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

[User]
RADIOLOGY NOTE:
A 46-year-old woman with morbid obesity, hypertension, hyperlipidemia, active smoking, and bipolar disorder was evaluated for paroxysmal atrial fibrillation as an outpatient. A transthoracic echocardiogram showed a right atrial mass close to the RA-IVC junction. A transesophageal echocardiogram confirmed the presence of a pedunculated right atrial mobile bilobular mass measuring 2.1 × 1.8 cm, not arising from the interatrial septum with extension into the inferior vena cava (Figures –). A secundum atrial septal defect was also identified. The patient was referred to cardiac surgery for resection of a presumed right atrial myxoma given the possibility of embolization. The intraoperative TEE suggested the presence of one bilobulated mass arising low in the right atrium.
Using aortic and bicaval cannulation, a right atriotomy was performed and a discrete 2 × 3 cm mass was removed from the IVC-RA junction near the Eustachian valve. The right atrium was closed and the patient weaned from bypass. The specimen did not appear to be a myxoma, so it was sent for frozen section and interpreted as being ectopic liver tissue. In the interim, a repeat TEE showed an additional discrete 2 × 2 cm mass in the IVC near the hepatic veins. Femoral venous cannulation was then performed to allow for visualization of the IVC below the pericardial reflection. Through the same right atriotomy and using additional suction directly in the IVC, the IVC mass was visualized and resected. Both specimens were interpreted as showing partially encapsulated liver parenchyma with mild steatosis, fibrosis, ductal proliferation, and periductal chronic inflammation, consistent with ectopic hepatic tissue ().
Despite a brief period of cardiopulmonary bypass, the patient had persistent hypoxemic respiratory failure ascribed to her morbid obesity and underlying lung disease. She also developed extensive left lower extremity deep venous thrombosis from a presumed heparin-induced thrombocytopenia for which she

[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 was a 30-year-old Spanish Caucasian man; the third child from healthy and non-consanguineous parents. The first child was a healthy boy and the second child was also a boy who died after two days due to hyaline membrane disease and prematurity. Our patient was delivered by caesarean section after 39 gestational weeks because of macrosomy, with a weight of 4250 g and an Apgar score of three, thus, intensive reanimation was required. Within five hours of life he suffered apnea. He was also hypoglycemic and hypocalcemic, but responded well to treatment without suffering a recurrence. Clinical examination showed bilateral cryptorchidism. During her pregnancy our patient's mother was treated with diazepam towards the end of the pregnancy.
When our patient was 19 months old, his weight and length were two standard deviations below normal. During further development, he showed psychomotor delay and a bilateral convergent strabismus; also he started walking when he was 22 months old. At the age of 10 years, his testes were surgically descended. And at the age of 13 years the strabismus was corrected. At school he had slight learning difficulties, with normal social behavior. He later left studying to become a painter.
When he was 22 years old, he had no facial dysmorphism, he weighed 89 kg, his height was 165 cm and he had a corporal index mass of 32.7. He had hypogenitalism, with a short thick penis (6 cm), and testes of 8 and 10 cc. He has multiple hyperpigmented nevi all over his body, showing no sign of malignancy after biopsy (Figure ). He also had a left vesicoureteral reflux grade III, with normal renal function. His cardiac, audition and fundus of the eye examinations were normal, as was his blood biochemistry. His feet are short with a pes cavus and claw toes (Figure ). At this time, he was referred to a Genetic Laboratory and one sS

[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 32-year-old man was referred to Seoul National University Dental Hospital for further evaluation and treatment of bilateral nodular lesions of the neck that had been present for several months. He had visited a local plastic surgery clinic with a chief complaint of a large lesion and pain in the right cervical area. Documentation from the clinic stated that he had only agreed to a drainage procedure and had refused surgery to remove the lesions. According to the patient, the pain and swelling had subsided as a result of the aspiration performed during his visit to the clinic. Additionally, while the patient had an operative history of cardiac septal defect repair performed when he was 10 months old, he gave no family history associated with skin lesions like those that he exhibited.
Panoramic radiography showed abnormal dentition. First, the deciduous second molars were in a state of prolonged retention and submergence on both sides of the maxilla and the right side of the mandible. Second, multiple permanent teeth were missing, including the maxillary second premolars on both sides and 2 mandibular incisors on both sides and 1 mandibular molar on the right side. Finally, microdontia of 2 maxillary lateral incisors (peg lateral incisors) and 2 mandibular premolars was observed ().
To accurately evaluate the soft-tissue lesions, contrast-enhanced computed tomography (CECT) was performed. The images revealed multiple well-defined round to ovoid, smooth or scalloped, nodular lesions with diameters ranging from 2 to 20 mm in the subcutaneous layer on both sides of the cervical region. The internal structure showed fat attenuation on the level of −110 to −100 Hounsfield units (HU) and some lobulation. Additionally, the large lesion of the right upper neck, where the patient experienced the pain, displayed peripheral enhancement with mild swelling, suggesting that it was accompanied by inflammation. The epidermis of that lesion was elevated, and the adjacent platysma mu

[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 nonsmoking 53-year-old male with a history of obesity (body mass index 32 kg/m2), type 2 diabetes mellitus, and hypertension who developed fevers, diarrhea, and cough. After 6 days of worsening symptoms, he presented to an outside hospital for rapidly worsening dyspnea and confusion. Upon arrival, he was found to have profound hypoxemia with an oxygen saturation of 33% by pulse oximetry. He was emergently intubated and admitted to the intensive care unit (ICU). Initial chest X-ray demonstrated mild bilateral pulmonary infiltrates (). He was started on broad-spectrum antibiotics including vancomycin, piperacillin-tazobactam, and doxycycline. While in the ICU, his condition continued to worsen and he remained profoundly hypoxemic despite escalating ventilator support. Within five hours of hospital admission, he was on maximal ventilator settings, in the prone position, chemically paralyzed, and on inhaled epoprostenol. Despite these interventions, the patient remained severely hypoxic with oxygen saturation of 70% and PaO2 of 48 mmHg. Our institution was contacted to evaluate for initiation of VV ECMO. The patient was transferred to our surgical ICU still in a prone position and paralyzed.
On arrival to our surgical ICU, approximately 9 hours after his initial hospital presentation, his oxygen saturations were found to be between 40 and 60%, and he was increasingly hypotensive requiring norepinephrine and vasopressin to maintain an adequate blood pressure. His arterial blood gas identified a respiratory acidosis with a pH of 7.29 and elevated pCO2 to 59 mmHg. His PaO2 : FiO2 ratio was 36, consistent with severe ARDS. Initial management in our ICU included increasing PEEP to 24 cm while continuing 100% FiO2. Epinephrine was added as a third vasopressor for worsening hypotension. Despite these interventions, the PaO2 remained low at 44 mmHg and his oxygen saturation remained <70%. A bedside echocardiogram was obtained and identified globally diminished

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


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

[User]
RADIOLOGY NOTE:
A 74-year-old man was referred to the opthalmology clinic with a history of a mass in the left upper eyelid that had been present for four years. Visual acuity was 7/10 for the right eye and 6/10 for the left eye, anterior segment examination revealed grade 2 nuclear cataract for the right eye and grade 3 nuclear cataract for the left eye. Motility was bilateral normal with no diplopia. Levator functions were bilateral normal, except there was a minimal mechanical ptosis for the left eye. There was also a subcutaneous mass on the left forearm. Systemic check-up relevead no other illness or malignancy. On clinical examination, there was a subcutaneous, firm and round mass located on the central left upper eyelid, which was non-tender to palpation. It was inconspicuous on inspection. There was no eyelid movement restriction but a feeling of friction on the superior orbit during lid movement. Ultrasonography showed a homogeneous echogenic and well defined mass in the anterior orbit. No internal vascularity was seen. An excisional biopsy was taken through the crease of the upper eyelid under local anesthesia. The lesion was 9x7x7 mm in diameter and located 15 mm superior to the eyelid margine and located under the orbicularis muscle. During the removal operation, it was noted that the lesion was stuck to the tarsal border from its base. The mass was removed completely and its location was cauterized while preserving the underlying tarsal plate (Figure 1 ). Histologically, this nodular lesion, which was composed of mature adipose lobules with a patch of proliferating vascular components and well-circumscribed by fibrous connective tissue, was classified as angiolipoma (Figure 2 ). Postoperatively, visual acuity was 7/10 for the right eye and 6/10 for the left eye, with no change in the anterior segment examination. The patient did not have any motility restrictions and there was no recurrence during follow-up for the next 12

