[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 Caucasian female who was a non-smoker, with a history of heart ischemic disease, hypertension, anemia and diabetes, underwent a laparoscopic left radical nephrectomy for a renal neoplasm of 10×7 cm in the superior left renal pole in 2011. The postoperative course was uneventful and the patient was discharged after 6 days. The histological examination revealed the presence of a renal cell carcinoma, Fuhrman grade 2, with extensive necrosis and phlogosis areas (TNM 2009 RCC pT2a). Informed consent was obtained from the patient.
After discharge, the patient was readmitted for a sciatica episode and underwent two abdomen ultrasonography examinations, with no notable pathological findings.
After a few days, the patient noted an indolent swelling in the proximal third of the right thigh. The patient subsequently underwent ultrasonographic evaluation, revealing the presence of a solid, vascularized mass that was ∼40×22 mm in size.
The subsequent CT documented the presence of a pathological, solid, dishomogeneous bulk that was ∼4.5 cm diameter, in the front of the right iliac vessels, immediately cranial to the inguinal region. Another smaller (1.5 cm) lesion was observed in the ipsilateral inguinale region, while an additional solid expansive lesion was noted in the rectus femoris muscle ().
The fine needle biopsy of the muscle mass documented a metastasis of renal cell carcinoma (). The histochemical analysis revealed positive staining for vimentin and CAM, and negative staining for cytokeratin 7.
Moreover, we performed a cerebral CT and a total body bone scan, in order to achieve a complete stadiation of the patient. Neither of the examinations revealed further meta-static localization.
A joint evaluation of the patient was performed with the oncologist, the general surgeon and the radiotherapist. With regard to the pathological stage of the disease and the comorbidity of the patient, it was decided to refer the patient for targeted therapy with sunitinib.

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


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

[User]
RADIOLOGY NOTE:
This study is approved by our institutional review board and this patient has signed informed consent.
A 33-year-old Chinese male initially presented with an epileptic seizure. Magnetic resonance imaging (MRI) detected two extra-axial, homogeneous, well-defined, dural-based lesions. The large one is in the left frontotemporal parietal region, and the small one is in the right frontal region. T1-weighted images show isointense and slightly hyperintense signal intensity, and T2-weighted images show isointense with intralesional hypointense foci, obviously uniform enhancement with an enhancing dural tail sign (Fig. ). This patient was initially diagnosed with multiple convex meningiomas and underwent a craniotomy for resection of the large lesion. After the left lesion was resected, this patient recovered very well and restored normal speech function. We recommended adjuvant hormone therapy or radiotherapy but the patient declined any further treatment until progression was seen on the MRI and the patients suffered from a symptomatic seizure 20 months after surgery. MRI showed the size of the right lesion increased obviously. Then the second craniotomy was taken to remove the right lesion, and the patient recovered again with no neurological deficit. There was no seizure nor tumor recurrence on follow-up so far (2 years follow-up).
In the sections from the first operation, microscopic examination showed a large number of lymphocytes and plasma cells infiltrated in fibrous tissue scattered large histiocytic cells with abundant cytoplasm. Immunohistochemical staining showed positive for S100, CD68, but negative for CD1a (Fig. ). Both morphological and immunohistochemical profiles of the left lesion supported the diagnosis of RDD.
Histopathological examination for the sections from the second operation exhibited similar results as the first one (Fig. ). Histiocytes were the predominant cells and contained abundant pale to vacuolated cytoplasm and mildly pleomorphic vesicu

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


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

[User]
RADIOLOGY NOTE:
A 48-year-old Greek female patient was referred to our institution for the management of biliary trauma after laparoscopic cholecystectomy. In her medical history, she had had two laparotomies: an ileoanal anastomosis with j pouch for ulcerative colitis 15 years ago, while 5 years ago she was driven to the operating room after a colonoscopy for peritonitis. Due to non-specific upper gastrointestinal symptoms she had had an upper abdominal ultrasound (US) that revealed cholelithiasis (at least two gallstones of diameter 0.8 and 0.7 cm) 2 months before surgery and elective laparoscopic cholecystectomy was performed 18 months before her referral to us.
The duration of laparoscopic cholecystectomy was 150 minutes while the procedure was completed laparoscopically and there is no record of intraoperatively identified biliary injury. From the 2nd postoperative day and up to her referral to our institution, recurrent episodes of cholangitis with severe pain, fever with chills and jaundice began. Magnetic resonance cholangiography (MRC) was performed in order to delineate the biliary anatomy and assess the level of injury. A triple bile duct injury, with right and left hepatic duct ligation and common bile duct cross-section, was revealed (Bismuth type V, Figure ). Attempts at permanent biliary decompression with repeated endoscopic retrograde cholangiopancreatographies (ERCP), combined with percutaneous transhepatic duct catheterization failed and for 1 year postoperatively bile drained from abdominal drains. On the 13th postoperative month, she was referred to another hospital for biliary draining (Figure ). Through the left drain, a guidewire was passed only to be found later during ERCP in the duodenum in a place other than the papilla of Vater via a false route. On the next episode of cholangitis, both left and right biliary trees were successfully decompressed and 18 months after LC, she was referred to our hospital for surgical reconstruction.
The intraoperative find

[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:
Otherwise healthy, 12-year-old boy was admitted to the ward with a history of swelling of the right and left forearms, for 1 day duration.
He gave a history of a swelling in the right forearm first noticed six weeks prior to the current presentation, and it has resolved gradually without any acute intervention. During the initial presentation, the mother claimed that he was treated with a course of amoxycilline for an upper respiratory tract infection prior to the onset of the swelling. Since then, he was well till this current admission.
During this presentation, the swelling of the right elbow joint along with the forearm swelling worsened progressively. He did not have any history of trauma or febrile illness associated with the current presentation.
He denied any bleeding tendency in the past except a history of mild extra bleeding which settled spontaneously following a dental extraction one month back. There was no history of photosensitive skin rashes, renal problems, recent weight loss, or poor appetite. He did not have any family history bleeding disorders.
On examination, he was alert, pale but not icteric or febrile. His weight : height ratio lied between 1 SD and median. He did not have lymphadenopathy, hepatosplenomegaly, or ballotable masses.
Examination of the upper limbs revealed that the range of movements was reduced due to the pain and there was diffused tense swelling of both forearms. But there were no inflammatory changes noted on the over line skin or adjacent joints of the swollen areas. Rest of his systemic examination was unremarkable.
During initial investigations, his full blood count revealed a white cell count of 8.62 × 109 with a normal differential count. His haemoglobin was 7.7 g/dl with a platelet count of 278 × 109/L.
His clotting profile showed a normal PT/INR with normal bleeding and clotting time but his APPT was significantly prolonged (patient: 109.9 seconds; control:

[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 man who was 42-years-old in 1997, was admitted with a chief complaint of abdominal pain, and was later diagnosed with colon cancer. He was treated with sigmoid colon cancer radical surgery on 23 June 1997. Postoperative histopathological analysis revealed sigmoid colon cancer graded as Dukes C1 (Fig a). The patient did not receive any chemotherapy or radiotherapy after the surgery.
In October 2003, the patient again presented with abdominal pain and colonscopy revealed colon cancer. He underwent radial ascending colon carcinoma sugery in 08 October 2003. Histopathological analysis demonstrated moderately and poorly differentiated adenocarcinoma of the ascending colon invading to the outer membrane (Fig b). Following surgery, the patient was then treated with oral Carmofur 150 mg t.i.d.
In April 2009, the patient was admitted to the First Affiliated Hospital of Zhejiang University School of Medicine with gross hematuria, which was later diagnosed as bladder cancer. The patient underwent right pelviolithotomy combined with excision of the remaining right ureter and the bladder cuff. Postoperative histopathological analysis revealed (bladder, right ureter and right renal pelvis) multiple invasive stage II urothelial papillary carcinoma (Fig c). The patient was treated with infusion chemotherapy (Doxorubicin) following surgery.
In July 2010, the patient again complained of gross hematuria and was subsequently admitted to People's Hospital of Jinyun Town. He received a partial bladder resection and postoperative pathology subsequently indicated invasive high-level papillary urothelial carcinoma of the right wall of the bladder (Fig d).
In September 2011, a mass (2 × 2 cm) which was stiff and fixed in the left neck was discovered. With no treatment, biopsy of the mass was taken one month later (23 October 2011) at the Cancer Hospital of Fudan University. Pathological study showed metastatic carcinoma with necrosis (Fig d). Chest CT scan showed a mass (5.9 × 5.0 cm) in t

