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

[User]
RADIOLOGY NOTE:
A 29 years old primigravida patient presented with a 6 weeks history of amenorrhea. In physical examination she had a uterus of 6 weeks pregnancy and the ultrasonography examination of the abdomen showed a myoma measuring about 107 × 60 mm (Fig. ).
She didn’t have any symptoms related to the myoma such as abnormal uterine bleeding or pain, before pregnancy and also there were no complications during pregnancy due of myoma. For example the level of her hemoglobin before and after operation was 13.4 and 12.8 mg/dl.
In serial sonographic studies, the size of the myoma was increasing and in the last one, the weight of fetus was below 10% of normal growth curve. At the third trimester, the myoma was palpable, about 15-20 cm. so she was considered to undergo the elective cesarean section due to the probability of obstructed labor in 38-39 weeks of pregnancy.
After consultation with anesthesiologist, the cesarean section was performed.
The abdomen was opened with pfannenstiel incision. After take down of the bladder the lower segment of the uterus was incised and due to the huge myoma in the lower segment, the incision was extended a bit upper. When the amniotic membrane was found and ruptured, a female 2500 gr. weighted newborn was delivered with difficulty. The apgar score of the newborn was 8 at the first minute.
After removal of the placenta high dose oxytocin (30 IU /1000 cc. ringer lactate) was infused in 1 hour.
The myomectomy was done and a single intra-mural myoma measuring about 20 cm. weighting 1500 gr. was removed. During the procedure of myomectomy, infusion of oxytocin was continued.
The amount of hemorrhage was almost 1200 cc that was similar to other cesarean section cases which was compensated with ringer-lactate solution.
The duration of operation was 38 minute that added 10 minutes and Hgb. level

[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 68-year-old male, farmer by occupation, presented with the complaints of nasal blockage and intermittent streaking of blood from left nostril for six months. There was no relevant past medical / family history. On examination, there was swelling of the left alar region. Anterior rhinoscopy showed a shiny polypoidal mass in the left nasal cavity which was friable and bled on touch. Patency was reduced and cavity was filled with blood stained discharge. Posterior rhinoscopy was normal. Examination of the throat, ears and larynx were normal. Evaluation of the case demonstrated only mild anemia with otherwise normal baseline hematological and biochemical profile. Urine and stool examinations were normal. Chest radiograph, ultrasonography of abdomen and all other relevant investigations were normal. Computed tomographic (CT) scan showed an enhancing soft tissue lesion in left nasal cavity with a suggestive diagnosis of a polypoidal mass not otherwise specified. CT guided aspiration cytology of the lesion was carried out. The smear showed large epithelioid and few spindle cells showing hyperchromatic nuclei, macronucleoli and both intra- and extra-cellular melanin pigments that led to a provisional diagnosis of malignant melanoma []. All other possible sites of primary malignant melanoma were excluded. The patient was operated and tumor was excised by lateral rhinotomy. The tumor was polypoidal and capsulated which ruptured during removal and hence it was removed in pieces. The tumor was attached with a broad base and was found on the inferior turbinate of left nasal cavity. After removal of tumor, the gross examination revealed several bits of blackish, irregular, soft and friable tissue, totally aggregating to form 5 cm × 6 cm mass. The hematoxylin and eosin stained section showed the tumor was composed of epithelioid and spindle cells which were medium to large in size, arranged in lobules and small bundles. The nuclei were pleomorphic, hyperchromatic with prominent

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


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

[User]
RADIOLOGY NOTE:
A 48-year-old married woman presented to our hospital with intermittent gross hematuria for 3 months. She had regular menstrual cycle of 28 days without pain around her waist line or abdominal pain and no history of gynecologic surgery. She denied a family history of cancer, endometriosis, genetic and psychosocial diseases.
There was no obvious mass on the palpation of the bilateral kidney area, and no percussion pain. An ultrasound of the urinary system was recommended first. Conventional ultrasound examination was performed under standardized settings using Toshiba ultrasound systems (Aplio500, Tokyo, Japan) (ultrasound transducer: PVT-375BT, frequency 3.5 MHz). Ultrasonography showed a cystic mass in the lower pole of the right kidney with septa and well-circumscribed. The thickness of the cystic mass wall is about 4 mm. Doppler color flow imaging showed a small signal in the wall of the mass, but no blood flow was detected in the cystic part. Contrast-enhanced computed tomography (CT) of the kidney was then performed. It showed a heterogeneous hypodense mass in the lower pole of the right kidney, measuring ~1.8 × 1.5 × 1.4 cm (). The mass was polycystic, with slight enhancement of the wall and septa and no enhancement of the cystic area. Contrast filling of the mass was not observed during the excretory phase. The right lower pole of the kidney was partially depressed, and there was some local thinning of the renal cortex. Given the slight enhancement of the mass, the possibility of cystic renal tumor could not be ruled out, and surgical resection was planned. Laparoscopic right renal mass resection was subsequently performed at our hospital on the 7th day after her menstruation. After successful anesthesia, the surgeon opened the lateral retroperitoneum under laparoscopy, pushed the colon away and opened the Gerota's fascia, then carefully dissociated the right kidney. The right lower pole of the kidney was partially irregular and contracted. 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 59-year-old man presented to our hospital with a two-month history of swelling over the dorsal surface of the cuboid bone of his right foot. Radiography showed an osteolytic lesion over his right cuboid bone (). Initially, a bone tumour was suspected and so computed tomography (CT) and magnetic resonance imaging (MRI) scans were performed. The CT scan showed bony destruction over the patient’s right cuboid bone (). MRI scans showed multilocular fluid collection over the right cuboid bone extending from the plantar to the dorsolateral side (). Fluid accumulation was noted along the plantar fascia with a hypointense lesion observed on both T1-weighted (TIW) and T2-weighted (T2W) images without enhancement ().
On further questioning, the patient described that he had been stabbed accidentally two years previously by a nail in his right foot and that he had removed the nail himself without specific wound care. His wound had healed well and he had continued with normal working life. Blood samples taken at the hospital showed the patient to have a moderately elevated erythrocyte sedimentation rate (ESR) (37 mm/hr) without leucocytosis. Therefore, chronic osteomyelitis with abscess formation over the plantar to dorsolateral side of right foot with cuboid bony destruction was suspected. Debridement surgery was arranged.
During the operation, bony destruction of the cuboid bone with abscess accumulation and sinus tracts extending to the plantar fascia were observed. A plastic-like foreign body (1 cm × 0.8 cm) surrounded by an abscess was found over the plantar fascia (). The patient recognized the foreign body as a fragment from the sole of his shoe that he was wearing at the time he sustained the stabbing injury.
Analysis of specimens collected during the operation showed the presence of acute and chronic inflammatory cell infiltration, granulation tissue, necrosis, fibrosis and aggregation of degeneration leukocytes, all findings compatible with an abscess. The deep-woun

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


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

[User]
RADIOLOGY NOTE:
A 50-year-old male was brought to the emergency department after he jumped from a 5-meter bridge in an attempted suicide and fell on the hard concrete below. Upon admission, the patient was agitated, disoriented, and in intense respiratory distress. Examination revealted that the patient’s airway was clear, but there was a bilateral absence of breath sounds and hyperresonance on percussion. The patient was hemodynamically stable. He was intubated due to respiratory failure. Bilateral chest tubes were inserted based on a high clinical suspicion of pneumothorax. Thereafter, the patient developed a large subcutaneous emphysema, despite the fact that the chest tubes were functioning with his severe air leakage. Past medical history was unremarkable with no previous formal depression diagnosis. A social history check showed daily marijuana and tobacco use.
The patient was sent for a head, neck, thorax, abdomen, and pelvis CT scan. The scan revealed giant bullous emphysema on the superior lobes bilaterally, right pneumothorax with a collapsed lung, along with multiple rib fractures, and lung emphysema (, ). A hip dislocation was detected, and closed reduction was performed.
The patient was sent to the ICU, where he improved clinically after conservative treatment with continuous negative pressure suction using a 20 cm water column. He was extubated after 48 h, with persistence of the air leakage on both chest tubes.
On the day following extubation, he developed hypoxia associated with disorientation and agitation and had to be intubated again. Hypoxia was postulated from pulmonary contusion and ventilator-associated pneumonia worsening his already baseline compromised lung. He developed sepsis, and subsequently acute kidney injury with the need for dialysis.
During the course of 5 days, the patient presented hypoxia and a severe mixed metabolic and respiratory acidosis, despite the use vancomycin and piperacillin/tazobactam. The treatment with bilateral chest tubes associ

