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

[User]
RADIOLOGY NOTE:
An 8-year-old female patient visited the university hospital due to delayed eruption of her right permanent maxillary central incisor. Her medical history revealed no systemic diseases, and the dental history proved no facial trauma or other tooth abnormalities have occurred. She avowed that she was operated on, at the age of seven years, for a supernumerary tooth delaying the eruption of the left permanent maxillary central incisor. A previous panoramic radiograph (one year ago) revealed the presence of a mesiodens associated to two supernumerary teeth [].
Clinical examination revealed a mixed dentition and the absence of the right maxillary permanent central and lateral incisors []. The left ones have already erupted.
The patient was referred to CBCT examination of the maxilla to assist the localization and orientation of the mesiodens. CBCT images were requested for diagnosing accurately the morphology and exact location of the mesiodens and the radicular formation of the permanent maxillary central incisors. The images were created and viewed interactively using a dental computed tomography (CT) software program.
The 3D CBCT panorex showed the impaction of the right permanent maxillary incisor and the presence of a supernumerary tooth; moreover, the axial slice image of CBCT revealed the palatal position of the impacted and inverted mesiodens and the sagittal slices showed that the supernumerary tooth was in palatal position over the impacted permanent maxillary central incisor [].
A comprehensive treatment plan was formulated, which included surgical extraction of the mesiodens and the supernumerary tooth []. The patient was administered local anesthesia. Using a mucoperiosteal elevator, a full thickness palatal flap was raised. The supernumerary tooth was exposed, luxated, and removed. Hemostasis was achieved and the flap was replaced back and sutured. For the mesiodens, a simple palatal anteroposterior incision was done and the extraction followed. Postchirur

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


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

[User]
RADIOLOGY NOTE:
A 62-year-old woman was admitted for evaluation of dyspnea and chest discomfort in September of 2009. The patient had a past medical history of a mastectomy of the right breast due to abscess 35 years earlier. She had been diagnosed with effusive tuberculous pericarditis in December 2008, at which time she underwent pericardiostomy and drainage. Since then, she had taken antituberculous therapy with isoniazid, rifampin, ethambutol, and pyrazinamide. In January 2009, her regimen was changed to isoniazid, ethambutol, and levofloxacin due to development of drug-induced hepatotoxicity, after which she had no discomfort and her laboratory findings normalized. However, from May 2009, her dyspnea and chest discomfort showed a gradual increase. Upon physical examination, her blood pressure was 130/85 mm Hg, heart rate was 63 bpm, and respiratory rate was 18 bpm. No neck vein engorgement, pitting edema, or organomegaly were observed. In addition, her heart and lung sounds were normal, as were the results of her laboratory examinations.
A chest radiography revealed a new rounded bulging of the superior cardiac border and an adjacent lung nodule (). Subsequent evaluation of her mass lesion included enhanced chest CT, and two-dimensional echocardiography. CT images confirmed a pericardial mass measuring approximately 4-5 cm protruding into the lung parenchyma. The mass was located on the superior-anterior aspect of the left ventricle and had an irregular margin with non-enhanced central necrosis. In addition, the pericardial mass was connected with the lung nodule (). The pericardium showed mild thickening, and a subcarinal lymph node showed significant enlargement. Echocardiography revealed a pericardial mass along the anterior wall of the left ventricle. No evidence of constrictive physiology or mass effect was noted. Because the patient had maintained her antituberculous medication, and lung cancer is more prevalent than primary pericardial tumor or abscess, lung cancer 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 60-year-old man with a past surgical history of C5–C7 anterior arthrodesis for cervical fracture 17 years ago was found on the floor after an unwitnessed ground-level fall, resulting in a head strike. He was taken to the local hospital in an Aspen collar with a GCS of 15 and no neurologic deficits. Routine ECG and laboratory evaluation was unremarkable except for elevated serum alcohol level. Full cervical spine computed tomography (CT) scan was performed which showed an Anderson and Montesano classification (20) type III left occipital condyle fracture (), a Levine and Edwards classification (21) type III (Jefferson) fracture with mild lateral subluxation of bilateral C1 masses (), and an asymmetric widening and slight anterior subluxation of the right AOJ (). A head CT was performed which showed no acute intracranial abnormalities.
The patient was immediately transferred to a level I trauma center for further management. In the emergency department, he reported severe midline neck pain, worse with movement, and unchanged paresthesia to bilateral upper extremities which he states is his baseline. Physical exam was unremarkable except for a right forehead hematoma with overlying abrasions and tenderness to palpation over the midline posterior neck. He exhibited full strength and unchanged baseline sensation to all extremities. He denied bowel or bladder incontinence and had strong rectal tone and intact perianal sensation. Through his clinical course, he became increasingly altered and agitated, refractory to medication. He was unable to maintain spinal precautions due to his agitation, and in an attempt to protect his cervical spine, he underwent endotracheal intubation.
MRI of the cervical spine was performed and showed ligamentous injury at the craniocervical junction (CCJ) (Figures and ), asymmetric left odontoid-lateral mass widening, widening and subluxation of the right AOJ (), and edema of the paravertebral soft tissues around the fracture. CT and MRI esta

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


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

[User]
RADIOLOGY NOTE:
A healthy 7-year-old boy was referred from the dental emergency department to the pediatric dentistry department in the Dental School of Casablanca.
Clinical examination revealed that the child has a flexible splint on maxillary teeth and a coronal restoration with a glass ionomer on 11. Radiographic examination showed incomplete root formation of both central incisors (Nolla's stage 8: short root with thin walls) ().
Based on the emergency file, it was found that the boy fell at school three weeks ago. Clinical examination revealed that 11 had a lateral luxation with an uncomplicated crown fracture and 21 had a subluxation. Emergency treatment was carried out on the same day and consisted of reattaching the tooth fragment, repositioning 11 with a gentle digital pressure, and stabilizing it with a flexible splint. One week after trauma, the patient presented with intraoral swelling on 11 revealing necrosis. Consequently, an endodontic treatment was performed and the root canal was instrumented using hand files with gentle irrigation using 0.5% sodium hypochlorite. Calcium hydroxide was placed as intracanal medication. The access cavity was sealed with glass ionomer cement.
For this purpose, the apexification technique using calcium hydroxide has been initiated on 11. The calcium hydroxide was renewed once resorbed. A regular clinical and radiological follow-up was carried out to check the vitality of 21 ().
6 months after the beginning of the treatment of 11, a radiolucent lesion in the periapical region was detected on 21 (). The negative response to the cold test confirms a pulp necrosis. Considering the immaturity of the tooth and the thinness of the root and after obtaining parental consent, the optimal treatment option was revascularization.
An access cavity was made under a dental dam. Once the canal orifice was well cleared, gentle root canal irrigation was performed with 2% sodium hypochlorite followed by irrigation with saline solution. Subsequently, the ro

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


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

[User]
RADIOLOGY NOTE:
A 69-year-old man was brought to the emergency room due to shortness of breath. The patient had diabetes and a history of cerebral infarction 10 years ago. The sequelae of cerebral infarction included slight motor weakness of the left leg that did not interfere with activities of daily life. He had received conservative treatment for symptoms such as myalgia, fever, and chills at a nearby hospital 2 weeks prior. He was transferred to Dankook University Hospital for shortness of breath that had started 1 day before admission. Left-sided hydrothorax was observed on an initial chest X-ray conducted in the emergency room. Consequently, thoracostomy was performed for chest tube placement. The drainage was also very turbid. Subsequent chest computed tomography (CT) revealed left thoracic empyema (). Laboratory tests revealed an initial C-reactive protein level of 30.76 mg/dL, a white blood cell count of 15.71×103/μL, and a negative tuberculosis test result. A pleural fluid culture study, the results of which came back on the sixth hospital day, showed the growth of Streptococcus constellatus and an anaerobe. The patient was admitted with the chest tube, and ceftriaxone and clindamycin were used as empirical antibiotics. When the total amount of drainage reached 1 L on the day of admission, tube clamping was performed considering re-expansion edema. The next day, natural draining resumed. From that day onward, redness, warmth, swelling, and tenderness were observed in the left flank. On the following day, symptoms worsened, and another CT scan was performed. On chest CT, signs of infection, including gas formation, were found in the soft tissue and the muscle layer of the left chest wall (). At this point, an internal medicine doctor contacted cardiovascular and thoracic surgery department, and we performed surgery immediately, after making a diagnosis of necrotizing fasciitis (NF). Surgery was performed under general anesthesia, with the patient in the right lateral posit