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


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

[User]
RADIOLOGY NOTE:
A 57 year old woman was admitted to our hospital on July 18, 2017 because of tiredness and fever. The patient had a body temperature of 39 degrees without other discomfort. Physical examination indicated no positive symptoms. MRI of the epigastrium showed that there was an elliptical hyperintense signal below the pancreas on the T1WI (Figure ) and slight hyperintensity on the fat-suppression T2WI (Figure ). The internal signal was heterogeneous and a clearly bounded tumor 3.4 cm × 2.8 cm in size was observed. Marked enhancement on the arterial phase was inhomogeneous (Figure ). In addition, the venous phase and delayed phase continued to intensify (Figure -F). On account of the hypervascular mass located under the pancreas, it was highly possible that the mass was a nerve incretory tumor.
Laboratory examinations showed that the HIV antibody was negative and the white blood cell count was 14.6 × 109/L. Tumor markers and other laboratory test results were within the normal range. The preoperative diagnosis was an retroperitoneal neuroendocrine tumor. Laparoscopic surgery was performed to remove the retroperitoneal tumor. No ascitic fluid or obvious conglutination were found. When the gastrocolic ligament was incised, the lesion was located behind and below the transverse mesocolon. Intraoperative ultrasonography indicated that the tumor had an abundant blood supply, and its right side was close to the inferior mesenteric artery and vein (Figure ). The flexible tumor was 3.0 cm × 3.0 cm in size with a clear border (Figure ). The tumor was completely removed by blunt and sharp separation for further analysis (Figure ). Rapid histopathological examination revealed that the mass was possibly retroperitoneal CD together with a follicular dendritic cell tumor, which was confirmed by subsequent postoperative pathology (Figure -F). Immunohistochemical staining showed that a portion of cells were positive for CD21 and negative for CK, a small number of cells were positive

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


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

[User]
RADIOLOGY NOTE:
A 66-year-old woman suddenly developed motor impairment of both lower extremities and sensory impairment of the left lower extremity with one day duration. Three years earlier, she had undergone instrumented fusion from T10-S1 at another institution secondary to degenerative lumbar kyphosis and spinal stenosis. On this occasion, she initially presented at another hospital, where she denied any obvious trauma, and was admitted for observation after the radiographs. The motor impairment of both lower extremities deteriorated gradually over 2 days, which prevented her from standing without assistance. She presented at our institution 6 days after the onset of symptoms.
The physical examination revealed mild tenderness over the thoracolumbar area. The neurological examination showed positive bilateral Babinski reflexes, motor impairment both lower extremities (grade 1) on the manual muscle test scale, last normal sensory level at T10 with hyposthesia at T11 onwards with preservation of the anal wink and tone, and no bowel/bladder incontinence. The preoperative ASIA score for cervical myelopathy was calculated with a score of 60 on motor. The plain lumbar radiographs revealed instrumental fusion from S1 to T10 and narrowing of the intervertebral disc at T9-10 as well as sclerotic changes and a gas shadow (). Plain lumbar radiography and computerized tomography (CT) of the thoracic and lumbar spinal regions failed to show any evidence of nonunion or ossification of the posterior longitudinal ligament or ligamentum flavum. Magnetic resonance imaging (MRI) revealed localized compression of the spinal cord at the T9-T10 level, and axial MRI showed a mass located around and compressing the dural sac ().
A posterior approach was used to remove the mass. After a total laminectomy (using a high-speed burr) of T9-T10, the sequestrated disc was detected posterolateral to the dural sac, and was excised without damaging the spinal cord. Instrumented fusion was then performed from T8

[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 man developed a sudden epigastric pain. He was presented at this hospital as an emergency outpatient. Six years earlier, he underwent laryngoesophagopharyngectomy, bilateral lymph node dissection for hypopharyngeal cancer, and esophageal reconstruction with a free jejunum flap. On physical examination, the abdomen was flat and soft with tenderness in the epigastric region, but no sign of peritoneal irritation. Blood biochemistry findings revealed elevated values: creatinine, 1.16 mg/dl; lactate dehydrogenase, 364 U/l; and creatine phosphokinase, 622 U/l.
Abdominal contrast computed tomography (CT) revealed twisted mesentery with the small intestine around the point of torsion (whirl sign) and the superior mesenteric artery as the axis. Contrast enhancement was weakened in the same area of the small bowel (Fig. ). Given this information, we suspected small bowel volvulus and performed emergency surgery on the same day.
A 5-mm camera port was placed in the umbilicus and 5-mm ports in the lower and right lower abdomen. During laparoscopic examination, the upper jejunum adhered to the small bowel close to the terminal ileum with overlapping of the small bowel. The entire part from the upper jejunum to the terminal ileum was twisted clockwise with the superior mesenteric artery and vein as the axes and the adhesion site as the starting point. There were areas of poor color enhancement throughout the twisted section of the small bowel (Fig. ). We laparoscopically separated the adhesion between different sections of the intestinal tract and traced the bowel from the small bowel in the region of the ligament of Treitz toward the anus to confirm the absence of adhesions or torsion up to the terminal ileum. The color of the small bowel improved; hence, the surgery was completed without resecting any part of the intestine.
Postoperatively, the patient made good postoperative recovery, resumed oral intake on day 2, and was discharged on day 5 after surgery

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


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

[User]
RADIOLOGY NOTE:
The patient was a 60-year-old man who referred to our emergency department due to worsening dyspnea and hemoptysis since 2-3 days prior to admission. He reported to have dyspnea and hoarseness during the previous year. He had undergone a direct laryngoscopy which had revealed left vocal cord palsy and a chest computed tomography (CT) scan which had shown a mediastinal mass and with possibility of a malignancy process a direct needle biopsy was done which demonstrated inflammatory cells in the background of blood. His past medical history only included a mild stroke 6 years before without any sequel.
At the emergency department he had pulse rate of 86 beats/min, respiratory rate of 18/min and blood pressure of 135/80 mm Hg. He had a continuous murmur in left sternal and pulmonic area and decreased breathing sound in left hemithorax.
A chest x-ray was obtained which showed a large density in mediastinum and left sided pleural effusion. In echocardiography he had normal left ventricle but dilated right sided chambers with supravalvular pulmonic stenosis. Trans-esophageal echocardiography revealed a pseudoaneurysm of distal aortic arch with clot formation and compression of the main and left pulmonary artery. As a result a chest CT scan with contrast and angiographic construction was done which confirmed the previous finding of a 45 mm × 37 mm pseudoaneurysm in lateral side of aortic arch distal to left subclavian origin with associated 9.5 cm × 10 cm hematoma in mediastinum ( and ). At this stage and upon further investigation he remembered to have fallen down from a few stairs 10 years ago which did not result in any injuries and accordingly he did not seek medical advice.
The patient initially refused operation but a few days later developed severe chest pain and so finally agreed to a surgical plan.
The patient had a preoperative selective coronary angiography via right radial artery which was normal. He underwent left thoracotomy via femorofemoral bypass. A large p

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


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

[User]
RADIOLOGY NOTE:
A 20-year-old female from Ethiopia presented with a giant skull-based tumor with a massive orbitocranial deformity distorting her facial anatomy and right eye.
Diagnostic angiography, CT, and MRI revealed a giant, moderately hypervascular, multilobulated, and peripherally calcified expansile mass lesion which appeared to arise from the skull base and occupy the entire nasal cavity, maxillary sinus, and ethmoid sinus regions []. The intracranial extension of the tumor obliterated the sella turcica, bilaterally invaded the cavernous sinuses, and caused extensive elevation and splaying of the internal carotid arteries, anterior cerebral arteries, optic chiasm, and intracranial optic nerves. The mass measured approximately 10 cm × 8 cm × 11 cm. There was no evidence of edema or gliotic reaction in the adjacent brain parenchyma.
The patient underwent resection of the tumor through a subcranial transfacial approach. A bicoronal incision was carried down, preserving the galeal layer for possible use as a graft later. An incision was made over the face and nose to expose the front of the tumor. We broke through the thin bony shell and entered the multiloculated cystic tumor cavity. Fluid was drained and the operating microscope was brought into the field. This allowed us to work circumferentially to remove the entire solid tumor components all the way back to the circumferential bony shell. This left a massive cavity measuring over 15 cm in diameter. All soft tissues were removed and bone was drilled down. The lateral wall of the tumor was drilled, allowing for replacement of the globe to a more natural position. Bone was also drilled off the medial wall to decompress the lesion. The dura was never entered. Calvarial bone grafts were harvested by taking a large frontal parasagittal craniotomy.
A craniofacial reconstructive surgeon with the help of an oculoplastic specialist completed a complex reconstruction. We used the bone grafts to reconstruct a new orbit and mid-face.

