). Upon clinical examination, it was determined that the maxillary incisors (i.e., teeth numbers 7, 8, 9, and 10) were compromised and that horizontal bone resorption had occurred as a result of aggressive periodontitis. The right central incisor was extruded and dislocated due to secondary occlusal trauma, and the left central incisor possessed a horizontal root fracture (Figures and ). Intraoral periapical radiographs revealed horizontal bone defects in all four of the maxillary incisors (). Severe resorption of the alveolar ridge in the premaxillary area, along with complete resorption of the buccal and palatal bones adjacent to the roots of maxillary incisors, was also observed ().
After apprising the patient of her situation, we offered a number of viable treatment options; however, the patient has adamantly opposed many of them. Because the patient did not wish to use dentures and wanted to retain the ability to floss between prosthetic teeth, we were restricted from implementing a number of conventional treatment options. Despite being constrained by both the extent of patient's periodontitis and her aforementioned wishes, we nevertheless outlined a treatment plan that conformed to the patient's desires and would restore the aesthetics and functionality of the compromised teeth. In agreement with the patient, it was decided that the compromised incisors be extracted and replaced with four short locking-taper implants using a minimally invasive surgical technique which would not require flap raising or bone grafting procedures.
The patient was treated with a local anaesthetic prior to extraction (4% Articaine with 1 : 100,00 adrenaline, Ubistesin R; 3M ESPE). Care was taken to extract the teeth with minimum trauma so as not to damage the buccal or palatal bone pla

[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 2-year-old female child patient visited the department of oral and maxillofacial surgery with a complaint of diffuse swelling in the right mid face since one year. The swelling was progressive with gradual increase in size, consequently involving the contralateral side causing a swelling in the left mid facial region after 6 months. Both the swellings exhibited gradual increase in size with evidence of nasal blockage ().
On examination, the swellings were diffuse extending on to the zygomatic arch, nontender with no secondary changes. Intraoral examination revealed a nontender, lobulated swelling which was firm to bony hard in consistency (). The swelling caused labial and buccal cortical expansion bilaterally and extended up to the pterygoid plates along with palatal bone thickening. The overlying mucosa was intact. The patient's family history revealed that the elder sister, who is currently five years old, had a similar complaint 3 years ago, which was then operated, and a histopathology report of ameloblastic fibroma was rendered. Presently she is free from any recurrence.
Computed tomography with 3D reconstruction was performed which revealed a hyperdense mass involving the labial and buccal cortex and extending up to the pterygoid plates. The palatal bone also showed thickening with irregular surface (). Based on the clinical and roentgenographic findings, a presumptive preoperative diagnosis of odontogenic tumor was made. The lesion was excised and curettage of the adjacent maxillary bone was performed under general anesthesia. The surgical specimen was then sent for histopathological analysis. Macroscopically, the specimen measured 3.5 × 1.5 cm in greatest dimension and was firm in consistency with a smooth surface ().
Microscopically, the lesion showed proliferation of strands of ameloblastic epithelial cells within a moderately cellular connective tissue stroma that closely simulates the dental papilla. The epithelial islands, nests, and strands were com

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


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

[User]
RADIOLOGY NOTE:
A 50-year-old woman was referred to our hospital for investigation of a mass in the right external auditory canal. She had suffered from hearing loss and ear fullness in her right ear for some months. She had no significant past medical history. On physical examination, right otoscopy revealed a soft mass totally filling the external auditory canal and hiding the entire tympanic membrane (Figure ). Right threshold of hearing (averaged over 0.5, 1, 2 and 4 kHz) was 51.25 dB with conductive hearing loss. A tympanogram showed type B in her right ear.
An enhanced temporal bone computed tomography (CT) scan demonstrated a soft-tissue mass lateral to the tympanic membrane that filled the right external auditory canal without involvement of the tympanum. There was no evidence of bone erosion. The tympanic membrane and the ossicles appeared normal. Magnetic resonance imaging (MRI) of the temporal bone demonstrated a slightly hypointense external auditory canal mass in T1-weighted images, and hyperintensity in T2-weighted images (Figure ). This finding was considered to be a vascular lesion. There were no feeding vessels to a mass found by magnetic resonance angiography (MRA).
The lesion was removed using a transcanal and retroauricular approaches under general anesthesia. The base of the lesion was found to be in the posterior wall. The lesion was close to the annulus tympanicus, but did not adhere to the tympanic membrane. The tumor and skin were fully removed from the external auditory canal leaving a part of the anterior wall. We could not identify the feeding vessels. Total bleeding during the operation was 30 ml. Bleeding was easily controlled by monopolar and bipolar coagulation. We transplanted a skin graft excised from her right thigh to the right external auditory canal (Figure ). Ten days after surgery, the skin was fully engrafted. Eleven days after surgery, she was discharged from our hospital.
Histopathological analysis revealed capillary vessels consisting of

