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

[User]
RADIOLOGY NOTE:
A 69-year-old female was referred to our clinic for an incidental finding of a large Morgagni hernia found on a recent CT chest scan for lung cancer screening. Patient reported occasional shortness of breath after prolonged ambulation but denied chest pain. She did have remote history of acid reflux symptoms but nothing recently. She denied issues with prematurity or issues with development as an infant, chest trauma, or MVA history. She did complain of occasional right shoulder pain but attributed this to arthritis. Denied history of heart attack, stroke, DVT, or PE. She had a 30-pack-year smoking history but quit a year prior. She was up-to-date on her colonoscopy, current within the past year. She denied hematochezia and melena, bowel habit changes or major body weight changes as well as any current abdominal pain. On examination her vitals were within normal parameters. Heart and lungs were unremarkable. Abdominal examination was soft with normal bowel sounds and nontender. Remainder of examination was unremarkable. Laboratory values included a normal CBC and BMP. A CT chest scan had demonstrated a large retroxyphoid hernia of Morgagni involving several loops of small bowel and transverse colon located in the right inferior hemithorax (Figs and ). No evidence of acute incarceration or strangulation were noted. A detailed discussion was undertaken with the patient regarding her hernia and she was consented for a laparoscopic repair with mesh.
Patient underwent a laparoscopic approach in lithotomy positioning with the primary surgeon working between the legs. Three working ports were used, a 12 mm port at the umbilicus and two 5 mm ports; one in the LUQ and one in the RUQ. Upon initial laparoscopy multiple loops of small bowel were progressively reduced out of the hernia sac which also included the ascending colon and part of the transverse colon (Figs and ). All the small bowel and the colon

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


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

[User]
RADIOLOGY NOTE:
A 52-year-old woman with a significant medical history of end-stage renal disease, chronic hypertension, and type two diabetes mellitus presented to the emergency department two hours after experiencing chills and hypotension during her weekly scheduled hemodialysis. She initiated hemodialysis two weeks ago after having a permcath placed. The patient had a grade two sacral decubitus ulcer recently diagnosed and treated with clindamycin six days prior to admission. She reports one week of chills, constipation, and non-productive cough and denies any other symptoms such as shortness of breath, dysuria, chest pain, subjective fevers, nausea, vomiting, abdominal pain, or dysphagia. Blood cultures were drawn after dialysis and she was admitted the next day because of concern for sepsis from the permcath and or the decubitus ulcer, although the ulcer was clean, dry, and intact.
After blood cultures were drawn the patient was empirically begun on intravenous (IV) vancomycin and cefepime. The vancomycin was dosed after dialysis based on blood levels. The cefepime was renally dosed at cefepime 1 gram IV loading dose and 500 mg IV daily. On dialysis days it was given post-dialysis. The next day the blood cultures from the outpatient dialysis unit grew pseudomonas and streptococcal species. The vancomycin was discontinued and the permcath was removed, and tip cultured. The permcath was not replaced and so the patient did not receive hemodialysis until blood cultures were negative, five days later. The patient’s hemodynamic state improved, and the white blood cell count returned towards normal over the next few days, however on day four a new 2/6 left upper sternal border murmur was noted. There was concern for bacterial endocarditis, so a transthoracic echocardiogram was done and no vegetations or significant valvular abnormalities were detected. The patient continued to clinically improve otherwise, remaining afebrile with no leukocytosis. On the sixth hospital day, she was n

[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 man sustained a tibial shaft spiral fracture (AO/OTA classification 42-A2) with a fibular fracture (). He had no previous medical history. The fracture was treated initially at another hospital with a reamed statically locked intramedullary nail (). He noted increased external rotation of the affected leg immediately after the surgery. The tibial fracture united after a year (), but he still complained of the asymmetry of his legs, difficulty walking and running, and inability to ride a bicycle. Computed tomography (CT) of both tibias showed 24° of increased external rotation of the affected leg (Figures , ). Because it was a symptomatic rotational deformity, we decided to perform corrective osteotomy in a minimally invasive fashion.
The surgical procedure consisted of, first, a 1 cm skin incision at the original fracture site. Multiple efforts were then made to drill around the nail in a radial manner (leaving the nail in place) while using a 3.0 mm Kirschner wire to prepare a percutaneous osteotomy line. Osteotomy for the affected tibia was performed percutaneously using an osteotome on the prepared osteotomy line while retaining the intramedullary nail (). Fibular osteotomy was also done at the same level. Next, two 3.0 mm Kirschner wires, which created a 24° rotational angle in the axial plane between the bone fragments, were inserted as guides for correction (). The distal locking screws were then removed. After matching the two Kirschner wires in a straight line, correct rotation was confirmed (). We assessed the rotational correction intraoperatively to evaluate both sides of the thigh-foot angle [, ]. Finally, the distal three locking screws were inserted into holes different from the original hole (). At 1 year postoperatively, the patient obtained bony union and has returned to his preinjury activities with no symptoms. The implant was removed 1 year postoperatively on the patient's demand. The appropriate correction of the rotational deformi

[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 66-year-old man, who complained of upper abdominal pain, was found to have EGJ tumor by endoscopy (Fig. ). He was diagnosed as having Siewert type II adenocarcinoma (E=G, cT1b, cN0, cM0, cStage I) []. We planned to perform lower esophagectomy and proximal gastrectomy with double tract reconstruction.
In the computed tomography (CT) scan before surgery, a 10-mm aneurysm in the middle third of the splenic artery was found (Fig. ). Due to the anatomical location of the aneurysm, endovascular treatment was not considered due to recanalization and coil migration. The size of the aneurysm was not a high risk of rupture [], but we concerned about the possibility of SAA rupture due to postoperative pancreatic fistula (PF) associated with suprapancreatic lymph node dissection such as station 11p and 11d. We thought that spleen blood flow could be preserved even after SAA resection by preoperative CT scan and unnecessary invasive procedures could be avoided by simultaneous surgery. However, during simultaneous proximal gastrectomy and SAA resections, it was not clear whether there was sufficient blood supply to the spleen. Thus, we performed the surgery with a minimally invasive abdominal and left thoracic approach (MALTA) while continuously examining for the presence of blood supply to the spleen using fluorescence imaging.
The patient was placed under general anesthesia and was positioned in reverse Trendelenburg with the left side of the upper body lifted and the legs spread. Laparo- and thoracoscopic proximal gastrectomy and lower esophagectomy with D1+ lymph node dissection and double tract reconstruction were performed. First, we resected the SAA. Next, laparoscopic proximal gastrectomy was performed using five ports. Four ports were inserted into the thoracic cavity through the 9th, 10th (× 2), and 11th intercostal spaces, with the patient in the same body position. Lower thoracoscopic esophagectomy and lymph node dissection of the lower mediastinum was performed und

[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:
Case 2. A 50-year-old non-insulin-treated woman with diabetes sustained a right distal radius fracture after a slip on ice. She was casted for six weeks and developed right hand and wrist pain by the end of the six weeks. X-rays revealed that the fracture healed well. She was assessed one year after injury and reported diffuse hand and wrist pain. She was unable to make a complete fist on the right, and there was loss of joint extension. In particular, the 5th digit was contracted at the interphalangeal joints; the hand was not uniformly swollen. The digits were all flexed at rest. Due to the late presentation and maturity of the contractures, she was sent for hand therapy, an extension splint, and a bone scan. Four days after this visit, she was involved in an accident and sustained a left wrist fracture of the distal radius and ulna. She required open reduction internal fixation and underwent a bone scan several weeks after the second fracture. The right side, the older fracture, showed no significant periarticular uptake. In contrast, on the newly fractured left hand, there was diffuse hyperemia in the left wrist, distal forearm, and fingers, as well as uptake at the left sided ribs in the 5th, 6th, 7th, and 10th ribs, consistent with fractures. On the newly fractured left arm, she had developed swelling in the digits and capsular restrictions. The 5th digit was difficult to extend. There was an obvious deformity in the left wrist. She experienced pain with MCP compression. While the right hand had continued to settle, the left hand was acutely swollen and a diagnosis of CRPS was made. She was treated with the titrating dose of prednisone with instructions to monitor her blood sugars. The inflammation rapidly improved; however, her blood sugars proved difficult to control and her weaning was escalated. She gained improvement in the left hand and wrist, with the return of normal range of motion, skin