[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 this peculiar case, a 59-year-old woman with dyspnea, severe mitral regurgitation, and atrial fibrillation was scheduled for elective mitral valve replacement (MVR). Coronary angiography showed mild atherosclerosis of coronary vessels without significant lesions. The right femoral artery was cannulated directly with a 19 French cannula (Medtronic DLP femoral) because right mini-thoracotomy access to the mitral valve was planned. After the opening of the chest, a bluish color of ascending aorta was noticed, and a type A AD was suspected, which was confirmed by transesophageal echocardiography. Management of AD with retrograde extension from entry tear in the descending aorta is controversial, especially when the false lumen of the ascending aorta is completely thrombosed in patients who are often clinically stable. In selected patients, a more conservative approach consisting of initial medical management with timely surgical repair gave excellent outcomes[.
Therefore, the surgery was continued converting the procedure in median sternotomy, the right subclavian artery was directly cannulated, and antegrade extracorporeal circulation (ECC) was initiated with good flow and pressures in the cannula maintaining a deep hypothermia until 24°C. MVR with a mechanical Bicarbon mitral valve prosthesis (n. 29) was performed, and cardiopulmonary bypass (CPB) was terminated without any significant event. In early postoperative period, a conservative medical approach based on hemodynamic stability of the patient was planned. A computed tomography scan performed in the 7th, 14th, and 19th postoperative days revealed persisting type A acute AD with false lumen of ascending aorta without thrombosis. Based on this evidence, the surgical team changed the strategy towards a surgical approach. The patient successfully underwent surgery with a simple tube graft ascending aorta and hemiarch replacement and venous grafts to the right coronary artery because of suspected extension of diss

[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 20-year-old right-handed male. He presented to the General Surgery Clinic with recurrent episodes of severe "piercing" epigastric abdominal pain for six months. These episodes were associated with non-projectile vomiting followed by lethargy or loss of consciousness which lasted for a "few minutes" after each episode. They were neither associated with food intake nor had any aggravating or relieving factors. Each episode of abdominal pain lasted for 8-12 minutes and occurred three to five times per day. They were sudden in onset and resolved spontaneously. His birth, developmental, and past medical histories were unremarkable.
General and local examinations of the abdomen and nervous system did not reveal any significant findings. He was prescribed analgesics and proton pump inhibitors and he was reviewed after one week. He did not report any significant improvement in his symptoms. His complete blood picture, stool for ova and parasites, 24 hr Holter ECG, ultrasound abdomen and CECT abdomen were unremarkable.
Following this visit, he was put in for a gastroenterology referral; upper gastrointestinal (GI) endoscopy and barium swallow studies were found to be normal after which he was referred to the psychiatrist in view of psychogenic abdominal pain. There was no psychiatric intervention and he was referred to the neurology department for a second opinion.
MRI brain was found to be normal. At this point, an epileptic aetiology was suspected. As in many Indian settings, the facilities for an ambulatory-EEG or video-EEG are either unavailable or beyond the affordability of most patients, a 30-minute awake EEG was ordered which revealed an abnormality in the form of repetitive sharp waves in the right temporal leads which were highly suggestive of an epileptogenic focus arising from the right temporal lobe as seen in Figure .
Then, the conclusive diagnosis of AE was made and he was started on oxcarbazepine 450mg BID. He was scheduled with regular month

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


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

[User]
RADIOLOGY NOTE:
A 45-year old man of Vietnamese origin was admitted with a ten day history of fever, anorexia, fatigue and rightsided abdominal pain. He had no previous history of disease and no medication. At examination, he had signs of peritonitis, hypotension and a red and swollen left eye. He was initially treated with intravenous fluids and imipenem for suspected septicaemia. Pulmonary X-ray and CT-scan revealed right-sided pulmonary infiltrates with pleural effusion and a large mass in the liver with the appearance of multiple cysts. (Fig. ) Examination of the eye showed marked chemosis, absence of light reflex and intravitreal hemorrhage. Empiric treatment for endophtalmitis was given intravitreously (ceftazidime and vancomycin). Cultures of blood, urine, aspirates from liver and pleural effusion all grew K. pneumoniae sensitive to imipenem and ceftazidime. Cultures that were taken from the eye, after initiation of intravenous therapy, were negative. Despite adequate treatment and continuous drainage of both liver abscess and empyema, repeated cultures from these sites showed the same mucoid strain of K. pneumoniae up to 23 days after initiation of intravenous antibiotics. Two repeated blood cultures taken one week after initiation of therapy were negative. Following three weeks of intravenous therapy, the patient was treated with oral ciprofloxacin for another five weeks. His recovery, although slow, corresponded well with repeated CT-scans of lungs and liver showing regress of the infection. Although the pain in his left eye decreased, his vision is permanently damaged, and he is now blind on the affected eye. The patient had immigrated to Sweden 8 years previously, passing a refugee-camp in Hong Kong, and had been back to visit Vietnam once, 10 months before start of symptoms. Initial investigations of the patient therefore included TB-analyses and a broad parasitic screen, all found to be negative.
The K. pneumoniae isolate that caused the infection was found to express

[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 28-year-old male patient presented to our surgical emergency with a history of pus discharge per urethra and recurrent episodes of urinary tract infection (UTI) for 1 year. The patient had a history of cystolithotomy done 1 year ago for which he was seeking treatment outside; the operation details were not available with the patient. There was no associated fever, hematurea, loss of appetite or constipation. The urine stream was normal. On examination, we found the patient was of average build and all the vitals were stable. Abdominal examination showed a horizontal scar in the lower abdomen at the previous cystolithotomy site and external genitalia were normal. Gross examination of urine showed turbid urine with pus flakes. The patient’s blood parameters were within normal limits. On initial presentation, urine culture was done, yielding Klebsiella spp. for which appropriate antibiotics were started. The patient presented again after 2 weeks with same symptoms and was investigated for the cause of recurrent UTI. An ultrasonography of the urinary bladder was done in view of recurrent episodes of UTI, revealing an echogenic mass in the urinary bladder, 30.8 mm in size and suspected to be vesical calculus. However, an X-ray of the kidney and urinary bladder did not show any radiopaque shadow. A CT scan was done which showed a diffusely thickened wall of the urinary bladder, predominantly the right lateral wall with multiple vesical calculi and the possibility of a foreign body in the bladder (). A cystoscopy was performed showing organised white colour sediments adhering to the anterior wall of the urinary bladder, possibly a retained gauze piece with organised pus flakes (). The mass was big and fragile and not amenable for cystoscopy removal. The patient underwent an exploration of the urinary bladder which revealed a gauze piece adhering to the anterior wall with organised pus flakes (). The rest of the bladder wall was found to be normal. The patient was dischar

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


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

[User]
RADIOLOGY NOTE:
A 75-year-old man was referred to our hospital for abdominal fullness and nausea since 2 months. He had a medical history of hypertension and hyperlipidemia and a surgical history of the right inguinal hernia. The patient's laboratory findings were within normal limits. Abdominal computed tomography (CT) revealed a well-demarcated oval isodensity mass of 25 mm at the tip of his appendix. Contrast-enhanced CT revealed a lesion with gradual homogeneous contrast enhancement from the arterial phase to the equilibrium phase (). No abnormal findings were found in the root to the middle of the appendix. Abdominal ultrasonography (US) revealed a well-demarcated hypoechoic tumor. The tumor size was 22 mm × 18 mm × 18 mm, with some cystic area and blood flow (). Colonoscopy findings were normal. The patient's symptoms naturally alleviated during examination period.
Preoperative diagnosis indicated appendiceal neuroendocrine tumor (NET) G1 or gastrointestinal mesenchymal tumors, such as GIST. Malignancy could not be ruled out; therefore, laparoscopic ileocecal resection with D3 lymph node dissection was recommended. Intraoperative findings revealed a well-demarcated tumor at the tip of the appendix, with no invasion into the surrounding tissue. This observation was similar to the preoperative imaging findings. According to another intraoperative finding, dissecting the adhesion between the terminal ileum and the peritoneum, which was the effect of the past herniorrhaphy, was necessary. The operation time was 167 min, and the amount of blood loss was 100 ml.
Pathological findings revealed a well-demarcated tumor originating from the muscular layer at the tip of the appendix and spindle-shaped heterotypic cells proliferating in a bundle. Vascular invasion and lymph duct invasion were not detected. No tumor cells were found in the dissected lymph node. Immunohistochemical studies revealed negative values for KIT and CD34 and positive values for S-100 protein (), which confirmed t

