[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 September 2011, a 38-year-old man was admitted in urgency regimen to our department because of a moderate left flank pain starting 6 h before hospital admission. The patient also presented vomiting and diffuse abdominal tenderness. Minor discomfort had been present in the left flank for a few days. The patient had a 3-year history of melanoma, starting in November 2008 with the removal of a forehead superficial spreading melanoma, 7 mm in diameter, Breslow thickness being 0.44 mm, with discrete lymphocytic infiltrate mainly in the surrounding tissue, without ulceration or regression. Only radicalization of local excision and follow-up were required according to the initial staging; sentinel node biopsy was therefore not performed.
In June 2011, 31 months after primary tumor excision, and 3 months before the episode of acute abdominal pain, the patient underwent an emergency orchiectomy because of the onset of acute scrotal swelling, with a pathologic diagnosis of metastatic melanoma to the testis (with an immunohistochemical profile positive for HMB-45, S-100, MART-1, and negative for pancytokeratin and inhibin). At that time, PET and CT scans showed several possible metastases, in soft tissues, gastro-intestinal tract, lungs, and brain; biopsies of masseter muscle, stomach, and duodenum confirmed the diagnosis.
The patient, after testing positive on screening for MO 255515 protein, was recruited to an experimental protocol using BRAF inhibitors and thus received a first cycle of therapy with vemurafenib at an oral dose of 960 mg twice daily. He did not undergo combined therapy with cytotoxic drugs, but received vemurafenib alone. Such experimental protocol was part of a compassionate care strategy and foresaw specific exclusion criteria, such as the presence of second malignancies, renal failure and diabetes mellitus, co-morbidities that our patient did not have. The acute abdominal event occurred 12 days after starting treatment, when the patient had assumed a

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

[User]
RADIOLOGY NOTE:
A 60-year-old female presented with swelling in the left gluteal region for the last 2 years. The patient also complained of pain in the swelling for the past 6 months. Additionally the patient gave history of pain in the left lower limb for the past month with blackening of the toes of left lower limb for the past week ().
The patient was found to be hypertensive on general examination. Fine needle aspiration cytology was attempted at a peripheral health centre, and on aspiration of blood, patient was urgently referred to our hospital.
Local examination revealed a swelling of about 6 × 6 cms in the left gluteal region. The swelling was cystic in consistency with ill-defined margins and was visibly pulsatile. Additionally, there were ischemic changes in the left lower limb with gangrene of the 1st and 2nd toes. Arterial examination revealed a cool left lower extremity with severely diminished femoral pulse, a normal popliteal pulse, and absent anterior tibial and dorsalis pedis pulse. The arterial pulses on the right side were normally palpable.
A duplex ultrasound of the left gluteal region revealed a deep-seated swelling with a marked arterial Doppler signature (see the video in the Supplementary Material available online at ). A CT angiogram was ordered. The angiogram revealed a remarkably large left internal iliac artery with fusiform aneurysmal dilatation ().
This artery was determined to be the PSA because of its continuity with the internal iliac artery, its course which was dilated and tortuous through the lateral thigh, and finally its distal run-off into the popliteal artery ().
The left superficial femoral system was hypoplastic and the superficial femoral artery ended distally in the thigh with no connection to the popliteal artery. The opposite limb had normal arterial anatomy ().
The patient underwent a femoropopliteal bypass followed by a peripheral angiography and embolization of the left PSA aneurysm. After embolization, no flows were seen in the an

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


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

[User]
RADIOLOGY NOTE:
An asymptomatic 73 year-old man with a remote history of surgically treated gastric cancer at the age of 40 presented with a 50 mm-sized mass on a chest radiography (). He had no significant familial history without any drug use nor allergic history. Chest contrast-enhanced Computed Tomography (CT) revealed an irregular homogenous mass in the anterior mediastinum, which extended along the left diaphragm without any specific enhancing effects (19–27 Hounsfield Unit) (ab). Magnetic Resonance Imaging (MRI) revealed a septate cystic lesion with a high intensity on the T2-weighted image (a). Fat-suppressed T1-weighted images revealed that the mass contained less fatty tissue (b). An invasive thymic epithelial tumor or soft tissue tumor were suspected mainly because of its location and a radiological extent, and a radical excision was planned via video assisted thoracoscopic surgery by an attending thoracic surgeon at our institute.
With the patient in the right semi lateral decubitus position, a total of 3 ports were placed on the 6th, 7th, and 8th left intercostal anterior axillary lines, respectively. Under Carbon dioxide insufflation at a pressure of 8 mmHg, the lesion was visualized adjacent to the pericardium. The lesion was also observed to have grossly invaded into the diaphragm and lower lobe of the left lung. He underwent a total tumorectomy with a combined resection of the pericardial fat, left lung, and diaphragm. Since a complete resection was achieved, no intraoperative frozen section examination was performed. The postoperative course was uneventful and the patient was discharged on the third postoperative day. The macroscopic findings of the specimen revealed a circumscribed mass embedded in the fat tissue (). The histopathological findings revealed dilated medium sized blood vessel proliferation in the adipose tissue. Those vessels were mainly muscular veins with a small number of arteries. Those findings were compatible with the diagnosis of a mediastina

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


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

[User]
RADIOLOGY NOTE:
Patient 1 is a 65-year-old female with no smoking history and rare alcohol use who presented with a left tonsillar mass, confirmed as p16+ squamous cell carcinoma (SCC). She underwent left tonsillectomy via transoral robotic surgery and left neck dissection, revealing 2/21 involved lymph nodes (largest measuring 1.3 cm) without extracapsular extension. Lymphovascular invasion was indeterminate and perineural invasion was not identified. All deep and peripheral margins were free of invasive carcinoma. The closest margin from the left tonsil resection was 0.5 mm and was associated with a deep soft tissue margin on the lateral aspect. She was staged as pT2N2bM0.
The patient received adjuvant radiation therapy of 60 Gy to the tumor bed and ipsilateral neck and 54 Gy to the contralateral neck (Figure ). Subsequently, she experienced four sequential recurrences, including three endotracheal and one lung. Each was visualized on positron emission tomography/computed tomography (PET/CT) and pathologically confirmed as p16+ SCC, strongly suggesting metastases from the original tonsillar primary. (1) Thirteen months after the initial treatment (completion of adjuvant radiation therapy), she experienced a 7 mm endotracheal metastasis just inferior to the level of the thyroid isthmus, for which 4 cm of the trachea was resected with negative margins. (2) Two years after the initial treatment, she experienced a 6 mm endotracheal metastasis just inferior to the cricoid cartilage on the left and a 3 mm endotracheal metastasis just inferior to the right vocal cord, for which she received 66 Gy (Figure ), concurrently with cetuximab, after an incomplete resection. She also received 60 Gy and 54 Gy to a small portion of the trachea extending inferiorly. (3) Two and a half years after the initial treatment, she developed a 16 mm metastatic focus in the left lower lobe of the lung and malignant left hilar adenopathy, for which she received 60 Gy via proton beam therapy (Figure ), concurr

[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 male presented to the Emergency Department with an acute episode of central left facial palsy (House–Brackmann Grade III and National Institutes of Health Stroke Scale of 9) 10 h after the symptoms onset. No other abnormalities were identified on the initial neurological exam. The MRI performed at the Emergency Department demonstrated diffusion restriction on the right globus pallidus and head of the caudate nucleus. There was no PWI/DWI mismatch at that time [Figure and ]. Twelve hours later, the patient presented with progressive worsening of the symptoms, becoming hemiplegic on the left side. The new MRI (performed approximately 22 h after the first symptoms) revealed no major extension of the diffusion restriction but did reveal significant compromise of the perfusion in the whole territory of the right MCA [], with an estimated PWI/DWI mismatch >60%. MR angiography reconstructions suggested acute occlusion of the right MCA at the M1 segment [Figure and ].
The case was presented to the endovascular team which decided to submit the patient to a digital subtraction angiography which confirmed complete occlusion of the proximal MCA []. At that point, more than 24 h had already passed from the initial symptoms onset. Given the patient's young age, the absence of major clinical morbidities, and the fact that the new MRI demonstrated a significant PWI/DWI mismatch, an interventional approach was considered. After an extensive discussion with the family about the risks and benefits of such procedure, the endovascular team decided to perform a combined mechanical thrombolysis followed by intra-arterial thrombolysis. A microcatheter was advanced until the superior trunk of the right M1, and the thrombus was removed with a clot retrieval system (Catch mechanical thrombectomy device, Balt, Montmorency/France). After the mechanical thrombolysis, rt-PA was injected super-selectively in the right M1 at an initial dose of 4U followed by two additional doses of 1U