[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 Caucasian woman was referred to our institution because of the suspicion of peritoneal carcinomatosis, raised by the findings of ascites at a transvaginal ultrasound performed as a yearly routine exam; a pre-surgical staging exam with computed tomography (CT) scan show thickening of the gastric walls, multiple omental nodules and ascites ().
Her previous personal history was unremarkable and she denied any clinical symptom or cancer history.
At our hospital, she underwent an esophagogastroduodenoscopy and colonoscopy, with results negative for gastric/colon cancer.
Her comprehensive metabolic profile revealed mild liver dysfunction with an alanine transaminase of 77 U/L and aspartate transaminase of 71 U/L. When tumour markers were assessed, CA125 demonstrated increased levels of 290 U/mL (normal values <35 U/mL), whereas carcinoembryonic antigen, CA 19.9 and other immunohistochemical markers were within the normal ranges. Serological assessment of HIV, hepatitis C virus and hepatitis B virus were negative.
Ten days later, the patient underwent an ultrasound-guided biopsy () with a diagnosis of suspicious carcinoma from the an unknown primary site.
After 2 weeks, the patient received a CT scan of the thorax (to complete pre-operative staging), demonstrating a spontaneous (with no therapy) dimensional and numerical reduction of peritoneal lesions in the upper abdomen, partially included in the chest CT scan, as well as resolution of peri-hepatic and peri-splenic ascites ().
Since there was no evidence of primary cancer at pre-operative examinations and the second CT scan revealed a partial resolution of peritoneal implants and ascites without therapy, the suspicion of an infectious disease was raised.
The pathological evaluation of the biopsies performed on the omentum and peritoneum revealed the presence of lymphoid aggregates with a central core of epithelioid cells with large eosinophilic cytoplasm, without atypia or mitosis () and with no immunohist

