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

[User]
RADIOLOGY NOTE:
A 64-year-old man was admitted to our clinic with similar complaints. He had undergone placement of the same type of penile prosthesis three years earlier. He reported the prosthesis had been functioning well, providing a high degree of satisfaction for him and his wife []. He had a 17-year history of DM (type II) with good control. He also described having trapped his penis against a toilet seat while sitting down to defecate four days earlier.
At presentation, both patients displayed fever (38.6°C and 39°C, respectively), and reported receiving broad spectrum antibiotics from general practitioners in their home towns. They denied any previous similar episodes since prostheses implantation. Physical examination in both cases revealed an erythematous, edematous and indurated penis with mildly macerated skin. The first patient also had ischemic spots over the penile shaft and localized soft swelling (3 × 2.5 cm) on the left side of the peno-scrotal junction (Fig. ). Penile and perineal palpation indicated intact devices in place, and this was further confirmed by radiography of the pelvis. However, the appearance of the patients' organs looked abnormal with poor concealment of the devices. The patients' white blood counts were elevated (13.200/mL and 14,100/mL, respectively). Urine analyses and cultures yielded negative results. Diabetes was well controlled in both patients as evidenced by normal levels of fasting and postprandial blood sugars and glycosylated hemoglobin levels. Ultrasound examination of the genitalia was performed to identify any possible hematoma but yielded no relevant results other than edema at the peno-scrotal junction of the first patient. Blood examination for bleeding, coagulation, prothrombin and partial thromboplastin times yielded normal results.
After discussion in each case, we decided to perform an exploration and extrusion of each penile prosthesis. The operations were performed under spinal anesthesia. The tunica was opened and a sig

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


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

[User]
RADIOLOGY NOTE:
A 20-year-old female patient reported to the Department of Oral Medicine and Radiology with a chief complaint of inability to close her mouth since birth. Her mother stated that she was also unable to close both eyes since birth and there was difficulty in suckling. Her milestones were normal and there was no history of prenatal or postnatal trauma. Her medical history revealed that she had visited a medical hospital previously for augmentation of the upper lip at the age of 15 years and breast augmentation at the age of 18 years. Intelligence quotient (IQ) evaluation revealed normal IQ level of the patient. There was no history of consanguineous marriage between the parents.
On general examination, all the vital signs were within normal limits. No abnormality was detected in lower limbs whereas shortening of the index finger was noted in both the upper limbs (). Her sensory functions were normal. She was unable to close both eyes () and raise the eyebrows. There was absence of wrinkles on her forehead (). The patient was neither able to whistle or blow air between her cheeks nor was able to smile. She was not able to completely abduct her eyes and was unable to rotate her eyeballs upwards or downwards and could only partially move it in medial and lateral directions. Other ocular manifestations were the presence of ptosis of the right eye and strabismus. Other facial and intraoral features were wide nasal apertures, incompetent lips (), scar mark over the upper lip and a high-vault palate ().
Based on history given by the patient and features shown on clinical examination, the case was diagnosed as Mobius syndrome. Routine hematological investigations were within normal limits. Panoramic view showed decays with respect to maxillary left second premolar, first molar and mandibular right and left first molar (). Wrist radiographs showed short middle phalanges in the index finger of both hands (Figure and ). A lateral cephalogram showed no

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


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

[User]
RADIOLOGY NOTE:
A 30-year-old man presented to the emergency department after “falling into a hole”. The patient was a construction worker and fell with his back in a 2-meter hole which was followed by a blunt abdominal trauma due to a falling of a 30 kg bag of cement on his abdomen. The patient had no past medical history and was not on any treatment or drug abuse. On primary survey, the airway was intact and a hard collar had been put on. The breathing, lung auscultation, and O2 saturation were in normal range. The blood pressure was 128/75 mmHg, pulse rate 90/min, and oxygen saturation of 96% while the patient was breathing ambient air. The patient underwent focused abdominal sonography for trauma patients (FAST) which showed small free fluid on lower pole of the right kidney. The patient was awake and fully conscious, the pupils were normal size and reactive, and there was not any neurologic deficit.
The secondary survey was significant for the mild abdominal tenderness on right upper quadrant. The chest, and lateral neck portable x-rays were normal. After surgery consultation, it was planned to have an abdominopelvic computed tomography (CT) scan with intravenous contrast agent in order to pin point the problem. In few minutes, the pain had been increased in intensity which was claimed to be 7 out of 10 in numerical rating scale (NRS). The blood pressure did not show any significant change but the patient pulse rate was increased up to 110. Serial FAST exam showed increase in free fluid volume. The patient underwent CT imaging (). It showed a moderate volume of free fluid in pelvic area, perihepatic, and also perisplenic spaces. Small bowel wall thickening due to mural hematoma of proximal part of jejunum with mural wall hypodensity in mid jejunal loop which are all suggestive of hollow viscus injury. There was no visible sign of solid organ damage or extra luminal free air. Regarding to the CT scan results

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


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

[User]
RADIOLOGY NOTE:
A 46-year-old man, with no history of systemic disease, was complaining about sudden onset of balance disorders and dizziness for 10 days. These symptoms were marked by severe headaches and several episodes of vomiting. He also reported having undergone a tooth extraction one month ago which was complicated by fever according to his own statements. Therefore, he consulted a neurologist who diagnosed intracerebral hypertension and a cerebral scan was then ordered and revealed, indeed, the presence of 3 cerebellar ring-enhancing mass lesions of variable size measuring 28∗20 mm and 15∗20 mm. Afterwards, he was transferred to the Emergency Department (ED) at the University Hospital Center of Sahloul, Sousse, for further investigations.
On physical examination, he was found to have ataxic walking with no loss of feeling in the skin and muscle weakness.
With all these findings, he was admitted under the care of the neurosurgery service for a potentially intracerebral abscess. Given this information, the infectious diseases service was consulted to determine the most appropriate antibiotic treatment to begin. With that service's recommendation, the patient was started on metronidazole 500 mg intravenously every 8 hours, vancomycin 500 mg IV every 6 hours, and cefotaxime 2 g IV every 4 hours.
He was then taken to the operating room for a right retrosigmoid mini craniotomy for abscess drainage. Brain abscess specimens were submitted to microbiology, and the bacterial cultures returned positive exclusively for numerous cocci gram + (Staphylococcus aureus).
Besides, blood and urine samples were negative. Upon receiving these results and taking into account the fact that the patient underwent an extraction one month ago, the dentistry service was consulted to identify a possible odontogenic focus.
On extraoral examination, there was no cervical or submandibular lymphadenopathy.
There was no overt trismus or facial swelling. On intraoral examination, the patient was found to hav

[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 with a medical history of high blood pressure and gout was referred to our department for oral mucosa burning causing him pain and discomfort. He was an ancient smoker and reported the sensation of headache with notorious dizziness on two occasions recently. The extraoral examination showed slight facial erythrosis (). Intraoral examination showed slightly hyperkeratotic erythematous lesions located on the inner side of the labial mucosa (). They were pruriginous and painful causing the symptomatology of the patient. The inner sides of the cheeks showed erythematous erosions especially on the right side (). We noticed also two erosive ulcerations as well as hyperkeratotic lesions at the right lateral edge and the ventral side of the tongue forming a discrete reticular network ().
In front of these signs, we suspected oral lichen planus associated with candidiasis infection. Mycological examination confirmed candidiasis, and initial treatment consisted of topical mouthwashes with Amphotericin B (50 mg; 5 ml 3 times per day) and Chlorhexidine (0.12%; 3 times per day). Biological tests were requested and a biopsy was scheduled a week after. Two biopsies were performed at the inner side of the lower lip and the right lateral edge of the tongue. The result was oral lichen planus ().
Almost all the biological tests (VS, CRP, glycated hemoglobin, and thyroid checkup) were within the normal levels, and serologies (hepatitis and VIH) were negative. However, the complete blood count was unusually marked by an increase in the number of red blood cells, hematocrit, and hemoglobin reaching a value of 19 (). This fortuitous finding led us to suspect polycythemia vera and to refer our patient to the department of hematology where he has undergone an emergency phlebotomy. Two days later, he was a victim of a myocardial infraction. He was hospitalized in the cardiology department where he was diagnosed with atrial fibrillation, stented, and put under