[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 gravida five, para four woman presented for workup and management of abnormal uterine bleeding. Her past medical history was significant only for hypertension and anemia. On review of her social history, she admitted to drinking six packs of beer on the weekends but denied further substance use. She denied previous treatments for her bleeding including any previous intrauterine device usage.
Ultrasonography revealed a 7 cm fundal fibroid with otherwise normal pelvic anatomy. She was initially offered medical management of her bleeding. She declined any medical treatment and strongly desired definitive surgical treatment. She then underwent a total vaginal hysterectomy with adnexal conservation. Due to the large size of the uterus, a myomectomy was performed to facilitate vaginal removal. Her postoperative hospital course was relatively uncomplicated and she was discharged home on postoperative day three.
On postoperative day ten, she presented to the Emergency Department (ED) for fever, worsening abdominal pain, and new onset of nausea and vomiting. In the Emergency Department, she was tachycardic and tachypneic but afebrile. Her exam was significant for abdominal tenderness to minimal palpation, vaginal cuff erythema, and significant tenderness to palpation of the vaginal cuff. Lab work showed an elevated white blood cell count. She was admitted for management of presumed pelvic infection.
A CT of the abdomen and pelvis was obtained and showed a 6.2 x 9.7 cm pelvic abscess adjacent to the vaginal cuff (Figures and ).
Interventional Radiology placed a drain into the abscess and the patient was started on IV piperacillin/tazobactam. She was transitioned to oral amoxicillin/clavulanate potassium after four days on intravenous antibiotics and her drain was removed on hospital day 5. Vaginal wound cultures remained pending; however, due to continued clinical improvement on the oral antibiotic regimen, she was discharged home on hospital day 5 with a two-we

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


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

[User]
RADIOLOGY NOTE:
A previously healthy, 52-year-old Caucasian man presented to his family physician a week after having a tonic-clonic seizure. A magnetic resonance imaging (MRI) scan showed a 10 cm left frontal tumor, which was confirmed as an atypical meningioma following craniotomy and resection (Figure ).
Postoperatively, he took 400 mg of phenytoin PO once a day. He had no seizures postoperatively or afterward. The patient uneventfully received 60 Gy of adjuvant radiation therapy to the postoperative bed in 30 fractions. Three months after the resection of the tumor, the patient began a trial of phenytoin but nine days later, he developed symptoms consistent with a generalized seizure. He resumed his daily phenytoin prophylaxis with good effect.
Two months later, he complained of blood in the stool and after an evaluation was diagnosed with a locally advanced nonmetastatic adenocarcinoma of the low rectum (Figure ). A curative-intent dose of 50.4 Gy in 28 fractions of neoadjuvant radiation therapy was prescribed, with 2000 mg PO BID of concurrent radiosensitizing capecitabine []. After 20 of the planned 28 fractions, he began to feel unwell and experienced new, right-sided upper and lower limb dysfunction and an unsteady gait. A contrast-enhanced computed tomography (CT) scan of the brain showed no suspicious findings but his phenytoin level was dramatically elevated at 138 µmol/L, compared to 49 µmol/L just prior to neoadjuvant therapy (normal range: 40-80 µmol/L). His albumin level from a few weeks prior to these symptoms had also been normal at 39 g/L (normal range: 34-46 g/L), and he was taking no other medications other than an occasional stimulant laxative. Capecitabine was discontinued, and the patient was treated with charcoal and admitted for observation. Phenytoin was temporarily discontinued and then reintroduced at the previous dose of 400 mg PO per day once levels began to normalize. His symptoms quickly resolved and he showed no further

[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 presented with an incidental mass that had been firstly noticed for microscopic hematuria during evaluation of lower urinary tract symptoms. A hyperechoic cystic lesion was firstly detected with ultrasound at proximal to dilated left renal pelvis. Cystic lesion, originated from renal pelvis, containing multilocular cystic structure divided by contrasted septate, and covered with calcified wall in 7 × 6 × 6 cm size (Bosniak-IIF) was displayed on contrast-enhanced computerized tomography ().
Partial nephrectomy was planned because of suitable size in spite of location at expanding to the renal hilum. The inadvertent minimal opening on the cyst wall caused a change in the decision about operation plan as radical nephrectomy. We prevented any leakage from content of cyst during radical nephrectomy by clamping the two sides of tear on the wall.
Grossly, the tumor was a multilocular cystic mass filled with chocolate color mucinous fluid (). This morphologic appearance called to mind metastatic spread of ovarian or appendiceal mucinous neoplasia. Although this cyst had morphologically looked like mentioned possibility, patient's gender and medical history, who was male and appendectomised, were not proper to suggested theories.
Microscopically, renal parenchymal thinning, multiloculated and mucoid content, and partially papillary structures were defined in this cystic lesion. Histologically, multilayered tall columnar mucinous epithelium forming the cyst wall and resembling intestinal and endocervical epithelium, was seen gaining gradual malignancy potential with formation of glands of different sizes and shapes lined by columnar cells having hyperchromatic and pleomorphic nuclei, and eosinophilic-to-vacuolated cytoplasm (). Also nuclear atypia and stromal invasion which are characteristic features of malignant type of MC were obviously seen. Positive immunohistochemical staining with CEA, CK7, and EMA and negative staining of CK20 fortify diagnosis.
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 72 year old African American male, with past medical history of hypertension and recently diagnosed diffuse large B-cell lymphoma, was admitted to the hospital for fever and chills that started a day ago. He was discharged from the hospital two days ago on intravenous vancomycin for methicillin resistant Staphylococcus Epidermidis infection. The patient was initially admitted to a general medical floor, but his condition worsened within 24 hours and he went into septic shock and had to be transferred to the medical intensive care unit. He was hypotensive, tachycardic and tachypnic and had evidence of disseminated intravascular coagulation from sepsis. He was endotracheally intubated and placed on mechanical ventilatory support. Blood cultures grew Clostridium Difficile colitis. Appropriate antibiotics were started, and he was treated aggressively with intravenous fluids and also needed norepinephrine infusion for adequate blood pressure maintenance. He had a left subclavian central venous catheter inserted on the day of admission to the intensive care unit for administration of the vasopressor agent (Figure : Arrows show the tip of the central venous catheter abutted against the wall of superior vena cava).
The patient's condition improved and he was weaned off the norepinephrine by the third day. On the following day, patient suddenly became hypotensive. While he was being supported by aggressive resuscitative therapy, he had a chest radiograph done as part of the work up to diagnose the etiology of acute deterioration in the clinical condition. The chest radiograph showed widened mediastinum. A subsequent computed tomographic (CT) scan with intravenous contrast given through the left subclavian central venous catheter showed that the catheter had eroded through the wall of superior vena cava and there was extravasated contrast within the superior mediastinum (Figure : Computed scout image of the chest; arrows showing the extravasated contrast in the superior med

[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 4-year 7-month-old boy and his parents were referred to the Pediatric Dentistry Postgraduate Program Clinic in June 2016, requesting dental treatment due to multiple dental caries cavities, local infectious processes, and associated pain. Two years previously, the patient had been diagnosed with early infantile GS, confirmed on the analysis of the beta-GAL both in peripheral blood leucocytes and in cultured skin fibroblasts (sequencing of the CTSA gene was not carried out). Previously, the child was insufficiently treated by a pediatric dentist, due to the child's very poor level of cooperation. Only the upper right anterior segment was treated: a pulpectomy procedure on the lateral incisor and extraction of the root remnant of the central incisor. However, the patient did not continue the treatment.
Medical and dental history revealed that when the child was 1 year of age, his parents noticed the existence of a mild soft outpouching swelling in his lower abdomen, which progressively increased in size. The patient was evaluated at a local public hospital, and the condition was diagnosed as peritoneal ascites, together with three abdominal hernias, due to enlarged liver and spleen.
At the moment of the patient's first dental visit, the presence was evident of a huge abdominal growth due to ascites (). According to the treating medical team, this anomaly was unable to be surgically repaired. Because of the significant swelling, the patient had difficulty in maintaining a straightened body posture, and he could not be adequately positioned on the dental chair. In addition, the patient manifested mild mental retardation, language delay, severe bilateral hypoacusia, hepatic damage, and bilateral hydrocele (swelling in the scrotum).
The patient's head exhibited a squared form, coarse face, and short neck. The facial profile was markedly convex with an increased lower third, retrusive chin, protruding maxilla, closed nasolabial angle, and manifested lip incompetence (mou

