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

[User]
RADIOLOGY NOTE:
A 75-year-old male was referred to our hospital in May 2010 with a two-month history of diffuse abdominal pain and intermittent rectal bleeding. He also reported low-grade fever in the evenings. No weight loss or other symptoms were noted. His previous medical history was unremarkable except for hypertension and type 2 diabetes. On physical examination, the patient had a good general status and was not septic. A painful, poorly defined, and nontender mass was noted in the right hypochondrium; there were no signs of peritoneal irritation. Blood counts, renal and hepatic biochemistry tests, LDH levels, and tumour markers values were all within the normal range. Only the fibrinogen level and the C-reactive protein were elevated (841 mg/dL and 209.1 mg/L, resp.).
A full-body CT scan revealed a heterogeneous, well-circumscribed mass in the right abdominal loin that seemed to originate from the hepatic flexure colon and descended towards the anterosuperior iliac spine (). The mass displaced the right kidney and appeared to infiltrate the anterior renal capsule. There were air bubbles in the interior of the tumour. There were no other imaging abnormalities. The colonoscopy revealed in the transverse colon, near the hepatic flexure, both an extrinsic compression of the colonic lumen and more proximally an intraluminal tumour that occupied the whole of the circumference and did not allow the further passage of the colonoscope. Biopsies of the mass, however, revealed only necrosis but no malignant cells.
An exploratory laparotomy was performed in May 2010. A right colonic mass was seen that occupied the whole right abdominal flank and infiltrated the distal ileum. There was a small quantity of ascitic fluid. The right kidney was not infiltrated. An extended right hemicolectomy with a distal ileal resection was performed. The postoperative course was uneventful and the patient was quickly discharged.
The pathologic analysis showed a poorly delimitated 14 × 13 cm tumoural mass,

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


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

[User]
RADIOLOGY NOTE:
A 63-year-old Korean man visited the clinic at Kosin University Gospel Hospital for the management of a palpable abdominal mass. Upon presentation at the clinic, he was otherwise healthy. His carcinoembryonic antigen level was 4.65 ng/mL (reference value, <5.0), and the results of a complete blood count, plasma electrolyte analysis, coagulation analysis, kidney and liver function tests, and urinalysis were normal. A physical examination revealed no other significant findings. Abdominal CT showed a large irregular mass at the transverse colon, which had extended to and invaded the duodenum to form a fistula (). A colonoscopic examination revealed poorly circumscribed infiltrating masses with ulceration in the transverse colon (). The mass occupied nearly the entire lumen, which the colonoscope could not access. An upper endoscopic examination revealed a 2-cm fistula tract covered with yellowish exudate (). A multidisciplinary team decided to treat this patient with pre-operative CRT and subsequent surgery. The chemotherapy regimen was FOLFOX4, and radiation treatment was administered at a total dose of 3,000 cGy divided into 10 fractions (5 times per week). After the completion of chemotherapy and radiation treatment, an abdominal CT and upper endoscopic examination were performed to assess resectability. Abdominal CT revealed that the enhancing lobulated mass in the transverse colon had decreased in size and that the invasion of the adjacent anterior abdominal wall and duodenum had also improved (). The upper endoscopic examination showed that a whitish scar had replaced the fistula opening, which was now closed (). The patient suddenly developed abdominal pain while waiting for the scheduled operation, and chest X-ray revealed free air. The patient then underwent an emergency operation; our surgical team, which was aware of his disease status, confirmed that the perforation had occurred in the cancer lesion and performed a transverse colon segmental resection. Hist

[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 female repeatedly presented to our hospital with a cough for 3 months. No other symptoms were associated with the cough. The findings during the physical examination were unremarkable except that her Body Mass Index was 28.5. Contrast-enhanced computed tomography imaging of her chest revealed a posterior superior mediastinal lesion with an area of approximately 2.7 × 1.3 cm () and a value of approximately 122 HU. The mediastinal lesion manifested as an intensely enhancing mass with a circumscribed and well-defined margin. A bronchoscopy showed that the membranous trachea was raised, a mass oppressing the membranous region of the trachea from the posterior mediastinum. No pedunculated or polypoid tumor was in the trachea lumen.
A surgical excision was performed using a right thoracoscopy. This procedure revealed a well-circumscribed vascular lesion that was located above the carina and behind the trachea that measured 1.5 cm in length and was highly vascularized. Additionally, the tumor closely adhered to the membranes of the trachea. During the process of tumor resection, to decrease tension, we emptied the balloon of an endotracheal tube with the assistance of anesthetist. After the lesion was resected, the endotracheal tube cuff was inflated and extruded into the chest. Regretfully, we ruptured the membranes in the trachea, which resulted in a longitudinal tear that was approximately 0.8 cm in length. This tear was sutured with interrupted stitches using 4-0 Prolene sutures and a pad of pleura. It was further reinforced with a pedicled pleural flap to avoid small amounts of air from leaking from the suture line (). There was no air leakage when an airway inflation pressure of 20 cm of H2O was applied. The patient experienced an uneventful recovery and no postoperative complications and was discharged home on the 16th postoperative day. Fiberoptic bronchoscopy was performed 1 week, 3 months after surgery. No incidence of tracheostenosis occurred.

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


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

[User]
RADIOLOGY NOTE:
A 73-year-old male presents with a 5-week history of nausea, vomiting, and abdominal pain. Past medical history is significant for stage IV transitional cell cancer with angiolymphatic invasion treated with neo-adjuvant chemotherapy and radiation followed by radical cystectomy with ileal conduit formation and bilateral pelvic lymphadenectomy. He had also undergone a diverting sigmoid colostomy for rectal outlet obstructive symptoms from metastases to the rectum. Subsequent surveillance imaging and colonoscopies were negative for any recurrence as recent as nine months prior to the current symptoms.
For the abdominal pain, patient was evaluated with CT of the abdomen and pelvis which revealed new circumferential thickening and inflammatory stranding involving the ascending colon extending to the hepatic flexure as well as the descending/transverse duodenal junction with adjacent inflammatory stranding (Figs. and ). Diffuse intra- and extra-hepatic biliary ductal and main pancreatic duct dilatation (double duct sign) was noted as well. Transaminases and bilirubin were initially normal.
Magnetic resonance imaging (MRI) of the abdomen was pursued to further investigate the double duct sign, which did not reveal choledocholithiasis or pancreaticobiliary malignancy. The dilated biliary tree was suspected to be secondary to thickened descending duodenum. This thickening was abutting the hepatic flexure. Additional findings included hydroureteronephrosis on the right with a focally enhancing soft tissue mass (Fig. ).
Upper endoscopy for evaluation of gastric outlet obstruction demonstrated duodenal stenosis with significant edema and congestion without an obvious ulcer (Fig. ). The stenosis could be traversed only with an ultrathin endoscope but biopsies were nondiagnostic. Based on the MR imaging findings, endoscopic evaluation of the colon was pursued in hope of getting a better yield for diagnosis. Colonoscopy demonstrated a mass at the hepatic flexure (Fig. ). Biopsies

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


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

[User]
RADIOLOGY NOTE:
A 73-year-old male, height 172 cm and weight 75 kg, was referred to our institution after having been seen 3 months previously due to worsening lower back pain which radiated to the left buttock and thigh as well as claudication that had lasted three months. His lower back pain had been treated with caudal blocks for the last 3 years. A lumbar spine radiograph revealed degenerative scoliosis and narrowing of multiple intervertebral disc spaces. A magnetic resonance imaging (MRI) scan demonstrated marked lumbar 3-4 (L3-4) intervertebral disc extrusion, lumbar spinal stenosis, and an L3 compression fracture. He was treated with one L3-4 epidural block, medial branch blocks, and received nonsteroidal anti-inflammatory drugs. His radicular pain and claudication improved, but he complained of low back pain consistently. Therefore, a transforaminal epidural block and percutaneous epidural neuroplasty were performed. After the treatments, all symptoms improved, and only mild lower back pain which increased with walking remained. However, 2 weeks later, he was hospitalized for left leg paralysis and excruciating lower back pain that did not diminish when laying down. MRI was repeated, which identified aggravated L3-4 disc extrusion and a dilatated abdominal aortic aneurysm of nearly 6.0 cm (). Careful review of the previous MR images identified a curvilinear atherosclerotic (calcified) lateral wall of an abdominal aortic aneurysm and fusiform aneurysmal dilation of the abdominal aorta anterior to the vertebral body (). The patient was referred to the neurosurgery department of our hospital for further examination and treatment for the disc extrusion and abdominal aortic aneurysm.
He presented to our hospital with intractable lower back pain and pitting edema of both lower extremities. His blood pressure was 110-130/79-90 mmHg and his pulse rate was 70-80 min. Abdominal contrast enhanced computed tomography (CT) confirmed a focal lower abdominal aortic aneurysm with crescent

