[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 C was also a 10-year-old girl, who was otherwise healthy other than exhibiting poor growth. At baseline, she was involved in gymnastics; however, this changed when she started to experience right hip pain. This pain persisted at all times of day and was partially relieved by ibuprofen. It was never in the left hip or knees, but she reported some discomfort in her ankles. She had no fevers but developed a transient pustular rash on her palms and soles.
As the pain became increasingly disabling, she developed a limp. She was referred to orthopedics, who prescribed crutches and obtained a hip MRI. This showed a lesion in the right medial proximal femur (). A bone scan was then performed to look for additional lesions, but none were found. Biopsy of the lesion was consistent with osteomyelitis but was undifferentiated between an infectious vs. inflammatory cause. The patient was thus referred to both infectious disease and rheumatology.
Infectious disease specialists suggested that the patient's presentation was more consistent with CRMO than bacterial osteomyelitis, given the chronicity and negative culture on biopsy. Our rheumatology team came to the same conclusion (1-year after symptom onset). When we saw the patient, she was tired and pale appearing, with thinning hair. Her BMI percentile was 1%. Musculoskeletal examination was notable for tenderness in the sacroiliac region and right femur, as well as reduced range of motion of her ankles. There were no skin lesions at the time of our exam. WBMRI showed lesions in her proximal right humerus, proximal right femur, bilateral proximal tibias, and bilateral distal femurs. She was treated with indomethacin and has since clinically improved.
Given her history of poor growth, a fecal calprotectin was performed to screen for IBD and was positive. This led to a colonoscopy, which showed granulomas throughout her intestinal tract (Chronic Granulomatous Disease was evaluated and excluded). She was given

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


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

[User]
RADIOLOGY NOTE:
A 48-year-old, previously healthy male was admitted to the hospital with altered mental status of one day duration. The patient was confused and was not answering questions appropriately. Vital signs were remarkable for low-grade fever of 100.7 ºF and tachycardia. His physical exam was remarkable for a holosystolic murmur at the apex, radiating to the axilla. He was alert and oriented to self, but not to place or time. Cranial nerves were grossly intact with no focal neurological deficits. Laboratory evaluation revealed leukocytosis and mild hyponatremia. A computed tomography scan of the head did not show any acute intracranial hemorrhage. A lumbar puncture was performed and cerebrospinal fluid analysis did not suggest meningitis; however, the patient was started empirically on vancomycin, ceftriaxone, ampicillin, acyclovir, and dexamethasone. Magnetic resonance imaging of the brain showed large area of infarction in the left frontal, left parietal, and left caudate body, suggestive of a cardio-embolic source (Figure ). An echocardiogram revealed a large, mobile, vegetation (1.5 x 1.5 cm) on the mitral valve likely affecting the anterior and posterior leaflets with mild to moderate mitral regurgitation (Figures -). Blood cultures were sent to the lab, which later grew Streptococcus agalactiae. An infectious disease team was consulted and antibiotics were switched to penicillin G and gentamicin.
A cardiothoracic surgery team was consulted and he was not deemed a surgical candidate as it was thought it would be unlikely that the patient will have a meaningful recovery, and the risks outweighed the benefits of surgery. The patient’s mental status remained the same; he remained alert and oriented to self only despite several days of antibiotics. His repeat blood cultures remained negative.
In the third week of his hospitalization, the patient experienced worsening of his altered mental status and he was not responding to questions. An MRI of the brain showed hemorrhagi

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


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

[User]
RADIOLOGY NOTE:
A 47-year-old male patient with no relevant medical history presented with left hemiparesis for one hour. He had minor left facial paralysis and dysarthria, severe hemiparesia pointing 9 on the National Institutes of Health Stroke Scale. Brain tomography and angiotomography were performed; no brain lesion, arterial stenosis, or occlusion on cerebral circulation was visible. With clinical history, physical exam and image were compatible with stroke with significant deficits, intravenous thrombolysis was performed. The following day, MRI showed diffusion-weighted increased signal on the right pontine side as expected to a stroke (Figure ). A transesophageal echocardiogram was normal. Initial investigation for rheumatologic and hematologic was normal. The patient had a moderate continuous recovery. Five days after admission, he was discharged to ambulatory care follow-up and was prescribed statins and aspirin. At discharge, neurologic examination revealed left-sided hemiparesis and mild dysarthria.
Two weeks after the initial stroke, the patient returned to the ED due to worsening left hemiparesis and dysarthria. MRI showed an expansion of the area of diffusion-weighted increased signal on the right pontine side (Figure ); the patient was managed as a stroke expansion. No indications of infection or hypotension were noted. However, the patient developed right central facial paresis and anarthria 12 hours after admission. A more comprehensive evaluation was performed with brain contrast MRI due to the new symptoms and longer time frame between the first stroke and stroke expansion than expected. The new brain MRI revealed a left pontine infarction (Figure ) with the characteristic “heart appearance” sign. We performed an extensive search for stroke etiology with negative results: arteriography and lumbar puncture were normal and there was no evidence of thrombophilias. After the initial worsening, the patient stabilized and had a stable recovery. He was discharged one m

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


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

[User]
RADIOLOGY NOTE:
A 14-year-old Caucasian girl with JIA diagnosed at 2 years of age returned to our pediatric rheumatology clinic with complaints of increased morning stiffness of both knees and a mass of the left knee. Three weeks prior to the onset of knee stiffness, she noticed a mass on the lateral side of her left knee. She had decreased knee flexion and pain with walking that was greater on her left side. She reported a painful snap when she moved her left knee from a flexed to extended position, but no instability or locking. There was no warmth, erythema, interval growth, or fluctuance of the mass. She also did not have any systemic symptoms including fever, chills, or recent weight loss.
Her past medical history was significant for extended oligoarticular JIA with 5 joint involvement and a positive Anti-nuclear antibody (ANA at 1:80), HLA-B27 negative, and rheumatoid factor (RF) negative. Over the first two years of her illness, she required only NSAIDs until she developed a photosensitive rash with Naproxen. Over the next 6 years, she needed methotrexate and ibuprofen intermittently for flare ups and was maintained on these medications for 1 to 2 year intervals and then tapered off. She had been disease free for three years when she presented with this new knee mass. She had a brief episode of mild iritis earlier in the course of her disease with full resolution while on methotrexate. Our patient lived on a neighboring island far from pediatric rheumatology services. When we were informed about the patient’s knee mass, we were extremely concerned because of her strong family history of cancer and her earlier treatment with methotrexate. Her family had a range of cancers including liver, pancreatic, stomach, throat, lymphoma, melanoma, non-Hodgkin's lymphoma, and glioblastoma in different members of the family.
On examination, there was a 1.5 × 2.0 cm well-circumscribed, and non-tender mass.

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


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

[User]
RADIOLOGY NOTE:
A 2.6 kg, 2-day-old female child, delivered by cesarean section, was brought to us with malformed external genitalia and a swelling over the lower part of the abdomen and the perineum.
Physical examination revealed a lobulated bowel projection with a skin-covered swelling extending over the lower part of the abdomen and the perineum. The umbilicus was low set, situated just above the upper extent of the swelling. The pubic symphysis was widely separated with a bulging urinary bladder occupying the space in between. The introitus was replaced by the swelling which was continuing on to the lower abdomen. There was duplication of the introitus with two openings, each flanked by the single labia majora located laterally, in the groin area []. The clitoris was bifid. The two orifices on either side were in communication with each other as a catheter introduced from one orifice exited through the other. The urethral orifice could not be seen from the outside; however, both the introitus openings were discharging urine intermittently. The anal opening was absent. An infantogram and cross-prone-lateral X-ray showed a high type of anorectal malformation and the absence of calcification in the area of accessory bowel loop.
The baby was resuscitated and undertaken for surgery. A midline laparotomy showed that the small bowel and large bowel were normal and in continuity. The internal genitalia were female type and the uterus was unicornuate with normal fallopian tubes and the ovaries. The urinary bladder was intact although subcutaneous in location. The accessory bowel loop was attached to the lower part of the swelling and the lumen was in continuity with lumen of the terminal part of the rectum. The extra piece of the bowel was excised and the terminal part of rectum fashioned as a neoanus []. A suprapubic cystostomy (SPC) was also inserted as the anatomy of the bladder neck and urethra was still not clear.