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


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

[User]
RADIOLOGY NOTE:
A 46 year old male presented with severe pain in the left arm for 1 week. Six months earlier, he had sustained a closed fracture of the left clavicle and upper five ribs. This was managed nonoperatively with an arm sling. Following a duplex scan, a left brachial embolus was diagnosed and an embolectomy was done; but this had to be repeated a few days later, as he presented again, with the same symptoms. As his pain and numbness did not abate after two explorations, the patient was referred to this center.
At the time of presentation to us after the second embolectomy, the left arm was cooler than the right and finger pressure was zero. The left brachial, radial and ulnar pulses were absent. Sensation was decreased below the elbow and motor power was grade 4 (Medical Research Council Grade). On examination of the clavicle, there was a bony discontinuity palpable along the middle one third, with abnormal mobility. There were no pulsatile swellings or palpable bruit at the nonunion site. A chest X-ray revealed an atrophic nonunion of the middle third of the clavicle with significant over riding of the ends []. A computed tomography angiogram (CTA) showed a pseudoaneurysm of the left subclavian artery, adjacent to the nonunion of the clavicle [].
Patient underwent excision of the pseudoaneurysm and fixation of the clavicular fracture. The vessel was approached via an infraclavicular incision. Proximal and distal control of the subclavian artery was obtained followed by identification of the pseudoaneurysm. The sac was opened and thromboembolectomy was done. The defect was then closed with a primary repair []. This was followed by operative stabilization of the clavicle. The atrophic ends of the nonunion were dissected and the intervening fibrous tissue resected. The distal end of the nonunion was found to be in close proximity to the aneurysm and had probably button holed into the subclavian artery causing the primary injury. A 3.5 millimetre precontoured locking

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


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

[User]
RADIOLOGY NOTE:
A 35-year-old Greek female patient, gravida four and para two, presented to our breast unit department due to a non-palpable breast lesion which was revealed via ultrasonic examination, with malignant ultrasonographical features. Her personal medical history and her psychosocial history were uneventful and Pap Smear tests were up to date and all negative. She was non-smoker and consumed alcohol only in social occasions. Her body mass index (BMI) was 30, 48 Kg/m []. Because of her mother’s breast cancer history (diagnosed with breast cancer at the age of 50, but never tested for BRCA), the patient was followed up via transvaginal ultrasonography and breast ultrasonic examination every six months since 2004.
Upon arrival, physical examination of her breasts did not reveal any palpable mass. Breast ultrasonography showed a hypoechoic lesion of 0,9 × 0,8 cm located in the lower inner quadrant, while breast magnetic resonance imaging confirmed the suspicious and possible malignant finding on her right breast (MRM BIRADS IV) (). The chest x-ray test was normal. Her laboratory workup was all normal.
Under general anesthesia, a total excision of the lesion (which had been marked via a hook wire) was performed by a gynecologist specialized in breast surgery with 6 years’ experience in breast surgical procedures. The normal tissue of the breast, the nipple and the areola were conserved. The excised mass was almost 1 cm in diameter. The contralateral breast was normal. Ultrasound guided biopsy was not performed because BIRADS IV was overestimated (not necessarily malignancy). There were no peri-operative complications and the breast healed well. Post-operatively, the patient was followed up in the breast ward. She was administered antibiotics, fluids and painkillers intravenously. Histology confirmed the ultrasonic diagnosis, revealing a central low grade invasive ductal carcinoma and a peripheral in situ ductal breast carcinoma grade III (). The margins of the resected surgic

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


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

[User]
RADIOLOGY NOTE:
A 52-year-old man, after a fall on the ground, suffers from an intertrochanteric fracture of the left hip, and during the operation, a biopsy was performed from the area. In the description of pathology, evidence of metastatic lesions from prostate or kidney or thyroid gland had been reported. During the whole-body bone scan, there were other lesions in the T8–T9 and ankle and left knee areas []. Two months later, the patient had deep-venous thrombosis (DVT) of the left leg, and 1 month after the DVT, he had an atrial fibrillation rhythm that was detected after thyroid tests that revealed T3-thyrotoxicosis. In the thyroid examination, thyromegaly and the left lobe nodule were touched. After performing thyroid ultrasonography, a heterogeneous hyperechoic nodule was reported at a size of 78 × 50 × 42 mm that occupied the entire left thyroid lobe. The right thyroid lobe was large but without a nodule. The laboratory data are summarized in . The thyroid scintigraphy with technetium-99m showed a large cold nodule in the left lobe of the thyroid gland []. The patient was treated with methimazole, and after endocrinology consult and performing fine-needle aspiration from the left lobe of the thyroid nodule, pathology report showed follicular neoplasm. And then, the patient underwent total thyroidectomy. The pathology report was that there was no specific lesion in the macroscopic examination of the right thyroid lobe, but the left thyroid lobe occupied a mass of 6.5 cm in diameter with relatively distinct margin, which seems to remain a narrow rim of the thyroid tissue. In a microscopic examination, the thyroid specimen was that sections of the capsular mass composed of follicular cells, mainly with a microfollicular and trabecular arrangement. In some areas of the cytoplasm, these cells were acidophilic and in some areas clear. The nucleus of the cells is usually round and sometimes has a nucleus of prominence, and localized necrosis was seen. In limited areas (<4

[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 80-year-old woman underwent total knee joint arthroplasty due to the degenerative arthritis of the left knee joint. She did not have any history of trauma or coexisting medical illnesses. Her body weight was 45 kg, height was 153 cm and body mass index (BMI) was 19.34. She had been prescribed sodium alendronate and cholecalciferol composite agent (Fosamax plus D®; Merck & CO, Inc., West Port, PA, USA) for 1 year at local medical clinic. At a preoperative work-up, the patient received dual energy X-ray absorptiometry (DXA); this showed that the T-score of the femoral neck and lumbar spine were -3.6 and -3.1, respectively. Hematological investigations were within normal limits. A 5 days after operation, the crutch walking was started. The patient was discharged on 1 week after operation without significant complication. On postoperative month 3, the patient visited the outpatient clinic of the clinical department due to the presence of pain in the left heel. The patient told us that there was no trauma. On examination, there were edema and tenderness on the lateral and superior side of the left calcaneus. A compression test was also performed for the calcaneus; this also showed positive findings. There were no findings that are suggestive of burning sensation or erythema. On lateral and axial view of a plain radiography of the posterior region of the calcaneus, radiopaque lesions were shown as an irregular line that is parallel with the posterior joint of the subtalar joint (). The patient was informed of the possibility of insufficiency fracture and then prescribed with anti-inflammatory drugs. In addition, the patient was advised to limit a weight bearing during a gait. One month later, the patient visited the outpatient clinic again, presenting with a persistent presence of edema and pain again. A compression test was also performed for the calcaneus; this also showed positive findings. Radiopaque lesions that had been seen on lateral

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


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

[User]
RADIOLOGY NOTE:
A 73-year-old Chinese woman with a history of hypertension presented with a one-month duration of fever and chills. There were no localizing symptoms to suggest a source for her fever. Physical examination was unremarkable.
In the past month before admission, she had received 3 courses of oral antibiotics with no resolution of fever. She was worked up extensively for pyrexia of unknown origin. Blood, urine, fungal, sputum AFB cultures, autoimmune and hepatitis viral screens were negative. Syphillic markers were negative. There was no evidence of a malignancy. Computed tomography of the abdomen and pelvis were normal.
A transthoracic echocardiogram showed a severely dilated ascending aorta with an end diastolic diameter of 5.8 cm. There were no valvular vegetations. A contrast enhanced computed tomography aortogram revealed a large eccentric, cresenteric thrombus at the anterior aspect of the ascending aorta with two large ulcerations in its anterolateral aspects as a result of a chronic type A aortic dissection (Figures and ).
Intra-operative findings showed a chronic Type A dissection with a large 3 cm tear involving the anterior and anterolateral aspects of the ascending aorta. There were large amounts of intramural thrombus extending from the aortic root to the origin of the innominate artery. The aortic valve and coronary ostia were not involved. A hemiarch replacement with a 28 mm Gleweave Vascutek Graft was performed with resuspension of aortic valve commisures. Bacterial cultures from the aortic thrombus revealed coagulase negative Staphylococcus aureus and repeat blood cultures were negative. Histology of the ascending aorta showed chronic dissection of the aorta with a split occurring in the outer third of the aortic media. There were atheromatous changes throughout the resected segment, with marked destruction of the elastic tissue framework which was particularly extensive at the dissection site. There were previous episodes of hemorrhage with varying deg

[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 yr-old woman with complaints of massive abdominal distention and respiratory distress was referred to the gynecology and oncology department of an academic hospital, Mashhad University of Medical Sciences in Aug 2017. In past medical history, she mentioned a secondary infertility for four yrs and had one child aged eight yrs. The patient was candidate for In Vitro Fertilization (IVF) protocol due to tubal factors. In the first cycle of ovarian stimulation, metformin and Gonal-f 75 IU for six days were prescribed () and then continued for two days. The cycle was cancelled due to poor response after the second month from this protocol. She suffered from gradual abdominal distention.
Despite the failure of IVF, she was under the outpatient care and supportive treatment with possible diagnosis of hyperstimulation syndrome. Therefore, antagonist GnRH was prescribed for two days. At the next delayed month visit, because of persistent symptoms with the probability of hyperthyroidism, she received gonadotropin hormone agonist (Decapeptyl). She was re-evaluated due to unresponsive to treatment within this period.
Trans-abdominal and transvaginal ultrasonography were performed that showed multiple multiloculated cystic masses with predominantly solid components in both adnexa. The results of cross-sectional CT-scan and magnetic resonance imaging suggested the ovarian neoplasm. Also, massive peritoneal and pleural effusion was detected (). In this time, 4 months after management of hyperstimulation syndrome, due to persistent large ovarian mass and increased tumor marker inhibin more than 3000 pg/mL, she was referred to our oncology department. Physical examination demonstrated enlarged masses extended up to hypogastric region which resembled 36 wks of pregnancy.
Exploratory laparotomy was performed that showed massive ascites fluid and multi solid cystic masses in both ovaries extended up to the Xiphoid. Complete resection of the tumor was done. Pathology report of froze