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


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

[User]
RADIOLOGY NOTE:
A 68-year-old man presented to the emergency department of our hospital with a 6-day history of left hemiparesis and 1-day history of fever. The patient had a history of advanced non-small-cell lung cancer and was receiving 3-week cycles of pembrolizumab (200 mg) for approximately 4 months before admission. Initial cranial CT and MRI showed two lesions in the left frontal and right parietal lobes. Both lesions were <2 cm in size and exhibited homogeneous hyperintensity on diffusion-weighted MRI [-]. The primary consideration in this case was brain abscess. Due to the small size of the lesion, neurosurgical aspiration was planned in case the causative pathogen could not be identified by blood culture or treated by antibiotics.
After blood cultures were obtained, empirical treatment with intravenous meropenem administration was initiated. Levetiracetam was started for seizure prophylaxis. Although the causative pathogen was not identified by blood culture, the lesion sizes reduced remarkably following antibiotic treatment, and left hemiparesis was improved. Therefore, neurosurgical aspiration was not performed. However, his left hemiparesis worsened 7 weeks after treatment initiation. Cranial MRI revealed that the mass lesion in the right frontal lobe was slightly enlarged and the surrounding vasogenic edema was exacerbated []. Blood cultures were taken again, and then neurosurgical aspiration was performed. Stereotactic needle aspiration of the lesion in the right frontal lobe yielded purulent discharge, leading to a confirmed diagnosis of brain abscesses for both lesions. S. intermedius growth was detected only in the purulent fluid culture and not in the blood cultures. There was a considerable reduction in the lesion sizes after surgical drainage and antibiotic treatment based on antibiotic-sensitivity test results. The origin of the brain abscesses could not be identified even after several examinations, including intraoral examination and panoramic radiography [

[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 Belgian Caucasian man complained of cramps in the right calf and walking difficulties that had started 6 months previous but had progressed to the point of needing support from the banisters when walking up a staircase. He did not report sensory disturbances. His personal history included arterial hypertension, hypercholesterolemia, complete deafness of the right ear due to a mastoidectomy in early childhood, and completely asymptomatic PDB that had been diagnosed 7 years previously by elevated alkaline phosphatases in a routine blood check, and had been confirmed by bone diphosphonate technetium-99m scintigraphy. His sister had died of dementia at the age of 62 years, while his mother had died at 67 years suffering from dementia and walking difficulties. At the first neurological examination he had slight paresis of the dorsal extensors of the left foot, eft quadriceps, and right deltoid muscle, atrophy of the left thigh, and diffuse tendon hyperreflexia. Fasciculations were noted in the right deltoid muscle but not in the tongue, which was not atrophic. Cranial nerves and sensibility were intact and there was no Babinski sign.
The first electromyography (EMG) investigation revealed a diffuse chronic neurogenic pattern in all tested muscles of the left leg and in the right deltoid muscle, without signs of subacute denervation such as fibrillations or positive sharp waves. There was a marked slowing of the motor nerve conduction of the right peroneal nerve, without conduction block.
An extensive laboratory workup produced normal results except for slight elevations of alkaline phosphatase (115 mU/mL, normal range 30-90 mU/mL) and lactate dehydrogenase (308 mU/mL, normal range 140-280 mU/mL). Magnetic resonance imaging (MRI) of the lumbar spine and computed tomography scans of the cervical spine and pelvis did not reveal significant abnormalities.
Walking for longer than 20 minutes had become difficult in the intervening 3 years since these initial inve

[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 female patient with prior THA presented with a seven-year history of groin pain and weakness during initial hip flexion. The THA was initially performed at a different hospital to address painful dysplastic osteoarthritis. Ipsilateral groin pain was presented soon after the THA. Moreover, stair climbing and exiting cars were aggravating activities. Pressure on the iliopsoas tendon of the groin was painful, especially during the Stinchfield test. A relatively large cup was implanted (58 mm in diameter) in the shallow hypovolemic acetabulum. Insufficient medialization was observed on the anteroposterior (AP) radiograph from the first outpatient clinic (Fig. ). It was thought that periprosthetic joint infection could be the cause of the pain and was excluded using laboratory tests and ultrasound screening. The pelvis tilted upward posteriorly due to global sagittal malalignment associated with multiple spondylolistheses and degenerative kyphotic deformity in the lumbar spine. The upper border of the pubic symphysis was at the level of the third sacral vertebral body on a standing pelvic AP radiograph. The abduction angle of the acetabular component was 57.3°. On the axiolateral radiograph, the anteversion angle of the cup was 30.3°. The protrusion of the acetabular component was approximately 25 mm on the sagittal computed tomography image (Fig. ).
NSAIDs and physical therapy failed to manage the pain. Multiple ultrasound-guided injections provided only transient analgesia. After conservative treatment failed, revision THA was offered as a treatment of choice, but she refused a revision arthroplasty because she was not satisfied with the index THA. Informed consent was obtained for arthroscopic tenotomy. It had been sufficiently explained that revision THA is necessary if there is no effect. Finally, she agreed to undergo arthroscopic iliopsoas tenotomy instead of a cup revision as an alternative minimally invasive manner instead of revision THA. Hip arth

[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 Japanese woman, who was treated for cervical carcinoma with conization, returned to her gynecologist for a follow-up visit with a complaint of mucous hypersecretion and urinary leakage. Suspecting VVF, her gynecologist instilled 2ml of crystal violet dye diluted to 1% concentration. No VVF could be identified but the physician was unable to drain the dye from her bladder as his patient refused catheterization. She then developed an irritable bladder, frequent urination and gross hematuria. She was diagnosed to have acute cystitis and prescribed antimicrobial agents for one week. However, her symptoms did not improve and she was referred to our urology department.
A blood examination showed only a mild degree of elevated C-reactive protein. Her urinary sediment showed a red blood cell count of >100 cells/high-power field and a white blood cell count of >100 cells/high-power field. Her condition was gradually getting worse, with severe urgency to urinate every 10 minutes and gross hematuria with clots. Cystoscopy showed abnormal mucosa of her bladder. The surface of her bladder was hemorrhagic with a lot of necrotic tissue (Figure ). Her bladder capacity was about 100mL.
We diagnosed our patient with chemical cystitis and started therapy with nonsteroid anti-inflammatory drugs (NSAIDs). An abdominal computed tomography scan showed thickening of her entire bladder wall with spotty high-density lesions of >100 Hounsfield units. We suspected these to be the dye, which had adsorbed into the mucosa (Figure ). After two weeks, her urinary urgency had been relieved to some degree. However, her bladder capacity was only 50mL. We wanted to do a urodynamic study but our patient was not willing to undergo the procedure. We added glucocorticoids to her NSAID therapy to prevent scarring of her bladder as a result of inflammation. Her bladder capacity improved to 75mL, and pelvic magnetic resonance imaging (MRI) also showed an improvement in the thickening of her blad

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


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

[User]
RADIOLOGY NOTE:
A 40-year-old male presented in casualty with a history of seizures that let to fall from 10 feet height resulting in injury to both hips and left shoulder. He was diagnosed with cerebral venous thrombosis and started on heparin. On X-rays & CT scan (, ), he was diagnosed to have bilateral acetabular fracture and three part left proximal humerus fracture. He was operated for bilateral acetabular fracture using modified Stoppa’s approach and fixed with buttress plate in true pelvis on both sides (). On post op day 3, he had fever & discharge from suture site, dressing was done and pus culture and sensitivity done. Wound wash was done to eradicate infection. Culture showed growth of Klebsiella and anaerobes sensitive to cefoperazone sulbactum, clindamycin and amikacin. The pus discharge resumed again after 3 days of wound wash and antibiotics. This time culture sensitivity tests showed resistance to cefoperazone sulbactum so chloremphenical was started which decreased the pus discharge but could not stop it. Based on the sensitivity tests, meropenem was started which stopped the discharge for 5 days then again the discharge started. At this time about 2 weeks after the first surgery, it was decided to start irrigation with Qurion solution for an hour and then continue Vacumn assisted suction (VAS). At both ends of the suture line single stitches were removed, at one end infant feeding tube was put for irrigation with qurion solution and at the other end infant feeding tube inserted for vacuum assisted suction (). Daily Qurion irrigation was done in morning and evening for one hour during which vacuum assisted suction was stopped. After one hour again vacuum assisted suction was started. After 2 days of starting Qurion irrigation & vacuum assisted suction therpy (QiVAS), the suture site became dry. We continued QiVAS therapy for 2 weeks with antibiotic meropenem. Blood counts and CRP were within normal range after 2 weeks 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 63-year-old Caucasian female with a past medical history (PMH) of arthritis presented originally to the hospital due to an abnormal MRI. The patient was having weakness on the left side for the past few weeks along with difficulty concentrating. Her symptoms started to worsen when she was leaning towards the left upon standing, veering to the left when driving, and had difficulty standing from a seated position. She was evaluated by her primary care physician (PCP) who ordered a brain MRI. The MRI showed a right frontal lobe mass with surrounding mild vasogenic edema and a small focal area of hemorrhage as seen in Figure .
These findings were concerning for high-grade glioma with other differentials including lymphoma and other causes. She was then sent to the hospital for further evaluation. Family history is significant for NHL in the father and brother diagnosed with NHL ~15years ago, who are in remission. On initial exam, vitals were significant for mildly elevated blood pressure but otherwise unremarkable. On neurologic exam, the patient was notably alert and oriented x 3, with intact speech but mild difficulty swallowing. She had mild left pronator drift, left-sided facial droop, left hemiparesis with 4/5 strength on the left upper and lower extremity, and 5/5 strength on the right upper and lower extremity. Sensations were intact in all extremities. She was started on 500 mg of Keppra, every 12 h and 4 mg of dexamethasone, every 8 h. A CT chest/abdomen/pelvis was obtained which showed no evidence of metastatic disease. Neurosurgery evaluated the patient and she underwent right frontoparietal craniotomy and partial removal of the tumor. The patient had a post-surgical brain CT that showed small amounts of high attenuation material in gas bubbles along the track of the resection, likely representing residual acute blood (Figure ).
A follow-up MRI of the brain revealed that surgical changes of the right frontal lobe

