[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-yr-old woman was referred to our center with the inability of weight bearing, five days after primary cesarean section for her twins. She had recently given birth to a pair of healthy twins at 33 wk of pregnancy and had two other pregnancies leading to another healthy child and a miscarriage. Her body mass index was 25 kg/m2. Physical examination showed the severe limitation of motion in the right hip and moderately painful left hip. Right femoral neck fracture was clearly identified in the X-rays. In pelvic magnetic resonance imaging, fracture lines at both femoral necks along with peripheral bone edema were visualized, confirming the presence of a simultaneous fracture in the left femoral neck of the patient too. The fracture of the right femoral neck was managed by close reduction and internal fixation (CRIF) along with dynamic hip screw, while CRIF and screw were used for the fixation of left femoral neck fracture ().
Since no history of trauma was reported by the patient, she was referred to the rheumatologist, where further investigations of the underlying cause of the fractures were performed. The positive past medical history points were repeated weekly courses of antenatal Betamethasone injections for fetal lung maturity, started from 26 wk gestation, plus daily oral 5 mg prednisolone due to the history of a previous miscarriage and complete bed rest during the whole third trimester of pregnancy.
In the laboratory evaluation, patient serum calcium, phosphorus, creatinine, alkaline phosphatase, parathyroid hormone and 24 hr urine calcium were normal; Serum vitamin D was 15 ng/ml, which was compatible by vitamin D deficiency. The results of bone mineral density showed a Z-score of -2.2 in L1-L4, suggesting low bone mineral density (Z score <-2). The woman was advised to discontinue breastfeeding, while her medical treatment was initiated with a daily subcutaneous injection of teriparatide (CinnoPar® 20 µg per day) along with calcium and vitamin D supplem

[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 31 weeks preterm male was born by cesarian section to a 30-year-old mother. His birth weight was 1080 gm and the circumference of his head was 27 cm. Apgar scores were 6 (1 min), 5 (5 min), and 5 (10 min). His left hand was swollen due to a constriction band and, therefore, put in an elevated position. Due to respiratory distress syndrome (RDS), non-invasive positive pressure ventilation (NIPPV) was applied for two days. Also renal failure with anuria and ischemic encephalopathy were diagnosed during the next few days. The neonate's general clinical condition was critical.
Prenatal history included twin-to-twin transfusion syndrome. At the 17th week of gestation, there was an attempt to separate the fetuses, but two days later, one of them was diagnosed dead. Three days before the delivery, the fetus was diagnosed with a constriction band around its left forearm.
The neonate was transferred to our institution’s neonatal intensive care unit on the second day after birth. A constriction band around the distal third of the forearm was noticed. Severe swelling and vascular compromise of the hand were evident (Figure ). Capillary refill time at the fingers was delayed and radial pulse was barely palpable. The hand and fingers were tense and not easily compressible. The fingers did not show any signs of spontaneous movement. Radiographs of the left forearm revealed a displaced fracture of the radius and ulna at the level of the band on the distal third of the forearm (Figure ). Abnormal motion was detected at the site of the forearm defect.
We decided to perform a reduction of the fracture and release the band. Under anesthesia and sterile preparation, a 5 mm longitudinal incision with an 11 blade scalpel over the dorsal part of the band was performed. Due to the swelling of the hand, a second 5 mm longitudinal incision was made dorsally in order to decompress it. Wounds

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


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

[User]
RADIOLOGY NOTE:
The patient is a 28-year-old male with a history of intravenous heroin abuse and untreated hepatitis C. He presented with worsening shortness of breath–requiring mechanical ventilation–a hemorrhagic stroke, methicillin-sensitive Staphylococcus aureus bacteremia, and large bilateral pleural effusions. Computed tomography (CT) scan of the chest revealed extensive pulmonary infiltration of the lungs with large loculated complex pleural effusions bilaterally. There was no evidence of pulmonary embolism. Transesophageal echocardiography revealed mitral and tricuspid valve endocarditis. Mainly due to his hemorrhagic stroke, it was decided that his endocarditis would be treated medically. However, due to his complex loculated pleural effusions and significant concern for empyema, it was felt that he would benefit from pulmonary decortication and drainage of his pleural abscesses.
He was taken to the operating room for right thoracotomy with decortication, lysis of adhesions, and drainage of intrapleural empyema. He tolerated this procedure well, and his initial postoperative chest X-ray showed a significant improvement in his right-sided effusions []. However, on postoperative day 2, despite two appropriately placed chest tubes, he demonstrated what appeared to be a new hemothorax []. Its etiology was unclear. Due to reluctance to return him to the operating room to evacuate his hemothorax, it was decided to attempt instillation of tPA and pulmozyme, through the chest tube, into his pulmonary space on postoperative day 3. At the bedside, 10 mg of tPA in 50 cc of 0.9% normal saline was combined with 5 mg of pulmozyme inhalation solution for a total of 60 cc, and this was administered into the chest tube through an 18-gauge needle into the self-sealing portion of the chest tube connection system []. The chest tube was then clamped for 1 h to allow the drug to accumulate in the pleural space. Upon unclamping of the chest tube, 730 cc of dark sanguinous fluid immediately drain

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


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

[User]
RADIOLOGY NOTE:
A 10-year-old male patient was referred to orthodontic traction of an impacted right lower first molar (tooth 46). During clinical examination, no alteration was noted except the absence of tooth 46. No abnormalities were detected in previous medical history. A cone-beam computed tomography (CBCT) showed the presence of a radiolucent image measuring <1 cm located between teeth 46 and 48, which was initially interpreted as a dental germ (). The patient was submitted to surgery under local anesthesia to achieve tooth crown exposure and bonding of an orthodontic device to traction of its right lower first molar. Six months after the procedure, in a routine panoramic radiograph during orthodontic treatment, a well-defined radiolucent image with radiopaque foci was identified in the region of the suggestive dental germ. Additionally, an increasing volume with cortical expansion and fenestration was observed in a CBCT investigation ().
Thereby, a provisional diagnostic hypothesis of odontogenic lesions was made, suggesting adenomatoid odontogenic tumor and COC. The chosen clinical conduct was the surgical enucleation of the lesion. A straight incision was made in the alveolar ridge with flap detachment to facilitate access to the lesion, and an aspiration puncture was performed revealing a liquid content (). During surgery, the lesion was completely detached from the mandibular bone, allowing visualization of a capsule with a cystic aspect (). The specimen was sent for histopathologic examination, and the microscopic findings revealed a cystic cavity lined by a thin odontogenic epithelium with ameloblastomatous features. Ghost cells and calcification foci were also observed. Furthermore, the formation of dentinoid matrix, immature enamel, and fibrous connective tissue was noticed. Therefore, the diagnosis of COC associated with odontoma was established (Figures and 3(b)). One year later, no signs of recurrence were observed and a CBCT revealed new bone formation in the re

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

[User]
RADIOLOGY NOTE:
A 63-year-old male with a history of hypertension, 20 pack-years of smoking, thyroid cancer in remission with partial thyroidectomy, and chronic obstructive lung disease (COPD) presented to the emergency department (ED) with acute abdominal pain. Abdominal ultrasound showed gallstones with no evidence of cholecystitis or biliary obstruction. The patient was diagnosed with biliary colic and discharged home with a plan to perform an elective cholecystectomy. Computed tomography (CT) scan of the abdomen was performed as an outpatient as part of the preoperative workup which showed evidence of gallstones, small bilateral pleural effusions, and moderate pericardial effusion with high density suggestive of hemorrhage (). Consequently, the patient was referred to the emergency department for further workup. Upon arrival, the patient was asymptomatic, his vital signs were normal, and his physical examination was unremarkable. An electrocardiogram (EKG) revealed a nonspecific interventricular conduction delay. Chest x-ray showed a mildly enlarged cardiomediastinal silhouette with prominent perihilar opacities suggestive of a prominent vasculature (). Complete blood count and basic metabolic profile were within normal limits. Further laboratory workup showed normal erythrocyte sedimentation rate, rheumatoid factor, complement level, and procalcitonin with negative serology for antinuclear antibodies and double-stranded DNA antibodies. A transthoracic echocardiogram (TTE) showed a large pericardial effusion without signs of tamponade, moderate aortic regurgitation, and normal left ventricular ejection fraction and size. Given the large volume of pericardial effusion, a pericardial window was attempted. A total of one liter of hemorrhagic fluid was drained. Pericardial tissue biopsy showed acute and chronic inflammatory cells with thickened pericardium, and no malignant cells were detected (). Tuberculosis quantiferon assay, acid-fast bacilli staining, and fungal and bacterial