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


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

[User]
RADIOLOGY NOTE:
A previously healthy 10-year-old girl presented to our emergency department with a history of back pain, fever, and night sweats for 4-month duration associated with progressive walking difficulty and back deformity over the last 2 months. Physical examination revealed middle back swelling with kyphotic (gibbus) deformity. Neurological examination revealed grade 4/5 motor weakness in both lower extremities with normal deep tendon reflexes and sensations. There was no evidence of cranial nerve involvement, meningeal irritation, or cerebellar dysfunction. Laboratory tests showed a normal complete blood count, elevated C-reactive protein of 81 mg/dl, and erythrocyte sedimentation rate of 111 mm/h. Serology testing for HIV was negative. Her Mantoux test was positive of 25 mm although there was no history suggestive of tuberculosis in the family. Chest X-ray was normal; however, spine X-ray demonstrated destruction of the thoracic vertebra (T11) body and inferior end plate of the T10 vertebra with loss of disk spaces between T10, T11, and T12 (). The contrasted magnetic resonance imaging (MRI) of her spine showed kyphotic destruction of thoracic vertebrae T10, T11, and T12 with abnormal high signal on T2 and low signal on T1 in addition to a large heterogeneous multiloculated prevertabral and paraspinal abscess extending from T7 through T12 with a peripheral thick wall that had low T2 and high T1 signal with intense enhancement. These are associated with an epidural collection and retropulsed collapsed T11, which result in complete attenuation of the anterior subarachnoid spaces and compression of the distal cord (). She underwent open surgical drainage of the paravertebral abscess and posterior spine fixation from T6 to L2 with pedicle screws. During surgery, a massive purulent fluid was discharged, and biopsy from the bone and soft tissue was taken and sent for microbiological examination and cultures including Mycobacterium tuberculosis. Both acid-fast staining and my

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


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

[User]
RADIOLOGY NOTE:
A 65 yr old female presented to the Ear Nose and Throat [ENT] clinic of our institution with a one-month history of a lump in the right neck. On examination, a mobile lump was palpable in the angle of the mandible/upper cervical region. A flexible endoscopy did not reveal any mucosal lesion in the posterior nasal space, oropharynx, hypo pharynx or in the larynx. Clinically a lymph node mass was considered as a possible diagnosis. Fine needle aspiration [FNA] and Magnetic Resonance Imaging [MRI] were then performed.
MRI showed a well-defined oval shaped mass measuring 3 × 2 cm just inferior to the right parotid gland. The epicenter of the lesion was in the inter muscular plane, medial to the sternocleidomastoid muscle but separate from it. It was heterogeneous on both T1 & T2 W images with a well defined margin (Fig & 2). Following contrast administration, there was moderate heterogeneous enhancement (Fig ) In view of the location of the lesion, a differential diagnosis of lymph nodal mass & Spinal Accessory nerve Schwannoma were considered.
FNA of the lesion showed a mix of bland epithelial cell, clusters of spindle cells and myxoid matrix, which was typical of a pleomorphic adenoma.
A decision to perform an excision biopsy was subsequently made. At surgery, the tumor was found to be a pedunculated mass arising from the inferior aspect of the tail of the parotid gland. It was closely related and superficial to the spinal accessory nerve but separate from it. The mass was excised completely incorporating a limited cuff of macroscopically normal parotid tissue, taking care not to injure the inferior branches of the facial nerve.
Histopathology of the excised specimen showed uniform proliferation of epithelial elements within a patially myxo-chondroid stroma, again, consistent with a diagnosis of a pleomorphic adenoma. There was no definite salivary gland tissue within the specimen.

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


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

[User]
RADIOLOGY NOTE:
A 67-year-old female patient was admitted with a six-month history of lower back pain accompanied by a two-month history of intermittent claudication. The patient had visited a community hospital when the lower back pain developed and was diagnosed with osteoporosis following assessment by radiography of the lumbar spine. Despite treatment with medication and physiotherapy, the patient’s symptoms did not subside. Two months prior to this admission the patient began to experience progressive intermittent claudication. The patient was referred to the West China Hospital (Sichuan University, Chengdu, China) as an MRI of the lumbar spine had been recommended three weeks prior to the admission. A neurological examination showed no notable changes in the function of the spinal nerve.
The patient had previously been diagnosed with a vulvar melanoma (13 years prior to the current admittance) and had undergone a melanoma resection at the West China Hospital. The patient received post-surgical radiotherapy. No local melanoma recurrence or other metastatic melanoma was reported prior to the present admission. The patient had been treated with anti-hypertensive drugs for 11 years, but had no other medical history.
The current MRI revealed compression of the lumbar spinal cord in the spinal canal from the posterior direction caused by an extradural mass at the L3 and L4 level. The mass showed a low signal intensity on the T2-weighted images, a mixed low signal intensity on the T1-weighted images and slight enhancement following a gadolinium-contrast injection (). Over the subsequent week, radiography and computed tomography (CT) of the lumbar spine were recommended. There were no clear changes in the radiograph (). CT scans faintly revealed the mass ().
Although the patient had a medical history of vulvar melanoma, a lumbar stenosis resulting from hypertrophy of the ligamentum flavum was suspected instead of metastatic melanoma due to the extended time-period (13 years) since th

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


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

[User]
RADIOLOGY NOTE:
A 40-year-old homeless female presented from an outlying facility with chills and body aches for two weeks. Her medical history was significant for hepatitis C, mitral valve (MV) replacement secondary to MV endocarditis, and IV drug use. At presentation, she was in septic shock, and her blood cultures subsequently yielded group A streptococcus. Of note, she stated that her last use of IV drugs was two weeks before presentation. Fluid resuscitation, antibiotics, and vasopressors were appropriately utilized. Transesophageal echocardiography revealed infected mitral valve leaflets, 2-3 cm vegetation in the left atrium, a 0.9 cm atrial septal defect with the left to right shunt, and LV ejection fraction of 15%. No abscesses were visualized. Two weeks later, transthoracic echocardiography revealed a large LVPA originating from the posterolateral wall as shown in Figures -. Cardiac computed tomography (cardiac CT) scan further elucidated the PA that measured 6.9 x 8.4 x 7.2 cm as shown in Figures -.
The cardiac CT also disclosed a fistulous tract communicating from the infected MV annulus to the aneurysmal portion of the LV. A left heart catheterization was performed to rule out a septic embolus to the coronary vessels as a cause for the PA. No coronary artery disease (CAD) or suspicious lesions were discovered. The sheer size of this PA placed this patient at a very high surgical risk. Various institutes were contacted for LVPA repair and redo MV replacement. Due to the high perioperative mortality and poor healthcare coverage, attempts to transfer the patient to tertiary cardiac care centers were futile. The patient’s ongoing drug use also affected her candidacy for MV replacement. When stabilized she was discharged from hospital care on antibiotics and supportive cardiac medications (beta blocker and ACE-inhibitor). She returned to the hospital six weeks later in cardiogenic shock and multi-organ failure. Repeat imaging revealed significantly increased LVPA size. Despi

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


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

[User]
RADIOLOGY NOTE:
This 54-year-old female was referred to the Neurofibromatosis outpatient clinic of the Oral and Craniomaxillofacial Surgery Department for treatment of numerous cutaneous tumors that preferentially covered her trunk and extremities. On admission, the patient described the tumors to be painless and disfiguring. Besides the cutaneous tumors the patient sought advice for treatment of a painful region of her left small finger (Figure 1 ). For some time the ulnar side of the distal phalanx of this finger had become very touch-sensitive. There was neither a tumor visible nor any other pathological alteration of the skin. However, the finger could not be examined by palpation. The suspected diagnosis was initially a glomus tumor [] or a non-palpable nodular PNF.
MRI at 3T revealed numerous, popcorn-like, contrast-absorbing, hyperintense formations on T2-weighted images, up to 1.2 x 1.9 cm² in size located on the palmar side of the left hand (Figure 2 ). These small lesions mainly affected the metacarpal bones II and III. MRI also showed a sharply defined lesion of max. 1 cm in diameter in the subcutaneous layer at the level of the radiocarpal joint and distal to first digit that reached to the tendons of the extensor musculature. The bony structures showed a homogeneous signal. The findings were interpreted as disseminated subcutaneous and cutaneous neurofibromas of the entire left hand. Structures were found on the distal phalanx of the left small finger whose intensity pattern corresponded to that of the other lesions.
During surgery for the excision and vaporization of numerous neurofibromas of the trunk and extremities, the pain sensitive finger region was also explored. After incision of the skin, no tumor was visible. Therefore, a circumscribed subcutaneous excision was taken as a tissue sample and examined histologically.
The tissue findings confirmed cutaneous neurofibromas for the numerous nodules excised from the trunk and extremities. Surprisingly, there was 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 66-year-old African American female with a past medical history of refractory immunoglobulin G (IgG) lambda MM, essential hypertension, and chronic kidney disease presented to the emergency department with five days of right upper quadrant pain.
Her MM was diagnosed one year prior when she presented with altered mental status, uremia, hypercalcemia, hypoalbuminemia, and paraproteinemia. A skeletal survey at that time revealed multiple thoracic spinal lytic lesions and an eroding soft tissue mass at the level of T10. Further evaluation revealed a very high IgG level, elevated M protein band, and a kappa/lambda ratio <0.01 (normal 0.26-1.65). A biopsy from the soft tissue mass revealed a plasmacytoma. Radiation therapy was initiated for 10 days. She received three cycles of bortezomib and dexamethasone followed by two cycles of bortezomib, dexamethasone, and lenalidomide. Her disease progressed, and a subsequent bone marrow biopsy revealed hypercellular bone marrow with 70% atypical plasma cells. The patient subsequently received seven cycles of carfilzomib, lenalidomide, and dexamethasone. She was not a candidate for bone marrow transplantation given the high plasma cell burden.
On her current presentation, the pain was sudden in onset, intermittent, worse with eating, and without radiation. The pain was associated with nausea and anorexia, but she was without any change in bowel habits. She denied any previous similar episodes. Upon physical exam, the patient was in distress but remained alert and oriented. Her vital signs were all stable. She exhibited right upper quadrant abdominal tenderness without rebound or guarding. Her initial labs are presented in Table . The patient was admitted to the hospital for further evaluation of her abnormal labs and supportive treatment.
The patient was started on intravenous hydration and was made nil per os. An abdominal ultrasound revealed a distended GB with sludge (Figure ). The GB wall was thickened up to 9.5 mm, and the s