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

[User]
RADIOLOGY NOTE:
The second case shows a 53-year-old female. Clinical and radiographic examination confirmed a unilateral posterior crossbite due a transverse maxillary deficiency with a significant mandibular skeletal deviation towards the side of the crossbite (Fig. ). Treatment objectives.
SARME was planned to correct the transverse discrepancy followed by arch leveling with lingual appliances and then a second surgery to correct the mandibular asymmetry.
Similar to case 1 impressions were obtained and this time the lingual appliances were manufactured by DW Lingual Systems (Bad Essen, Germany).
During the planning for the production of the lingual brackets, it was noted -similar to case 1- that a surgically assisted rapid maxillary expansion takes place. The transverse width of the upper jaw should be adapted to the lower jaw.
Two trans sagittal Benefit mini-implants were inserted in the T-Zone. A silicon impression with the transfer caps was taken. The impression was given to the laboratory together with the lingual molar bands. A Hybrid Hyrax [] was then made and laser welded to the molar bands (Fig. ). Similar to case 1, the lingual appliance was indirectly bonded with a dual cured resin and the maxillary expansion appliance was inserted. In this case the molar bands were cemented with a dual cured resin and the hybrid hyrax was fixed to the mini-implants using the Benefit fixation screws. The first lower arch wire 12 NiTi was inserted while in the upper the brackets were secured with a continuous steel ligature in each quadrant (Fig. ). SARME was performed with an activation rate of two quarter turns twice a day until crossbite correction was achieved at two weeks post-surgery (Fig. ). The Hybrid Hyrax was then blocked. The first upper archwire (12 NiTi) was placed four weeks after surgery (Fig. ). After complete leveling and radiographic re-examination the surgery to correct the asymmetry was performed.
The patient has

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


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

[User]
RADIOLOGY NOTE:
A 57-year-old woman presented with signs of inflammation, hardness, and lymphedema, with orange peel appearance of the skin of the right breast. A palpable mass of the right axilla preceded the breast lesion. It was gradually enlarging during a three-month period and did not respond to treatment with antibiotics. A mammography, performed when the axillary mass, was first observed, and it did not detect any abnormality in the breast, except of an enlarged lymph node in the axilla (). Her medical history included hysterectomy for a mucinous borderline tumor of the right ovary four years ago.
Initially, a clinical diagnosis of inflammatory breast carcinoma was made and an FNA of the axillary lymph nodes was first attempted elsewhere. The cytology reported bloody material with few lymphoid cells and scant atypical epithelial cells, suspicious for malignancy. Immunocytochemistry was not performed. Following blind core biopsies of the breast did not reveal malignancy. The patient refused further investigation. A month later, she complained for further enlargement of the axillary mass and mild fever. At that time, clinical examination also showed palpable ipsilateral supraclavicular lymph nodes in the right region. A subsequent computed tomography (CT) scan confirmed the enlargement of axillary and supraclavicular lymph nodes. In addition, CT revealed a lesion with ill-defined border in the right breast considered suspicious for primary malignancy, skin thickening, and lymphedema (). Her biochemical and full blood tests were within normal limits but showed an elevated red blood cell precipitation of 107 mm/h. The patient refused surgical biopsy of the axillary lymph node block; thus, she was referred to us for repeated FNA.
By ultrasound (US), we observed in the right breast a hypoechoic, partially ill-defined lesion with mild posterior acoustic enhancement, measuring 8 mm in its maximal diameter. It was classified as BIRADS 4 ().
US-guided FNA targeted the breast lesion a

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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 47-year-old female with a past history of hypertension and metastatic cervical cancer presented with abdominal distention and minimal stool output from her ostomy for two weeks duration. She described having small amounts of liquid stools which gradually decreased to the point of only mucous discharge from her ostomy. She had anorexia, abdominal cramping, and bloating with food intake, but no nausea or vomiting. Three years prior, she was diagnosed with stage IIB cervical cancer after presenting with abnormal vaginal bleeding. Her disease progressed rapidly despite chemotherapy and radiation. It was complicated by rectovaginal fistula for which she underwent laparoscopic diverting colostomy years prior to presentation. The patient had recently noted an enlarging mass near the ostomy site which was biopsied and showed metastatic adenocarcinoma of endocervical origin.
On presentation, examination revealed a soft but distended abdomen with palpable peristomal subcutaneous masses. A CT scan of the abdomen and pelvis showed a large heterogeneous mass adjacent to the colostomy with both intra-abdominal and extra-abdominal components. The mass was causing compression and partial obstruction at the level of the colostomy with significant proximal colonic dilation measuring up to 8 cm in the cecum and ascending colon (Figure ).
As a temporizing measure, a red rubber catheter was passed through the stoma to irrigate and decompress the colon. Given the extensive metastatic disease, she was not a candidate for any operative intervention, and subsequently, endoscopic stent placement was pursued.
Colonoscopy was performed under moderate sedation. Examination showed a severe stenosis 4 cm in length at the surgical stoma which was traversed with the adult colonoscope. A 25 mm x 6 cm covered self-expandable metal stent (SEMS) was successfully placed with the distal edge visible externally but not protruding beyond skin level (Figures , ).
No complications occurred during or after

[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:
Our patient is a 58-year-old male with past medical history of hypertension and distant right femur fracture who was involved in a motocross accident suffering left- (1st-12th) and right-sided (7th, 9th, and 12th) rib fractures with bilateral hemopneumothoraces requiring bilateral chest tube placements. The patient also suffered a right intertrochanteric and a peri-implant femur fracture as well as a nondisplaced ulnar styloid process fracture. The patient was transferred from an outside hospital for further care. Upon arrival the patient was remarkably asymptomatic, in normal sinus rhythm, hemodynamically and respiratory stable, maintaining an O2 saturation between 95% and 100% with minimal supplemental O2 via nasal cannula. The patient denied significant chest pain or shortness of breath despite his significant injury burden. ECG findings showed some ST wave abnormalities suggestive of early repolarization. An initial troponin level of 0.15 normalized within 24h of admission. Given the patient's injury pattern and troponin leak in the absence of known coronary artery disease (CAD), congestive heart failure (CHF) pulmonary embolism (PE), or shock, a formal TTE was obtained. TTE revealed severe tricuspid regurgitation secondary to flail anterior tricuspid valve leaflet with preserved right ventricular geometry and systolic function. The cardiac surgery team recommended outpatient follow-up for elective repair in two months with repeat TTE.
The femur fracture was repaired on hospital day two under general anesthesia and the patient recovered well. The chest tubes could be sequentially removed without recurrence of pneumothoraces over the course of the admission. On hospital day three the patient experienced an episode of atrial fibrillation with rapid ventricular response that responded well to a single 5 mg intravenous bolus of metoprolol. After a few hours the patient converted back to normal sinus rhythm, in which he remained until the day of discharge on hospital

[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 woman was screened for LFS after her 10-year-old daughter tested positive for germline TP53 gene mutation while undergoing evaluation for newly diagnosed sarcoma. She was found to carry familial heterozygous missense TP53 gene mutation in exon 7 causing nucleotide change c.733G>A with corresponding amino acid change p.G245S in the gene protein. Her two other children from the same partner, aged fourteen and four years, also carried the same mutation. Her partner did not carry the mutation and she had no family history of cancer.
Hence she was enrolled in the high-risk cancer screening program, eighteen months later, she presented with a cough with white sputum and upper back pain. Symptoms did not improve with the course of antibiotics, therefore, she underwent further evaluation. Computed tomography (CT) scan of the chest (Figure , left panel) showed a right upper lobe mass. Bronchoscopy and transbronchial biopsy of this mass were diagnostic of lung adenocarcinoma with EGFR exon 19 deletion mutation, clinical stage was T3N2M1, stage IV. Staging positron emission tomography (PET) scan revealed fluorodeoxyglucose uptake in the osteoblastic lesions involving the thoracic spine. Evaluation by neurosurgery deemed the patient not a candidate for surgical intervention, therefore she was treated with external beam radiation therapy of 30 Gray to the thoracic spine in ten fractions for impending cord compression.
As the tumor was EGFR mutated, treatment with erlotinib 150 mg by mouth once daily was recommended. Within two weeks of the treatment, she reported improvement in cough and back pain. Later, she developed flares of moderate cutaneous toxicity (as defined under international EGFR inhibitor dermatological toxicity grading system) to erlotinib. It was treated with the periodic use of topical corticosteroids, topical urea, and two-week courses of doxycycline 100 mg capsules twice daily. Besides cutaneous toxicity, she had no other significant adverse effe

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


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

[User]
RADIOLOGY NOTE:
A 39-year-old man was involved in a high-velocity motor vehicle accident. He sustained an open fracture of the right elbow, with significant loss of the external humeral condyle and partial loss of the olecranon. This fracture was classified as a Gustillo type IIIA injury. There was no neurovascular compromise. The patient was treated in a community center, close to the accident, where he received surgical care (debridement and partial excision of the olecranon). The wound was fully closed. The upper arm was then immobilized in a splint (). IV antibiotics (cefazolin-gentamicin) were started for 5 days.
The day following his elbow surgery, the patient fell in a staircase and sustained a C7-C8 and C8-T1 fracture-dislocation. This injury caused neurologic damage (quadriparesis), and his right arm became his only functional limb. Following this injury, the patient was moved to our tertiary center to get spinal fusion. During the spinal surgery, the elbow was tested under fluoroscopy. The patient's elbow showed varus instability and a positive pivot shift test. A CT scan of the elbow was obtained the following day and showed bony loss from the external humeral condyle and subluxation of the radial head ().
We decided to treat the patient's elbow surgically. The surgery underwent nine days after the initial trauma (after transfer from the community center, spine procedure and elbow imaging). A posterior approach to the elbow was used along with an extensive elbow debridement. A tricortical iliac crest graft was then collected from the patient's right side to replace the humeral condyle bone loss. A tendinous graft was collected from his third and fourth extensor digitorum longus tendons to reconstruct the lateral collateral ligament. The tendinous graft was fixed to the bone graft through two tunnels (anterior to posterior and lateral to medial). The iliac crest graft was then fixed to the humerus with a cancellous screw. A five-