[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 15-year-old female was seen in neurology clinic after several episodes of transient paralysis that were started when she was one year old. Her mother stated that during these episodes she was fully conscious, but half of her body was paralyzed, and she had difficulty in speaking. The paralysis was characterized by recurrent episodes of transient hemiplegia alternating in laterality or affecting both sides simultaneously. There was no associated or preceding vomiting, fever, seizures, loss of consciousness, or headache. The episodes lasted from few hours to few days and recurred every 10–30 days without leaving any residual deficit. The paralysis disappeared after a good sleep and reappeared within half an hour after awakening. She was dysarthric when the episode was unilateral and mute when it was bilateral. The child became ataxic with deterioration of cognitive and intellectual functions after seven years of disease onset. She also lagged developmentally behind her chronological age. She was a product of a nonconsanguineous marriage at 39 weeks of gestation following a spontaneous vaginal delivery. The pregnancy and neonatal period were uneventful. There was no family history of a similar disease including migraine. Her neuroimaging was normal on several occasions. At the age of 14, she developed sudden onset of a partial motor seizure of the face with secondary generalization and status epilepticus. The seizures were difficult to control, lasted several hours, and necessitated an admission to the intensive care unit with intubation and mechanical ventilation. The final diagnosis was AHC with status epilepticus and catastrophic cortical necrosis due to severe hypoxic brain insult. is showing her magnetic resonance imaging (MRI) few months following discharge from the hospital on multiple antiepileptic drugs. She was mute, quadriparetic, and psychotic. In a follow-up visit to the clinic, three years following discharge from the hospital, she showed some improveme

[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:
Mr. K. F. a 57-year-old man, right-handed, bipolar schizophrenic, was the victim of a mechanical fall from standing height. On admission, neurological examination was normal. A painful strain evoked a broken left wrist. The right shoulder was swollen, painful and nonfunctional. Radiography objectified anterior marginal fracture of the distal radius and fracture of the proximal humerus with suspected posterior dislocation associated (). The computed tomography scan confirmed the diagnosis of complex proximal humeral fracture associated with posterior dislocation of the humeral head. This was a fracture in four fragments of Neer associated with posterior dislocation or fracture of the head and metaphysis of the humerus from the anterior notch of posterior dislocation in reference to Duparc classification []. An anteroinferior marginal fracture of the glenoid ( and ) was associated.
An osteosynthesis of the wrist bone was carried out in an emergency. Ten days later, the synthesis of the humeral fracture was performed by the extended deltopectoral approach. The minor tubercle held up, the long biceps broken is resected and undergoes tenodesis in its groove. The humeral cap united to the metaphyseal-diaphyseal posteromedial beak is reduced then screwed in compression. We fix again the fragment of the major tubercle fractured by osteosuture and the minor tubercle is screwed into the cephalic notch. The synthesis is carried out by a small fragment locking compression plate. The incision is closed over a suction drain. The limb is held by a derotation device. Analgesic treatment, preventive heparin therapy were prescribed. The immediate postoperative course was uneventful and the control radiography satisfactory ( and ). Healing was obtained in the normal time. Rehabilitation started on the 4th day by assisted passive and active mobilization, joint and muscle maintenance. The derotation system is kept between sessions for 5 weeks.
The discharge from the hospital was carried

[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 was a 32-year-old gravida III para II Amhara woman who came from a rural area of North West Ethiopia. Her first delivery was an uncomplicated spontaneous vaginal delivery at home at the age of 22 years. Her second delivery was a spontaneous vaginal delivery in a health center 4 years later with early neonatal death for unknown reasons. She was seen by a health professional only once during the current pregnancy, when she experienced progressive abdominal pain 4 months prior to her delivery. She was assessed in a health center and referred to a regional hospital where she underwent an ultrasound scan and was reassured. She presented to the University of Gondar Teaching Hospital with the principal complaint of shortness of breath with associated progressive abdominal distension and pain. Her last menstrual period was unknown but she reported 9 months of amenorrhea.
On general examination, she looked emaciated and was slightly pale. Her vital signs were within normal limits. Her cardiovascular and respiratory system did not reveal any abnormalities. On abdominal examination her symphysis fundal height was term sized, with longitudinal lie and breech presentation. The fetal heart rate was 132 beats per minute and there were no uterine contractions. On vaginal examination the cervix was closed and uneffaced. There was no vaginal bleeding. On ultrasonography examination, there was a singleton live pregnancy with excessive amniotic fluid. The placenta appeared to be attached to the serosal surface of the fundus of her uterus and her uterus was empty. The gestational age was 40 weeks by ultrasound estimation. Her preoperative hematocrit was 34%. An emergency laparotomy was performed with the impression of abdominal pregnancy. Upon opening her abdomen and entering the peritoneum, the fetus was seen in an intact amniotic sac and there was no hemoperitoneum (Fig. ).
On opening the amniotic sac a live female neonate was delivered weighing 2.6kg. The uterus was ruptu

[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 to the outpatient cardiology clinic for evaluation of worsening chronic hypertension for which she had been on hydrochlorothiazide/Valsartan for 10 years. Her systolic blood pressure exceeded 200 mmHg in the office, and aggressive medical therapy was initiated in the outpatient setting. She returned to the emergency department the following day with headache and malaise and systolic blood pressure above 200 mmHg for which she was treated and discharged.
She returned to the emergency department again 5 days later, this time with complaints of word finding difficulty, blurred vision, and lower extremity tingling. Her blood pressure on presentation was 216/81 mmHg. She was admitted, and workup demonstrated no acute intracranial process or carotid stenosis. Echocardiography revealed mild concentric left ventricular hypertrophy with a preserved ejection fraction. Her blood pressure continued to be refractory to medical therapy despite five antihypertensive agents and eventual initiation of an esmolol infusion. A renal artery ultrasound identified renal artery stenosis with flow at the arterial origin measuring 350 cm/s on the right and 208 cm/s on the left (); flow velocity in the supraceliac aorta was also noted to be elevated. She had no history of kidney disease and no elevation of her creatinine. Vascular surgery was consulted and a history of lower extremity claudication was elicited. On exam she had weak but palpable femoral pulses and an audible abdominal aortic bruit; ankle-brachial index measurements were deferred and the patient was scheduled for angiogram.
The patient underwent aortography the following day and on selective angiography the renal arteries were found to be widely patent. Significant stenosis was identified at the distal thoracic aorta extending into the abdominal aorta but terminating proximal to the celiac trunk. The degree of stenosis was deemed to be greater than 90% and a pressure gradient between the upper ext

[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 58-year-old male patient was admitted to our clinic with the diagnosis of remnant gastric cancer. Nine years ago, the patient underwent open subtotal gastrectomy and Billroth II reconstructive surgery due to stomach cancer. A biopsy of a suspected ulcerous lesion of the remnant stomach was made in the esophagogastroscopy for the evaluation of the patient who had radiotherapy and chemotherapy story after surgery. Laparoscopic complementary gastrectomy was planned in the patient whose biopsy pathology result was poorly cohesive carcinoma. The patient in the ASA-3 class with a history of diabetes mellitus and oral antidiabetic use was operated on. Pneumoperitoneum was formed with Veress needle from the left upper quadrant in the patient with a median incision on the upper abdomen. The 10-mm working trocars were placed under the umbilicus, the lower right quadrant and the lower left quadrant; the 5-mm working trocar was placed in the upper right quadrant. Because the liver was sticking to the diaphragm, the liver retractor was not used. Adhesions to the anterior abdominal wall were removed. The intestinal loop of antecolic Billroth II gastroenterostomy anastomosis was cut and sealed with linear staples. The greater curvature was released along with the remaining omentum. Lesser curvature lymph nodes were dissected and included in specimen. The oesophagus was cut and closed with a linear stapler. Subsequently, antecolic oesophagojejunostomy was performed intracorporeally with single layer 3/0 prolene. The jejunojejunostomy with linear stapler was performed between the place that was 100 cm distal after oesophagojejunostomy anastomosis and the loop that was 15 cm away from the ligament of Treitz. The specimen was removed by suprapubic route. The operation time was 390 min with bleeding 100 cc. The patient was discharged without any problems on the 10th day. The pathology was reported as a 3 cm × 1.5 cm poorly cohesive carcinoma type (signet ring cell form) lesion 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 previously healthy 20-year-old female presented to the clinic with a 2-month history of an enlarging submental neck mass. She originally noticed the mass while pregnant. Four weeks after giving birth, however, the area became increasingly more painful and firm to palpation. She began to have pain with swallowing. Physical examination revealed submental and floor of mouth fullness that was exquisitely tender to palpation, limiting the ability to examine her.
A neck ultrasound and computed tomography (CT) scan were obtained and showed a multiloculated cystic lesion with calcifications and a central solid component present in the submental space extending down towards the hyoid (). There was no radiologic or clinical evidence of thyroid gland disease or neck lymphadenopathy.
A clinical fine-needle aspiration (FNA) was performed to further evaluate the mass and showed mixed inflammatory cells with histiocytes in a background of proteinaceous fluid, consistent with a cyst. Thyroglobulin was significantly elevated within the cystic contents, raising suspicion for malignancy. A repeat FNA with ultrasound guidance was then performed of the solid component of the mass and cytologic preparations demonstrated nuclear overlapping and nuclear grooves with pseudonuclear inclusions, consistent with papillary thyroid carcinoma.
The patient underwent a Sistrunk procedure along with total thyroidectomy. A total thyroidectomy was performed due to the large size of the TGDC carcinoma, the patient's young age, and the likely need for postoperative radioactive iodine therapy. There was no radiographic evidence of lymphadenopathy, and therefore, no neck dissection was planned; however, given the size and location of the mass, contents of level IA and the superior part of level VI were taken with the specimen. A formal level VI neck dissection was not performed due to the negative preoperative imaging.
Intraoperative findings included a large cystic mass consistent with a TGDC and a smal