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


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

[User]
RADIOLOGY NOTE:
A 65-year-old man presented to the Outpatient Department of Elpis Hospital, for evaluation of a chronic bacterial prostatitis. He reported mild irritative voiding difficulties such as urgency, frequency, nocturia, dysuria, a mild low back pain and perineal discomfort. Although there was no urethral discharge, the patient complained of local burning sensation on urination and an itching sensation in the urethra. The symptoms lasted for fifteen days.
A complete review of systems was unremarkable as well as his medical and family history. The patient's hemogram was normal without leucocytosis. The midstream urine showed microscopic hematuria, pyuria but no bacteriuria indentifying the organism infecting the urinary tract was present. The PSA values were elevated 7,6 ng/ml with a free PSA/total PSA ratio 39%. The transrectal ultrasonography revealed a cystic mass in the transitional zone of the prostate with a solid and a nodular inner portion.
On rectal examination, the prostate was normal in size and consistency. The prostatic secretions obtained by prostatic massage showed a number of inflammatory cells (more than 30 white cells per high-power field) but no causative infectious agent was found by culture or other means. Several eggs were observed amongst the inflammatory cells measured 51–59×26–29 μm with one convex side (Figure ). The size and shape of the eggs identified them as a group of Enterobius vermicularis. On examination of the prostatic secretions we found a soft palpable material which was 5 mm diameter in size and spherical shape. Palpation gave the impression of a tissue than a stone. An incision was performed in this material and a 4 mm long living worm was found. (Figure ). The microscopic examination identified the worm as Enterobius vermicularis.
Although there was a speculation that the infection was sexually transmitted, the patient denied it. The patient did not experience any symptoms from the gastrointestinal tract or itching sensation in the a

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


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

[User]
RADIOLOGY NOTE:
A 59-year-old female patient visited our oral and maxillofacial department clinic complaining of a sense of discomfort in the right posterior palatal area. The patient did not remember exactly when the symptom began. The patient had no other concerned medical history. On clinical examination, a dome-shaped mass of 2.0 × 2.5 × 1.0 cm with clear border and no ulceration was observed in the right posterior palatal area. On the next days of admission, incisional biopsy was performed under local anesthesia. Pleomorphic adenoma (with central coagulative necrosis, most likely traumatized pleomorphic adenoma) was reported histopathologically. Hence, the patient underwent simple mass excision with safety margin under general anesthesia without any additional examination (Fig. ). Postoperative histopathologic report was epithelial myoepithelial carcinoma with positive basal resection margin. Magnetic resonance imaging of the head and neck and whole-body positron emission tomography were performed for further examination, but there was no evidence of distant metastasis (pT2N0M0, stage II) that was shown (Fig. ). Postoperative radiation therapy was administered to the primary site at the Department of Radiation Oncology, and the total radiation dose was 6148, 5400, and 4500 cGy at the operation site, border area, and lateral cervical lymph node level IB and II, respectively, for 39 days. There were no significant complications other than oral mucositis.
After radiation therapy, a 1.5 × 1.0 cm fistula occurred in the right site, which was the operated site, and a fistula closure was done using two-flap palatoplasty under general anesthesia at 8 months after radiation therapy. However, the operated right side flap, which had poor blood circulation after radiation therapy, was necrotized (Fig. ). We removed the necrotized flap under general anesthesia and designed a facial artery myomucosal island flap containing the right mucosal membrane and buccinators, using the facial artery

[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 woman was referred to our dentomaxillofacial radiology center in order to perform a panoramic radiography for dental treatment in March 2012. In panoramic view, we found diffuse sclerosis with a flocculent appearance in the jaws. The width of the mandibular canal was normal; however, the cortical border of the canal was not apparent. In addition, the roots of the teeth were obscured by sclerosis to some extent (). Therefore, we undertook further periapical radiography for greater evaluation of this area and found diffuse sclerosis in these views, too. There was also obscured lamina dura and normal periodontal ligament (PDL) space. No caries or periapical lesions were detected ( - ). In the posteroanterior skull view, increased density with flocculent appearance was found ().
In order to make an accurate diagnosis, the patient’s complete medical history was taken, and it was determined that the patient had been diagnosed by PHPT since two years ago. She had had severe pain in her lower back and lower extremities for a long time. Her family physician had referred her to a rheumatologist to perform proper diagnostic laboratory tests in April 2011.
Her serum levels of calcium (Ca), PTH, and alkaline phosphatase (ALP) were significantly higher than normal limits; however, the results of other blood tests, including renal function tests, were in normal range. Hence, with suspicion of hyperparathyroidism, ultrasonography of the neck region was performed. Ultrasonographic evaluation revealed a 34×22×17 mm mass in the right lower parathyroid gland, and parathyroid adenoma was considered as the first differential diagnosis. Bone mineral density (BMD) was measured in September 2011, and the patient’s T-score and Z-score for the lumbar spine and the femoral neck region were reported to be -3.3 and -3.8, respectively, which were consistent with osteoporosis in both regions. In October 2011, excisional surgery of the mass was performed and, after histopathologic

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


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

[User]
RADIOLOGY NOTE:
In March 2017, a 65-year-old Japanese man, a ship designer, had mild epigastric discomfort and general malaise. An attending doctor thought that he had a digestive tract disease; in upper gastrointestinal endoscopy, however, there was no abnormality. He continued to complain of epigastric comfort and general malaise; he was misdiagnosed as having functional dyspepsia and depressive state, and he started taking medicine for them. He continued the same treatment for approximately 6 months, but the symptoms did not disappear. In September, 2017, he had nausea and vomiting, and finally he could not take any meal. He was then hospitalized in our institution so that we could supply him with nutrition.
His height and body weight were 169 cm and 52.9 kg. Systolic and diastolic blood pressure and heart rate were 119/87 mmHg and 87 beats/minute. Body temperature was increased up to 38.5 °C. In physical examination, there was no special abnormality in his heart, lungs, and abdomen. Table shows the clinical characteristics on admission. His C-reactive protein (CRP) was increased up to 13.36 mg/dL, suggesting the presence of inflammation. An increase of blood urea nitrogen (BUN) and uric acid was observed which we think was probably due to dehydration. Although he had high fever and high CRP, all the infection markers that we examined were negative. In addition, several antibodies which we examined were all negative. Taking into account these data, we thought it unlikely that he had some inflammatory disease and/or autoimmune disorder such as collagen disease. Since his blood glucose level was relatively low and the number of eosinophils was relatively high, we examined the possibility of adrenal deficiency. As shown in Table , ACTH and cortisol levels were low and urinary cortisol level was also low, suggesting the presence of ACTH deficiency and adrenal insufficiency. An increased prolactin level was also observed which we assumed was induced by the side effect of dopamine blo

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


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

[User]
RADIOLOGY NOTE:
A 50-year-old male patient with aortic dissection originating just above the aortic valve and extending down to the common iliac arteries (Stanford A, Figure ) underwent immediate surgery with repair of the ascending aorta in moderate hypothermia under cardiopulmonary bypass. The arterial line was inserted in the right axillary artery, the vent was placed in the right upper pulmonary vein, and two-stage venous line was inserted through the right auricula. The intact aortic valve was resuspended. Extracorporeal circulation was suspended after induction of moderate hypothermia (25°C) and the aortic cross-clamp from the ascending aorta was removed. The false lumen was then glued and an open distal anastomosis to a prosthetic graft was constructed. Then, extracorporeal circulation was resumed, systemic circulation was deaired and the patient was warmed.
Early on the first postoperative day, CT of the aorta was requested because of marked elevation of lactate-dehydrogenase (129 μkat/l) and signs of acute renal insufficiency (creatinine 292 μmol/l). CT showed good postoperative result in the ascending aorta, but large amount of air in the branches of the superior mesenteric artery up to the arcades was found (Figure ). There was absolutely no air in the portal-venous system including the liver. The bowel loops were not distended, and there were no signs of bowel paralysis.
At midnight on the first postoperative day, a biphasic CT scan of the abdomen was requested due to elevated intra-abdominal pressure (18 mmHg). The CT showed distribution of the intra-arterial gas more into the periphery and into the wall of the bowel loops that still did not display signs of ileus (Figure ). The next morning, surgical exploration was performed due to increasing intra-abdominal pressure as a sign of imminent abdominal compartment syndrome. An extensive bowel resection from oral ileum down to the splenic flexure had to be performed due to extensive necrosis of the bowel. Shortly after th