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


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

[User]
RADIOLOGY NOTE:
A 4-year-old female child was brought to the Pediatric Dentistry Clinic of the School of Dentistry of the Federal University of Rio Grande do Sul (UFRGS), Brazil, for esthetic rehabilitation of anterior teeth. The patient's general health status and past medical history were satisfactory. The mother reported that the primary incisors were darkened and nonuniform, and that the girl would start in the school next year and this clinic situation could disturb her.
All posterior teeth had active cavitated carious lesions and/or extensive restorations showing a past history of ECC. In the anterior region, teeth 52, 51, 61, and 62 had extensive restorations associated with carious lesions. All canines have active not cavitated carious lesions and the lower incisors (72, 71, 81, and 82) were healthy (). In the radiographic examination, none of the posterior teeth presented pulpal involvement. Teeth 51 and 61 presented irreversible pulpal involvement with an extensive root resorption and considerable bone loss around them, associated with draining sinus, and tooth extraction was indicated.
The treatment plan was settled and explained to the mother, who signed an approved informed consent form authorizing the treatment as well as disclosure and publishing of this case report. Initial dental care consisted of removal of hopeless teeth (51 and 61) and intervention in etiologic factors of caries disease as plaque control, diet, and rational use of fluoride.
All posterior restorative treatments were conducted undergoing the selective caries removal technique and a composite resin was used for the restoration. In the anterior region, teeth 52 and 62 had unsatisfactory restorations and 52 have a dentin lesion in the palatal surface, presenting them dark and not aesthetic. A fixed functional space maintainer replacing both teeth 51 and 61 was planed, and direct composite resin veneers in 52 and 62 were placed.
Teeth 52 and 62 were worn on the vestibular surface to remove old restora

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


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

[User]
RADIOLOGY NOTE:
A 40-year-old male with a 20-year history of schizophrenia presented to the emergency department with long history of pharyngeal foreign body sensation which had progressed over one month to include sore throat, odynophagia, and dyspnea. Physical exam revealed asymmetric prominence of the right posterior oropharyngeal wall and trismus with maximal interincisural distance of two centimeters. There were tenderness, edema, and erythema of the right submandibular triangle without palpable mass.
Flexible laryngoscopy showed fullness of the right posterior pharyngeal wall without mucosal abnormality, resulting in anterior displacement of the right aryepiglottic fold. This was encroaching on the airway but not causing critical airway stenosis. A computed tomography (CT) scan of the neck with contrast was obtained. This demonstrated a linear opacity extending from the oropharynx to the right thyroid ala. Reconstructed 3D images showed a uniform mass consistent with a foreign body (). Further psychiatric history was obtained and revealed a history of auditory hallucinations that had on several occasions led to suicide attempts, including one attempt two years ago in which the patient stabbed himself in the pharynx with a broken toothbrush handle. Prompt removal was recommended given risk for infection and airway compromise.
The patient was transorally intubated over a flexible bronchoscope and then underwent direct laryngoscopy. Swelling of the right posterior oropharynx and hypopharynx was noted (). An anterolateral neck incision was made and subplatysmal flaps were raised. The mass was easily palpated overlying the right thyroid ala, and blunt dissection allowed entry into the fibrous capsule surrounding the foreign body (). The capsule was opened, and the foreign body was removed. The length corresponded exactly to the length of the foreign body on the CT (). A sample was obtained for bacterial culture, the wound was irrigated, and a drain was placed. The patient was extu

[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 77-year-old Caucasian gentleman was admitted with acute kidney injury discovered on blood tests. He was known to have high-grade prostate intraepithelial neoplasia and atypical small acinar proliferation from prostate biopsies performed for a raised prostate-specific antigen (PSA), with a bone scan negative for potential metastases and was on PSA surveillance with the latest reading of 43 pre-admission. Prior to admission, he had lower urinary tract symptoms in the form of frequency, nocturia, intermittent urinary stream, terminal dribbling and a feeling of incomplete emptying. There was no significant past medical history. On examination, he was haemodynamically stable and afebrile. There was a palpable non-tender bladder with dullness to percussion and no renal angle tenderness.
Blood tests revealed a Stage 3 acute kidney injury (baseline renal function was normal) with raised inflammatory markers and elevated PSA compared with baseline (Table ). A mid-stream urine specimen sent for microscopy, cultures and sensitivities yielded no growth of organisms. A bedside bladder scan revealed a bladder volume of >999 ml, necessitating the insertion of a urethral catheter with a residual volume of 2.4 l, and intravenous antibiotics were commenced. An ultrasound scan (USS) of the urinary tract was performed to evaluate for the presence of hydronephrosis; but while this demonstrated a minor dilatation of the left renal pelvis, it also found a shallow fluid collection around the left kidney extending into the left lateral retroperitoneum, separate from the left psoas muscle (Fig. ). In the urinary bladder, there was an irregular 4 cm mass on the left posterolateral aspect. In view of the findings, an urgent flexible cystoscopy was performed, revealing a massive median lobe of the prostate protruding up and back into the bladder; the ureteric orifices were not visualized because of this, and the bladder mucosa was normal. The patient subsequently underwent a computed tomograp

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


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

[User]
RADIOLOGY NOTE:
Our patient, a 58-year-old Caucasian male, presented to the emergency department with the acute onset of quadriplegia extending from C5 throughout the rest of the pan neuroaxis while awakening from bed the morning of presentation. Upon initial physical examination there were no signs of trauma noted that were significant to the presenting symptoms, additionally, patchy sensation was noted in the upper and lower extremities with clonus in the legs only and hyperreflexia in both arms and legs. Initially, our patient was administered one intravenous dose of methylprednisolone and allowed to enter a state of permissive hypertension which improved our patient's arm strength bilaterally to 2/5, but had no positive effects on the lower extremity paraplegia. As a result of minimal improvement, immediate imaging of the cervical spine was ordered and highlighted a severe cervical stenosis from C3 to C7, as seen in Figure , due to extra-axial posterior compressive spinal mass with cord signal change.
Additional imaging of the brain was completed as a precautionary measure and was normal. Upon obtaining full patient history and medical records from nearby hospitals, it was found that our patient was on a prolonged regimen of warfarin for many years due to a prior diagnosis of congestive heart failure without regulation and regular INR/prothrombin evaluation. Our patient also did not follow up with his primary care physician throughout the duration of the warfarin regimen. At presentation, our patient's INR was found to be 5.0 necessitating the prompt correction with intravenous injection of fresh frozen plasma (FFP) and vitamin K. Additional magnetic resonance imaging (MRI) of the thoracic and lumbar spine revealed large compressive acute epidural hematoma posteriorly compressing the thoracic spinal cord from T6 to T10, visualized in Figure , with cord signal change, as well as L4-S1 posterior acute epidural hematoma compressive of the cauda equine, visualized in Figure .
Upon