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


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

[User]
RADIOLOGY NOTE:
A 28 year old male patient presented initially in December 2013 with clinical features of acute osteomyelitis of right tibia. His haemogram was normal and the blood culture was negative for bacterial study. The erythrocyte sedimentation rate was 22 mm/h and C-reactive protein of 34 mg/dl. Polymerase chain reaction and culture for Mycobacterium tuberculosis were negative. There was no regional or generalized lymphadenopathy. X-ray of the right leg showed an osteolytic lesion of the right tibia within distinct margins, cortical breach, and moth-eaten appearance. Magnetic resonance imaging (MRI) scan done prior to the biopsy was reported as osteomyelitis of tibia. Biopsy report came as inflammatory granulation tissue densely infiltrated by lymphocytes and histiocytes consistent with nonspecific chronic osteomyelitis. Tissue cultures were negative for bacterial or fungal elements. Tumor markers or special strains were not done. The patient was treated with antibiotics and anti-inflammatory drugs. He was then discharged from the hospital once his pain subsided and was kept under close followup.
He remained asymptomatic except a diffuse swelling over the anteromedial part of the right tibial shaft. After 6 months, he presented again with complaints of pain and rapidly increasing swelling on his right leg, which increased to a size of 10 cm []. There was no regional lymphadenopathy. X-ray showed a permeative lesion with significant periosteal reaction over the mid-diaphysis of the tibia. We suspected some type of aggressive bone tumors in view of the rapidly increasing swelling and the permeative lesions in the X-ray. Hence, his chest X-ray, computed tomography of chest, and ultrasound abdomen were taken which were negative for any lesion. This prompted us to take a repeat MRI contrast study, which showed (coronal image) altered signal intensity and irregular patchy enhancement lesion involving the marrow of the diaphysis of the tibia. There is enhancing soft tissue compon

[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 male patient reported to clinic with a chief complaint of swollen gums of 5 year duration and wanted to replace his missing teeth. Patient noticed swollen gums prior to his 4 years of edentulous state and the condition persisted to present. He was a known hypertensive and was on medication for the same since 7 years (10 mg Nifedipine/day).On intraoral examination- pink, firm, irregular, nodular, non- tender enlargements were found on labial aspects of maxillary and mandibular residual alveolar ridges. The enlargements were asymptomatic in nature with no history of bleeding. Both arches were completely edentulous (Fig. ). Panoramic radiograph showed no osseous deformities of maxilla and mandibular ridges (Fig. ). Patient’s complete blood count, bleeding time, clotting time and platelet count were with in normal limits. An incisional biopsy was obtained from anterior right side of the maxilla. Histological report revealed hyperplastic and acantholytic stratified squamous epithelium with elongated rete ridges extending into connective tissue which was fibro collagenous and showed focal areas of fibrosis. Infiltration of chronic inflammatory cells and congested blood vessels were seen which suggested of gingival hyperplasia (Fig. ). As patient wanted complete dentures, we planned to surgically excise entire overgrowth. Considering medical status of the patient, drug was not altered because, dose taken by the patient was low (10 mg/day). Local anesthesia devoid of vasoconstrictor was used to remove fibrous tissue from alveolar ridge with help of 15 no. B.P blade (Fig. ). To avoid any discomfort during the early phase of wound healing, a surgical splint was placed on both ridges after thoroughly covering the operated site with periodontal dressing (Coe Pack). The patient was recalled and followed at a period of 1 week, 3 months, 6 months and 1 Year intervals (Figs. , , and ). No recurrence of growth was observed during any of the recall visits. After 3 month

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


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

[User]
RADIOLOGY NOTE:
A 36-year-old male with no chronic disease admitted for laparoscopic exploration for intermittent abdominal pain after an open appendectomy that was performed 11 months ago. On previous admission, he was operated for clinical and radiological diagnosis of acute appendicitis. Initial CT scan showed distended appendix measuring 8-9 mm in diameter, showing abnormally thickened enhancing the wall, with surrounding fat stranding, free fluid, and adjacent pocket of pus collection measuring 2 × 4 cm. Open appendectomy was performed with findings of the gangrenous appendix, where the base was healthy and appropriately secured with Vicryl suture. He was discharged in good condition two days postsurgery. Pathology of the specimen showed 4.5 cm long appendix and 0.7 cm in diameter with a diagnosis of acute appendicitis and periappendicitis. After almost a year, he was seen in the clinic as he complained of recurrent abdominal pain for one month and a slight decrease in appetite. His ultrasound abdomen showed a complex heterogeneous collection with internal echoes in the right iliac fossa measuring 5.5 × 2.7 × 6.4 cm, corresponding to a volume of 50 ml. His CT abdomen showed a well-defined mass-like lesion about 5 × 5 cm in diameter of fluid density (22 HU) suggesting thick fluid in the right iliac fossa; the stump of the removed appendix is well demonstrated and about 4 cm in length and closely related to the lower part of this collection (). The patient underwent laparoscopic exploration with excision of the subserosal appendicular stump of about 5 cm and cyst extending from the tip and distal part of the appendix to the pelvis, easily separable from the pelvis, containing gelatinous yellowish material (Figures –). The terminal ileum and right-sided colon were normal, and no peritoneal deposits were observed. Because of these findings, we resorted only to stump excision.
Cytology of the gelatinous fluid was negative for malignant cells. At the same time, the histopathology of

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


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

[User]
RADIOLOGY NOTE:
A 35-year-old 105.5 kg male with a previous history of ALS for 7 years, history of respiratory insufficiency with a tracheostomy, and PEG for over two years, was admitted from a nursing home after a cardiac arrest. The return of spontaneous circulation (ROSC) was 12 minutes, and the patient was treated for aspiration pneumonia and urinary tract infection. In the past, he has had three previous cardiac arrests associated with respiratory insufficiency. Cardiac echocardiogram revealed a normal left and right ventricular function. Serum albumin was 3.1 g/dl. The patient has had quadriplegia felt secondary to his ALS and multiple cardiac arrests and has always stabilized and been treated for various infections. Neurologically, the patient still had a pupillary reflex on the left with spontaneous eye movement and he had partial mouth opening and closing. The patient does not visibly respond to pain. No gag or corneal reflexes were noted by the ICU team or neurology.
Over the last several years, the family was approached by the health care team on multiple occasions regarding consideration of Do Not Resuscitate (DNR). The family was told that the overall situation was hopeless due to his underlying primary disease. Despite this, the family always had hope that an ALS cure would be found and always wanted everything done.
Initially, a 24 hr urine creatinine was collected (patient with indwelling foley catheter) and was 172 mg. This was repeated since the value was very low but still came back 199 mg of urinary creatinine in 24 hr. The coefficient of variation was 10%, and the average was 186 mg of urinary creatinine excreted in 24 hr (see for data summary). In addition, the patient's height was 185 cm.
The patient was treated successfully over several weeks in the ICU and was eventually transferred back to his nursing facility. Within one month after discharge, the patient died at another facility.

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


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

[User]
RADIOLOGY NOTE:
In September 2014, an 18-year-old, non-smoking male was diagnosed with an open fracture of the right tibia, Gustilo’s classification grade IIIB [] following a traffic accident. The patient weighed 65 kg. Emergency debridement was performed at the local hospital following injury (Fig. a and b). The fracture and wound had not healed 3 months after injury. Copious pus was drained and the patient was transferred The Second People’s Hospital of Yunnan for further treatment.
The patient was admitted to The Second People’s Hospital of Yunnan 97 days after the injury. A physical examination of the patient’s right calf revealed a soft tissue defect and exposed tibia. A 4 × 10 cm incision was observed on the anterior medial side of the upper calf and a 3 × 12 cm-sized wound was seen on the anterior medial side of the lower leg. Significant foot drop was observed. The patient experienced hypoesthesia on the lateral side of right calf and the dorsal surface of the foot; however, normal sensation was felt on the plantar surface of the foot and the dorsalis pedis artery appeared normal. The range of motion of the knee was 0–80°, and ankle extension and flexion were 10 and 20°, respectively. Level III myodynamia was observed in the pretibial muscle and the triceps surae (Fig. ).
Following discussion with the patient, a limb salvage protocol was adopted in favor of amputation. The treatment plan consisted of two stages. The first step was to treat the infection by performing repeated debridement, replacing the external fixation, vacuum sealing drainage (VSD) and local and systemic application of antibiotics. In the second stage, the bone transport technique was used to repair the bone defect, and rehabilitation exercise was performed to restore the function of the affected limb as much as possible. The patient was informed about the treatment plan and the associated risks. A series of examinations were performed