[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 first patient is a 58-year-old man who was a previous smoker who presented to an outside hospital with abdominal pain and was diagnosed with gallstone pancreatitis. However, despite having a laparoscopic cholecystectomy, he continued to have episodes of pancreatitis yearly for the next 3 years. Computed tomography (CT) scan demonstrated a pancreatic duct dilated throughout its course to a maximum size of 8 mm without a discrete pancreatic mass in the head of the pancreas. Endoscopic retrograde cholangiopancreatography confirmed a dilated pancreatic duct with a suspected filling defect of the common bile duct, after which the patient underwent sphincterotomy and stent placement.
He then presented to our institution for consultation. Further workup with endoscopic ultrasound (EUS) was performed, which also confirmed the dilated pancreatic duct, but noted irregular contour of the duct. In addition, free mucin was seen exiting the main papilla, and there was a papillary growth noted in the pancreatic duct in the head of the pancreas, all of which was consistent with a main duct IPMN (). Preoperative laboratory values, including CA19-9, were within normal limits. Of note, it was unclear if the dilatation of the pancreatic duct was secondary to obstruction from the mass in the pancreatic head or due to main duct IPMN involving the entirety of the duct.
He was scheduled for surgical resection after the stated workup. He was planned for a Whipple procedure (pancreaticoduodenectomy) with possible total pancreatectomy if intraoperatively the main duct was found to be involved by IPMN with high-grade dysplasia. Transection of the pancreatic neck identified cells of high-grade dysplasia free floating near the margin (although exclusive of the margin). In addition, upon probing the pancreatic duct in the tail of the pancreas, the probe did not slide smoothly, suggestive of additional growths in the duct. Due to his young age and high risk of developing pancreatic cancer, a c

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


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

[User]
RADIOLOGY NOTE:
A diabetic 90 years old woman with cough and diffuse abdominal pain was admitted into our hospital with an initial diagnosis of sepsis. Blood sample investigation revealed mild leucocytosis with PRC augmentation and normal AST, ALT and bilirubin levels. Preoperative ultrasound revealed thickened gallbladder wall suggestive of acute cholecystitis. She has had previous sigmoid resection for diverticulitis and ERCP for choledocholithiasis without any mention of biliary abnormality. She was scheduled for a laparoscopic cholecystectomy during which the incidental intraoperative finding of a left sided gallbladder was made. Standard trocar positions were used (A) without any variation of technique, simply following the Strasberg criteria for safe cholecystectomy []. Having seen the anatomical variation (B), a careful dissection of Calot’s triangle was carried out, the cystic duct and artery were identified and isolated, and subsequent complete dissection of the gallbladder from the liver was done (C). This manoeuvre allowed us to demonstrate a right sided positioning of the cystic duct. Furthermore, a safe clipping and transection of the cystic duct and artery was achieved (D), and the gallbladder was extracted in an endobag. The postoperative course was complicated by an aggravation of diabetes and basal pneumonia which were controlled postoperatively in the intensive unit. The patient was discharged on postoperative day 16, in good condition. Retrospective analysis of the clinical case was done and a previous CT scan was reevaluated. Even with the knowledge of a left sided gallbladder, the CT scan was unable to demonstrate its attachment to the left side of the liver. This was probably due to the presence of a hypertrophic left lobe mimicking only a contiguity with the gallbladder, which itself appeared to be in a physiological position (). A vascular and biliary reconstruction was then evaluated with evidence of agenesis of the right anterior sector of the liver () wit

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


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

[User]
RADIOLOGY NOTE:
A 48-year-old woman was referred to our hospital because of upper abdominal pain. Her medical and family histories were unremarkable, and her abdomen was soft, with no palpable mass. Laboratory investigation revealed slight leukocytosis (white blood cell count 10 280/μl), but other data, including the serum concentrations of tumor markers, immunoglobulin (Ig) G and IgG4, and pancreatic hormones (gastrin, insulin, glucagon, somatostatin, and pancreatic peptide) were all within their normal ranges.
Abdominal-enhanced computed tomography (CT) revealed a low-density pancreatic body tumor of 25 mm in diameter, which was close to the gastroduodenal artery (GDA), and was accompanied by atrophy of the distal pancreatic parenchyma and dilation of the upstream MPD (). Moreover, CT imaging of the portal phase revealed a filling defect within the splenic vein where it was in contact with the tumor (). On magnetic resonance imaging, the tumor appeared as an area of signal hyperintensity on T2-weighted and diffusion-weighted images (). On positron emission tomography-CT scan, the tumor exhibited greater uptake of 18F-fluorodeoxyglucose (). Although a definitive preoperative diagnosis could not be made, we suspected pancreatic ductal adenocarcinoma, and distal pancreatectomy with lymph node dissection was scheduled, without neoadjuvant chemotherapy, after obtaining consent from the patient. The pancreas was divided along the left edge of the GDA after mobilization of the artery; however, pathological examination of a frozen section of the pancreas stump was positive for PNET, and therefore a total pancreatectomy was performed (). The duration of surgery was 610 min, the intraoperative blood loss was 195 mL, and blood transfusion was not performed.
The gross appearance of the resected specimen was of a white, solid, nodular tumor measuring 25 × 15 mm, which was located in the pancreatic body, with spread into the MPD and protrusion into the splenic vein (). Microscopically, the tum

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


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

[User]
RADIOLOGY NOTE:
A 32-year-old man presented with colicky abdominal pain in the left lower quadrant for 2 weeks duration. He had a significant weight loss of approximately 30 kg over 2 months associated with decreased appetite. He also has a history of chronic alcoholism and smoking. There was no associated nausea, vomiting, hematemesis, melena, or hematochezia. Review of symptoms was negative for fever, arthritis, skin rash, jaundice, and pruritus. Two months prior, the patient was discharged from another hospital following a 6-week hospitalization for alcohol-induced necrotizing acute pancreatitis, which was treated successfully by conservative measures. Admission vitals revealed an afebrile and normotensive patient with a heart rate of 92 beats per minute and oxygen saturation of 98% on room air. On physical examination, the abdomen was soft with mild tenderness to deep palpation in the left iliac fossa and lumbar region. There were no signs of peritonitis. Laboratory results and abdominal sonogram showed no significant findings. Abdominal CT scan from the episode of acute pancreatitis 2 months ago showed findings consistent with necrotizing acute pancreatitis ().
A colonoscopy was done because of the abdominal pain and significant weight loss. The scope revealed ulceration with a partial stricture at the descending colon approximately 30 cm from the anal verge (). However, the scope could not be navigated beyond the stricture. Controlled radial expansion balloon dilatation was tried without success in dilating the stricture.
Due to tuberculosis (TB) being a possible differential diagnosis, a workup for TB was warranted. This included sputum for acid-fast bacillus, chest X-ray, purified protein derivative test, erythrocyte sedimentation rate, and pathological examination, all of which were negative for TB. Biopsy of the lesion revealed active focal colitis with ulceration, but no granulomas were seen. Barium enema and CT colonoscopy were done to assess the length of the stricture

[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 37 year-old patient from a small town in northern Italy, was welding when he was hit by a spray of liquid metal on the periorbital region that burned the upper eyelid and part of the lower eyelid. The patient was treated by eye-specialists at the local hospital with multiple debridements of the palpebral lesions, that take several weeks to heal, save for the complete loss of the upper eyelid, albeit partially maintaining the medial and lateral canthus, along with a loss of the ciliary margin of the entire lower eyelid. In the weeks which followed, the inflammation of the eyeball, which was undamaged by the metal but irritated due to a lack of palpebral protection, worsened further, partially compromising the eye's functionality. So, surgery was scheduled to reconstruct the eyelid in a single operation, because of the distance the patient had to travel, which would also provide satisfactory functional and aesthetic results. The patient was operated on to reconstruct the entire upper eyelid using, as a posterior lamella, a mucochondrial autologous graft taken from the ala of the nose as a tarsus and conjunctiva substitutes that were sutured to the levator palpebrae
superioris aponeurosis and muscle. On the other hand, to reconstruct the anterior lamella, which consists of skin and muscle, the surgeons used a myocutaneous temporal flap taken from the region immediately lateral to the external canthus of the palpebral region, and which, after being isolated following a drawing of the upper eyelid to be reconstructed (Fig. ), was rotated and then sutured to the posterior lamella using the orbicularis oculi muscle as a pedicle. The donor area was closed, following the ample undermining of the edges, with a linear scar (hardly noticeable) on the temporal area. The incision performed on the lower palpebral rim, necessary for the preparation of the orbicularis muscle as a myocutaneous temporal flap