[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 male with established Alagille syndrome, complicated by hemodialysis-dependent end-stage renal disease and liver cirrhosis, presented with an 8-month history of headaches and hearing loss (right worse than left). Brain magnetic resonance imaging (MRI) revealed a 3 cm, extra-axial, diffusion restricting, posterior fossa mass involving the right temporal bone posterior to the mastoid air cells, invading and occluding the transverse/sigmoid sinuses, and distorting the cerebellum [] Surgery was recommended for the goals of pathological diagnosis and maximal safe resection.
A C-shaped retroauricular incision was made, and the underlying muscle and fascia were reflected to expose the retromastoid region. Drilling was performed to create a quarter-sized retrosigmoid craniotomy; then, dissection under the operating microscope showed an epidural white keratinizing pearly lesion displacing the cerebellum inferomedially. Samples of the lesion were removed and sent for pathological analysis. The lesion was hypovascular and removed completely with suction and microdissection to carefully elevate the capsule of the lesion from the dura. The exposed mastoid air cells were covered with muscle grafts and oxidized cellulose along the superior and anterior aspects. The lesion was further resected to the occluded transverse and sigmoid sinuses, which were filled with thrombus. The surrounding bone was thoroughly curetted, and the surgical cavity was copiously irrigated, then carefully inspected to confirm the absence of gross residual disease. A small myofascial free tissue graft was placed over the resection cavity. There were multiple small rents in the dura, which were covered with a synthetic dural graft. A titanium mesh was used to cover the entire craniectomy defect. The fascia and skin were closed in standard fashion.
On microscopic examination, permanent sections showed multiple portions of tumor wall containing acellular keratin debris. The tumor was lined by ker

[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 70-year-old female patient was referred to department of Oral Medicine and Radiology with a chief complaint of a swelling in left side of neck since 12 days and pain in swelling since 10 days. Pain was increased in intensity while swallowing. Patient gives no history of fever and difficulty in eating and speaking. Patient noticed that initially swelling was initially small in size and gradually increase to present size of 4-3 cm. The patient's medical history was unremarkable.
Clinical examination revealed that spherical shape swelling was present and that measured 4-3 cm in diameter. Swelling extending from 1 cm below lower border of mandible to upper border of thyroid cartilage. Swelling has well-defined and regular border, surface was smooth and skin over the swelling was red and shiny. It was tender on palpation but temperature was not raised. Consistency of swelling was soft and rubbery and fluctuation was present but it was not fixed to overlying skin. Other intraoral findings were grossly carious lower left second molar and fracture crown with right and left first molar. Considerable deposition of sub- and supragingival calculus and stains was noticed. Missing teeth were upper right and left molars.
When swelling is seen at the side of neck, it is important to formulate the differential diagnosis since this would help further evaluation of the condition and management of the patient. After considering all clinical findings following entities were considered in differential diagnosis—acute submandibular sialadenitis and benign swelling of neck ().
After that patient was advised for drainage of abscess. The investigatory work up included complete hemogram, intra oral radiographs, orthopantomograph and ultrasonography. Routine hematological investigations were within normal limit. Orthopantomograph shows carious root fracture with lower left second molar and advanced mesial caries with periapical radiolucency with lower left third molar. Ultrasonographic findi

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


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

[User]
RADIOLOGY NOTE:
A 49-year-old nonsmoking male presented to the dental office complaining of missing maxillary right lateral incisor []. The tooth was extracted 2 months before presenting to the clinic due to root fracture. Previous dental history revealed that the tooth had received a root canal treatment and had a postretained crown. A removable partial denture was fabricated for him by his previous dentist immediately after extraction to restore the space of the extracted maxillary lateral incisor.
Radiographic examination revealed a socket of recently extracted maxillary lateral incisor with bone level 2–3 mm below the cementoenamel junction (CEJ) of the adjacent teeth []. Intra-oral examination revealed a fair oral hygiene with 1–2 mm recession of the gingival margin below the CEJ. The space available of the area related to maxillary lateral incisor was 6 mm mesio-distally and 7 mm interocclusal distance. Upon presentation of the various options of treatments, the patient opted to restore the space with implant treatment. Clinically, there was enough bone to place an implant size 3.5–4 mm. Radiographically, enough bone height was available to receive up to 13 mm implant. The decision was made to proceed with a single implant to restore the space of the maxillary right lateral incisor and to maintain and to create natural soft tissue contour and emergence profile around the tooth to improve esthetic.
Maxillary and mandibular study models with a face bow transfer were obtained, and a diagnostic waxing of the maxillary lateral incisor was performed. A surgical guide was then fabricated to insure proper position of the implant during placement procedure. The patient had decided to concentrate only on replacing the missing lateral incisor, declining esthetic enhancement of the surrounding dentition.
Before surgery, the patient received a session of prophylaxis with oral hygiene instruction. New periapiacl rediograph was taken [], and surgical placement of the implant completed using

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


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

[User]
RADIOLOGY NOTE:
We present a case of a 25 year-old man who complained of worsening back pain and left lower limb weakness and radiculopathy for two weeks. He was unable to walk due to the pain and weakness. There was no bowel or bladder incontinence but he had loss of appetite and significant weight loss.
He had history of fall and sustained a stable burst fracture of T12. He was treated with an extension body cast at that time as there was no suspicious lesion on the radiographs. During follow-up, he developed a kyphotic deformity of which we performed pedicle subtraction osteotomy of T12 a year after the primary injury. He defaulted the follow-up after surgery.
Examination revealed a posterior midline surgical scar measuring 12cm. There was a mild kyphotic deformity. His hip and knee flexion were weak with a medical research council (MRC) muscle power grading of 3. The ankle and toes had MRC muscle power grading of zero. Magnetic resonance imaging (MRI) was suggestive of an aggressive spinal tumour over T12 with extension to T11 and L1 (). Computed tomography of the lungs revealed no lung metastasis.
He underwent posterior extension of fusion from T8-L4 with total vertebrectomy of T11, T12 and L1. Excision of the posterior elements of T11 and L1 then removal of the pedicles of T11 and L1 was done. En bloc tumour removal was attempted but scarring and adhesions to the diaphragm prevented an en bloc removal, so piecemeal vertebrectomy of T11, T12 and L1 and excision of tumour was performed. Three segmental arteries were ligated on the right side to facilitate cage insertion and the bone gap reconstructed with a titanium mesh cage filled with bone cement (). The reconstructed mesh was shorter than the total height of the removed vertebral bodies, as we shortened the spinal column, but not exceeding one vertebral body and two discs height to prevent cord buckling. Intra-operatively there

[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 male, presented with history of sudden onset shortness of breath of 20 days duration, which had worsened from New York Heart Association (NYHA) class I to NYHA class IV over a course of 3 days along with, orthopnea and extreme fatigue. The patient had been completely asymptomatic prior to these 20 days. There was no history of specific triggering events or undue exertion prior to symptom onset. General physical examination was unremarkable. The patient was profoundly dyspneic at rest. His pulse rate was 110/min, feeble in volume and of no special character. Blood pressure was 82/58 mm Hg in the left upper limb in sitting position. Jugular venous pulse was elevated to 12 cm with prominent v waves. He had a left parasternal heave and on auscultation the cardiac apex was laterally displaced 3 cm lateral to the left mid clavicular line. The first heart sound was soft, pulmonary component of second heart sound was loud, left ventricular third heart sound was present and a mitral regurgitation murmur of grade 4/6 was noted. Haematological and biochemical investigations were within normal limits. Chest X-ray revealed cardiomegaly with straightening of the left heart border, electrocardiogram showed sinus tachycardia and left atrial abnormality. On two dimensional echocardiography, modified apical 4 chamber view revealed a grossly dilated (8.53 × 7.46 cm) submitral aneurysm arising from the wall of the left ventricle adjacent to the posterior mitral leaflet. It is one of the largest aneurysms ever reported. The aneurysm was compressing the left ventricle practically preventing any reasonable cardiac output from the left ventricle (, ). The compressive effect of the aneurysm was also hindering venous blood from entering the collapsed right ventricle. Pulse wave Doppler revealed bidirectional flow between the left ventricle and the aneurysm. On cardiac catheterization, left ventricular angiogram in right anterior oblique 30 degree view further confirmed the diag