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


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

[User]
RADIOLOGY NOTE:
A 39-year-old female with a history of obesity and tobacco use presented to the emergency department with a 10-day history of increased swelling, redness, drainage, and pain of the right breast and upper abdomen. The patient reported associated fever, chills, nausea, and emesis. There was no history of trauma or previous surgery. She also stated she was reluctant to visit her primary care physician or any emergency department when her symptoms began due to anxiety related to COVID-19 viral exposure.
On clinical examination, the right breast was noted to have a 12 × 14 cm area of skin sloughing along the inferior inner aspect of the breast. A necrotic open wound was also seen within the lower outer quadrant with foul-smelling drainage surrounded by edema, erythema, and crepitus extending onto the right anterior abdominal wall (Figures and ) The patient was noted to be hypotensive with mild tachycardia.
Pertinent laboratory findings revealed a leukocytosis of 16.9 × 109/L with neutrophilia, thrombocytosis of 608 × 109/L, and mild hyponatremia of 133 meq/L. Mild anemia was present, but renal function and lactic acid were found to be within normal limits.
A chest computer tomography (CT) ordered by the emergency room physician revealed the right breast wound with several locules of gas within the superficial subcutaneous tissues of the right lateral and posterior breast with minimally increased attenuation of the subcutaneous tissues. (Figures –) These findings were consistent with a necrotizing soft tissue infection, and general surgery was consulted. After surgical evaluation, a decision was made to proceed with emergent surgical intervention to provide source control. Prior to surgery, resuscitative intravenous fluids were administered in addition to vancomycin, clindamycin, and aztreonam, due to an unknown reported allergy to cephalexin.
The patient was taken to the operating room for an emergent wide excision and debridement of the infected tissue within the inferi

[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 boy presented to a retina specialist with symptoms of nyctalopia and decreased vision. He was referred by an optometrist after an evaluation that included an abnormal optical coherence tomography (OCT) scan. He was followed since the age of two by the optometrist and his examination was limited to refractive evaluation prior to this scan. His parents became concerned when he could not see objects directly in front of him and he frequently ran into household objects. They noted that he even ran into a tree while at a birthday party at the age of six, and has been followed by his primary care physician for multiple complaints. This history prompted further workup by the optometrist.
The patient had a relatively complex medical history, starting during gestation. During pregnancy, his mother had oligohydramnios and decreased fetal movements. At birth, the patient had joint laxity with associated hypotonicity. Shortly after an in-hospital birth, he required resuscitation due to a nasolacrimal cyst obstructing his airway, which was subsequently removed. Both physical and mental development were delayed, as he did not sit until eight months of age, the cruise until 14 months, and walk until 17 months. He had a history of growth hormone (GH) deficiency and delayed bone age, which, after discussion of the risks and benefits with the parents, were not treated with GH replacement. MRI of the brain at age two for GH deficiency revealed mild vermian hypoplasia among other non-specific findings. He had also had frequent illnesses, particularly ear infections with high fevers. He recently failed his hearing test at school but had not yet had a formal hearing evaluation.
On physical examination, visual acuity was 20/50 right eye (OD) and 20/40 left eye (OS) with an intraocular pressure (IOP) of 18 and 19, respectively. His refractive error was -2.25 OD and -2.50 OS. An informal illustr

[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 heavy smoker, otherwise healthy male, presented with 3 weeks of gallstone pain. After a couple of admissions where the patient was treated with a non-selective COX inhibitor (Todolac 600 mg daily) for ∼2 weeks, he was scheduled to outpatient laparoscopic cholecystectomy.
Dissection of gallbladder was complicated by blood oozing from the liver. It was treated successfully, and haemostasis established. A drain was placed to monitor further bleeding episodes. The drain was removed on the second postoperative day as the output was negligible. Treatment for postoperative pain included 10 mg morphine tablet on need with a maximum dose of six times, Paracetamol tablet 1000 mg four times per day and Ibuprofen 400 mg three times per day.
On the evening of the second postoperative day, the patient complained of increasing diffuse pain. Vital signs were normal and stable. Blood tests were normal. He was observed overnight, and the following morning the situation worsened with rebound tenderness and rigid abdomen. The situation was rapidly deteriorating, thus an immediate surgical intervention was indicated without diagnostic imaging. An emergency diagnostic laparoscopy revealed a diffuse peritonitis due to perforation of a diverticulum in colon sigmoidium. The abdomen was irrigated, and two drains were placed in both the right and left sides according to the department's guidelines. The following day, a leakage around the drains was noted, and a brilliant blue was given. A blue-coloured output in the drains confirmed the suspicion of perforation. The patient's condition was deteriorating, necessitating a new diagnostic laparoscopy that showed massive intraperitoneal fibrin plagues and terminal ileum adherent to the pelvis most probably due to the inflammation of the re-perforated colon sigmoideum. Resection of the diverticulosis-bearing segment in colon sigmoidium ad modum Hartmann was performed, and the patient was treated with broad-spectrum antibiotics. The po

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


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

[User]
RADIOLOGY NOTE:
We present a case of a 58-year-old female patient with a large recurrent ventral hernia. Six years before, the patient had been operated on for the umbilical hernia, with the simple repair without a mesh. The patient was an active smoker who suffered from morbid obesity with a body mass index of 43 kg/m2 and COPD as comorbidities relevant for this case report.
The patient was introduced to the surgeon during hospitalization at the gastroenterology department where a diagnostic workup due to a clinical picture of chronic small bowel obstruction was conducted. While taking the anamnesis, the patient reported frequent abdominal cramps, swelling, and pain in the area of the hernia that had intensified in the last few weeks. The physical examination revealed a large irreducible ventral hernia in the lower abdomen that was quite painful on palpation, but soft and, at that time, without signs of incarceration or strangulation. Taking into account the clinical picture with threatening hernia incarceration, the surgeon did not opt for preoperative optimization of the patient in terms of smoking cessation and starting a weight loss program but made an indication for semielective surgery.
On operative procedure, greater omentum, part of the transverse colon, and a cluster of small bowel loops with signs of chronic obstruction were found as hernial content. After adhesiolysis hernial content was reduced into the abdominal cavity. Hernial defect measuring about 7 cm in diameter and about 15 cm in the vertical line with significant rectus diastase in the supraumbilical part of the abdomen was revealed. Using the Rives-Stoppa technique a wide retromuscular space was created. Lateral dissection boundaries of this space were perforating neurovascular bundles in the area of the lateral edges of the rectus muscle on both sides. The posterior fascia was easily closed using also a portion of the hernia sac to bridge the defect between the posterior rectus sheaths. A 30 × 25 cm polypropy

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


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

[User]
RADIOLOGY NOTE:
A 19-year-old female patient came with a complaint of massive, painful, and swollen with mobile upper anterior teeth with detached mucoperiosteum from the palatal mucosa since 1 month []. The swelling started slowly and attained the present size. She was associated with fever since 2 days and also complains of discomfort and unable to eat since 1 week. Patient was from a low socioeconomic back ground, residing in a rural area. She had a history of mouth breathing with poor generalized periodontal status. The swelling was extending from infra-orbital region bilaterally to the entire upper lip. Skin over the swelling appeared stretched, erythematous and there was localized rise in temperature.
Intraoral examination revealed poor oral hygiene with severe halitosis. Swelling may be seen involving the lips, anterior portion of hard palate. Palatal flap in the premaxillary region was necrotized, detached from the underlying bone. Computed tomography revealed that there was no involvement of maxillary sinus, nasal cavity which was suspicious for involvement. Maggots were seen between the palatal bone and flap. The case was posted for surgery under local anaesthesia after taking informed consent. Turpentine oil was placed in the wound area during which maggots were coming out [Figures , and ]. Around 25-27 maggots were removed. Based on the clinical findings and the presence of maggots the provisional diagnosis was made as myiasis. The larvae were preserved in 40% formaldehyde and sent for pathological investigation. On pathological examination the diagnosis of larvae of Musca domestica was confirmed.
Complete treatment was executed with Taxim 1 g, Metranidazole 100-ml IV injections along with intramuscular injection of Voveran injections for 10 days faster and better recovery. Postoperative healing was uneventful in the wound area. A week later patient discharged and was asked to report back after a period of 6 months to evaluate the healing status and the healing was unev