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


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

[User]
RADIOLOGY NOTE:
A 53-year-old female patient reported to the Department of Oral Medicine and Radiology, with a complaint of a nonhealing ulcer on the left buccal mucosa. The patient was edentulous and a denture wearer for 10 years. She gave a 6 months history of loosening and impingement of her upper denture which caused discomfort while eating. As a result of the trauma caused by the loose denture, an ulcer developed over the left buccal mucosa which gradually increased in size and caused the patient severe pain because of which she had a limited mouth opening.
There was no history of any deleterious or pernicious habits and no relevant medical history.
The intraoral examination was difficult due to restricted and painful mouth opening which was <2½ cm. A single well-defined, ulceroproliferative lesion could be visualized, measuring approximately 1 cm × 2 cm in dimension, present over the left buccal mucosa, extending into the left posterior gingivobuccal sulcus [].
The margins of the ulcer were everted; floor showed slough, and surrounding mucosa appeared erythematous. The ability of the patient to inflate her cheeks suggested that the left buccinator was negative for tumor infiltration. Palpation confirmed findings of the inspection and further revealed that the ulcer had indurated borders, bled easily, and appeared fixed to the underlying mucosa.
A single left submandibular lymph node was palpable, mobile, and tender and measured approximately 1 cm × 1 cm in dimension.
Complete hemogram, blood glucose, liver, and kidney function tests were normal. Fine-needle aspiration cytology of the clinically palpable lymph node showed reactive hyperplasia.
Incisional biopsy revealed a well-differentiated squamous cell carcinoma (i.e., by Broder's histopathological grading system) []. A wide excision of the lesion along with modified radical neck dissection was performed. Clear margins were obtained and the lesion was diagnosed as stage II buccal carcinoma according to the STNMP staging sys

[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 70-year-old man who presented with exertional dyspnea, which had persisted for one week and aggravated dyspnea, which had persisted for two weeks. He had been diagnosed with asthma two years previously and had regularly used inhaled corticosteroids since then. He had a 48 pack-year smoking history. On admission the patient had decreased breath sounds and coarse crackles in the left lower lung field. A laboratory test showed a normal blood leukocyte count and abnormal partial pressure of oxygen (59%) and oxygen saturation (88%) values. Chest radiography revealed an area of high density in the left lower lung, which led to a diagnosis of obstructive pneumonia and atelectasis (Fig. A). Computed tomography (CT) revealed a mass of 20-mm in diameter with smooth edges and a uniform density in the left main bronchus (Fig. B). Magnetic resonance imaging (MRI) revealed water signal intensity with low signal intensity on T1-weighted imaging (Fig. C) and high signal intensity on T2-weighted imaging (Fig. D), further suggesting a cystic lesion.
Flexible bronchoscopy revealed a shiny mass with a smooth surface and abundant blood vessels blocking the left main bronchus (Fig. A). When grasped by forceps, the cyst wall was easily broken and a sticky transparent secretion flowed out of the cyst. Polypectomy through bronchoscopy was finally performed. Histopathology confirmed a cystic lesion that consisted of ciliated columnar epithelium lining cells covering the lumen and collagenous fibres with a bronchial gland covering the wall (Fig. B). The cyst was not infected and nor malignant. The patient underwent follow-up examinations at six and 16 months after polypectomy. The remaining part did not grow in size. The detailed examination of the lesion by CT showed the oesophagus running on the dorsal side of the rear wall of the left main bronchus, which was the site of occurrence. We understood that the lesion was entering the gap between the two.

[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 woman with no history of smoking or history of malignancy presented with bilateral breast tenderness and a palpable mass in her right outer breast. Screening mammograms performed 1.5 years prior to the development of symptoms were negative. Diagnostic mammograms were obtained to evaluate the breast symptomatology and demonstrated 2 new masses in the right breast and 1 in the left ( and ). Note that the largest/palpable mass appeared oval in shape with circumscribed margins. Since these masses were new from the prior study, further evaluation with ultrasound was performed. Targeted breast ultrasound confirmed indeterminate imaging features of the breast masses (), and findings were all classified as BI-RADS 4, suspicious. Ultrasound-guided core needle biopsies of all 3 breast masses were performed at an outside institution. Histopathologic examination of all 3 masses was consistent with high grade neuroendocrine neoplasm. No ductal carcinoma in situ was observed. Breast markers including ER, PR, and HER2 were negative. Synaptophysin and chromogranin were diffusely positive in the tumor cells, supportive of neuroendocrine origin. Immunohistochemistry was negative for pankeratin, cytokeratin 7, cytokeratin 20, GATA-3, and CD45 (LCA). TTF-1 positivity suggested the possibility of a lung primary, and absence of CDX-2 made a gastrointestinal primary less likely . Ki-67 expression was reported as high as 70%.
CT of the chest, abdomen, and pelvis, PET/CT, and MRI of the brain were performed for initial staging. In addition to the biopsied bilateral breast masses, imaging demonstrated a 2.2 cm right lower lobe pulmonary nodule in a central location (), ipsilateral hilar and mediastinal lymphadenopathy (), a single 1.1 cm liver lesion (), and a nodule in the right temporal subcutaneous tissues (). No axillary lymphadenopathy was noted. Based on imaging and pathology, this was determined to be a primary lung small cell carcinoma with metastases, including bilater

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


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

[User]
RADIOLOGY NOTE:
A 10-year-old male child presented with complaints of cyanosis since age of 1 year and currently with New York Heart Association (NYHA) class II dyspnea on exertion. He had no history of cyanotic spells. On examination he was averagely built with central cyanosis and grade 2 clubbing. His pulse rate was 90 per minute with blood pressure of 110/76 mmHg. The cardiovascular system examination revealed normal S1, single S2 and continuous murmur best heard in third parasternal area in left intercostal space. The baseline arterial oxygen saturation was 85%. Chest roentgenogram showed decreased pulmonary blood flow with right ventricular type of apex, presence of pulmonary bay and large aorta. Electrocardiogram revealed normal sinus rhythm with features of right ventricular hypertrophy and right axis deviation. There was no evidence of myocardial ischemia. The transthoracic echocardiography showed large subaortic ventricular septal defect (VSD) with 60% aortic override, right ventricular hypertrophy with severe infundibular and pulmonary valve stenosis.
Catheterization and angiography study confirmed diagnosis of tetralogy of Fallot (TOF) with large VSD, right ventricular hypertrophy and aortic override. There was only trickle of flow to the pulmonary artery in right ventricular injection. The aortic root injection showed presence of large communication from left coronary system opacifying pulmonary trunk. Selective coronary angiogram confirmed presence of fistulous communication arising from left anterior descending (LAD) coronary artery opacifying the main pulmonary artery []. At surgery the fistulous communication was ligated and intracardiac repair performed with Dacron patch VSD closure, infundibular resection, pulmonary valvotomy and right ventricular outflow tract augmentation using autologous glutaraldehyde treated pericardial patch. The patient had an uneventful recovery and discharged on day 10.
The congenital coronary artery to pulmonary artery fistula is a rare

[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 man was admitted to the intensive care unit on November 2017 for a ruptured penetrating atherosclerotic ulcer of the ascending aorta identified on CT scan (Figure).
He had a significant past medical history: end-stage renal failure undergoing dialysis, and myocardial infarctions with previous stentings (the last infarction dating back 10 months). Earlier in the day, the patient had presented with severe retrosternal chest pain for which a myocardial infarction was initially suspected, but the electrocardiography and the transthoracic echography performed in emergency excluded the diagnosis. A CT scan was realized and showed a local aortic plaque rupture of the ascending aorta with active contrast leakage, the patient was then transferred to our institution.
At admission the patient was haemodynamically stable with good blood pressure, a normal pulmonary auscultation with oxygen saturation at 100%, and no more pain. The patient was considered for open cardiac surgery but was evaluated at a high mortality risk based on his age, his medical history, and significant calcifications on his aorta. Our vascular surgical team decided then to perform an endovascular repair.
In emergency, an off the shelf endovascular stent graft was used. The rupture measured 12 mm and was located at just a few millimetres proximal to the IA. The ascending aorta measured 8 cm from the coronary sinuses to the IA. The largest diameter measured along the length of the ascending aorta was 33 mm (Figure). The shortest available off the shelf thoracic stent graft was the 10 cm length Conformable GORE® TAG® Thoracic Endoprothesis (WL Gore & associates, Flagstaff, AZ, USA).
In a hybrid operative room, first we performed an IA debranching with a left to right common carotid bypass through a cervicotomy using GORETEX vascular graft (8 mm). Via a transfemoral approach, the IA was embolized with a plug emplatzer (16 mm). Then, we considered a femoral approach to place the stent graft

[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 58-year-old man reported to the dental and maxillofacial clinic with complaint of heaviness over the right side of face and nasal discharge for the last 1 month. The history revealed multiple surgical episodes for implant placement at a dentist's clinic 4 months back, following which there was considerable discomfort and swelling over the right side of face which lasted 7-10 days. This was followed by loss of all implants over a period of 3 months.
The patient currently wore a complete tissue borne denture in maxillary arch. Intra-oral examination revealed considerable hard and soft tissue loss with lack of good bound-down keratinized tissue. Radiographic investigations by way of an orthopantomograph showed two implants in the right maxillary sinus with one of them close to the floor of the orbit []. A complete maxillary rehabilitation was planned for implant-supported prosthesis with bilateral sinus grafts and anterior maxillary onlay grafts under general anesthesia.
On raising a mucoperiosteal flap in the right maxillary sinus region a perforation was seen in lateral wall of the maxilla, the sinus membrane was tense and fluctuant []. The membrane was incised and spontaneous purulent discharge was observed, following which the membrane was curetted out [Figures and ]. Two implants were removed from the sinus encapsulated in granulation tissue.
Following a through lavage, a double-layered cross linked type 1 collagen membrane with a delayed resorption pattern (Biomed, Zimmer Dental) was used to create an artificial membrane to contain the graft []. The membrane was secured by Titanium tacs (Autotac, biohorizons Inc.) on the medial wall of the sinus inferior to the ostium and brought out laterally and fixed with tacs to the lateral wall of the maxilla.
A 50:50 mixture of autograft and xenograft (Bioss, Geistlich) was used mixed with Plasma Rich Protein to graft the sinus []. A second layer of collagen membrane covered the access opening to the sinus