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


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

[User]
RADIOLOGY NOTE:
A 30-year-old woman noted an increase in weight of 20 kg during her second pregnancy, which was delivered by cesarean. Her postpartum weight decreased by 17 kg, but she noted persistent abdominal bulging. Computed tomography showed a separation of the rectus abdominis at the site of the abdominal wall scar. The patient presented to us desiring cosmetic improvement. Her history was significant for a 20 kg weight gain with her first pregnancy, but she had no subsequent abdominal distension. Her medical history was otherwise unremarkable.
A 5 cm vertical surgical scar was noted to extend distally from the umbilicus. The abdomen bulged outward from the level of the lower sternum to below the umbilical fossa (), and a 15 cm separation of rectus abdominis was palpated both above and below the umbilical fossa. Computed tomography showed the midline separation of the rectus abdominis muscle around the navel. The rectus abdominis fascia was maintained, and there was no extrusion of abdominal contents. The inter-recti distance (IRD) was 36 mm at 3 cm above the superior border of the umbilicus, 40 mm at the center of the umbilicus, and 36 mm at 2 cm below the inferior border of the umbilicus ().
Surgery was performed under general anesthesia. An abdominal midline incision was made on the cesarean scar, and the linea alba was noted to be thinned and being pulled to the left and right sides of the abdomen. The rectus abdominis muscle was separated horizontally. The anterior rectus sheath was sutured in the midline using nonabsorbable suture without the performance of the midline incision on the anterior sheath, and a high-density polyethylene mesh was applied to the linea alba and rectus abdominis muscle. Attention was then turned to the excess skin and subcutaneous adipose tissue, including the pigmented portion of skin. A spindle-shaped incision was used to excise this tissue, with the spindle measuring 15 cm in the horizontal direction (

[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 Caucasian female had a past medical history significant for bilateral fibrocystic breast disease resulting in bilateral subcutaneous mastectomy, followed by bilateral cosmetic breast reconstruction with textured silicone gel implants at age 30 (). Subsequently, she had multiple complications from the implants including capsule contractures, infections, chronic seroma, and ruptured breast implants, leading to capsulectomy and implant replacements 15 and 22 years post original implantation. During these periods, the patient was noted to have several areas of calcifications in both breasts (L > R) that had been monitored with routine mammography. The patient noted that at 30 years post original implantation, her left breast became edematous; however, this self-resolved a few months later. Two years later, edema was noted again in the left breast and confirmed by MRI ()], resulting in a third replacement of the silicone gel implant. Recently, at 35 years post original surgery, the patient presented with swelling in the left breast which progressively worsened over 2–3 months. A targeted ultrasound examination of the left breast at the approximate twelve o'clock position, left axilla, and of the right breast at the ten o'clock position over areas of concern demonstrated no discrete cystic or solid abnormalities (). Unremarkable parenchyma was observed throughout the entire region. However, given the extent of edema in the left breast and associated pain, bilateral total capsulectomy was performed for a fourth time.
Breast tissue obtained during surgery was sent for pathologic evaluation. The left capsulectomy specimen revealed a thickened fibrous capsule with chronic inflammation, consisting of small lymphocytes, eosinophils, plasma cells, and macrophages. The luminal surface of the breast capsule showed fibrin deposition with a thin row of highly atypical cells. The atypical cells were large and pleomorphic, with hyperchromatic nuclei and occasional promin

[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 58-year-old man, on treatment for hypertension, who was admitted to a vascular surgery service because of an incidental finding of two aneurysms of the SMA, identified during preoperative imaging exams preparatory to repair of an incisional hernia. The patient had no abdominal symptoms and on physical examination his abdomen was flaccid and painless and with a pulsating mobile mass in the epigastrium. Abdominal ultrasonography indicated a partially thrombosed saccular aneurysm in the retroperitoneal space, with no communication with the aorta. Multislice angiotomography revealed two aneurysms of the SMA, a proximal one measuring 5.9 × 5.2 × 5.0 cm and a distal one measuring 5.3 × 3.5 × 3.2 cm (
 ). Since multiple collateral branches emerged from both aneurysm bodies, which meant the endovascular treatment would have involved a risk of damaging the intestinal blood supply, the decision was taken to perform open surgical repair. During the operation, by explorative laparotomy, access to the retroperitoneal space was achieved after performing the Cattell-Braasch maneuver, with medial displacement of the ascending colon and part of the transverse colon, exposing the infrarenal aorta and its branches. This revealed two true aneurysms of the SMA, the larger of which was around 3 cm from the arterial ostium and the smaller approximately 2 cm from the end of the first ( ). It was also possible to observe collateral branches (right colic, ileocolic, jejunal artery, and ileal arteries) projecting from the bodies of these aneurysms. A mesenteric-mesenteric, end-to-end bypass was therefore constructed, using a dacron prosthetic graft, excluding both aneurysms but preserving branches distal of the proximal aneurysm. It was decided to ligate and resect the aneurysms – sending specimens for cultures – and their lumens were opened, revealing large quantities of intraluminal thrombi ( ). Inspection of the abdominal cavity found the intestines to be viable and free

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


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

[User]
RADIOLOGY NOTE:
A 37-year-old male was seen in the outpatient clinic because of weight loss, fatigue, and abdominal discomfort. Current height was 175 cm, weight 67 kg, with an unintended weight loss of 6 kg over the last few months. There had been symptoms of fatigue, which the patient attributed to increased workload. The abdominal discomfort included distention without pain or nausea. There were normal and unchanged stools and no icterus.
The patient had no other symptoms at presentation and showed a good performance status. At age 8, he had been diagnosed with right-sided WT with metastases to lymph nodes and lungs, and with thrombosis of the inferior vena cava and right renal vein. He was treated with intended curative right-sided nephrectomy and thrombosis evacuation, in combination with adjuvant radiation and chemotherapy. He received chemotherapy pre- and postoperatively with dactinomycin, actinomycin D, and vincristine, and 20 cycles with 30 Gy of radiation treatment to the right side of the abdomen for lymph node metastases. There was a cover over a large portion of the right lobe of the liver.
The patient had mildly elevated liver enzymes during the pre- and postoperative chemotherapy, with a maximum ASAT at 224 U/L (10–40), an elevated alkaline phosphatase level between 350 and 650 U/L (80–250), with persistent normal γ-glutamyltransferase.
The liver enzymes normalized after the end of treatment. There was no evidence of hepatomegaly, jaundice, ascites or liver pain during the 10 years of follow-up after radiation and chemotherapy. Follow-up included periodically clinical evaluation, blood tests, whole-body CT scan, ultrasound of the abdomen, and a plain thoracic X-ray. Blood tests were normal apart from a moderate thrombocytopenia at 90–125 × 109/L (150–450). Radiographically, there were venous collaterals at the level of the previous inferior vena cava thrombosis. In addition, ultrasound showed slowly progressive splenomegaly to 16 cm developing over the years, 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:
The patient was a 63-year-old woman who was seen by a local physician for pain in the epigastric region that started back in December 2006. An abdominal CT scan revealed pancreatic cystic lesions and pancreatic duct dilatation, and the patient was referred to our hospital for further examination on December 27. The patient had a history of hyperlipidemia for which she was being treated, but no history of pancreatitis or abdominal trauma, and no notable family history. The patient did not smoke or drink alcohol. Examination results on admission were as follows: height, 157 cm, weight, 40 kg, and body temperature 37.2°C. The patient was alert and her abdomen was soft and flat with no palpable masses. The patient had tenderness in the epigastrium but no rebound or guarding.
Her blood chemistry revealed a slight elevation of the pancreatic enzymes amylase and elastase 1. While no other evidence of inflammation could suggest active pancreatitis, a slight elevation of the tumor marker CA19-9 was detected.
Abdominal ultrasonography (US) revealed a multilocular cystic lesion of 45 mm in length with node-like projections in the body of the pancreas. The main pancreatic duct was noticeably dilated from the body to the tail. The pancreatic parenchyma was overall atrophic, and her echogenicity was moderate. Comorbidity with chronic pancreatitis was suspected. An abdominal CT revealed a cystic lesion with a relatively thick septum-like structure in the body of the pancreas. A solid component with slight contrast enhancement was noted inside the cyst. Magnetic resonance cholangiopancreatography revealed a multilocular cystic lesion in the body of the pancreas, and continuity with the main pancreatic duct that was slightly dilated more distally was suspected (fig. ). Endoscopic US revealed a multilocular cystic lesion (26 mm long) in the body of the pancreas. A dilated main pancreatic duct communicating with this lesion was noted. There were extensive node-like raised lesions 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 40-year-old male presented to our office in 2017 complaining of chronic left knee pain. This was his first visit to this office and was establishing care after moving to the area. The patient's electronic medical record was obtained from an outside institution which indicated a past medical history of diabetes, hyperlipidemia, and hereditary multiple exostosis. The patient disclosed that he had multiple osteochondroma removal surgeries which included his left knee, lumbar spine, and left foot at an outside institution. In addition, he had a left hip arthroplasty with refractory numbness/tingling of the leg. The patient stated he had left knee pain for years until he had an osteochondroma removed in his left distal femur in 2016 which seemed to help for 6 months. He stated the pain returned at 7/10 and is worse with movements. He had limited range of motion with 70° of flexion, negative pain with varus and valgus movement, and negative secondary tests. Baseline X-rays were ordered for this patient's knee ().
There were osteoarthritic changes with significant osteochondroma formation; however, arthroplasty was not recommended at that time because of the patient's young age and his left lower extremity being distally neurovascular intact. The patient was adamant about having his knee replaced and was referred to a specialist at an outside institution where an arthroplasty of the left knee was performed. The patient returned 3 months later with continued limited active and passive range of motion (<90° flexion). Follow-up radiographs were ordered showing good alignment of a Smith & Nephew posterior stabilized prosthesis without subsidence (). It was decided to perform manipulation under anesthesia followed by 6 weeks of physical therapy which improved his range of motion to 110° flexion.
The patient continues to have limited range of motion of his left knee with flexion to 90°. The large posteriorly projecting osteochondroma of his left tibia continues to be asymptoma