[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 lady presented to the emergency department following a fall and sustained isolated capitellar fracture (). On CT scan, this was found to be Type III capitellar fracture according to Bryan and Morrey’s classification (). She was taken to theater on a routine trauma list and an attempt was made to fix the fracture fragment but in view of severe communition and osteoporosis, it was not possible to fix the fracture and hence the fragment was excised (). She was found to have mild valgus instability on table. The elbow was immobilized for few weeks in back slab and then the patient was referred to physiotherapy. She achieved range of motion of 30–90 degrees in elbow joint with full supination and pronation.
Her repeat radiograph at 4 months showed slight subluxation of the elbow toward radial side with some incongruency in humeroulnar joint. She continued to have pain in her elbow, especially on loading and also features of lateral instability. Radiocapitellar resurfacing option was thought of, but in view of very poor bone stock and subluxation, it was felt that this would not be suitable option for her. Other treatment options were discussed in the form of tendon interposition arthroplasty, total elbow replacement, and allograft reconstruction. All options were discussed with her and having understood the pros and cons of each procedure, she opted for capitellar reconstruction using allograft. The configuration of defect was replicated with the help of 3D printing prepared from her latest CT scans.
The freeze-dried humerus allograft was used for surgery. After GA, the patient was positioned supine on table and sterile tourniquet was used. Kocher incision was used and common extensor origin was identified and soft tissue was freed anteriorly and posteriorly to expose the lateral condyle and the size of defect was assessed. Soft tissue and synovium were removed with curette. Defect was measured with the help of ruler and guide wire and was found

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


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

[User]
RADIOLOGY NOTE:
A 22-year-old woman was referred to our outpatient department. She complained of lower left abdominal pain without radiating to other parts of the body, which had occurred for the previous 2 months. She did not complain of any urinary or bowel symptoms such as urinary frequency, urgency, dysuria, or incontinence. She denied any significantly surgical or medical history. Bimanual pelvic examination detected a well circumscribed firm and slightly movable spherical lesion located in the left of the vaginal wall. Urinalysis was within normal limits. Ultrasonography (US) revealed a relatively irregular and heterogeneous mass in the left posterior wall of the bladder. Contrast-enhanced computed tomography (CT) scan demonstrated a 3.2 × 2.5 cm soft, mild enhancement mass near the left posterior wall of the bladder, protruding into the bladder locally (). The cystoscopy found a hemispherical mass located in the left wall of the bladder close to the internal urethral orifice with intact urothelium, indicating that the mass was either external to the bladder or arising from it. The subsequent transurethral resection deep biopsy was normal. Based on clinical evaluation and all complementary findings, an equivocal diagnosis of pelvic mass could only be obtained. The tumor was resected transvaginally for diagnosis and treatment. The operative procedures were as follows: first, bilateral ureteral stent implantation was performed with cystoscope in order to protect the ureters; second, we separated the tumor through the vagina part and partly incised the bladder neck. We found that the mass was intramural of the bladder neck. Finally, we probed and removed the tumor completely without cutting through the whole bladder. The whole process was within simultaneously cystoscopic control. The resected mass had smooth surface and its measured diameter was proximately 3 cm. The cut surface of the tumor showed white laminated periphery. To avoid the possible postoperative complications 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:
An 8-year old girl presented with a history of left-sided submandibular swelling of 1-week duration. There was no reported fever, loss of weight or appetite, or any other generalized symptoms. There was no throat pain or difficulty in swallowing. She was started on broad-spectrum antibiotic treatment with no improvement, and the swelling increased in size. Computed tomography (CT) scan was done outside our institution and showed a large cystic mass lesion in the submandibular area. She had an open drainage procedure as an outpatient on the assumption of an abscess. The family was told that the drainage was successful and no further information was given to the family regarding microbial culture results.
She then presented to our outpatient clinic for further investigation since the mass did not change in size. On examination, she had a large submandibular mass measuring 5 cm × 5 cm which was slightly tender on palpation; she had no evidence of fever or tachycardia.
Examination of the throat revealed normal tonsils and no lesions could be found in the oral cavity. No abnormalities could be found in the nasopharynx or hypopharyngeal area.
Laboratory examination showed leukocytosis with a white blood cell count of 24,000 with 70% neutrophils, 20% lymphocytes, and 7% monocytes. The C-reactive protein was mildly elevated at 83 mg/L. Levels of serum lactate dehydrogenase and uric acid were normal.
Neck ultrasound and CT scan [] showed a necrotic mass lesion in the left submandibular region, measuring 5.6 cm × 5.2 cm × 5.2 cm, suggestive of an abscess with associated adjacent reactive appearing lymph nodes.
The patient was admitted and was started on intravenous clindamycin and oral augmentin and dexamethasone. The next day, she underwent an open drainage on the assumption of an organizing abscess. During the procedure and on opening the mass, we found an inflamed firm tissue surrounding the wall of a cystic cavity which was attached to the submandibular gland. The salivar

[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 presented with complaint of mild grade, intermittent fever without chills and rigor and diurnal variation for last 2 months along with occasional dull aching pain in left hypochondriac region. Ultrasonography revealed multiple abscesses in spleen. He was managed on antibiotics for 21 days but fever continued. Computed tomographic (CT) scan of abdomen showed multiple abscesses in spleen without any other significant findings in abdominal organs. Around 200 ml of pus was aspirated under guidance, which was negative for bacteriological examination. He was kept on parenteral antibiotics but did not have any relief.
Color Doppler of heart excluded any possibility of infective endocarditis. X-ray chest was normal. Montoux test was positive up to 11 × 11 mm and he was put on antitubercular treatment to which he did not respond in 6 weeks. Surgical consultation was done and it was decided to proceed with splenectomy.
At laparotomy, there were dense adhesions between the spleen and the adjacent structures and the diaphragm. The patient went into shock after 2 hours of surgery and was resuscitated and taken back to operation theatre for reexploration. Exploration revealed generalized ooze from the area and hemostasis was achieved but again after 2 hours, the patient went into shock and was reexplored again but the patient succumbed to the continued hemorrhage.
Gross specimen measured 18 × 12 × 6 cm and cut surface showed multiple lobulated, solid, well-circumscribed nodules of variable sizes 1 cm to 7 cm diameter with areas of hemorrhage and cystic degeneration replacing most of splenic parenchyma (Figure ). The microscopic examination on Hematoxylin & Eosin stain showed dilated, sinuous vascular channels surrounded by oval to spindle tumor cells having scanty cytoplasm and hyperchromatic nuclei, mitotic figures were occasional (Figure ). There were areas of hemorrhage and cystic degeneration. The Reticulin stain showed intricate reticulum laid down around