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


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

[User]
RADIOLOGY NOTE:
A 71-year-old man was admitted to our hospital with chief complaints of abdominal pain and vomiting.
A 71-year-old man was on treatment for chronic hepatitis B for 22 years when he was diagnosed with HCC. He was noted to have tumor nodules of size 20 mm in diameter, located in segment 8, on a follow-up abdominal computed tomography (CT) (Figure ) and had undergone partial liver resection 7 years previously. Based on the 8th Union for International Cancer Control classification of HCC, the tumor was classified as pT1N0M0 stage 1. Seven months after the first surgery, abdominal CT revealed recurrent HCC with nodules 10 mm in diameter, in segment 6 of the liver (Figure ). When laparotomy was performed, a peritoneal mass was found that was not apparent preoperatively; therefore, partial liver resection and peritoneal tumor resection were performed (Figure and ). The peritoneal tumor with peritoneal metastasis of HCC was diagnosed based on histopathological findings. Fourteen months after the first surgery, abdominal CT revealed a tumor nodule 32 mm in diameter in the pelvis, which was diagnosed as a peritoneal recurrence of HCC (Figure ). We determined that the recurrent tumor was solitary and decided to perform tumor resection. However, many small peritoneal nodules were found at the time of laparotomy, and radical resection was impossible (Figure ). Subsequently, the patient was followed up by the department of gastroenterology of our hospital, and 16 mo after the initial resection of HCC, administration of sorafenib of 400 mg/d was started. Since he developed a grade 2 hand-foot syndrome, the dosage was reduced to 200 mg/d. The administration was continued for 54 mo without any other major adverse events, and the disease was well controlled. Seventy months after the first surgery, he was admitted to our hospital with chief complaints of abdominal pain and vomiting.
The patient’s history was significant for extensive gastrectomy for duodenal ulcer at the age of 22 yea

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


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

[User]
RADIOLOGY NOTE:
A 4-year-old girl who had been complaining of intermittent abdominal pain since 2 years prior presented with a right lower abdominal mass that had been palpable since 6 months prior. At the time of her visit to Seoul National University Children's Hospital, the patient had no abdominal or leg pain. On examination, she had no fever but a 5-cm pulsatile mass-like lesion was palpable on her right lower abdomen. The patient was born, weighing 3.3 kg, by vaginal delivery after 38 weeks and 1 day of gestation. No other abnormalities were found in the screening test. The patient, who had been healthy with no special medical history after birth, had a medical history of hand-foot-and-mouth disease 1 year earlier. She had also been hospitalized to receive pneumonia treatment 12 months after birth and 1 month before visiting our hospital. She had no medical history of abdominal injury. No evidence of inflammation or collagen vascular disease was found in the blood test, and all test results were within their normal ranges.
Abdominal ultrasonography revealed a 4.6 × 5.0-cm well-defined mass in the right lower quadrant, with large internal vascularity (). Abdominal CT revealed a 5.2 cm × 4.5 cm × 5.1 cm, right-sided, partially thrombosed, saccular, iliac artery aneurysm. The aneurysm could be observed at the aortic bifurcation level. The left iliac artery of the patient was normal. However, in the right iliac artery, a communication with the aneurysm, which was located at the level where the common iliac artery bifurcates into the internal and external iliac arteries, was confirmed with contrast enhancement during the CT (). The aneurysm was pushing the internal iliac artery to the medial side, and the external iliac artery could not be traced (). The right common femoral artery was found at the inguinal ligament level by joining of the deep circumflex iliac artery and inferior hypogastric artery, which were more prominent than those of the left side. The

[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 90-year-old Caucasian gentleman with a past medical history of prostatectomy 20 years ago for prostate cancer, chronic venous insufficiency, and lymphedema since a few years presented to the dermatology office with a nonhealing wound in the left medial foot since a few months. He was initially diagnosed with a fungal infection and was given a 4-week course of antifungal agent and wound dressings, not yielding any response to treatment. Bacterial cultures performed a month later showed mixed infection with aerobic and anaerobic flora. He was then given a course of oral and topical antibiotics for 4 weeks, bearing a minimal response to treatment. In the last 2 months before presentation to the clinic, the lesion progressed. On examination, the epicenter of the lesion was located in the medial aspect of the foot. There were two major areas of ulceration in medial foot measuring approximately 5 × 5 cm that emanated a serosanguinous discharge (), with blistering satellite lesions in the medial and lateral aspect of the foot. Smaller lesions were also present on the plantar surface of foot. There was nonpitting edema in both extremities. Marked restriction in the movement of the left ankle was noted.
Subsequently, a punch biopsy of the one of the ulcers revealed cutaneous angiosarcoma, moderate to high grade in differentiation. Microscopically, there was extensive spindle cell proliferation involving dermis, subcutis, and deeper fibroadipose tissue (). There were multiple vascular sinuses lined by tufts of neoplastic endothelial cells (). Immunohistochemical stains revealed negative staining for cytokeratin while vascular markers CD31 (), CD34, and D2-40 were strongly positive. No necrosis was identified in the specimen. Mitotic rate was 0 to 9 mitoses per 10 high power fields. Lymphovascular invasion was indeterminate.
The patient was referred to the radiation oncology center with the above clinical and pathological data. MRI of the left foot with contrast revealed dif

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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 46-year-old female patient was brought to our Accident and Emergency Department with a 5-day history of a painful perianal and perineal swelling, which was increasing in size each day and discharging pus. This was preceded by perineal scratching for itchiness. A day prior to presentation, the pain had increased in intensity and the patient had difficulty in passing stool.
She had asthma and hypertension, which were well controlled. She was on salbutamol 4 mg three times a day and used becotide inhaler for her asthma and nifedipine 20 mg twice a day for her blood pressure. Her recent human immunodeficiency virus (HIV) test was negative. There was no family history of diabetes or malignancies. She was married with one child, and she neither drank alcohol nor smoked cigarettes.
On examination, she was ill-looking and in pain. She was hypotensive with a blood pressure of 85/35 mmHg, a pulse rate of 110 beats per minute, and respiratory rate of 30 breaths per minute. She had an elevated temperature of 38 degrees Celsius and a low oxygen saturation of 88%. Examination of her perineum and perianal area showed a huge mass with extensive necrosis and oozing pus from its surface. This is shown in her preoperative image below (Figure ).
Crepitus was elicited in the tissues adjacent to the ulcer. There was exquisite tenderness on digital rectal examination. Examination of other systems was normal. A random blood sugar test done showed a high blood sugar of 18.05 mmol/L. A diagnosis of necrotizing fasciitis was made in a patient with newly diagnosed diabetes mellitus.
The patient was very sick and in septic shock from fulminant sepsis. She needed high dependency unit (HDU) admission for septic shock treatment before surgery. Aggressive fluid resuscitation, antibiotic treatment, and insulin per sliding scale for glycemic control were commenced. Empirical antibiotics used were ceftriaxone 1g daily and metronidazole

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


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

[User]
RADIOLOGY NOTE:
A 61 year-old lady presented to clinic with a lesion in her anterior abdominal wall. It was present for four weeks and initially thought to be a sebaceous cyst but had rapidly expanded in that time frame. She had no other symptoms of note. On clinical examination the patient had a lesion measuring 4 × 3 cm firm, fixed, hemispherical with a smooth edge. There was a punctum and some indurated fat around it.
Her past history was of a right-sided breast cancer, she underwent a wide local excision and axillary dissection for a grade 1 lobular carcinoma with no nodal involvement. She underwent adjuvant treatment with radiotherapy and tamoxifen.
She was initially referred due to concern that this lesion was related to her previous breast cancer, however clinically it appeared benign and she underwent elective excision of the lesion under local anaesthesia.
Histopathology revealed a tumour growing as solid sheets diffusely infiltrating the dermis and subcutaneous fat with significant areas of necrosis. The tumour was monomorphic with intermediate sized cells with scanty cytoplasm. There was a hint of rosette formation (Figure ) but no other differentiating features relating to pigment, gland formation or mucin. Special stains showed cytoplasmic glycogen (Figure ) and immunohistochemistry showed strong expression of CD99, focal expression of CD56 and focal dot-like expression of cytokeratins, expression of S100 but no expression of other melanoma markers. The combination of morphology and immunochemistry was consistent of the spectrum of primitive neuroectodermal tumours.
She was referred to Oncology for adjuvant therapy. Staging CT scan of the chest, abdomen and pelvis revealed ill defined haziness in the subcutaneous fat of the right upper abdomen but no solid or cystic lesions were apparent. No other significant abnormalities were seen. Whole body bone-scan showed no evidence of bony metastases. Bone marrow trephine biopsy showed normocellular marrow with no evidence of n