[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 woman presented with fatigue, nausea, and vomiting for three days. She was diagnosed with metastatic melanoma to pelvic nodes in July 2014 and was treated with ipilimumab (anti-CTLA-4) in combination with nivolumab (PD-1 inhibitor) between September 2014 and April 2015, receiving a total of 4 cycles of combination therapy and 9 cycles of nivolumab monotherapy with an initial mixed response followed by slow progression of disease. In April 2015 she was enrolled on a study of radiation (to pelvic mass) in combination with pembrolizumab (PD-1 inhibitor), receiving a total of 9 cycles of pembrolizumab with no toxicities. In December 2016 she was found to have new brain metastases and in January 2017 pembrolizumab was added. The day following her second dose of pembrolizumab, she developed fatigue and nausea and began having intermittent vomiting and diarrhea. Abdominal CT scan demonstrated diffuse colitis. Infectious studies including C. difficile antigen, stool culture, viral PCR, and ova and parasites exam were all negative. She was started on methylprednisolone 2m/kg/day. Over four days of hospitalization, her abdominal pain worsened and she developed melena, which progressed to bright red blood per rectum. She was given infliximab at 10mg/kg. Repeat imaging performed 48 hours later due to severe abdominal distension showed large amounts of free air with gaseous distention of large and small bowel loops, consistent with perforation in the context of colitis with ileus. She was taken to the operating room for emergent bowel resection and a perforation site was identified at the transverse colon. The resected transverse colon serosa was congested and dusky with site of perforation identified (). The colonic mucosa revealed diffusely edematous folds as well as confluent areas of yellowish exudate and multifocal ulcers (). Histologic sections confirmed the presence of transmural necroinflammation and multifocal ulceration (Figures and ). The findings were 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 19-year-old man was brought to the emergency department following a road traffic accident after his motorcycle skidded and hit the road divider. His Glasgow Coma Scale (GSC) on initial examination was 12/15. He sustained laceration of his upper lip and tongue, comminuted fracture of the right mandible parasymphysis, and avulsed teeth 11, 12, 41, 42, 43, and 44 (). He was intubated immediately for airway protection. An emergency head CT scan showed that he also sustained depressed fracture of the frontal bone with subdural and epidural hemorrhage. CT scan also showed right parasymphysis mandible fracture and dislocated left condyle (). The left condyle was dislocated anteriorly and superiorly into the infratemporal fossa medial to the zygomatic arch. There were no fractures of the condyle and zygomatic arch.
He underwent emergency craniotomy with evacuation of blood clot by the neurosurgical team. In the same setting, the facial laceration injury was sutured and an arch bar with intraosseous wiring was placed to stabilize the fractured mandible. Condyle dislocation reduction was also attempted. Due to the orotracheal intubation tube, the occlusion was not assessed following reduction. The patient was then transferred to the intensive care unit (ICU) subsequently with the orotracheal intubation kept in place. Following extubation 5 days later, it was noted that the patient kept his mouth open without any closure movement. There was also excessive drooling of saliva due to the inability to close his mouth. On examination, his mandible movement appeared restricted and the mandible was unable to move in any direction. He was not obeying instruction well. Multiple manual reduction attempts at bedside were unsuccessful.
An open reduction and internal fixation was planned for the right parasymphysis of mandible fracture, and it was planned to perform reduction of the dislocated condyle on the left side. Owing to the patient's neurological injury, the surgery could only be

[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, a 16.3 year-old girl, was in excellent health, both physically and emotionally, with no known adverse drug reactions or allergies and good oral hygiene. The major concern of both the patient and the referring general dentist was the persistence of several deciduous teeth. Possible systemic, endocrine, metabolic or genetic-syndromal disorders as possible etiologic factors could not be detected by a physician and endocrinologist, to which the patient was referred prior to orthodontic examination. In addition, there was no family history of eruption failure of permanent and persistence of deciduous teeth. The first deciduous upper molar on the right side (tooth 54) was extracted 1 year earlier by the referring general dentist, but no spontaneous eruption of the permanent first premolar could be achieved within this timeframe (Table ). Thus and due to no previous referral by the general dentist or presentation of the patient for orthodontic planning, treatment was started quite late.
The clinical examination and study model analysis (Figs. and ) in conjunction with the panoramic radiograph (Fig. ), taken by the referring general dentist, showed initially nine persisting deciduous teeth – all deciduous canines and molars of the upper jaw and those on the right side of the mandible, minus the already extracted upper right deciduous molar. All upper permanent canines and premolars were impacted and malpositioned. The lower right canine, which was severely rotated, was also impacted to a higher and the lower right first and second premolars to a lesser degree, whereas the corresponding teeth on the lower left side were in good occlusion and showed no signs of impaction. No adequate root resorption of the deciduous teeth could be detected radiologically with exception of the lower deciduous molars on the right side. Radiographically the impacted teeth showed no evident signs of ankylosis. Some physiological spacing of the incisors was present and both the first

[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 46-year-old man was referred for left chronic leg pain. The patient was involved in a plane accident 30 years before sustaining a femoral shaft fracture treated with a reamed Kuntscher nail and a posterior wall acetabulum fracture treated with open reduction and internal fixation with lag screws (). The patient came to our outpatient clinic complaining about inguinal pain and chronic leg pain with limitation of activities of daily living, although he was able to walk for more than one hour. On physical examination, the patient had no limitation of the hip range of motion. The ipsilateral knee had full range of motion and the patient did not need any crutches to walk without limping. Neurovascular examination was normal. The PostelMerléd’Aubigné scale was 14 points (4 for pain, 5 for walking and 5 for range of motion). Overall alignment of the extremity was anatomic. As a part of the initial evaluation, a blood test with infection parameters was performed and was negative for infection. Pre-operative radiographs showed a healed femoral fracture in all 4 cortices with an intramedullary Kuntscher nail without locking screws and cortical thickening at the fracture site ().
The patient was informed about the incipient arthritis of the hip and the possibility to perform a one-stage or two-stage surgery. The surgical risks were discussed with the patient, including pain after hardware removal and failure to remove the nail, specially this last point because other surgeons had tried to do the same procedure few years before and had failed after many hours of surgery. The patient decided to have two-stage surgery. Firstly, remove the nail at all costs and depending on the outcome of this first surgery he would assess the hip replacement surgery.
The patient was put in a lateral position and a lateral hip approach was done. The first step was to find the proximal tip of the nail which was found seated deep in the great trochanter. The initial device used to remove the nail