[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 man presented with cardiac arrest after choking on food at home. He had been suffering from dementia and right-sided weakness after a traumatic intracranial hemorrhage 7 years prior. He received immediate bystander CPR and was brought to our emergency department (ED). Asystole was documented at admission, and the resuscitation attempt was continued in the ED. After endotracheal intubation, a TEE transducer was inserted to find the cardiovascular cause of cardiac arrest. TEE revealed no cardiac contraction. No structural cardiac abnormality or pericardial effusion was noted. A focal separation of the intimal layer at the anterior wall of the descending thoracic aorta (DTA) was seen 10 cm from the distal portion of the aortic arch (). The DTA was compressed and deformed repetitively whenever the chest was compressed (). After 19 minutes of resuscitation, the patient regained spontaneous circulation and the TEE transducer was removed. His systolic blood pressure rose to 130 mmHg. Ten minutes after restoration of spontaneous circulation (ROSC), his systolic blood pressure dropped to 80 mmHg. Transthoracic echocardiography showed a newly developed pericardial effusion with diastolic collapse of the right ventricle, suggesting cardiac tamponade. Bloody pericardial fluid was drained during emergency pericardiocentesis. Follow-up TEE was performed to investigate the origin of pericardial effusion. TEE revealed an intimal flap, not seen on the first TEE, in the DTA (). The intimal flap was observed between the distal portion of the aortic arch and 11 cm down from the aortic isthmus ( and , ). Thoraco-abdominal angiography with a multi-detector computed tomography (CT) scanner (Brilliance 64; Philips Medical Systems, Cleveland, OH, USA) revealed aortic dissection of the DTA with no involvement of the ascending and abdominal aorta (). Bloody pericardial effusion was thought to be one of the complications from CPR because there was no evidence of dissection 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:
The subject described in this case report is a 21-year-old male who suffered a concussion 356 days prior to the physical therapy evaluation. The injury occurred during a fall out of a moving golf cart onto his left shoulder/neck region. The subject reported loss of consciousness and post-traumatic amnesia following the injury. The subject was taken to a local emergency department and CT scan results appeared negative for cerebral bleeding but identified a left temporal bone fracture not requiring medical intervention. The subject received no education on symptomology or symptom duration, and no referral or follow-up was scheduled at the time of discharge. The subject reported a history of four previous concussions, three of which were sport-related, but otherwise had no co-morbidities or significant past medical history. Only minor residual symptoms from his previous concussions were reported that all gradually resolved. The subject had constant, persistent symptoms since the injury that impaired his abilities in school as well as his social life and had restricted athletic or recreational activities, reducing his overall quality of life. The subject visited his primary physician a few weeks prior to evaluation; his cervical spine was cleared via radiographs, and he was referred to a metropolitan outpatient physical therapy clinic.
The subject was given the Rivermead Post-Concussion Questionnaire (RPQ) to assess symptomology. The RPQ is a subjective, self-report measure that encompasses 16 items, each of which is scored from 0-4 in increasing severity, assessing separate cognitive, emotional, and somatic physical factors. The RPQ demonstrates high test-retest and inter-rater reliability for both total score and individual items via spearman rank correlation coefficients (r = 0.91, r = 0.87 respectively). The subject’s chief reported symptoms during the initial evaluation were neck pain and stiffness, bilateral radicular symptoms that were worse in the left shoulder

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


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

[User]
RADIOLOGY NOTE:
A 43-year old, asymptomatic woman was admitted to our hospital by her family doctor after receiving a chest-x-ray during routine clinical examination. The x-ray showed a mediastinal mass overlapping the aortic arch region (Fig. ). For verification a computed tomography (CT) was performed and revealed incidentally a type B dissection, which was most likely chronic without information of the index date, originating from an aneurysm of a left cervical arch with a maximum diameter of 6 cm (Fig. ). The left renal artery, the coeliac trunc and the main part of the superior mesenteric artery branched from the false lumen without a sign of malperfusion of the organs. Because of the huge diameter and the potential risk of rupture, an urgent surgical repair was planned. Before intervention the patient got a blood pressure adjustment by ACE inhibitor. Betablocker was not necessary because of a resting pulse under 60 beats per minute. For neurological online monitoring, sensitive and motor evoked potentials were monitored. Spinal drainage was installed 1 day before the procedure. Surgical access was carried out through median sternotomy and an additional left lateral thoracic incision through the fourth intercostal space (Hemi-Clemshell). Simultaneously to the preparation of the aneurysm, partial cardiopulmonary bypass was installed in the left groin by cannulation of the femoral artery and vein under echocardiographic guidance. During selective ventilation of the right side, the left lung was mobilized by transsection of the Ligamentum pulmonale and preparation of the perianeurysmatic tissue and adhesions. After identification and preparation of the recurrent and phrenic nerve and the supraaortal branches, the descending aorta was clamped and a distal anastomosis performed with a straight graft (20 mm). The visceral arteries partially branched from the false and true lumen without a sign of malperfusion. Before the final distal anastomosis, we performed a fenestration of the d

[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:
Patient B was a 74-year-old woman with a history of breast cancer that had been treated with curative intent 10 years earlier. She was referred with shortness of breath. A CT scan showed multiple lung nodules. In addition, a PET-CT scan showed 4 PET-positive lesions in the right lower lobe, as well as 2 nodules in the right middle lobe and an enlarged PET-positive lymph node in station 7, which were suspicious for metastatic breast cancer lesions. Mammography of the right breast showed no local recurrence of the tumor. EUS-FNA of station 7 was performed using a 19G needle. Directly after the procedure, the patient experienced pain and was admitted for observation. A chest X-ray showed subcutaneous emphysema on the left side of the neck. A non-contrast CT scan showed pneumatosis in the mediastinum, and pleural effusion and atelectasis on both sides (). The laboratory results demonstrated a CRP of 600 mg/L and a WBC count of 22×109/L. The patient was placed on a fasting regimen and intravenous antibiotics were started. The patient experienced clinical deterioration and was admitted to the intensive care unit (ICU) 2 days after the EUS-FNA. She was septic, with a blood pressure of 90/50 mm Hg, a regular heart rate of 110 beats/min, a temperature of 37.7°C, and a respiratory rate of 21 breaths/min. Upper gastrointestinal endoscopy revealed a laceration of the esophagus at 27 cm from the incisor teeth. Consequently an 8-cm colon stent was placed endoscopically. The next day, a chest tube was placed in the left pleural space, draining 400 mL of turbid fluid immediately. Then, u-VATS debridement of a right-sided thoracic empyema was performed and 2 chest tubes were placed in the posterior mediastinum. Postoperatively the patient returned to the ICU. On the following days, the drains kept producing excessive turbid fluid. On day 4 after surgery, upper gastrointestinal endoscopy 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 65-year-old Chinese woman presented with a history of abdominal pain for 3 days. The patient developed paroxysmal abdominal pain in the past 3 days, accompanied by nausea, bloating and acid regurgitation. The pain was limited to the middle and upper abdomen, and anal exhaust and bowel movements were normal. The symptom did not become aggravated during the 3 days. She denied the symptoms of steatorrhea. The patient has had type 2 diabetes for more than 20 years and used a drug regimen to control the DM, but the patient complained that her fasting blood glucose was still poorly controlled. She had no other diseases. Her family medical history was unremarkable.
No positive signs were found in the physical examination. The results of the hematological examinations were normal. Only the blood sugar (11.7 mmol/L) and triglycerides (4.3 mmol/L) were abnormal in the blood biochemical examination, and no signs of infection were found. No abnormal results were observed from the electronic gastroscopy and electronic colonoscopy, which were performed 2 months ago. An enhanced abdominal CT scan revealed slightly increased gastrointestinal contents and no signs of acute abdominal (obstruction, perforation, etc.) or celiac vascular disease but found that the patient did not have the body and tail of the pancreas (Fig. a-b).
So the preoperative diagnosis is gastrointestinal dysfunction, agenesis of the dorsal pancreas, and pancreatic exocrine insufficiency were not excluded. Mosapride and trimebutine were used to improve gastrointestinal function, and 0.6 g pancreatin enteric-coated capsules were given to the patient before each meal continuously to supplement her pancreatic exocrine function. And Intermediate effect insulin were used to help control the fasting blood glucose.
The patient returned to the gastrointestinal surgery clinic 1 week later, complaining that although the symptoms were significantly relieved, but there was still mild postprandial bloating. Here fasting blo

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


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

[User]
RADIOLOGY NOTE:
A 65-year-old Mexican man presented with a three-month history of a skin rash and recurrent blisters. He was a resident at a skilled nursing facility and had multiple medical problems including ankylosing spondylitis, chronic pain syndrome, cognitive impairment, dysphagia with a feeding gastrostomy tube, epilepsy since childhood with occasional seizures, manic depressive disorder, and weakness. His long-term seizure medications included carbamazepine, phenobarbital, and phenytoin; citalopram had been added three years ago for the management of his psychiatric disorder.
Initially, blisters appeared on both of his feet. Within a month, he developed a lesion on his arms and legs. His physicians initially suspected a scabies infestation and he was treated with permethrin 5% cream; however, his skin condition persisted. Subsequently, a skin infection was also considered and he received several courses of oral antibiotics without improvement.
Three months after the onset of his cutaneous condition, he was brought to see a dermatologist for an evaluation. Cutaneous examination showed hemorrhagic blisters on both the dorsal and plantar surfaces of his feet and toes (Figure ). There were no mucosal lesions. Erythematous plaques were present on his arms and legs (Figure ); biopsies from a left thigh plaque and adjacent skin were performed for routine staining and direct immunofluorescence, respectively. Initial management included soaks to feet with aluminum acetate solution and application of triamcinolone 0.1% cream to the lesions on his body; both interventions were to be done three times daily.
Microscopic examination of the hematoxylin and eosin-stained specimen showed eosinophilic spongiosis (showing eosinophils being present in the widened spaces between the epidermal keratinocytes), marked edema in the papillary dermis, and abundant eosinophils with some lymphocytes present in the inflammatory infiltrate in the upper dermis. These changes were consistent with those of