[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 7-year-old boy underwent the Nuss procedure at the age of 5 years for funnel chest wherein bar displacement occurred, and the Nuss method was performed a second time at the age of 6 years at the same hospital. However, even after the second surgery, the bar displaced, and he visited our hospital. The preoperative photograph showed strong depression on the left, centering on the solar plexus from the lower end of the sternum, and the ends on both sides of the bar protruded subcutaneously [Figure and ]. The pretreatment radiograph taken at the previous hospital showed a depression below the sternum []. The bar was placed horizontally immediately after the first surgery []. In the radiograph obtained 5 months after the first surgery, there was displacement toward the foot side []. The angle of the bar relative to the sternum was 23°. The second surgery was performed 1½ years after the first operation. However, the reinserted bar caused displacement to the head side. The patient visited our hospital 2 years after the initial surgery. During radiography at our hospital, the central part of the bar rotated toward the head side, and the displacement of the bar with respect to the sternum was 27° []. The computed tomography (CT) index was 4.1 [Figure and ].
In this case, we considered that double bars should be used because the chest deformity is extensive depression and performed the third Nuss procedure using a new stabilizer. The new stabilizer was constructed based on the conventional stabilizer developed by Lorentz, and the stabilizers were fixed by connecting the two bars []. We planned to insert bars in the fourth and fifth intercostal spaces and set the interval between the two bars to 3 cm. Lifting of the sternum by the Nuss method was carried out as expected. We confirmed that the morphology of the thorax was corrected adequately. A new stabilizer was placed under 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 24-year-old woman came first time to the pulmonary clinic complaining of progressive breathlessness on exertion, chest tightness, audible wheezing, and dry cough for the past few months. Since her late childhood, she was diagnosed as being asthmatic with intermittent exacerbations. She had received inhalational bronchodilators, antibiotics, and several courses of corticosteroids over the past few years but, never subjected to any spirometry testing. The worsening symptoms, in spite of aggressive medical treatment, compelled her to consult a pulmonologist.
Her physical examination revealed mild inspiratory and expiratory wheezes over the upper anterior chest with stridor, though her pulse oximetry showed 100% oxygen saturation on room air. Otherwise, the rest of the physical examination was normal. A routine chest roentgenogram showed absent aortic knuckle on the left side with a right-sided aortic arch and an abnormal distal tracheal air shadow (). In addition to X-ray findings, the flattening of both inspiratory and expiratory segment of flow-volume loop during spirometry raised a possibility of aortic arch and branch vessel anomaly ().
Subsequent, spiral CT of chest with 3-dimensional reconstruction () showed a right-sided aortic arch with 3 branch arteries. The left carotid and right carotid arteries were originating as the first and second branches, respectively, whereas the left subclavian, the 3rd branch with aberrant origin (Kommerell's diverticulum), was originating from the distal portion of the arch and traversing the space behind the esophagus. The descending aorta was only slightly to the right of the midline. A deviation to the left and compression of the trachea and esophagus were seen as a result of the right aortic arch and the anomalous origin and course of left subclavian artery. The ductus arteriosus could not be visualized, possibly due to fibrous obliteration.
She underwent a standard left posterolateral thoracotomy, and through the bed of 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 34-year-old female patient reported to the department of Periodontics with exposed root in relation to maxillary right lateral incisor. The patient's general medical condition (American Society of Anesthesiologists 1) was good. History revealed previous endodontic treatment in tooth no. 12 performed by a private practitioner 2 years back. On intra oral clinical examination, crown of tooth no. 12 showed distinct discoloration. Apical portion of the root was seen perforating the buccal cortical plate and overlying mucosa with the fenestration defect measuring approximately 4 mm × 3 mm []. The patient was unable to recollect the period of its occurrence but confirmed the presence of exposed root since 1-year. The patient had also not sought any dental treatment for the past 1-year despite being aware of the existing defect. Plaque and calculus were seen deposited on the exposed root but no pus discharge was evident in the area []. Probing depth in the gingival sulcus above the fenestration defect was within normal limits. Palatal examination revealed presence of a palatal groove possibly extending onto the root and an isolated periodontal pocket of >5mm [Figure and ]. The tooth presented with grade I mobility.
Radiographic examination of the concerned tooth revealed faulty root canal treatment in right maxillary lateral incisor and a lateral radiolucency on the mid mesial aspect of its root []. A thin parapulpal radiolucent line was observed on the radiograph which confirmed the presence of a palato gingival groove. It was decided to repeat endodontic treatment in the affected tooth, treat the palato gingival groove and perform periodontal surgical correction of the fenestration defect by raising a full thickness flap.
The exposed root tip of right maxillary lateral incisor was cleared of the deposited plaque and calculus []. Endodontic treatment was reinitiated in the tooth. Previous gutta percha filling was removed from the canal with the help of a hand file and wo

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


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

[User]
RADIOLOGY NOTE:
A 6-month-old Chinese male child was admitted to our department with recurring episodes of hypoglycemia for 6 months. His parents were healthy and not consanguineous, and his family history was not notable. The child was first admitted to the hospital because of repeated cyanosis and poor reaction at the age of 2 days. He was diagnosed with hypoglycemia based on his blood glucose level (which was 0.3 mmol/L) and recovered after receiving glucose and glucocorticoid infusion.
At the age of 22 days, the infant appeared pale and had a poor reaction and reduced muscle strength after fasting for 4 h for Magnetic resonance imaging (MRI) examination. His blood glucose was 2.06 mmol/L and he was recovered from glucose infusion again. Subsequently, the child showed increased muscle tension and movement retardation.
At the age of 4 months, the child experienced repeated vomiting and diarrhea for one day, and hypoglycemia reappeared (blood glucose, 4 mmol/L). In addition, the child had an episode of convulsions that lasted for 2–3 min. After intravenous infusion of glucose, blood glucose returned to normal.
At the age of 6 months, the child was admitted to the hospital for a systematic examination. Physical examination at admission showed that his body weight was 6600 g (3th centile); body length, 76.0 cm (97th centile); head circumference, 41.0 cm (3th centile); chest circumference, 43.0 cm (50th centile). He was conscious and had a good mental reaction, nutrition levels, and skin elasticity. He had strabismus in both eyes, but it was prominent in the left eye. He was unable to use the support of his elbows to get up from a reclining position, and when he stood upright, his head was tilted to one side. He could not turn over or bear his weight. He leaned forward fully in the sitting position and flexed his legs in the standing position.

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


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

[User]
RADIOLOGY NOTE:
A 54-year-old gentleman with cirrhosis and end-stage liver disease secondary to chronic hepatitis C presented for evaluation for liver transplantation. The patient was first diagnosed with hepatitis C in 1990, and subsequently diagnosed with cirrhosis in 1991 by liver biopsy. At that time he was briefly treated with interferon, but sustained a severe allergic reaction following his fourth dose prompting discontinuation. In February of 2007, he developed worsening fatigue and sought care from his primary care physician. A computed tomographic (CT) scan was performed which demonstrated a small, irregular-appearing liver consistent with cirrhosis, but no liver masses were appreciated and the portal venous system was patent (Fig. ). An alpha-fetoprotein (AFP) level was noted to be elevated at 7,100 ng/ml in September of 2007. A CT scan was repeated in October of 2007 and demonstrated thrombus within the left portal vein (Fig. ). Magnetic resonance imaging of the liver was performed and demonstrated cirrhosis with left portal vein occlusion. A heterogeneous nodular mass had replaced the entire left lobe of the liver and the caudate lobe of the liver with evidence of increased enhancement. There was another heterogeneous lesion with abnormally increased signal intensity in the medial segment of the left lobe measuring 2 cm in diameter. Both of these lesions were highly suspicious for hepatocellular carcinoma (HCC). A metastatic evaluation was negative and a repeat AFP level was 24,100 ng/ml. The patient was referred to an outside institution for transplant evaluation, and was deemed unsuitable due to evidence of an infiltrating form of HCC with evidence of portal vein thrombosis. By December of 2007, the patient's AFP level had increased to 194,000 ng/ml. A CT scan at that time demonstrated extensive thrombus within the main portal vein near the bifurcation that extended into the right and left portal veins. Sorafenib was started at a dose of 400 mg twice daily in January