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


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

[User]
RADIOLOGY NOTE:
A 35-year-old young adult male presented to our department with pain over lower one-third of the right arm. Detail history taking revealed that the patient was a chronic smoker and alcoholic who sustained a compound fracture of the right shaft humerus 1 year back for which he underwent interlocking nailing at some private center. He further told us that the operating surgeon did iliac crest bone grafting 6 months after the initial surgery when no signs of union were evident. However, in spite of that, no signs of union were seen and he had persistent pain at fracture site when he used to perform household activities. He again went to the operating surgeon who referred the patient to our center. We got the anteroposterior and lateral X-rays done which revealed atrophic non-union at fracture site with one locking hole proximally and one distally (). The nail seemed to be of appropriate diameter well seated in the medullary canal and removal of nail would have caused more damage to the rotator cuff. The patient was in a lot of mental trauma after the failed previous two surgeries, so he was counseled properly, and the decision was made to apply a locking compression plate (LCP) with nail in situ with iliac crest autogenous bone grafting. The patient being a chronic smoker and alcoholic was told that both smoking and alcohol cessations were mandatory before any definitive procedure and he agreed to that. After the preanesthetic checkup clearance, the patient was taken up in the theater; fracture site was opened posteriorly using triceps-splitting approach. As expected, there was rotational instability at the fracture site and no signs of callus formation were seen. The fracture margins were freshened till bleeding bone was visualized, fibrous tissue cleared, and locking compression with two monocortical holes on each side was applied along with bone graft harvested from iliac crest. Immediate post-operative anteroposterior and lateral radiograph were obtained ( and ). A

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


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

[User]
RADIOLOGY NOTE:
A 61-year-old female was admitted to our department with complaints of right facial pain for three years with coexisting severe cervical pain and itch for one month. The onset of the right facial pain was June 10, 2010. The patient stated that the pain was not serious (verbal pain scale, VPS 2) and that she never needed any analgesics to relieve it. As the pain did not change, she paid no attention to it, and no imaging studies were performed until one month previously. New symptoms of right facial and cervical pain, as well as right cervical itch, developed on July 5, 2013. The pain (VPS 9) and itch were severe, and drugs (tramadol, carbamazepine, and antihistamines) did not relieve the symptoms. Physical examination showed only paresthesia of the right cervical area, with no abnormal observations of the limbs, the central nervous system, or the right cervical skin. Magnetic resonance imaging (MRI) of the head was performed one day after admission. Unfortunately, the head MRI showed that the right trigeminal nerve was compressed by the right posterior cerebellar artery (). A trigeminal nerve microvascular decompression was planned; however, the right cervical pain and itch were not explained by the trigeminal nerve compression. After a group discussion involving the whole department, a cervical MRI was performed. The cervical MRI demonstrated a round intramedullary lesion located at the C2 level, exhibiting a core of increased signal intensity and surrounded by a low signal intensity rim on the T2-weighted images ().
A debate was held on which surgery should be performed first: microvascular decompression or intramedullary lesion resection. Considering that the right cervical pain and the itch were recent developments, we opted for the removal of the C2 intramedullary lesion first. After the preoperative examinations were completed, the patient was sent to the operating room. Microsurgical extirpation by posterior middle incision under general anesthesia was perfor

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

[User]
RADIOLOGY NOTE:
A 23-year-old female was admitted with computed tomography (CT) and magnetic resonance image (MRI) findings of intracranial tumor bleeding, after presenting with clinical symptom of dysarthria a week before admission. The patient had a past medical history of seizure due to diffuse astrocytoma, diagnosed 7 years previously. Initially she had undergone craniotomy and total tumor removal at another institution. The pathologic result from the first operation was diffuse astrocytoma, World Health Organization (WHO) grade II and afterwards the patient had not undergone chemotherapy or radiation therapy. Her annual follow-up MRI showed slow changes in most medial corner of the tumor margin in MR fluid attenuation inversion recovery (FLAIR) image which was not recognized until they were review retrospectively (). She was free of symptom for 7 years until she developed seizure with dysarthria and mild headache. The patient immediately underwent CT scanning which revealed hemorrhage at the right temporal lobe correlating with her tumor site. She was admitted to our hospital a week after the initial onset of the symptoms and brain MRI scan with enhancement, diffusion, spectroscopy, and perfusion were performed to confirm the tumor site and any other changes, such as evidence of malignant transformation. On MRI imaging there was evidence of acute hemorrhage at the previous tumor site with thin rim enhancement of the mass-like lesion with surrounding edema, suggesting possible malignant change to higher grade glioma. Increased regional cerebral blood volume (about >2-2.5) from the peripheral enhancing thin rim of the Lt. perisylvian superior temporal hemorrhagic lesion was also another evidence which suggests recurred tumor with probability of malignant transformation with intratumoral recent hemorrhage ().
Suspecting the transformation of the hemorrhagic lesion to higher grade glioma, we performed frontotemporal craniotomy and total removal of the tumor. The tumor tissue was d

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


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

[User]
RADIOLOGY NOTE:
A 19-year-old male presented to our emergency room with one day history of left flank pain and dysuria. He endorsed mild chronic mild low back pain, which did not impair his daily activities and which he attributed to a previous car accident. During initial workup for hematuria, abdominal computed tomography (CT) scan revealed diffuse lumbar spinal osseous lesions with both osteoblastic and osteolytic features (Figure ). The patient was therefore admitted to internal medicine service for workup of potential metastatic malignancy. His grandmother had cervical cancer; otherwise his family history was unremarkable. Physical examination showed mild tenderness to palpation on thoracic and lumbar spine. His right orbital rim was slightly more prominent than left side and there was a dark skin mark on right front thigh along L1-2 distribution (Figure ).
During the hospital stay, the patient’s laboratory tests were significant only for bacteriuria and vitamin D deficiency with a normal complete blood count/comprehensive metabolic panel, including alkaline phosphatase. Serum protein electrophoresis was negative for any M protein. Tumor markers including CEA and PSA were negative.
Chest, abdominal and pelvic CT scan with contrast was carried out, which showed additional similar thoracic spinal lesions. No primary tumor lesion was identified, except a small 4 mm non-specific pulmonary nodule. Single photo emission computed tomography (SPECT) and whole body nuclear scan were carried out for further characterization of patient multiple bone lesions. SPECT showed ground-glass sclerotic lesions on maxillofacial region and right calvarium, which is typical for fibrous dysplasia (Figure ). All bony lesions are associated with increased nuclear signal uptake (Figure ). Retrospectively, the patient reported to have a small lump on right forehead at the age of five, for which he had an X-ray. We were able to retrieve the original image and found that the same sclerotic lesion on right

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


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

[User]
RADIOLOGY NOTE:
A 65-year-old male presented with a three-week history of progressively worsening abdominal distension. He denied any abdominal pain but stated that he noticed an increased frequency of bowel movements. His past medical history was unremarkable. On examination, he was afebrile and had a hugely distended abdomen with an immobile, nontender mass occupying all four quadrants of the abdomen. Computed tomographic (CT) scan revealed a large, heterogeneous lobulated mass occupying most of the abdomen (Figure ). The peripheral component appeared lipomatous and the margins of this component were difficult to estimate accurately. There was also a heterogeneous nonlipomatous component that contained areas of lesser density, as well as a central stellate region of calcifications. The preoperative differential diagnosis included a retroperitoneal sarcoma (especially dedifferentiated liposarcoma), desmoid tumor, undifferentiated carcinoma, carcinoid or sclerosing mesenteritis; lymphoma was also considered.
While neoadjuvant chemotherapy and radiation comprise a frequent approach for retroperitoneal sarcomas at our institution, the extent of the tumor made this approach unfeasible. Resection was therefore planned unless an intraoperative biopsy revealed lymphoma. Resection was accomplished through a T-type incision (Figure ), and entailed removal of the right kidney, terminal ileum, ascending colon, sigmoid colon and the left spermatic cord structures, all of which were intimately attached to the mass. Encasement of the external iliac artery and vein was also encountered near the end of the procedure. This was not fully appreciated preoperatively, as that component of the tumor was so much less conspicuous on CT than the rest of the tumor, given its fatty consistency (Figure ). The mass was split in half to facilitate dissection from the iliac vessels. An anastomosis was constructed from descending colon to rectum. A transverse colon mucous fistula and an ileostomy were brought ou