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


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

[User]
RADIOLOGY NOTE:
A 57-year-old female with medical history of diabetes and hypertension was transferred to our facility with complaints of high-grade fever for the past 3 days. There was no other significant associated history to explain the probable cause of fever except that she had a history of fall about 2 weeks ago. She had taken initial treatment at a primary health center and was ambulating well at home. On arrival at the emergency room, she was conscious and oriented, febrile, hypotensive, and with minimal respiratory distress. An initial diagnosis of sepsis due to the unknown source was considered and managed per protocol with fluid resuscitation, cultures, and imaging to identify the potential source and broad-spectrum antibiotics. Complete hemogram revealed leukocytosis with toxic neutrophil granulation. Renal, liver, and coagulation panels were within normal limits. Electrocardiogram revealed right axis deviation, S1Q3T3 pattern, and echocardiography did not suggest right heart strain. Lower limb venous Doppler and compression ultrasound did not show any evidence of lower limb deep venous thrombosis (DVT). Computer tomography (CT) pulmonary angiogram was performed which ruled out pulmonary embolism (PE), and she was initiated on unfractionated heparin for DVT prophylaxis.
Blood cultures grew methicillin-sensitive Staphylococcus aureus (MSSA), and the antibiotic was appropriately de-escalated, and the patient was gradually improving. Rest of the cultures did not reveal any bacterial growth and screening for tropical infections was also negative. CT abdomen revealed a fracture of body of D8 vertebra. In view of MSSA bacteremia, transesophageal echocardiography was performed which did not show any features of infective endocarditis.
Subsequently, during the course in hospital, she developed acute left lower limb swelling with pain and redness. Repeat venous Doppler of the left lower limb revealed acute DVT extending from the left internal iliac vein to popliteal vein. Repea

[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 2-month-old female was seen in our emergency department for evaluation of a congenital infection. During pregnancy, mother was routinely screened for human immunodeficiency virus (HIV) and syphilis in the first trimester and tests results were negative. Throughout the entire pregnancy, mother had regular prenatal care at scheduled visits. She presented to her obstetrician at 28 weeks gestation with generalized skin lesions on palms and soles, as well as a painless lesion in her genital area. At both the 28-week and 36-week prenatal visits, she was referred to dermatology, and mother was subsequently treated with topical hydrocortisone cream. No further workup was done. Two months after delivery, mother followed up with her primary care provider due to lack of resolution of skin lesions. At that time, a sexually transmitted infection was suspected and mother was tested for syphilis, and rapid plasma reagin (RPR) came back positive at 1:128. Infant was referred for further workup.
On presentation, physical exam of the infant was significant for desquamation of the skin on the bilateral soles of her feet, pinpoint pink dots on the soles of her feet bilaterally, and a erythematous skin lesion 1 × 1 cm on her right medial knee. Mother did report that infant was not moving her left leg. Infant did not exhibit any neurological deficits on physical exam. Significant laboratory findings included slight anemia, hemoglobin of 8.9 g/dL, and hematocrit of 26.5%. Further workup for congenital infection was done including lumbar puncture. All findings in the cerebrospinal fluid in this patient were within normal limits, including normal cell count, glucose, and protein. Venereal disease research laboratory (VDRL)tests was negative as well. Long-bone radiographs were also done, which were significant for osteochondritis and periostitis. This was seen in the medial metaphysis of the proximal left tibia and distal left femur (), the metaphysis of the medial right proximal tibia, an

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


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

[User]
RADIOLOGY NOTE:
A 64-year-old right-handed retired male teacher was referred to our clinic with an inability to flex the interphalangeal (IP) joint of his left thumb. One week previously, he was gardening. He had flexed his thumb around the stem of a firmly embedded weed, and as he pulled hard, he felt a sudden pop in his left thumb and found he could not flex his left thumb. Although he often played saxophone, he could not recall any specific episode of pain or discomfort within the left thumb. There was no evidence of any history of rheumatoid or other inflammatory arthritis and his rheumatoid serology was normal.
Upon examination, no specific painful swelling in the left thumb was detected. However, the patient was unable to actively flex his thumb at the IP joint (Fig. ). He had full passive range of motion of IP joint.
Initial plain left thumb radiographs revealed no bony abnormalities resulting in secondary tendon rupture. Magnetic resonance imaging (MRI) revealed complete FPL tendon rupture at the level of the distal one-third of the proximal phalanx and the proximal end of the ruptured tendon was retracted to the level of the metacarpophalangeal (MP) joint (Fig. ).
With the patient under general anesthesia, the FPL tendon was explored through a volar zig-zag incision. During the operation, the FPL tendon was found to be ruptured completely. Gross examination revealed a slightly yellowish denaturated tissue at the distal end of the ruptured tendon and the gap of the ruptured ends was interposed by a fibrous tissue (Fig. ). No bony prominence was observed throughout the excursion of the tendon. We excised the denaturated tissue from the distal end of the ruptured tendon and sent it for histological examination. FPL tendon was repaired primarily via modified Becker method (Fig. ). Histopathological examination revealed normal vasculature in the tendon tissue and degenerative changes associated with lipid deposits in

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


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

[User]
RADIOLOGY NOTE:
The patient was an 82-year-old male who was scheduled for a robotic left lower lobectomy for the resection of a biopsy-proven squamous cell lung carcinoma. He had a medical history of hypertension controlled with multiple medications; a 40-pack-year history of tobacco abuse, with a 20-year history of abstinence; and a prior history of melanoma of his left upper extremity, which was successfully resected.
Standard American Society of Anesthesiology (ASA) monitors were placed and preoxygenation was performed; general anesthesia was induced with propofol, followed by the administration of muscle relaxant and the placement of a left-sided, double-lumen endotracheal tube. Additional venous access and arterial line placement occurred concurrently while the correct placement of the endotracheal tube was confirmed by bronchoscopy. The placement was then reconfirmed after the patient was situated in the right lateral decubitus position. The left lung was isolated and deflated, and the surgeon proceeded to place ports to facilitate the robotic resection as follows: the sixth intercostal space in the anterior axillary line, the third intercostal space in the anterior axillary line, and the ninth intercostal space in the posterior axillary line. The surgical procedure continued uneventfully from an anesthesia perspective with level 7 and 10 lymph node dissections, extensive lysis of adhesions and pericardial and pleural fat to facilitate visualization, and a left lower lobectomy. Surgical blood loss was estimated at less than 50 cc. Chest tubes were placed through the sixth and ninth intercostal port incisions. A bolus of 30 cc of 0.5% bupivacaine was administered via a catheter placed at the tenth intercostal space in the posterior axillary line for an elastomeric pump ball to infuse local anesthesia for post-operative pain management. Within 15 minutes of this, the patient began to experience hypotension, requiring incrementally increasing doses of vasopressors. Over the cour

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


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

[User]
RADIOLOGY NOTE:
A 30-years-old male with no comorbidities presented with nonlocalized anterior knee pain since 3 years. The pain was only on squatting and climbing up and down the stairs. He reported no pain on regular daily activities. The body mass index was 23.4. Clinical examination was unremarkable, except for a significant bump on the superior lateral aspect of the right knee. Before the presentation, he had been treated with anti-inflammatory, physiotherapy, and local steroid infiltration in the knee with failure to relieve his symptoms.
On the current presentation, plain radiographic study anteroposterior (AP, lateral and skyline views) revealed a bipartite patella fragment. MR imaging confirms the absence of any other significant pathology []. There is no bony edema on the fragment. Squat stress skyline view was done and demonstrated separation of fragment []. However, in the absence of direct tenderness on the superolateral aspect, equivocal radiological findings, and high suspicion, another test was performed.
The test performed to the best of my knowledge had not been reported earlier. The pull of the lateral structures causes a repetitive strain and relative motion on the synchondrosis and generates pain, forming the pathophysiological basis of this test. The pain arising from the synchondrosis was blocked using the 2% lidocaine infiltration. The test was performed using an image intensifier using three (26 gauge, 13 mm) Dispovan needles. The three needles were inserted in the synchondrosis using an image intensifier and checked in AP and skyline views. Inject 0.75 ml lidocaine 2% in all three needles []. After a latent period, the patient was allowed to do pain-generating activities, which in this case was squatting and stair climbing. The absence of pain in performing the activities was considered to be a positive confirmatory test.
The patient underwent the test as described with a positive result. The surgical diagnosis was achieved, and arthroscopic excision of th