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


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

[User]
RADIOLOGY NOTE:
An 81-year-old gentleman presented acutely to the surgical assessment unit with a painful, diffuse swelling in the left popliteal fossa. The swelling, which was first noticed 6 weeks prior to admission, came on suddenly and was associated with pain and tenderness. Over the following weeks, it had progressed in size and become increasingly painful. The patient had a background history of hypertension, but was not on any regular medication.
A provisional diagnosis of a Baker’s cyst had been made by the patient’s primary health care provider and he had subsequently been awaiting an Orthopaedic clinic appointment for this. The swelling continued to increase in size, restricting the range of movement at the knee. The patient subsequently attended the emergency department where a pulsatile popliteal fossa mass was found. The impression was still of a Baker’s cyst and the patient was sent home. In the weeks to follow, the patient struggled to bear weight on the left leg. The 24 hours leading up to his present admission was accompanied by a sudden onset diffuse swelling in the entire left lower leg. An urgent ultrasound was arranged to exclude a deep venous thrombosis which instead revealed a large, 8 cm, popliteal aneurysm in the popliteal fossa, the outer wall of which was not well defined. There was a 5 cm patent channel noted within the centre of this structure with extensive intramural thrombus noted at the periphery. No obvious abdominal aortic aneurysm was seen.
On initial surgical evaluation, the patient was haemodynamically stable and apyrexial. The left leg was grossly oedematous from below the knee, with a pulsatile firm tender mass in the popliteal fossa. The pedal pulses were all palpable with good range of movement in the feet; however, there was marked reduction of movement at the knee joint. Initial blood tests including white cell count and C-reactive protein were normal. To get a more detailed image of the aneurysm and arterial tree in the left leg, an urg

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


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

[User]
RADIOLOGY NOTE:
A previously healthy 31-year-old woman, gravida 3, para 3, was admitted to the hospital with a history of lower abdominal pain lasting more than two weeks. On the day she was admitted, her pain had suddenly increased in intensity and she had noted the presence of fresh blood on her toilet paper.
The woman had been examined by a gynecologist three days earlier after experiencing mild to moderate abdominal pain. She had had a copper intrauterine device (IUD) for three years and usually had regular periods. However, for the last few weeks, she had only experienced some spotting. A physical examination by the gynecologist revealed some vaginal discharge, but no vaginal bleeding. The uterus and the adnexa were tender when bimanual palpation was performed. Ultrasound showed an endometrial lining of approximately 5 mm. The IUD was located in the uterine cavity. Both ovaries were normal, but some fluid was seen in the right fallopian tube. No fluid was visualized in the pouch of Douglas. The gynecologist tried to remove the IUD, but this procedure was unsuccessful since the IUD strings could not be seen. The patient's temperature was 36.7°C. However, routine biochemistry showed that serum CRP was 100 g/L and β-HCG was 412 mIU/mL. The gynecologist concluded that the woman had a pelvic infection and prescribed doxycycline and metronidazole tablets. As the serum β-HCG was suggestive of an early stage of pregnancy, an ectopic pregnancy could not be excluded. A follow-up consultation was therefore scheduled for three days later. The patient was also encouraged to contact a hospital immediately if her condition worsened.
Two days later, the patient saw fresh blood on her toilet paper. Her pain was also more intense. Following the recommendation of the gynecologist, she contacted the hospital. When she arrived at the hospital, her condition was in general good. She reported pain of mild to moderate intensity. No blood

[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 13-year-old female initially presented with a history of pain and swelling along her right distal fibula. A physical exam was remarkable for point tenderness along the distal fibula with no skin changes and an otherwise normal neurovascular examination. Radiographs obtained demonstrated a lytic, expansile, geographic lesion with no cortical disruption or periosteal reaction (). MRI revealed a multiloculated, minimally enhancing, expansile lesion (Figures and ).
She underwent an open biopsy which showed cyst-like spaces filled with blood surrounded by fibrous septa composed of a cellular proliferation of bland fibroblasts, scattered multinucleated giant cells, and chronic inflammation consistent with the diagnosis of an ABC (). A curettage, application of phenol, and allograft bone grafting were performed, and she was followed with serial radiographs. Six months following surgery, she presented to the clinic complaining of pain with sprinting. Radiographs obtained showed resorption of the bone graft indicating local recurrence. MRI showed a homogeneously lobulated, hyperintense lesion with multiple fluid-fluid levels confirming the recurrence (Figures and ). She underwent a repeat extended curettage with the application of phenol and bone grafting at about one year following her index procedure.
Approximately eleven months following her second procedure and eighteen months following her index procedure, she again complained of pain in the right ankle with exercise. Repeat radiographs demonstrated another recurrence. Since she had failed two operative treatments, a referral to pediatric oncology was placed for the consideration of denosumab therapy for off-label use. The patient and her mother elected to proceed with the initiation of therapy after the risks including osteonecrosis of the jaw, and hypocalcemia had been discussed. The regimen used to treat giant cell tumor (GCT) was implemented which consisted of subcutaneous denosumab (120 mg) given every 4 weeks (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 42-year-old woman who had undergone twice cesarean sections presented with hematochezia and was evaluated by CT scan in August 2011. A CT only detected an enhanced abdominal wall mass near the abdominal scar, which was thought to be desmoid at the time (Fig. a and b). As the hematochezia continued, a further endoscopic workup was performed, and well-differentiated adenocarcinoma was detected at sigmoid colon. The whole body CT scan detected no other distant metastasis. She underwent elective open sigmoidectomy with D3 lymph node dissection for sigmoid colon cancer with mid-line incision in May 2012. Histology of the sigmoid colon showed well-differentiated adenocarcinoma invading to subserosa with 8 out of 20 regional lymph nodes involved. The sigmoid colon cancer was classified as pT3N2b, according to the TNM classification of the Union for International Cancer Control Eights Edition []. Molecular analysis showed KRAS mutation and microsatellite-stable. Postoperative course after sigmoidectomy was uneventful and the patient was treated with 12 cycles of FOLFOX regimen as adjuvant chemotherapy. The patient entered a scheduled clinical follow up program which included: regular physical examinations and CEA test every 3 months, and whole-body CT every 6 months. CT after adjuvant chemotherapy revealed the lesion on the abdominal wall had decreased in size and inguinal lymph nodes were all normal in size (Fig. c and d). In April 2014, a routine follow-up CT scan revealed enlarged left inguinal lymph nodes as well as a growing enhanced mass lesion on the abdominal wall at the site of cesarean section scar (Fig. e and f). 18F-fluorodeoxy glucose positron emission tomography (FDG-PET) revealed significant accumulation at both lesions (Fig. g and h). A CT showed no distant metastases were detected in other organs and laboratory data showed serum CEA level was within the normal range (1.3 ng/ml). Although metastases to both inguinal lymph nodes and the abdominal wall from

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


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

[User]
RADIOLOGY NOTE:
A 43-year-old right-handed man presented to the emergency room, brought in directly from a hospital in Mexico by air ambulance. The medical records accompanying the patient stated he had suffered an upper respiratory tract infection 3 weeks previously, subsequently developing ascending weakness that eventually required intubation and mechanical ventilation 7 days from the onset of symptoms. Further history of the patient revealed that it was his second occurrence of GBS and that he had experienced a complete recovery after the first insult 12 years previously. The patient's family did not choose a hospital close to the United States-Mexican border because they wanted the patient to be seen by the neurologist who treated him during the first occurrence.
On arrival, initial vital signs were stable. The patient was heavily sedated, and his physical examination established a GCS score of 3 (1/1/1), fixed and dilated pupils, unresponsive deep tendon reflexes, and flaccid extremities in all four limbs. Initial CT scan of the head and stat EEG returned normal. On repeat evaluation, the pupils regained some activity, but remained highly fluctuating in terms of their size and reactivity to light.
After the initial assessment, the patient was promptly admitted to the intensive care unit. Due to the confounding factor of sedation, a formal assessment of consciousness could not take place for 3 days. Once the designated time had passed, the patient displayed an ability to nod in response to questions. The patient was inquired whether he had retained sensation, to which he responded with a nod, thereby officially establishing a “locked-in” state.
Family reported that the patient did not receive any treatment in Mexico, as they could not afford either the IVIG or the plasma exchange. On day 2 of arrival (approximately 10 days after the onset of symptoms), plasma exchange was initiated. Due to the fact that Adventist Health White Memorial only carries medical records up to 8 years