[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 woman was diagnosed with cancer in the right breast during health screening. Magnetic resonance imaging (MRI) showed a 70 × 40 × 36-mm non-mass-like enhancement from the exterior of the right breast to the nipple region. Ductal carcinoma in situ (DCIS) was diagnosed on core needle biopsy; thus, mastectomy was considered necessary. As the patient desired to undergo immediate breast reconstruction, she was referred to our department. She underwent nipple-sparing mastectomy (NSM), sentinel node biopsy (SNB) performed by a breast surgeon and breast reconstruction with a de-epithelialized DIEP flap using thoracodorsal vessels as recipient vessels performed by a plastic surgeon (). The cancer was pathologically diagnosed as DCIS. Postoperative hormone therapy was continued at a nearby medical facility. At an outpatient visit three years and eight months after surgery, a tumor measuring 5 mm was detected by palpation at the lower right region of the right breast and a tumor shadow was identified on ultrasound. Fine-needle aspiration cytology indicated the possibility of C4 local recurrence. Thus, we performed enucleation of the lesion, and a subsequent pathological examination confirmed that the tumor was invasive ductal carcinoma (IDC) with the ductal spread. In addition to the enucleated tumor, a contrast-enhanced lesion extended from the upper exterior area to just below the nipple on MRI. The patient was diagnosed with multiple cancer recurrences in the reconstructed breast. As the patient desired to undergo autologous breast reconstruction again, extensive extirpation of the nipple-areola, breast skin including the buried DIEP flap and initial breast reconstruction with an anatomical tissue expander (TE) were performed at another hospital (). We did not give an irradiation to the breast in this case because surgical margins were free from cancer by the intensive pathological examination with 5-mm serial sectioning on the surgical specimen. At one year 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 24-year-old Japanese woman presented to our hospital with complaints of recurrent fever and subcutaneous abscess on her left upper limb. She had been previously healthy and worked as a nurse in a general hospital. She had a history of multiple subcutaneous abscesses in a year, all occurring after surgeries of the shoulder and forearms performed for bone fracture and impingement syndrome. For 3 months before admission she had repeated episodes of subcutaneous abscess on her left forearm, which was the site of blood collection and arterial line puncture. Cefazolin, cefotiam, piperacillin, sulbactam/ampicillin, clindamycin, ceftazidime, gentamicin, and meropenem were sequentially administered, but the problem was not resolved. The cellulitis worsened in spite of these antibiotic treatments, and finally she developed bacteremia. Incision and drainage of her left upper limb was conducted 1 week before admission, and she was referred and admitted to our hospital for further investigation and treatment.
She did not have underlying diseases or any family members with psychiatric disorders, autoimmune diseases, or malignancies. Her social history revealed no trouble with her surroundings, including her workplace. Her physical characteristics on admission were as follows: height, 155 cm; weight, 45 kg; body temperature, 37.4 °C; blood pressure, 122/76 mmHg; heart rate, 70 beats/minute and regular; and respiratory rate, 15/minute. A physical examination on admission did not reveal any focus of infection other than her left forearm. The skin of her left upper extremity had been incised at two points. Redness, swelling, and induration of the skin by cellulitis were seen around the incision (Fig. ). Laboratory data suggested systemic inflammation and mild liver dysfunction (Table ).
On admission, we considered the possibility of immunodeficiency, but there were no abnormalities of her immune system, such as changes in the number of lymphocytes and neutrophils, neutrophil phagoc

[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 14-year-old caucasian girl is followed at our Department of Pediatrics for type 1 diabetes mellitus since the age of three years with poor glycemic control despite regular insulin therapy. She occurred with a 7-day history of dental pain, facial swelling (extending superiorly from the supraorbital margin and inferiorly to the angle of the mouth), and ecchymosis in the left periorbital region with decreased visual acuity and colour vision, unresponsive to antibiotic therapy with amoxicillin. Physical examination showed left-sided facial numbness, lagophthalmos with inability to complete closure of the left eyelid and tongue deviation to the left. Intraorally there were carious lesions and low sensitivity of the upper teeth. Biochemical investigations revealed neutrophilia and increasing of inflammatory markers. The electromyography showed a severe VII nerve damage. Radiographic examination showed haziness of left maxillary sinus with erosion of lateral sinus wall. Magnetic resonance imaging of her head revealed a marked mucosal thickening of the left maxillary sinus extended to the sphenoid, ethmoid and frontal sinus with moderate inflammatory effusion (Figure ). For three times inflammatory tissue was excised from the sinuses through an Endoscopic Sinus Surgery for microbial eradication and histopathologic examination. The tissue biopsy showed fragments of mucosa lined by respiratory epithelium with chronic aspecific inflammatory infiltrate and growed fungal species belonging to the Zygomycetes. After a 20-day treatment with imipenem, teicoplanin, metronidazole and aciclovir, she was given intravenous amphotericin B to which posaconazole (POS) was immediately replaced, due to the onset of side effects such as hyperglycemia, marked hypothermia and profuse sweating. The follow-up magnetic resonance images showed progression of the disease with significant intracranial extension. The magnetic resonance angiography showed the involvement of the neurovascular retromand

[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 62-year old female presented with complaints of on and off episodes of pain in the right upper quadrant of abdomen since 4 months. It was associated with significant loss of weight and generalized weakness since one month. Clinical examination was unremarkable except for hypertension. Her baseline blood investigations were within normal limits. Ultrasonography of her abdomen suggested enlarged right adrenal gland measuring 4.9×3.3 cm. No obvious calcification was noted. Her urinary vanillyl mandelic acid levels and plasma steroid levels were within normal limits. Computed tomography (CT) scan of abdomen and pelvis suggested 4.3×2.5 cm well defined moderately enhancing right adrenal mass with central necrosis (). No calcifications or fat components were seen within the lump. There was no free fluid and no appreciable abdominal lymphadenopathy. Patient underwent ultrasonography guided tissue biopsy of the right adrenal gland. Histopathology suggested it to be tumor composed of spindle cells and permeated by intense inflammatory infiltrate chiefly neutrophils. The tumor cells showed strong immunopositivity for vimentin and focal immunopositivity for epithelial membrane antigen. CT scan of pelvis and thorax was done to search for the primary focus of malignancy but both suggested no obvious focus except patient having a 60% thrombosis of distal arch of aorta. Hence decision was taken for right adrenalectomy. The surgery was completed uneventfully. On gross examination, specimen was brown and nodular measuring 6.5×5.5×3.5 cm and weighed 55 g. Its cut surface showed an unencapsulated firm greyish white tumor (). On microscopy the tumor showed pleomorphic tumor cells with epithelial and spindle cell morphology with evidence of foci of necrosis and intense inflammatory infiltrate with neutrophils and lymphocytes (). The tumor cells on immunohistochemistry showed strong positivity for vimentin (). Focal immunopositivity for pancytokeratin () and Bcl-2. The tumor cells were

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


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

[User]
RADIOLOGY NOTE:
A 70-year-old man with a T3V1N0M0 rectal tumor underwent laparoscopic APR followed by adjuvant chemotherapy with oxaliplatin, fluorouracil, and calcium folinate. At 1 year control, radiological work-up and colonoscopy showed no signs of recurrence or distant metastases. Thirteen months after the APR, the patient developed a perineal hernia and had a reconstruction of the pelvic floor with a biological mesh (Permacol™) via a transperineal approach. The postoperative course was uneventful, and the initial follow-up with a pelvic–abdominal computed tomography (CT) scan 4 months after the surgery showed no signs of locoregional recurrence or reherniation. Nine months after the perineal hernia operation, the patient experienced weight loss. A thoracic–abdominal CT scan was performed and showed multiple metastases to the liver and lungs. The patient was treated with chemotherapy: bevacizumab, irinotecan, calcium folinate, and fluorouracil. Twelve months after the perineal hernia operation, but only 6 weeks into chemotherapy, the patient developed signs of sepsis with a high temperature, tachycardia, and hypotension and complained of pain in the right buttock. Physical examination showed signs of infection at the area. Possible differential diagnoses could have been local recurrence of the rectal cancer, intraabdominal abscess, or pelvis sepsis. We could have chosen to examine the patient with a positron emission tomography scan or, for example, an ultrasound (US)-guided biopsy, but we chose an acute US examination. This revealed an abscess, and drainage was established by a US-guided procedure. The patient was moved to an intensive unit and started treatment with intravenous fluids and broad-spectrum antibiotics. The following CT scan with contrast given through the drain showed a subcutaneous abscess cavity located in the perineum, with communication to the small bowel (). The patient underwent a laparotomy, and operative findings confirmed a perineal fistula from the di