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


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

[User]
RADIOLOGY NOTE:
A 4-month-old baby Ibibio tribe girl was referred in August 2019 to our Radiology Department, UUTH, Uyo, Nigeria from the Orthopedic Unit for plain radiography of her lower limbs; this was on account of her short left lower limb noticed from birth. Her parents said that her left lower limb was getting progressively shorter but she had no other abnormalities. Antenatal history, past medical history, and family history were not remarkable. There was no history of trauma to the mother during pregnancy or perinatal exposure to radiation. Developmental milestones had been normal so far.
On physical examination, she appeared otherwise normal and well nourished. Both her lower limbs were actively mobile. Her left lower limb was shortened and in external rotation (see Fig. ). Her right lower limb measured 27 cm from the anterior superior iliac spine to the tip of medial malleolus, whereas her left lower limb measured 23 cm on similar landmarks. Normal range of motion of both knee joints and hip joints were observed. Hip abduction was full and back examination was normal. Her upper limbs showed no anomaly with full range of movement. Aside from umbilical hernia, no other congenital abnormalities were seen on abdominopelvic ultrasonography. A diagnosis of PFFD was made and she was referred for radiographic examinations.
Plain radiographs of her thigh and lower limbs showed shortened and hypoplastic left femur with preserved left femoral capital epiphysis. Her left femur had normal configuration but had a shorter shaft than the contralateral femur. The shaft of her left femur measured 9.41 cm whereas the shaft of her right femur measured 11.88 cm (see Fig. ).
On receipt of the radiographs, the possible plans of management were discussed with her parents. Unfortunately, they have not kept any further appointments. Recent telephone communications in December 2019 with the parents revealed that the child has been left to her fate. This is because of the parents’ belief of spontan

[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 23-year-old male patient presented to us in June 2011 with a deformity of the back, weakness of both lower limbs, and with a history of multiple surgeries on the back. At three years of age, spontaneous disappearance of the right clavicle and upper humerus was noticed without any preceding trauma. Biopsy was taken from the lesion and diagnosis of Gorham's disease was made based on the histopathological examination of the tissue. The disease was subsequently not progressive. In May 2010, he noticed progressive deformity of the upper back, spasticity, and an altered gait. He was diagnosed with myelopathy and kyphotic deformity of the spine. On August ninth 2010 he pedicle screw instrumentation with decompression of the cord. The patient experienced an uneventful post-op period. His spasticity reduced and his gait improved over a period of two months and he was then able to walk normally. On May 25th 2011, a routine follow up X-ray showed breaking of the implant for which a revision surgery was performed the same day. Post-surgically, the patient developed complete weakness of both lower limbs with loss of bladder and bowel control. He was taken for immediate decompression. As the patient's neurology did not improve, a revision decompression was performed on 3 days later. The patient noticed the return of some movement in his right lower limb a few days after surgery. His bladder control returned one month later. He was referred to us for rehabilitation (, ).
On examination, the patient showed dyspnoea, tachypnoea, and paradoxical breathing. Neurological examination revealed complete absence of motor power on the left lower limb and the power in the right lower limb was 1-2/5. Sensation was decreased from T5 below. Deep tendon reflexes were exaggerated with ankle clonus and extensor plantars. A loss of the rounded contour was observed on the right shoulder with painless exaggerated passive movements. A chest X-ray revealed pleural effusion on the left side. Chylous 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 47-year-old male visited an otorhinolaryngologist with a chief complaint of bilateral hearing loss since July 2019, which was gradual in onset. In November 2019, the treating otorhinolaryngologist after managing conservatively and reporting no relief in symptoms referred the case to the medical oncology department of a private hospital in New Delhi. On examination by a medical oncologist, the patient reported the loss of hearing and pain. He complained of pain over the preauricular region, which was described as dull, aching, and bilateral. Pain which used to be on and off and started as mild but gradually increased on rare occasions which got relieved by taking tablet tramadol 50 mg. At the clinic, the patient got investigated, and one small growth was found at the posterior nasopharyngeal wall which was confirmed to be NPC on biopsy. PET scan report shows that the disease is confined to its anatomical site of origin and is not metastasized yet. He was given six cycles of chemotherapy (CT) over a span of 9 weeks. He responded to the treatment and planned for further therapies. Then, the patient was given concurrent chemoradiation. The patient got the last radiotherapy on April 10 and chemotherapy on April 8.
One week later, he developed a low-grade fever which was considered as a complication of chemotherapy. However, when fever continued, he was suspected of corona infection, so he was sent to the COVID-19 testing center where he came negative. Then, the patient developed urinary retention the next day and found to have some growth in urinary bladder and bladder was overflowing according to CT scan. Urinary catheterization tried but failed, so the patient was planned for suprapubic catheterization. Before the procedure, he was again tested for COVID-19, and the report came out to be positive. Plan for suprapubic catheterization was changed and urinary catheterization tried which was successful this time with smaller size catheter (10 F). Then, the patient

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


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

[User]
RADIOLOGY NOTE:
A 27-year-old morbidly obese African American, gravida 1, para 0 female presented during the first trimester of her pregnancy with swelling in the right jaw and loosening of teeth. The patient also complained of localized pain but denied fever, weight loss, and other constitutional symptoms. On examination, there was a tender swelling of the right mandible. A biopsy was performed that showed mixed inflammation with numerous foamy histiocytes suggestive of Rosai-Dorfman disease. A CT scan was subsequently performed to delineate the extent of the disease to rule out nodal disease and other possible areas of involvement. The CT scan demonstrated a lytic lesion involving much of the body of the right side of the mandible, extending into the mentum of the mandible and crossing the midline into the anterior aspect of the left body of the mandible (). The lesion showed avid radiotracer uptake on scintigraphy (). Needle core biopsies were performed of the suspicious lymph nodes, which on histopathologic evaluation showed reactive hyperplasia. The patient subsequently underwent a segmental mandibulectomy.
The gross specimen received in pathology consisted of a 14.0 cm segment of the mandible with teeth number 19-27 and 31-32 (). Teeth 17-18 and 28-30 had been removed previously. The mandible was markedly asymmetric with an enlarged and bulging right lateral portion. Sectioning revealed a gray, soft, focally cystic mass involving two-thirds of the resected segment of the bone. Histologic evaluation showed a locally destructive lesion composed of numerous foamy histiocytes, admixed with lymphocytes, neutrophils, and scattered eosinophils and plasma cells infiltrating into the peri-mandibular soft tissue ().
Some of the histiocytes also demonstrated emperipolesis (). Immunohistochemical stains showed the histiocytes to be positive for CD68 and S100 while negative for CD1a (). The morphology and immunohistochemical profile were consistent with Rosai-Dorfman disease. The concomit

[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 38-year-old male who presented with right chest wall and shoulder pain after a weight lifting injury. The patient was performing a one-rep max bench press when he felt a pop in his right upper arm, accompanied by severe pain. There was no history of anabolic steroid use. He was initially treated with ice and a sling by a trainer and presented to the emergency department for further evaluation. Plain films were negative for fracture or dislocation and the patient was neurovascularly intact, so he was discharged home by ER staff in the sling. He presented to the orthopedic clinic the following day with moderate pain in the chest and arm. He denied numbness and paresthesia. On physical examination, there was a large amount of swelling and ecchymoses throughout the right upper arm extending into the pectoralis major muscle belly. Additionally, there was a large bulge in the anterior chest with loss of contour of the axillary fold (). The patient had full active range of motion of the elbow, wrist, and digits. He was sensory intact throughout the right upper extremity with a 2+ radial pulse. An MRI was scheduled to determine the extent of the injury and to aid in surgical planning. The patient was given oxycodone and valium to alleviate the pain and muscle spasms until surgery, which was scheduled after his MRI. The MRI demonstrated avulsion of the pectoralis major tendon from its insertion on the humerus with retraction as well as strain of the anterior deltoid (Figures and ). He was scheduled for surgery in five days. Two days later, the patient returned to our facility with severe worsening pain in the right upper arm. Intracompartmental pressure readings in the anterior compartment of the arm taken about the midpoint of the biceps at the point of maximal swelling were 37, 39, and 42 mmHg with a diastolic blood pressure of 71 mmHg (). Thus, with a diagnosis of compartment syndrome confirmed, we proceeded to the operating room for an emergency fasci