[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 52 years old male presented to the accident and emergency department of our institution with complaints a painful swelling over the right lateral malleolus for two days. () This swelling was localized to the distal end of a surgical scar from an open reduction and internal fixation of a Weber B ankle fracture 20 years ago.
Clinical examination revealed a 3x3 cm fluctuant swelling surrounded by soft tissue oedema and erythema over the lateral malleolus. The swelling was inflamed and tender. The erythema was limited to the lateral malleolus and did not extend proximally. The skin was intact. There were no palpable lymph nodes proximally. The ankle movements were significantly restricted due to the pain over the fibular end but the patient was able to fully weight-bear with some discomfort.
The patient was apyrexial and systemically well. His white cell count was normal. His CRP and urate were increased at 50 mg/L (normal <5) and 493 µmol/L (normal 200-430 µmol/L) respectively. Radiographs revealed no recent bony injury with intact screw and plate fixation over the distal fibula. Although there was significant soft tissue swelling over the lateral malleolus, there were no signs of osteomyelitis.
The patient was suffering from osteoarthritis of the ankle requiring non-steroidal anti-inflammatories as necessary and allopurinol 300mg once daily for hyperuricaemia. The patient had sustained a Weber B right ankle fracture 20 years ago, which was treated with a lag screw and a neutralization one-third tubular plate. Since the fixation the patient had experienced occasional mild discomfort but not requiring medical attention.
Based on the clinical findings, an infection involving the implants was suspected and the patient was scheduled for incision and drainage of the removal of the implants.
Intra-operatively, no pus collection was found, no signs of loosening of the implants and no infected bone. The deposit was evacuated, the soft tissues debrided and the implants

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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 66-year-old male with a history of Hepatitis C treated in 2009 with Ledipasvir/Sofosbuvir (Harvoni®) initially presented to the Medical Oncology team in Hackensack University Medical Center, NJ with abdominal discomfort and distention for 45 months associated with an approximate 15 pounds of weight loss. He underwent CT scan of the abdomen with contrast and was found to have a large 15.0 × 11.0 × 13.0 cm heterogenous mass attached to the left lobe of the liver, with compression of surrounding intra-abdominal contents including the stomach and transverse colon, as well as the abdominal wall (Figure ). Subsequent percutaneous biopsy was performed for genetic testing, and results demonstrated hepatocellular carcinoma with extensive necrosis. He was then referred to the Surgical Oncology team for further workup and management. Follow up MRI demonstrated two additional satellite lesions consistent with multifocal hepatocellular carcinoma without evidence of invasion into surrounding vital structures. Surgical intervention was deemed necessary given the size of the mass and symptomology. A baseline AFP was 6.1, he was designated as a Child Pugh Score of 8 and he had a MELD Score of 9.
In the operating room, two large-bore intravenous catheters were placed but fluid was kept at a low rate along with placement of a foley catheter. A laparotomy was performed; making a midline sub-xiphoid incision, which was extended down to the pubic symphysis due to the size of the tumor (Figure ). Multiple friable blood vessels were noted at the umbilicus. The omentum as then resected, freeing the anterior abdominal wall. The transverse colon was then carefully separated away from the tumor using a GIA stapler. The transverse colon and its mesentery were preserved and protected from the dense mass. It was also noted that the distal stomach was adhered to the mass along the greater curvature. A sleeve gastrectomy was also completed, requiring three fir

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


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

[User]
RADIOLOGY NOTE:
A 67-year-old male was admitted to the emergency department of our hospital due to severe head trauma. The patient was in a coma with a Glasgow Coma Scale (GCS) score of 9 upon admission. A head CT scan revealed a bilateral frontal contusion and a large left frontal lobe hemorrhage. A left cranioectomy and hematoma evacuation was performed and the postoperation clinical situation kept stable. Eight weeks later, the patient underwent another surgery for cranioplasty and was then discharged for further rehabilitation.
During the next couple of months, the patient initially did quite well. He could walk without assistance and was able to take care of his own affairs. However, 10 months after the first surgery, the patient developed symptoms of urinary incontinence and gait instability. An MRI scan demonstrated marked ventricular dilatation when compared to his previous images. He was then hospitalized again with a diagnosis of hydrocephalus. After admission, a lumbar puncture showed the initial CSF pressure was 140 mmH2O, with positive CSF tap test. A VP shunt was undertaken with an Aesculap Adjustable Valve System (opening pressure 100 mmH2O). Correct placement of the ventricular catheter was accomplished at the first attempt. There was no observance of ventricular cannulation produced blood in the cerebrospinal fluid. The postsurgery course was uneventful. The patient did not have a history of hypertension and his blood pressure was within the normal range after surgery. Neither anticoagulation nor antiplatelet therapy was indicated in the perioperative management. A routine CT scan was administered on the 8th day following surgery and showed similar ventricle sizes when compared to the presurgery images (Figure A, B). The valve was reprogrammed to 60 mmH2O before the patient was discharged the same day.
However, he was sent back to our hospital again 8 h after being home for sudden decrease of consciousness and urinary incontinence. The neurological examination show

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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 the case of a 51-year-old woman with a history of major depression after a suspected suicide attempt with olanzapine intoxication (maximum dose 160 × 7.5 mg of olanzapine; corresponding to 1200 mg). The legal representative of the patient signed informed consent for publication.
At first presentation in a primary care center, the patient was comatose and intubated. Activated charcoal was administered at an early point of time; however, no subsequent waking reaction occurred. An initial CT scan of the brain () revealed a left-hemispheric deep intracerebral hemorrhage (ICH). Upon admission, blood pressure was in normal range with no documented history of arterial hypertension. There was no medication history of anticoagulants nor was there a reported history of alcohol or drug abuse or any preexisting diseases such as arterial hypertension or liver insufficiency. Laboratory results showed a normal platelet cell count (218/μl), standard coagulation parameters (PTT: 26 s, INR: 0.9), and liver function (GPT: 30 U/l). Factor XIII was normal (85%). There were no signs of any preceding head trauma. Prior medication was olanzapine 5 mg daily and duloxetine 90 mg daily as well as lorazepam in an unknown daily dose.
For further therapy, the patient was transferred to our tertiary care center 12 hours later. At admission, we conducted a follow-up CT scan, which presented not only significant secondary enlargement of the left-hemispheric hemorrhage but also newly developed right-hemispheric ICH in the basal ganglia areas. In a CT-angiographic study, no source of the hemorrhage was detected. MRI at day 2 after admission confirmed bilateral intracerebral hemorrhage but neither showed any underlying cause of ICH (). Olanzapine serum levels measured approximately 24 hours after suspected intake were highly elevated (820 μg/l) confirming severe intoxication []. Corrected QT interval was 450 ms.
Two days after admission, the patient's conditions improved significantly. She r

[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 85-year-old male patient with conjunctival tumor in his right eye (uncertain onset) was referred to our department for a detailed examination. Initial evaluation showed best-corrected visual acuity was 30/60 in his right eye, with an intraocular pressure that was within the normal range. He has been receiving anti-VEGF treatment for age-related macular degeneration over the past 5 years. For the tumor, he underwent conjunctival tumor resection and amnion transplantation without mitomycin C in his right eye. The patient was then started on a topical treatment that consisted of 0.5% levofloxacin and 0.1% betamethasone four times daily. The postoperative course had been good until a scleral ulcer emerged at a nasal ischemic necrotizing lesion 4 months later (2 months after stopping the local steroid drop treatment). The postoperative examination at 4 months showed that scleral melting to the uvea had occurred on the center of the tumor-resected sclera. The conjunctival graft was avascular with the presence of ocular pain (Fig. ). Anterior slit-lamp examination revealed that there were no remarkable ﬁndings in the eye. Magnetic resonance imaging showed that there was no orbital lesion. After diagnosing SINS, 0.1% betamethasone was immediately restarted four times daily, preparing for an urgent scleral patch transplant surgery. The peripheral conjunctiva contact with the melting site was removed, and free conjunctival autograft transplantation was also performed. Histopathological analysis of the removed conjunctiva led to the current diagnosis and subsequent pathological search. After 2 weeks, there was complete and rapid regression of the scleral melting (Fig. ). Following this episode, only local steroid therapy was continued for treating the SINS, and at 6 months, there has been no recurrence. However, ultrasound biomicroscopy revealed local thinning of the uvea (Fig. ). Histopathological and immunohistochemical analysis additionally revealed infiltration of infla

[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, nulliparous woman was referred to our institution at 29 gestational weeks for the evaluation of incidental abnormal finding in the right eye detected by routine midtrimester screening ultrasound. The level II ultrasound in our hospital showed no structural anomaly including brain, heart and kidney except for a 6.2-mm-sized hyperechoic mass lesion in the right eye ball at posterior medial side of the lens adjacent to the hyaloid artery (). The lens was normal and there was no specific finding of congenital cataract (). The right and left orbital axial diameter was 13.2 and 13.5 mm, respectively, which were in the normal ranges (). The couple was healthy without a history of genetic disorder. There was no history of medication use during pregnancy, exposure to X-rays, or maternal infection. Other prenatal examinations including viral screening test, the sequential test and 50 g oral glucose tolerance test were normal.
Subsequent ultrasound assessment was done at 31, 34, and 38 week of gestation. The size of the hyperechoic mass lesion in right eye ball was 6.6 mm at 31 week of gestation (). The estimated fetal weight, amniotic fluid and other fetal structures were all normal. However, the subsequent scan of the orbits was limited due to fetal prone position, thus orbital diameters (ODs) were not measured correctly.
The women delivered a male neonate weighing 3.44 kg vaginally at 41 weeks of gestation. The newborn baby did not open his right eye spontaneously. The ophthalmologist examined the baby and right congenital microphthalmia was diagnosed with coloboma, small orbital fissure, iris atrophy and hyperpigmentation of the fundus. Other facial features were normal. Postnatal orbit MRI showed right microphthalmia including globular and dysmorphic right lens (). A soft tissue lesion at posteromedial aspect of the right lens () was found in the orbit MRI which was the hyperechoic mass lesion in the right eye ball detected by prenatal ultrasound. This lesi