[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 87-year-old woman was referred to our hospital in May 2010 with severe left ocular pain since 4 days before. On initial examination, the left orbit was severely necrotized with several live larvae attached to the necrotic tissue. The upper and lower eyelids and the eyeball were completely destroyed. Periorbital tissues were swollen and erythematous ().
According to her grandchild, the patient had not been able to walk or sit for several years, presumably due to back injury. She also had bladder and bowel incontinence. However, her mental status was intact. She had history of eyelid surgery due to a skin lesion 15 years ago which had been confirmed to be skin cancer. There were no medical records or documents however, and she had experienced no recurrences ever since.
Orbital CT scan revealed disorganized globe and periocular tissues, with hemorrhagic patches in the left orbit filled with larvae. The orbital walls seemed intact and no larvae could be detected in the periorbital sinuses or cranium.
On the day of admission, the patient underwent exenteration of the left orbit (). All necrotic tissues and over 150 larvae were removed. A few larvae were collected and preserved in 70% ethanol. The larvae were identified as Chrysomya bezziana (Diptera: Calliphoridae) or old world screwworm fly. The most distinctive characteristics of this species include one pair of anterior spiracles with 4 to 6 digit projections at the ends, located on the first segment of the third instar of the larvae above the cephalopharyngeal skeleton (one pair of hooks at the base) (), and one pair of posterior spiracles at the bottom of the third instar of the larvae. Each is surrounded by a complete peritreme, without a distinct button. There are 3 slits inside each peritreme, which continue to its end (). is a picture of the complete third instar larva of Chrysomya bezz

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


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

[User]
RADIOLOGY NOTE:
A 76-year old female, previously fit and well, was admitted to hospital with new onset melaena. Two weeks prior she had accidentally swallowed a date pit. Seventy-two hours prior to admission she developed odynophagia and 24 h prior to admission she experienced a syncopal episode and hematemesis. She had no risk factors for gastro-intestinal bleeding. Following one night in hospital, the patient developed large volume haematemesis, hypotension and increased work of breathing. She was subsequently intubated due to airway compromise. A Blakemore tube was inserted, with both oesophageal and gastric balloons inflated, and traction applied. The haemorrhaging continued and a massive transfusion protocol was activated. The patient was referred to the intensive care unit (ICU) where she continued to haemorrhage profusely.
No obvious bleeding point was identified in the stomach or duodenum at endoscopy. A small, bleeding lesion was visualized on the oesophageal mucosa ~20 cm from the incisors. Attempts to control the haemorrhaging through localized adrenaline injection were unsuccessful. Computed tomography (CT) angiography was planned to identify a bleeding point. Profuse bleeding continued to the point of haemodynamic instability. The Blakemore tube was once again placed in the oesophagus and inflated to 30 mmHg. A total of 32 units of packed red blood cells, 20 units of fresh frozen plasma, three units of platelets and two units of cryoprecipitate were given. Control was eventually established by deflating the Blakemore tube and pulling it distally to the approximate site of the lesion. The oesophageal balloon was inflated to 100 mmHg and the gastric balloon was inflated to a lesser pressure.
Computed tomography angiography (CTA) identified a large abnormal ‘vessel’ projecting from the medial aspect of the aortic arch extending towards the oesophageal wall ( and ). This structure did not have an aneurysmal configuration and was blind-ending ( and ). No discrete vascular r

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


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

[User]
RADIOLOGY NOTE:
A 74-year-old Japanese woman was referred to our hospital with a history of several days of jaundice. She had no past medical history and no family history. On examination, her skin was jaundiced, and her abdomen was flat and soft. Her laboratory data revealed obstructive jaundice and cholangitis, and tumor marker levels were elevated with carcinoembryonic antigen at 3.6 and carbohydrate antigen 19-9 at 4573.9. Computed tomography (CT) revealed an enhancing mass in the biliary duct hilum and dilation of the intrahepatic bile ducts, and there was no evidence of lymph node metastasis or distant metastasis. Endoscopic retrograde cholangiopancreatography revealed a luminal filling defect in the biliary hilum (Fig. ). We diagnosed the tumor as a Bismuth type 1 cholangiocarcinoma, and performed endoscopic retrograde biliary drainage. Biopsies of the tumor revealed adenocarcinoma. The estimated volume of the postoperative liver remnant was less than 35%. Therefore, percutaneous transhepatic portal vein embolization (PTPE) of the right branch of her portal vein was performed (Fig. ). Twenty-one days later, the volume of the left lobe of her liver increased, and we performed right hepatectomy, caudate lobectomy, extrahepatic bile duct resection, and lymph node dissection. Node dissection included resection of hilar and pericholedochal nodes in the hepatoduodenal ligament, common hepatic artery nodes, and those at the celiac trunk, and posterior and anterior pancreaticoduodenal nodes.
Histological examination of the tumor showed moderately differentiated tubular adenocarcinoma without regional lymph node metastasis, a pathological stage II tumor according to the Union for International Cancer Control classification of malignant tumors, 7th edition (Fig. ). Postoperative blood laboratory tests showed that liver enzymes were slightly elevated, but that total bilirubin was within normal limits. Resumption of diet started on postoperative day (POD) 3. Although the fluid in the ab

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


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

[User]
RADIOLOGY NOTE:
A 34-year-old man was referred to our hospital in May 2014 with a history of pain and swelling of the right hand for a duration of 3 months. The patient sustained an electrical shock to the right hand while repairing a domestic electrical appliance. He denied any cutaneous injury, loss of consciousness or injury to any other body part due to the electrical shock. He noticed pain in his right hand within one week of injury, which was treated with analgesics without relief. He noticed a subsequent swelling, deep aching pain, cutaneous hypersensitivity and discoloration of the right hand. The patient denied aggravation of symptoms during exposure to cold or any diurnal variation of the symptoms. The patient indicated severe pain, which he rated as 9 on a 10-point visual analogue scale (VAS). He was treated with a short course of oral prednisolone with physiotherapy at a peripheral hospital, but the improvement was not significant. The patient is employed as an infantry soldier, and the condition prevented him from being able to handle any weapons. He was also unable to use his right hand for activities of daily living. The patient denied alcohol consumption or tobacco use, and his previous medical history was unremarkable. Examination revealed stable vital parameters, and systemic examination was unremarkable. His right hand was markedly tender, hyperemic with diffuse swelling and cutaneous hypersensitivity (Figure ). Other vasomotor changes were absent, and the radial pulse was normally palpable on the right side. Muscle atrophy was not apparent, and there was generalized weakness of the hand muscles, likely because of the reduced effort by the patient.
His hematological and biochemical parameters were all normal, including the C-reactive protein, creatine kinase, calcium, phosphorus, alkaline phosphatase and 25-hydroxy vitamin D levels. A nerve conduction study and electromyography of the left upper extremity showed no evidence of neuropathy or myopathy. A Dual Energ