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


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

[User]
RADIOLOGY NOTE:
A 54-year-old male patient was admitted to our hospital with bloody stool and mild anemia for 2 months and he was diagnosed as rectal cancer in our hospital in March 2013. He received surgery for rectal cancer on March 26, 2013 and 6 cycles of chemotherapy were given after the surgery (the chemotherapy regimen is FOLFOX). A single metastatic carcinoma of the liver was discovered in September 2013 and then he was given the RFA in the liver. Since then, the patient was in a stable condition for more than a year. In March 2015, multiple metastatic lesions were found in his liver, and chemoembolization was performed 0n March 25, 2015, then, 4 cycles of adjuvant chemotherapy were given after the operation (raltitrexed + bevacizumab). The patient received PET-CT examination and a recurrence lesion was found in the rectal anastomotic stoma in August 2016. He was given the radiotherapy with a total dose of 70 Gy in the next 50 days. Unfortunately, the patient complained of persistent abdominal pain (physical examination found that the tenderness of left side of abdomen was obviously), diarrhea and hematochezia in June 2017 and he was diagnosed as the RE by colonoscopy soon. It was a pity that intestinal probiotics, intestinal mucosal protectants, antidiarrheal drugs, and other treatments were not effective. The patient was treated with the RFA (COVIDIEN, Barrx Flex RFA Cart 1190A-115A, The United States) on 4 September 2017. The RFA procedure: lesion size and scope were observed by routine colonoscopy. RFA electrode (power 48W 12 J/cm2) was placed on the lesion for burning in order to cause coagulation and necrosis of the intestinal mucosa. Removing the tissue which was solidified and necrotic and repeating the above procedure again (Fig. and Fig. ). The clinical symptoms of the patient were gradually decreased after the RFA. A colonoscopy examination was performed 3 months later and the intestinal mucosa was found healed well (

[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 gentleman of Indian origin presented to a regional Ear, Nose, and Throat Department as a tertiary referral. The history of a painful lump over the left side of his upper neck was for approximately one year. The patient reported that the lump fluctuated in size and was initially painful but this improved with time. The accuracy of history was limited by the fact that the gentleman had a thick beard and may not have noticed the enlargement during shaving or from the external appearance. The pain was intermittent but worse after talking for long periods. He did not have any difficulty eating, shortness of breath, or alteration of hearing. There was no history of preceding trauma. Otherwise the patient was in good health, with no significant comorbidities.
On examination the lump was located in the level 2 area of the neck extending into the preauricular area. The mass was firm and pulsatile. There was no facial nerve weakness or paralysis.
All routine blood investigations, which included full blood count, renal function, clotting, C-reactive protein, liver function, fasting glucose, and lipids, were within normal limits. An ultrasound scan (US) of his left parotid region demonstrated a large aneurysm measuring 45 mm in maximum diameter, closely related to the left parotid gland. A subsequent computed tomographic (CT) angiogram was performed (Figure ()). This showed a thick walled aneurysm superficial to the mandible arising from the maxillary branch of the external carotid artery (Figure ()). Doppler US of his aorta and popliteal vessels excluded any further concurrent aneurysms.
After discussions in the vascular surgical multidisciplinary meeting and with the patient it was decided to attempt endovascular embolisation.
The external carotid artery was selectively catheterised with a 5 French vertebral catheter. Angiography during the procedure showed a very tortuous maxillary artery and the giant aneurysm arising from its midportion. The outflow branches

[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 center with recurrent episodes of disabling episodes of palpitation and dizziness for 6 months. The clinical tachycardia presented with abrupt onset and offset and could be terminated by 5 mg of verapamil. She had undergone a left modified radical mastectomy for breast cancer 21 years prior. The patient had been diagnosed with hypertension and diabetes mellitus at that time. A chest radiograph revealed no evidence of cardiomegaly. Echocardiography revealed no evidence of structural heart disease with a normal left ventricular function. The 12-lead electrocardiogram (ECG) at the time of admission demonstrated regular sinus rhythm with a narrow QRS complex and a normal axis (, left panel). An ECG recorded during an episode of palpitations revealed a narrow QRS complex tachycardia with a cycle length of 480 ms. The P wave polarity preceding the QRS complex was negative in leads V4-6, biphasic (initially negative and a late positive component) in leads V1 and V3, and undetermined in the limb leads (, right panel).
After giving informed consent, an electrophysiological study was performed without sedation. Three catheters were introduced to the right atrium, the right ventricular apex, and at the His-bundle region via the femoral veins. Also, a 7-Fr multipolar catheter was advanced within the coronary sinus via the left subclavian vein. During initial ventricular pacing, the ventriculoatrial conduction was absent. A tachycardia was induced and terminated reproducibly with incremental atrial pacing and extrastimulation. During the tachycardia, the local electrogram recorded at the His bundle preceded the onset of the surface P wave by 40 ms and the proximal coronary sinus by 15 ms ().
Ten radiofrequency applications were delivered near the His-bundle region where the atrial activation during the tachycardia recorded from the distal electrodes of the ablation catheter, preceded the onset of the surface P wave by 45 ms. The tachycardi

[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 otherwise healthy 33-year-old male with a history of bilateral patellar tendonitis and OS presented to a level-one trauma center after sustaining bilateral knee trauma. He was playing volleyball and felt a snap and heard a popping sound while jumping after having both knees in flexion. He sustained a ground-level fall and subsequently could not ambulate and immediately noticed a loss of bilateral knee extension. He denied any significant orthopedic or rheumatologic family medical history and had no recent antibiotic, steroid, or medication usage.
Physical exam revealed a fit male with easily palpable defects along the superior poles of both the left and right patellae. There was diffuse surrounding soft tissue edema over both knee joints. The patient was unable to perform a straight leg raise on either side or extend either leg. There were no signs of neurovascular compromise. All laboratory values were unremarkable, including a normal vitamin D level.
Plain radiographs revealed high-riding patellas bilaterally and increased distance between the tibial tubercle and patella. There was notable central ossification of both patellar tendons, indicative of chronic injury (Figures -). Based on clinical evidence and confirmed radiologically, the patient was diagnosed with closed acute bilateral patellar tendon ruptures.
The patient underwent semi-urgent bilateral patellar tendon repair without complications via midline incisions over bilateral knee joints. Torn patellar tendon remnants were identified and a #5 FiberWire (Arthrex, Munich, Germany) suture was used to create two Krackow sutures into the torn distal segment. Four total drill holes were created into the patellar from the inferior to the superior pole. A suture was then passed through to reduce the patellar tendon onto the inferior pole of the patella. The torn medial and lateral retinaculum was repaired with #5 FiberWire sutures. At the completion of the procedure, excellent stability of the patella, along 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:
Our patient is a 32-year-old otherwise well man who was initially diagnosed with melanoma following excision of a 5 mm naevus from his back in June 2012. The primary pathology showed it to have a Breslow thickness of 5 mm, a Clark level of 4, no evidence of ulceration, and a mitotic count of 7/mm2. Subsequent gene testing demonstrated the tumour to be BRAF positive. On the basis of this poor pathology, a Wide Local Excision and sentinel node biopsy were performed. The positive nodal biopsy resulted in the patient having an axillary clearance (5 out of 30 nodes positive). He had adjuvant radiotherapy (48 Gy to the axilla) and he was enrolled in a clinical trial which involved the administration of two immunomodulatory drugs: Nivolumab and Ipilimumab.
On a routine staging CT-abdomen/pelvis in December 2014, the patient was first noted to have a mild left-sided hydroureter. Neither the CT scan nor ultrasound performed soon after demonstrated a clear cause. A repeat CT-abdomen/pelvis in March 2015 showed the development of a 6 mm nodule in the mid left ureter at approximately the level of L4 vertebrae. A PET Scan performed at the time did not suggest it to be a metastatic deposit. A further repeat CT was performed in May 2015 by which time the nodule had progressed to being 10 × 9 mm and the hydroureter had progressed significantly. Throughout this period, serial measurements of renal function did not demonstrate any abnormalities, with a stable Creatinine between 90 and 100 μmol/L. The patient denied haematuria, and urinary cytology was negative. At this time, another metastatic deposit was found (a metastatic deposit in the left parafalcine region of the brain, subsequently treated with stereotactic radiotherapy) in addition to apparent lymphadenopathy.
On the basis of evidence of the progression of the nodule and increasing hydroureter, the patient was referred to the Uro-