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


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

[User]
RADIOLOGY NOTE:
A 42-year-old woman with a history of chronic migraine presented to the emergency department for a sudden thunderclap headache after swimming. She regularly used nonsteroidal anti-inflammatory medication and ergotamine associated with caffeine for chronic headache. At admission she described diffuse, explosive, and unusual headache with spontaneous resolution in 8 h. On initial examination, general and neurological clinical examination was normal. Arterial blood pressure was normal. The initial cerebral computed tomography (CT) scan without contrast was normal. The cerebrospinal fluid sampling obtained by lumbar puncture revealed presence of oxyhemoglobin with 290 red blood cells/mm3. The diagnosis of SAH was retained and a cerebral angiography scheduled for the next day. On day 1, she presented severe unusual headache with arterial hypertension followed by aphasia and a right hemiplegia. Shortly afterward, her consciousness worsened requiring intubation and intravenous sedation. A cerebral CT scan was immediately performed and revealed a left rolandic ICH (Fig. ). Cerebral angiography was performed showing a diffuse segmental narrowing of cerebral arteries without aneurism or arteriovenous malformation (Fig. ). The diagnosis of RCVS with hemorrhagic complication was retained and intravenous nimodipine was introduced. The ICH was removed by a neurosurgeon and an ICP monitoring probe was inserted in the left frontal lobe. Initial ICP reading was 15 mm Hg. Intravenous sedation was continued in the intensive care unit. However, norepinephrine was required to keep cerebral perfusion pressure (CPP) over 60 mm Hg. Immediate postoperative transcranial Doppler (TCD) was normal. A control cerebral CT scan was performed the next day showing a residual intracranial hematoma and perilesional edema. Forty-eight hours later, ICP increased to above 30 mm Hg despite optimization of medical treatment (head elevation, increased sedation, and osmotherapy). TCD readings for the right 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 22-year-old Sri Lankan woman was referred from the orthopedics unit to the endocrinology unit, National Hospital of Sri Lanka, for further evaluation of recurrent femur fractures. She first experienced a right sided subtrochanteric fracture following a low trauma injury at the age of 20 years (), for which she underwent internal fixation. Thereafter, she experienced a left intertrochanteric femur fracture at the age of 22 years, 2 months prior to the current presentation.
She had an interesting past medical history. She was diagnosed to have a left side nephroblastoma at the age of 8 years, for which she underwent left side radical nephrectomy followed by chemotherapy. Thereafter, at the age of 14 years, she developed a right sided facial swelling and was found to have a maxillary tumor which was described during the surgery as a well-circumscribed mass lesion in the left maxilla, eroding the anterior wall of maxilla and lateral nasal wall. She underwent partial maxillectomy for this, and histology revealed features suggestive of fibrous dysplasia.
She did not have a history of chronic steroid use, hypogonadism, hyperthyroidism, rheumatoid arthritis, and exposure to cigarette smoking to suggest secondary causes for osteoporosis. She had neither any features of malabsorption nor inadequate exposure to sunlight to suggest a vitamin D deficiency causing these fractures. The histology of bone biopsies was negative for metastatic deposits.
She did not have a family history of hyperparathyroidism, renal, or uterine tumors. There was no past history or family history suggestive of MEN 1. Her general and systemic examinations were normal apart from the healing fracture sites.
Her investigation findings are summarized in .
Her investigations revealed high total calcium and urinary calcium excretion, with low serum phosphate level. She was found to have a vitamin D deficiency, which was corrected by vitamin D replacement. As high calcium and low phosphate were suggestive of

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


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

[User]
RADIOLOGY NOTE:
A 52-year-old woman presented with pain and active function loss in her left shoulder, and was admitted to our hospital in June 2017. Her shoulder problem had started 3 months earlier, and there was no history of trauma or fracture. At first the pain was intermittent and bearable, but then gradually increased. On examination, there were no positive signs except for localized pain. A radiologic examination on 3 April 2017 found no destruction of the shoulder (Fig. ). Pain at the shoulder joint became gradually aggravated, together with the appearance of shoulder joint dysfunction. Two months later, physical examination revealed mild swelling of the shoulder, and markedly restricted shoulder and elbow motion. Mild distal nerve function defects appeared gradually. Radiography on 3 June 2017 showed that the head of the humerus had disappeared within the past 2 months (Fig. ), which was confirmed by magnetic resonance imaging (Fig. a, b).
The patient is a healthy, active individual with no history of weight loss, anorexia, or fever during this period. General and systemic examination findings were within normal limits. Routine laboratory investigations were also normal, including levels of serum calcium, phosphate, alkaline phosphatase, high-sensitivity C-reactive protein, and erythrocyte sedimentation rate. An open biopsy of the lesion revealed that the bony tissue had been replaced by fibrous connective tissue, and small areas of bony trabeculae with occasional osteoclasts were visible (Fig. ). There was no evidence of malignancy or tuberculosis. Because of the lack of any clinical findings or supporting data for other causes, the features were confirmatory of GSD. Computed tomography of the shoulder joint (Fig. ) revealed a bony defect of the glenoid cavity.
We performed surgery involving glenoid cavity amplification with an autologous iliac bone graft and a reverse total shoulder arthroplasty. The grafts were from autologous iliac bone (Fig. , Fig. ). A deltopectoral

[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:
Case 3: a 43-year-old female patient, 55 kg, was admitted 1 month after pancreaticoduodenectomy with 1 day of fever. She was admitted with a diagnosis of intra-abdominal infection and type 2 diabetes mellitus. Due to recurrent vomiting, the physician arranged for her to have a jejunal nutrition tube placed under gastroscopy. On August 3, 2020, the patient underwent gastroscopy under local anesthesia. After confirming the absence of gastric contents, the procedure was subsequently started with 12 mL of intravenous propofol at 16:10, with additional 2 mL of propofol intermittently during the operation. At 16:35, the patient's SpO2 suddenly dropped to 76%, and the patient was immediately ventilated with a face mask under pressure, followed by a gradual increase in the patient's oxygen saturation to 89%. During this process the patient's blood pressure fluctuated between 180 to 210/100 to 122 mmHg. At 16:45, the patient's blood pressure suddenly dropped to 64/32 mmHg and heart rate dropped to 30 to 40 bpm. The anesthesiologist instructed the surgeon to immediately withdraw the gastroscope while giving the patient intravenous epinephrine 1 mg and performing tracheal intubation, then the patient was under mechanical ventilation, at that time oxygen saturation rose to 95%, blood pressure rose to 105/58mmHg, ECG showed a heart rate of 62 bpm and ETCO2 showed 25mmHg. At 17:00 the patient's heart rate dropped to 30 to 40 bpm again and blood pressure and SpO2 could not be measured. The anesthesiologist immediately organized to give the patient resuscitation measures such as chest compressions, intermittent intravenous epinephrine, and ice caps. Then the patient's systolic blood pressure fluctuated from 58 to 85 mmHg, heart rate from 30 to 50 bpm, oxygen saturation from 75% to 90%, and ETCO2 from 8 to 12 mmHg. At 17:17, the anesthesiologist performed a TEE, which showed a significant enlargement of the right heart and a large volume of gas

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


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

[User]
RADIOLOGY NOTE:
A 60-year-old man was brought to the emergency department with a chief complaint of periumbilical abdominal pain. He suffered from abdominal pain for two weeks but it was significantly increased in the three days prior to admission. The pain radiated to the back and no accompanying signs or symptoms were present. It was described as a constant pain without any alleviating or exacerbating factors. The patient was a heavy smoker without any history of previous surgery or drug use.
The patient showed stable vital signs and a nuisance general appearance. No objective signs of weight loss or cachexia were observed. The physical exam was normal in the head and neck, chest, and extremities. In the abdomen a pulsatile mass was palpated in the periumbilical region. Routine laboratory tests revealed mild normocytic normochromic anemia, normal ESR and CRP, and liver function and diagnostic tests within normal limits.
Due to the pulsatile nature of the mass a CT angiography of the abdomen was ordered to look for vascular pathology. The tomography revealed a 5-by-4 cm pseudoaneurysm with hematoma formation in the infrarenal aorta alongside diffuse dilation of the infrarenal inferior vena cava with extension into both common iliac veins (), and the patient was prepped for surgical repair.
During surgery a pulsatile mass 20 by 20 cm in diameter with surrounding hematoma was observed in left zones 1 and 2. Upon further investigation a huge retroperitoneal mass 11 by 8 by 6 cm in diameter with apparent local invasion to the aorta and the inferior vena cava was found. En bloc resection was attempted along with involved vascular segments. The abdominal aorta was reconstructed using 16 mm-by-8 mm Dacron bifurcated graft, while the IVC was ligated below the renal veins but perhaps because of chronic process of disease no lower extremity edema happened and the patient was discharged after a week.
Pathologic evaluation of the specimen showed an undifferentiated pleomorphic sarcoma (a.k.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 52-year-old man applied to the outpatient clinics with the complaints of abdominal pain and weight loss for two months. Abdominal pain had worsened for the last two days. He also complained of diarrhea for the last week. His past history revealed restless leg syndrome. He had undergone an operation for sinusitis four months before the admittance day. Physical examination revealed a mass and tenderness in the right lower quadrant with local signs of peritonitis. White blood cell count was 11,330/mm3; haemoglobin level was 11 gr/dL with normal platelet count. Liver and kidney function tests were in normal limits except an increased blood glucose level (146 gr/dL) but the patient denied a history of diabetes. Computerized tomography (CT) scans of the abdomen demonstrated a 90 × 83 × 95 mm mass with gas containing abscess involving cecum and distal ileum with luminal narrowing and marked inflammatory changes in the contiguous tissues. Multiple lymph nodes measuring up to 19 × 11 mm were seen in the pericecal region (). On the same day, the patient was referred to the general surgery department with suspicion of perforated colonic carcinoma. Colonoscopy was not performed. Broad spectrum antibiotics were given and the patient underwent laparotomy and right hemicolectomy with segmental ileal resection and partial omentectomy. The intraoperative findings were compatible with perforated cecal neoplasm that invaded the parietal peritoneum. The postoperative period was uneventful and the patient was discharged on postoperative day 9.
The mass was 11 × 8 × 3 cm in macroscopic evaluation. Pathology revealed pseudotumor formation with necrosis of cecum and ileocecal valve () involving multifocal colonies of Actinomyces with periodic acid-Schiff and Grocott's dye (). There were multifocal Entamoeba trophozoites on the surface of the necrotic tissue (). Transmural and mesenteric fibrosis with lymphocytic infiltrate was seen. Similar inflammatory granulomatous process was present