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

[User]
RADIOLOGY NOTE:
A 43-year-old man was admitted to our hospital for intensive rehabilitation 115 days after a traffic accident. Cervical computed tomography (CT) and magnetic resonance imaging (MRI) on the day of the injury had shown a C6 vertebral body fracture as well as a cervical cord signal change on T2-weighted MRI images (). He had undergone a C5-6-7 lateral mass fusion on the day of the injury. Six days after injury, he was transferred to the rehabilitation department. A subsequent C5-6-7-T1 anterior and posterior fusion was additionally performed 35 days after injury due to spinal instability detected on follow-up cervical spine X-ray (). There was no concomitant brain injury on brain CT scans and all cognitive evaluations including cognitive score subsets of the Functional Independence Measure showed intact cognition. Other than a past history of type 2 diabetes mellitus, no other significant medical history including psychiatric history existed. The patient also had no history of drug or alcohol misuse.
According to the International Standards for Neurological Classification of Spinal Cord Injury, the patient had a complete lesion (American Spinal Injury Association impairment scale A [ASIA A]) with a C6 neurologic level of injury. According to neurologic exams performed 6 days after injury, the initial upper extremity motor score was 27 and the lower extremity motor score was 0. These scores improved to 31 and 0, respectively, at 115 days after injury when he was transferred to our hospital. Total light touch scores were initially 21 for the right side and 21 for left side and improved to 28 and 29, respectively, at 115 days follow-up. Total pin prick scores were initially 23 for the right side and 24 for the left side, but improved to 27 and 27, respectively on follow-up. There was no interval change in the neurologic exam at 6 months follow-up. Electrodiagnostic studies performed 2 months after injury revealed complete myelopathy and bilateral symmetric peripheral sens

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

[User]
RADIOLOGY NOTE:
A 36-year-old woman presented in 2006 at the department of surgery, Maria Pia Hospital, Turin, for important chronic constipation and abdominal pain. She had a long history of constipation with an average of one evacuation every four days despite continual use of laxatives and had been hospitalized several times before for intestinal partial obstruction. Furthermore, the patient suffered of left hemiparesis with difficulty speaking because of a subarachnoid hemorrhage at one year of age. She was implanted a neurostimulator in the third sacral nerve root, but the device was removed two years later due to its inefficacy. In 2010, she was hospitalized again after another partial obstruction, and loop ileostomy was performed. Despite this, the symptomatology did not improve, and the obstructive episodes continued. Colonic manometry and abdominal X-ray revealed a picture of inertia coli.
On November 2015, during the programmed closing operation of ileostomy, the ileum appeared distended with brownish serosa. Therefore, a decision was taken not to close the ileostomy, and a diagnostic surgical biopsy of the ileum was made. Histologic examination showed an abnormal accumulation of eosinophilic granules in the cytoplasm of smooth muscle cells with disruption of muscular fibers (). The mucosa was normal. The pigment was interpreted as lipofuscin, and a suspicion of BBS was raised.
Blood levels of vitamins A, D, E, and K were dosed, and vitamins D and E were found to be low (0.3 mg/dl and 6 ng/ml, respectively). Antibodies against transglutaminase were negative, and there was no clinical or laboratory suspicion of coeliac disease.
After 8 months of nutritional supplementation, the vitamin values were at the lower limit of the normal range (0.8 mg/dl and 10 ng/ml, respectively), but the patient still suffered of recurrent intestinal functional obstruction. Abdominal X-ray and CT evidenced severe intestinal dilatation (), indicating the persistence of a severe impairment of col

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


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

[User]
RADIOLOGY NOTE:
A 75-year-old male patient was admitted to the emergency service with fatigue, headache, dizziness, weakness in the left arm and leg, unsteady gait, difficulty in swallowing, dysarthria, and hiccups for 8 h. He had a history of coronary artery disease and hypertension. He was nonsmoker with a long history of high amounts of alcohol consumption.
His blood pressure was found to be 110/60 mmHg in the systemic examination, and his heart was rhythmic. In the transthoracic echocardiogram, ejection fraction was 50%, and no additional pathologies were detected. Laboratory tests showed no other abnormalities except elevated levels of urea and creatinine. Abdominal CT performed in the emergency service showed that left renal artery occlusion and renal atrophy. In his initial neurological examination in the emergency service, he was conscious with speech and comprehension abilities, full cooperation and was able to perform simple tasks. Horner syndrome (ptosis and myositis) and horizontal nystagmus were detected in his left. In the motor examination, proximal and distal areas in the left arm and left leg had a muscle strength of 3/5. He had increased deep tendon reflexes and a positive Babinski reflex on the left. He had contralateral loss of pain and temperature sensation on the left side of his face and right side of his body. Neurological findings suggested that ipsilateral hemiparesis accompanied the typical findings of lateral medullary infarct. Opalski syndrome was considered for the diagnosis, as the clinical presentation was acute, and the patient had the risk factors of stroke.
No pathological findings were detected in computed tomography of the brain. In the diffusion-weighted image (DWI) of diffusion magnetic resonance imaging (MRI), lacunar lesion concordant with the left occipital hyperintense acute ischemic infarct was observed (Fig. ). The patient was considered to have ischemic stroke on atherothrombotic base, and antiplatelet treatment (acetylsalicylic acid) w

[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 came in our emergency room for consult due to sudden painful loss of vision of the right eye. The History of the present illness started 1 week prior to consult, the patient noted a sudden blurring of vision of the right eye described as curtain loss of vision. No history of trauma, pain, flashes, and floaters was noted, and neither consult done nor medication taken. Three days prior to consult, the patient noted a total loss of vision of the right eye associated with intractable pain, eye redness, headache, nausea, and vomiting, which prompted consult.
The patient had no known systemic diseases except for well-controlled bronchial asthma and hypertension. The patient was maintained on losartan 50 mg twice a day with poor compliance and control. The patient came in with no light perception for the right eye and 20/20 for the left eye. The blood pressure at the time of consult was at 240/100. Gross examination and extraocular muscles were normal. The right pupil was 6 mm non-reactive to light, and the left pupil was 3 mm brisk reactive to light with positive reverse relative afferent pupillary defect. Slit lamp examination of the right eye revealed shallow chambers with moderate corneal edema with microcyst and an intraocular pressure (IOP) of 60. On gonioscopy of the right eye, the angles on all quadrants were closed. Indirect ophthalmoscopy of the right eye revealed total retinal detachment with large subretinal hemorrhage. The examination of the left eye showed a formed chamber with an IOP of 12 and a cup-to-disc ratio (CDR) of 0.4 with arteriovenous crossing changes. On gonioscopy of the left eye, the angles on all quadrants were open to ciliary body band. The right eye had poor streak on refraction, while the left eye’s refraction was –0.50 D sphere. Ocular ultrasound of the right eye (Figure 1 ) revealed massive hemorrhagic

[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 male patient reported to the Department of Oral Medicine and Radiology with a complaint of swelling in the mandibular left posterior region since 6 months []. History revealed that it was initially peanut sized, 6 months back but had gradually increased to the present size. There was no history of pain, trauma, paraesthesia or anesthesia, or pus discharge associated with the swelling. On examination, there was a solitary well-defined sessile swelling seen on the left body of the mandible, measuring approximately 3 cm × 2 cm in dimension. The skin over the swelling was normal with no abnormalities in the surrounding area. On palpation, there was no local rise in temperature. The swelling was nontender, firm in consistency, noncompressible, nonfluctuant and possessed no mobility. Intraoral examination revealed a mild vestibular obliteration in the region of 34, 35 and 36 []. Root stumps were present in relation to 18, 27 and 37. Based on the clinical findings, a provisional diagnosis of soft tissue tumor was given. The differential diagnoses considered were peripheral nerve sheath tumor, soft tissue fibroma and soft tissue sarcoma. The patient was subjected to various imaging investigations.
Orthopantomograph showed root stumps in relation to 37 and a subtle change in the trabecular pattern in the periapical region of 35, 36 and 37 []. Occlusal radiograph showed a well-defined soft tissue outline of the tumor on the buccal aspect with erosion of the buccal cortex in the region of 35 [].
Ultrasonography (USG) revealed an ill-defined hyperechoic soft tissue lesion in the deep planes of the left submandibular region abutting the body of the mandible. The tumor revealed ill-defined margins with erosion of the underlying bone and insignificant vascularity. Marginally enlarged lymph nodes were noted in the left cervical region, largest measuring 1.1 cm in dimension. Computed tomography (CT) showed a well-defined encapsulated fusiform soft tissue mass with a de

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


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

[User]
RADIOLOGY NOTE:
A 68-year-old male with stage III IgA kappa multiple myeloma who had completed two cycles of chemotherapy using bortezomib and dexamethasone presented to the hospital for shortness of breath and respiratory distress. His diagnosis of multiple myeloma was made four months prior after he was found to have lytic lesions in the right humerus, left tenth thoracic vertebra, left first lumbar vertebra and right sacrum on imaging performed after a right humeral pathological fracture. The imaging also revealed a large left chest wall mass, thought to be likely from extraosseous involvement by myeloma. Staging workup was completed including skeletal survey and bone marrow biopsy. Bone marrow biopsy showed hypercellularity with 90% involvement by atypical plasma cells which appear as large-sized, binucleated cells with dense chromatin and prominent nucleoli (Figure ). Syndecan-1 (CD138) and kappa light chain IHC staining showed extensive plasma cell involvement belonging to kappa subtype (Figures ). The cytogenetic analysis also revealed multiple chromosomal abnormalities compatible with a complex cytogenetic profile of male karyotype with derivative chromosomes 17, 14 and 10. Serum protein electrophoresis detected a monoclonal spike, with immunofixation detecting IgA kappa type. Serum IgA levels were 2519 mg/dL (normal reference range: 66-436 mg/dL); immunoglobulin G (IgG) and immunoglobulin M (IgM) levels were decreased. The patient was determined to have stage III using the revised international staging system (R-ISS). The treatment plan was to start the patient on nine to 12 weeks of bortezomib, lenalidomide and dexamethasone velcade, revlimid, low dose (VRd) regimen followed by re-staging. However, the patient did not receive lenalidomide due to poor performance status and underlying comorbidities. He then completed two cycles of bortezomib and dexamethasone before presenting to the hospital. At the time of presentation to the emergency room (ER), the patient was in respi