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


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

[User]
RADIOLOGY NOTE:
A 24-year-old female patient presented to the Department of Oral and Maxillofacial Surgery at Homerton University Hospital in East London, UK, with a 4-week history of suspicious upper lip swelling. This patient was referred by her general practitioner on the urgent head and neck cancer referral pathway.
The patient's primary concern was the sudden onset of a large upper lip swelling with associated pain. The patient was not forthcoming and defensive when questioned regarding precipitating factors or possible trauma to the region. She was medically fit and healthy with no risk factors for oral cancer, such as smoking and alcohol consumption [].
On extraoral examination, the patient appeared to be well with no clinical signs of systemic illness. In general, the upper lip was disproportionately enlarged with an incompetent lip seal (). On close examination, a 2 cm × 1 cm firm, erythematous, swelling was noted in the upper right lip. The lesion was not encroaching on the midline and there was no associated cranial nerve deficit or lymphadenopathy. At the vermillion border, there was a puncture wound on a background of traumatised tissue adjacent to the firm swelling (). The lesion was painful on palpation with no suppuration, induration, or ulceration noted. Intraoral examination revealed a concurrent firm swelling within the labial sulcus. Dental health was unremarkable, and there were no signs of systemic infection.
Upon revision of the patient's electronic health-care record, it was noted that the patient had attended the Accident and Emergency Department at the Homerton University Hospital four weeks prior. The clinical clerking from this visit showed the main complaint to be swelling of the upper lip following self-injection of a dermal filler, purchased over the internet. When questioned again directly by the OMFS team regarding the true mode of injury, the patient revealed that she had purchased the filler material over the internet. The patient was uncertain 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 7-year-old boy was brought to the ER after being involved in a road traffic accident, in which the car he was riding in rolled over. He had a history of loss of consciousness and repeated vomiting. There was no history of fits or bleeding from ear or nose.
On arrival his pulse was 95 beats per minute with a blood pressure of 95/60 mmHg. His GCS was 12/15, and both his pupils were equal in size and reaction to light. There was a 4-cm laceration on the patient's posterior parietal area on the right side. He had a left-sided hemiparesis with power of 3/5. The patient had a deformity of the right upper limb with suspected fracture of the humerus which was stabilized using a long arm back-slab. The rest of the_neurological and systemic examination was unremarkable.
The initial CT scan of the brain showed a large hematoma in right putamenal area with perifocal edema []. There was associated mass effect and midline shift. An X-ray of the right humerus revealed a reduced fracture of humerus, which was immobilized in cast. The rest of the radiological survey was unremarkable. His scalp laceration was sutured and dressed in the ER.
The patient was managed nonoperatively with hypertonic saline in Pediatric Neuro-Intensive Care Unit for 24 h after which his imaging was repeated and he was shifted to step down unit, and started on regular limb physiotherapy. He was discharged home after a week on rehabilitation.
At 3-month follow up, he was able to perform basic tasks and was seen comfortably playing with a toy. He was also able to walk with support. A repeat CT scan showed an area of hypodensity with decreasing perifocal edema []. He was advised to continue with physiotherapy and regular clinical follow-up. His recovery was not as good as the previous cases as he remained moderately disabled with a GOS score of 4

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


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

[User]
RADIOLOGY NOTE:
A 22-year-old, G2P0010 with 32 weeks pregnancy was admitted in neurosurgery intensive care unit (ICU) with complaints of sudden onset severe headache and recurrent episodes of vomiting for 1 day. Her pregnancy was supervised at a peripheral hospital and her blood pressure records were normal. At 22 weeks of gestation, she had one episode of generalized tonic clonic seizures, lasting for 2-3 minutes. She had no prior history of seizures. She was attended at the peripheral hospital and started on antiepileptics but continued to have headache for which a computed tomography (CT) [] and magnetic resonance imaging [Figure and ] were done at 20e and 28 weeks, respectively, which showed a left frontal hematoma with mass effect in form of effacement of ipsilateral ventricle with edema. She had one more episode of seizure 10 days before reaching neurosurgery department of our hospital. At the time of admission, she was conscious, obeying simple commands but was disoriented. Her pupils were bilaterally symmetrical and reacting to light. She had right hemiplegia. Her abdominal examination revealed a gravid uterus of 30 weeks size, relaxed with fetus, presenting as cephalic having regular fetal heart rate of 142 bpm. A CT angiography was done which demonstrated a left supraclinoid internal carotid artery (ICA) aneurysm. She was posted for digital subtraction angiography (DSA) (with precaution for fetal exposure of radiation). DSA showed a giant supraclinoidal ICA segment aneurysm []. During the procedure, she had neurological deterioration and also developed per vaginal discharge. She went into spontaneous labor at 32 weeks and delivered a male child with birth weight of 1.1 kg. The baby was immediately shifted to the neonatal ICU. In the immediate postpartum period, she developed hypotension and respiratory distress for which she required ventilator support. Repeat CT scan showed rebleed in anterior interhemispheric fissure. She was taken up for surgery after 12 hours postpart

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


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

[User]
RADIOLOGY NOTE:
A 33-year-old pregnant woman was admitted to our department in the 16th week of her first gestation because of suspicion during a routine ultrasound of decreased fetal movements and fetal malformation consisting of postural deformity of both lower limbs associated with a uterine fibroid. The family history was unremarkable and the mother's medical history nonsignificant except for the presence of two intramural uterine myomas diagnosed before the current pregnancy and smaller than 47 mm in maximum diameter in previous control one year before gestation.
Our ultrasound investigation verified the presence of an intramural-submucosal tumor with a muscular echogenic pattern and a size of 110 × 88 mm in the anterior uterine wall near to the internal cervical os and another intramural one with a size of 28 × 21 mm in the uterine fundus. Fetus presented a normal heart rate pattern and was observed with absent movements and displaced to the right uterine wall in an abnormal position, with hyperextension of head and strongly flexed lower limbs (). Fetal measures according to the gestational age and the amount of amniotic fluid were normal. On the basis of these findings, the diagnosis of arthrogryposis secondary to fetal akinesia due to giant leiomyoma was done.
According to the Spanish legislation, the parents decided the elective termination of pregnancy. A vaginal delivery was induced with local prostaglandins without complications. At the time of birth, the fetus had not cardiac activity and showed external male genitals, a weight of 105 g and a length of 125 mm. His position consisted of internal rotation of the shoulders and stiffness of the limbs with symmetrically flexed and fixed elbows and wrists and severe equinovarus deformities of the feet ().
The pathology report concluded that internal organs of the fetus did not present abnormalities. Histopathological examination reported extraconnective tissue developed around the joints and tissue between the muscle fibers

[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 nonsmoker male presented in December of 2007 with right supraclavicular lymphadenopathy. An excisional biopsy of the lymph node was performed. Histopathology () showed the morphologic features of SCLC including small to medium size cells, high nuclear/cytoplasmic ratio, salt and pepper chromatin with inconspicuous nucleoli, nuclear molding, and high mitotic activity. Immunostaining showed that the tumor cells expressed synaptophysin and chromogranin and discontinuous cytokeratin markers. TTF-1 was also positive. Imaging was performed with PET/CT showing a 5 cm right hilar mass and right paratracheal lymphadenopathy and no disease elsewhere including a negative brain MRI.
Thus, he was deemed to have limited stage disease and was treated accordingly with cisplatin and etoposide and concurrent radiation therapy (). He achieved a complete response after 6 cycles of chemotherapy and subsequently underwent prophylactic cranial irradiation. He was monitored clinically and by imaging every 3 months. In May 2009, the disease relapsed with left supraclavicular lymphadenopathy and was confirmed by excisional biopsy. He underwent radiation therapy with concurrent cisplatin and etoposide for 2 cycles followed by 4 cycles of oral topotecan. He had complete response again that lasted for one year. In September 2010, he had a relapse presenting with mediastinal lymphadenopathy. After another 5 cycles of cisplatin and etoposide, he had near complete response, and he was monitored clinically. After progression in September 2011 with increased hypermetabolic activity in the right hilum and paratracheal lymph nodes, he was started on carboplatin and etoposide. He had good response after 4 cycles and was switched to oral etoposide. He again progressed with increased metabolic activity in the right hilar and paratracheal region.
At this time, genomic profiling of his prior tumor biopsy was undertaken. This showed that his tumor harbored a novel JAZF1-MYCL1 gene fusion but l

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


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

[User]
RADIOLOGY NOTE:
A 24-year-old previously asymptomatic male presented to his primary care physician with a complaint of focal penile irritation related to sexual intercourse. The irritation originates from a lesion along the midline on the dorsum of his penile glans. He was referred to a urologist for further evaluation.
The patient reported noticing a small dimple along the midline on the dorsum of his glans for as long as he could remember. The lesion had not previously caused him any discomfort, nor did he report a history of discharge, including urine, semen, blood or pus from the orifice. In recent months, the patient has become more sexually active and he has become aware that during and after intercourse the site is painful and inflamed for a short period of time. The patient wants to make sure there is not something wrong with his anatomy and seeks a solution.
The patient had no significant past medical history. There is no family medical history of relevance, specifically no one has reported any genital malformation. Physical examination by a urologist demonstrated a well-developed adult male. A small midline opening was present on the dorsum of the penile glans. There was no focal erythema or discharge present at the time of examination. Manipulation of the opening demonstrated a thin lumen that appeared to continue proximally along the dorsum of the penile shaft. The most likely aetiology was determined to be urethral duplication. Imaging was necessary for confirmation and to delineate the particular anatomic presentation in order to plan treatment. Demonstration of communication with the urethra or bladder would require more extensive surgical intervention to eliminate the sequelae of discharge accumulation in the lumen causing infection, cyst formation or recanalisation of the accessory orifice. The patient was referred to radiology for urethrography.
Since no urine, semen or other discharge had ever been noted to exude from the accessory urethra, a retrograde urethrogr