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


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

[User]
RADIOLOGY NOTE:
The patient is a 16-year-old male without a significant past medical history who was transferred to our institution after a gunshot injury to the right lower extremity. On physical examination, two bullet entry points were evident at the right popliteal fossa and dorsal soft tissues of the distal right leg. Initial radiographs were negative for fractures or dislocation.
Computed tomography angiography (CTA) demonstrated a retained bullet fragment within the popliteal fossa abutting the dorsal aspect of the popliteal artery. An 8 millimeter (mm) soft tissue density abutting the medial aspect of the popliteal artery was also identified, concerning for either a small pseudoaneurysm or short segment intramural hematoma. Streak artifact from the retained bullet precluded adequate assessment of this region. The peroneal artery demonstrated a 10 centimeter (cm) occlusion 2.5 cm distal to its origin but reconstituted distally at the level of the mid-tibia. The anterior and posterior tibial arteries were both normal in appearance and patent. The dorsalis pedis artery was unremarkable. There was subcutaneous emphysema throughout the deep and superficial posterior compartment of the knee and throughout the medial aspect of the leg.
The patient was taken to the interventional radiology suite and a right lower extremity diagnostic runoff angiogram was performed. Initial images obtained with the patient’s leg held in extension demonstrated abrupt cutoff of the popliteal artery immediately adjacent to the bullet fragment (Figure ). We then proceeded to reposition the patient’s right leg in the “frog-leg position”. A second diagnostic runoff angiogram was then performed demonstrating mild short segment narrowing of the popliteal artery immediately adjacent to the bullet fragment but with reconstitution of flow down to the level of the tibial-peroneal trunk (Figure ). The anterior and posterior tibial arteries demonstrated patency on both the extension and frog-leg positions. It was

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


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

[User]
RADIOLOGY NOTE:
A 19-year-old Korean man visited us with large, infiltrated plaques on his right temporal scalp and soft cystic masses on the ear. The lesions had been present since birth and grew slowly over time. Dermatologic examination showed large, brownish infiltrated plaques studded with numerous follicular comedo-like openings and multiple, various-sized subcutaneous cystic masses on the right temporal scalp and ear (). Mature hairs were barely seen on the lesional scalp. The lesions occurred on the right temporal scalp and ear only, and no other cutaneous lesion was observed in the whole body, including the face, trunk, extremities, and oral mucosa. He had no specific history and familial history of tuberous sclerosis. Moreover, laboratorytests including complete blood count, blood chemistry analysis, and urine analysis showed no other abnormality. He underwent incisional biopsy of a subcutaneous cystic mass on his right temporal scalp under the impression of nevus sebaceous (). The incisional biopsy specimen showed variable-sized multifocal cysts packed with keratin and lined by an infundibular epithelium, comedones plugged with keratin, and sebum in the papillomatous epidermis. The amount and thickness of hyalinized, eosinophilic collagen bundles in the papillary dermis had increased markedly and extended into the subcutaneous fat tissues as fibrous stands. Mature sebaceous glands and hair follicles surrounded by variable concentric fibrosis were observed in the mid dermis. Concentric fibrosis as well as perifollicular fibrosis also involved the small and medium vessels (). Masson's trichrome staining confirmed the increased collagen bundles and the variable concentric fibrosis of hair follicles and other skin appendages (). These characteristic histopathologic findings were not consistent with collagen nevus, nevus sebaceous, and other well-known diseases; thus, we concluded a diagnosis of folliculocystic and collagen hamartoma, on the basis of a literature search revea

[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 48-year-old male and had a body weight of 95 kg. He was admitted to the hospital on August 31, 2019 for memory impairment and nonspecific dizziness that persisted for 4 months.
The preoperative laboratory results were normal, and the chest computed tomography (CT) scan showed no evidence of a pathology. Upon examination, the patient was found to be a little drowsy but was able to obey commands. His vital signs at the time of admission were as follows: blood pressure of 104/66 mmHg, pulse rate of 97 beats per minute, respiratory rate of 24 breaths per minute, and temperature of 36.7°C. His Glasgow coma scale score was 15/15. His vital signs were all within normal ranges. The rest of the neurological and respiratory examination findings were found to be unremarkable. A CT scan of the head showed an intraventricular mass attached to the anterior third of the septum pellucidum and Monro's foramen and enlargement of the left lateral ventricles (Figure ). A magnetic resonance image confirmed an intraventricular cystic tumor 1.9 cm in diameter without enhancement with gadolinium (Figure ). Furthermore, active left lateral ventricle hydrocephalus was present. A colloid cyst was considered the primary diagnosis.
With the patient in the supine position and the head turned 10 to 15 degrees to the opposite side, a curvilinear skin incision that was 12 cm long was made around Kocher's point, which was located 1 cm in front of the palpated coronal suture and 3 cm from the midline (along the midpupillary line). A craniotomy that was 5 cm long and 4 cm wide was performed to expose the main part of the middle frontal gyrus. After the cortical surface was coagulated, a soft catheter (Medtronic, Minneapolis, Minnesota, USA, #27703 or 26026) was used for the initial accurate ventricular entry. The catheter was aimed at the ipsilateral

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


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

[User]
RADIOLOGY NOTE:
The case concerns a 16-year-old female patient with single ventricle, pulmonary atresia and malposed great arteries after the Hemi-Fontan procedure and aortic valve homograft implantation between the right atrium and right pulmonary artery. The homograft was closed interventionally, while the left lung was separated and supplied by a Blalock Taussig shunt at the age of 7 years []. Nine years later, this shunt became occluded and the left lung was supplied by collaterals only. The shunt was replaced by an 8 mm Gore-Tex tube graft. After an initial increase in the oxygen saturation from 60% to mid 70%, she developed massive left sided pleural effusions with haemodynamic compromise. It was clear that the left sided shunt was too large. So far the only therapeutic option for patients with pulmonary overcirculation due to an inadequate shunt size has been surgery. However, a seventh surgical intervention was much too risky and undesirable for the patient. The decision was made to place several bare stents into the shunt in order to reduce the internal graft lumen. The procedure was performed under general anaesthesia. An initial angiography confirmed a large 8 mm left shunt (). The shunt was crossed with the JR catheter and Terumo glide wire from the right femoral artery. Then the Cook extra-stiff wire and over it the Mullins long 7 Fr sheath were advanced into the left pulmonary artery. Four Genesis XD stents (Johnson & Johnson, NJ, USA; two 10 mm × 25 mm and two 10 mm × 29 mm) mounted on Opta Pro balloons (Cordis, NJ, USA) were implanted into the Gore-Tex tube one over another. Control angiography confirmed the proper position of the devices (). The day after the procedure oxygen saturation rose from 45% to 60% (with no additional oxygen supply) and transthoracic echocardiogram (TTE) showed an increase in the peak gradient across the shunt from 10

[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 female with symptomatic paroxysmal atrial fibrillation (PAF), statuspost atrial fibrillation ablation, and prior history of breast cancer, statuspost bilateral mastectomy and left lymphadenectomy, presented with diziness and near syncope and was found to have sinus bradycardia. Given her symptomatic sick sinus syndrome (SSS), she was planned for a dual chamber pacemaker implantation.
The placement of a dual chamber pacemaker insertion was attempted from the right side as the patient previously underwent left-sided lymphadenectomy. The right subclavian vein access was obtained and cannulated under fluoroscopy. The right ventricular (RV) lead was advanced attempting to access the right superior vena cava (SVC). While attempting to advance the lead, resistance was encountered and the lead was withdrawn. A venogram was performed revealing the absence of a right SVC with the presence of a persistent left superior vena cava draining into a massively dilated coronary sinus (Figures and ).
The lead could not be advanced into the right ventricle, and as a result, the procedure was aborted and cardiothoracic surgery was consulted for possible epicardial lead placement.
After discussing the potential need for cardiothoracic surgery with the patient, she considered another attempt at transvenous placement of a dual chamber pacemaker with us. After repeated attempts, left subclavian vein access could not be obtained. The venogram revealed stenosis of the left subclavian vein. The decision was made to make an additional attempt from the right subclavian vein utilizing the previous pocket. After successful cannulation of the right subclavian vein, an active fixation lead was advanced through the subclavian vein into the PLSVC through the coronary sinus and then through the tricuspid valve into the right ventricular septum. Following successful right ventricular lead placement, an active fixation bipolar pacing lead was advanced into the right atrium using a straight

[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 man with a history of rectal bleeding for the previous one month was referred to our clinic. He presented bright blood which was not mixed with the stool. The patient who was otherwise healthy, had no previous history of urologic intervention. Digital rectal examination found a firm, round solid submucosa nodule in the anterior rectum, it was 1cm in size and 5cm above the anal verge. After administration, systemic examination showed normal results with normal level of serum cancer embryo antigen (CEA 2.38 ng/ml) and prostate specific antigen (free PSA 0.8 ng/ml, total PSA 2.38 ng/ml). Colonoscopy confirmed the nodule was 1cm in diameter and in the anterior rectum 5cm above the anal verge with an otherwise normal look of the surface rectal mucosa (). Magnetic resonance imaging (MRI) demonstrated a well-circumscribed and submucosa nodule measuring 1cm in diameter at the level of 5cm above the anal verge protrude to the rectal lumen (), with relatively low intensity on T1-weighted images and high intensity on T2-weighted images, however it was enhanced on the contrast imaging. The border between the nodule and the prostate was clear. After the diagnosis for a nodule in the submucosa rectum was made with the clinically suspicious of carcinoid tumor, local excision of the nodule en bloc with 5mm normal mucosa around the nodule and some superficial muscularispropriawas performed.
During the procedure a well-encapsulated round nodule was found in the submucosa. The nodule was 1cm in diameter, and could be separated from the surrounding submucosa tissue. Postoperative days were uneventful, and the patient was discharged on the second postoperative day. Under the microscope, the histologic sections revealed a well-encapsulated nodule of dilated glandular structures. The nodule was full of dilated glandular structures which was located between the severe burnt rectal mucosa and muscularispropria. The dilated glandular structures were surrounded by a dense fib