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


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

[User]
RADIOLOGY NOTE:
A 50-year-old male presented with complaints of chronic, intermittent abdominal pain. The patient had a 20-year history of mild-to-moderate amount of alcohol consumption. There was no history of jaundice, fever or weight loss. His laboratory tests revealed no significant abnormal findings. Serum amylase and lipase, and tumour markers [CA 19-9, carcinoembryonic antigen (CEA)] were within normal limits. The patient was subjected to a CT examination. On unenhanced CT image, a poorly defined soft tissue mass was seen in the pancreaticoduodenal (PD) groove with a hypodense cystic lesion within the mass (). On post-contrast study, the lesion showed minimal enhancement in the portal venous phase ( and ), but delayed imaging at 2–3 min showed mild persistent enhancement of the lesion compared with the pancreatic parenchyma that was consistent with scar tissue () and a non-enhancing cystic lesion within the lesion. The lesion showed poorly defined fat planes with the adjacent second part of the duodenum on its right side and pancreatic head on the left side. Mild thickening of the wall of the second part of the duodenum adjacent to the lesion with variable luminal narrowing was noted. The common bile and pancreatic ducts appeared grossly normal. The pancreatic body and tail were normal. In order to clearly delineate the ductal system and the periampullary region, and to know the extension of the lesion, the patient was also subjected to an MRI examination. Axial two-dimensional fast imaging employing steady-state acquisition () sequences showed soft tissue signal intensity lesion in the PD groove with a cystic lesion within the lesion and the aforementioned CT scan findings. MR cholangiopancreatography sequence () revealed smooth and regular tapering of the pancreatic and common bile ducts. The gallbladder was distended and the cystic duct was normal. Incidentally, a few simple cysts (Bosniak 1) were noted in both the kidneys. The patient was advised further surgical interve

[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 67-year-old Caucasian man presented to the emergency room because of a 4 days’ history of abdominal pain, with one episode of vomiting.
The patient’s past medical history was significant for colonic diverticulosis and an episode of gastrointestinal bleeding one year before. The event had been investigated by two different gastroscopies, a colonoscopy and a MDCT, which produced inconclusive results. Ten months later he was newly admitted because of abdominal pain and fever at 38.0 C°, with valid urination and defecation. A CT of the abdomen was performed, which confirmed the colonic diverticulosis and revealed the presence of multiple diverticula of the small intestine, fat stranding, signs of inflammation as well as a small amount of free liquid in the abdomen. The patient was hence diagnosed with jejunal diverticulitis and managed conservatively with intra-venous antibiotics, with an apparent complete recovery.
He re-presented to the emergency department two months later with acute abdominal pain. The pain was described as severe and constant, localized mainly in the lower abdomen with clinical signs of peritonitis. No change in bowel habits nor urinary symptoms were complained. His vital signs were stable, with a temperature of 37.2 C°; he appeared fully oriented and not in any acute distress. Laboratory examination reported a hemoglobin of 121 g/dL, a WBC count of 12.2 × 10E9/L and a CRP of 249 mg/L. Other laboratory data were within normal limit. An abdominal and pelvic contrast-enhanced computed tomography, with administration of oral contrast, was performed. Jejunum and ileum showed several diverticula as well as an inflammatory thick-walled mass involving different loops of the intestine. In addition, free fluid in the abdomen and a small amount of subdiaphragmatic air were reported (, ). On the basis of these findings, the diagnosis of perforated diverticulitis was hereby proposed.
The patient underwent a diagnostic laparoscopy which revealed plenty of pur

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


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

[User]
RADIOLOGY NOTE:
A 39-year-old Asian male presented to our department with a chief complaint of a painless swelling involving the left lateral border of the tongue. History revealed that the growth began as a pea-sized nodule and gradually increased in size to its present state over a period of 4 months.
The past medical history did not reveal any cardiovascular, respiratory, genitourinary, gastrointestinal, endocrine, haematological, neurological, or any other medical history of relevance. The past dental or familial history was not of any consequence to our particular case. A complete blood count was performed and no abnormality was detected. No history of trauma, bleeding, pain, or paresthesia was present. There were no signs of any cervical lymphadenopathy noted. Orthopantomographic examination did not reveal any bony abnormalities. Extraoral examination revealed multiple soft cutaneous nodules involving either side of the face, back, trunk, and the lower and upper extremities. They were round to oval in shape and were of various sizes ranging from a few millimetres to centimetres across. On palpation they were found to be sessile and some pedunculated also, soft to firm in consistency, nontender, and noncompressible and showed no signs of fixity. Around 15 café au lait (coffee in milk) macules were present over 15 mm in diameter throughout the body with increased prevalence in the back and trunk. The largest one among these was located over the right arm measuring a whopping 22 × 13 cm across with smooth borders. It was roughly ovoid in shape and there was a brownish macule with long thick dark hair involving the surface of the lesion and it extended from the acromioclavicular joint all the way down to the upper arm (). The distribution of the lesion did not follow the lines of Blaschko. Rubbing the affected area exhibited a pseudo-Darier sign which consisted of a transient piloerection. Neither axillary freckling (C

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


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

[User]
RADIOLOGY NOTE:
A 52-year-old previously healthy man with an 11-year history of recurrent, bilateral carpal tunnel syndrome presented with a 22-month history of severe NP in his right hand. The same condition was present on the left side, although to a lesser degree.
The patient had undergone multiple decompressive surgeries (two on the left side, three on the right) during the 11 years prior to the presentation. After each operation, he experienced symptom relief lasting from 6 to 9 months, followed by gradual recurrence. His last operation on his right wrist, 30 months prior to presentation, resulted in roughly 8 months of pain relief. Further surgical intervention was not recommended on pain recurrence. Various treatments were tried without satisfactory pain relief (see ). The pain was eventually deemed chronic and treatment refractory.
The patient described the pain as constantly present, with intensity usually ranging between 5 and 8 on a 0–10 Numeric Rating Scale (NRS). The pain was located primarily distal to the wrists, in the area of median nerve innervation. Although there were both pain and sensory symptoms beyond this, both in the hand and lower forearm, he did not describe it as radiating. The pain was associated with numbness, tingling and prickling sensations. The most striking and clinically debilitating aspect of the patient’s pain was the degree to which it was aggravated by cold, in terms of both cold allodynia and the effect of ambient temperature. He scored 22/38 on the PainDETECT questionnaire, indicating >90% probability that the pain had a neuropathic component.
MRI of the right wrist revealed scar tissue in close proximity to the median nerve. Neurological examination found cold and light touch allodynia as well as decreased sensation distal to the wrist scars in both hands. These findings included but also went beyond the distribution of the median nerves. Findings were similar on both sides, but more severe on the right. Neurography confirmed damage to th

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


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

[User]
RADIOLOGY NOTE:
A 24-year-old female presented to our outpatient department with complaints of foreign body sensation of the throat for the last 1 year. She also complained of change in voice for the past 4 months. She had no associated history of dysphagia or difficulty in breathing. On examination there was a 3 × 3 cm smooth, grayish-white, firm, nontender swelling in the right side of base of tongue occupying the oropharynx (). No cervical lymph nodes were palpable in the neck. Rest of examination of the ear, nose, and neck, as well as general physical examination, was unremarkable.
Contrast-enhanced computed tomography of the neck revealed a well-defined moderately enhancing soft tissue lesion involving the right side of base of tongue nearly 2.34 × 2.29 cm in size which was compromising the oropharyngeal airway. The thyroid gland was normally located in the anterior neck (). Transoral fine needle aspiration cytology from the swelling was done which showed scattered cohesive clusters of epithelial cells surrounded by hyaline material. There was mild hyperchromasia and scattered squamous cells in background. Overall features suggested the possibility of pleomorphic adenoma.
The patient was taken up for surgical excision. Tracheostomy was done prior to the procedure. A midline glossotomy was performed and deepened until the tumor was palpable. The lateral surface of the tumor was palpated and dissected using electrocautery. This approach provided an end on view to the lateral and inferior aspects of the tumor. The tumor was removed in toto with a cuff of normal tissue. The wound was sutured vertically in the midline from vallecula to tip of tongue (). Patient was started on oral feeding on the first postoperative day and was decannulated on the 5th day.
Postoperative histopathology confirmed the diagnosis of pleomorphic adenoma with focal area of skeletal muscle involvement ().
A postoperative computed tomography was done after 2 months of the operation which showed complete remo