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


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

[User]
RADIOLOGY NOTE:
A 79-year-old Caucasian female presented to our institution with chest pain, dyspnea, and a rapidly enlarging thyroid goiter. The patient endorsed that she was previously quite healthy aside from stable hyperthyroidism and a nonenlarging thyroid goiter. Her thyroid had been overactive for years, treated with stable dose of 7.5 mg daily of methimazole for at least the past four years. In 2002, 2003, and 2010, she had had thyroid uptake scans indicating heterogeneous elevated uptake consistent with toxic multinodular goiter and a cold area was identified in the lower right lobe. In 2000 and 2010, she had biopsies of the nodules of the right and left lobes with benign results. Since treatment with methimazole, she had been asymptomatic up until three months prior to presentation, living a mostly independent and having active lifestyle that included cooking, gardening, and daily errands.
The patient's family became concerned approximately three months before presentation to our facility because the patient lost a significant amount of weight while her goiter rapidly enlarged. Soon after, she had sudden “terrible pain” in the left side of her neck, diagnosed as an internal jugular vein thrombus. At the time of this diagnosis, her thyroid measured 8.4 × 12 cm. She saw her endocrinologist who noted that her thyroid was hyperfunctioning again and no longer controlled with her daily dose of methimazole, which was subsequently increased. A month later, her labs showed that her thyroid was even more overactive. Her dose of methimazole was subsequently increased to 30 mg per day. She was evaluated for surgery the following month, but surgery was deferred due to uncontrolled hyperthyroidism. The day prior to presentation at our institution she developed chest pressure and tightness when lying down. A computed tomography (CT) scan of her chest and neck showed that her thyroid had grown to 9.8 × 13.2 cm.
Upon admission, her TSH measured <0.003

[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 six-day-old female child was referred from the Department of Pediatrics, with multiple swellings protruding from the mouth, which were noticed at birth.[]. Antenatal history of pregnancy was uneventful and normal vaginal delivery occurred at 37 completed weeks. There was no family or hereditary history of this type of a case. The baby weighed 3.5 kg, and had two large lesions on the alveolar ridge of the maxilla and three smaller lesions on the mandible [].
The masses were pedunculated and covered with mucosa, which was macroscopically normal and had brisk capillary refill. On clinical examination, a round, pedunculated, 3 cm diameter, soft tissue mass, exhibiting an erythematous and smooth surface, was found in the midline and was attached to the anterior gingiva. The masses were preventing normal closure of the mouth. Three other soft tissue masses of 1.5 cm each were also found attached to the mandibles, which were smooth surfaced. Two masses were attached laterally and one at the midline of the mandible. At presentation there was no respiratory difficulty. A nasogastric tube had been placed due to feeding difficulties and the baby was breathing normally. The swellings had not increased in size in the last six days. The patient also had a depressed nasal bridge, with decreased nasal patency; however, no other structural abnormality was detected. All other mile stones were normal [].
The general physical examination, along with laboratory tests, was otherwise normal. The patient underwent fine needle aspiration cytology (FNAC), which showed a benign fibrous lesion. The midline lesion was gently pushed laterally and subsequently oral intubation could be performed with some effort. The lesion was completely excised under general anesthesia, with minimal intraoperative hemorrhage. A regular oral feed was started on the seventh postoperative day and was well tolerated. The patient was discharged with her mother on the ninth day. At a three-week follow-up, the patien

[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 Chinese female was referred to National University Hospital, Singapore in February 2016 for management of a hard swelling over her right TMJ. This patient suffered from chronic right TMJ pain for more than 5 years. She had consulted several physicians over the past few years, but could not obtain a definitive diagnosis. There was no prior treatment provided. Her past medical history includes surgical excision of left breast fibro-adenoma, recurrent upper urinary tract infection, stress urinary incontinence and infective colitis. She was on active follow up with the Otolaryngology department for hoarseness of voice. She was a non-smoker and non-drinker. There was no known history of any genetic disorder. The patient denied any history of trauma or infection to the jaw area. There were no other family members with a history of temporomandibular joint or jaw swelling.
On examination, a localized swelling was palpable over the right pre-auricular region which measured 15 mm by 20 mm. It was tender upon palpation and had a bony hard texture. The swelling appeared distinct from the TMJ capsule as it did not move when the right mandibular condyle translated anteriorly during mouth opening. On maximal mouth opening, the condylar translation at both TMJs was similar. The maximal mouth opening was normal. The overlying skin was normal in consistency and was not fixed to the swelling.
A series of lab tests were ordered, including liver function test, renal function test and complete blood count. All results were being found to be within normal ranges. A dental panoramic tomogram (DPT) was taken (Fig. ), but no distinct lesion could be observed at the right TMJ. Unenhanced computed tomography (CT) was taken subsequently (Fig. a-b). It revealed a sharply defined hyper-dense benign-looking ovoid mass measuring 10 mm by 13 mm by 20 mm within the subcutaneous layer over the right pre-auricular region. It was closely associated with the lateral aspect

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


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

[User]
RADIOLOGY NOTE:
A 38-year-old male with no significant past medical history who took no medications and had allergies to penicillin, cefepime, and cantaloupe, fell backward from the bed of a moving truck onto his head. He sustained a significant blunt head trauma, with bilateral subdural hematomas, temporal bone fracture, nasal and orbital bone fractures, effacement of cisterns, cerebral compression, and possible diffuse axonal injury. He was intubated and placed on mechanical ventilation for airway protection due to his severe traumatic brain injury and coma, and placed in the surgical intensive care unit. His hospital course was relatively uncomplicated, though he did remain on the ventilator for 12 days and required tracheostomy placement due to prolonged decreased mental status. After tracheostomy placement on hospital day 8, he was being weaned fairly aggressively from the ventilator and was showing signs of improvement from a mental status perspective.
On hospital day 9, the patient had an arterial blood gas that revealed a pH of 7.53, a pCO2 of 38, a pO2 of 67, a bicarbonate level of 28 with a base excess of +4. In an effort to help his primarily metabolic alkalosis, a single dose of ACZ was given, 500mg intravenously. He had received the same 500mg intravenous dose of ACZ on hospital day 3 for a similar indication, a week prior to this dose. At this point, he had an indwelling foley catheter, a normal creatinine, and was producing over 2 L a day of clear urine.
On hospital day 11, the patient was successfully on tracheostomy collar and was more lucid and able to communicate relatively clearly. He began complaining of severe bilateral flank pain with dysuria and had a significantly decreased urine output of only 275mL of cloudy, sediment containing urine. A urinalysis revealed red cells, no white cells, no nitrates, and no bacteria. He had some mucoid-like discharge from the indwelling foley catheter with irrigation. A