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


[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, with persistent AF refractory to the pharmacologic treatment underwent RFA in our hospital. As a routine practice in our centre, the patient was assessed pre-procedurally by transesophageal echocardiography (TEE) on the day of procedure to delineate anatomy of pulmonary veins and left atrium (LA) and to exclude LA appendage thrombus. During RFA procedure all four PV were individually isolated under guidance of intracardiac echocardiography. RF energy was delivered using a conventional 4 mm and 8 mm tip ablation catheters and a power setting of 30 W, 50 °C around a circular decapolar catheter located at the pulmonary veins ostia. Application of the RF was immediately interrupted when microbubbles were detected by the intracardiac echocardiography (ICE). After a curative ablation therapy patient was kept on aspirin to prevent pulmonary venous or arterial thrombosis and recurrence of AF. Ambulatory follow-up cardiac computed tomography (CT) angiogram was done 3 months following RFA and showed approximately 60% left superior PVS but no intervention was performed because the patient was asymptomatic and he was kept on oral anticoagulation ().
Two months later, the patient developed cough associated with hemoptysis, mild intermittent fever, mild left-sided pleuritic chest pain and shortness of breath on exertion. He visited the primary health centre close to his residency where chest radiography was done and showed left upper lobe poorly marginated opacities and minimal left pleural effusion. Further laboratory studies were done to rule out pulmonary tuberculosis (TB) which were within normal limits. A definitive diagnosis was not made and the patient was given broad spectrum antibiotics and referred to pulmonology clinic in our hospital for further investigation.
Patient presented to our hospital 6 months after ablation without improvement in the symptoms. Non-enhanced CT was done and showed increased parenchymal attenuation and multiple perip

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


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

[User]
RADIOLOGY NOTE:
A 48-year-old female Chinese patient was admitted to our department for discontinuation of bowel movements for 2 months. The patient reported the alternation of constipation and diarrhea after an abdominal mass was found 3 years earlier. No laxatives or illicit substances had been used. She had chest tightness and shortness of breath. However, there were no signs of intestinal obstruction, including vomiting or abdominal pain. Family history was unremarkable. On examination, the abdomen was grossly distended, and a hard, round mass was found in the right lower abdomen. No peritoneal irritation was found, and rectal examination revealed an empty rectum.
The carbohydrate antigen 125 level in the blood was 91 U/mL, and the hemoglobin was 103 g/L. The serologic test for syphilis was positive. Abdominal computed tomography (CT) revealed fecal accumulation and dilatation of the colon above the sigmoid colon and suspicious wall thickening of the sigmoid colon (Fig. ). Anorectal manometry revealed relaxation of the anal sphincter.
Conservative treatment was ineffective, and an urgent surgical intervention was planned. The laparotomy revealed a significantly dilated transverse and descending colon (Fig. A) and the sigmoid colon was redundant and narrow. The transverse colon was cut open, and a drainage tube was placed to flush intestinal feces. We excised the sigmoid colon partially and performed a transverse colostomy.
The postoperative period was uneventful. Histological examination of the sigmoid colon showed chronic inflammation of the intestinal mucosa and a decreased number and the vacuolar degeneration of ganglion cells in the myenteric plexuses, on average more than 4 cells/cm (Fig. B). Inflammatory cells had infiltrated the serosa, and the blood vessels were dilated and bruised. Immunohistochemistry showed the tissue was positive for soluble protein-100 (S-100), synaptophysin, and neuron-specific enolase. The patient did not have a history of chronic constipation or

[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 male patient came to the department of Oral medicine and Radiology with the chief complaint of pain in the upper lip for the past 15 days. The patient experienced a mild, intermittent, dull aching type in the same region. His Past medical history was non-contributory and in the past dental history the patient revealed the history of trauma from road traffic accident 15 years ago, during which the patient had suffered from lip laceration and fracture of anterior teeth. Laceration in the lip was sutured immediately and later root canal treatment and crown placement was done. He further added that, 2 years after the trauma, he had developed pain and swelling in the upper lip in relation to 11, 12. A minor surgical procedure was done and a tooth spicule was removed. Constitutional signs and review of all systems appears to be normal on general examination. On local examination, inspection revealed no abnormality in the upper lip, labial mucosa and the entire oral cavity. On palpation a painful tiny hard mass measuring about 5 mm approx was palpable in the upper lip 0.5 cm lateral to the midline in relation to 11 and 12. On hard tissue examination prosthetic crown was present in relation to 11, 12. Considering the chief complaint, history and correlating with the clinical findings the mass in the upper lip was provisionally diagnosed as a foreign body in the upper lip.
An intra oral Periapical radiograph of the upper lip revealed a single radiopaque mass measuring about 3 X 2 mm in size (Fig .1).
Blood investigation was performed which revealed to be within normal limits. Then an excisional biopsy was done by placing a single incision under local anesthesia (Fig.2).
All procedures were performed under aseptic condition (Fig.3).
A review was done after 7thday, first month, third month and after 6 month. All necessary check radiographs were taken. The wound healing was satisfactory.
Histopathological examination

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


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

[User]
RADIOLOGY NOTE:
A 76-year-old woman had an 8-year history of atrial fibrillation (AF) and severe TR. Her history included mild hypothyroidism and right upper lobectomy for lung carcinoma 11 years previously. For 2 years, she had complained of shortness of breath when lying in the left lateral decubitus position. She had felt dyspnea after mild exercise for 9 months. Recently, she had a sense of abdominal fullness. Although administration of diuretics was started, her symptoms did not completely improve, and she was referred to our department for surgical treatment. The follow-up chest X-ray showed a gradually protruding right-side shadow of the cardiac silhouette, and the cardiothoracic ratio on the chest X-ray reached 88% (Fig. ). The electrocardiogram showed AF with low fibrillatory wave amplitude. Echocardiography showed an enlarged right ventricular (RV) cavity and mild paradoxical motion of the ventricular septum. The tricuspid valve had no findings of an organic and constructive abnormality, with no severe tethering. The annular size of the tricuspid valve was 50 mm, and the tricuspid annular plane systolic excursion was 21 mm (Table ). Repeated preoperative cardiac catheterization showed slightly elevated wedge pressure with mild pulmonary hypertension, although LV function was preserved with a cardiac index of 4.0 (Table ). There was no L-R shunt disease. Computed tomography (CT) findings showed that the maximum size of the RA reached 121 mm (Fig. ). The change in dimension of the RA by CT showed that the size of the RA increased with time (Fig. ). Blood tests showed no liver dysfunction.
Surgery was performed via median sternotomy. The pericardium was extremely thin on the RA side without any defect. There was no adherence in the pericardial cavity. Cardiopulmonary bypass was established by ascending aorta cannulation with bicaval drainage. The RA was extremely thin and the tricuspid valve annulus was enlarged, with a diameter of 55 mm, but there was no tricuspid structura

[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:
18 years old, 54 kg male was admitted to the Third Xiangya Hospital for the upper right abdominal pain and fever on 12th October. Ultrasonography and CT scan showed large common bile duct cyst involving left and right hepatic bile ducts. Blood test showed a normal coagulation function with APTT of 45 s, liver enzymes and bilirubin were slightly elevated. There was no bleeding history, no family history of hemophilia either. Conservative treatment included antispasmodic agents, antibiotics, and choleretic medicine, but conservative treatment was ineffective and his symptoms got even severe and with a very high temperature of 39 °C, and his white blood cells count elevated to 20 × 109/L. So, he underwent resection of choledochal cyst and gallbladder followed by Roux-en-Y anastomosis on 24th Oct. The operation went well and finished at 12 AM without any blood transfusion. However, coffee like liquid came out of gastric tube at 4 AM, on first POD, and Hematemesis and hematochezia followed afterwards. The hemorrhage was unstoppable with conservative management, and the hemoglobin reduced to 60 g/L despite of prompt transfusion. The coagulation function test showed aPTT of 47 s at the moment. So, a technique fault related bleeding was suspected and an emergency explorative laparotomy was done at 1 PM, on second POD. No blood was found in abdominal cavity, but the jejunal loop was full of blood clots. After removal of the blood clots, an oozing was found at jejuno-jejunal anastomosis and it was controlled by sutures. The bleeding seems to be stopped for 2 days after the second operation but unfortunately, gastric tube and T tube inside hepatic bile duct drained bloody liquid on the third POD of second laparotomy, and it could not be controlled by conservative treatment. Bleeding even came out of abdominal drain tube on eighth POD of second surgery, so an emergency gastroscopy and DSA were performed, but neither