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


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

[User]
RADIOLOGY NOTE:
A 71-year-old hypertensive man presented to hospital with a 1-day history of chest pain and dyspnea. Enhanced computed tomography (CT) revealed type B aortic dissection. He was transferred to our hospital for further investigation and care. His medical history included medically managed hypertension, untreated diabetes mellitus, and a 50-year smoking habit (Brinkman index: 1500).
On presentation, blood pressure was controlled below 120 mmHg with nicardipine. The patient complained of back pain. Abdominal and peripheral pulse examinations revealed no abnormality. Enhanced CT showed dissection and coagulation in the false lumen from distal to left subclavian artery at the renal artery level. Contrast-enhanced CT and echocardiographic findings did not reveal any congenital heart defects such as right-sided aortic arch or cardiac malformation. Two arterial anomalies were observed. The right subclavian artery arose from the aortic arch posterolateral to the origin of the left subclavian artery. The right vertebral artery arose from the right common carotid artery (). All aortic branches including the aberrant right subclavian artery arose from the true lumen.
Upon admission, antihypertensive and analgesic treatment with bed rest were initiated. The symptoms were gradually ameliorated; therefore we performed rehabilitation in accordance with the type B acute aortic dissection rehabilitation protocol utilized by our hospital. Contrast-enhanced CT was performed on hospitalization days 2, 4, 7, and 12 to assess the aortic condition. No changes such as dilation or emergence of ULP were noted. After the rehabilitation protocol was completed, the patient was discharged. Hypotensive drugs were prescribed to control blood pressure, and the patient was scheduled for outpatient follow-up aortic imaging.
On day 11 after discharge (day 25 after onset), the patient visited our hospital for outpatient follow-up. Contrast-enhanced CT findings revealed a ULP (). We determined that the pa

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


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

[User]
RADIOLOGY NOTE:
A woman aged 52 years, presented in May 2015 with pain and swelling of the left elbow of 5 months duration. Movements at the elbow were restricted.
At the age of 50 years, 4 years after menopause, she had an episode of heavy vaginal bleeding. Endometrial curettings showed well-differentiated endometrioid adenocarcinoma. She underwent a total abdominal hysterectomy and bilateral salpingo-oophorectomy in July 2013. Histopathological examination confirmed a well differentiated endometrioid adenocarcinoma, with myometrial invasion (Stage Ib, Grade 1). She received adjuvant external beam radiotherapy to pelvis (5040 cGy) and brachytherapy to vault thrice. She completed her treatment in December 2013 and since then has been on regular follow-up.
At presentation, her performance status was 1. She weighed 59 kg, and her height was 1.4 m. Her body surface area was 1.48 m2 and body mass index is 29.3 kg/m2. Breast and abdomen examinations were unremarkable. Pelvic examination did not reveal any local recurrence. A soft, tender swelling was noted over the lateral aspect of the left elbow toward the lower end of the humerus. Rest of the skeletal examination was normal.
Plain X-ray showed an osteolytic lesion in the distal humerus with soft tissue swelling. The joint space was well preserved. There was no fracture [].
Magnetic resonance imaging (MRI) of left elbow showed a lytic expansile lesion in distal metaphyseal region of humerus with cortical erosion. The zone of transition of the lesion with normal bone marrow appears to be wide with irregular margins. There was edema in the muscles around the elbow both anterior and posterior compartments [].
A technetium bone scan showed focal increased tracer uptake in the distal end of the left humerus. Rest of the skeletal survey was normal.
A sonography-guided fine needle aspiration cytology showed metastatic deposits of poorly differentiated adenocarcinoma.
Sonography and contrast enhanced computed tomography scan of abdomen and pe

[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 54-year-old female was referred to our respirology specialty clinic for evaluation of a small amount of blood-tinged sputum. She had had a chronic cough accompanied by small amounts of sputum for 10 months, and had noticed intermittent small amounts of blood-tinged sputum in the last few days. One week prior to her hospital visit she had visited a local clinic and had been diagnosed as bronchiectasis on the basis of simple radiographs. She had been treated with antibiotics for 7 days, but her symptoms had not been relieved. About 20 years previously she had been diagnosed with pulmonary tuberculosis and had been treated successfully, and had had no further respiratory symptoms until 10 months before. She had had a history of spine operation for her back pain 14 years prior to her admission but no other underlying disease had been diagnosed. She had never had upper respiratory infections or pneumonias requiring antibiotic treatment, nor had she been hospitalized. To her knowledge she had never undergone chest image before visiting the local clinic. The patient was a lifetime non-smoker, and at baseline was active and healthy. She did not complain of chest pain or dyspnea, or any limitation of her activity level. Vital signs on admission were stable, and her chest was completely clear to auscultation, without wheezes, rhonchi, or rales. The rest of her examination was unremarkable. The spirometry test was notable for a forced expiratory volume in 1 second (FEV1) of 1.40 L (71% predicted), forced vital capacity (FVC) of 3.53 L (88% predicted), and FEV1/FVC ratio of 69%. The flow-volume loop suggested mild obstruction, and lung volumes were not measured at the time.
Simple chest radiographs revealed a patchy opacity with multiple thin-walled cystic structures in the right lower lobe of the lung field (). A computed tomography (CT) scan of the chest showed multiple large air-filled cystic lesions in the

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


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

[User]
RADIOLOGY NOTE:
An 18-year-old female, height of 165 cm and body weight of 55 kg, was diagnosed with a native aortic coarctation. She has no significant difficulty in her usual activities and exercises. She has complained only of intermittent headache. Her blood pressure (BP) measurements were 123/64 mm Hg and 123/62 mm Hg at her right and left arm, while 86/47 mm Hg and 83/49 mm Hg at her right and left ankle, showing 50 mm Hg higher BP in the upper extremities (). On echocardiographic study, discrete aortic coarctation was diagnosed with the peak pressure gradient across the stenotic lesion of 50 mm Hg by Doppler study (). On chest CT angiogram a discrete narrowing at the isthmic portion of the aortic arch due to a posterior shelf lesion was seen (). The narrowest dimension of the stenotic lesion was 4-5 mm, and the dimensions of the pre- and post-coarctation descending aorta were 16 mm and 19 mm, respectively (). The distance from the origin of left subclavian artery to the coarctation site was 24 mm.
A 20 mm self-expandable nitinol stent (Hercules vascular stent 20×60 mm, S&G Biotech, Seongnam, Korea) was deployed across the coarctation site, without previous balloon dilatation procedure (). No further balloon dilatation was done immediately after the stent deployment to avoid unnecessary tissue injury. Immediately after the procedure, the peak pressure gradient across the coarctation site decreased from 50 mm Hg to 20 mm Hg (), and the dimension of the stenotic lesion shown by the stent waist somewhat increased from 4-5 mm to 8 mm on angiography and plain chest X-ray images (). We decided to wait and see for further self-expansion of the stent.
Three months after the procedure, the dimension of the stent waist had enlarged gradually up to 13 mm on plain X-ray and 11.5 mm on CT images (). Further interventional procedure, such as instent low-pressure balloon

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


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

[User]
RADIOLOGY NOTE:
A 65-year-old man was referred to the department of oncology with complaints of right chest and back pain, cough, expectoration, and dyspnea for more than 9 months and had been diagnosed with PPSCC by another hospital. He was also diagnosed with type 2 diabetes for 7 years, with a past history of varicose veins in both lower extremities. No other family history of cancer was reported.
A review of the patient’s medical history showed that the initial symptoms of the patient were pain in the right chest and back, with cough and expectoration; however, subsequently, the patient was inadvertently found to have multiple lymph nodes of different sizes in the left neck, which was neglected by the patient. With progressive enlargement of the lymph nodes and aggravation of the cough, sputum, and chest pain, he visited a local hospital. After paracentesis of the pleura, immunohistochemistry revealed that the tumor tissue (TT) was a poorly differentiated squamous cell carcinoma, and the final pathological diagnosis was PPSCC. No abnormality was found in head magnetic resonance imaging and bone scan. Computed tomography (CT) scan showed extensive inhomogeneous thickening of the right and interlobar pleuras that invade the right pericardial invasion with mediastinal lymph nodes surrounding the superior vena cava. Therefore, he received radiotherapy for mediastinum as well as chemotherapy. The treatment of cisplatin plus paclitaxel systemic chemotherapy was terminated after two cycles of the chemotherapy, since the patient could not tolerate severe gastrointestinal distress. L858R mutation in epidermal growth factor receptor (EGFR) exon 21 and EML4-anaplastic lymphoma kinase (ALK) fusion gene mutation was found in genetic testing. Due to economic reasons, the patient first chose gefitinib instead of the ALK inhibitor. Tumor progression was observed after the patient received gefitinib as the targeted therapy for 4 months. However, both lung and liver metastasis were detected by C