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


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

[User]
RADIOLOGY NOTE:
A 12-year-old girl reported to our department with a complaint of missing lower teeth and an unaesthetic facial appearance with progressive loss of hearing over a period of 3 months. Patient complained that only few permanent teeth had erupted and she had difficulty in chewing and was unable to eat. Past dental history revealed extraction of upper left permanent molar by a private dentist because of gross decay. There was no relevant medical history or family history. Her general examination revealed short stature and she was well oriented with normal intelligence. Extraoral examination revealed hypertelorism (increased intercanthal distance of eyes), frontal bossing with brachycephalic skull, depressed and flattened nasal bridge, malar hypoplasia, and an underdeveloped maxilla with a prognathic mandible and concave facial profile []. Hand showed hypoplastic distal phalanges [], and brachydactyly of the fourth toe [] was seen. The thorax was narrow and cone shaped, and spinal abnormalities like mild scoliosis and kyphosis were appreciated []. On palpation, a depression over the sagittal suture with presence of metopic suture of the frontal bone was felt and the patient could approximate her shoulders in midline []. Intraoral examination revealed normal mouth opening and jaw movements. Erupted upper right permanent first molar and retained deciduous teeth were seen with high arched and narrow palate [Figure , ] with erupted right permanent first molar and retained deciduous teeth [] were seen. Panoramic radiograph revealed few impacted teeth, multiple retained deciduous teeth, and underdeveloped maxillary sinuses []. AP view of pelvis demonstrated a widened pubic symphysis and triradiate cartilage []. Skull AP and lateral views showed the presence of multiple wormian bones with open fontanelles []. Chest radiograph showed bell-shaped rib cage and hypoplastic clavicles []. Based on the clinical and radiographic findings, a diagnosis of CCD was made. She was referred 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 15-year-old female patient (bodyweight 50 kg, height 160 cm) presented with syncope. Severe arterial hypertension was diagnosed (178/147 mmHg left arm, 102/83 mmHg left leg). She reported previous episodes of exercise independent headaches and nose bleeds. Auscultation revealed no cardiac murmurs, but an accentuated second heart sound and reduced pulses in the lower limbs. There were no clinical signs to suggest Alagille or William’s syndrome or clinical evidence of neurofibromatosis. Blood tests showed normal inflammatory markers and normal creatinine. The urine dip showed no markers for blood or protein. No regular medication was taken at the time she presented. The electrocardiogram showed normal sinus rhythm, no significant signs of left ventricular (LV) hypertrophy or abnormal repolarization. Echocardiography detected a severe concentric LV hypertrophy (14 mm diastolic septal diameter, 15 mm diastolic diameter of the LV posterior wall) and a long hypoplastic segment in the abdominal aorta with massive arterial collateralization. Cardiac catheterization confirmed the diagnosis of a midaortic syndrome with a minimum diameter of <1.5 mm and a gradient of 50 mmHg between the aortic arch and the femoral arteries (Figure ). The narrow part began directly under the diaphragm above the truncus coeliacus and continued down to the bifurcation of the arteriae iliacae including the renal arteries, with reversed flow in the caudal aorta up to the renal arteries. Because of the extraordinary length of the hypoplastic segment of 23 cm, we decided for a stepwise interventional therapy with a paclitaxel covered balloon. No additional computed tomography scan or magnetic resonance imaging (MRI) was performed. Consultation with our surgeon, supported the interventional approach. The proposed procedure was reviewed and approved by our institutional review board, extensively discussed with the patient’s family, and informed consent was obtained before proceeding.
After balloon in

[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, Vietnamese male, living in Switzerland for the last three years, consulted our unit for unremitting pain in his right knee. He had a right knee contusion two months ago. On history, he related occasional night sweats with chills since that accident accompanied with a weight loss of 5 kg. Otherwise, he is in good health, does not smoke, and takes no medications.
Clinical examination showed a painful red nonulcerating indurations measuring 3 × 4 cm in surface at the level of the right fibular head. It is fluctuating and seems to be adherent to the deep subcutaneous plane. Right knee mobilisation was complete, and neurovascular examination was normal. Blood analysis revealed a marked microcytic anaemia (haemoglobin: 76 g/L, VGM: 61 fl), no leukocytosis, and a CRP of 4 mg/L. Knee radiography showed a lytic lesion with ill-defined margin in the proximal right fibula measuring 1 × 1 cm and breaking through the outer cortex (). We reserved the differential diagnosis of focal osteomyelitis versus a tumoral process since the radiography showed that progressive lesion (). MRI examination demonstrated a hypersignal on T2 images of the proximal right fibular head with breakage through the outer cortical bone and an abscess extension in the surrounding soft tissues. This excluded the tumoral process as a causal agent and oriented us to a focal osteomyelitis with local infiltration of peripheral tissues (). Surgical debridement was done through a centred lateral incision and tissue fragments sent for bacteriology and path anatomy analysis with a special request to look for tuberculous infection. This atypical request was based on the ethnical origin of the patient and the lytic lesion on radiography. Antibiotic therapy has been started empirically with Augmentin (amoxicillin and clavulanic acid) at a dose of 2, 2 g intravenous three times a day. The path anatomical analysis revealed the presence of an acid-alcohol resistant bacillus within an inflammatory process.

[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 59-year-old female initially presented to the neurosurgery clinic with complaints of insidious onset of right leg radicular pain. She has no history of numbness, tingling, weakness, or bowel or bladder incontinency. She has never experienced any similar pain episodes. Physical examination had significant right side straight leg test positive at 45 degrees and left lower extremity at 70 degrees. Plain lumbosacral X-ray was inconclusive. The patient's lumbar MRI reported right L4-L5 lateral disc herniation with extrusions and the patient had partial response to conservative management.
She underwent a minimally invasive hemilaminotomy of right side L4-L5 and removal of the extruded disc particles. The patient had an uneventful postoperative course. She had immediate pain relief after surgery and was able to ambulate on postoperative day one. She was discharged from the hospital the following day after surgery.
The patient reported a new pain experience on the left buttock that started insidiously two weeks after discharge. The pain was constant burning at the left pelvic region, with sharp shooting pain in the left leg. The patient reported pain radiating in multiple trajectories but on clinical assessment had no specific dermatomal distribution. Pain was not aggravated by coughing or sneezing but is more during a sitting position.
On a new physical examination, a healed surgical scar of posterior approach was seen over the midline lower lumbar area. There was no sign of infection at the surgical scar. The patient walked with an antalgic and waddling gait. There was a significant Tinel sign on the left gluteal region over sciatic nerve. Straight leg rising test was negative in supine, sitting, and prone position. Detailed physical examination included spine mobility with great range of motion with no pain, manual muscle testing with normal muscle strength, and deep tendon reflexes were normal. Piriformis stretch test was significantly positive and could aggravate 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:
We report a 30 year old man referred to our institution for road traffic accident and presented with pain, swelling, deformity, Gustilo grade 3A open wound in right elbow with compound fracture. His personal and family history was not significant. The patient has no history of fever, anorexia, weight loss and night sweats.
Plain radiograph revealed a compound intercondylar fracture right humerus with communited right olecranon. Open reduction and internal fixation after proper debridement with plates was performed. On the 5th post-surgical day, patient had sero sangious discharge from the operative wound, for which debridement was done. After repeated debridement's and wound closure patient was sent home. The patient came with chronic discharging sinus from the wound over posterolateral aspect of elbow, for which repeated pus culture and serological tests were performed, which was found to be negative. Prophylactic broad spectrum antibiotic therapy was started for 6 weeks but the patient still had persistent discharging sinus. Six months later the patient returned to outpatient clinic with recurrence of discharging sinus, pain associated with increased range of motion, hyper and abnormal mobility. On earlier plain radiography, there were no notable findings, however after 6 months implant failure was revealed [], with joint space narrowing and peri articular osteopenia. Laboratory investigations included hematocrit value of 36.6%, total leukocyte count was normal, ESR was 57mm/hour, and C-reactive protein was 6 mg/dl. Rheumatoid factor and anti-nuclear anti-body was negative. Pus culture was negative. Patient underwent thorough generalized clinical and radiological examination. Various specimens like sputum and urine were send for ZN staining but there was lack of any primary foci elsewhere in his body.
Repeat debridement and implant removal was performed. Some suspicious rice seed like bodies were removed and sent for histopathological examination. Histological exa

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


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

[User]
RADIOLOGY NOTE:
A 47-year-old man (an employee of the hotel sector from Bogotá) with a past medical history of polycystic kidney disease presented to the emergency room with complaints of one week of erythema and purulent drainage of the anterior chest wall associated with a fever of up to 38.5 °C. He received cephalexin during a three-day course without any improvement.
Upon physical examination, he was in no acute distress, and his skin exam was remarkable for an erythematous left periareolar nodule with swelling, warm, and purulent discharge (), along with signs of systemic inflammatory response without clinical findings of sepsis organic dysfunction (). The patient started on therapy with intravenous clindamycin. However, he deteriorated due to the worsening of chronic kidney disease with the further requirement of renal replacement therapy.
The patient was taken to surgery, where a 15-cm abscess with skin necrosis over the area of renitence was found. The cytochemical results of the abscess showed abundant leukocytes and the isolation of Chromobacterium violaceum (). Antibiograms were not made, and blood cultures were negative. The patient continued intravenous clindamycin with no improvement at the third day of admission, so doxycycline was started at a 100 mg BID dosage with partial response. At day five of admission, he was taken to another surgical procedure, and negative pressure therapy was placed over his wound. This therapy allows one to draw fluid from an infected site using a vacuum system, which is especially useful for deep, complicated, and nonhealing wounds. The antibiotic was again changed to tigecycline at a 50 mg BID dosage for ten days.
After five days of tigecycline, he underwent surgery again, negative pressure therapy was withdrawn, and the wound was covered with a fasciocutaneous flap. He was discharged after completing 10 days of antibiotic treatment, with no signs of systemic inflammatory response and with adequate closure of the skin wound ().