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


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

[User]
RADIOLOGY NOTE:
A 36-year-old woman with gravida 0 had a history of infertility and clinical diagnosis of polycystic ovarian disease since the age of 22. Her menstrual cycles were irregular with oligomenorrhea and menometrorrhagia.
She had received 3 cycles of clomiphene citrate and 2 cycles of ovulation induction (OI) and artificial insemination before the in vitro fertilization (IVF) attempts. She was administered the luteal long gonadotropin releasing hormone (GnRH) protocol in the first and second attempts and the GnRH antagonist protocol in the third attempt. In the last IVF treatment cycle, 5 oocytes were yielded and two good quality embryos were transferred on day 3.
The patient was admitted to our clinic due to abnormal vaginal bleeding, whose last menstrual period was 5 weeks earlier following the third IVF attempt. She was 150 cm in height and 64 kg in weight with a body mass index of 28.4 kg/m2 who was found to be normotensive on physical examination. She had no remarkable abdominal or pelvic pain and no tenderness on abdominal examination. Vaginal spotting was observed in speculum examination. Complete blood cell count, urinalysis, and coagulation values were within normal limits. The blood chorionic gonadotropin (βhCG) level was 2226 mIU/mL. Endovaginal ultrasonography revealed irregular lining of endometrium with 21 mm thickness, enlarged diameters of bilateral ovaries with multiple corpus luteomas, and minimal free fluid at the Douglas pouch. The patient was monitored for βhCG elevation. Two days after the first evaluation of the patient, the endometrial thickness slightly increased giving the pseudogestational sac appearance. Imaging revealed increased free fluid at 33 mm depth and a suspicious mass in the right adnexal region adherent to the ovary which was giving the impression of ectopic pregnancy. The blood βhCG level was elevated to 4406 mIU/mL. A dilatation and curettage was performed after the administration of methotrexate (50 mg/m2) for excluding the hetero

[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 Tunisian woman, with no past medical history, was admitted for a pelvic mass. She had no associated history of vomiting, fever, jaundice or weight loss. On physical examination, the patient was anicteric and afebrile. The abdominal palpation found a bloating in the right iliac fossa. Her gynecological examination showed a right pelvic mass in the recto-uterine pouch. Her blood tests were normal. The abdominal ultrasound revealed a suspicious cystic mass of 9 cm in diameter, located at the right side of the uterus. The right ovary was not seen. The thoracic-abdominal pelvic scan showed a heterogeneous right lateral rectal mass of 9 cm.
Tumor markers, including CA 125, alpha fetoprotein, Beta human chorionic gonadotropin (hCG) hormone, carcinoembryonic antigen (CEA) and CA19–9 were tested and found within the normal range. With nonspecific signs and symptoms, wide radiological image findings, an anatomical contiguity, and the absence of a clinical history of a previous hepatic echinococcal cyst, a preoperative diagnosis of pelvic tumor was suggested.
Our patient was scheduled for an exploratory laparotomy. Three cystic masses were observed intra-operatively: the first one was 4.5 cm in diameter and was closely located to the appendix; the second one measured 2 cm in diameter and was attached to the uterovesical pouch; and the third cyst was of 6 cm in diameter, and was detected laterally to the right of the rectum. The rest of the abdominal cavity was normal.
An appendectomy and a complete resection of the cysts were conducted. The frozen section showed the presence of hydatic cysts, which were later confirmed by the histopathological examination. The operation ended with peritoneal cleansing with a hypertonic saline solution. Our patient had an uncomplicated postoperative course and was discharged from the hospital on the third postoperative day.
Our patient was then referred to a general surgery department to undergo an appropriate follow-up. We also 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 72-year-old African American male presented to the emergency department from the outpatient oncology office with a week of mild abdominal pain, which was not life-threatening. His past medical history was notable for metastatic pancreatic adenocarcinoma, which had been diagnosed one year earlier, from endoscopic retrograde cholangiopancreatography (ERCP) brushings when he presented with obstructive jaundice and required biliary and duodenal stent placement at the time. He had undergone a routine CT scan of his abdomen and pelvis for disease progression two days prior to admission, which revealed a massive pneumoperitoneum (Figures , ). The ominous imaging prompted his admission to the hospital. On presentation to the emergency department, he was in no distress with a blood pressure of 126/85 mm Hg, pulse rate of 93 beats per minute, respiration rate of 18 breaths per minute, and a temperature of 36.9° C. Physical examination was significant for marked abdominal distension with a benign non-peritonitic exam and mild tenderness on palpation. Laboratory tests were unremarkable, except for a white blood cell count of 10.5 x 103/uL with neutrophil predominance (83%). A repeat CT scan showed patent biliary and duodenal stents without a definite source of perforation; however, three suspicious locations were noted by the radiologist containing small foci of free air adjacent to the bowel.
Given the initial concern for perforated viscus, the patient was started on broad-spectrum antibiotics and antifungals. He was managed conservatively with intravenous hydration and strict bowel rest. He remained hemodynamically stable and non-septic throughout his hospitalization and continued to have flatus and intact gastrointestinal function. General surgery recommended no acute surgical intervention. In a few days, he was started on a clear liquid diet which he tolerated well. His abdominal distension gradually improved without any surgical intervention, and he was discharged home 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:
The patient, a 53-year-old female, was admitted to the hospital on April 05, 2019 in a car accident resulting in a fracture of the distal left tibiofibula, and was given routine heel traction and symptomatic treatment to reduce swelling after admission. On April 18, 2019, we performed “tibiofibular fracture incision and internal fixation + bone grafting,” after which we were given symptomatic treatment for swelling and pain relief. He was discharged from the hospital on May 16, 2019, and at the time of discharge there was still about 3 cm of poorly healed skin and localized redness and swelling in the lower and middle sections of the left ankle incision, and then continued to have the left ankle dressing changed at the local community hospital, and the wound never healed. One year after the operation, he was readmitted to the hospital for rehabilitation.
A follow-up X-ray showed that the metal internal fixation of the left inferior tibiofibular fracture was in place, no loosening was seen, the alignment of the severed end was acceptable, and the left inferior tibial segment was mildly osseointegrated (Fig. ).
On examination: the left ankle incision was interrupted for about 3 cm with poor healing, a small amount of muscle necrosis, fat liquefaction, a large amount of yellow purulent secretion overflow and necrotic material was seen in the local wound. The wound did not improve after routine dressing changes.
PRF gel preparation and application the preparation process was strictly aseptic: - A disposable screw-in 20 mL syringe with an 18G needle was used to draw 20 mL of autologous blood under strict aseptic conditions, and the screw-in syringe was tightened with a disposable plug, and the posterior projection and tail were cut off. Weigh, level, and centrifuge at 3000 r/min for 10 minutes. After resting, the blood sample was divided into 3 layers, the upper layer of yellowish clarified liquid was platelet plasma,

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


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

[User]
RADIOLOGY NOTE:
We present the case of a 42-year-old man who presented to the emergency department with a complaint of abdominal pain and diarrhea for 3 days. The abdominal pain started in the periumbilical region and was shifted to the right lower quadrant of the abdomen. The pain started gradually and had been progressing in severity. He described the pain as a stabbing in nature. It was exacerbated by movement and food intake. The pain was partially relieved by oral analgesic medications like paracetamol. The pain was associated with low-grade fever and decreased appetite. The patient also complained of diarrhea with five bowel motions/day. The stools were watery with no mucus or blood. He reported that diarrhea developed after he received an oral antibiotic therapy (cefuroxime) for a recent upper respiratory tract infection.
The past medical history of the patient was remarkable for diabetes mellitus that was well-controlled with oral antidiabetic agents. He did not undergo any previous abdominal surgeries. He had a smoking history of 15 pack-years. He had never drunk alcohol before. He worked as a taxi driver. The family history was unremarkable for any inherited gastrointestinal disorders.
Upon examination, the patient appeared sick. He was not pale, jaundiced, or cyanosed. Vital signs revealed tachycardia (115 bpm), low-grade fever (37.5℃), normal respiratory rate (14 bpm), and maintained blood pressure (122/80 mmHg). The oxygen saturation was 99% on room air. Abdominal examination revealed a soft abdomen with diffuse tenderness. However, the tenderness was more pronounced in the right iliac fossa with a positive rebound sign. Further, the Rovsing sign was positive. Initial laboratory investigation revealed elevated leukocyte count and elevated inflammatory markers, including erythrocyte sedimentation rate and C-reactive protein. The renal and hepatic profiles were within the normal limits (Table ).
In light of the aforementioned clinical information, the patient was diagnos