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


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

[User]
RADIOLOGY NOTE:
A 56-year-old woman, a mother of 3 children, presented to the surgical department with a history of multiple neck lumps of 4 months duration. She also had generalised vague abdominal pain, loss of appetite and lower back pain. She had no significant medical, family or psychosocial history. Clinical examination revealed multiple, bilateral enlarged cervical lymph nodes which were firm to hard in consistency. Thyroid examination revealed a 2 × 2 cm firm lump on the lower pole of the left thyroid lobe. Examination of other lymph node groups revealed enlarged right inguinal lymph nodes. Abdominal examination and rectal examination were normal. Vaginal examination revealed a hard, unhealthy uterine cervix. Breast and axillary examination were unremarkable. She had spinal tenderness, but the neurological examination of the lower limbs was normal.
Her basic blood investigations, liver profile and renal functions were within the normal limits. Ultrasound scan of the abdomen revealed no abnormalities. Ultrasound scan of the neck revealed multiple nodules in the thyroid, with increased vascularity, and multiple enlarged cervical lymph nodes with obliterated fatty hila suggestive of malignant deposits. Contrast enhanced computed tomography of the neck, chest, abdomen and pelvis showed a mass in the uterine cervix (Fig. ) with multiple enlarged lymph nodes in the inguinal, iliac, para-aortic, anterior mediastinal and bilateral deep cervical groups (Fig. ). There were multiple low-density nodules in the thyroid gland (Fig. ). A mixed density mass lesion was also noted in the lower pole of the left thyroid lobe (Fig. ). Furthermore, an anterior wedge fracture of the L2 vertebra was seen, probably secondary to bone metastases.
Biopsies from the uterine cervix and endometrial curettage revealed moderately differentiated squamous cell carcinoma, signifying local extension of the cervical carcinoma into the endometrium (Fig. ). Excision biopsy of a left cervical lymph node revealed m

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


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

[User]
RADIOLOGY NOTE:
A 51-years old man presented with a clinical diagnosis of multinodular goiter. The patient did not show evidence of autoimmune disorders or thyroiditis and the thyroid function was normal. He was referred to surgery and complete thyroidectomy with intraoperative histological examination was performed. The thyroid was enlarged with a weight of 55 g, measuring 5×4.5×4.5 cm in the right lobe and 5×3×3 cm in the left lobe. Macroscopically, the right lobe harboured a cystic-colloid hemorrhagic nodule 2.5 cm diameter while two colloid nodules of 2 cm and 3 cm respectively, were found in the left lobe. All of the aforementioned nodular lesions were examined intraoperatively. The cystic nodule in the right lobe showed a diffuse papillary architecture with slight overlapping and enlarged nuclei; as a consequence an intraoperative histological diagnosis of suspicious papillary thyroid carcinoma/papillary hyperplasia with atypia, was posed. The two nodules in the left lobe were considered benign, although one of them also showed cystic aspects with papillary architecture. The lesions were finally sampled, formalin fixed and paraffin embedded for the final histological evaluation. Microscopically two colloid-cystic nodules showed papillary structures with a delicate stroma and prominent intralesional mature fat (). Furthermore, the nodule in the right thyroid lobe showed cytological features suspicious for PTC. The nuclei in fact were sometimes enlarged, with scattered grooves, overlapping and clearing, but no nuclear pseudoinclusion or psammomabodies were found (). The lesion did not show a complete capsule and merged with the surrounding thyroid tissue. Neither mitotic figures nor necrosis were found. In the left nodule the nuclei were basally located with dark chromatin without atypical features. To exclude the diagnosis of a PTC and to better categorize these lesions, the expression of two well known thyroid cancer associated antigens namely Galectin-3 (Gal-3) and HBME-1 wa

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


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

[User]
RADIOLOGY NOTE:
An 82-year-old lady was referred to gynaecology outpatients in June 2007 with a one month history of post menopausal bleeding. Her past gynaecological history included a negative hysteroscopy in 1998, and previous use of hormone replacement therapy. She had previously given birth to two children. The patient was fit and well, with no significant past medical history apart from hypertension for which she took bendroflumethiazide and atenolol.
Physical examination revealed a bulky uterus with no adnexal masses. A pipelle biopsy demonstrated only tiny fragments of blood clot. A subsequent transvaginal ultrasound scan showed a large endometrial mass with calcification (Figure ). The ovaries appeared normal. She underwent a hysteroscopy in July 2007 when a 6 cm uterine fibrotic polyp, which filled the uterine cavity, was removed.
Microscopy demonstrated polypoid tissue with a variably cellular and fibrotic stroma, focal adipose and possible chondroid metaplasia, but no malignant features. The glands showed focal mucinous and keratinising sqaumous epithelial metaplasia. There was focal nuclear atypia, focal mitotic activity and occasional cribriform gland fusion. These features were in keeping with either atypical complex hyperplasia within an endometrial polyp associated with metaplastic changes, or a polypoid uterine teratoma.
Immunohistochemistry showed positive staining of the small crowded epithelium for the epithelial marker cytokeratin (CK)-7 and the thyroid and lung marker TTFI. There was positive staining of the chondroid area for S100 protein, focal staining of dilated gland epithelium and stromal cells for oestrogen receptor and progesterone receptor, and staining of stromal cells for smooth muscle α-actin (SMA). Thyroglobulin, desmin, CK20 and CDX2 staining was negative. A diagnosis of benign teratoma with thyroid gland and cartilaginous elements was therefore made.
Following hysteroscopy, the bleeding continued. A repeat ultrasound scan revealed that the tera

[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 1-month-old male infant was brought to the outpatient department with a complaint of a palpable nodule in the chest wall noticed for 1 week. There was no record of any swelling at birth. There was no history of fever or fast breathing. Antenatal and birth history was unremarkable. Antenatal ultrasound examinations were within normal limits. On physical examination, the there was a small 2 cm × 2 cm sized hard nodular, nontender, immobile lesion palpable in the posterolateral chest wall on the right side. The lesion appeared to be in continuity with the underlying 8th rib. At this location, the rib could not be separately palpated from the lesion. The skin over the lesion was pinchable. The rest of the physical examination was within normal limits. Chest radiograph revealed a lytic destructive lesion in the posterior part of the right 8th rib. The lesion was expansile, had permeative nature with a wide zone of transition and areas of matrix mineralization. Adjacent ribs were unremarkable []. Noncontrast computed tomography (CT) [Figure -] revealed a 5 cm × 3 cm × 3.5 cm sized expansile mass lesion arising from the posterior part of the right 8th rib with a large extra-osseous component projecting into the right thoracic cavity compressing the right lung. The inner cortex of the rib was destroyed. The outer cortex of the rib was relatively preserved with a small outward projection which likely corresponded to the clinically palpable hard nodule. The mass shows extensive matrix mineralization which was mixed osseous/cartilaginous in nature. There were no cystic areas in the lesion. The lower lobe of the right lung was displaced by the mass. No lung nodules or enlarged lymph nodes were seen. As the lesion was expansile, causing bony destruction and there was cosmetic deformity, surgical excision of the involved rib was planned. The option of close follow-up was discussed, but in the institutional tumor board discussion, the consensus opinion

[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 lady reported to our institution with an endometrial biopsy showing well-differentiated adenocarcinoma. Slide review confirmed the diagnosis. Magnetic resonance imaging (MRI) of the pelvis showed a 3 × 2 cm lesion in the endometrial cavity with superficial myometrial invasion without any enlarged pelvic or paraaortic nodes. She underwent robotic staging surgery for carcinoma endometrium in February 2015 using the da Vinci Xi robotic platform. As there is facility for fluorescence imaging in the robotic platform, it was decided to use ICG for sentinel mapping in her. Consent for the procedure was obtained from the patient and also from the hospital’s ethical committee.
Concentration of ICG used was 0.5 mg/mL, a 4 mL of this solution was injected intracervically at 3 and 9 o’clock positions, both submucosally and deep into the cervical stroma. The injection was done after port placement but before the docking of the robotic platform. After complete inspection of peritoneal cavity and collecting pelvic washings, the fluorescent imaging was switched on. The time taken from the cervical injection till this point was 20 minutes. Under fluorescence imaging, the site of intracervical injection was well lit up but no lymphatics or lymph nodes were identified in the pelvic nodal areas. We then looked into the paraaortic area with fluorescence imaging and saw a lit up lymphatic channel crossing the right common iliac and lighting up of a right periaortic node (). Bilateral pelvic lymphadenectomy and removal of the lighted up paraaortic nodes were done. Complete paraaortic nodal dissection was not done as it is our practice to do paraaortic lymphadenectomy for high-risk histologies.
Histopathology report showed 4.5 × 4 × 2.5 cm grade 2 endometrioid carcinoma infiltrating to outer one-half of the myometrium with lymphovascular emboli. Two out of three paraaortic nodes removed were positive for tumour metastasis. Three out of 11 left iliac nodes were also found to b