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


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

[User]
RADIOLOGY NOTE:
A 58-year-old obese middle-aged housewife had a history of insidious pain in her right hip with difficulty in walking for the past three years. She went to a surgical centre for management in her native town and was diagnosed with a right femoral neck fracture. Further workup revealed osteomalacia and vitamin D deficiency. She underwent reduction and fixation with three cannulated cancellous screws for her initial management. Her medical management with calcium supplements and vitamin D was initiated. Restricted weight bearing with the use of crutches was allowed after six weeks and progressed to full weight-bearing within three months on the advice of her local practitioner. Though she was unable to ambulate without support since surgery, the ambulatory status further deteriorated in two months with a progressive left hip pain. She was no longer able to walk for daily routine activities. She presented to us with the relevant concern for treatment.
She complained of severe pain in both hips (left more than right) and marked difficulty in doing her routine daily activities including unrestricted utilization of toilet for the last two months. No history of trauma is reported. She was a postmenopausal obese female weighing 106 kilograms for her height (170 cm). Her body mass index (BMI) was 36.6 kg/m2. There was tenderness over bilateral hip joints (left more than right), external rotation deformity, and shortening of the left lower limb. Movement of the left hip joint was extremely painful and was not encouraged. There was pain at extremes of motion of the right hip joint. The patient was able to do straight leg raise on the right side but not on the left side. There was no distal neurovascular deficit in both lower limbs.
Sequential radiographs were available and first radiograph showed fmoral neck fracture in the right lower limb with an initial in-situ fixation by three partially threaded screws (Figure ).
The second follow up radiograph at two years of right hip f

[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 cardiologist calls as they are planning a coronary angiogram for a 68-year-old trans woman and are concerned because the estimated glomerular filtration rate (eGFR) is unknown. They are uncertain how to risk stratify her for potential contrast-induced nephropathy. She has a history of longstanding hypertension and hypercholesterolemia, vaginoplasty, and has been on various formulations of estradiol therapy for over 20 years. On review of her investigations, her serum creatinine is 109 umol/L (1.23 mg/dL) but her eGFR has not been reported for the last 18 months. Laboratory providers cannot report eGFR if a male or female marker is not provided on the request form, as this is required along with age to estimate eGFR. Using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formula, if classified as female, the eGFR would be 45 mL/min/1.73m
classed as Stage 3 chronic kidney disease and would meet the guidelines for intravenous hydration prior to procedure. However, if classified male, the patient would have an eGFR of 60 mL/min/1.73m
which would be classed as Stage 2 chronic kidney disease and would not require prehydration. Which is the most appropriate eGFR to use?
Accurately assessing renal function is essential for not only assessment of renal diseases, but also clinical situations that may potentially affect renal function (such as diabetes or radioiodine contrast administration) as well as considerations for medication dosing of renally cleared drugs. The most commonly used marker of renal function in clinical pathology laboratories is eGFR, which is calculated based upon an individual’s serum creatinine level, age, and sex (). Typically, people presumed male at birth have a higher eGFR than people presumed female at birth at the same level of serum creatinine because the formula assumes a higher muscle mass in men contributing to the serum creatinine independent of renal function. The difference between these groups (given the same age and weight

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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 38-year-old Saudi female presented in July 2014 complaining of bilateral nasal obstruction for 10 years, for which she sought medical attention and underwent septoplasty and functional endoscopic sinus surgery 7 years ago at a different institute. Postoperatively, the patient noticed minimal improvement in her symptoms with persistence of right nasal obstruction. She also noticed right nasolabial fold fullness for a year, which increased in size over time associated with right facial pain. Clinical examination revealed a swelling in the right nasolabial fold measuring 2 × 1 cm. It was tender to palpation, hard in consistency, but with normal overlying skin. Anterior rhinoscopic examination of the right nasal cavity revealed lateral nasal wall swelling obliterating 90% of the nasal vestibule with normal overlying mucosa and skin colour externally. Computed tomography (CT) and magnetic resonance imaging (MRI) revealed a well-defined subcutaneous soft tissue density measuring 1.6 × 1.6 cm located in the right nasolabial fold. The lesion demonstrated isointensity with no drop in fat saturation T1 but showed hypointensity on T2 and homogeneous enhancement postcontrast ().
In August 2014, the patient underwent surgical excision of the mass through a sublabial approach, and the mass was found to be encapsulated with no infiltration to surrounding tissues and was excised completely with its capsule with uncomplicated postoperative period. Histopathological examination of the mass revealed spindle cells proliferation, forming fascicles and whorls on a background of collagen fibres. The fascicles were associated with foci of mixed inflammatory cells infiltrate composed mainly of lymphocytes and plasma cells, along with scattered eosinophils and neutrophils. The lesion infiltrates the surrounding striated muscles and fatty tissue with no infiltration to cutaneous and subcutaneous tissue. Moreover, immunohistochemical studies on the spindle cells revealed they are diffusely p

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


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

[User]
RADIOLOGY NOTE:
A 47-year-old female patient was admitted to the orthopedics service to undergo elective decompression surgery and lumbosacral spine arthrodesis (L4, L5, S1).
The orthopedic procedure was performed without complications. On the first postoperative day, the patient presented severe pain in the anterior aspect of the thigh, bilateral burning in the gluteal region and lower limbs in shock with neurogenic claudication.
Patient’s comorbidities comprised type II Diabetes Mellitus and hypothyroidism. The patient used 500 mg Metformin twice a day and 50 μg Levothyroxine once a day, on a regular and continuous basis, and did not have allergies.
The patient was in good general condition; she was flushed, hydrated, eupneic, afebrile and presented obesity grade I. The physical examination of the chest and cardiovascular system did not present relevant findings. Patients’ abdomen was flaccid and painless; it presented normal noises and did not show visceromegaly or palpable masses. Her orthopedic surgical incision presented satisfactory appearance. She had been submitted to a specific spinal cord MRI prior to her orthopedic surgery.
Lumbar CT was requested and, since the patient presented persistent pain on the 5th postoperative day, MRI of the lumbar spine was also requested; results showed posterior epidural collection in L3 and L4 with dural and spinal canal compression, as well as massive heterogeneous nodular perihepatic lesion (of undetermined nature) anterior to the right kidney. There were no association between the collection and the Schwannoma. The patient was subjected to a new surgery to drain the 50 mL collection that caused dural sac compression; the procedure did not show complications.
Given the heterogeneous mass found in front of the right kidney, which led to significant thinning of the inferior vena cava in lesion topography, the general surgery team was required to assess the patient, who had her pain stabilized and did not have new episodes of it. MRI of 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:
An 84-year-old female presented with progressive dysphagia to both solids and liquids and failure to thrive over several months. Her other medical problems included gastroesophageal reflux disease, hypertension, deep vein thrombosis, severe osteoarthritis of both hips, lower extremities contracture, and chronic low back pain. Initial laboratory work up was essentially unrevealing. Manometry study confirmed severe achalasia type 2. The decision was made to proceed with POEM procedure. During endoscopy, she was placed in supine position which was standard practice at our institution. Incision site was first injected with a premixed solution of saline and methylene blue (5 mL/500 mL) followed by careful dissection to the submucosal layer using a triangle-tip knife. A submucosal tunnel was being made from the incision site to 2 cm distal to the cardia, but after a complete submucosal tunneling process just before myotomy (Figure ), she developed severe hypotension and bradycardia. Consequently, the procedure was aborted. Chest X-ray revealed left apical pneumothorax, pneumomediastinum, pneumoperitoneum, and extensive subcutaneous emphysema. Her hypotension resolved with supportive care within minutes of aborting the procedure. A gastrografin swallow study was obtained which did not show any evidence of contrast leakage, but it demonstrated a grossly dilated esophagus consistent with achalasia, and postoperative edema with slow emptying at the gastroesophageal junction (Figure ). Thereafter, she underwent an upper endoscopy with Botulinum injection every 2-3 mo but eventually her symptoms stopped responding to botulinum treatment. Repeat POEM was thus performed 1 year later. She was placed in the same supine position due to her medical comorbidities. A severely dilated sigmoid esophagus was observed (Figure ). The GE junction was tight, and some pressure was required to traverse the endoscope, consistent with known achalasia. Due to great difficulty orienting the endosco

[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:
CC, a 25-year-old, had been referred to this unit after she developed erratic behavior while traveling abroad. As detailed in the summary that was brought to our attention, she was sectioned under the mental health act and upon returning to her premorbid state, she was allowed to fly back to Oman. In the discharged summary, she was given a tentative diagnosis of an acute psychotic/manic episode. She responded when prescribed with Olanzapine (10 mg BD).
Upon arrival in Oman, she sought consultation with the present unit. The accompanying family member informed the clinical team of her distress while traveling abroad, of which CC has minimal recollection. The family informed us that she often experienced uneasiness with others and exhibited strongly inappropriate emotion and culturally devalued conduct in the last 5 years. They noted that the distress occurred periodically (approximately every 29 days) with abrupt onset during a full moon. In traditional Omani society, certain lunar cycles are thought to trigger bad omens and malevolent spirits. Her symptoms were deemed manageable by the family since they appeared to dissipate with lunar changes. Further exploration of her changed self and conduct appeared to occur during the second half of her menstrual cycle and end at the onset of menstrual bleeding.
Premorbid, her life during childhood was uneventful. She excelled in her education, graduated with a university degree and was on the lookout for a job. CC denied having consumed any mind-altering substances including tobacco or its rejuvenated forms and alcohol. A routine urine drug screening did not reveal the presence of any illicit drugs in her system. Physical examination was unremarkable and her medical workup—including hormonal study, brain CT scan, and EEG—was inconclusive.
CC and her family were offered the option of continuing with the same medication she was prescribed abroad. CC and her family refused the option under the pretext