[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 us with chief complaint of reddish-blue discoloration on the left buttock and trunk after receiving IM injection of paracetamol. He experienced pain while the injection was being administered and the pain continued after the injection, after which it regressed and was managed with the use of analgesics. The patient had a history of fever for the last 10 days for which he had taken some oral drugs, and an injection of paracetamol was prescribed to him by the local practitioner. Two days after receiving IM paracetamol in the left buttock, the patient developed reddish discoloration at the injection site, which in a span of 2 days changed to reddish-blue color and spread to the left side of trunk, shoulder, and right shoulder and arm. History of any spontaneous bleeding from any orifice was not reported. History of any joint swelling or any episode of unconsciousness or abnormal body movements was not reported. On physical examination, his vitals were stable. Systemic examination was unremarkable. Cutaneous examination revealed large areas of nonpalpable ecchymotic patches involving left buttock reaching up to the right buttock, left side of trunk, shoulder, and arm and right shoulder, neck, and anterior chest [] . On diascopy, the bluish discoloration persisted, confirming the purpura. Laboratory investigations revealed positive enzyme-linked immunosorbent assay for HIV, which was an incidental finding. Rest of his laboratory tests including platelet count and bleeding, clotting, and prothrombin times were unremarkable. He was advised skin biopsy for histopathological examination in view of the extensive purpuric lesions with some lesions distant from the main site of injection and separated by areas of normal skin. However, consent for biopsy was not given. On the basis of history and a suggestive clinical examination, a diagnosis of NS secondary to IM injection of paracetamol was made. He was managed conservatively with oral diclofenac an

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


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

[User]
RADIOLOGY NOTE:
A 35-year-old G4P2012 presented to labor and delivery at full term in early labor with spontaneous rupture of membranes. She had undergone living donor kidney transplant 8 years prior for ESRD suspected secondary to IgA nephropathy versus post-streptococcal glomerulonephritis. She was maintained on Prograf and prednisone throughout her pregnancy with a stable baseline serum creatinine 1.2 mg/dL. Obstetrical history was significant for two prior uncomplicated Cesarean deliveries, both prior to her kidney transplantation. It was unclear from her records whether she had undergone counseling regarding pregnancy post-transplant. She declined a of trial of labor after Cesarean section despite counseling on the risk of injury to the transplanted kidney given its location in the operative field, which was confirmed on transabdominal ultrasound prior to the case.
The patient was taken to the operating room for and indicated repeat Cesarean section. Routine dissection was performed down to the level of the fascia through a Pfannenstiel incision and the fascia was carefully transected horizontally in the usual fashion. When the superior fascial edge was lifted for traction to allow for dissection from the underlying rectus muscle, brisk pulsatile bleeding was noted. The transplanted kidney was noted to be densely adherent to the overlying anterior abdominal wall, and avulsion of a portion of the transplanted kidney was confirmed (Fig. ). Direct pressure was applied to the organ while the Trauma Surgery team was consulted. The avulsion was repaired using 3–0 pledgetted Prolene sutures in interrupted horizontal mattress fashion and using Evarrest compound. At this time, the decision was made to extend the skin incision in the vertical midline for improved access to the uterus given the concern for further shearing forces to the exposed transplanted kidney in the process of delivering the baby. The rest of the case was uneventful. No blood product transfusion was necessary. After

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


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

[User]
RADIOLOGY NOTE:
A 60-year-old woman visited our hospital for evaluation of a tumor arising in a remnant cystic duct 30 years after cholecystectomy for gallbladder adenoma. Laboratory data, including tumor markers such as carcinoembryonic antigen and carbohydrate antigen 19-9, were within normal ranges. The patient had no chief complaint. Previous medical history included breast cancer that was completely resected three years prior to her visit. Since that time she had taken an aromatase inhibitor. Annual follow-up for breast cancer by contrasted computed tomography (CT) showed an intraductal papillary mucinous neoplasm (IPMN) in the pancreas head and an enhanced tumor image around the hepatoduodenal ligament (). Endoscopic ultrasonography (EUS) demonstrated branched IPMN of the pancreas and a residual cystic duct tumor. The tumor was located at the junction of the cystic duct and was enhanced with Sonazoid (). Endoscopic retrograde cholangiopancreatography indicated that the tumor had not invaded the common bile duct. Enhanced CT in the artery phase revealed a 6 mm round tumor. Surrounding lymph nodes were not swollen. Magnetic resonance cholangiopancreatography (MRCP) showed that the tumor presented with a slightly high signal on T2 weighted imaging, and the periphery remnant cystic duct of the tumor presented as a high-intensity lesion on T2 weighted imaging (). During surgery the tumor was located at the cutoff position of the remnant cystic duct and presented as a white nodule that adhered tightly to surrounding tissue. There was severe adhesion around remnant cystic duct and the hepatoduodenal ligament due to previous surgery. The remnant cystic duct and the tumor could not be separated; however, no invasion toward common bile duct was observed. Rapid intraoperative pathological examination demonstrated that the tumor was a neuroma. The operation time was 251 min, and blood loss was 80 ml. Macroscopic findings had two components; the dilated remnant cyst with white bile, and t

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


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

[User]
RADIOLOGY NOTE:
A 54-year-old male patient presented with a two-day history of severe left-sided, lower back pain which disappeared with the appearance of left-sided lower limb pain felt deep inside the whole lower limb and described by the patient as intense internal pressure (VAS 8/10). On examination, power was 5/5 with no sensory deficit and normal reflexes. The patient received NSAID painkillers and active bed rest was advised. However, on the patient's insistence, a lumbar spine X-ray and MRI were done which showed mild IVD protrusion. The patient was reassured and sent home. A week later the patient presented to the ER with an 18-hour history of heaviness and difficulty in raising the left foot when walking, with numbness along the lateral part of the leg and dorsum of the foot. The pain was moderate (VAS 5/10). No sphincter-related symptoms were observed. According to the patient, the decreased pain caused the delay in presentation, against the instructions on first evaluation. On examination of the foot dorsiflexion was 2/5 (movement on gravity alleviation) with decreased sensation along the left L5 dermatome. There were normal reflexes and sphincters. The patient underwent immediate, new lumbar MRI which showed a large disc sequester with disc migration. His status was fully explained; he was admitted and underwent microdiscectomy L4/5.
The initial back pain lasted for 2 days, mostly caused by stretching and pressure on the weakened annulus fibrosis. This type of pain disappears or decreases once the annulus opens and nucleus pulposus leaks to the spinal or root canal. Initial left lower limb pain is a typical description of painful radiculopathy where mass pressure and inflammatory irritation of the nerve root and dorsal root ganglion cause neuropathic pain. This is different from nociceptive and referred pain types. Dorsal root ganglion hosts the cell bodies of sensory nerves with bidirectional connections (to the periphery and spinal cord). Injury

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


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

[User]
RADIOLOGY NOTE:
A 25-year-old male was brought to our emergency department following a road traffic accident in July 2018. The patient was intubated in view of poor score on Glasgow Coma Scale (GCS). He was hemodynamically stable. On clinical examination, the patient had bilateral decreased air entry and positive chest compression. There were no abdominal signs. On focused assessment with sonography in trauma (FAST) there was minimal free fluid in the abdomen. Contrast-enhanced computed tomography (CECT) of thorax and abdomen showed bilateral hemopneumothorax and a grade III liver laceration. Initial non-contrast computed tomography (NCCT) of brain showed no intracranial injury but later the patient was declared to have a diffuse axonal injury and was shifted to critical care unit for monitoring. The liver laceration was managed conservatively since the patient was hemodynamically stable. Hemopneumothorax was managed with bilateral intercostal drains. The patient’s GCS was persistently poor. Initially, the patient was started on enteral feeds through nasogastric tube and later a PEG tube placement was planned for the purpose of continuing enteral feeds.
The procedure was performed while the patient was on endotracheal tube, and under intravenous (IV) sedation. A 20 Fr PEG tube was placed by the standard ‘Pull’ technique. Second look endoscopy confirmed the position of the internal bumper against the anterior wall of the stomach. Externally the tube was fixed and free flow of saline through the PEG was confirmed. There were no complications during the procedure and the patient was started on enteral feeds through the PEG tube on the same day. The patient was extubated after few days but he was continued on PEG feeds as his GCS was persistently poor.
At four weeks after PEG there was peritubal leakage noted during feeds with resistance to the flow of feeds initially, which later progressed to complete the blockage. On examination, there was a slight bulge at the site of PEG tube inse

[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.