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


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

[User]
RADIOLOGY NOTE:
A 64-year-old man who underwent a right upper lobectomy in our institute, involving an extended resection of the posterior chest wall to treat a stage IIIA lung cancer. The dorsal portion of the third to fifth rib was additionally cut during the procedure, and the defect of chest wall was covered using Gore-Tex® Dual Mesh (Japan Gore-Tex Inc., Tokyo, Japan), which is a pure and unique expanded polytetrafluoroethylene (ePTFE) prosthesis, consists of two functionally distinct surfaces [].
Postoperative acute course was uneventful. However, at postoperative Day 6, he experienced acute severe pain in the right shoulder. The slightly purulent drainage through drainage tube positioned on the mesh was also found. Pus culture from the drain discharge isolated Corynebacterium atrium. Computed tomography (CT) revealed that when the symptoms appeared, abnormal position of the right scapula with the inferior angle of the scapula was caught inside the top of the sixth rib (Fig. ). The conservative treatment failed to improve the scapular dislocation. We performed a redo surgery. We found that all suture threads which attached Mesh to sixth rib were cut, and the dislocation of the right scapula with the inferior angle of the scapula protruding into the right intrathoracic cavity though his thoracotomy defect (Fig. ). We also found a local infectious change at the head side of the Mesh (not the site of scapular dislocation), and found no macroscopic intrathoracic infectious changes. A removal of mesh was carried out. After improving the scapular dislocation and removal of mash, washing with 10 L of physiologic saline was carried out. We did not want to use synthetic materials because of infection. In this case, however, the infection was localized and titanium plate is reported to be resistance to infection [], we performed titanium plate fifth rib fixation to avoid the recurrent dislocation of the scapula (Fig. ). After the redo surgery, continuous lav

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


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

[User]
RADIOLOGY NOTE:
A 69-year-old man presented to our hospital with lung nodules at the right upper and right lower lobes, which were detected at a different institution during an examination for intermittent hemoptysis. The patient's past medical history was significant for hypertension, with a smoking history of 50 pack-years. Physical examination and routine laboratory tests revealed no significant findings. A chest computed tomography (CT) scan revealed a 2.1 × 1.7 cm sized mass in the posterior segment of the right upper lobe (RUL), along with a 3 × 2.3 cm sized mass in the superior segment of the right lower lobe (RLL)(Fig a). The nodule in the RUL was suspected to be primary lung cancer, while the nodule in the RLL was suspected to be a benign neoplasm or double primary lung cancer. Therefore, we performed a staging workup for suspected lung cancer. Positron emission tomography showed increased uptake only in the RUL and RLL (Fig b). Bronchoscopy showed no endobronchial involvement. As the pulmonary function test indicated no contraindication, we recommended surgery because of the possibility of malignancy in each nodule. Thoracoscopic wedge resection was performed with a frozen section for each nodule. The intraoperative frozen section revealed adenocarcinoma with poor differentiation in the RUL and non-small cell lung cancer with very poor differentiation in the RLL. CT findings showed a RUL lesion with spiculated margins and a RLL lesion with well-defined margins. We performed an additional upper lobectomy with mediastinal lymph node dissection after the thoracotomy considering the CT findings and an insufficient wedge resection margin of the RUL. The patient was discharged from the hospital without any complications on postoperative day eight.
The results of the biopsy revealed that despite poor differentiation of the tumor cells, the RUL mass was an adenocarcinoma positive for CK7 and TTF-1 (Fig a,b). The RLL mass was a tumor consisting mostly of cells that morphologically

[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 72-year-old female was initially found to have morphea on the skin 4 months prior to presentation with 3 months of progressive thickening of the skin on the ankle, chest, back, arms, and neck. The findings were diffuse, and there was no fever, myalgias or arthralgias. The skin changes were asymmetric and not associated with any pain or pruritis; however they had been progressively worsening over the past 3 months (). She reported decreased mobility of her extremities as a result. There were no other identifiable pertinent systemic manifestations outside of the skin. This presentation was associated with an elevated ESR, but negative antibodies for lupus, scleroderma and other autoimmune processes. As a result, a skin and muscle biopsy was done and the findings revealed a thickened fascial layer associated with a lymphocytic infiltrate. The patient was started on 60 mg of prednisone and was prescribed the medication from April 2013 to March 2014. The patient had improvements in skin thickening throughout the body and was started on topical fluocinolone acetonide 0.01% once oral steroids were discontinued.
The patient was re-evaluated in the year of 2018. Her skin thickening showed improvement and had a return of nearly normal ankle motion. She was able to walk downstairs normally and exercise comfortably. She took precautions such as limited sun exposure and decreased strenuous exercise. However she noticed that some areas of skin thickening had returned after 3 months on the posterior aspect of the right lower extremity. She attempted use of topical corticosteroid; however the lesion did not resolve and within a few months, this lesion became ulcerated (). The patient underwent biopsy which revealed SCC. After that, wide and deep excision skin biopsy involving muscular layer was performed (). Wound care was able to reduce the size to a superficial ulcer of about 2 × 3 cm diameter with good granulation tissue. She returned for routine follow-up without signs of rec

[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 man was found dead from the driver of a passenger van, upon arrival at the city of destination. With other passengers leaving the van, he waited for the man to descend, thinking that he was asleep. The victim was immediately brought at the city hospital, where the death was declared. The autopsy was performed immediately the same day; samples were sent at the Institute of Forensic Medicine where microscopy was made on the organs of interest.
The medical staff examined the previous medical files and documentation of the victim; no chronic diseases were suggested. He was referred to be a heavy smoker (30 years with twenty cigarettes per day); he was obese; but no hypertension or other major risk factors were found. Toxicology revealed no signs or suggestions for medications, intoxications, or recent use of ethanol.
The day of the trip the victim woke up early and left his home at dawn; he used to go working every day at the city of destination.
The forensic pathologist performing the autopsy found nothing unusual at the thoracic cavity, no enlargement of cardiac rooms was seen. The autopsy showed no thrombi inside the cardiac cavities; nor was any sign of thrombotic event found in the major extra cranial vessels. The coronary arteries showed atherotic signs compatible with the age and the body mass (his weight was 97 kilograms for a height of 165 centimeters).
The brain was swollen and clearly hyperemic; a massive basilar thrombus with complete occlusion of the median segment of the basilar artery was macroscopically seen ().
The dissected basilar artery, from the origin of the vertebral arteries to its top, is shown (); samples of brain stem tissues were microscopically examined. The occlusion of the basilar artery was in the median portion; thrombotic fragments were found as well in the oral portion of the basilar artery.
The brainstem showed an infarcted zone in the pons, with secondary hemorrhagic changes, mainly in the form of multiple pet

[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 2019, a 10-year-old Caucasian boy presented one day after trauma during ice skating and sustained a complicated crown fracture of tooth 11 and complicated crown-root fracture of tooth 21. The fragment of tooth 11 was found immediately after the traumatic dental injury and was stored in mineral water. The patient and his guardian promptly visited his general practitioner, who performed splinting from self-cure resin from tooth 53 to 63, performed direct pulp capping, and referred the patient to our department for further treatment.
An intraoral examination showed the presence of splinting only from tooth 21 to 63 and a complicated fracture of tooth 11 (A). The patient mentioned the partial loss of splinting within a short time after emergency treatment. In the maxillary right central incisor, the fracture was oblique, extending in the apical direction from the labial to palatal surface. The margin on the palatal surface was 2 mm above the marginal gingiva (B). The maxillary left central incisor displayed first-grade mobility even with the presence of splinting, but the patient denied any discomfort or pain. The percussion of the upper incisor was not painful, as well as the palpation of alveolar bone. The thermal sensitivity (cold) tests were positive for both central incisors and comparable to adjacent teeth, so a pulpal diagnosis of normal pulp was made. The diagnostic X-rays showed the presence of crown-root fracture (class III according to Ellis classification of dental traumatic injuries []) of immature tooth 21 (class IV according to Cvek’s classification of root development []), which was located subgingivally all around; therefore, it was not possible to locate the exact path of the fracture line ( and A). The diagnostic X-ray of immature tooth 11 (class IV according to Cvek’s classification of root development []) showed no tooth dislocation (A). The guardian was informed about the clinical situation and about the preliminary treatment plan,