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


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

[User]
RADIOLOGY NOTE:
A 10-year-old girl visited our affiliated hospital, complaining of pudendal deformity. The patient was born at 39 weeks of gestation by normal delivery as the second child, and the birth weight was 3,144 g. There was no disorder in the course of pregnancy in her mother. Intake of androgenic medicine or the disorders of ovaries and uterus was not observed by a periodic medical examination. No pudendal deformity was clearly observed at birth, but lateral asymmetry of the pudendal region was noticed at about 4 years old. A child care worker pointed out that she pressed her heel to the crotch while sitting on her folded legs. After 5 years old, her mother confirmed that her clitoral hood clearly hypertrophied. After entering primary school, a teacher in charge pointed out that she pressed her crotch to a chair or bar, and the mother told her to stop it, but she repeated this behavior every day. When she strongly wanted to be absent from an overnight school trip at 9 years old, the mother brought her to the Pediatric Department. Various tests were performed suspecting disorders of sex development (DSD). On the first visit, the height was 132 cm and the body weight was 26 kg. The clitoral hood was enlarged. The appearance was similar to the vulva in children with congenital adrenal hyperplasia, and the clitoris size was 8 x 5 mm. Labial fusion or adhesion was not detected, and the urinary tract and vagina were open at the normal positions. No masculinization, such as acne and polytrichosis, was noted (). Intake of androgenic medicine or the disorders of prepuce was not observed. In the blood test, the sex chromosome was 46, XX. The blood count, blood chemistry, and hormonal test were normal (). On abdominal ultrasonography, the uterus and ovaries were present. Abdominal CT and MRI examinations showed no tumor

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


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

[User]
RADIOLOGY NOTE:
The patient is a 58 year-old female with relapsing remitting MS treated with subcutaneous GA since 2006, and otherwise unremarkable medical history. She presented at our department with a painful livedoid and haemorrhagic skin lesion that developed on her left abdomen approximately 24 h after GA injection. She reported correct injection practice.
She had no fever. Blood cell count, C-reactive protein, renal function, creatine kinase (CK), IgE, autoimmune screening, lupus anticoagulants and cryoglobulins were unremarkable. Superficial ultrasonography at skin lesion showed diffuse oedema without fluid collections. The patient was dismissed with symptomatic non-steroidal anti-inflammatory treatment and GA was stopped.
After 2 days, a livedoid violaceous skin patch with dendritic extensions below the injection site became apparent (Fig. and ). At surgical evaluation at the Emergency Department cellulitis was suspected and a surgical revision proposed to avoid potentially lethal complications (such as sepsis and renal failure following rhabdomyolysis). Considering the negative inflammatory parameters and normal renal and CK values, we referred her before surgery to the Dermatology department for further counselling. Here, a NS was suspected and confirmed by a skin biopsy showing coagulative necrosis of dermal collagen and local adipose tissue, as well as several hyaline thrombi inside small and medium-sized blood vessels (Fig. ), without skin infection (cellulitis). Bacteriological culture of lesion samples grew only resident flora. The livedoid figures around the central haemorrhagic skin lesions disappeared spontaneously after a week. The haemorrhagic patch of NS necrotized (Fig. ). The skin necrosis was limited at the dermis and was removed by a surgical debridement. It was treated with a continuing multifunctional dressing to cleanse, fill, absorb and moisten the wound. A healing by second intention was obtained in 2 months after first evaluation. GA was definitively

[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:
32-year-old woman with CD localized in the small intestine and in the ileocaecal valve has been treated in the conventional manner (azathioprine (2,5 mg/kg), mesalamine (2 g a day) and budesonide (9 mg a day)) for half a year. The diagnosis of the disease was confirmed by colonoscopy, abdominal ultrasound examination, and microscopic evaluation of samples taken during colonoscopy. In the past, the patient was treated by a gynecologist because of chronic ovaritis. She was not suffering from any other diseases and the results of laboratory tests showed only moderate anemia and elevated CRP (C-reactive protein) level.
Due to the ineffectiveness of such therapy (abdominal pain, diarrhea), she received biological treatment, anti-TNFα (tumour necrosis factor α), infliximab (at a dose of 5 mg/kg) intravenously at weeks 0, 2, and 6 with the outcome of clinical and endoscopic remission. Treatment with azathioprine (2,5 mg/kg) and mesalamine (2 g a day) was continued during the remission period.
After three years, the disease course worsened. In addition to the severity of diarrhea and abdominal pain, an increasing abdominal circumference has been observed, as well as swelling of lower extremities. The patient returned to the gynecologist for consultation. Due to suspicion of ovarian cancer with concomitant ascites, numerous laboratory tests were performed, which showed a decrease of total protein, including albumin fraction, and an increase of CRP and CA125 level, which exceeded the normal upper limits more than five times (). Abdominal ultrasonography and CT (computed tomography) showed the presence of ascites, as well as wall thickening with features of inflammation in the jejunum (). Apart from the so far used mesalamine and azathioprine, budesonide was included to the treatment at a dose of 9 mg a day. Additional tests were performed to rule out infection, tuberculosis, kidneys and liver diseases. Within two months there was no improvement in general condition of the pat

[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-years-old female at the 14th week of gestation was admitted in April 2016 due to headache, vomiting, and progressive asthenia in the previous 3 weeks. A brain magnetic resonance imaging (MRI) demonstrated a large right thalamic tumor [], and the MRI-spectroscopic study showed a high level of choline and low level of N-AcetylAspartate consistent with a high-grade glioma. She presented fully awake, with a slight left hemiparesis and headache. Later on, due to progressive neurological deterioration, she underwent in May 2 external ventricular drainage (EVD) in local anesthesia and 1 week later craniotomy and partial removing of the tumor under general anesthesia, with continuous fetal heart rate (FHR) monitoring, maintaining good fetal conditions during the operation. At the end of the month, she was discharged following the gynecological evaluation who revealed good clinical conditions of both, mother and fetus. 2 weeks later, she deteriorated neurologically presenting vomiting, stupor, and severe hemiparesis. A brain computer tomography scan showed hydrocephalus and she underwent on the left side, a ventricular-peritoneal shunt. The brain-MRI performed 2 days later showed a light improving the hydrocephalus. The abdomen ultrasonography was normal and she was discharged in good clinical conditions except a moderate left arm paresis. In July 5, a brain MRI showed a large thalamic tumor. In July 7, she had elective cesarean section and the day later, underwent a gross debulking of the tumor. Her clinical conditions improved progressively and in August she began CTX with temozolomide (TMZ) and XRT in a standard way.[,] 12 months after surgery the patient had a moderate left arm paresis with small residual tumor showed on the brain-MRI []. The baby was born with a retinopathy and bronco dysplasia due to the premature birth. He was treated with retinal laser therapy bilaterally and Lucentis intravitreous on the right side successfully. He was also treated with Synagis

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


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

[User]
RADIOLOGY NOTE:
A 45-year-old male from the Netherlands presented with a painless right parotid swelling that was progressively increasing in size for the past 8 months. Though occasionally he suffered from jaw lock, other symptoms associated with neurologic deficit such as drooling, facial weakness, paresthesia, or auditory defects were absent. Apart from being a social alcohol consumer, there was no history of smoking, prior radiation, or significant family medical history, especially in regard to his present illness.
Physical examination revealed a tender right parotid swelling below the ear lobule, which extended inferiorly to the angle of the mandible (). The skin overlying the swelling was slightly erythematous, thickened, and nodular. The swelling was firm, diffused, and fixed to the underlying muscles, and there was no associated lymphadenopathy. Otoscopic examination of both ears was within normal limits.
The patient initially had a neck ultrasound and then a magnetic resonance imaging (MRI) to characterize the nature of the lesion. The neck CT scan revealed a well-defined altered signal enhancing mass measuring 3.5 × 2.2 × 2.0 cm at the posterior aspect of the superficial part of the right parotid gland (). The radiologist's impression was an altered signal enhancing mass lesion, likely to be a benign pleomorphic adenoma. The patient then underwent MRI of the parotid glands, which showed a well-defined focal lesion of altered signal intensity at the posterior aspect of the superficial part of the right parotid gland, measuring 3.5 × 2.2 × 2.0 cm along its maximum transverse, craniocaudal, and anteroposterior diameters, respectively. The impression was again benign pleomorphic adenoma of the right parotid gland. However, the radiologist could not exclude other diagnostic possibilities and recommend fine-needle aspiration cytology.
Fine-needle aspiration cytology of the mass was nonconclusive as the smears only showed polymorphous population of lymphoid cells in keeping wit