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


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

[User]
RADIOLOGY NOTE:
A 70 year old woman with a history of B-Cell Chronic Lymphocytic Leukemia (B-CLL) presented with a several week history of progressive right upper extremity weakness and increasing confusion. She had no prior history of cardiac surgery or cardiac abnormalities. Pertinent physical exam findings included a normal cardiac exam and 3/5 strength in the right arm. She was afebrile and her white cell count was at her baseline but markedly elevated (> 170 × 103/μL).
The initial workup was focused on the patient’s neurologic complaints. A brain MRI revealed multiple bilateral rim-enhancing brain lesions with surrounding vasogenic edema. The differential diagnosis included embolic or metastatic lesions, with a high suspicion for metastatic disease given the patient’s presentation and history. Workup for primary malignancy was negative, and the patient subsequently underwent a right craniotomy for biopsy. The resected lesion was found contain necrotic tissue with branching fungal hyphae suggestive of Aspergillus. Tissue cultures revealed Aspergillus Fumigatus species. IV Voraconazole (6 mg/kg every 12 h day 1 then 4 mg/kg every 12 h) and Micafungin (100 mg daily) were started. The Galactomannan assay was positive but all blood cultures were negative. A 2D echocardiogram was performed to evaluate for possible embolic source for the brain abscesses. This revealed a 1.3 × 1.1 cm pedunculated mass in the inferior wall of the left ventricle (Fig. ). There was no evidence of any cardiac dysfunction and the LV ejection fraction was measured at 55%. Cardiac surgery was consulted and the patient underwent median sternotomy with cardiopulmonary bypass for removal of the left ventricular mass using a left atriotomy incision. The mitral valve was first inspected through the atriotomy incision and demonstrated no vegetations. Subsequently, a retractor was placed through the mitral valve and the left ventricular mass was easily identified. A 1 cm soft, smooth appearing mass was found adhere

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


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

[User]
RADIOLOGY NOTE:
A 51-year-old male with Hepatitis C cirrhosis and hepatocellular carcinoma underwent piggyback orthotopic liver transplantation (OLT). During the immediate postoperative period, the patient had typical recovery with postoperative sonographic interrogation demonstrating expected perioperative edema. Increased velocities were reported near the inferior vena and portal veins which resolved with improving perioperative edema. No additional vascular compromise was identified in the immediate postoperative period.
The patient presented 4 weeks following OLT with shortness of breath and was found to have bilateral pleural effusions, recurrent ascites, and acute renal insufficiency. The findings were all assumed to be related to OLT vascular compromise. Thoracentesis and paracentesis (3 liters of ascitic fluid drained) were performed, and the following day ultrasound and Doppler imaging were performed to evaluate the hepatic vasculature. This revealed mild ascites without evidence of hepatic vascular compromise. Clinically, the patient demonstrated no improvement and had additional paracentesis 3 days following admission in which 5 liters of ascitic fluid was drained. On the 10th day following admission, laparoscopic exploration of the abdomen with liver biopsy and lysis of adhesions was performed. The liver biopsy revealed sinusoidal congestion without evidence of hepatic graft rejection or malignancy. On the 13th day following admission, repeat ultrasound with Doppler imaging demonstrated severe stenosis of the intrahepatic vena cava, portal hypertension, and perihepatic ascites. The stenosis was shown to be worse in the supine position.
The following day, inferior vena cavagram was performed demonstrating high grade intrahepatic IVC stenosis with extensive collateral flow through the azygous system and thoracolumbar venous plexus ().
The pressure gradient across the stenosis measured 11 mm Hg. The stenosis was sequentially dilated with a 12 mm × 40 mm Conquest balloon (C

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


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

[User]
RADIOLOGY NOTE:
A 41-year-old woman, G1P0, had a DD (dichorionic-diamniotic) twin pregnancy by in vitro fertilization after 2 years of treatment for primary infertility. She had a history of cervical conization for adenocarcinoma in situ. At 20 weeks of gestation, she visited our hospital with a complaint of abnormal bleeding from her vagina. We found abnormal development of cervical varix by vaginal ultrasound and the bleeding seemed to be caused by varix. We performed vaginal gauze packing for hemostasis and the bleeding was decreased for a week. We performed a cervical pap test at that time and the result was negative for intraepithelial lesion or malignancy (NILM). However, at 21 weeks of gestation, massive bleeding occurred and the amount of bleeding reached almost 800 g. We recommended surgical hemostasis or termination of the pregnancy, but she refused both opinions because of the risks of the surgery, including infection and premature rupture of the membrane, and she wished to have further preservative treatment. Therefore, we added vaginal gauze packing once more and observed her with the administration of blood transfusion. However, the bleeding persisted and the amount of bleeding gradually increased. The total amount of bleeding reached about 2000 g at 22 weeks of gestation. We informed her that the bleeding was becoming life-threatening and that we must perform surgical treatment or termination of the pregnancy. She and her husband finally accepted to try surgical hemostasis by cervical cerclage.
Under spinal anesthesia, we detected two bleeding points on the surface of the cervix caused by rupture of cervical varix, the findings of a developed varix by vaginal ultrasound seemed to be match the bleeding points []. We gently held the cervix with the varix using segond uterine forceps and performed the first cerclage by the usual McDonald cerclage method using Teflon tape, enclosing the ruptured points of the varix. However, the bleeding only decreased slightly after the

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


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

[User]
RADIOLOGY NOTE:
A 57-year-old woman with diabetes and hypertension presented to our hospital complaining of severe right upper quadrant pain and vomiting. She reported having an elective open cholecystectomy done seven years before and noted that the symptoms she now experienced were similar. She had been hospitalized six times in the preceding two years for similar episodes. Although abdominal ultrasounds were done on these occasions, the emergency room physicians did not entertain the possibility of a stump cholecystitis because the patient insisted that her gallbladder had already been removed. Operative notes were not available but she reported that the operation was uncomplicated and she was discharged 72 hours after open surgery.
Upper gastrointestinal studies excluded the presence of upper gastrointestinal pathology. Liver function panel and serum amylase levels were normal. Abdominal ultrasound suggested that stones were present in a thick walled gallbladder.
The patient's history was revisited on this presentation. She insisted that open cholecystectomy was performed seven years before and there was a surgical scar at the right upper quadrant, but no operative records or histology reports were available to corroborate the surgical history. Once the symptomatology resolved, the patient was discharged with a request for magnetic resonance cholangiography (MRCP) from another institution. This confirmed the presence of a gallbladder remnant with normal biliary anatomy. There was no evidence of choledocholithiasis ().
She was prepared for general anaesthesia and taken to the operating theatre for laparoscopic completion cholecystectomy. Laparoscopic shears were used to perform adhesiolysis in order to visualize the structures in the right upper quadrant. There were dense adhesions at gallbladder bed precluding clear visualization of relevant anatomy (). Careful and patient dissection with the cautery hook eventually presented the gallbladder remnant (). The remnant was followed

[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 with long-standing hepatitis C virus related cirrhosis, and advanced HCC with portal vein (PV) invasion, diagnosed two months prior to presentation by CT scan and core needle biopsy, was evaluated in the emergency department for dizziness, incoherent speech, agitation, and diaphoresis after completing bowel preparation and fasting for colonoscopy. The patient was initially found to have a blood glucose level of 22 mg/dL, which corrected to normal limits after administration of dextrose. The patient was discharged from the emergency department in stable condition; however on presentation for endoscopy later that day the patient complained of visual changes and was noted to have slurred speech. Blood glucose at that time was 20 mg/dl and the patient was admitted for further evaluation and management of severe hypoglycemia. The patient was treated with continuous dextrose 10% infusion with titration and high carbohydrate diet; however symptomatic fasting hypoglycemia persisted requiring frequent IV dextrose 50% pushes. Insulin level was 0.37 mcIU/mL and the C-peptide level was 0 ng/mL, suggesting a non-islet cell etiology. Surreptitious insulin use was excluded with regular monitoring. His home medications of Tramadol and Lexapro were discontinued on admission due to their potential for hypoglycemia. Adrenal insufficiency was excluded with cortisol stimulation test and a pancreatic protocol CT of the abdomen showed no pancreatic mass. There were no signs or symptoms of sepsis to suggest infectious etiology of this patient's hypoglycemia and infectious workup, including urinalysis, stool culture, and chest X-ray, was negative. Diagnostic paracentesis was not possible due to negligible ascites accumulation. The patient was subsequently started on daily oral prednisolone, with some improvement in the severity of hypoglycemia; however due to frequent episodes of hypoglycemia, continuous dextrose could not be discontinued. A trial of octreotide at 25 mcg/