[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:
25 y/o male playing Rugby Union at scrum-half position was engaged in full contact training when he received a tackle. The exercise was a simple tackle drill, with two players at a standing start 10 meters apart. One player runs towards the other to initiate a tackle. The patient presented here received the tackle in an unremarkable fashion hitting the ground without loss of consciousness, then stood up briefly before collapsing. He was noted to be unresponsive and received CPR on scene and advanced medical intervention including intubation, placement of IV access and resuscitation before arriving as a trauma alert to UF Health Shands Level I Trauma Center in Gainesville, Florida.
On arrival in the trauma bay his vitals were GCS 3 T, HR 60s with a bradycardic episode to 30s that was short lived, and SBP 97 with on-going fluid resuscitation. ATLS primary and secondary surveys were completed along with laboratory investigations. A central line and arterial line were placed along and the patient received a CT head 24 minutes after ambulance arrival. This revealed a diffuse SAH in a non-traumatic pattern. The imaging protocol was then altered in the CT scanner to include a CT angiogram of the head/neck that confirmed a right-sided internal carotid dissection with occlusion of the right ICA at the junction of the right cavernous sinus and supraclinoid ICAs. Mannitol and 3% saline were administered and a ventriculostomy was placed. CSF fluid was noted to be grossly bloody. Maximal medical therapy continued overnight with repeat CT head revealing right ICA dissection, large volume SAH extending into high convexity sulci bilaterally with early central incisural herniation, right MCA and ACA stroke, and right ACA distribution cytotoxic edema.
At 24 hrs following admission, the patient was noted to have new left sided pupillary dilatation with ICPs that remained in 70s despite maximal medical therapy.
His clinical condition continued to

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


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

[User]
RADIOLOGY NOTE:
The patient was a 44-year-old female craftswoman who had been suffering pain in the right upper limb for several months. The pain had increased progressively over the previous 3 months. She described pain at rest associated with coldness, pallor, and paresthesia of the limb. She had fallen from stairs when 9 months old, fracturing her clavicle, which was managed conservatively.
Physical examination revealed discrete deformity at the level of the mid third of the right clavicle. The right hand was cold and blue and ulnar, radial, brachial, and axillary pulses were all absent. Continuous wave Doppler detected no blood flow distally and monophasic flow in the brachial and axillary arteries. The chest X-ray showed a deformity of the mid third of the right clavicle, compatible with pseudarthrosis ( ).
Doppler ultrasonography demonstrated segmental occlusion of the subclavian artery with distal refilling via collateral vessels and very fine, threadlike flow in the axillary artery with occlusion of the brachial and radial arteries and refilling of the distal ulnar artery. Magnetic resonance angiography confirmed the Doppler ultrasonography findings ( ).
The pseudarthrosis was treated surgically, via a right supraclavicular incision, with resection of the mid segment of the clavicle ( ). The right subclavian artery was compressed and had thrombi with a chronic appearance inside. Thromboembolectomy of the subclavian artery was conducted with a 3F Fogarty catheter, followed by closure of the arteriotomy with a patch harvested from the saphenous vein in the thigh. Thromboembolectomy of the brachial, radial, and ulnar arteries was then conducted via an arteriotomy in the brachial artery, resulting in considerable improvement in terms of pain, temperature, color, and perfusion of the limb.
Throughout the examination, Doppler ultrasound of the hand showed triphasic flow in the radial and ulnar arteries. The patient was kept on clinical anticoagulant treatment with warfarin, maint

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


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

[User]
RADIOLOGY NOTE:
A 52 year old female was emergently transferred from an outside hospital for higher level of care for suspected thrombotic thrombocytopenic purpura (TTP). Her past medical history is significant for Stage 3 estrogen receptor positive/progesterone receptor positive/HER2-neu negative left breast infiltrating lobular carcinoma diagnosed in Dec 2014. She received four cycles neoadjuvant chemotherapy with docetaxel and cyclophosphamide followed by bilateral mastectomy with 15/15 left sided lymph nodes positive for disease, with pathologic staging IIIC of the left breast. She then completed 7 cycles of adjuvant chemotherapy gemcitabine and cisplatin followed by adjuvant postmastectomy radiation and subsequently started adjuvant anastrozole. She was closely followed with imaging and labs by her primary oncologist given her high risk of recurrence. She was noted to have stable imaging findings through October 2015, when it was noted that she had elevated CEA of 1,570 and mild transaminases with jaundice. Anastrozole was stopped, and PET performed in October 2015 showed increase uptake in the porta hepatis, with follow up CT abdomen/pelvis concerning for new but poorly defined liver lesions. She subsequently developed gross hematuria after the CT scan and was sent to a community hospital where she was found to have hemoglobin 6.0 g/dL and hematocrit 22%, with normal platelet count. She was then transferred to a second hospital for higher level of care, where her hemoglobin was found to be 5.3 g/dL and platelets 103 bil/L on presentation. On day 2 at the second outside hospital, she developed severe thrombocytopenia (platelets 23 bil/L) with worsening renal function, and lactase dehydrogenase (LDH) elevation to 3,565 U/L. She underwent esophagoduodenoscopy (EGD) for evaluation of anemia which showed extrinsic compression at the gastroesophageal junction and documented linitis plastica appearance of the gastric wall with biopsy showing signet ring adenocarcinoma, diffuse type

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


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

[User]
RADIOLOGY NOTE:
A healthy, single, 40-year-old academic man with heterosexual preferences and no history of sexual abuse presented to his primary care unit with abnormalities in his testicles, severe scrotal pain, erectile dysfunction, and lowered semen production. After an initial examination at the primary care unit, he was referred to a urology department for further investigation.
At the first consultation with a urologist, the testicles were examined, and several small lumps were found bilaterally. The lab results showed low testosterone (3.2 nmol/L) and normal markers for testicular carcinoma. Several ultrasounds and one MRI were performed.
The testicular lumps were bilateral so it was decided to do open ultrasound-guided bilateral testicular biopsies with a scrotal approach in order to rule out malignancy. The histopathology showed no sign of testicular carcinoma.
The patient continued to experience scrotal pain postoperatively. He now told the urologist that he had been injecting alcohol in his testicles for a year hoping that the testicles would be so damaged that a urologist would remove them. If the urologist would not do so, he said that he was prepared to do it himself. He was then referred to the Department of Andrology for a psychiatric evaluation and was scheduled for a new appointment at the urology office. During that time, the urologist planned to investigate if it was legal to remove healthy gonads. The patient accepted this and agreed to wait for the answer from the authorities before he would self-inflict himself.
The patient was declared psychiatric sane, but before the urologist got an answer from the health authorities, the patient arrived to the emergency unit within a few weeks after the latest appointment with the urologist. He had self-administrated local anesthesia in the scrotum and removed both of his testicles at home. He had secured the vessels on both sides with vascular clamps, but had a large bleeding wound in the

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


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

[User]
RADIOLOGY NOTE:
A 20 year old female was referred to our Medical Oncology department after a gastric antrum GIST resection. A subtotal gastrectomy revealed a pathologic specimen compatible with an epithelioid GIST variant localised to the muscularis propia. The diameter of the tumor was 1.8 cm and the mitotic count rate was of 18 per 50 HPF (high-power field). IHC assays revealed that the cells presented a strong positive expression of CD117 (KIT) and DOG1, which supported a GIST diagnosis. The tumor was classified as a pT1pN0 (0/1) with a high mitotic rate - stage II – according to the eighth edition of TNM classification. Armed Forces Institute of Pathology (AFIP) criteria calculate the risk of this tumor relapsing and/or progressing as zero, due to the low number of published cases. The mutational analysis revealed that the tumor was KIT and PDGFRα WT. After complete resection, a whole body computed tomography (CT) scan with contrast was performed, revealing no signs of metastases. Two years after the initial diagnosis, during the follow-up, a CT scan, a magnetic resonance imaging (MRI) of the liver and a positron emission tomography (PET) were performed. These procedures revealed the presence of multiple hepatic metastases. After confirmation of resectability, she underwent surgical resection of the hepatic metastases and postsurgical image studies confirmed no evidence of disease so, in accordance with current medical evidence in patients with complete resection of WT GIST, adjuvant treatment with imatinib was not delivered. At present, the patient is 26 years old and she has no evidence of active disease.
Because of the age at presentation and the molecular features of her tumor, the patient was sent to our Hereditary Cancer Genetic Counseling Unit for further investigations. Complete physical examination was irrelevant and no typical phenotypic features suggestive of a specific syndrome were detected. The family history of the patient seemed to be unremarkable: she has a 19

[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.