[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 man, with a known history of osteopetrosis and previous fractures in his bilateral femurs and right tibia, was referred for treatment of a right subtrochanteric femur fracture in January 2018. His medical history is summarized in Table , which shows that the patient suffered from chronic osteomyelitis of tibia after traction treatment of tibial tubercle. A pedigree chart was drawn according to his family history (Fig. ). In the chart, III-2 is the patient, and his previous generation, sister, cousin and his wife had no similar medical history, whereas two of his brothers suffered from osteopetrosis, and one of them presented with osteomyelitis of the mandible. Additionally, his daughter was healthy, but his niece suffered from osteopetrosis. When admitted to the hospital, he presented with severe functional limitation of the right hip and pain, and his radiograph (Fig. ) showed that the lateral transverse fracture of the right femur was mildly displaced with a dense sclerotic line. In addition, the bone cortical density of the pelvis and the bilateral femur increased, and the proximal regions of bilateral femurs were deformed, with rough and irregular bone cortex, as well as narrowed medullary cavity, and signs of "sandwich vertebrae" were seen on the lower lumbar vertebrae. Additionally, laboratory testing showed mild anemia and slight hypocalcemia. According to family history, we judged the genetic pattern of the patient to reflect autosomal recessive inheritance. Together, his condition was diagnosed as IRO, accompanied by chronic osteomyelitis, mild anemia and hypocalcemia.
Before the operation, we evaluated the patient's bone condition and decided to treat the fracture using internal fixation with DHS. Importantly, we made sufficient preparation for the operation to deal with potential adverse events, such as drill bit fracture and bone necrosis. During the operation, we exposed the fracture site and found that the end presented a solid white amor

[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 73-year-old Asian woman with an underlying anxiety disorder, functional headache, and hypertension was prescribed escitalopram and lorazepam when she presented with progressively worsening headaches to her primary care doctor. Her symptoms did not improve with the medications, and she was unable to eat well and required bed rest. She was transported to our hospital 4 days later after developing chest and back pain with altered consciousness. She was a housekeeper, had no allergies, and had no alcohol or tobacco smoking history. On arrival, her Glasgow Coma Scale score was 3/15 (E1V1M1); both pupils were approximately 4 mm in diameter and reactive. Her blood pressure was too low to be measured, her carotid artery pulse was palpable, her heart rate was 112 beats/minute, and her respiratory rate was 30 breaths/minute. Her conjunctiva was pale. An auscultation of breath sounds did not reveal upper and lower airway obstructions and was within normal limits. Her abdomen was soft and flat without tenderness. She had no skin abnormalities (such as rash). Both legs had no edema. Echocardiography on arrival was performed as point of care ultrasound and revealed a hypercontractile left ventricle with an eliminated left ventricular cavity and a collapsed inferior vena cava without right ventricular dilation. There was no pericardial effusion or obvious large regurgitant jet observed on color Doppler. In response, we immediately inserted a peripheral venous catheter and began introducing fluid resuscitation; however, she developed PEA. Conventional CPR according to the adult advanced cardiovascular life support guidelines (including adrenaline) was initiated and a return of spontaneous circulation (ROSC) occurred. However, her blood pressure was unstable and PEA returned, prompting repeated CPR with immediate administration of fluids and three adrenaline injections. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) was initiated for refractory PEA. Whole-body 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 asymptomatic 9-year-old male had a past medical history of interventricular communication due to interventricular septal defect in infancy, which spontaneously closed without residual regurgitation. The child was referred for preoperative cardiac evaluation due to auscultated systolic murmur in view of orthopedic surgery (removal of a foreign body on the left foot). It is of paramount importance to point out, that the absence of a remarkable cardiac murmur does not exclude any severe cardiac disease. His routine biochemical parameters were within normal rates.
In the electrocardiogram (ECG) of 12 leads of the child at rest, there were observed negative T in the V1-V3 leads, which is a normal variant of the electrocardiogram in children and young women. It was also observed biphasic T in V4 which is sometimes present in the normal pediatric ECG.
Echocardiography revealed normal left ventricular contractility, with ejection fraction (EF) >65%. The internal dimensions of the left abdomen were increased with age. Its end-diastolic diameter (LVIDd) was 44 mm with normal values for the age and body weight of the child up to 41 mm. The thickness of the left ventricular wall at dilation was normal (intraventricular septum [IVSd] 7 mm). The left atrium showed mild dilation.
The echocardiography also showed ventricular communication that has been closed in infancy and insignificant leak through it. Also, multiple pathological flows emerged in the area of the interventricular septum that gave the impression of multiple remaining muscular type of interventricular communications (Figure ). Inside the myocardium of the left ventricle, elongated flows were detected which were also considered as potential communications.
In addition, the pulmonary artery stem developed a diastolic flow which, as it turned out, was due to an anomalous outflow of the left circumflex coronary arterial branch from the pulmonary artery. Due to the above findings in the echocardiography examination it