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


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

[User]
RADIOLOGY NOTE:
A 73-year-old Chinese man was found a cervical mass for 1 month. He had a history of coronary heart disease for 2 years, but no relevant personal or family history of malignancy. Physical examination showed bilateral neck asymmetry, the trachea was deflected to the left, the carotid pulse was normal, approximately 6 × 5 cm solid masses were felt in the right lobe of the thyroid gland. The tumor mass border was unclear with smooth surface, and the tumor moved up and down with swallowing. The left lobe of the thyroid gland had no palpable mass and the neck had no palpable swollen lymph nodes. Accessory examination of neck color Doppler ultrasound at our hospital showed increase in size of the right lobe of the thyroid gland, which had abnormal shape. The upper right pole of the thyroid gland had an approximately 5.6 × 6.0 × 4.2 cm sized mass, with unclear margin, and multiple cystic nodules in the thyroid. The CT of thyroid showed increase in size of the right lobe of the thyroid gland, and an approximately 5.6 × 6.0 × 4.2 cm sized mass, the trachea was compressed and deflected to the left, the thyroid cartilage was compressed, deformed and reached the right subglottic region. The right thyroid lump had multiple calcifications, indicative of a tumor (Fig. ). Electronic laryngoscope examination showed ventricular bands thickening, the right ventricular bands compartment showed a rice-like projection, arytenoid region movement was poor (Fig. ). Thyroid function test was 5.07 mIU/L. The patient underwent subtotal thyroidectomy and excisional biopsy of neck mass under general anesthesia. Intraoperative findings indicated a hard mass in the thyroid gland area, the lateral border and the lower bound were closely related to the surrounding soft tissues, but there was an extremely close relationship between the medial border, the thyroid cartilage, and cricoid cartilage, with no gap between them. An ENT doctor was invited for intraoperative consultation, who suggested that so

[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 8-month-old baby boy was presented to our clinic with a one month history of right elbow mass. The patient's mother claimed that the child is moving his right upper extremity actively without any limitation. She also reported gradual increase in the mass size in the last month.
The patient is previously healthy without any past medical or surgical history. The patient is a product of full-term pregnancy with no perinatal complications. His developmental history was uneventful with no family history of malignancies.
Physical examination revealed a 3 × 2 × 4 cm mobile soft nontender mass extending from the right proximal ulnar aspect volar surface crossing the elbow crease proximally with no signs of erythema (). The full elbow active extension with mild restriction of full flexion is around 15 degrees.
Plain radiograph of the right elbow showed a lobular soft tissue swelling () with a normal blood profile (complete blood count, ESR, CRP).
The MRI of the right elbow revealed a 3.3 × 2 × 4.5 cm (AP, transverse, and CC dimension) lobular juxta articular subcutaneous soft tissue lesion along the medial aspect of the elbow. The lesion appeared multiseptated with a predominantly high T2 signal intensity and contains a 1.8 × 1.8 × 1.5 cm area with low T2 and high T1 signal intensity and no perilesional edema or joint effusion (Figures and ).
The overall findings were in favor of an endolymphatic malformation. Decision was taken for radical excision.
Radical excision was performed under tourniquet control with dissection of the mass from the ulnar, the median nerves, and the antebrachial muscles ().
Pathology specimen of the tumor showed a multiloculated lymphangioma with no evidence of malignancy (). The lesion showed vascular spaces with thick vascular walls incorporating adipose tissue and nerve fascicles. The vascular spaces were lined by regular endothelial cells. Surrounding synovial fluid cytology was negative for malignancy

[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 19-year-old female was the fifth child of first-cousin parents. One sibling passed away at 20 days of age because of pneumonia and another died at the age of 4 months due to kidney failure. There was also a full-term idiopathic stillborn. Unfortunately, none of them were seen at our institution and we did not have access to their charts. It is not possible to make any inference about the etiology of their diseases.
The patient was born uneventfully at 36 weeks of gestational age by caesarean section, had a birth weight of 2600 g (5th–15th percentile) and 46 cm birth length (5th percentile). Head circumference information was unavailable. There was no clinical sign or laboratory findings consistent with cholestasis at neonatal period or in her first 2 years of life. She had global developmental delay that was first recognized after 6 months of age. All domains were affected. She was not able to hold her head up and sit without support until 1 year old. She started walking with support at 6 years old and without support at 7 years old. She started speaking some words at 4 years old. She did not name colors, recognize numbers or letters, and she can only produce scribbles. She started using a spoon at 11 years old. At that moment, her functional age according to Denver II was gross motor 12–13 months, fine motor 15–16 months, language 18–19 months, and personal/social 7 months. A formal neuropsychological assessment was not conducted.
She had recurrent hypoglycemia associated with fasting from 6 months to 7 years of age without hyperinsulinism and was not responsive to glucagon. At the age of 10 months, she experienced a febrile seizure without hypoglycemia and at the age of 9 she started having focal motor seizures with impaired awareness and automatisms. The seizures were rare and easily controlled with carbamazepine.
An etiological investigation was initiated when she was admitted to our service at the age of 10 years old

[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 presented with sudden headache. A left VA dissecting aneurysm (15 × 6 mm) coexisting with a right internal carotid artery-posterior communicating artery aneurysm was found by MRI at a neighborhood clinic. He had a medical history of hypertension and heavy smoking (30 cigarettes per day for 40 years). On preoperative MRI, the dilated segment started at the height of the jugular foramen, ran transversely at the height of the 7–8th nerves toward the contralateral side, and ended at the point exceeding the midline (). The distal end was >20 mm proximal to the VA union. On preoperative DSA, the common trunk of the anterior inferior cerebellar artery (AICA)-PICA originated from the basilar artery, while the affected V4 had no angiographically identifiable branches (). The contralateral VA was as developed as the affected side. In addition to the irregular-shaped VA aneurysm in the subacute phase, there were other unruptured aneurysms. The patient also requested treatment to allow early return to his work (taxi driver). Thus, we decided to treat the left VA aneurysm at 2 months after onset.
It was impossible to maintain the left VA by reconstructive clipping because of the aneurysm shape. However, it was possible to secure the distal neck and trap the aneurysm because it was located caudal to the 7–8th nerves. PICA revascularization was not necessary because the common trunk of the AICA-PICA was well-developed. Note that there was >20 mm space between the distal neck to the VA union. Furthermore, there was a concern that many brainstem perforators would be occluded because of thromboembolism after blinding of this segment by trapping. Thus, to preserve the anterograde blood flow of the VA, it was reconstructed using RAG to anastomose the V4 segment just distal to the aneurysm and the extracranial V3 segment (V3-RAG-V4 bypass) (, ). The actual surgical procedures of case 2 is shown in .