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


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

[User]
RADIOLOGY NOTE:
We presented a case of 32 years old female referred to our Cipto Mangunkusumo Hospital (RSCM) Emergency Department with altered consciousness following by a motor vehicle accident. Two hours before the admission, she was walking across the road when a high-speed motor bike suddenly hit her form her right side. She fell and was unconscious. Then, she was brought immediately to PGC Cikini Hospital and diagnosed as Moderate Head Injury. She was resuscitated using fluid therapy, and they put her into sleep using a sedative. After initial resuscitation, her family asked to refer her to RSCM. When she arrived at the ED, we immediately put her a cervical neck collar and do a few examinations such as head and neck X-ray, FAST, and Head CT-scan. No bleeding or vomiting was observed.
The patient was presented with a mainly stable haemodynamic with altered mental status. Local examination of the neck shows no deformity, swelling, bruise, and all normal skin color (). On palpation, all pulsation on the radial artery was regular, yet despite unable check on tenderness, we felt a step off the sign. We avoid moving the head until we obtained the cervical radiograph. We immobilized the patient's neck to protect it by using a hard rigid cervical collar. The sensory and motor function on this patient cannot be assessed because of the previously used sedatives.
When the patient regained her consciousness, she felt numbness and tingling at her four extremities. She also felt weakness using both arms and legs, and she felt that her right half of the body is weaker than the other half. Her urination and defecation control were all normal. On the reflex examination, the patellar tendon and Achilles reflex all in normal function, yet there is a positive sign of Babinski reflex. Her laboratory results showed an increase of Leukocyte levels in 19.600 with possibility due to sterile inflammation, and the patient has Hyp

[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:
62-year-old Caucasian female underwent right nephrectomy for T4N0 renal cell carcinoma, clear cell type, Fuhrman grade 3/4 in 1999. In January 2001, a CT scan revealed a right adrenal mass and multiple left side kidney masses. She underwent left partial nephrectomy and right adrenalectomy. At that time, the surgical pathology showed renal cell carcinoma, clear cell type, Fuhrman grade 3/4. The tumors were located in the upper and lower portion of the left kidney. The surgical margin at the upper portion kidney was positive. Right adrenal masses were also excised which revealed adrenal gland with metastatic renal cell carcinoma, clear cell type. Surgical margin of adrenalectomy was negative. The patient subsequently had repeated left partial nephrectomy performed in 2004, and again in 2007 for tumor recurrences. The pathology revealed metastatic renal cell carcinoma. On January 27, 2010, the patient underwent left kidney radical nephrectomy, which revealed multifocal renal cell carcinoma, clear cell type, Fuhrman grade 3/4. The largest tumor nodule was 2.5 cm, with tumor extended focally to renal sinus adipose tissue. Tumor located in 0.1 cm from the nearest soft tissue resection margin. The patient was subsequently started on hemodialysis after surgery. In May 2010, the patient underwent evaluation for possible kidney transplant. During the workup, an ultrasound of the abdomen showed a hypoechoic nodule in the body of the pancreas. A CT scan revealed multiple small enhancing nodules throughout the pancreas, best seen on arteriography, which suspicious for metastatic disease of the pancreas (Figure ). On September 20 2010, the patient underwent distal pancreatectomy. Histologically, the tumor consisted of cells arranged in trabecular and alveolar structures with clear or eosinophilic granular cytoplasm, compatible with a metastatic RCC, clear cell type, involving pancreatic parenchyma (Figure ). The surgical margin was negative. Postoperatively, the patient recovered

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


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

[User]
RADIOLOGY NOTE:
The case of a 54-year-old male patient is reported. The patient, an ex-smoker, with systemic arterial hypertension (SAH) and heart failure (Chagasic cardiomyopathy with implanted pacemaker) had been submitted to coronary angioplasty. On being admitted to the emergency room of the University Hospital de Base in São José do Rio Preto, the patient reported he had pain in the right lower limb associated with edema, paresthesia, and coldness that had started suddenly. He also complained of pain in the left leg but said the pain was less intense. A duplex ultrasound of the iliac arteries showed total occlusion by an intraluminal thrombus on the right side with the superficial femoral and popliteal arteries occluded along their complete length. The popliteal artery of the left leg was also distally occluded (bifurcation). Bilateral embolectomy was performed without complications.
On the following day, he complained of “burning” pain and said that even the blanket on his legs bothered him. He had difficulty bending and straightening his knee and the sole of his foot. On physical examination, the patient had edema of the lateral and posterior compartments, and a lot of pain on compression, especially of the anterior compartment that was highly sensitive to slight pressure.
The chosen conduct was intermittent manual compression (massage) of the musculature of the compartments with the objective of stimulating lymphatic and venous return during the physical examination. The posterior compartment had a 100% improvement in the pain after 20 minutes of massage, the lateral compartment improved the pain completely after around 40 minutes, and the anterior compartment improved the pain by about 70% within one hour. With this improvement, the patient spontaneously bent his knee (without pain) and the sole of his foot (with a little pain in the anterior compartment). The patient was asked to evaluate his pain using an analog scale with the worst imaginary being 10 and no pain at all

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


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

[User]
RADIOLOGY NOTE:
A 19-year-old female patient was admitted with a history of headache and vomiting for last 1 month. Headache was more or less continuous and throbbing in nature, gradually increasing in intensity. There was history of right sided weakness since last 15 days. She had past history of menorrhagia at the time of menarche 5 years ago, for which she was treated conservatively and at this time she was diagnosed as a case of idiopathic thrombocytopenic purpura (ITP). She also had history of prolonged bleeding from wounds, gum bleeding, petechial rashes since birth. On examination she was conscious and normotensive, pallor present. Few purpuric spots were noted on her upper limbs. Patient was advised to take corticosteroids by her physician, but she was not taking any medication at the time of presentation. Neurologic examination showed an alert individual with normal higher functions with grade 2 power in both upper and lower limbs on right side. Hemiparesis developed gradually over a period of 20 days which corresponded to slow increase in the size of the chronic subdural haematoma and pressure effect over motor cortex. Ocular fundi showed bilateral papilloedema and cranial nerves were normal. Motor, sensory and cerebellar systems were normal. Deep tendon reflexes were exaggerated with plantars being up-going on right side. Spleen was not palpable.
At the time of admission, haematological investigations revealed haemoglobin of 9.0 gm/dl with normal total and differential leukocytic counts. Platelet count was 30,000/mm3. Liver and renal function tests were normal. Bone marrow aspiration cytology showed an increase in the megakaryocyte series, which consisted of monolobate and multilobate forms. CT scan of the brain showed a hypodense lesion at left posterior parietal and occipital region suggestive of chronic subdural haematoma with significant mass affect with effacement of ipsilateral ventricles []. She was given two units of platelet rich plasma (PRP) and three units 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:
The patient, a 16-year-old female complained of recurrent instances of swelling on her neck, chest wall, and left arm. Her medical history included two surgeries under general anesthesia with orotracheal intubation; septoplasty (one year prior) and nasal septal perforation repair (two months prior). After septoplasty, she had recurrent epistaxis episodes for six months which were treated with nasal packings when needed. She eventually had a nasal septal perforation and was referred to another tertiary care hospital by her primary surgeon. There she underwent her second surgery under general anesthesia which involved septal perforation repairment. After this surgery she started having epistaxis episodes which were treated with cauterization and nasal packing.
One month following the septal perforation repairment surgery, the patient suffered her first episode of subcutaneous emphysema on her left arm, chest, and neck. The chest computed tomography (CT) revealed pneumothorax and subcutaneous emphysema. The pneumothorax was treated with chest tube insertion. The patient underwent an endoscopic examination of head and neck, as well as bronchoscopy to discover the etiology of pneumothorax and subcutaneous emphysema, which revealed normal findings. The subcutaneous emphysema regressed slowly and disappeared. Two months after the first episode of emphysema, she was referred to the pediatric surgery department at our hospital with swelling on her neck and on her upper part of the chest. She underwent a detailed investigation, involving several consultations with otolaryngology, dentistry, pediatric gastroenterology, infectious disease, allergy and dermatology departments, however, these provided little clarity into the patient’s condition. All initial laboratory tests (erythrocyte sedimentation rate, blood count, urine tests, liver and kidney function tests) and cultures (blood, nasal cavities, nasopharynx, lung aspiration and throat for bacteria) were essentially normal. O