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


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

[User]
RADIOLOGY NOTE:
A 19-year-old Asian man, was admitted to the emergency services (ES) at our hospital with acute onset of severe breathlessness following a short duration of dry cough, without any associated fever, chest pain or hemoptysis. He also had lower-back pain and right lower limb weakness with paresthesia, which was attributed to an injury sustained while playing football. He was prescribed analgesics and advised by an orthopedic surgeon to take bed rest for his lower limb ailment. His lower-back radiograph was normal. On examination at the ES, he had tachypnea and tachycardia with elevated jugular venous pressure and was normotensive with no pallor or pedal edema. His cardiovascular system examination revealed a loud second heart sound and a right ventricular third heart sound. His respiratory system examination was normal. The examination of his nervous system was suggestive of a right lower lumbosacral (L3-S1) radiculopathy. A moderate, tender hepatomegaly was detected in abdominal palpation. His oxygen saturation in the ES was 92 percent at room air temperature.
Initial blood investigations revealed leukocytosis with neutrophilia and normal liver and renal function. An acid base analysis showed compensated respiratory acidosis. His chest radiograph revealed a wedge-shaped opacity in the right midzone with dilated main pulmonary artery and focal oligemia in the right lower zone, which may have been suggestive of a pulmonary embolism. High-resolution computed tomographic (HRCT) imaging showed an acute, large, saddle embolus completely filling the left pulmonary artery and partly occluding the right pulmonary artery, as well as multiple, detached peripheral pulmonary artery thrombi in both the upper and right lower lobes (Figure ). Emergency echocardiography was performed, which revealed a large thrombus at the main pulmonary artery bifurcation and extending into the right and left pulmonary arteries. The right atrium and main pulmonary artery were dilated.
Considering 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 female patient without a significant medical history presented symptoms that evolved over a period of one year, initiating with jaundice and epigastric pain. A computerized axial tomography of the abdomen was performed, which showed an increased liver size with multiple hepatic lesions and dilation of the intrahepatic bile duct. Magnetic resonance cholangiography evidenced a solid 9 cm mass and lesions suggestive of hepatic neoplastic compromise. A hepatic biopsy was done, which documented low grade compromise caused by a neuroendocrine tumor (grade 1). The OctreoScan showed multiple enhancing lesions in the liver with multifocal tumoral compromises with somatostatin receptors. Positron emission tomography evidenced hypermetabolic hepatic lesions consistent with a malignant pathology. Initial workup showed chromogranin A, 99.5 μg/L, and 5-hydroxyindoleacetic acid, 10.3 mg. A diagnosis of low grade neuroendocrine tumor (well-differentiated tumor, histological grade WHO 2), with unknown primary and with documented hepatic metastases, was made. The case was presented to the neuroendocrine tumors committee and treatment with transarterial hepatic embolization was considered. A preprocedural transthoracic echocardiogram was conducted, which appeared normal. Initially, the patient was in a good general state. Blood pressure was 130/70 mmHg, and heart rate was 75 beats/minute, without other significant findings on physical examination. On the second day of hospitalization, hepatic arterial embolization was performed without chemotherapy using polyvinyl alcohol particles, without complications. On the fourth day of hospitalization, the patient presented deterioration in the functional class and on physical examination presented moderate jugular ingurgitation and edema of lower limbs. Computerized axial tomography was performed, which ruled out pulmonary thromboembolism; a transthoracic echocardiogram showed left ventricular systolic function in the lower norma