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


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

[User]
RADIOLOGY NOTE:
A 71-year-old male with diabetes, hypertension, and hyperlipidemia underwent coronary bypass surgery (CABG) for 3-vessel coronary artery disease in 2005. He presented 11 years later with chest pain, weight loss, night sweats, and vision changes. He had recently completed treatment for locally advanced prostate cancer with prostatectomy in addition to hormone and radiation therapy. Computed tomography angiography (CTA) of his chest was performed to evaluate for pulmonary embolism and instead revealed an ascending aortic pseudoaneurysm measuring up to 4 cm in diameter (). One year prior, he had undergone a cardiac catheterization at another facility, and no pseudoaneurysm was appreciated at that time.
The patient had no leukocytosis or bandemia on presentation nor during his hospitalization, but blood cultures and inflammatory markers were ordered to evaluate for potential infectious etiology. Blood cultures were negative. C-reactive protein was elevated at 4.3 mg/dL. His diabetes was well controlled; HbA1c was 6.5% on admission.
During his workup, both transthoracic and transesophageal echocardiograms were utilized to evaluate the pseudoaneurysm and baseline cardiac function. His left ventricular ejection fraction was 55%. Aneurysmal dimensions measured by echocardiogram were 4.2 × 6.9 cm with extension into the aortic root. Foreign material was floating within the lumen, concerning for an infected pseudoaneurysm. No valvular vegetations were seen. The aortic valve had moderate to severe insufficiency.
Surgical intervention was planned for both the aortic pseudoaneurysm as well as the occluded bypass grafts that had been identified on the recent cardiac catheterization. He was taken to the operating room and the right axillary artery and right femoral vein were cannulated for cardiopulmonary bypass prior to redo-sternotomy. Aorta was cross-clamped distal to pseudoaneurysm and cardioplegia was administered.
Contrary to preoperative imaging, the ascending aorta actuall

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


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

[User]
RADIOLOGY NOTE:
A 17-year-old male patient presented to the emergency room with a day history of sudden right inguinal pain and irreducible right groin swelling that was partially reducible and discovered since birth. He had vomiting, colicky lower abdominal pain but no distension or constipation. His scrotum was empty from birth but social reasons hampered his presentation to hospital for appropriate medical care.
He was in mild painful distress, otherwise he was clinically stable. He had normal male secondary sexual characteristics for his age. There was an 8 × 10 × 12 cm firm, tender, irreducible right inguinal mass with no differential warmth. The normal circumcised penis had normal-situated urethral meatus. Both hemiscrota appeared developed but empty (), with no palpable testis in the left inguinal region. A diagnosis of obstructed right inguinal hernia with bilateral cryptorchidism was made. Pcv result was 38% and urinalysis was normal. Abdominal ultrasound noted a 3 cm defect in the right inguinal region through which aperistaltic bowel loops herniated. Both testes were in the right inguinal region and were normal in size, outline, echo pattern, showed normal flow on Doppler interrogation and had no focal mass lesion. The consultant surgeon worked up the patient and did emergency groin exploration.
Right inguinotomy revealed two testes of equal appearance within the inguinal region. The right testis, terminal ileum and apparently normal appendix were within the hernial sac in the inguinal canal, while the left testis was lying anterior to the sac and abutting on the right superficial ring (). The right undescended gonad had its vas deferens and blood vessels coming from the right inguinal canal.
The sac was isolated and the contents were reduced and high ligation done. A left inguinotomy revealed that the vessels and vas of the left ectopic gonad originated from the left side, and passed through the left superficial inguinal ring to reach the penopubic area where it was s

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


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

[User]
RADIOLOGY NOTE:
A 43-year old male weighing 53kg, without any comorbidity presented to the hospital with gradually increasing breathlessness of 3 months duration, one episode of haemoptysis, and oedema of legs. Examination revealed a baseline heart rate of 106/min and blood pressure was 114/70 mmHg, grossly reduced breath sounds on left lung fields and a grade 3/6 ejection systolic murmur. Chest X-ray showed heterogeneous opacity in left lower lung fields [ (Panel A)]. Transthoracic echocardiography revealed asymmetric hypertrophy of interventricular septum (IVS) (19 mm) and IVS to posterior wall thickness ratio of 1.3 with mid-cavitary gradient of 60 mmHg. There was also mitral inflow variation of more than 25%, tricuspid inflow variation of 40%, expiratory flow reversal of hepatic veins and inferior vena cava plethora consistent with CP. Computed tomographic scan showed pleural and pericardial calcification [ (Panel B)]. A catheterisation study demonstrated normal coronaries and confirmed presence of pericardial calcification []; however myocardial biopsy for confirmation of HCM was not taken. The patient was already on anti-tubercular treatment (ATT) for previous 2 months and sputum examination was negative for acid-fast bacillus. The patient was started on tablet metoprolol 25 mg twice daily in view of the HCM.
As the patient refused any surgical intervention for HCM, he was scheduled for decortication and pericardiectomy in single session surgery via anterolateral thoracotomy. ATT and beta blockers were continued up to the day of surgery. In the operation theatre standard monitoring were applied. Defibrillation pads were applied in anteroposterior position. The patient was premedicated with IV fentanyl 50 µg and midazolam 1 mg. Arterial and central venous lines were placed in the right radial artery and right internal jugular vein, respectively. Thoracic epidural anaesthesia was avoided because of the potential adverse effects of sympathetic block and vasodilation on an HCM pa

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


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

[User]
RADIOLOGY NOTE:
A 28-year-old female patient with a chief complaint of swollen gums was referred to the Department of Periodontology, Navodaya Dental College and Hospital, Raichur (India) completing her orthodontic treatment at a private setup. On clinical examination, patient presented with abundance of calculus, with oral hygiene index of 3.3 referring to poor oral hygiene status. Patient presented with generalized erythematous gingiva with diffuse gingival enlargement. There were generalized deep true periodontal pockets with average probing pocket depth of 7-8mm with Grade II to Grade III mobile teeth in relation to11, 21 []. Patient was systemically healthy.
A provisional diagnosis of generalized chronic periodontitis with inflammatory gingival enlargement was made. Radiographic investigations such as orthopantomograph (OPG) [] and full mouth intraoral periapical radiographs (IOPA) were advised []. OPG revealed moderate-to-severe bone loss. Angular defect was best appreciated in IOPA of tooth region 11-21. The inference from the clinical and radiographic investigations leads to the definitive diagnosis of generalized chronic periodontitis. No radiographs were available for comparing the condition before the orthodontic treatment.
A comprehensive treatment plan was proposed which included an initial nonsurgical therapy, full mouth flap surgery with platelet rich fibrin (PRF), hydroxyapatite (HA) bone graft and subsequent esthetic rehabilitation along with reevaluation in between the treatment phase. The patient was explained about the treatment plan and informed consent was obtained for the same. Routine blood examinations were carried out and nothing of relevance was noted.
Treatment started with Phase-I therapy that included patient motivation, thorough scaling and root planning with proper oral hygiene instructions Patient was on maintenance phase and recall visits were scheduled once in a month to assess plaque control measures and evaluate her response to Phase-I therapy.

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


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

[User]
RADIOLOGY NOTE:
A 76-year-old female patient was admitted to our emergency department early in the morning with suspected acute coronary syndrome. The patient had suffered from a major stroke causing Broca's aphasia three months prior to this admission and was referred to us from a nearby neurorehabilitation clinic. Initial ECG showed no signs of acute ischemia, but troponin I levels were about 1000-fold elevated. History taking was complicated by patient's aphasia, but she did not appear to be in acute pain at the time of admission.
With a history of heart failure and an implanted single-chamber ICD, the patient was brought to the catheter lab to undergo coronary angiogram, where no culprit lesion could be detected ().
In a phone consultation with the rehab clinic's doctor in charge, he described how the patient had multiple episodes of acute chest and back pain with “electrical twitches” for the course of several hours during the past night. Pain medication was administered and the pain interpreted as musculoskeletal but no other diagnostic or therapeutic steps were taken. Eventually, in the morning, a troponin test was done and found positive, so the patient was referred.
Subsequently, we performed an ICD interrogation, which revealed an EOS (end of service) status and multiple inappropriate ICD therapies in the time between 00:07 AM and 03:46 AM until the battery of the Biotronik ICD was depleted and the device eventually stopped antitachycardia therapy. In summary, the patient suffered 105 consecutive inappropriate ICD shocks within 219 minutes (), to our knowledge, the highest shock incidence in such a short period of time. The shocks were caused by cluster missensing on her right ventricular lead (), presumably resulting from an insulation defect near the header. Further episodes of oversensing due to clusters could be seen over the preceding five months, occasionally followed by antitachycardia pacing but no shock therapy.
The ICD was implanted in 2008 and exchanged for

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