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


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

[User]
RADIOLOGY NOTE:
A six-year-old boy was referred with a painful swelling in the left thigh and difficulty in walking since four months. On examination, a firm swelling approximately five centimeter in size was noted on the posterior mid thigh. The swelling was diffuse, tender, and deep to the muscles. The overlying skin was normal. The child was febrile and total counts were elevated. Sonography reported the possibility of abscess deep to the thigh muscle. He symptomatically responded to antibiotics, analgesics, and rest. Magnetic resonance imaging (MRI) and computer tomography (CT) angiography reported the possibility of an infected hematoma or hemorrhage in non-involuting hemangioma with close proximity to the sciatic nerve [Figure and ]. The child was advised surgical excision for diagnostic confirmation with an explained risk of nerve damage. However, the parents did not give consent, so it was deferred.
On follow-up, the child developed weakness in the limb. The swelling was now more localized, firm, and non-tender. Fine needle aspiration was done, which revealed small round cells with mitotic figures. He was advised surgical excision. Operative findings revealed a variegated consistency mass in the substance of sciatic nerve []. The mass originated from the sciatic nerve with no gross involvement of the surrounding tissue []. The parents were counseled and informed consent was taken for nerve excision. The tumor was excised completely with one centimeter of the intact nerve at the upper and lower pole. In view of an established peroneal neuropathy for distal limb, a size-matching, peroneal nerve was harvested as a donor nerve for autologous nerve grafting. A 7.5-cm-long segment of the peroneal nerve was grafted with 7-0 polypropylene epineural sutures, avoiding any twist or torsion or tension at the anastomotic sites [].
Histopathology and immunohistochemistry studies were suggestive of Ewing's Sarcoma in the substance of the sciatic nerve. Nerve endings were tumor free []. Wo

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


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

[User]
RADIOLOGY NOTE:
A 35-year-old female was admitted to our hospital complaining of an intermittent headache for 5 years, menopause for more than 2 months, and blurred vision and lactation for more than 1 month. Five years prior, the patient began suffering from intermittent and gradually deteriorating occipital and frontal headaches. One month prior to admission, she had impaired vision and an absent right temporal view and simultaneous bilateral galactorrhea, without purulent or bloody secretions. Since the onset of symptoms, the patient experienced no nausea or vomiting, sleepiness, chills, hair loss, or fatigue. Computed tomography (CT) showed an irregular cystic solid mass in the suprasellar area. The size of the mass was 1.4*1 cm and could be markedly enhanced. The CT value of the solid part of the lesion on plain CT was 40 Hounsfield units (HU); in the enhancement, the value was 74 HU, and the cystic part showed no enhancement. The boundary of the lesion was less clear, the density was not uniform, and no obvious calcification was observed. The cavernous sinus was involved. There were no abnormalities in the ventricular system, sulcus, brain split and pool. Moreover, there was no shift in the midline structure, and no abnormalities were found in the skull structure. The sinuses exhibited no obvious abnormalities. Magnetic resonance imaging (MRI) of the brain and pituitary showed an irregular cystic solid mass in the suprasellar area, involving in the pituitary stalk, and the boundary between the lesion and pituitary was unclear. In addition, the mass pressed on the optic chiasm, and the solid part of the lesion was significantly enhanced, while the cystic part showed no enhancement. There was no abnormal signal in the brain or paranasal sinuses nor signs of calcification (Figure ). Auxiliary examinations revealed that the patient's urine volume and specific gravity were within the normal range (urine volume: 1,800 mL/day; urine specific gravity: 1.015). A pituitary function eva

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


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

[User]
RADIOLOGY NOTE:
A 64-year-old Japanese man consulted our hospital due to an abdominal mass that had persisted for 1 month. He also had a history of appetite and weight loss. He had a past history of a duodenal ulcer and resection of the left adrenal gland due to primary aldosteronism. He had hypertension and paroxysmal atrial fibrillation, as well as rheumatoid arthritis. Computed tomography (CT) revealed a 180-mm tumor in the posterior region of the gastric body (Fig. A and B). The tumor consisted of solid and cystic parts. The primary tumor site was unclear on imaging. There was no significant lesion observed in the mucosa of the upper and lower digestive tracts on endoscopic examination.
Resection of the tumor was carried out. Intraoperatively, the tumor was not in contact with the gastrointestinal tract, but was present in the transverse mesentery immediately anterior to the pancreas, and it seemed to invade the body of the pancreas. The tumor was also in contact with the omentum and peritoneum just anterior to the pancreas. Therefore, the tumor was resected, along with the pancreatic body and tail and the spleen (Fig. A and B). The size of the resected tumor was 210 × 200 × 200 mm. There was a large cyst in the tumor (Fig. C). The tumor was found to be very close to the pancreas (Fig. A). Although the tumor did not invade the pancreas, it was impossible to detach the tumor from the pancreas surgically. Microscopically, the solid component and cyst wall of the tumor showed similar histological features, being mainly composed of mesenchymal spindle cells with plump cigar-shaped nuclei (Fig. B and C). Immunohistochemically, the tumor cells were positive for cluster of differentiation (CD)117 (c-Kit) and CD34, and negative for alpha-smooth muscle actin and S100, suggesting that the tumor was an EGIST (Fig. D and E). The number of mitotic cells in

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


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

[User]
RADIOLOGY NOTE:
A 55-year-old female patient from Southeast Ethiopia, presented to Goba referral hospital with complaints of right flank pain and swelling on the right lumbar region. The pain was a dull ache and not associated with urinary complaints like dysuria, frequency, urgency or hematuria. She had no cough and chest pain.
The patient reported that she had been visiting more than three hospitals with complaints of right flank pain for the last eight years and had been taking an ultrasound, magnetic resonance imaging, renal function test, and urine analysis. However, the patient reported that the results of these investigations were normal, and she was only treated with different types of anti-pain medications. Four years later, the patient noticed that swelling on the right lumbar region, and the swelling had increased gradually and was associated with pain. She had no history of flank trauma, surgery, chronic constipation, and other abdominal infections. In addition, the patient had no history of chronic cough, difficulty of urination, and history of diabetes mellitus.
On admission, the patient was clinically active and had normal vital signs. On abdominal examination, there was round protruding swelling immediately beneath the 12th rib of the right upper flank region (). The swelling was palpable and bowel sound was heard in the region. The swelling was easily reducible and protruded when the patient was coughing or straining. The opposite side lumbar region was normal, and chest examination was clear and normal. The hematological and urine analysis laboratory findings were normal. The ultrasound picture revealed the bowel contents within the hernial sac. Otherwise, all visceral organs were normal.
With the diagnosis of primary acquired superior lumbar hernia, the patient underwent open surgery. The open approach was designed due to the absence of laparoscopy services in the hospital. The defect was reduced back and repaired using a retro-muscular or sublay prolene mesh (15

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


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

[User]
RADIOLOGY NOTE:
This case report will focus on a 39-year-old male with a smoking history of one pack per day and regular alcohol intake of beer for over 20 years. He has had ongoing respiratory and abdominal symptoms which had been attributed to his smoking and drinking history. Starting in his early twenties, he began to have multiple episodes of mild upper respiratory tract infections and bronchitis on a yearly basis. He also experienced mild abdominal discomfort and nausea which would come and go sporadically. High-resolution computed tomography of the chest confirmed emphysematous changes of the lung as shown in Figures - below.
His liver enzymes had been slowly trending up throughout the years. Over the span of a few months, his aspartate transaminase (AST) level increased from 52 units per liter (U/L) to 58 U/L. His alanine transaminase (ALT) level increased from 81 U/L to 86 U/L. The upper limit of normal for both AST and ALT levels fall in the low 40s U/L. Other markers of liver damage, including serum prothrombin concentrations and serum albumin, were not affected.
His primary care physician instructed him to quit smoking and drinking, eat healthily, and exercise regularly. He was successful in making these lifestyle changes, but over the next few years, his liver enzymes remained elevated and his lungs continued to show persistent emphysema. There was little to no improvement in his overall symptoms. Due to these abnormal findings, he was tested for alpha-1 antitrypsin deficiency (AATD) and was found to be homozygous for the Z allele (PI*ZZ). His alpha-1 antitrypsin (AAT) level was 18, which is well below the protective threshold of 57. Once the diagnosis was confirmed, the patient was immediately started on weekly Prolastin infusions. Since his diagnosis, our patient has completed eight infusions of Prolastin and will continue to receive weekly infusions for as long as he is able to tolerate them in order