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


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

[User]
RADIOLOGY NOTE:
A 62-year-old man presented in the emergency department complaining of a recent deterioration of general condition with the appearance of a painless progressive abdominal gangrene without any obstructive lower urinary tract symptoms (LUTS). On medical history, he was diagnosed two months before with a bladder tumour. The patient did not consult because of the Covid-19 pandemic. No history of any trauma or urethral instrumentation was found. On examination, he had a bad general condition and was dehydrated with a blood pressure of 120/75 mm Hg. On abdominal inspection, we noticed a painless large necrotic lesion spread over the anterior wall of the abdomen under the umbilicus with a smell of urine (, ). On palpation, there was a renitent mass in the hypogastrium. There were no features suggestive of peritonitis. A urethral catheterization by a Foley catheter failed due probably to anterior urethral stenosis. Basic investigation on admission reported high creatinine levels at 513 umol/l with no electrolytic disorders. Complete blood count showed a decreased haemoglobin level at 6.6 g/dl with thrombocytopenia at 96,000 cmm. A contrast-enhanced abdominal and pelvic computed tomography (CT) was then performed and revealed the presence of a large tumour of the posterior wall of the bladder with bilateral ureteropelvic dilatation, the bladder was distended and perforated on its anterior wall with an extraperitoneal urinoma 10 × 12 cm evoking an extraperitoneal urinary bladder rupture. There was no peritoneal effusion (). The established diagnosis was abdominal gangrene secondary to an extraperitoneal rupture of the urinary bladder. Our attitude was to put a catheter to relieve the urinoma and a suprapubic catheter to drain urine from the bladder and to begin empiric antibiotic therapy. Bilateral nephrostomies were set in order to improve creatinine levels. The patient remained afebrile and stable. After a rapid optimization of the patient’s condition, we carried out excisi

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


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

[User]
RADIOLOGY NOTE:
A 60-year-old woman, gravida 3 para 2, presented with a growing mass at the left side of a cesarean section scar (lower abdominal longitudinal incision). She had no relevant medical history and had undergone cesarean section twice, the first in 1977 due to breech presentation and again in 1979. She had no pertinent family history other than breast cancer diagnosed in her sister and had experienced menopause at 50 years of age.
The patient noticed the nodule near the abdominal operation scar with no tenderness 4 years before presentation. The nodule grew quickly in size with no significant pain, even during menstruation. Physical examination revealed a smooth mass measuring 4 cm in diameter on the middle-left side of the cesarean median scar (). A biopsy of the mass showed atypical cells, and subsequent pelvic magnetic resonance imaging (MRI) showed two lesions, measuring 2.5 × 3.3 cm and 3.3 × 4.0 cm along the abdominal scar (). The mass located at the right side of the scar consisted of solid components, while that on the left was polycystic. There were no obvious mass-like lesions in the intraperitoneal cavity or any of the abdominal or pelvic lymph nodes. Laboratory tests revealed no increase in the serum levels of tumor markers (CEA, CA19-9, and CA125). Radical resection of the abdominal wall mass was performed with adequate margins under general anesthesia. Histopathological examination showed clear cell adenocarcinoma (), suggesting malignant transformation from endometriosis of the abdominal wall. Positron emission tomography (PET) showed no evidence of malignancy, including in the uterus, bilateral ovaries, and pelvic lymph nodes. Considering these findings together, we diagnosed clear cell adenocarcinoma of the abdominal wall arising from endometriosis after cesarean section. Eight months after the resection, a nodular lesion appeared in the patient's abdominal scar again. MRI and PET scan showed local recurrence, and she was hospitalized for resection of t

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


[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 female child presented to us initially when she was 5 years old with an episode of generalized convulsion, loss of consciousness and left sided hemiplegia. A non-contrast CT scan done at this time showed a right posterior frontal hematoma. CT angiography did not show any evidence of a vascular malformation. Digital substraction angiography did not show any arteriovenous malformation, though an early draining vein was visualized []. The patient was managed conservatively. The patient presented 1 year after the episode. She had improved in power in her left sided limbs which was now Grade 3-4/5. She was able to walk on her own with little support. A MRI was performed that showed resolution of the hematoma and the presence of a gliotic cavity. A contrast image showed the normal vessels in the region, and there was no evidence of any flow voids in the region of the cavity. MR angiogram performed at the same time also did not show any evidence of an arteriovenous malformation or nidus []. The patient was again observed and asked to follow-up. The patient presented after 4 years, at the age of 9 years, with complaints of intermittent episodes of seizures. A MRI was again repeated which showed the gliotic cavity on T1 weighted scan. On T2 weighted image, some abnormal vessels were seen in the region of the gliotic cavity. MR angiography showed the presence of an arteriovenous malformation fed by the branches of the middle cerebral artery []. A four vessel angiogram was performed which showed an arteriovenous malformation fed by multiple anterior branches of the middle cerebral artery and drained via multiple veins in the superior sagittal sinus. The patient was advised surgery at this time, but since she only had intermittent episodes of seizures the parents were not willing for surgery. One year after this the patient again presented with complaints of intractable seizures. Digital substraction angiography showed the arteriovenous malformation, similar in si

[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 61-year-old African-American man with a history of coronary artery disease presented to his internist with complaints of fatigue and lower extremity edema. On examination, he was afebrile with a heart rate of 75 beats/minute and a blood pressure of 127/70 mmHg. His oxygen saturation was 97% on room air. He had faint crackles at the bases of his lungs bilaterally. His cardiovascular exam was remarkable for 10 cm of jugular venous distension, a regular rhythm, and a 2/6 systolic flow murmur at the left upper sternal border. His abdominal examination was benign. His extremities were warm to touch with 2 + bilateral lower extremity edema. Pertinent laboratory studies were remarkable for a hemoglobin of 9.1 g/dl, a platelet count of 105,00 per microliter, a blood urea nitrogen of 13 mg/dl, a creatinine of 1.0 mg/dl, an albumin of 3.9 g/dl, and a calcium of 9.2 mg/dl. His ECG demonstrated normal sinus rhythm, normal voltage and left atrial enlargement. An echocardiogram with Doppler conveyed hyperdynamic left ventricular function with an ejection fraction of 70%, no wall motion abnormalities, mild concentric left ventricular hypertrophy, normal diastolic function, moderate to severe left atrial enlargement (47 cc/m2) and no valvular abnormalities. A bone marrow biopsy was performed and revealed a monoclonal population of lambda-positive plasma cells making up 90% of the total cell population. A skeletal survey demonstrated multiple lytic lesions throughout the pelvis, right humerus and skull. While the diagnosis of multiple myeloma was being investigated, the patient developed worsening lower extremity edema despite oral furosemide therapy. Cardiac catheterization was subsequently performed (Table ). Based on the diuresis noted in the first case, it was decided to initiate thalidomide 50 mg daily and increase the dose to 200 mg over the next 4 weeks. He was also given oral dexamethasone. Two weeks after the initiation of therapy, he no longer had peripheral edema. The t

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


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

[User]
RADIOLOGY NOTE:
A 12-year-old female patient reported to the College of Dentistry, Jouf University, Saudi Arabia, with pain in the left mandibular posterior region. Intraoral examination revealed disto-occlusion caries with respect to tooth #36. A diagnosis of acute irreversible pulpitis with respect to tooth #36 was made after the radiographical investigation, and the tooth was planned for multivisit pulpotomy. The case was allotted to an intern for performing the dental procedure. The assigned intern performed access opening and biomechanical preparation in that specific tooth and gave her dressing using FC-soaked cotton. The assigned intern cleaned the patient’s cheeks with wet cotton and sent the patient. After 24h, the patient reported with complaints of moderate pain and burning sensation with respect to patches of darkly discolored skin, one measured approximately 2.5 × 1.5 cm and the other measured nearly 0.5 × 1 cm on the left cheek []. The burns were extending from the middle of the upper lip on the left side toward the corner of the mouth and further to the left cheek. Owing to the involvement of the angle of the mouth, her mouth opening was also reduced with difficulty in food intake. Immediately before the patient left, she complained of mild burning sensation on left cheek around the corner of the mouth with no erythema or discoloration. After reaching home, she started complaining of mild burning and discoloration with respect to these patches. Slowly, this burning sensation was accompanied with moderate pain. It was learned that the operating intern squeezed the cotton pellet dipped in FC with gloved hand and continued the treatment without washing his gloved hand. This led to mild skin burns.
Treatment: An analgesic was also administered to relieve the symptoms of pain. She was recommended soft diet and advised to avoid spicy food. After 1 week, her condition improved markedly []. On her next visit after 2nd week, 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 62-year-old Chinese man was admitted to hospital on July 25, 1985, because of recurrent palpitations and shortness of breath. On examination, there was an increased respiratory rate. A raised jugular venous pressure was noted, together with hepatomegaly and marked peripheral edema. His pulse was 94 beats per minute and regular. Blood pressure was 90/10 mmHg. The apex beat was displaced laterally. Auscultation revealed a grade IV/IV systolic murmur, a harsh low-pitched diastolic murmur at the apex and fine rales at the lung bases. An electrocardiogram showed sinus rhythm. A chest radiograph revealed cardiomegaly and pulmonary venous congestion. Serum potassium, sodium, calcium and magnesium were normal. The patient was diagnosed as congestive heart failure, rheumatic heart disease: mitral stenosis and insufficiency, and was treated with inhalation of oxygen, vasodilator, diuretics and antibiotics. Two days later, his condition improved. On the third hospital day, the patient's palpitation recurred. Heart rate was 180 beats per min. The electrocardiogram revealed ventricular tachycardia. After administration of 100 mg of lidocaine in 40 ml of 25% glucose intravenously, the ventricular tachycardia was reverted to sinus rhythm. Two hours later, the ventricular tachycardia recurred (Figure ). Heart rate increased up to 200 beats per min. Even though, 100 mg of lidocaine in 40 ml of 25% glucose being intravenously administered for four times at interval of 10 minutes, it failed to convert ventricular tachycardia to sinus rhythm. Blood pressure dropped to zero. Intravenous infusion of dopamine and normal saline were administered to maintain blood pressure because no other antiarrhythmic agents and defibrillator were available in the hospital. After blood pressure had returned to 90-100/50-60 mmHg, ventricular tachycardia persisted. Twelve and half hours later, the patient suddenly felt cold and chill, the intravenous infusion was immediately stopped, and 25 mg promethazi