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


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

[User]
RADIOLOGY NOTE:
A 41-year-old male was admitted to our hospital because of progressive pain and discomfort during swallowing. His past medical history was characterized by surgery for clival giant cell tumor complicated by ICA rupture 10 years ago. Indeed, in 2008, the patient was operated on by a fully endoscopic neuronavigation-guided EEA [, , , , , , , , , , ]. Thanks to the working angle and the better visualization offered by the EEA, we were able to maximize the tumor resection preserving at the same time craniovertebral junction stability and avoiding posterior fixation with his relative complications [, , , , , , , , ]. Indeed, the lesion was completely removed, but during the drilling of the surrounding healthy bone, there was a little tearing of the left ICA. Local control of the bleeding was challenging, but it was obtained by using topic hemostatic agents and balloon catheter for nasal tamponade. Immediately after surgery, the patient underwent angiography disclosing a pseudoaneurysm originating near the inferior meningohypophyseal trunk, which was successfully treated by embolization with coils (Fig. ). After 2 days of intensive care unit stay, the patient was transferred to our department, showing no neurological deficit and no signs of CSF leak or other CSF disturbances [, , ]. The nasal tamponade was removed 4 days after surgery, and no bleeding was observed coming out from the nasal cavity. The patient was dismissed and sent home 1 week later. Histologic evaluation of surgical specimens revealed the aspect of a giant cell tumor with no infiltration of the surrounding bone [].
Radiation therapy was not performed. Brain magnetic resonance imaging with angiographic sequences was done regularly 3, 6, and 12 months after surgery in the first year and every 6 months for a further 2 years, then annually for a further 5 years. All these examinations showed no tumor recurrence or pseudoaneurysm repermeabilization.
For the presence of pain and discomfort during swallowing, 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 66-year old man, who had been a heavy smoker for longer than 30 years, had a remote history of hypertension, hypothyroidism, and repeated surgical procedures (laparotomic surgery for appendicitis at 29, L5-S1 laminectomy at 44 and right hip surgery at 60). At the age of 65 he was diagnosed with a cancer in the sigmoid-rectum (pT3 pN1a adenocarcinoma) and underwent laparoscopic left hemicolectomy. Two days after the intervention, stump dehiscence required further laparotomic surgery. The clinical course was then complicated by bowel obstruction and sclerosing peritonitis which had to be surgically treated 20 and 32 days after the first surgery. During the latter procedure, the microbiological analysis of the surgical wound indicated the presence of a MRSA, and intravenous meropenem 3g/day was started. On day 35 since the first intervention, another surgery was needed because of the development of hemoperitoneum. The patient received repeated transfusions because of the worsening anemia. On day 48 he started developing a renal failure, which eventually required a kidney biopsy leading to the diagnosis of IgA nephropathy. The clinical conditions worsened during the following nine weeks, with fever up to 38.6°C and blood cultural examination positive for MRSA. He was treated with ceftriaxone, and then with methylprednisolon 40mg/day for 3 days. Up to this moment he had never had either neurological or psychiatric symptoms; some days later, however, he became anxious and restless and had a relapse of mild fever. He did not complain of headache and showed psychomotor retardation with preserved orientation and without any significant consciousness impairment. A neurologic consultation indicated an amimic face with bilateral myosis and reduced blinking. A preexisting and already known mild postural tremor was accompanied by almost continuous stereotyped limb movements, generalized weakness and suction-like mouth dyskinesias; no signs of meningeal irritation were found. 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:
In May 2008, a 39-year-old man visited Wonkwang Dental Hospital in the city of Daejeon with pain in the anterior region of the mandible originating several months earlier. Intraoral examination revealed a slight gingival swelling and mobility of the mandibular anterior teeth. The past history of the patient was not contributory. There was no cervical or axillary lymphadenopathy. A panoramic radiograph showed an ovoid shaped, unilocular radiolucent lesion with a well-defined margin in the alveolar bone from the left lower lateral incisor to the right lower canine, with involvement of the apices of the mandibular incisors (). An intraoral radiograph revealed that the border of the lesion was non-corticated with beveled edges. The distal part of the right lower lateral incisor showed a typical floating tooth appearance. However, there was no tooth displacement and no root resorption (). The patient underwent root canal treatments of the mandibular left central incisor and right canine for his dental pain (). However, the pain did not subside, and the patient was referred to our department. We suspected an aggressive lesion rather than a cystic lesion due to the non-corticated border and floating tooth appearance. A biopsy of the mandibular anterior lesion was performed, and the patient was diagnosed with eosinophilic granuloma.
About one month later, Cone beam Computed Tomography (CBCT), magnetic resonance (MR) imaging, and whole body bone scintigraphy with a Tc-99m MDP were performed at the dental hospital of Wonkwang University and the medical hospital of Eulgi University in the city of Daejeon. An axial CT showed destruction of the buccal and lingual cortex and a focal bony destructive lesion in the anterior mandible (). An MR image showed a focal high signal intense lesion in the left femur trochanter with adjacent bone marrow edema (). Bone scintigraphy revealed that there was no uptake of radiotracer in the trochanteric portion of the left femur on the initial st

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


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

[User]
RADIOLOGY NOTE:
A 10-year-old male patient reported to the dental clinic with the chief complaint of broken upper left front tooth associated with pain and sensitivity. A detailed history revealed the etiology as a fall from stairs 24 h back. The fractured tooth fragment was retrieved by the patient's mother from the site of injury and was stored in water. Medical history and other events associated with injury were noncontributory. Intraoral clinical examination revealed that maxillary left central incisor had undergone complicated horizontal crown fracture in the cervical one-third []. Palatally, the fracture line was oblique. The fracture fragment was intact, and it was approximating optimally with the remaining tooth structure []. The fragment was transferred to normal saline immediately to prevent dehydration. No mobility was noted in the fractured tooth. An intraoral periapical radiograph was advised to evaluate the extent of the fracture, the root status and to rule out an alveolar bone fracture. The fracture line was passing through the coronal pulp with the open root apex and without any alveolar bone fracture. Electric and thermal pulp testing were performed to evaluate the pulp vitality of all the upper anterior teeth, and the result was negative only on tooth number 21 whereas, all the adjacent teeth displayed a normal response. Hence, the diagnosis was established as Ellis Class III fracture with an open apex.
A treatment plan was formulated which included apexification with mineral trioxide aggregate (MTA) followed by root canal treatment and either composite build up or reattachment of the fragment using fiber post. Parental informed consent was obtained after explaining the advantages and disadvantages of composite resin build versus reattachment. Since esthetics was the prime concern, fragment reattachment was considered as the best option. The fracture fragment was cleaned and rinsed with 2% chlorhexidine solution and lightly air-dried. Under local anesthesia, roo

[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-day-old male infant born of full-term normal vaginal delivery was referred to our Tertiary Care Eye Hospital in South India for an eye check-up. The infant was the second born of a third degree consanguineous marriage. There was no family history of anyone born with similar eye and skin problems or cleft lip/palate.
On examination, the right eye had a thin band of tissue 1 mm wide and 6 mm long, stretching from the gray line of the medial part of the upper lid and attached to the medial aspect of the lower eyelid inferiorly. The lower eyelid also had notches along its margin, which appeared as freshly de-epithelized lesions []. The band did not restrict the eye from opening []. The palpebral fissure was equally wide bilaterally. Meibomian gland orifices were present. There was no swelling over the lacrimal sac area and no regurgitation of fluid on pressure over the lacrimal sac, suggesting that there was no nasolacrimal duct obstruction. The anterior and posterior segments of the eye were well visualized and did not show any abnormalities. The left eye did not show any band joining the lids, but both upper and lower lid margins showed notching similar to the right eye []. The anterior and posterior segments of the left eye were normal.
The infant had multiple patches of hypopigmentation of the skin over all the four limbs [Figs. and ]. The skin over the face, however, appeared normal. There were no skin erosions over the scalp or elsewhere. There was no cleft lip or palate. There were no structural limb abnormalities and no syndactyly. There were no obvious nail lesions. The child was feeding and thriving well.
Although an initial neonatal checkup by the referring doctor did not reveal any systemic abnormalities, the infant was referred to the pediatrician to specifically rule out cardiac, genitourinary, neurological, and odontological abnormalities and advised to review with us. A simple division of the