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


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

[User]
RADIOLOGY NOTE:
A 27-year-old female patient with a known case of triple-negative breast cancer admitted to the emergency room complaining of documented fever 40°C at home which was relieved with an antipyretic. She was status post 4 cycles of neoadjuvant dose-dense AC regimen which consists of doxorubicin 60 mg/m2 and cyclophosphamide 600 mg/m2 administered every 14 days. She was prescribed primary prophylaxis filgrastim after all cycles. Physical examination was unremarkable apart from her fever. The patient was admitted to the hospital having febrile neutropenia with no focus of infection and started on empiric antibiotics and filgrastim. She had a low white blood cell (WBC) count with an absolute neutrophil count (ANC) of 1100 cells/microlitre on day 11 after cycle 4 despite being on appropriate filgrastim dose at 300 μg per day for 9 days. On the second day of her admission, she recovered from neutropenia but continued to have persistent high-grade fever for almost two weeks despite escalation of the antibiotics and addition of an antifungal agent. She underwent series of investigations to identify the cause of her unexplained fever. She had extensive blood and urine cultures after each spike of fever, which all came back negative. Computed tomography (CT) scan ruled out infectious focus and showed hepatosplenomegaly with multiple splenic hypodensities and minimal perisplenic fluid which did not appear in the baseline scan (Figures and ). Infectious disease team advised for a splenic biopsy which showed splenic infarction only with no evidence of bacterial, fungal, viral, or malignant involvement (). She also underwent an echocardiogram study, sinoscopy, and series of rheumatologic investigations that were normal. General surgery team was consulted and did not recommend any surgical intervention since the follow-up CT scan turned out negative for splenic abscesses with interval improvement in the previous splenic wedge-shaped hypodensities (). Eventually, the patient was disch

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


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

[User]
RADIOLOGY NOTE:
An 18-year-old morbidly obese male with no reported past medical history presented to the emergency room after a high-speed motor vehicle collision (MVA). He had been positioned in the middle of the backseat and was ejected from the vehicle. The injury was reported to have occurred 1 hour prior to presentation at the hospital. Field responders had placed the patient on a backboard and placed a cervical collar. He was resuscitated with intravenous fluids during transport. No manipulation of the extremities was completed prior to arrival. Upon arrival to the emergency room, he was intubated and sedated for airway protection due to low Glasgow Coma Scale. He had sustained facial lacerations and closed head trauma. CT of the abdomen and pelvis was obtained showing a dislocated left hip, with the femoral head displaced into the intrapelvic space compressing the urethra (Figures and ). There was a small bony fragment noted, representing a minor acetabulum fracture, but no evidence of proximal femur fracture. He presented in critical condition due to subdural hemorrhage and was taken emergently to the operating room for a craniotomy performed by the neurosurgical team. Due to the acuity of his head injury, no other imaging of the orthopedic injuries was obtained prior to transfer to the operating room. He was already in the operating suite after completion of the craniotomy when the orthopedic team was able to evaluate the patient. Physical exam demonstrated gross deformity of bilateral lower extremities as both legs were externally rotated and shortened. On the right thigh, there was crepitus at the distal femur suggesting a distal femur fracture. Fluoroscopic imaging was obtained intraoperatively, confirming a right distal femur fracture and left hip dislocation. After receiving clearance from the trauma surgery and neurosurgery teams for further intervention on the patient at that time, the decision was made for emergent closed reduction of the left hip under general 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:
A previously healthy 60-year-old male was referred to the outpatient clinic due to atrial fibrillation. The patient reported pain in the lower left leg for 3 weeks followed by right-sided chest pain and dyspnea for 2 weeks. Transthoracic echocardiography (TTE) revealed a dilated right atrium (RA) with a large longitudinal thrombus (1–1.5 cm × 15–20 cm) fluctuating through the tricuspid valve (). The patient was stable and had no signs of right or left ventricular strain. Treatment with rivaroxaban 15 mg × 2 was initiated, and he was admitted to our center with suspected multilevel VTE: deep venous thrombosis (DVT), RA thrombus, and acute pulmonary embolism (PE). Computed tomography confirmed PE in the lower right pulmonary artery with associated pleural effusion. TTE and transesophageal echocardiography (TEE) confirmed the RA thrombus. Ultrasound revealed a large DVT in the left femoral vein stretching from the popliteal to the iliac vein. The patient was switched from rivaroxaban to unfractionated heparin (UFH) 5000 IE bolus followed by infusion starting at 1000 IE/hour and monitored by APTT. APPT remained in the lower range (maximum 77) treatment despite increasing doses of UFH to a maximum dose of 1900 IE/hour. After 3 days of UFH treatment, there was no regression of RA thrombus on TTE. The thrombus appeared to be attached in a thin fibrotic pedicle to the area between the superior vena cava and RA (). No persistent foramen ovale or atrial septal defect was found. Due to the large size and thin attachment, the risk of a possibly fatal PE was considered significant. As there were no regression in thrombus despite 7 days of anticoagulation treatment, it was decided to refer the patient for catheter-based embolectomy using the AngioVac system.
Preprocedural planning included a new ultrasound of the lower extremities that confirmed regression of thrombus in the lower veins bilaterally. This allowed for a femoral venous-venous access. The procedure was performed in a

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


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

[User]
RADIOLOGY NOTE:
A 76-year-old female admitted to hospital with a two-year medical history of type 2 diabetes mellitus, hypertension, and a diabetic foot ulcer on her left mid-foot that had not healed in over 4 months. The patient sustained a snake bite on the left midfoot at 6 years of age, resulting in a severe foot infection. She recovered from the infection but acquired a residual foot deformity. She has been suffering from numbness and pain in the left mid-foot for many years. To cope with the left foot pain, she attempted to bear more weight in the right foot but reduced activity than the right foot. Two years ago, she was diagnosed with type 2 diabetes mellitus. Subsequently, a recurrent chronic ulcer appeared at the site of the snakebite and for more than 4 months was difficult to heal.
Physical examination revealed an ulcer of approximately 1.5cm×0.5cm on the left medial midfoot with purulent discharge (). The ulcer had a 0.8cm deep cavity and a portion of bone was observed at the wound bed with a positive probe-to-bone test. The surrounding tissue was pale. There was no obvious pain and bleeding on the wound surface. The left foot was hypoesthesic and slightly swollen. Light touch sensation was intact in the left foot. The distal pulses, including pedal and posterior tibial pulses, of both feet were palpable.
Laboratory investigation showed elevated random blood glucose of 14.3 mmol/L and hemoglobin A1c of 7%. The C-reactive protein level was 1.8 mg/L. The erythrocyte sedimentation rate was 17 mm/h. The ankle-brachial index greater than 1.3 in both legs suggested posterior tibial and dorsalis arteriosclerosis. Vibration perception threshold testing indicated severe peripheral neuropathy. Radiographic imaging of the left foot revealed changes in the distal part of the first and second metatarsal bones and abnormal bone morphology. MRI showed multiple bone marrow edema of metatarsal, navicular

[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 Sri Lankan woman with longstanding hypothyroidism, diabetes mellitus, hypertension, hyperlipidaemia and bronchial asthma presented to a general medical ward with a recent history of a large, spontaneous, painless bruise over her right thigh. Medication included low dose aspirin 75mg daily. There was no family history of bleeding disorders and she was haemodynamically stable. An ultrasound scan excluded coexisting deep soft tissue haematomas and a full blood count demonstrated a white blood cell count of 11.2×109/L with normal differentials, haemoglobin level of 12.3g/dL and a platelet count of 258×109/L. Coagulation screening revealed an aPTT of 66.4 seconds with normal bleeding, prothrombin and thrombin time, results that were confirmed over repeated assays. The results of her blood films, urea, electrolytes, creatinine and liver function tests were all normal.
Further investigation in our haematology unit demonstrated the presence of a time-dependent inhibitor of coagulation via prolonged aPTT and a mixing study that did not correct with the addition of normal plasma and incubation for 2 hours (aPTT was 52 seconds when the mixing test was performed, with a ratio of her plasma to normal plasma of 50:50). A mixing study of incubated and fresh mixed plasma did not demonstrate a temperature-dependent inhibitor of coagulation (aPTT was 27 seconds with a ratio of her plasma to normal plasma of 50:50). Clotting factor VIII assay and inhibitor titres were not possible due to a lack of facilities. An indirect assay of deficient factor was carried out by adding factor VIII or IX deficient plasma to her plasma. The aPTT was corrected by adding factor IX deficient plasma, but not by factor VIII deficient plasma, thus suggesting factor VIII deficiency. Plasma fibrinogen was 260mg/dL (150 to 250) and platelet aggregation studies were compatible with the expected aspirin-induced changes. This therefore suggested a diagnosis of acquired haemophilia A. Investigation