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


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

[User]
RADIOLOGY NOTE:
A 65-year old male patient with early gastric cancer was transferred from Aruba to our institution. He had a 3-year history of black stools and anemia. His past medical history included multiple comorbidities: diabetes, chronic renal failure, alcoholic cirrhosis Child A, complete heart blockade and thrombocytopenia of unknown etiology. An upper endoscopy and biopsy revealed a well-differentiated intestinal type adenocarcinoma in the antrum. Endoscopic ultrasonography showed a hypoechoic, 3.2 cm neoplasm, without muscularis externa infiltration and reactive ganglia (). Endoscopic mucosal resection was chosen due to tumor size, stage and comorbidities of the patient. The tumor was fully resected without complications. At the end of the procedure the anesthesiologist had difficulty with ventilation and abdominal distention was observed (). He had a 128/91 mmHg blood pressure and 70 bpm heart rate. An endoscopic revision was done before finishing the procedure, without identification of any macroscopic perforation. A nasogastric tube was placed and therapeutic strategies to improve abdominal-wall compliance were instituted (changes in ventilation parameters, nasogastric suction, change to a supine position and removal of any strap over the abdomen). A plain abdominal radiography in the operating room showed a massive pneumoperitoneum (). Decision of a nonsurgical management was conducted and the patient was taken to the intensive care unit (ICU) for monitoring. The IAP measured by a trans-bladder catheter was 33 mmHg. Six hours after ending the procedure the patient developed dyspnea and anuria. The diagnosis of an abdominal compartment syndrome was established. Given the worsening status, interventional radiology evaluated the patient. A CT scan confirmed the massive pneumoperitoneum without intraperitoneal extravasation of contrast (a & b). A percutaneous decompression guided by CT scan was performed with a pigtail catheter G14 (c & d). Air was immediately released un

[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:
Herein we presented the case of a 48-year-old male who presented to our emergency service due to ocular pain and blurred vision in his right eye. While cleaning an oven with a metallic brush, the patient felt a foreign body sensation in the right eye. Best-corrected visual acuity of his right eye was 0.9.
Slit lamp examination of the anterior pole of the right eye revealed conjunctival congestion, watery discharge. Around 12 o’clock, a metallic foreign body was detected near the corneoscleral limbus, which perforated the cornea, the iris, the anterior capsule of the lens and the lens (). We could not perform the full examination of the posterior pole, so we could not establish the trajectory of the intraocular foreign body. Ocular B-scan was not performed because of the penetrating corneal wound. X-ray of the orbit did not offer enough details and computed tomography could not be performed at that time in our service.
After performing an anti-tetanic prophylaxis, we decided to extract the intraocular foreign body by using a forceps. Since it had a helicoidal shape, we had to perform several circular movements (). We were surprised to find out that the wire that perforated the eye was almost 20 mm long (). We injected an antibiotic in the anterior chamber and placed a contact lens to protect the cornea and facilitate the healing of the point-like corneal wound
On the first day postoperatively, the slit lamp examination revealed a stable anterior chamber and a totally opacified lens with anterior capsule rupture. B-scan ultrasound showed no sign of vitreous haemorrhage and an attached retina. Visual acuity of the right eye was hand motion determined because of the traumatic cataract. We decided to extract the opacified lens. Due to the age of the patient, the lens was very soft so we performed its extraction with a blunt cannula under viscoelastic protection, with good results (). We noticed a posterior capsule break because the foreign body passed through the lens

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


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

[User]
RADIOLOGY NOTE:
We present the case of a 56-year-old female with history of syncope due to third degree atrioventricular heart block presenting initially with onset of stroke symptoms six days after pacemaker placement and two days after hospital discharge. At 5 PM she developed abrupt onset of left facial droop along with left upper and lower extremity weakness. The patient was initially treated at an outlying hospital and received alteplase at 6:35 PM for treatment of acute ischemic stroke.
A chest radiograph performed at the outlying hospital prior to alteplase administration demonstrated an enlarged cardiac silhouette when compared to prior radiographs showing only borderline cardiomegaly. Upon administration, the patient reported mild chest pain and was given nitroglycerine and morphine. Her chest pain resolved and she was transferred to our comprehensive stroke center for admission. The patient presented to our emergency department at 10:10 PM with a heart rate of 122 beats per minute (bpm) and a blood pressure of 109/41 millimeters of mercury (mmHg).
At 11:20 PM the patient went for a computed tomography angiogram (CTA) after an initial assessment by the emergency physician in consultation with the stroke-team attending physician. After CTA at 10:28 PM, she was documented to have a blood pressure of 49/25 mmHg and heart rate of 109 bpm. She was returned to the resuscitation bay for re-evaluation. Cardiac tamponade was suspected due to the extreme hypotension in the setting of thrombolytic administration after recent pacemaker placement.
On reassessment, the patient had become confused with a Glasgow Coma Scale of 14. The emergency physician performed a POCUS, which demonstrated a pericardial effusion with features of cardiac tamponade including diastolic collapse of the right ventricle (). At that point the diagnosis of cardiac tamponade was made. The patient was alert and responsive, so an intravenous bolus of normal saline was given while a stat surgical consult was obtain

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


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

[User]
RADIOLOGY NOTE:
A 47-year-old male patient was admitted to the Department of Neurosurgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China in November 2016, 1 month after a previous head trauma that caused a loss of consciousness and was treated with decompressive craniectomy, which was initially followed by a good recovery. The earlier head trauma was caused by a fall injury and the patient had become unconsciousness immediately. He was sent to the Sir Run Run Shaw Hospital, Zhejiang University School of Medicine with the right pupil dilated and fixed. An immediate craniocerebral computed tomography (CT) scan found an epidural haematoma in the right temporal area and a severe right-to-left midline shift. A right fronto-temporo-parietal craniotomy was performed and the haematoma was evacuated. The bone flap was not replaced in case of delayed cerebral oedema. The patient recovered his consciousness after the operation and had a favourable prognosis during the subsequent 3 weeks of uneventful clinical recovery, although paralysis in the left upper limb was evident. However, his conscious state deteriorated again in postoperative week 4 and he had a cranial defect bulge. The following CT scan found a contralateral subdural effusion with the midline shifted more than 1 cm to the right side. He underwent a burr-hole drainage operation to evacuate the subdural effusion while his attending physicians implanted an Ommaya reservoir in case of the recurrence of the effusion. His condition recovered after the operation but deteriorated again after the drainage was removed. His condition only improved during short periods after each percutaneous fluid aspiration of the Ommaya reservoir. He was transferred to the Department of Emergency and Trauma Centre, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China 1 week after the second surgery with the hope of him achieving a full recovery

[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 male patient presented with worsening symptoms of chest discomfort and exertional dyspnea {New York Heart Association (NYHA) III} for 2 months. He had past medical history of hypertension and dyslipidemia. Four years ago, the patient had been treated with percutaneous coronary intervention with implantation of stents at the left main artery and the distal left circumflex artery. At that time he also underwent percutaneous transluminal angioplasty with implantation of self-expandable nitinol stents at the bilateral iliac arteries. On admission, transthoracic and transesophageal echocardiography showed severe AS and mild aortic regurgitation (AR) due to degenerative change with calcification (). The aortic valve area was 0.44 cm2. The peak and mean pressure gradients across the aortic valve were estimated to be 97 and 59 mm Hg, respectively, while the diameter of the aortic annulus by echocardiography was 25 mm. The left ventricle (LV) showed a dilated enddiastolic dimension (64 mm) with LV hypertrophy. The LV systolic function was globally reduced with an LV ejection fraction (EF) of 39%. Based on the coronary angiography, the stent at the left main artery was patent. However, the stent implanted at the distal left circumflex artery showed in-stent restenosis, which was subsequently treated with a 3×30 mm paclitaxel-eluting balloon (SeQuent® Please, B. Braun Melsungen AG, Berlin, Germany). The previously inserted stents at the right and left iliac arteries were patent, however computed tomography (CT) angiography revealed that the minimal lumen diameter of the stented right iliac artery was 5.5 mm and that of the left iliac artery was 4.5 mm. Both common femoral arteries also showed significant stenosis with a minimum lumen diameter of 4.0 mm (). The diameter of the left subclavian artery was measured to be 7 mm on CT angiography. The calculated EuroSCORE was 44.08%.
In this patient we decided to perform TAVI by transsubclavian approach. The procedure