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


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

[User]
RADIOLOGY NOTE:
This is a 72-year-old Caucasian male with a past medical history of hepatitis C-related cirrhosis (status post-liver transplantation 14 years prior), with recurrence of HCV genotype 1a, untreated, who was admitted three times over 3 months for recurrent episodes of small bowel obstruction. During the first two admissions, the patient presented with early satiety, abdominal pain, and inability to pass flatus or have bowel movements, which led to him being treated conservatively with nasogastric tube decompression and intravenous fluids with clinical improvement. The patient presented 4 days after discharge from his second hospital admission with similar abdominal pain complaints, decreased appetite, and increased abdominal distention. The patient denied nausea, vomiting and was able to pass flatus. However, he had no bowel movements for three days. His white blood cell count, electrolytes, and liver function tests were all within normal limits. CT of the abdomen and pelvis showed dilated loops of small bowel concerning ileus versus small bowel obstruction (). Due to the failure to improve symptoms after 9 days from conservative management, the patient was taken for exploratory laparotomy with lysis of adhesions and peritoneal biopsy.
Intraoperatively, it was noted that there were chronic fibrinous inflammatory changes to both the bowel and the mesentery. There was a trabeculated rind covering all of the bowels. The thickened bulky adhesions covered the terminal ileum, with a few bands at both the terminal ileum and the cecum. All bowel proximal to the terminal ileum’s thickened rind area was dilated, and a small amount of the ileum, and the large bowel, were decompressed. Some of the bands and adhesions near the ileocecal junction were taken down. The surgeon stated they could not safely dissect the peritoneum from the small bowel; therefore, the procedure was terminated without significant lysis of adhesions ().
Interestingly, the peritoneal biopsy results revealed

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


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

[User]
RADIOLOGY NOTE:
A 36-year-old woman was hospitalized at a local hospital for pelvic mass found by physical examination in November 2017. Exploratory laparotomy was performed at that hospital immediately. Intraoperatively, a free mass at approximately 6 cm × 5 cm × 5 cm in size was observed at the bottom of the right pelvis and adjacent to the uterosacral ligament without any other abnormalities. Due to the examination of frozen sections showing germ cell tumor and consultation with relatives of this patient, pelvic mass resection, biopsy of bilateral ovaries and partial omentum resection were performed. Postoperative pathology reported yolk sac tumor of the pelvic mass, normal biopsy from ovaries and normal tissue of omentum. From December 2017 to June 2018, six courses of chemotherapy with BEP regimen were administrated for her. After five cycles of chemotherapy, serum tumor markers of the patient were all normal, but her alanine aminotransferase (ALT) was elevated nearly to 600 IU/L. She was treated with hepatoprotective therapy for 20 days before completing the sixth cycle chemotherapy. Unfortunately, the serum AFP increased again after sixth cycle of chemotherapy.
Due to increase of serum AFP, the patient was admitted to our center in July 2018. Positron emission tomography–computed tomography (PET/CT) demonstrated a round-like mass at the right pelvis accompanied by increased [18F]-fluorodeoxyglucose (FDG) metabolism. CT scan also indicated a 2-cm mass at the right pelvis (
). Considering relapse of the disease, the patient was hospitalized at our department for a second surgery. During the operation, a dumbbell-shaped, hard, and smooth mass at approximately 3 × 2 × 1.5 cm in size was found at the posterior lobe of right broad ligament and near the uterus. No abnormalities were observed at any other sites of the pelvic and abdominal cavity. After mass resection and right adnexectomy, frozen section was examined and demonstrated yolk sac tumor of broad ligament and normal right

[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 an 18-year-old boy not known to have any medical illness previously, who was referred to the outpatient department from another hospital after 3 months history of seizures. Seizures started with blurring of vision and proceed to right sided head deviation and tonic posturing of the right upper limp which progress to generalized tonic-clonic seizures. The episodes are followed by loss of consciousness and postictal suboccipital and frontal tension headache. There was no history of fever, loss of weight, trauma, or any sensory/motor neurodificit. Family history was unremarkable, with negative past surgical history. All general and local physical examinations were done and all were within normal range. There were no physical findings or family history in favour of neurofibromatosis. Brain MRI with contrast was done and showed right parieto-occipital cortical and subcortical mass lesion measuring about 1.5 x 1.5 cm that has a low signal intensity on T1 and intermediate signal intensity on T2 and FLAIR with intense enhancement postgadolinium administration mainly peripherally with few small susceptibility artefact on T2 associated with significant vasogenic oedema and mass effect on the adjacent sulci ().
The radiological impression with the above description was most likely representing granulomatous infection (TB) or metastasis. Although a preoperative diagnosis could not be clearly established, the tumor was surgically removed through a right occipital craniotomy. The dura was incised and small area of discoloration was noted. Cortical dissection was done, with multiple pieces for frozen section, which was diagnosed later as suggestive of schwannoma, differential diagnosis meningioma. The tumor was encountered 2mm in subcortical area, which was firm, fibrous in content, yellowish in colour, and resembling meningioma. Postoperatively, the patient did not have any new neurological deficit, and he was discharged 1 day postoperatively in stable condition to

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


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

[User]
RADIOLOGY NOTE:
A 24-year-old female patient presented to our clinic with complaints of blurred vision and pain in her left eye for 4 days. She reported that at another medical center, her intraocular pressure had been measured as 38 mmHg and she had been treated with intravenous mannitol, oral acetazolamide, and topical antiglaucomatous therapy for glaucoma. On ophthalmologic examination, her BCVA was 10/10 in the right eye and 5/10 in the left eye. Intraocular pressure was 12 mmHg in the right eye and 14 mmHg in the left eye. Examination findings were normal in the right eye. In the left eye, diffuse, medium-sized brownish-gray keratic precipitates (KP) were observed in the corneal endothelium () and 2+ cells were noted in the anterior chamber. Dilated fundus examination of the left eye revealed a small amount of vitreous cells and 1+ haze. There was pronounced hyperemia and swelling of the optic disc (). There was peripheral vascular sheathing associated with vasculitis and a focus of hemorrhagic necrotizing retinitis in the superotemporal periphery (), with multiple smaller foci located more peripherally (). The patient reported no systemic symptoms or history of systemic disease.
The patient was diagnosed with ARN based on clinical findings and treatment with prednisolone acetate drops hourly, cyclopentolate hydrochloride drops 3 times daily, and intravenous acyclovir 750 mg, 3 times daily was initiated for anterior segment inflammation. Fundus fluorescein angiography (FFA) examination was recommended to confirm clinical findings, but the patient did not consent to the procedure. On day 3 of treatment, the patient decided she did not want to remain hospitalized and undergo the 14-day intravenous acyclovir treatment plan, and her therapy was changed to oral acyclovir 2 g, 3 times daily. On examination performed that day, the patient’s corrected visual acuity was 5/10 in the left eye and fundus examination revealed no further progression of the retinal lesions. On day 4 of treat

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


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

[User]
RADIOLOGY NOTE:
A 60-year-old man with a past surgical history of C5–C7 anterior arthrodesis for cervical fracture 17 years ago was found on the floor after an unwitnessed ground-level fall, resulting in a head strike. He was taken to the local hospital in an Aspen collar with a GCS of 15 and no neurologic deficits. Routine ECG and laboratory evaluation was unremarkable except for elevated serum alcohol level. Full cervical spine computed tomography (CT) scan was performed which showed an Anderson and Montesano classification (20) type III left occipital condyle fracture (), a Levine and Edwards classification (21) type III (Jefferson) fracture with mild lateral subluxation of bilateral C1 masses (), and an asymmetric widening and slight anterior subluxation of the right AOJ (). A head CT was performed which showed no acute intracranial abnormalities.
The patient was immediately transferred to a level I trauma center for further management. In the emergency department, he reported severe midline neck pain, worse with movement, and unchanged paresthesia to bilateral upper extremities which he states is his baseline. Physical exam was unremarkable except for a right forehead hematoma with overlying abrasions and tenderness to palpation over the midline posterior neck. He exhibited full strength and unchanged baseline sensation to all extremities. He denied bowel or bladder incontinence and had strong rectal tone and intact perianal sensation. Through his clinical course, he became increasingly altered and agitated, refractory to medication. He was unable to maintain spinal precautions due to his agitation, and in an attempt to protect his cervical spine, he underwent endotracheal intubation.
MRI of the cervical spine was performed and showed ligamentous injury at the craniocervical junction (CCJ) (Figures and ), asymmetric left odontoid-lateral mass widening, widening and subluxation of the right AOJ (), and edema of the paravertebral soft tissues around the fracture. CT and MRI esta