[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 with history of Rothmund-Thomson syndrome diagnosed at the age of two presented with acute right mid leg pain while cutting to kick the ball during a soccer game. He reported a history of prior right leg fracture four years ago sustained while playfully wrestling with his younger brother. After the prior fracture healed, the patient noticed a bump at the level of his mid right shin, which corresponded to the site of the patient's current leg pain. He denied any pain in the right leg prior to sustaining the fracture, and he denied any other preexisting medical conditions.
Presenting radiographs of the right tibia-fibula showed mild deformity of the right tibia from prior healed fracture with mildly displaced and comminuted fracture through the mid diaphysis of the tibia (). Focal anterior cortical thickening of the tibia was present at the level of the acute fracture. The fracture was treated with closed reduction and casting. Serial follow-up radiographs obtained over the next 13 months showed delayed and incomplete union across the tibia fracture (). At the 13-month follow-up, additional radiographs of the left tibia were obtained to evaluate a focal painless bump of the mid left shin the patient reported developing shortly after his right tibia fracture. Left tibia radiographs showed focal anterior cortical thickening of the mid tibia diaphysis corresponding to the palpable bump (). No fracture line or lytic bone lesion was appreciated. The patient did not return for additional follow-up.
The patient returned to clinic 4 years later for treatment of a left olecranon fracture sustained during a fall playing soccer 3.5 weeks earlier. Presenting radiographs showed a mildly displaced subacute fracture through the left olecranon (). There was early cortication along the fracture margins and more osteolysis than expected along the fracture line given the reported age of the fracture. Therefore, a bone biopsy of the fracture was performed, which 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 41-year-old female, with a past medical history of minimal change disease, diagnosed two years ago, being treated with a tapering dose of prednisone (on 7.5 mg daily at the time of admission) and biliary cancer status post percutaneous cholecystostomy drain placed 10 days prior, presented to the emergency department with nausea, vomiting, fever, and diarrhea of one-day duration. This was associated with a decreased output from the cholecystostomy drain.
Six weeks prior to this presentation, the patient had routine monthly blood work done by her nephrologist and was noted to have bilirubin in her urine. Her liver function tests were then ordered which were abnormal and a right upper quadrant ultrasound showed moderate to marked diffuse intrahepatic bile duct dilation with a suspected obstructing mass at the porta hepatis. Outpatient work-up including alpha-1 antitrypsin, ceruloplasmin, antimitochondrial antibody, Hepatitis B, Hepatitis C, cytomegalovirus, iron, and ferritin were all negative or within the normal range. Her antinuclear antibody titer was at 1:40. Given concern for an obstructing mass, the patient was referred to the emergency room for expedited endoscopic retrograde cholangiopancreatography (ERCP). A computed tomography (CT) of the abdomen was done and it confirmed a mass at the hepatic hilum with associated biliary obstruction.
The patient had ERCP where she was found to have a high-grade stricture at the hepatic bifurcation. A sample was collected and sent for cytology and a stent was placed within the left intrahepatic biliary tree. The cytology from the ERCP returned as rare atypical cells with no malignant cells. A follow-up magnetic resonance imaging (MRI) of the abdomen was ordered and again showed a solid mass at the porta hepatis. A CT-guided liver biopsy was performed and pathology was pending when the patient was referred to interventional radiology due to continued significant hyperbilirubinemia. The patient underwent a cholangiogram and

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


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

[User]
RADIOLOGY NOTE:
A 31-year-old male developed weakness of both lower limbs and severe low back pain after lifting a gas cylinder. Four days later he was admitted to Adan Hospital. X-ray of the lumbosacral spine revealed simple fracture at L1 and L2 vertebrae and magnetic resonance imaging of the lumbar spine confirmed the fracture. Within the next few days the weakness gradually progressed to 3/5 power in the upper limbs and 0/5 in the lower limbs bilaterally and bilateral lower motor neuron facial palsy. Deep tendon reflexes were absent in all four limbs and the plantar response was mute. He was assessed by a neurologist and was transferred to the ICU as he developed respiratory distress and bulbar weakness. NCS showed prolonged distal latencies with conduction block, prolonged F waves, reduced M-wave amplitudes, reduced nerve conduction velocities and absent H reflexes. Blink reflex was abnormal with prolonged latencies and reduced amplitudes. Routine blood counts and blood biochemistry were normal. Connective tissue disease and porphyria screening were negative. Serological tests for M. pneumonia, Epstein-Barr virus and hepatitis virus were negative. Cerebrospinal fluid study was not done because the patient refused it as he had back pain. The clinical and electrophysiological features were consistent with GBS. He was treated with a course of IVIG (0.4 g/kg/day for 5 days). While in the ICU he developed aspiration pneumonia and septicaemia which was treated by meropenem and ciprofloxacin. Follow-up electrophysiological studies showed progression of neuropathy with features of mixed axonal and demyelinating neuropathy. As he did not respond to the initial course of IVIG, he was treated with six sessions of plasmapheresis. However, he continued to be febrile in spite of treatment with appropriate antibiotics. He developed cardiovascular instability and renal impairment. Twenty-five days later the patient expired after developing cardiac arrest and resuscitative measures failed. The

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


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

[User]
RADIOLOGY NOTE:
A 70-year-old man presented to the orthopaedic clinic with an 18-month history of left knee pain, predominantly on the medial aspect of the joint. He experienced night pain, rest pain, and had increasing difficulty mobilising. He had undergone a successful right total knee replacement three years previously. Clinically his knee was in five degrees of fixed varus alignment, and range of movement was 0–100 degrees with pain at the limit of flexion. There was medial and lateral joint tenderness but no other significant findings on examination. Radiographs revealed severe degenerative changes in all three compartments.
Three months following his initial presentation, the patient underwent an uncomplicated cemented left total knee replacement with a Genesis II Posterior-Stabilised Prosthesis (Smith & Nephew). No synovial plicae were noted at surgery, nor was there any evidence of excess scar tissue within the joint. At review six weeks after surgery he was pain-free and walking unaided; range of movement was from 0 to 110 degrees flexion. At four months post-op he reattended clinic complaining of discomfort on the outer aspect of the left knee. This was treated with topical nonsteroidal anti-inflammatory drug (NSAID) gel and a course of physiotherapy. On review two months later, the pain had worsened such that his general practitioner had commenced amitriptyline as analgesia. He continued to complain of pain on the outside of the knee, particularly on weight-bearing, occasionally radiating down to the foot, and most severe on straightening the knee. On examination there was tenderness over the lateral aspect of the tibial plateau, but not around the fibular head or peroneal nerve. He had an unrestricted range of movement through 0–120 degrees. There was no motor or sensory deficit distally, and radiographs of the prosthesis were satisfactory (). Inflammatory markers did not reveal any evidence of infection (CRP 1 and ESR 5). Due to the presence of a clear mechanical symp

[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 woman presented with large varicose veins, CEAP C2s, in the left lower limb. The patient had never been treated before because she was afraid of surgery. She had no history of migraine headaches or cardiac diseases. She had never smoked cigarettes, never had high blood pressure, and never been overweight. Her only medication was 20 mg sinvastatin once a day, and her last lipid profile, and all blood tests were normal. Except for the large varicose veins in her left lower limb, physical examination was normal, including normal peripheral pulses and absence of bruits. The patient was treated in the Trendelenburg position with a total of 10 ml of 3% polidocanol foam via direct punctures, 5 mL into an 8 mm diameter great saphenous vein and 5 mL into large collaterals in the leg. Foam was prepared with a 1:4 ratio of liquid to room air, using the Tessari technique involving 40 passes of agitation through a three-way stopcock using one 5 mL syringe and one 3 mL syringe. With ultrasound guidance, foam was injected immediately after each of three preparations, 5 mL, 2.5 mL, and 2.5 mL. No air boluses occurred. Ultrasound scanning showed no foam in the deep venous system. The patient remained lying down for 10 minutes after the injections, before being discharged wearing compression stockings. Less than 1 hour after leaving hospital, impairment of speech capacity was observed. She encountered difficulties when she tried to talk, with incomplete and incomprehensible words. No other alterations were noted. She was taken to another hospital, where the clinical presentation was misdiagnosed as an allergic reaction. One gram of hydrocortisone IV was infused and 20 mg prednisone was prescribed per day for 5 days. The next morning she came to the office to report the allergic reaction. After detailed history taking and physical examination, including the Wells DVT clinical model, the only alteration detected was aphasia. This was Broc