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


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

[User]
RADIOLOGY NOTE:
A 69-year-old Saudi man with diabetes mellitus was admitted to the Neurology Department with an unremitting headache lasting 5 days, episodic confusion, and visual disturbances. According to his family, the headache started gradually over the left side of his head and then became holocephalic and moderate to severe in intensity. The patient reported feelings of nausea and 2 episodes of vomiting. Moreover, his family stated the patient was often seen “bumping” into surrounding objects while ambulating. The patient reported experiencing some visual disturbance during this period. The patient's family felt he appeared confused at times and was not responding to his surroundings. He had no clear history of seizure, according to the family, and his past medical history was unremarkable apart from diabetes. He had sustained a minor head trauma 3 years prior with no concussion; however, his scan was reported to have shown “scattered areas of bleeding” in his brain. He otherwise maintained a healthy life and never required a hospital visit for any medical issues. His family reported the patient had normal cognitive function, especially as someone who ran his own business.
The patient was lethargic upon arrival to the accident and emergency department. Given the apparent risk of airway obstruction, the emergency physician intubated the patient. On general examination, we found no facial phakomas. While the patient was sedated, we found tonic eye deviation with nystagmoid-like eye movement and subtle myoclonic jerks of the distal limb suggestive of subclinical seizures. He was given an intravenous (IV) loading dose of phenytoin in addition to a midazolam infusion. Despite this, he sustained several clinical seizures in the subsequent days. Therefore, he required further titration of midazolam infusion (up to 14 mg/hr) and IV levetiracetam was added to optimize the antiepileptic coverage. His electroencephalogram was obtained postictal. His brain MRI was obtained 1 day followi

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


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

[User]
RADIOLOGY NOTE:
An 82-year-old woman presented as a transfer from an outside facility with painless, obstructive jaundice. She observed yellowing of her skin, poor appetite, and fatigue for two days, as well as dark brown urine. She was otherwise healthy and independent at home. She did not smoke and had no family history of malignancy.
Diagnostic workup at the outside facility was notable for elevated total bilirubin to 14.4 mg/dL, alkaline phosphatase to 1,004 U/L, and white blood cell count was elevated at 23.6 × 103/μL. Magnetic resonance cholangiopancreatography (MRCP) had shown intra- and extrahepatic biliary dilation with evidence of a stricture in the distal common bile duct (CBD) suggestive of a pancreatic head mass. It also revealed the presence of a large, type III hiatal hernia, which had been previously asymptomatic other than mild reflux disease.
Given the concern for cholangitis, the patient was taken for an endoscopic ultrasound with subsequent ERCP to further evaluate her pathology and relieve her biliary obstruction. Endoscopy confirmed the presence of a large, type III hiatal hernia, which made advancing the endoscope into the duodenum difficult. The endoscopists were still able to proceed with ultrasound and were successful in identifying and obtaining biopsies of a mass in the pancreatic head. However, ERCP was aborted as the scope could not be advanced past the second portion of the duodenum. As the scope was being removed from the stomach, a small, linear tear was noted in the stomach mucosa along the greater curvature of the fundus, though the endoscopist believed it to be a partial-thickness tear. This was closed with serially placed 5 mm endoscopic clips, and complete approximation of the mucosa was seen.
The patient was subsequently placed on IV antibiotics and closely observed. Unfortunately, she progressed to develop signs of mediastinitis, peritonitis, and sepsis. A subsequent computed tomography (CT) scan showed a persistent hernia with intra-abdomina

[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 fit 45-year-old man, with a background of Brugada Syndrome had an ICD inserted 10 years previously for secondary prevention. He was initially admitted for lead replacement and ICD box change. This procedure was attempted, however failed due to an occlusion of the brachiocephalic vein. Therefore, a laser-assisted lead extraction was undertaken. Immediately following the procedure, the patient showed sign of tamponade and a pericardiocentesis was carried out. This was unsuccessful and the patient became hemodynamically unstable. He was transferred immediately to the operating theatre, intubated, ventilated and proceeded for emergency sternotomy. On arrival to theatre, the patient developed pulseless electrical activity and external chest compressions were delivered for 30–60 s.
Following sternotomy, the pericardium was opened and copious amounts of blood and clots were removed with prompt restoration of spontaneous circulation.
A bleeding point was identified on the right ventricular acute margin, which was repaired using a single 3/0 pledgeted Prolene suture. A large volume of blood was also noted in the right pleura, with extensive infiltration of the extra-pericardial portion of the superior vena cava. Careful dissection revealed a 5–7 cm linear tear extending from the right subclavian vein to the pericardial reflection of the Superior Vena Cava (SVC; ). In order to repair this, the patient was connected to cardiopulmonary bypass and cooled to 25° without circulatory arrest. A patch of bovine pericardium was used to reconstruct the SVC and the right subclavian vein (). The patient was rewarmed and hemostasis secured.
However, the patient remained hemodynamically unstable and the hemoglobin was noted to be low. The abdomen was very distended and an ultrasound demonstrated free abdominal fluid. The possibility of having a CT scan was dismissed due to the unstable condition of the patient. He proceeded for an emergency laparotomy with 4 L of blood drained from the 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:
An 18 year-old male patient presented with the chief complaint of pain and discolored upper front tooth. He had incurred trauma to the teeth due to a fall from a two-wheeler motor vehicle more than 10-years ago and underwent endodontic treatment followed by crown immediately after the trauma for the maxillary right central incisor. Patient was symptomless for sometime but in due course developed periodic swelling and now since 6 months had noticed intermittent pus discharge. On consulting another dentist, endodontic treatment for the right lateral incisor was started but as the pain was progressively increasing, so the patient was referred by the dentist to the college. The patient's medical history was noncontributory and vital signs were within normal limit.
Intraoral examination revealed the presence of porcelain fused to metal crown in right maxillary central incisor associated with a sinus tract in the periapical region. Tracing of the sinus tract with gutta percha confirmed the involvement of the central incisor. The tooth was tender on percussion and palpation. The periodontal status was normal (probing depth <3 mm) with no mobility ruling out any periodontal pathology. The lateral incisor showed incompletely done root canal treatment. Radiographic examination of the central incisor revealed poorly obturated root canal with incomplete root formation. The root end had thin dentinal walls with apical flaring and periapical rarefaction of 2-3 mm []. The lateral incisor had intact periodontal ligament space and showed complete root formation. Electric and cold tooth vitality testing were performed for all the maxillary anterior teeth except the maxillary right central incisor. The right lateral incisors gave a negative response and all the other teeth gave a positive response. According to the clinical and radiographic findings, there were two treatment options available for the central incisor, either a surgical removal of the periapical lesion followed by retro

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


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

[User]
RADIOLOGY NOTE:
A 36-year-old woman with no past medical history was admitted to hospital after slipping on the ice. The patient did not lose consciousness, but she immediately noted drooping of her right eyelid and double vision when she elevated the lid. There was a 3 cm laceration wound on the chin and some abrasions over the neck and the central region of her face ().
The right pupil was fixed and dilated, and there was complete right ptosis. The patient could not elevate, depress, or adduct the right eye, but the eye intorted on attempted downgaze (). The right pupil measured 5 mm in diameter and was sluggish reactive to light. Ophthalmologic tests of vision and intraocular pressure were within normal ranges in both eyes. Further physical and neurological examinations were normal. Skull X-rays and orbital computed tomography (CT) scans immediately after the accident failed to show fractures. MRI and MR angiography of the brain did not reveal any pathology on admission (). Contrast-enhanced spoiled gradient-recalled (SPGR) MR sequences with multiplanar reconstruction (MPR) was subsequently performed to produce high-resolution images of the cisternal portions of the cranial nerves. The 3D MR studies indicated a slightly rough-shaped ON near the the posterior petroclinoid ligament (PCL), but no nerve enhancement (). The patient's history, along with the ophthalmologic symptoms and the radiologic findings strongly suggested the diagnosis of an isolated lesion in the course of the ON without further damage in the right oculomotor nucleus.
She was then treated with oral prednisone in a tapering dose over several weeks. MPR of contrast-enhanced 3D MRI taken 2 weeks after the event clearly demonstrated strong enhancement and enlargement over the whole length of the right ON (). At the time of follow-up two months after trauma, her ptosis slightly improved. Three months later, ptosis was completely resolved, and there was some restoration of ocular motion in