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


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

[User]
RADIOLOGY NOTE:
A 39-year-old male patient was admitted to our clinic with a complaint of inability to extend his right knee after an epileptic convulsion that occurred at rest. He had no history of trauma. The patient had a history of left patellar tendon (PT) rupture from the patellar insertion during previous epileptic seizures at rest and underwent two operations in the previous two years. The proximal part of the PT was ruptured from the insertion area of the patella on his presentation.
The interface of the bone and the ruptured tendon were refreshed. Then, tunnels were carved in the patella from the distal to proximal direction. Krackow suture was used to fix the proximal end of the PT. The free ends of the sutures were guided into the tunnels. The proximal part of the PT was tensely tightened. In this way, the PT was secured to the region of the patella where it had ruptured from. No complications were observed during the two-month follow-up. The knee regained full range of motion. Muscle power, pain score, and knee function were evaluated according to the Knee Society Clinical Rating System (KSCRS). The score was excellent 2 months after the operation.
Active extension of the right knee was absent. Swelling and tenderness were detected in the supra-patellar region. Additionally, a gap was also detected by palpation, which occurred due to the displacement of the ruptured tendon endings.
The hematologic parameters (white blood cell count, hemoglobin, platelet count, creatinin, uric acid, alkaline phosphatase, parathyroid hormone, calcium, phosphorus, and 25-OH vitamin D) were within normal ranges.
The patient had a history of AEM use for 29 years.
Disruption of the QT was detected by magnetic resonance imaging (MRI) (). The patient was operated on the second day of hospitalization. The distal part of the QT was reached by a vertical incision. The distal part was ruptured from the insertion area of 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 20-year-old man with both upper limb disabilities admitted to our hospital for mandatory health screening before military service. He had no health complaints other than the skeletal disorder involving his upper limbs. In detailed questioning, he stated that he had four fingers in his left foot. He is the last of six children born to nonconsanguineous healthy parents. All of his brothers and sisters are completely healthy. There is no family history of any kind of congenital skeletal abnormalities in the extended family. His mother was at the age of 32 when she gave birth to our patient. There is no history of any drug, smoke, alcohol, or radiation exposure during pregnancy. Our patient was born uneventfully at full-term through normal vaginal delivery. No other significant health problem is present in the history of his childhood.
On physical examination, all skeletal elements beyond his left elbow and right wrist, and the fifth finger of his left foot were found to be absent (). He had oligodactyly of the left foot (). Anteroposterior radiograph of the right arm depicted the absence of the hand with well-developed radius and ulna. There was a rudimentary bone of about 1 cm in the medial neighborhood of the distal ulna (). Anteroposterior radiograph of the left arm demonstrated that the proximal forearm segment participating in the elbow joint structure was small but present, while the radius and ulna distal to this point were absent (). Anteroposterior, lateral oblique, and mediolateral radiographs of the left foot revealed absence of the fifth finger and the lateral cuneiform. The second to fourth fingers were short. The number, size, and joint relations of the other bones forming the foot were normal (). Magnified anteroposterior and lateral oblique radiographs of the left foot showed that the middle phalanges of the second and third fingers were shorter than the distal phalanges, and the middle phalanx of the fourth finger was absent ().
The patient was then

[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 case is of a 3.7-kg, 1-month-old male patient who presented at day 24 of life with severe aortic stenosis (AS) and coarctation of the aorta (CoA). He was born at term following an uncomplicated pregnancy. On day 5 of life, he was noted to be jaundiced and have a murmur. His jaundice resolved, and he was discharged home with cardiac follow-up. He then had progressive increase in his work of breathing and was not gaining weight. He had an echocardiogram on day 24 of life which showed a thickened and dysplastic bicuspid aortic valve with doming of the valve leaflets. The flow across the valve was measured on continuous wave doppler at 4 m/s. He was also found to have a discrete juxta ductal coarctation of the aorta with continuous doppler flow of 2.5 m/s with diastolic tail. His ventricular function remained preserved. He was started on intravenous prostaglandin and urgent surgery was scheduled.
Due to the complexity of the case and the need for both aortic valve and aortic arch intervention, it was felt the best course of action would be a hybrid approach with surgical end-to-end anastomosis of the aortic arch via a thoracotomy followed by surgical carotid cut down for AoVP. This plan was made to avoid the need for a sternotomy on bypass to alleviate the aortic valve stenosis. The patient was taken to the hybrid catheter laboratory theater, where he was placed in the left lateral position, prepped and draped. He underwent the surgical end-to-end anastomosis via the thoracotomy via the third intercostal space, as planned. The arch, patent ductus arteriosus (PDA) and descending aorta were then dissected out. Clamps were applied to the arch and descending aorta. The coarctation segment was resected and PDA ligated. After this, an end to side anastomosis was performed between the aortic arch and the descending aorta. The pleura and chest were closed in layers.
At this point

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


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

[User]
RADIOLOGY NOTE:
This study was approved by the Ethics Committee and institutional Review Board of the Affiliated Hospital of Chengde Medical University.
A 46-year-old Chinese woman visited our hospital 2 h after a motor vehicle accident. She had severe lower back pain, grade 0 muscle strength of lower limbs, no sensory function below the injury level, and an inability to urinate or defecate. The patient was alert but had no motor function below the groin level. Neurological examination showed that her muscle strength in the bilateral lower extremities was grade 0/5, with an obvious hypesthesia below the level of groin, impaired sensation of the perineum region, and absent voluntary anal sphincter contraction. Visual analog scale (VAS) score for back pain was 10. Computed tomography (CT) showed L1 burst fracture, and retropulsion of bone fragments into the spinal canal, with MSDCR 70.3% (Fig. ). Magnetic resonance imaging (MRI) showed that bone fragments had retropulsed into the spinal canal and dural sac was severely compressed (Fig. ). And the patient was diagnosed with a Magerl type A 3.2 L1 burst fracture. Given the patient's condition, emergency surgery was needed to prevent secondary spinal cord injury and induce neurologic recovery. We first performed PPSF to stabilize the spine, correct deformity, and achieve indirect decompression of the spinal canal via percutaneous reduction internal fixation.[ The specific procedure for PPSF was as follows: The patient was put under local infiltration anesthesia and in a prone position. The C-arm fluoroscope was used to determine the skin entry point. Infiltration anesthesia of the periosteum was achieved with the 0.5% lidocaine injection. The puncture needle was advanced into the vertebra via the vertebral pedicle guided with fluoroscopic imaging, followed by guide wire insertion. Suitable cannulated screws were inserted percutaneously along the guide wire and connected with a rod. The screws were tightened and fixed to realign the inju

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


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

[User]
RADIOLOGY NOTE:
This case describes a 29-year-old woman who was first diagnosed with ameloblastoma as a child at 7 years old. The lesion originated in the ascending branch of the left mandible, and the first surgical procedure was performed in March 1997 followed by disease recurrence in April 1999. A second resection was performed in May 1999, and during the next 16 years, the patient underwent several surgical approaches that were consistently followed by disease recurrence. Some of the procedures were conservative surgeries, but others were radical procedures that left her with several deforming scars. She presented to our clinic in January 2015 with a new magnetic resonance imaging (MRI) that evidenced a right, triangular aspect, paracellarlesion, extending to the homolateral cavernous sinus (13 × 9 mm), which was suspected to be a residual lesion that would have achieved the cavernous sinus by contiguity growth after several surgeries. Her last surgery had been performed in April 2014 and was followed by local radiotherapy in May 2014. She was asymptomatic and not willing to undergo a new invasive procedure. She decided to be followed without further intervention.
For the next 18 months, she was clinically stable and asymptomatic, but she returned in July 2016 with intense pain on the right side of her face that required multiple hospital visits for intravenous analgesia. MRI revealed an extensive heterogeneous lesion with contrast enhancement centered on the right cavernous sinus anterior to the cavus of Meckel and exhibiting anterior extension towards the upper orbital fissure (measuring approximately 19 × 15 × 16 mm). To identify new treatment possibilities, we decided to perform a new biopsy and conduct molecular testing (Fig. ). A BRAF mutational analysis by the allele-specific protein chain reaction (PCR) certified test revealed the presence of a BRAF c.1799 T > A;p.V600E mutation corresponding to a V600E amino acid substitution. After tumor board discussion and a carefu

[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.