[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 man was referred to our electrophysiology laboratory because of dizziness and dyspnea. He was diagnosed with leiomyosarcoma of the right lower leg and received wide excision at another hospital 5 years ago. Later, he underwent several operations due to recurrent pulmonary lesions. Histological examination confirmed metastasis of leiomyosarcoma. Recently, the patient was in good physical condition for 2 years and no abnormal findings were detected on the surface electrocardiography (ECG) 2 years prior. However, the current ECG revealed complete AV block and idioventricular escaped rhythm of bifascicular block morphology suggesting infrahisian block (). Chest computed tomography revealed multiple pulmonary lesions and significant thickening of interventricular septum. The patient underwent cardiac magnetic resonance imaging, which revealed huge interventricular mass (67×35 mm) from base to apex with low signal intensity, similar to the myocardium on the T1-weighted image () and mild higher signal intensity, as compared with the myocardium on the T2-weighted image (). After enhancement with gadolinium, the tumor showed peripheral enhancement (). Trans-thoracic echocardiography revealed normal left ventricular ejection fraction (LVEF 60%) and no hemodynamic compromise. Dual chamber permanent pacemaker was implanted on the second day of admission and we placed a right ventricular (RV) lead toward free wall of RV apex that was confirmed by fluoroscopy and echocardiography because of tumor invasion in the septum of RV apex. There were no procedure-related complications, however, ventricular tachycardia (VT) developed 3 days later. Twelve-lead ECG showed wide QRS complex tachycardia, left bundle branch block pattern with left superior axis morphology and late transition, which is compatible with VT from RV apex (). Administered amiodarone and ß-blocker suppressed further events of VT and the patient was discharged uneventfully. He received pazopanib for pallia

[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 Indian female patient presented with a complaint of slow-growing painless palatal swelling of 1-year duration. Clinical examination revealed an oval, non-tender, bony hard swelling on the left side of the hard palate, extending from the canine to second molar region []. A premolar was missing on either sides of the maxillary arch. The teeth associated with the swelling were firm. There was no functional disturbance with speech, swallowing, and breathing. The family and medical histories were non-contributory.
A reformatted panoramic image [] from a cone beam computed tomography (CBCT) scan showed a large amorphous hyperdense mass in left maxillary molar region. The lesion appeared to be extending beyond the apices of the molars, with the superior extent of the lesion not clear on this view. However, the cross-sectional image at the level of maxillary first molar [] showed a well-defined, hyperdense mass originating from the palatal root that measured about 19 mm in greatest dimension. The density of the mass appeared to be similar to that of the dentino-cemental complex. The superior margin of the lesion seemed to have pushed the floor of the maxillary sinus superiorly. The tangential (parasagittal) section [] showed the lesion to extend from the distal of premolar to the second molar region, superimposing over the maxillary sinus. This view showed a slight variation in the density of the lesion (heterogeneous appearance). The axial section [] at the level apical to the furcation area of first molar showed the mass to be originating from the palatal roots and appeared to have breached the palatal cortex. All the above features were suggestive of a lesion originating from the root and made up of odontogenic tissues. Based on these radiographic images a differential diagnosis of cementoblastoma, cemento-ossifying fibroma, hypercementosis and focal sclerosing osteomyelitis was considered.
Surgical enucleation of the lesion including removal of the involve

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


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

[User]
RADIOLOGY NOTE:
A 64-year-old woman presented with large varicose veins, CEAP C2s, in the left lower limb. The patient had never been treated before because she was afraid of surgery. She had no history of migraine headaches or cardiac diseases. She had never smoked cigarettes, never had high blood pressure, and never been overweight. Her only medication was 20 mg sinvastatin once a day, and her last lipid profile, and all blood tests were normal. Except for the large varicose veins in her left lower limb, physical examination was normal, including normal peripheral pulses and absence of bruits. The patient was treated in the Trendelenburg position with a total of 10 ml of 3% polidocanol foam via direct punctures, 5 mL into an 8 mm diameter great saphenous vein and 5 mL into large collaterals in the leg. Foam was prepared with a 1:4 ratio of liquid to room air, using the Tessari technique involving 40 passes of agitation through a three-way stopcock using one 5 mL syringe and one 3 mL syringe. With ultrasound guidance, foam was injected immediately after each of three preparations, 5 mL, 2.5 mL, and 2.5 mL. No air boluses occurred. Ultrasound scanning showed no foam in the deep venous system. The patient remained lying down for 10 minutes after the injections, before being discharged wearing compression stockings. Less than 1 hour after leaving hospital, impairment of speech capacity was observed. She encountered difficulties when she tried to talk, with incomplete and incomprehensible words. No other alterations were noted. She was taken to another hospital, where the clinical presentation was misdiagnosed as an allergic reaction. One gram of hydrocortisone IV was infused and 20 mg prednisone was prescribed per day for 5 days. The next morning she came to the office to report the allergic reaction. After detailed history taking and physical examination, including the Wells DVT clinical model, the only alteration detected was aphasia. This was Broc

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


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

[User]
RADIOLOGY NOTE:
The 72 year old male patient was referred to our clinic with the complaint of bilateral axillary masses and numbness in the right hand. In his medical history, he had hypertension for 4 years but no history of trauma. A physical examination showed the presence of palpable pulsatile masses in his both axillae (12 cm in size in the right axilla and 8 cm in size in the left axilla) (Fig. ). His neurological and systemic examinations were within normal limits. An upper-extremity ultrasound examination revealed an aneurysm in a 12-cm segment of the right axillary artery, reaching 67 × 45 mm in dimension. There was a 27-mm thick thrombus at the edge of the aneurysm lumen. Adjacent to the aneurysm, there was a 48 × 40 mm hyperechogenic mass not related to the aneurysm. There was also an aneurysm reaching 40 × 43 mm in dimension in a 9-cm segment of the left axillary artery, with a 17-mm thick thrombus. A Doppler ultrasonic examination revealed a thrombus surrounding the lumen and a turbulent, pulsatile flow in the center. The aneurysmal segment was continuous with the brachial artery. There was no blood flow in the region adjacent to the right axillary artery (Figs. and ). On CT angiography, giant fusiform aneurysms were detected, measuring 140 × 77 mm in the right axillary artery and 93 × 45 mm in the left axillary artery. There were thrombi in both aneurysms, allowing the flow in the lumen. There was also an extension to the brachial artery and contour irregularities at the distal end of the right-side aneurysm. These latter findings were proposed to be due to a spontaneously healed rupture. A physical examination of the eyes, bones, skin and joints revealed no signs of collagen tissue disease, nor was it detected through laboratory examinations. Because the patient was symptomatic and had a high risk of aneurysm rupture, endovascular closure was initially planned. However, appropriate size stents could not be found for aneurysms so large and tortuous. Besides, 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 56-year-old healthy male presented to the emergency room with facial injuries following an accident while riding his motor scooter. He was wearing a helmet and did not suffer from a head injury or loss of consciousness. He was alert and oriented on presentation; on examination he had ecchymosis around his eyelids and a lacerated left eyebrow. His systemic and neurological examination was normal. His complete blood count and complete metabolic panel were within normal limits and toxicology screen was negative. He had a sinus bradycardia with a heart rate of 50–60 beats per minute with normal blood pressure. The electrocardiogram showed sinus bradycardia with normal PR interval. CT head, cervical, chest, and abdomen studies were normal. Maxillofacial CT showed undisplaced fracture of the left zygomatic arch with intact orbits. He had a left temporal artery laceration which was sutured and pain was controlled with opioids.
Due to the patient's sustained bradycardia, he was admitted to a telemetry bed for continued observation. The following morning, he had a 16-second pause and became unresponsive but regained consciousness before resuscitation could be initiated (Figures and ). In view of this event, the patient was transferred to the cardiac intensive care unit and observed with transcutaneous pacer pads in place. Over the next 24 hours, he had 3 more episodes of asystole (Stokes-Adams) lasting 3–6 seconds. A transthoracic echocardiogram preformed to evaluate for evidence cardiac contusion was found to be normal. Cardiac biomarkers were obtained and were nonelevated.
The cause of his significant bradycardia and recurrent asystole was a diagnostic quandary. Our patient was not on any bradyarrhythmic medications, his urine toxicology was negative, and there was no history of any tick bite. Over the next 48 hours, his frequency and duration of asystole decreased and his bradycardia gradually resolved. His opioid medications for pain control were gradually decreased ov