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


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

[User]
RADIOLOGY NOTE:
A 40-year-old male belonging to a poor socioeconomic status was referred to the Outpatient Department of Periodontology from ENT Department with a chief complaint of constantly recurring pustule at the base of the right nostril (). Further questioning revealed that the pustule used to heal spontaneously within 15 days of eruption and then again exuberated thereafter. A thorough medical history was taken which disclosed that the patient had been under treatment for 6 months from a private practitioner and was prescribed antibiotics as well as intralesional steroids for the constantly recurring pustule which did not yield any positive outcomes. Additionally, the patient was a chronic current and heavy smoker and used to smoke > 20 filtered cigarettes (1 pack) per day for 15 years making it a total of 15 (15 × 1) pack years. Dental history acknowledged that the propositor had a history of trauma to his upper front teeth, when he was in his late 20's, yet no pain, swelling, or any other associated symptom was reported. The propositor had also undergone multiple nugatory biopsies of the concerned lesion only to disclose no abnormality. On extraoral examination, a pustule was detected near the right nostril. Intraoral examination revealed an attrited, noncarious, and significantly discoloured maxillary right central incisor (tooth number 11), bearing prominent enamel cracks running in a coronoapical direction. Generalised attrition with a poor oral hygiene status was also evident by plaque scores and gingival index (). On suspecting the patient's nasal sinus tract to be of odontogenic origin, we went in for further investigations. Initially, the pulp vitality tests were performed with the help of heated gutta percha and the results were found to be negative for right maxillary central incisor indicating pulpal necrosis or dental abscess. Intraoral periapical (IOPA) radiograph showed distinct periapical radiolucency with compromised periodontal status in relation to tooth

[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 female was referred from primary care with a 3-year history of generalised fatigue. She has background of ichthyosis, lichen sclerosis, asthma, depression and chronic herpes simplex virus infection. She had hysterectomy due to abnormal smear cells, which was then proven benign on histology. She was initially found to have microcytic anaemia with low ferritin level which did not improve despite oral iron replacement. Both oesophago-gastro-duodenoscopy and colonoscopy were unremarkable. A subsequent computed tomography (CT) scan of the abdomen and pelvis showed a splenic mass with a central area of calcification and a calcified 35 mm pleural-based nodule at the right costophrenic angle.
The latter was discussed in the lung multi-disciplinary team (MDT) meeting. They concluded that the pleural mass was most likely due to post-inflammatory changes. In absence of concerning features, further monitoring or intervention was deemed unnecessary. The splenic mass was then discussed in the hepatobiliary MDT meeting. They recommended obtaining tissue biopsy to aid diagnosis. However, it only showed fibrotic tissue with possible granulomas. The indeterminate histology prompted a repeat CT scan and further magnetic resonance imaging (MRI) to assess the mass further and exclude the possibility of lymphoma. These scans showed stable appearance of the splenic lesion at 6 cm ( and ). The CT scan also picked up numerous small calcifications scattered throughout the peritoneal cavity.
She then had a diagnostic laparoscopy with a view of performing a splenectomy. However, widespread nodules were found in the peritoneum and throughout the abdomen as shown in . There was no evidence of malignancy found on laparoscopy. Given these findings, further biopsies of the nodules were obtained and splenectomy was abandoned.
As the investigations thus far were non-conclusive, positron emission tomography (PET) scan was performed while awaiting for the result of the peritoneal biopsies

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


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

[User]
RADIOLOGY NOTE:
A 42-year-old male presented to our outpatient department with an incidentally detected renal mass on ultrasonography of the abdomen done for a routine health check-up. The patient had no history of loin pain or hematuria. He never had any complaint of bone pain, loss of weight, or hemoptysis. There was no family history of malignancies. He was neither a smoker nor an alcoholic. There was no history of exposure to thorostat or vinyl chloride and he was a farmer by occupation.
On evaluation of his hemogram, renal parameters and liver function tests were within normal limits. Contrast-enhanced computed tomography (CT) was done which revealed a 10 cm x 8 cm heterogeneous enhancing mass involving the upper pole and interpolar region of right kidney (Figure ). The inferior vena cava and renal vein were free of thrombus and there was no regional lymphadenopathy. There was no evidence of distant metastases in the liver or bones. CT of the chest was also normal (Figure ). The patient underwent right-sided open radical nephrectomy. On the cut section, the tumor was seen to be composed of focal fleshy and necrotic areas intermingled with vascular spaces (Figure ). Histopathological examination revealed areas of extensive necrosis and anastomosing vascular spaces lined by pleomorphic cells (Figure ). The tumor had a high mitotic index of 25 to 30 per ten high power fields and a ki-67 index of 40%. Immunohistochemistry was done which showed strong positivity for cluster of differentiation (CD) 34; whereas, it was negative for epithelial membrane antigen (EMA), CD 10, and human melanoma black (HMB) 45 consistent with angiosarcoma. The surgical margins were free of tumor and the pathological staging was pT2bN0M0.
In view of the histological diagnosis of angiosarcoma, the patient was treated with adjuvant chemotherapy. He received three cycles of paclitaxel-based chemotherapy. The patient is doing well on one year of follow-up. Several reports of primary

[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 13-year-old male presented with a fungating lesion on the scalp. He had sustained flame burns at the age of three. The lesion was never grafted and failed to heal completely. The primary care centre continued to manage the wound conservatively with frequent dressings. Eventually, a biopsy was performed and a well-differentiated squamous cell carcinoma was confirmed. He was referred to our tertiary centre for further management.
His main complaint was pain and a foul-smelling ulcer with a mucopurulent discharge. Specifically, the patient did not give any history suggestive of epilepsy or personality change. He was noted to be underweight for his age. On examination the lesion occupied the entire central vertex of the scalp []. The tumour measured 12 × 15cm. The central portion of the lesion was pulsatile. Bilateral cervical lymphadenopathy was present. On neurological examination no deficits were identified. No abnormalities were noted on the cardio-respiratory and abdominal examination. Blood investigations revealed microcytic anaemia and hypoalbuminaemia. The human immunodeficiency virus serology was negative.
Investigations included a skull radiograph, computed tomography (CT) and magnetic resonance imaging (MRI). These revealed extensive tumour infiltration of the soft tissue with underlying full thickness bilateral parietal bone erosion []. The depth of the infiltration included the dura and the cortex of the left cerebral hemisphere with underlying oedema of the brain []. A filling defect in the superior sagittal sinus indicated a thrombus. A chest roentegram and an abdominal ultrasound excluded metastatic disease in the lungs and liver respectively.
The cancer was staged clinically as T4N1M0. With Neurosurgical assistance the resection of the lesion was planned.
At surgery, the scalp, the involved cranial bones and dura were excised with 2cm tumour free peripheral margins. A suction-assisted resection of the involved cerebral cortex was done to the depth 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 27-year-old male with a medical history significant for FH diagnosed approximately 10 years ago presented for further evaluation. He had been diagnosed in 2006 with a particularly virulent genetic form of heterozygous FH involving mutations in low-density lipoprotein (LDL) receptor with Gln125 variant and APOE haplotype E3/E4. He had a strong family history of CAD. He was noted to be intolerant to several statins but had recently been tolerating simvastatin. Other pertinent medical history included only seasonal allergies. Current medications being taken included simvastatin, ezetimibe, evolocumab, aspirin, alprazolam, and albuterol.
The patient had significant family history including a recently diagnosed mother with heterozygous FH, a cousin who had a sudden death at age 29 from a myocardial infarction and a grandfather and an uncle who both required CABG in their 40s (). Social history revealed that the patient was an ex-smoker having quit at the age of 22 and he rarely drank alcohol. Review of systems was significant for dyspnea going up stairs but with good exercise tolerance however. The patient denied any chest pain on exertion to imply possible unstable angina.
On physical examination, the patient’s heart rate was in the 60s in regular rhythm and his blood pressure was normal. He has moist oral mucosa, clear conjunctiva, and a note of a gray arc on the upper area of his cornea. There were no palpable head or neck masses and heart sounds were normal with no murmurs. Neither carotid nor abdominal bruit was appreciated. Abdomen was soft, non-tender with no masses and peripheral pulses were normal with no peripheral cyanosis or clubbing of his extremities. Neurological exam was unremarkable. Electrocardiogram revealed sinus rhythm with no ischemic changes while chest radiograph showed no acute cardiopulmonary process but had a prominent heart ().
Given his strong family history of premature CAD and FH, the patient underwent a nuclear stress test which