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


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

[User]
RADIOLOGY NOTE:
A 3-month-old female child was seen by one of us (SV) in a multi-specialty hospital upon the request of the pediatrician. She was born after a normal full-term vaginal delivery and had no history of consanguinity in her parents. The child was thought to have hemorrhoids with a large hemangioma in the perineal area present since birth. Upon examination the child had a skin-colored perianal protrusion that was clearly located posterior to the anus []. There was in addition a large midline hemangioma that started from the gluteal cleft all the way to the medial root of the thigh skirting around the vulva []. The presence of inflammation around the pyramidal protrusion could not be assessed because of the presence of the large hemangioma. The parents said the child was born with a ‘red patch’ in the area of the hemangioma which evolved over the past 3 months into a hemangiomatous red plaque. The child also had a large hemangioma on the contralateral side of the face with involvement of the lower lip []. There were no neurological complaints. There were also small hemangiomas found on the ventral aspect of the left forearm and dorsum of the left foot. The hemangiomas were explained in detail to the parents and they decided not to give any oral corticosteroid for the perineal hemangiomas and rather wait for a year. A head and neck as well as spine X-ray was performed that did not show any abnormality. CT scan/MRI was refused by patient's parents due to cost factor. A referral was made to the pediatric surgeon for biopsy of the pyramidal lesion which they refused. A provisional diagnosis of large perineal hemangioma with a perianal skin tag was made. The large facial segmental hemangioma was thought to be Sturge-Weber syndrome with no clinical evidence of internal involvement. The patient was prescribed topical clobetasol cream under monthly supervision after which the lesion had flattened a little and showed a whitish area with pronounced flattening.

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


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

[User]
RADIOLOGY NOTE:
A 22-year-old male presented to our institution's emergency room with decreased hearing on the right side, ataxia, nausea, and vomiting. On physical examination, an occipital painless subcutaneous mass was noted and audiogram revealed non-serviceable hearing on the right side. A magnetic resonance image (MRI) of brain with contrast demonstrated two separate lesions with similar signal characteristics. A subcutaneous occipital mass measuring 4.8 × 2.9 × 4.1 cm was noted as well as an intradural extraxial 2.6 × 2 × 5.2 cm CP angle mass. There was extension of the CP angle mass into the enlarged jugular foramen and invasion of the internal jugular vein. Both lesions were T1 hyperintense enhancing lesions with a mixed iso and hypointense signal on T2 [Figures and ]. A cerebral angiogram confirmed obstruction of the right sigmoid sinus and jugular vein at the level of the jugular foramen with recanalization distally []. Imaging of the spine by MRI did not reveal other lesions.
Surgical resection of the two lesions was performed at our institution. The posterior fossa mass was approached through a right translabyrinthine approach and the subcutaneous lesion was resected in the same setting with a separate incision. Electrophysiologic monitoring with cranial nerve monitoring was performed. The extracranial lesion was resected first and did not show any continuity to the intracranial lesion.
A posterior petrosal translabyrinthine approach was utilized for the intracranial lesion which permitted presigmoid access as well as exposure of the sigmoid sinus and jugular bulb. The dura showed extensive patchy areas of melanocytic coloration over the entirety of the surgical exposure. The intradural lesion was readily visible with invasion of the sigmoid sinus. The sigmoid sinus was opened and found to be occluded with tumor. The sinus was ligated on either side of the tumor invasion and sacrificed. The mass was debulked using a combination of ultrasonic aspiration and suction. The

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


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

[User]
RADIOLOGY NOTE:
This 41-week-gestation male was born to a 30-yr-old mother with good health by normal spontaneous vaginal delivery in November 2009. His birth weight was 3,140 gm. There was no maternal complication during pregnancy. There was neither family history of congenital anomalies nor maternal exposure to drugs during pregnancy. The baby had APGAR scores of 7 and 5 at 1 and 5 min, respectively. He needed positive pressure ventilation with intubation because of progressive respiratory difficulties and hypoxia. The baby was immediately transferred to our hospital for further evaluation and management after stabilization.
The physical examination and laboratory findings for the baby were unremarkable on admission. He had the surfactant replacement therapy for acute respiratory failure. For the next few days, we tried extubation several times, but failed to succeed because the baby suffered from recurrent apnea and hypercarbia leading to the clinical suspicious of CCHS. On day 8 of life, a cranial ultrasound study was performed and it did not show evidence of hemorrhage or mass lesions.
During the second day of life, it was noted that the patient had distended abdomen and was unable to pass meconium without rectal stimulation. A gastrografin contrast enema study showed multiple meconium plugs in the colon suggesting meconium plug syndrome (). Meconium was passed and abdominal distension was relieved after contrast study. On day 6 of life, he showed sustained abdominal distension with poor bowel movement. A barium contrast enema study was needed to rule out other causes of lower gastrointestinal obstruction. It showed a transition zone in rectosigmoid colon suggesting HD. The diagnosis was confirmed by rectal suction biopsy with acetylcholinesterase immunohistochemistry (). The infant underwent an open laparotomy on day 12. He was noted to have long segment HD with a transition zone at mid descending colon. Seromuscular biopsies of the bowel taken 3cm proximal and distal to the

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


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

[User]
RADIOLOGY NOTE:
A 72-year-old woman was referred to our hospital with pancreatic head and neck carcinoma for more evaluations and surgical operation. She had been suffering from abdominal pain for about 1 year, and the pain has become more intense in the last 6 months. The pain was postprandial and localized to the right upper abdomen. She has become icteric with generalized spread plus itching since past 2 months. The patient had no history of alcohol consumption or smoking. The patient was referred to us with a highly probable diagnosis of pancreatic head and neck carcinoma to be consulted for surgery. Also, a plastic stent was implanted for her in the previous health center due to intra- and extrahepatic duct dilation for the relief of patient symptoms and signs. After admission to our hospital, she was evaluated by abdominal computed tomography (CT), endosonographic imaging, and diagnostic ampullary biopsy. The abdominal CT scan with contrast exhibited an 18 mm × 20 mm hypodense mass at the head and neck of the pancreas (). Also, endosonographic imaging was performed to rule out periampullary lesions (). A 20 mm × 19 mm lesion was seen in the pancreatic head and neck region, and the main pancreatic duct was slightly dilated in the body of the pancreas. Moreover, the common bile duct (CBD) was distally thickened and contained sludge. Subsequently, diagnostic biopsy for pathological assessment was done. The biopsy revealed an irregular gray-creamy soft tissue which had undifferentiated malignant tumor features at microscopic evaluations. During the Whipple procedure, after cutting the neck of the pancreas in the left side of the portal vein, the frozen section revealed more involvement of pancreatic tissue. Although additional 2 cm was resected, the pancreas residue still had tumor involvement, macroscopically. Therefore, the patient was undergone total pancreatectomy.
Postoperative pathological studies were established and indicated a tumor with the greatest dimension of 4 cm wh

[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 present case is a 40 year old male patient presented to us with a swelling of the right knee joint of one duration, associated with pain and inability to bear weight on the limb for the past 2 months. He was investigated with radiographs []. The radiographs reveal a geographic pattern of Ludloff’s type 1, with a breach in the posterior cortex. The patient was evaluated for the fitness for anesthesia and for the surgical procedure. We had taken an anteromedial approach to the knee joint. A radical (wide) excision of the tumor was done taking care of avoiding macroscopic spillage of the tumor mass in the operating field. Then the patella was enucleated without disturbing the extensor mechanism of the Quadriceps. Then the ipsilateral Fibula was excised and cut into two struts. The Patella was cut into two fragments. The articular surfaces of the patellar fragments were facing the both condyles of the femur and supported by two Fibular struts vide in []. Thus the joint was reconstructed and the whole construct was stabilized with multiple K wires, a cortical screw and the Quadriceps mechanism was retained by fixing the Patellar tendon to the nearby bone and the limb was immobilized in a plaster of Paris splint. The post op period was uneventful. The plaster was removed after the radiological union was evident and allowed range of movements as much as possible. After a period of one year there was a fracture of lateral Fibular strut which was again re-enforced by one more Fibular strut and followed the same post-op protocol as before. During the follow up period of about 15 years there was good consolidation of the Fibular struts and a reasonably good joint preservation as evident in the post op clinical photographs, video Fig no. & , and the clinical video, vide video no.1r