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


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

[User]
RADIOLOGY NOTE:
A 65-year-old gentleman, with a known case of chronic liver disease, presented with complaints of diffuse abdominal distension for two days associated with non-radiating, intermittent, colicky peri-umbilical pain. He had multiple episodes of bilious vomiting. He had not passed stool for one week and flatus for three days. There were no similar events in the past. He was not a known tobacco or alcohol abuser. He underwent no previous surgery.
On examination, he was found to be dehydrated with tachycardia. His abdomen was grossly distended and tender with diffuse involuntary guarding and rigidity. There was no mass palpable in the abdomen, no free fluid, and the hernial orifices were free. The bowel sound was absent. Digital rectal examination revealed collapsed and empty rectum with normal stool staining. His other systemic examination findings were clinically unremarkable.
His blood investigations revealed elevated blood urea nitrogen of 118 mg/dl and creatinine level of 3.6 mg/dl, suggestive of acute on chronic kidney disease, a normal hemogram, and a serum amylase of 207 IU/L. The serum amylase was at the upper limit of normal, and this was anticipated as such mild elevation is common in acute abdominal emergencies. A plain radiograph of the abdomen revealed multiple dilated small bowel loops with air-fluid levels, and ultrasonography (USG) of the abdomen revealed dilated aperistaltic small bowel loops (Figure ).
Thus, the diagnosis of acute intestinal obstruction was considered. A contrast-enhanced computed tomography (CECT) could not be done owing to a long waiting list for the procedure and also due to underlying renal failure in the patient. He was taken for emergency laparotomy as X-ray showed a classical picture of bowel obstruction and also for fear of poor outcomes in intestinal obstruction while waiting for CECT. As the patient was symptomatic for one week and with adhesive intestinal obstruction ruled out, as there were no prior abdominal surgeries in

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


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

[User]
RADIOLOGY NOTE:
A 40-year old infertile woman was referred to our center for IVF program (oocyte donation and embryo transfer). She had two previous histories of dilatation and curettage, one after spontaneous abortion and another for diagnostic purposes.
Hysteroscopy was done prior to IVF cycle which revealed a band of adhesion running from anterior to posterior wall for which adhesiolysis was done in the same session. The patient conceived in the second cycle of embryo transfer (oocyte donation). Pregnancy was confirmed by beta-human chorionic gonandotrophin (β–hCG) levels and later on, by ultrasound which confirmed single intrauterine gestational sac with a beating heart. She was followed up regularly for her obstetric examination with no other risk factors except for advanced maternal age.
Level two obstetric ultrasound examination was done at eighteen weeks of gestation which ruled out gross congenital anomalies and suggested grade 0 left fundo-anterior placenta with normal invasion and normal amniotic fluid. In the nineteenth weeks of gestation, patient presented in the emergency department of our hospital with acute abdominal pain and signs of early shock (pulse rate 180/min, blood pressure 90/60 mmHg, hemoglobin 7.5 g% and hematocrit of 24%).
Initially, the patient was revived from shock with adequate fluid replacement and other basic management procedures including central line placement for cental venous pressure (CVP) monitoring. Once the patient's condition was stable, she was sent for ultrasound and CT scan evaluations. Ultrasound examination revealed fresh intrauterine fetal death along with hemoperitoneum with no other gross finding.
CT scan was done to rule out other causes of heamoperitoneum. Findings were suggestive of weakening of the uterine musculature at the left fundal region with fetus inside the cavity. Patient was taken up for emergency laprotomy and a heamoperitoneum of 3000 ml was found along with a dead fetus coming out of a large uterine fundal defect.

[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 52-year-old male with a past medical history of cerebral palsy, essential hypertension, depression, and knee arthritis status post total knee arthroplasty, who presented to the emergency department after a mechanical fall. He was found to have a left distal femoral shaft fracture above the total knee arthroplasty which was fixed with an intramedullary rod placement. The patient was discharged home in a stable condition. Three weeks later, he developed increased redness and swelling at the surgical site. Vital signs were all stable on admission. Physical examination was significant for a 10 cm post-surgical wound around the left knee with mild dehiscence. Granulation tissue with drainage of serosanguineous fluid was noted along with mild erythema around the surgical site. Laboratory results including white blood cell count, erythrocyte sedimentation rate, and C-reactive protein were all normal at 3,900/µL, 1 mm/h, and 2 mg/L, respectively. Blood cultures were obtained and remained negative at 72 hours. He was taken to the operating room and underwent extensive excisional debridement including skin, muscle, and bone. There was one screw of the nail that was loose and, therefore, removed. Antibiotic (gentamycin)-impregnated cement beads were inserted. Gram stain from intraoperative culture showed no organisms. He was started empirically on cefepime 2 g IV every 8 hours and vancomycin 1 g every 12 hours postoperatively. After four days, there was no growth from the surgical cultures. Microbiology lab was asked to hold the culture for 10 days for the concern of slow-growing organism. The patient was discharged with ceftriaxone 2 g every 24 hours through a PICC line. Five days after discharge, aerobic cultures grew Corynebacterium species. The specimen was sent to Mayo Clinic (Rochester, Minnesota) for further testing. Quantitative antibiotic susceptibility testing was performed to determine the isolate’s minimum inhibitory concentration (MIC) to various

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


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

[User]
RADIOLOGY NOTE:
A 45-years-old woman brought in by EMS after she was found in distress on a subway platform. The patient with known history of diabetes type II and hypertension presented with stabbing chest pain radiating to the interscapular region after crack cocaine use. In addition to the chest pain and diaphoresis, the patient also complained of progressive pain and cold sensation over left lower extremity. Upon physical examination, the patient was noted to be agitated and combative with a blood pressure (BP) of 205/147 mmHg, a heart rate of 77 beats per minute, 17 respirations per minute, and was afebrile. Initial cardiovascular exam was positive for an S4 gallop and absent left lower extremity pulses. Lung examination was unremarkable. Initial management consisted of intravenous administration of a total of 9 mg of Lorazepam and 35 mg of Labetalol without acceptable reduction in BP. In addition to further Lorazepam, Labetolol later Esmololol infusions, IV Nitroglycerin was started and quickly titrated to 200 mcg/kg/hr but acceptable blood pressure reduction of blood pressure was still not achieved on this regimen (). A contrast-enhanced Computerized Tomography (CECT) of the thorax, abdomen, and pelvis confirmed a Stanford Type B aortic dissection beginning just beyond the left subclavian artery and extending to the iliac bifurcation. Upon arrival to the Cardiac Care Unit, decision was made to begin an infusion of Dexmedetomidine since all other therapies continued to be unsuccessful. The alpha 2 stimulation provided by the Dexmedetomidine was hypothesized to decrease the effects of the adrenergic surge induced by the cocaine thus mitigating alpha 1 and beta-receptor stimulation. Within 10 minutes of Dexmedetomidine bolus and continuous infusion, adjunct antihypertensive and sedative infusions were quickly weaned off. Evolving signs of ischemia in the left lower extremity warranted emergent femoral-femoral bypass. Vascular surgery team performed procedure successfully and un