[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 woman was admitted to our hospital on 27 July 2021 due to severe chest and back pain and weakness of lower extremities for 11 days. She also complained of urinary and fecal incontinence. Fever was not reported since the onset. She has had a history of hypertension, diabetes and depression. In addition, she used glucocorticoids and immunosuppressant for 2 months because of immune thrombocytopenic purpura. Physical examination revealed symmetrically completely paralysis in the lower extremities, decreased muscle tension, absence of knee and ankle reflexes, and the presence of bilateral extensor plantar reflex. Several subcutaneous lumps in the lower abdomen on the left side were also revealed. The patient’s blood routine, electrolytes, liver and kidney functions were normal, and the test for syphilis and human immunodeficiency virus (HIV) was negative. Albumin is reduced to 26.7 g/L (40–55 g/L as the normal value). Consecutive cerebrospinal fluid (CSF) examinations showed a normal range in white blood cell (WBC) count and significant increase in protein concentration.
The cranial and cervical spine, thoracic spine and lumbar spine magnetic resonance imaging (MRI) showed abnormal signal in the spinal cord and the pituitary. MRI examinations were performed for three times from July 29, 2021 to August 10, 2021 in Figs. and . The result shows abnormal signals in the entire spinal cord (cervical spinal cord and thoracic spinal cord) in Fig. A–G. Follow-up MRI of the thoracic spine (Fig. E VS Fig. H) shows cavitation changes in the thoracic spinal cord, suggesting that the lesion has changed in a short period of time, and necrosis and cavitation in the center suggesting infectious lesions. In addition, the posterior soft tissue of the cervical, thoracic and lumbar spine all showed patchy abnormal signals with enhancement, suggesting inflammatory changes. Meanwhile, two nodules were seen on the back of the pituitary gland with T2 hyperintensity in Fig. .
The pa

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


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

[User]
RADIOLOGY NOTE:
A 3-year-old boy admitted to the University Children’s Hospital of Krakow following the first epileptic seizure. The patient complained of headaches and vomiting. Based on clinical presentation and medical history, intracranial hypertension was suspected. CT scan demonstrated bilateral fluid-filled spaces in the middle cranial fossa (the larger being situated on the left side), with hypotrophy of the adjacent cerebral structures. In addition, CT showed a minimal mass effect manifested as displacement of the longitudinal fissure of the brain to the right and compression and stenosis of the left lateral cerebral ventricle, as well as mild thinning of the squama of the temporal bone at the level of the malformation (Figs. and ).
In differential diagnosis, consideration was given to the open type of bilateral schizencephaly or bilateral arachnoid cysts of the lateral sulcus, with type III on the left and type II on the right side (Galassi classification).
The CT scan favored the arachnoid cyst (the mass effect, discrete thinning of the squama of the temporal bone), yet schizencephaly could not have been ruled out based on a single CT scan and medical history of the patient. The scan was performed as an emergency procedure in a patient with severe and growing in intensity symptoms of intracranial hypertension, what did not allow for extensive, time-consuming diagnostic management.
A decision was made on a surgical intervention consisting in implantation of a cysto-peritoneal shunt on the left side. Following shunting, the patient developed complications consisting in small intracerebral and paracerebral hematomas (Figs. and ).
In subsequent follow-up scans, gradual resorption of hemorrhagic lesions was seen. The fluid-filled spaces were still present; albeit markedly smaller as compared to the initial scan, discrete asymmetry of the lateral ventricles persisted, but no displacement of the lateral fissure of the brain was detected. The patient improved clinically (Fig. ).

[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 with a past medical history of aortic stenosis, hypertension, type 2 diabetes mellitus, dyslipidemia, and benign prostatic hypertrophy presented to the emergency room following a near syncopal episode and fall at home. He described the event as an episode of dizziness and denied any loss of consciousness, palpitations, or chest pain. Although the fall was unwitnessed, the patient’s wife claimed that the patient was fully alert and oriented upon assisting him within one minute of the fall. Of note, the patient did endorse increasing fatigue over the past month but denied any syncope or near syncopal events prior to this episode.
The patient was on semaglutide and glimepiride for diabetes and had experienced two hypoglycemic episodes in the past year, however, he stated that this event felt different, and he endorsed no resolution of symptoms after taking a glucose pill. The patient had been on doxazosin 4 mg for several years for the treatment of his benign prostatic hyperplasia without any complaints. Notably, the patient was not on any heart rate controlling medications.
Upon further investigation, it was discovered that the patient had undergone a treadmill stress test two weeks prior as part of presurgical clearance for a noncardiovascular procedure. The patient experienced no angina during the test, and serial electrocardiograms (ECGs) revealed no ST or T wave abnormalities or arrhythmias. Previous echocardiograms were unable to be obtained as the patient endorsed not having seen a cardiologist in at least seven or eight years due to lack of cardiovascular-related symptoms. The patient did have a coronary artery catheterization performed in 2003 for a complaint of chest pain, which revealed a dominant circumflex system and a normal left ventricular function with no coronary artery disease. No further workup was done regarding this event.
On admission, the patient was hemodynamically stable with a baseline heart rate between 50 and 60 beats per

[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:
A 38-year-old male with no significant past medical history presented to the ER with complaints of exertional dyspnea associated with flu-like symptoms, including low-grade fevers, chills, occasional episodes of diarrhea, chest pain, and cough productive of yellow to gray sputum for two weeks. The patient initially went to an urgent care facility five to six days prior to admission where he was diagnosed with pneumonia (CXR not available). The patient completed a course of azithromycin and amoxicillin-clavulanate without improvement in symptoms and thus presented to the ER. He reported exposure to sick contacts (children with an upper respiratory infection) and a history of vaping until two to three weeks prior to admission, which he stopped due to the symptoms. History was unremarkable for any exposure to birds, occupational exposures, immunocompromised status, outdoor activities, or recent travel. On presentation, vital signs were remarkable for temperature 38.2°C, heart rate of 115, respiratory rate 33, and oxygen saturation of 76% requiring 3 liters of oxygen via nasal cannula. Lung examination revealed rhonchi on bilateral bases with associated egophony. Laboratory studies revealed a WBC count of 18.3 with left shift, thrombocytosis, and a lactic acid level of 2.2 mg/dL. CXR demonstrated bilateral lower lobe consolidation (Figure ).
The patient was admitted for severe sepsis secondary to bilateral pneumonia and was initiated on levofloxacin, which was later changed to vancomycin and ceftriaxone. Infectious disease was consulted due to the failure to respond to antibiotics and the possibility of fungal etiology. Over the course of the next few days, the patient did not show significant improvement. Imaging was repeated and included a CT scan of the chest, along with a CXR, for a more detailed evaluation of the lung parenchyma. This showed a rapidly worsening airspace opacities (Figures , ). Antibiotics were adjusted to include doxycycline, and ceftriaxone (dose

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


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

[User]
RADIOLOGY NOTE:
The study was approved by the Cyprus National Bioethics Committee and informed, written consent was obtained from all participants.
The patient under discussion is a 30 year old male, weight lifter with hyper-acute onset chest and back pain. Upon initial evaluation, the patient did not have any manifestation of any phenotypic findings (i.e. iris flocculi, livedo reticularis, aortic valve abnormalities) hinting towards connective tissue disorders or aortic pathology. Based on echocardiography and chest CT findings the patient was diagnosed with a Type A Aortic Dissection with severe aortic valve regurgitation. The patient was then emergently intubated and was transferred to the American Medical Center (AMC) in Nicosia, Cyprus where he had emergency aortic surgery and Bentall procedure. No angiography was performed due to the fact that the patient had aortic dissection and was an emergency. Intraoperative findings showed a 70 mm diameter aortic root aneurysm with dissection extending from the sinotubular junction to the aortic root. The aortic annulus was extensively dilated and the aortic dissection extended down the origin of the left main coronary artery involving also the aortic valve commissures that resulted in severe aortic valve regurgitation. There was no evidence of involvement of the distal ascending aorta and the aortic arch.
Further evaluation of the patient’s family showed that several family members had ascending aortic aneurysms. The patient’s father, a 60-year-old male had an asymptomatic aortic root and ascending aortic aneurysm of 52 mm that also required aortic valve, aortic root and ascending aortic replacement (Bentall procedure). Pre-operatively thefather had CT chest coronary angiography that confirmed the presence and dimensions of the aneurysm and coronary angiography did not show any coronary artery disease. The patient’s mother, a 56-year-old female was also screened with echocardiography that showed ascending aortic dilatation, 42 mm in di

[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.