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


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

[User]
RADIOLOGY NOTE:
A six and half year old boy referred to us from another center had complaints of an insidious onset of pain in his right forearm, which initially was less intense. The parents ignored it initially thinking it might be due to his excessive playful nature and cycling. They had a delay of three and half months to consult a doctor in their town when the child complained of an increasing pain. In the meantime, there appeared some swelling in his forearm, which was gradually progressing. A X-ray was done () which revealed an expansile lytic lesion in the proximal half of the radius. He was initially kept under observation and was then referred to a higher center. A repeat X-ray was done, which revealed an expansile lytic lesion involving the proximal half of the radius. On comparing the previous X-rays (), it was seen that the lesion had significantly increased in size with thinning of the cortex rendering it difficult to decide the treatment options. As per the protocol, an MRI was done (–) which revealed low to intermediate signal intensity with a rim of low signal intensity with internal septa. A bone biopsy was done which after radiological correlation was confirmed to be a case of aneurysmal bone cyst.
The tumor was expansile with papery thin cortices and hence was not amenable to curettage. It was decided to do wide resection of the tumor. Reconstruction of the radius following tumor resection can be done with different techniques. First to use child’s own fibula may be considered as vascularized or nonvascularized pattern. Second, the cadaveric allograft. Third, an allogenic allograft from the mother. The parents were informed regarding all the options for reconstructing the radius following excision of the tumor. We were a bit concerned with regard to the diameter of child’s own fibula to be used with the radius because of the possible size mismatch as well as the surgical trauma at two sites. The parents were reluctant to use the allograft stored in the

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


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

[User]
RADIOLOGY NOTE:
We present the case of a 75-year-old male whom initially presented to our service with a mass on his right upper back. The patient's medical history included coronary artery disease and hyperlipidemia. Further history revealed he had received (2) stents in the past and undergone multiple heart catheterizations (up to seven) approximately seven years prior at an outside facility. During his last catheterization and stent procedure, which took over 4 hours (approx. 33 mSv), he developed a radiation-induced injury to his right back around the T10 dermatome (). During the following years, the burn was closely followed at an outside facility, and the area developed a chronic nonhealing ulcer which continued to evolve over time eventually growing outward from his back and developing a foul odor on his presentation to our facility in 2017. He reported increasing pain at the periphery of the tumor margin. Up to a year prior to presentation, the area was flat and biopsies revealed no evidence of malignancy. Upon presentation to us, however, the physical exam demonstrated a fungating mass approximately 5 × 9 cm with central purulent necrosis and induration surrounding the periphery (Figures –). No additional nodularity or adenopathy was found on physical exam initially. At this time, punch biopsies demonstrated undifferentiated pleomorphic sarcoma along with frankly necrotic debris.
Initial staging showed only localized disease by MRI with no evidence of metastasis by CT scan (Figures and ). Approximately one month following diagnosis, the patient underwent a radical excision with a 20 × 9 cm elliptical excision of the site. In this case, the patient chose human dermal matrix reconstruction, as primary closure was not possible due to the size of the site. Our patient did not want an additional wound of autologous skin procurement.
Pathology of histologic sections revealed a highly cellular spindle cell neoplasm. Focal areas of necrosis comprised less than 50% of sampled tissu

[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 Sinhalese male patient presented to our clinic with a complaint of difficulty in swallowing and speaking due to a large growth on the dorsum of his tongue. It had been present from birth and had gradually enlarged over time. Due to the prevailing civil war in the country for over 30 years, he has had limited access to an Oral and Maxillofacial Surgery care during the past years and had been forced to live with this deformity. Though painless, the swelling affected his speech as his articulation was altered. In addition, the lump on his tongue caused difficulty in forming a food bolus and swallowing it, while the bifid tongue affected the cleansing of his mouth. The appearance of the abnormal shape of his tongue had harshly influenced his social life and he was subjected to bullying. He was nonsyndromic, and no other congenital anomalies were detected. On local examination, an asymmetrically bifid tongue involving the left side was noted. A large, firm, pink, nontender tissue mass was seen at the center of the tongue [].
A lingual thyroid was suspected initially, but the iodine scan showed normal functioning of the thyroid tissue in the anterior neck. Interestingly, iodine was noted to collect in the tongue mass as well, and thereby suggesting salivary/thyroid origin. The patient was otherwise healthy. The treatment plan was the complete removal of the growth and correction of the bifid tongue by closing the primary (or primarily closing it) under general anesthesia []. No intraoperative complications were encountered, and full function of the tongue was preserved. The excised growth was sent for histopathological examination. Two weeks later, the patient was followed up in the speech clinic to assist in speech and swallowing. The histopathology reported that the mass was predominantly mucous salivary tissue. It showed both mixed and mucous lobules, and the histological diagnosis was a salivary hamartoma. The patient had no recurrences at 1-year follow-

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


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

[User]
RADIOLOGY NOTE:
A 68-year-old male presented to the head and neck clinic with history of a progressive midline lower neck swelling which appeared suddenly, increased in size progressively and became prominent over 6 weeks. On examination, the swelling was about 5 × 2 cm in size, mobile and not adherent to the skin or underlying structures. The swelling was not prominent on tongue protuberance. Thyroid was impalpable and patient was clinically euthyroid with no evident Grave's disease features. It was neither associated with fever nor any other constitutional symptoms. His pressure symptom includes mild dysphagia to solids which compelled him to visit our hospital, but he did not encounter any respiratory complaint.
Patient was not on any anticoagulants, but he was taking regular medications for diabetes and hypertension for many years.
For treatment decision, the patient was referred to radiology department. Ultrasound neck showed a large well defined thin-walled cystic neck lesion measuring about 5.1 × 2.6 cm (transverse x anteroposterior). There was no appreciable internal septation or solid tissue in it (). No hypervascularity was noted within or periphery of the lesion (). The internal content of the cyst was of 2 types, basal part was homogenously low echogenic with curved upper border while rest of the part was filled up with anechoic fluid (). Few tiny echogenic foci were also seen in its low echogenic part which were not giving any comet tail artifact to be confidently called as colloid content (). Thyroid gland was not easily visible due to lateral push by this large cyst. Thyroid isthmus was hardly visible clearly. Lobes were found to be normal, but their echotexture was heterogenous and micronodular with normal vascularity and intact echogenicity. According to the location and content of cyst, the closest sonographic differential in our patient was thyroglossal cyst, but it is usually smaller in size, moves with tongue protrusion and more cranial in position. Other diffe

[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 four-year-old Japanese girl with no remarkable medical history was referred to our orthopedic clinic for treatment of 2 cm of LLD. She had a two-year history of progressive LM in a wide range of the posteromedial aspect of the right thigh and the medial aspect of the right lower leg. At the first presentation, skin lesions exhibited hyperpigmentation, induration, and xerosis. The range of motion of the right knee was full extension to 80° of flexion. Radiographs of the right lower extremity revealed dysplastic/atrophic femur and tibia. LLD increased with time and reached nearly 10 cm at seven years of age (). As she and her parents refused to undergo epiphysiodesis of the unaffected side of the lower extremity, we performed simultaneous lengthening of the right femur and tibia using a unilateral external fixator (EBI/Zimmer Biomet Carbon Rail Deformity System; Warsaw, Indiana, USA). She had taken low-dose prednisolone every day or every second day prior to the first lengthening procedure. The dosage regimen had been dependent on the disease activity based on clinical and thermographic assessment. Tibial osteotomy was performed with the Gigli saw, whereas femoral osteotomy was done with a multiple drilling technique. No postoperative immobilization was used, and full-weight bearing was encouraged from the second postoperative day. After 14 days of the waiting period, distraction of the femur and tibia was commenced at a rate of 1 mm and 0.5 mm per day, respectively. Femur was lengthened at the same rate throughout the distraction period, whereas the distraction speed of the tibia was gradually decreased after the lengthening callus showed thin and sparse on radiographs. Distraction of the tibia was occasionally interrupted until the callus width and continuity were reestablished. As a result, the lengthening period/amount of lengthening of the femur and tibia were 90 days/83 mm and 163 days/37 mm, respectively, and an overall leg length was 7

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


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

[User]
RADIOLOGY NOTE:
A 31-year-old female patient underwent left hepatectomy for an enlarging focal nodular hyperplasia tumor in April 2015. The diagnosis was confirmed by magnetic resonance imaging, which clearly showed typical features of focal nodular hyperplasia. Nevertheless, the patient was accepted for surgery due to the significant growth of the tumor (up to 6 cm in diameter) which doubled its size within 2 years. Following surgery, the patient presented with increasing jaundice (bilirubin of 9 mg/dl on day 7.) and abdominal pain with vomiting. Abdominal ultrasound confirmed a large fluid collection that was adjacent to the liver transection plane and proved to be bilious in origin at percutaneous drainage. A drain was left inside the collection and a biliary leak of around 300–600 ml/daily continued. At endoscopic retrograde cholangiography (ERC) which was performed twice, a slight leak combined with poor filling of the intrahepatic bile ducts was shown. At that time we believed the compromised filling of the intrahepatic bile ducts was due to the narrowing at the confluence. The common bile duct was stented endoscopically with a plastic (8.5 Fr) stent (day 8.) and as the leak continued, a self-expandable metallic stent (day 15.) was inserted. A few hours following the second ERC procedure, the patient presented with sudden abdominal pain, hypotension and a drop in hemoglobin from 12.2 to 6.6 mg/l due to a splenic rupture that was confirmed by the CT scan. An emergent relaparotomy was performed. During surgery, the patient required blood transfusion with inotropic support and her condition was unstable. In view of this, surgery was limited to splenectomy, abdominal lavage and drainage. Considering dense adhesions within the hepatoduodenal ligament and no obvious source of a biliary leak visible, no intraoperative investigations of the biliary tree were pursued. Following splenectomy the condition of the patient improved, however the biliary leak persisted. At this stage, it was