[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 16-year-old boy was admitted at age 8 years. He had mild hemiparesis on the right side that started at age 8 years (). His parents noticed this complaint when he was walking independently at age 18 months. He had a history of partial epilepsy with reduced consciousness that started at age 1 year and incompletely controlled by oral Na+ valproate treatment.
He had seizures usually twice a month, typically complex partial seizures or complex partial seizures evolving to generalized seizures localized to the right side. The patient was previously followed up with a diagnosis of perinatal hypoxic-ischemic sequelae at another center. His seizures were usually prolonged (>5 minutes) and sometimes lasted for about half an hour, which was compatible with status epilepticus.
He was born at home by spontaneous vaginal delivery with the help of a midwife without complication. Birth weight, head circumference, and height were unknown; therefore, the Apgar score could not be calculated. The mother had neither related significant medical history nor regular antenatal medical follow-up. Fetal movements during the antenatal period were normal.
His early motor development was normal, except having mild hemiparesis that was noticed at age 18 months. The patient's hand preference during the first 2 years is not known. The patient started walking without support at age 18 months. His social and language milestones were normal. At age 6 months, bilateral cataract was noticed. He was operated for cataract and glaucoma, and prophylactic glaucoma treatment was started.
His initial physical examination revealed a marfanoid appearance with disproportionately long arms and legs compared with the trunk. However, he had no signs of wrist (Walker) or thumb (Steinberg), or joint hypermobility or arachnodactyly, that are typical signs of Marfan syndrome. Cranial nerve examinations and eye movements in all directions were normal. He was using hypermetropic glasses. Ophthalmologic examination 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:
A 35-year-old male patient referred to us with a history of progressing right nasal early obstruction that tended to become bilateral during the period of 1 year. The patient also had the complaint of bloodstained, on and off nasal discharge. Over time he developed dull pain in the right facial region. Initially the patient took indigenous treatment. During this course of management, he did not get significant relief from his symptoms. Hence he came to the tertiary care center Ear, Nose, and Throat (ENT) OPD at IGIMS, Patna, Bihar, India for further treatment after 9 months of the appearance of initial symptoms. At the tertiary care center, the ENT surgeon examined him and found a lobulated fleshy mass obliterating his right nasal cavity, with deviation of the septum toward the left side. Computed tomographic (CT) scan of the peripheral nervous system (PNS) was advised, which revealed a large, enhancing, destructive nasal mass involving both nasal cavities, 9 × 4.5 × 4.4 cm3 in size, with significant bone erosion involving the lamina papyracea and cribriform plate without significant intracranial extension. On the basis of this, a diagnosis of inverted papilloma was made and a biopsy was taken. The histopathological examination (HPE) report revealed poorly differentiated malignant tumor and the possibility of malignant melanoma; the case was referred to the oncology department for further management and treatment.
The eye examination revealed eye movement in all quadrants with normal pupillary reflex. The oral cavity examination was normal, including normal alveolar process and palate, and no loose teeth. The rest of the ENT examination including ear, pharynx, larynx, and neck was within normal limits (WNL); the chest and abdomen were normal.
On the basis of these findings, total maxillectomy on the right side was done and a specimen was sent for HPE. The final examination revealed the possibility of malignant melanomas, and immunohistochemistry (IHC) was advised. I

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


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

[User]
RADIOLOGY NOTE:
An 18-year-old nulliparous woman presented with abnormal vaginal bleeding. Ultrasound detected the presence of an endometrial polyp, which was confirmed on hysteroscopy and removed using a resectoscope. The polyp was approximately 2 cm in length. Histological analysis revealed benign endometrial glands with moderately cellular stromatolites showing some degree of periglandular condensation and mild pleomorphism. No SO or MI was noted. The histological diagnosis of low-grade adenosarcoma was made. Subsequently, the patient was advised to undergo hysterectomy, BSO and lymphadenectomy, but she declined to preserve her fertility. She was referred for a second opinion and following extensive counselling, opted for conservative management.
Over the following 10 years, she was monitored with pelvic ultrasound, hysteroscopy and endometrial biopsy every 6 months, and with annual pelvic magnetic resonance imaging. Follow-up was largely uneventful, with normal imaging and histology. Nine years post-operatively an abnormal appearing area on the posterior aspect of the lower uterine segment was identified on hysteroscopy and subsequently resected. Histology was benign with no features of recurrence.
Eleven years post-operatively, she underwent in vitro fertilization (IVF) and successfully conceived following the first cycle. Unfortunately, she suffered a second trimester miscarriage at 16 weeks’ gestation, with a history suggestive of cervical incompetence after admission with a dilated cervix and bulging membranes. The following year she conceived twins following another IVF cycle. She underwent an uncomplicated elective trans-vaginal cervical suture. She delivered male twins at 28 weeks’ gestation following pre-term labour, which was attributed to placental abruption. Both children are alive and well. She was offered hysterectomy after delivery, and at each subsequent follow-up appointment, but declined as she was uncertain as to whether or not her family was complete. Followi

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


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

[User]
RADIOLOGY NOTE:
We describe a case of a 74 year old male patient, affected by a myeloproliferative syndrome. At the age of 26 he underwent a surgical gastrectomy for a hemorrhage caused by a perforated ulcer. Later, in December 2006, an upper gastrointestinal endoscopy revealed a neoplasm at the level of the thoracic esophagus. Multiple tissue biopsies histologically showed a scarcely differentiated squamous cell carcinoma. Subsequently all the necessary staging exams, including a total body Computed Tomography (CT) were performed. The CT did not show any suspected lymph nodes nor other lesions. In March 2007 the patient underwent a total esophagectomy and an esophago-gastroplasty with colon interposition for replacement of the esophagus.
The final histological findings confirmed the diagnosis of infiltrating squamous cell carcinoma; (Figure ). The lesion extended into the sub mucosal layer, a grade G3 was diagnosed and the surgical margins were considered free of infiltration. Since the regional lymph nodes were not reported, the final staging was pT1 pNx. In addition, a sample was taken at a distance from the original tumor as an occasional finding in the esophageal muscular tunica. This showed a fused cellular intramural micro nodule with a maximum diameter of 0.2 cm, and with morphological characteristics suggesting a very low risk GIST (Figure ).
The immunohistochemistry of the fused cells showed an intense and diffuse positivity for CD117, CD34 and CD99 and negative results for S100, desmin and actin (Figure ). The proliferate index Ki 67 was less than 5% with 4 mitoses per 50 HPF.
The aspects of this lesion reminded palisading-vacuolated spindle cell GISTs. In fact it showed nuclear palisading, resembling peripheral schwannomas and the typical feature of prominent perinuclear vacuolization.
In May 2007, a total body CT scan showed the presence of necrotic-hemorrhagic foci, of probable ischemic nature, in the cortical and sub cortical brain regions. At the same time, the thor

[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:
On March 2015, a 22-year-old right-handed male with a 2 month history of right sided weakness and numbness was diagnosed with a primary brainstem tumor on MRI. He was empirically treated with temozolomide, bevacizumab, and stereotactic radiosurgery (SRS). Six months later, while stable disease was noted on brain MRI, the patient was also treated with an additional hypo-fractionated course (~50Gy in 25 fractions over 2 months) of involved field radiation.
Patient received empiric chemotherapy and radiation therapy for 21 months and follow-up brain MRI on December 2016 revealed a stable, necrotic left midbrain mass lesion measuring 2.5 × 2.1 × 1.8 cm with subacute hemorrhage in the inferior posterior margin [].
Nearly 2 years after the initial diagnosis, the patient presented to the clinic with progressively worsening gait instability and left greater than right weakness. Additional symptoms included transient confusion with malaise and dizziness. Brain MRI at this time revealed progression at medial and inferior margins along with interval mild ventriculomegaly consistent with obstructive hydrocephalus []. Decision was made to place the shunt and resect the tumor in a two-stage procedure during the same admission.
The patient underwent an uneventful right occipital ventriculoperitoneal shunt placement with utilization of volumetric image guidance and laparoscopic assistance.
The following day, left posterior temporal-occipital craniotomy was performed with an intention to obtain tissue for diagnosis and remove as much of the brainstem tumor as safely as possible. Volumetric image guidance, microscope, neuro-monitoring, and intraoperative MRI were utilized. The brainstem lesion was approached through the posterior temporal-occipital supratentorial plane with sectioning of the tentorium to widen the exposure. The inferior posterior temporal gyrus was partially resected, allowing mobilization and preservation of the vein of Labbe. The midbrain was entered through the la

[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 woman with recurrent pneumonia, who had been repeatedly hospitalized every year since 1988, was admitted to our hospital. She was treated for pulmonary tuberculosis 9 years before admission to our hospital. She was a nonsmoker and did not have any other disease or a family history of any disease.
Chest radiography showed a calcified wall in the left lower lung field and multifocal nodular calcification in the adjacent lung parenchyma (). Computed tomography (CT) angiography () showed a multiseptated cystic mass in the left lower lobe, systemic arterial supply from the descending thoracic aorta, and venous drainage to the left inferior pulmonary vein. Therefore, she was diagnosed with intralobar pulmonary sequestration. A posterolateral thoracotomy with single-lung ventilation was performed through the fifth intercostal space, sparing the serratus anterior muscle. This procedure was performed under general anesthesia, with the patient lying in the right lateral position. A necrotic mass 10 cm in diameter was located in the left lower lobe with severe pleural adhesion, and 3 feeding arteries from the descending aorta were observed. After ligation and division of the feeding arteries, a standard left lower lobectomy was performed.
The resected mass measured 5×5×2 cm and showed multiseptated cystic spaces interposed by consolidated or fibrotic lung parenchyma and bronchus-like structures (). The mass was located at a distance of 2.5 cm from the bronchial resection margin. Microscopically, the mass consisted of congested alveoli, dilated bronchi and bronchioles, and accompanying thick walled vessels, consistent with pulmonary sequestration. A few atypical cells were identified in the cystic wall, spanning 0.5 cm. They were arranged in nests and cords without stromal reaction. The cells showed salt-and-pepper type nuclear features without prominent nucleoli. Small amounts of cytoplasm were eosinophilic with an indistinct boundary (). The nest and cord-like g