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


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

[User]
RADIOLOGY NOTE:
A 59-day-old, 5.3 kg, male patient presented for general anesthesia for undergoing craniotomy and vertical parasagittal right hemispherotomy. He was normally delivered at 39 weeks of gestation with a birth weight of 3,180 g without any complications or abnormal findings. One week after birth, his seizures started with repetitive clustered tonic spasms for 30 min, at a frequency of 10 clusters a day. He was admitted at an outside hospital, and vigabatrin 250 mg and phenobarbital 20 mg were administered. Yet his seizures were refractory to anticonvulsants, so he was transferred to our hospital at the age of 30 days.
There were no abnormal physical findings and laboratory investigations. The electrocardiogram and chest X-ray were also normal. After admission, he had generalized tonic seizure with right-ward eyeball deviation, blinking and nystagmus at a frequency of 1-3 a day. Flexor spasms in clusters were also observed for 10 minutes, at a frequency of 7 clusters a day. His magnetic resonance imaging (MRI) showed cortical dysplasia at the right temporal and parietal lobes (). On the positron emission tomography (PET) study, abnormal high uptake for that age was discovered at the right cerebral hemisphere. His video EEG for 2 days demonstrated excessively asynchronous and discontinuous rhythms, the so called suppression-burst patterns, and this was consistent with OS during both the awake and asleep states (). He was diagnosed with OS and right hemispherotomy was planned for treatment.
He was transported to the operating room and the immediate vital signs revealed a blood pressure, pulse rate and oxygen saturation of 83/42 mmHg, 152 beats/min and 100%, respectively. Before induction, 0.02 mg of glycopyrrolate was injected intravenously. The patient was preoxygenated and general anesthesia was induced with thiopental sodium 25 mg and atracurium 3 mg. Mask ventilation was begun with 100% oxygen and there was no difficulty in ventilation. After confirming full relaxation

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


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

[User]
RADIOLOGY NOTE:
A 48 year-old woman was scheduled for an urgent diagnostic flexible bronschoscopy, mediastinal washout as well as video-assisted thoracoscopic surgery. She was cared for in the intensive care unit having received a dual liver and lung transplant twelve days prior to the request for the thoracic procedure. The initial dual organ transplant (day 0) was complicated by intra-thoracic placement of the veno-venous bypass cannula. This was detected at the time and managed by resiting the cannula surgically into the axillary vein. The immediate post-transplantation course consisted of an initial uneventful recovery, monitoring and supportive management in intensive care unit. There was evidence of near complete resolution of the right-sided haemothorax with radiological confirmation on computed tomographic (CT) chest scan. Patient was afebrile with clinically stable markers of respiratory and haemodynamic function. She was extubated on day 9 post dual organ transplantation. The PICC line was inserted through the left basilica vein for total parenteral nutrition post extubation also on day 9. Both PICC lumens were found to flush and aspirate blood when tested clinically. Subclavian vein PICC tip placement was confirmed with a chest X-ray and total parenteral nutrition was commenced (). Patient developed mild voice changes and shortness of breath 36 hours later. The PICC line was checked. No blood could be aspirated. The PICC line was deemed likely blocked and remained in situ. This decision was made due to the high confidence in the initial appropriate placement of the line. Two days following the PICC line insertion, there were further changes with alteration in the quality of voice and difficulty verbalising. Patient developed difficulties with swallowing. Clinically, there was attendant deterioration in the respiratory function with chest pain, tachypnoea and hypoxemia. Patient oxygen saturation was low in the range of 91–93% despite oxygen therapy via hudson mask. Increa

[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 25-year-old man was transferred to the emergency department by ambulance with an injury to the left ankle, after been involved in a road traffic accident (fall from own motorbike). He had sustained a minor injury to the head with an extensive blunt laceration of the soft tissues of the scalp (Glasgow Coma Scale, 15/15), a rib fracture accompanied by pneumothorax, as well as bruises and abrasions of the lower extremities. His primary complaint was severe pain and deformity of his left ankle. On physical examination, the ankle joint was noted to be deformed, swollen, and tender without lacerations. The skin temperature was normal, the sensory function could not be estimated because of pain, and there was motor loss. As the peripheral pulse was not palpable, the initial vascular status was assessed by applying the capillary nail refill test (observed). There is an obvious clinical deformity, and the ankle is revealed in a medial position with the talus head raised under the skin (). Radiographic evaluation of the ankle revealed an anteromedial dislocation of the talus, without any accompanying fracture (). Due to the absence of other fractures or neurovascular trauma, a closed reduction was attempted under general anesthesia with image intensifier fluoroscopy. Utilizing a technique previously described [], the talus was not able to be reduced to its anatomical position, neither was any sign of a “click” perceptible. A second attempt was also unsuccessful, and thus, a decision was made to perform an open reduction. Probably, the anteromedial dislocation of the talus, without malleolus fracture, was responsible for the unsuccessful closed reduction. The joint was explored through a dorsomedial incision (). The anatomical elements were identified, and the deltoid ligament and the tibiotalar syndesmosis were found to be intact. The displaced talus was easily reduced into the joint using gentle traction of the foot. The ankle and subtalar joints were

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


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

[User]
RADIOLOGY NOTE:
A 29-year-old Chinese woman was referred to the outpatient department of our hospital on 1 September 2016 with a 4-month history of catamenial hemoptysis. The patient also had a history of a laparoscopic operation for treatment of an ectopic pregnancy and a 6-year history of secondary infertility.
In May 2016, the patient developed her first episode of catamenial hemoptysis with no prodrome. During the following 4 months, the hemoptysis became associated with her menstrual cycle. The patient reported that she began coughing blood on the first or second day of her menses and produced about 150 mL of hemoptysis during her menstrual cycle. She had no thoracic pain, respiratory embarrassment, cough, fever, night sweats, or weight loss. On 1 September 2016, chest computed tomography (CT) revealed exudation shadows in the right lower pulmonary lobe () and small fiber lesions in the right middle lobe and left lung (), which were suggestive of pneumonia and endometriosis. The patient’s clinical symptom returned when menstruation began, but she did not receive treatment. The patient agreed to undergo an examination on 27 September 2016 to obtain a definitive diagnosis. Chest CT revealed patchy infiltration in the right lower pulmonary lobe () and small fiber lesions in right middle lobe () and left upper lobe (); the clinical diagnosis was pulmonary endometriosis. Thoracoscopic wedge resection of the right lower pulmonary lobe was performed on 30 September 2016. We observed slight pleural adhesion under thoracoscopy; local stasis of blood in the lower lobe of the right lung, which was soft and had a smooth surface; no blood stasis in the right middle and lower lobes, chest wall, and pericardium; and no hydrothorax in the right thoracic cavity. The pathologic examination revealed chronic inflammation with hemorrhage and hemosiderin deposition in the lung tissue. Immunohistochemistry examination revealed estrogen receptor negativity, progesterone receptor negativity, CD positi

[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 81-year-old male patient was referred to our department with dysphonia. There was no history of smoking. A status past multiple myeloma was known in his medical history that was in complete remission at the time of presentation. The patient denied dyspnea, dysphagia, pharyngalgia, and fever. Laryngoscopy revealed a diminished mobility of the right vocal cord and a thickening of the right vestibular fold so that a microlaryngoscopy with tissue sampling was performed. The histological examination of specimens obtained from this region revealed fibrosis. Computed tomography (CT) scans of the neck and the thorax were without any pathologic findings. The patient was discharged to outpatient care.
Three months later, the patient was admitted with progressive dyspnea along with inspiratory stridor. The clinical examination revealed now a complete paralysis of the right vocal cord and a remaining glottic cleft of only 1 mm due to a supraglottic protrusion of the right vestibular fold. The CT scan () showed now a tumor of the right vocal cord extending to the right piriform sinus.
After tumor debulking in order to expand and secure the airway, the excised material that consisted of several red brown elastic tissue fragments measuring together 24 × 12 × 10 mm was sent for pathological examination. Histologically, one could see tight lymphoid infiltrates. The cells had large nuclei and were irregularly shaped, and the proliferation was strongly enhanced in the staining for Ki67 (50%). The immunohistochemical analyses showed a negative result for CD20 and CD3, and a positive staining for CD138. BCL2 and CD10 were coexpressed (). The clonal light chain restriction for lambda chains substantiated the diagnosis of a multiple myeloma. These results were consistent with laryngeal involvement from the patient's previously diagnosed multiple myeloma.
The patient was referred to the Department of Hematology and a systemic therapy with the proteasome inhibitor Bortezomib was discusse

[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 22-year-old male patient came to the orthopedic and rehabilitation clinics at our hospital with right equinovarus and gait disturbance. He had a history of hypoxic brain damage caused by the umbilical cord wrapping around fetal neck at birth, and was diagnosed with CP at the age of 1 year. He was experiencing severe dystonia in his neck and bilateral upper extremities; the Burke-Fahn-Marsden dystonia rating scale (DRS) showed 55 points on the dystonia movement scale, and 10 points on the disability scale.
On manual muscle test, the left extremities were within the normal limit, but the right upper and lower extremities only showed grade 3 (Fair). He showed right hip joint flexion contracture and right ankle plantar flexion contracture on the range of motion test. In terms of spasticity, his right upper and lower extremities scored grade 2 on the modified Ashworth scale (MAS). He had 78 points on the modified Barthel index (MBI), and 105 points on the functional independence measure (FIM). He showed asymmetry in the lower extremities and equinovarus in the right ankle on a plain X-ray, and 60 degrees right femoral anteversion, 15.3 degrees left femoral ante version, 38.9 degrees right tibial torsion and 37.1 degrees left tibial torsion on CT.
In gait analysis, he showed no dissociated movement between the pelvis and lower limbs, so we were able to see the bump sign, and the right pelvis were positioned superiorly to the left pelvis in the coronal plane during the whole gait cycle. Internal rotation of the right pelvis and external rotation of the left pelvis were observed in the transverse plane, and both hip joints showed internal rotation in the sagittal plane. Due to tightness in the hamstring muscle, both knee flexion posture and right ankle planter flexion posture were displayed during the whole gait cycle ().
To differentiate from hereditary torsion dystonia, when fragment analysis was performed on the DYT1 gene