[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 42-year-old African-American male with no significant past medical history who was admitted for increasing right knee pain over a period of three weeks. The patient had no history of trauma to the area but reported hitting it with a "pan" at work, as he works as a chef. The pain was not radiating and was moderate to severe in intensity. He had been taking nonsteroidal anti-inflammatory drugs (NSAIDs) for pain with minimal improvement and could not bear weight on the right knee due to pain.
The patient denied any history of sexually transmitted diseases (STDs), recent infection, travel, or sick contacts. The patient has lived in Illinois his entire life and has not seen a doctor in over 20 years. His social history was significant for smoking half a pack of cigarettes daily, occasional marijuana use, and alcohol use in the past. There was no history of intravenous (IV) drug use.
On physical examination, the patient's vital signs were stable. His right knee was swollen and tender to the touch with swelling in the medial aspect of the proximal tibia. There were no cuts, abrasions, or signs of obvious trauma locally. The knee had a limited range of motion with pain on movement. Ligament laxity was not assessed because of the discomfort the patient was in.
His labs showed elevated inflammatory markers. His C-reactive protein was 205.8 (normal: < 3 mg/L) and the erythrocyte sedimentation rate was 101 (range: 1 to 13 mm/hr). His white blood cell count was within normal limits.
X-ray of the right knee showed no bony abnormality (Figure ).
Computed tomography (CT) of the right knee demonstrated two positive findings: 1) prominent soft tissue swelling adjacent to the lateral aspect of the proximal tibial metaphysis with some associated underlying cortical irregularity of the tibia at this location. The findings were suspicious for a soft tissue infection with resultant

[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 12-year-old male who had his first seizure attack at the age of 10, and had four types of epileptic seizures. The first type of seizure was tonic axial seizures characterized by flexion of the neck and body and the extension of four extremities for several seconds. The tonic seizures could last several seconds. This type of seizure occurred predominantly at night and the frequency was about 4–5 times per week. The second type was atypical absence seizures, which manifested as a sudden loss of consciousness and the resuming of normal activity right after the seizure. This type of seizure could last about 15 s and the frequency was 4–5 times per week. The third type was the myoclonic seizure, presented as prominent myoclonic jerks of bilateral upper limbs. The frequency of this type of seizures was 2–3 times per day. The last type of seizure was the generalized tonic-clonic seizure, which could last about 5 min. The mean frequency of this type of seizure was <1 time per week.
The patient was a full-term infant with no history of perinatal asphyxia, head injury, encephalitis, and febrile convulsions. His family history was unremarkable. He had a mild degree of intellectual impairment and learning disability after the onset of the disease. The physical examinations were normal. Auxiliary examinations, including blood routine examination, serum biochemical examination, thyroid function, autoimmunity antibody, and blood ammonia, were normal. The electrocardiogram was normal and the QT interval (QTc) was 372 ms. There was no lesion on the brain MRI. The Wechsler Intelligence Scale showed a borderline cognition impairment. The electroencephalogram (EEG) before treatment showed that there was a large number of 3 to 5 Hz slow waves with middle and high amplitude in the anterior region in the background. Fast rhythms bursts of 16 to 20 Hz and multiple-spike-and-slow-waves of 0.5 to 1 Hz were observed during the sleep period. 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 38-year-old female with history of NF-1 (diagnosed at the age of 13) presented to the emergency with right upper-quadrant abdominal pain, progressively worsening over the last 48 hours and associated with nausea and recurrent vomiting. Her vitals at the time of presentation included blood pressure of 224/133 and pulse of 98/min. Apart from typical features of NF-1 (café au lait spots and neurofibromas), the only significant examination findings were signs of dehydration and tenderness in the right upper quadrant of the abdomen. On questioning, she confirmed being diagnosed with hypertension 5 years back but was non-compliant to her medications as none helped improved her BP. She denied being investigated for secondary hypertension while the last anti-hypertensive prescribed to her was labetalol. It is possible if she had been compliant, she may have been diagnosed earlier. Due to concerns for high blood pressure and suspected cholecystitis, she was admitted to ICU for further management. Apart from leukocytosis of 19,000, the rest of her blood workup including bilirubin, liver enzymes and lipase was unremarkable while electrocardiogram had no acute changes. An urgent ultrasound of the abdomen showed cholelithiasis along with pericholecystic fluid suggestive of acute cholecystitis which was confirmed on CT abdomen/pelvis with contrast. She was immediately started on intravenous fluids and antibiotics while the general surgery team was consulted. Due to the patient being very sick, a cholecystostomy tube was placed to decompress the distended inflamed gall bladder.
Despite the use of multiple antihypertensive medications, the patient continued to have elevated blood pressure. Interestingly, a review of the CT abdomen/pelvis done on admission revealed the presence of bilateral adrenal masses, this finding was concerning for an undiagnosed PHEO. On further evaluation (), she was found to have elevated levels of free meta- and normetanephrine in plasma and urine sample

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


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

[User]
RADIOLOGY NOTE:
The patient is a 61-year-old male with a history significant for NF-1, hypertension, esophagitis and intermittent gastrointestinal bleeding, who initially presented to an outside institution for acute onset of bleeding per rectum. The patient noted bloody bowel movements with diarrhea for several days, which had increased in frequency over the past 24 hours. The patient reported mild abdominal pain and denied nausea, emesis, chest pain, shortness of breath, syncope or other symptoms at the time. He was not on anticoagulation and denied excessive alcohol or nonsteroidal anti-inflammatory drug (NSAID) use. His family history was significant for NF-1 diagnosed in his mother and brother. He had no significant surgical history other than a total hip replacement.
On admission at the outside hospital, the patient’s hemoglobin was 6.6 g/dl, with normal platelets, partial thromboplastin time and prothrombin time. Diagnostic workup at the outside institution included a nuclear medicine gastrointestinal scan (mTc-labeled RBCs), which was negative for abnormal bleeding. On hospital Day 2, his hemoglobin failed to respond appropriately to transfusions and a computed tomography angiogram (CTA) was completed, which showed a 6.9 × 5.8 × 6.8 cm hyper-vascular mass in the left pelvis; abutting the left border of the bladder medially, iliac arteries and veins posteriorly, rectus sheath anteriorly and the small and large bowel (). Vascular supply of the mass was identified to originate from branches of the superior mesenteric artery (SMA) and appeared to be contiguous with the adjacent jejunum. The mass was noted to also abut, but not involve, the sigmoid colon. The CT scan further noted a 9 mm enhancing tumor in the second portion of the duodenum anteriorly (). After administration of five total units of packed red blood cells with limited improvement in hemoglobin, the patient was transferred to our institutions for further management.
The patient arrived hemodynamically stable and u

[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 man complained of left shoulder pain for 2 weeks without any history of trauma. Bloody effusions were aspirated 5 times at a local orthopedic clinic during a 2-week period before the patient was referred to us. He had no previous history related to hemorrhagic factors. On examination, he had slightly limited range of motion, with active forward flexion to 160°, abduction to 120°, external rotation to 30°, and internal rotation to the fifth lumbar spine with the arm at the side. Passive range of motion was the same as active range of motion. Neer's impingement test and Hawkins test were positive. The greater tuberosity was seen irregular on radiography. MRI demonstrated a hematoma in the anterior portion of the subdeltoid bursa and bony erosion of the lateral acromion, similar to case 1 ().
Arthroscopy was performed to determine the cause of the hemorrhage. A hematoma was not observed in the glenohumeral joint. The intra-articular portion of the long head of the biceps tendon had completely disappeared. A bursal-side partial tear of the rotator cuff was noted. The size of the tear was 25 mm in the anteroposterior direction. Crater formation on the undersurface of the acromion and irregularity of the greater tuberosity were observed, which seemed to be kissing lesions (Figures and ). Active bleeding was seen at the exposed bone marrow of the acromion when the pressure of irrigation was lowered. The undersurface of the acromion was coagulated and the greater tuberosity was abraded to avoid impingement (). Acromioplasty was not performed in this case. The bursal-side partial tear was not repaired at that time ().
One month later, the patient underwent arthroscopic rotator cuff repair. The patient regained full range of motion 3 months after rotator cuff repair and returned to work as a taxi driver. At the final follow-up, 14 months after the first arthroscopy

[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.