[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 28-year-old man, with history of chronic alcohol abuse was found unconscious, with approximately 24 h after a traumatic brain injury (TBI) of unknown mechanism. He was admitted to our hospital for neurologic assessment and management. As recommended by the American College of Surgeons,[] his treatment followed the Advanced Trauma Life Support Management of severe brain injury protocol. A neurological examination revealed a Glasgow Coma Scale score of 6 and left anisocoria. He underwent brain computerized tomography (CT) that showed left hemispheric swelling associated with a temporo-parietal linear fracture and an acute subdural hemorrhage.
He was immediately transferred to the operating room and, after balanced standard general anesthesia, he received a left question mark incision and a fronto-temporo-parietal craniectomy. After a durotomy and acute subdural drainage, he underwent dura mater reconstruction using galea aponeurotica. After standard subcutaneous tissue and skin closures, the extracted bone flap was bisected via osteotomy and both parts were subcutaneously stored in his left abdomen.
Immediately after the procedure, the patient underwent postoperative CT scanning before his intensive care unit (ICU) admission. This revealed an acute epidural hematoma, so he was returned to operating room for further neurosurgery. After standard balanced general anesthesia, the question mark incision was reopened and the hematoma was removed. No active bleeding site was identified. After careful hemostasis, the skin flap was sutured shut, and the patient was transferred to the ICU.
Because the patient presented diffuse brain edema, he was postoperatively sedated for 2 days, at which point CT scanning confirmed that his condition had improved. However, he was mildly sedated during the time of extubation. He developed pneumonia due mechanical ventilation, so he was tracheostomized and discharged from ICU without mechanical ventilation. Seven days before his hospital dis

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


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

[User]
RADIOLOGY NOTE:
An 11-year-old boy presented with a transverse fracture of his left femur after a fall from height (Figure ). Surgical treatment using titanium nails according to the principles of the ESIN technique was decided. Traction table and image intensification were used. Nails of 3.5 mm width were chosen, corresponding approximately to 40% of the width of the narrowest diameter of the femoral shaft. Prior to insertion, the nails were bent three times the width of the medullary canal. The nails entered the medullary canal from opposite sides of the distal femoral metaphysis and were advanced retrogradely up to the fracture level. After closed fracture reduction, the nails were further advanced into the proximal fragment and anchored firmly into the proximal femoral metaphysis (Figure ). Care was taken to obtain accurate reduction without a gap between the fracture fragments.
After resuscitation and transfer of the patient from the traction table to the stretcher, LLD due to a longer fractured limb was evident. The operated limb was about 1.5 cm longer than the contralateral (clinical measurement). LLD was evident as long as the patient was supine (Figure ).
Follow up examinations focused on fracture healing and on LLD. Partial weight bearing as tolerated by pain was recommended. The patient adapted well to the initially longer limb.
The patient was dismissed one week postoperatively with instruction of partial weight bearing as tolerated for one month. Progressive weight bearing was recommended on follow-up examinations, according to radiologically confirmed callus formation. At three months postoperatively, fracture healing was complete and the patient was encouraged to resume noncompetitive sports. On clinical examination, slight ipsilateral knee recurvatum might be the only hint for the straightened femur. Three months after surgery, loss of femoral antecurvatum of the operated limb was still evident on the long limb standing lateral X-ray. LLD due to longer operated fem

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


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

[User]
RADIOLOGY NOTE:
A 65-year-old male with the past medical history of chronic pancreatitis presented to the ER with the chief complaint of abdominal pain. Patient had a history of idiopathic recurrent pancreatitis that was treated with pancreatic stents.
Last CT of the abdomen on file was 11 days prior to the cystogastrostomy, a pancreatic stent was noted on that CT. On admission to the ER another CT was obtained which showed an 8.2 × 9.2 × 4.6 cm pancreatic pseudocyst with imaging feature suggesting an infected pseudocyst or abscess. Patient’s WBC was 14, 400. Patient subsequently underwent another ERCP with a pancreatogram, which did not show a communicating cyst. A pancreatic stent exchange was performed with the placement of a 5 F 7 cm pancreatic stent.
We then proceeded with cystogastrostomy. A pancreatic cyst was visualized in the pancreatic body, and the cyst was interrogated using a color Doppler imaging to identify interposed vessels. The cyst was punctured using 19-gauge needle using the transgastric approach, pus was aspirated. A jag wire was then inserted into the cyst under fluoroscopic guidance. The cystotomy was performed using a cystotome from cook endoscopy. We then dilated the tract using 12 mm balloon. We then placed a 10 mm × 4 cm fully covered SEMS. The cyst was then irrigated using 100 cc of saline resulting in the irrigation of the cyst and drainage of a large amount of pus into the stomach.
Patient was continued on broad-spectrum antibiotic and anti-fungal therapy. One day after the procedure the patient stated that his pain had resolved. He was discharged from the hospital 6 days later. His diet was advanced and he continued on broad-spectrum antibiotics at home. Follow-up in clinic revealed the absence of pain or any signs of infection. Follow-up CTs showed that the pseudocyst had resolved with diminished inflammatory changes in the pre-pancreatic region ().
Patient underwent another ERCP

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


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

[User]
RADIOLOGY NOTE:
A 29-year-old Caucasian man was seen in our department for a second opinion because of asymmetrical walking pattern and progressive sourness in his amputated leg. He was referred from a rehabilitation center where a standard roentgenogram showed evidence of a gauze in situ near the distal femur stump with progressive ossifications (Figure ).
His medical history noted a severe high energy trauma seven years ago. He had sustained multiple injuries among which a severe crush injury of the left leg with heavy bleeding for which an acute amputation was performed.
After six weeks he could be discharged from the hospital and was measured an advanced prosthetic leg for optimal rehabilitation. It took him 3 months to walk without aids. Two years later he fell on his stump in the bathroom. An X-ray was made of the left upper leg stump to rule out any fracture. The radiologist reported no fracture, but a swelling of soft tissue with calcifications at the femoral cutting edge. The report also mentioned that at the time of roentgenography, the stump was covered with a gauze, because a radio-opaque marker was visible on the X-ray. In the conclusion of the X-ray report, no mention was made on the gauze fibroma.
His painful stump recovered in a few weeks but five years later, he consulted his rehabilitation physician for asymmetrical walking pattern with soreness of the stump. A standard roentgenogram revealed progressive calcifications compared to the previous study. The radio-opaque marker was recognized as a retained surgical gauze which was left behind during initial surgery. The progressive ossifications were thought to cause his complaints. He was directed to our department for re-evaluation. Clinical examination showed an otherwise healthy man with a prosthetic leg with vacuum fitting. His walking pattern was slightly asymmetrical due to partial weight-bearing of his artificial leg. His left leg stump showed obvious thickening at the distal end. No painful or sharp masses co

[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 Asian woman was referred to our hospital with a history of weakness in her right hand of approximately one month's duration. She was a housewife and her symptoms developed after undertaking strenuous work helping her family prepare for a wedding. The patient remembered that she had sustained a fracture to the right elbow when she was 6 years old but could not remember the details of either the injury or its treatment.
On physical examination, the power of extension of the thumb and four fingers of her right hand was reduced to a trace, but the power of dorsiflexion of her wrist was normal (Figure ). Pre-operative electrodiagnostic data were compatible with PIN palsy. There was no sensory disturbance in the area supplied by the superficial radial nerve. The range of motion of her right elbow was limited, being 5° of hyperextension to 110° of flexion, 80° of pronation, and 40° of supination. A bony prominence was palpated on the anterolateral aspect of her elbow.
Plain radiographs of her right elbow revealed an anterior dislocation of the radial head and elongated radial neck (Figure ). Ultrasonography revealed that the posterior interosseous nerve was compressed by the dislocated radial head, and there was focal swelling from just distal to the radial head to just before it entered the supinator muscle (Figure ).
We performed an exploration with an anterolateral curved incision of the right elbow. The radial nerve was encased in fibrotic tissue that also enveloped the PIN and lay anterior and superior to the dislocated radial head. We dissected out the nerve and fibrotic tissue. We found that the PIN was compressed at the radial head, wrapped around the medial side of the radial neck, and ran into the distorted supinator muscle (Figure ). We found intra-operatively that the PIN was stretched. Therefore, neurolysis alone or reduction of the radial head could not release the P

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