[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:
Case One: A 35-year-old woman presented at six weeks of gestation, dated according to her last menstrual cycle, with painless vaginal bleeding. The patient had regular menses and a history of cesarean delivery 3 years prior with no other significant medical history, or history of sexually transmitted infections.
The patient’s transvaginal ultrasound was notable for a uterus anteflexed with a gestational sac of 12 mm and embryo of 4 mm with positive cardiac activity located on the anterior aspect of the lower uterine segment. The anterior aspect of the myometrium measured 5.2 mm and the lower uterine segment measured 1.5 mm. We could demonstrate color Doppler signal uptake in the area that contacts the posterior lip of the cervix and the preserved bladder. The patient’s serum quantitative beta human chorionic gonadotropin (β-hCG) was 3600 UI/L. At presentation, her vitals were within normal limits and stable.
These ultrasound findings raised the suspicion of cesarean scar ectopic pregnancy. Following appropriate counseling, the patient confirmed her desire for future fertility and, understanding the risks and benefits, she agreed to medical treatment. An initial dose of intramuscular methotrexate at one milligram per kilogram (mg/kg) was administered. At one week follow-up, she received a three multi-dose regimen over a period of five days. Three doses of folinic acid were added to the treatment. After a systemic treatment of multiple doses for one week, the patient was asymptomatic and the betahCG serum level was 5809 UI/L. An aspiration curettage was thus performed in the ultrasound operating room, affording possible transvaginal access by imprinting the sac at the cervical level. During the curettage, access to the gestational sac area was achieved by obtaining decidual material. The pathological report showed decidual remains. On follow-up the next day, the patient’s serum quantitative beta-hCG was 1371 UI/L. The following week, a transvaginal ultrasound confirme

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


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

[User]
RADIOLOGY NOTE:
A 39-year-old woman, gravida 1, para 0, was diagnosed with invasive squamous cell carcinoma of the cervix following conization. Pathological findings showed carcinoma consistent with FIGO stage IA1 with lymphovascular invasion. She was referred to Keio University Hospital. The patient and her husband were informed of the treatment options, including AmRT and pelvic lymphadenectomy. The patient was told that the outcome of this procedure could not be guaranteed because an insufficient number of these procedures have been performed worldwide to yield reliable conclusions. The patient wished to preserve fertility, and she and her husband signed a written consent form agreeing to this treatment. Pathological findings after AmRT and pelvic lymphadenectomy showed no residual tumor and no lymph node metastasis. There was no finding of an ovarian tumor before surgery. A left ovarian cyst of 4 cm was identified during postoperative follow-up.
At 3 years and 6 months after surgery, the patient underwent IUI and then had fever and pain in her left lower abdomen 10 days later. At her first visit, her temperature was mildly elevated to 37.5°C. The patient's pregnancy was denied because a qualitative urine human chorionic gonadotropin (hCG) test was negative. A tumor with tenderness was palpated in the left adnexal area. A cystic tumor of 64x 41 mm was found by transvaginal ultrasonography (). Blood tests showed increases in white blood cell (WBC) count to 11900/μL and C-reactive protein (CRP) to 22.80 mg/dL. The patient was diagnosed with PID with ovarian cyst infection and hospitalized for treatment. Conservative treatment with antibiotics was initially used, but her symptoms did not improve. On hospital day 8, blood tests showed a further increase in WBC count to 23900/μL and CRP to 28.17 mg/dL, and pelvic CT showed that the ovarian cyst had grown to 10 cm in size ().
We decided to perform laparoscopic left ovarian cystectomy on day 8.

[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 33-year-old primigravid African woman who had been pregnant for 40 weeks and three days dated from the first day of her last normal menstrual period presented to our unit with a three-day history of continuous pain around the umbilical area. She did not have any other complaints.
A review of her antenatal records revealed that she had sought medical attention at her local clinic for lower abdominal pain at eight weeks and four days and once again at 14 weeks and two days of gestation. Both episodes of lower abdominal pain were managed conservatively.
Throughout the pregnancy the patient continued to experience on and off abdominal pain which became better as the pregnancy progressed.
She denied any per vaginal bleeding during her pregnancy.
Of note, the patient said that her mother had developed hypertension when she was pregnant.
The results of her serologic tests for human immunodeficiency virus as well as rapid plasma reagin were negative at the antenatal clinic. Her hemoglobin concentration at 22 weeks of pregnancy was 10.7g/dL. Methyldopa and nifedipine were commenced for pregnancy-induced hypertension from 22 weeks of gestation. During antenatal care visits at 26 weeks and three days, 30 weeks and three days, 34 weeks and four days, and 37 weeks and three days she was normotensive. At 38 weeks and four days her blood pressure was 150/100mmHg.
The patient had an ultrasound scan done at 33 weeks and three days at a local clinic which showed a single viable breech intrauterine pregnancy with a left lateral upper segment placenta, slightly reduced liquor volume and some small free fluid in the hepatorenal area. The estimated gestational age by scan was 34 weeks and two days. From the time of this ultrasound scan, the presentation by clinical examination which had previously been documented as cephalic was then documented as breech.
Besides the on and off abdominal pain, her pregnancy had been uneventful until she developed periumbilical pain prompting her to pre

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


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

[User]
RADIOLOGY NOTE:
We present the case of a 13-year-old female patient, known with severe visual field loss, who referred for another opinion regarding the ophthalmological diagnosis.
Anamnesis at presentation revealed that at the age of 9 years and 3 months, on a routine ophthalmological examination, papillary calcification and retinal hemorrhage were discovered in the left eye. At that moment, the suspicion of intracranial calcifications was raised. The patient underwent clinical neurological examination, EEG, and cerebral MRI, all of them revealing a normal aspect. The patient was also recommended fluorescein angiography, which showed papillary autofluorescence. The diagnosis established then was papillary drusen in both eyes, buried in the right eye and mixed in the left eye and the patient was recommended to keep it under observation, together with a periodical examination of the visual field.
The patient had had multiple examinations of the visual field over the time.
The first visual field examination of the right eye showed an arcuate nasal defect, in the superior nasal quadrant, sketching an aspect of nasal step, structure of the sensitivity defect that in 3 years time evolved into a quadranopsia.
In the left eye, the first visual field examination showed inferior nasal quadranopsia, extended superiorly with a nasal arcuate defect respecting 20° centrally, which after three years evolved into a paracentral diffuse defect with an island of central vision of 5°.
However, over the time, the examination of the visual field was made with different types of machines, and no correlation of the modifications could be made objectively.
The patient received several different diagnoses from several different ophthalmologists, among which optic nerve drusen; papillary oedema and hamartoma have to be mentioned.
At presentation, the patient’s visual acuity was 20/ 20 with correction for the RE and 20/ 20 without correction for the LE, with a refraction ROD: -1 DSf<> -0.75 DCyl, 179* and RO

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


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

[User]
RADIOLOGY NOTE:
Our patient, a 67-year-old Caucasian man, presented in the morning to the emergency department complaining of a sudden onset of excruciating right-sided arm and neck pain radiating to his head, followed by two episodes of vomiting. Both arms had reduced power from the shoulder distally. He complained of weakness in his legs, but denied any recent trauma, falls or loss of consciousness. On initial examination, shoulder abduction and adduction were absent, and flexion and extension of the elbow joint 2/5 on the Medical Research Council (MRC) power scale. Power in the lower limbs was normal. All modalities of sensation were intact bilaterally in the upper and lower limbs. No cranial nerve abnormalities were detected.
The patient had recently been diagnosed with hypertension and type 2 diabetes. His blood results on admission showed no abnormalities apart from a high glucose level consistent with untreated diabetes. A computed tomography angiogram showed no signs of thrombosis or dissection of the aorta. A spinal MRI scan showed a high-intensity lesion in the anterior two-thirds of the gray matter extending from C3 to C5 (Figures and ). He was diagnosed with anterior spinal artery ischemia secondary to dissection of a distal vertebral artery. He was started on 300 mg aspirin, and his case was reviewed by both a physiotherapist and a diabetic specialist nurse while he was an in-patient. Within three days of presentation, power in both of his arms had improved (MRC score 4/5), except for abduction of his right shoulder, which he could not lift above the horizontal position.
Spinal cord infarction and ischemia are rare and often difficult to diagnose, but they represent important differential diagnoses of acute spinal symptoms. This case presentation describes an interesting presentation of ASCIS which differs from the classically described symptoms, insofar as the patient had no clinically detectable sensory deficit. This disorder is also associated with significant morbi

[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.