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


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

[User]
RADIOLOGY NOTE:
A 65-year-old white male presented to our clinic for a second opinion. Seven years earlier, he noticed a skin rash over the anterior part of his neck. He was initially evaluated by a dermatologist, who prescribed topical steroids leading to temporary improvement of the lesion. Unfortunately, the rash returned and was associated with the tightening of the skin over his neck.
Three years later, despite the occasional use of topical steroids, the skin tightness started to spread down his body, affecting his chest, upper and lower extremities. The patient underwent multiple skin biopsies, and the histopathological report was consistent with lymphocytic infiltration, possibly EF. Peripheral eosinophilia was also present.
Based on the biopsy report, the patient was referred to a rheumatologist who diagnosed his disease as EF and first prescribed Plaquenil, and then, due to a lack of improvement, switched to 15 mg of methotrexate (MTX) orally once a week, 1 mg of folic acid orally once a day, and prednisone orally as needed.
Despite being compliant with his regimen, the skin over his body was getting progressively tighter, and was associated with a lack of energy and joint pain that affected his hands, elbows, knees, and feet. The skin around his neck became so indurated that swallowing solid food was difficult. He developed contraction of the upper and lower extremities associated with severe muscle weakness, requiring a wheelchair for daily activities.
Three years prior to presentation in our clinic, he had developed a diffuse erythematous rash all over his body requiring hospitalization and was subsequently diagnosed with Stevens-Johnson syndrome and was treated with high doses of steroids.
At the time of our evaluation, the patient denied chest pain, skin rash, shortness of breath, Raynaud’s phenomenon, uveitis, episcleritis, mouth ulcers, or blood in his urine or stools. Physical examination showed a debilitated, frail male who appeared older than his age. Eyes,

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


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

[User]
RADIOLOGY NOTE:
An 80-year-old woman was referred to our clinic with a history of chronic abdominal pain and weight loss of 10 kilograms in the past six months. The patient was postmenopausal for 30 years and had a free medical history. Physical examination revealed no tenderness, but a hard and mobile mass palpable in the right iliac fossa. Further investigation by means of transvaginal ultrasound revealed a cystic formation, sized 83 × 65 × 64 mm in the right adnexal area. The mass was of mixed structure, comprising of solid and cystic areas. The wall was smooth and anechoic on ultrasound imaging. No papillary projections or septations were identified and there were no signs of blood flow during the color Doppler evaluation. The left ovary was illustrated measuring 25 × 13 × 11 mm, but the right ovary could not be visualized (Figures and ). A polyp of the endometrium was also recorded, with total endometrial thickness of 8 mm. No free fluid was seen in the Douglas pouch. However, it was inconclusive whether the mass originated from the right adnexa or it concerned a uterine necrotic leiomyoma that protruded towards the adnexa. Because of the indeterminate ultrasound findings, an abdominal CT scan was carried out which identified a cyst sized 100 × 80 mm with signs of peripheral calcification attributed to a lesion of the right ovary (Figures and ). As a routine investigation, when an ovarian tumor is suspected, our patient underwent colonoscopy, during which a benign polyp of the sigmoid colon was excised; also a submucosal round smooth cystic formation of one cm in diameter at the site of the appendix was identified. Tumor markers were within normal limits, with the exception of carcinoembryonic antigen (CEA: 54, 2 ng/mL).
The patient underwent laparotomy with the diagnosis of a pelvic mass, in which a cystic tumor originating from the appendix, sized 80 × 90 mm, was identified, whereas the uterus and ovaries were atrophic. The abdominal viscera were covered with surgical pad ga

[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 37-year-old female presented to the Center for Temporomandibular Disorders and Orofacial Pain, with a chief complaint of limitation of mouth opening and pain on the left side of the face of 1-month duration. The onset was sudden. The patient described the pain in the area of the left cheek and in front of the ear, sometimes radiating to the neck. The patient reported that the pain was related to function, such as talking, chewing, and yawning. The patient also reported a history of a similar episode a year earlier and was diagnosed with a TMD at that time. She was offered home care and stretching instructions (physical therapy) and advised to monitor the pain and limitation of opening. Over-the-counter medication (acetaminophen and ibuprofen) was recommended as needed for the relief of pain. For the limitation of opening, she was instructed to use hot and cold compressions bilaterally in the area of the masseter muscle.
The current pain began spontaneously, the week prior to the evaluation. Pain was frequent (4–5 times a day) and intense in nature, with a duration of a few seconds to minutes. The patient described her pain as continuous and aching with spontaneous attacks. The patient's concerns brought her to the orofacial pain clinic for an evaluation.
The current episode of spontaneous pain of 1 month's duration was not associated with a history of trauma. The patient did not report a history of fever, or neurological problems prior to the onset of the current problem. Her medical, family, and psychosocial histories were noncontributory. She is a vegetarian, but reported eating raw salads at restaurants. She reported that her ability to open her mouth was limited to one-finger width (approximately 4–5 mm). Her primary care physician prescribed a muscle relaxant, carisoprodol 350 mg three times per day for 2 weeks, and advised her to seek an evaluation for a temporomandibular joint

[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 92-year-old man with osteoarthritis and a remote history of right total hip replacement and bilateral total knee replacements presented with a two-day history of severe right hip pain accompanied by nausea, chills, and fatigue. He was unable to bear weight due to pain, and range of motion in his right hip was severely limited. He denied recent trauma or pain in other joints but had undergone routine dental cleaning one week prior to presentation. He had received 2 gm of amoxicillin immediately prior to his dental procedure. He presented afebrile, mildly hypotensive, and was noted to have exquisite tenderness with passive movement of the right leg and reduced range of motion secondary to pain. He had full range of motion and strength distally. He had a leukocytosis of 15,600 WBC per milliliter. Aspiration of right hip joint revealed cloudy fluid with WBC 68,000 cells per milliliter. The patient was resuscitated with IV fluids and started on vancomycin and piperacillin-tazobactam. On the third hospital day, he underwent prosthetic joint drainage and washout with retention of liners. Joint aspirate culture grew Gram-positive cocci in chains, which we subsequently identified by matrix-assisted desorption ionization time-of-flight mass spectrometry (MALDI-TOF MS) as S. salivarius. We narrowed antibiotic therapy to ceftriaxone to complete six total weeks of intravenous therapy, after which he was treated with amoxicillin for additional six weeks. At this point, the patient discontinued his oral antibiotics rather than complete a full three months of oral therapy or remain on long-term suppression.
Five months after completion of the above therapy, the patient presented to the ED with hip and back pain following a mechanical fall at home. He was found to have a fracture of L4 and was admitted. On hospital day 5, he was found to have an occult superior dislocation of the R femoral head on CT and an ESR of 71 and CRP of 12.3. He 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:
The 72 year old male patient was referred to our clinic with the complaint of bilateral axillary masses and numbness in the right hand. In his medical history, he had hypertension for 4 years but no history of trauma. A physical examination showed the presence of palpable pulsatile masses in his both axillae (12 cm in size in the right axilla and 8 cm in size in the left axilla) (Fig. ). His neurological and systemic examinations were within normal limits. An upper-extremity ultrasound examination revealed an aneurysm in a 12-cm segment of the right axillary artery, reaching 67 × 45 mm in dimension. There was a 27-mm thick thrombus at the edge of the aneurysm lumen. Adjacent to the aneurysm, there was a 48 × 40 mm hyperechogenic mass not related to the aneurysm. There was also an aneurysm reaching 40 × 43 mm in dimension in a 9-cm segment of the left axillary artery, with a 17-mm thick thrombus. A Doppler ultrasonic examination revealed a thrombus surrounding the lumen and a turbulent, pulsatile flow in the center. The aneurysmal segment was continuous with the brachial artery. There was no blood flow in the region adjacent to the right axillary artery (Figs. and ). On CT angiography, giant fusiform aneurysms were detected, measuring 140 × 77 mm in the right axillary artery and 93 × 45 mm in the left axillary artery. There were thrombi in both aneurysms, allowing the flow in the lumen. There was also an extension to the brachial artery and contour irregularities at the distal end of the right-side aneurysm. These latter findings were proposed to be due to a spontaneously healed rupture. A physical examination of the eyes, bones, skin and joints revealed no signs of collagen tissue disease, nor was it detected through laboratory examinations. Because the patient was symptomatic and had a high risk of aneurysm rupture, endovascular closure was initially planned. However, appropriate size stents could not be found for aneurysms so large and tortuous. Besides, 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.