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


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

[User]
RADIOLOGY NOTE:
An 82-year-old woman with hypertension and atrial fibrillation on warfarin presented with 2 h of acute onset epigastric pain with radiation to the chest, jaw, and left arm. Initial vitals were within normal limits. She was in moderate distress. Labs were significant for a subtherapeutic international normalized ratio (INR). Electrocardiogram revealed ST segment elevations in the inferolateral leads. After Allen’s test was done, she was deemed an appropriate candidate for approach via right radial artery and taken for urgent cardiac catheterization. The patient was found to have an acute thrombus in the distal posterior descending artery (PDA) and posterior left ventricular (PLV) branch. She was treated with angioplasty and aspiration thrombectomy, and the acute thrombi were thought to be secondary to thromboembolic phenomenon. The patient received dual antiplatelet therapy following the procedure, and a pneumatic band was placed over the patient’s right wrist and remained in place until it was removed per protocol. The following day, patient reported pain at the right wrist. On exam, a pulsatile 2.4-cm mass with an overlying bruit was noted. A color flow Doppler ultrasound study was performed and it revealed a radial artery pseudoaneurysm (). Initial discussions with vascular surgery, and interventional radiology did not yield a consensus approach towards resolving this complication. Nonspecific compression via pneumatic band was attempted for 18 h; however this was initially proved unsuccessful as seen on repeat Doppler. Following this, a different compressive approach was attempted. Pneumatic band was inflated until radial pulse flow was occluded as evidenced by absence of pulse oximetry wave form. The level of occlusion was achieved with 12 cc of air inflation. Air was removed in small segments until radial artery flow was noted (this was noted to be at 10 cc of air inflation of the pneumatic band). Upon dialogue with nursing staff, it was discussed that the pneu

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


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

[User]
RADIOLOGY NOTE:
A 30-year-old female came to the emergency department of our institute with difficulty in swallowing since one day. The patient was not even able to have water. An assessment of the nervous system was made because neuromuscular disorders may present with dysphagia as an initial symptom. Proper history revealed that the patient was a known case of rheumatoid arthritis and was taking routine anti-inflammatory drugs. The prior day, the patient was advised to take ayurvedic tablets by relatives for immediate relief. The tablet was about I cm in diameter and was spherical in shape. The moment the patient took the first tablet with water, she started having discomfort in the throat. She took more water but was not relieved. She visited local doctors and was referred to our institute.
On arrival she had drooling of saliva; the oxygen saturation was between 70%-80% and the patient was not able to take anything orally since 12-14 hours. While performing an indirect laryngoscopy, we found pooling of saliva in both pyriform fossae. Taking history into account rigid oesophagoscopy under general anaesthesia was planned. All routine blood tests were in normal limits. The X-ray of the neck lateral view revealed a radiopaque spherical shadow at the lower level of cricopharynx, which was a surprise to us, as routinely tablets are not radiopaque. There was also a slight prevertebral widening in front of C6 and C7 ().
To understand what we were going to encounter, the patient’s husband was asked to provide another ayurvedic pill of the same kind. The tablet’s colour was black, it was spherical, stony hard and its approximate size was of 1 cm. Not knowing the contents of the pill, it was decided that it should be removed immediately because a long-standing tablet may cause erosion/obstruction of the wall of the oesophagus. The patient was shifted to operation theatre for rigid hypoph

[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.