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


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

[User]
RADIOLOGY NOTE:
A 53-year-old woman presented with an open wound on the left lower leg. It was a de-epithelized abrasion and its size was about 3.5 × 1.5 cm2 (Figure A). The patient had no notable medical history. She works as a janitor, and was cleaning the floor of the building, when she spilled undiluted cleansing solution that consisted of sodium hypochlorite (NaClO) on her left lower leg. After the accident, an abrasion was noted on that area and she visited her local dermatologic clinic for treatment on the very next day. At the clinic, she received HeNe laser therapy directly to the wound daily for 10 days. The treatment continued for 8 to 9 minutes on each occasion. However, we were unable to determine the details of laser therapy, such as power, wavelength, and so on. The treatment was not beneficial and the wound size was constant. The patient visited our clinic three weeks after the injury and we planned an excision of the unhealed area under the local anesthesia.
During the first operation, the open wound was excised and primary repair was done (Figure B). We sent a specimen to the pathology department and the pathologic analysis revealed invasive squamous cell carcinoma, 2 × 1.5 cm2 in size, involving the lateral resection margin. We planned a second operation and evaluated positron emission tomography–computed tomography for metastatic lesions before the second operation. After confirming that there was no metastasis, the patient received a second operation 3 weeks from the first. Wide excision was done with a 2 to 3 cm safe margin (Figure A). During the operation, the resection margin including the tumor base was free from tumors, as demonstrated by a frozen study. The total defect size of the left lower leg measured 9 × 7 cm2 and the defect was successfully reconstructed with a thoracodorsal artery perforator free flap transfer (Figure B,C). Micro

[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 male collegiate football player presented to the emergency department (ED) with persistent neck pain following an injury at practice. The contact occurred during a blocking drill and reportedly forced his neck into hyperextension. Upon impact, he immediately experienced high cervical neck pain localized to the left side of his neck, although over time this pain became more generalized. The patient was removed from play, and on the sidelines, no weakness or sensory abnormalities were noted on his examination. The pain was exacerbated with palpation at the base of the skull and did not radiate. Cervical range of motion with rotation, flexion, extension, and lateral flexion was limited secondary to pain. The patient had persistent pain later in the evening, not relieved with analgesics and rest, and was ultimately instructed to go the ED for further work- up and evaluation.
In the ED, he had continued complaint of neck pain; however, he remained neurologically intact and denied numbness, paresthesias, or weakness on initial evaluation. Of note though, later that evening in the ED, the patient transiently experienced subjective numbness in his left lateral forearm in an ulnar distribution that later spontaneously resolved. He was an otherwise healthy individual with a medical history significant for one “stinger” in the past that completely resolved. Plain films revealed no acute fracture or dislocation []. A computed tomography (CT) scan of his cervical spine demonstrated absent bony fusion of the anterior midline synchondrosis, as well as the midline posterior arch of the C1 bony ring [Figure –]. The osseous components had well-developed cortical margins, strongly suggesting that the midline discontinuities were not the result of trauma. The patient additionally underwent magnetic resonance imaging (MRI) of the cervical spine that demonstrated prominent edema in the pre-vertebral soft tissues extending from the level of the clivus to the vertebral body o

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


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

[User]
RADIOLOGY NOTE:
A 42-year-old man with a past medical history of schizophrenia was found outside a behavioral health facility and appeared groggy with slurring of speech. The patient was given naloxone by emergency medical services without improvement in his symptoms and was transported to the emergency department for further evaluation. On presentation, the patient was afebrile and hemodynamically stable. He was alert and oriented to person, place, and time; however, exhibited slurred speech and an inability to stay awake despite repeated stimulation. Lab work did not show electrolyte abnormalities, leukocytosis, or a deranged thyroid-stimulating hormone level (Table ). Urine toxicology was negative for barbiturates, cannabinoids, cocaine, benzodiazepines, amphetamine, and opioids. His serum ethanol level was negative and his acetaminophen level was less than 5 µg/mL. His urinalysis was not indicative of infection. Clozapine level was noted to be 172 ng/mL (reference range: 350-650 ng/mL). Chest X-ray showed no acute cardiopulmonary abnormality. The patient reported that he was in his usual state of health the prior night when he restarted clozapine after approximately six weeks of medication noncompliance due to the inability to see his psychiatrist for a prescription. He stated that he took 300 mg of clozapine at the full dose the previous evening, and did not restart it with a taper. Medication history indicated that the patient had been prescribed haloperidol 5 mg daily and clozapine 100 mg in the morning and 300 mg in the evening for at least three years. He denied using any opioids or alcohol. He also reported no history of recent infection, shortness of breath, chest pain, or trauma. The following day, the patient was alert and oriented to person, place, and time, and was able to converse normally with no drowsiness or somnolence. He was evaluated by the psychiatry service, and his altered mental status was attributed to the resumption of clozapine at full dose after a

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


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

[User]
RADIOLOGY NOTE:
A 66-year-old lady presented to the general surgeons with a history of diarrhoea and abdominal distension. Examination revealed ascites and a CT scan was organised; this showed gross ascites with small pleural effusions, bulky ovaries, a fibroid uterus, and multiple peritoneal and mesenteric deposits. Tumour makers were within normal limits with Ca 125 17, CEA 2.1, and Ca19 9 6.2. A gynaecological oncology opinion was sought and an ascitic drain sited for symptom relief and to obtain possible cytological diagnosis. Histological analysis of ascitic fluid on two separate occasions revealed leukocytes, mesothelial cells, and scattered histiocytes with no malignant cells present. Further immunohistochemistry was performed confirming the cells to be lymphoid in origin.
She continued to be symptomatic with abdominal distension and vomiting and therefore, a diagnostic laparoscopy was performed by the general surgeons. Laparoscopy confirmed gross ascites with what appeared to be widespread carcinomatosis with peritoneal and omental seedlings, bulky uterus and ovaries. Omental biopsies that were taken revealed an inflammatory process suggestive of possible sclerosing peritonitis. Histology showed omental fat with fibrous proliferation at the surface infiltrated by inflammatory cells and nodules of mesothelial proliferation, with no evidence of neoplastic infiltration. Immunohistochemical analysis was negative.
Her clinical condition remained unchanged, and she required further ascitic drains for symptom relief. An MRI scan confirmed CT findings, and her case was discussed in detail at the Gynaecology and Colorectal MDT.
As extensive investigation failed to establish a definitive diagnosis. In view of the small possibility of the fibroid uterus being responsible for her condition the decision was taken to perform a total abdominal hysterectomy, bilateral Salpingo-ophrectomy, omental biopsy, and serosal bowel biopsy. The gynaecological procedure was completed without difficult

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


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

[User]
RADIOLOGY NOTE:
A 40-year-old man presented to us with a 2-year history of slowly enlarging, painless mass in his left upper lid with resultant progressive ptosis []. The patient complained of constant sense of heaviness in the upper lid as well as partial ptosis. The superior field of vision was reduced. Ocular examination was suggestive of a firm, non-tender nodule of size 2 × 1.5 × 1 cm on the left upper lid. The mass was non-adherent to the skin or the underlying tissue. A small ulcer 5 mm × 8 mm was present on the lateral margin of the mass []. The medial skin and conjunctiva were indurated and signs of inflammation were present. The lid appeared to have lost its function and was unsalvageable. Provisional clinical diagnosis was that of an eyelid malignancy. Fine needle aspiration cytology of the lesion was inconclusive.
The lesion was excised using a supratarsal incision. An ellipse was planned along the ulcer present on the lateral margin (0.8 mm) to excise the ulcer in continuity with the swelling. The lesion was 1.5 cm in diameter with a well-defined capsule, located below the subcutaneous tissue and above the muscle layer almost abutting the supraorbital rim. The incision was deepened and the lesion was isolated from the surrounding tissue by blunt dissection outside the capsule. Dissection was easily done in the extracapsular plane and the lesion was excised completely. No communication with the supraorbital nerve could be identified. However, the eyelid had strong evidence of induration and oedema, though no evidence of infiltration by the lesion was seen. As diagnosis of malignancy was suspected initially, the medial portion except for a small lateral margin was excised to ensure clear margins and reconstruction was done using a tarso-conjunctival flap from the lower eyelid in conjunction with a skin graft harvested from the left medial arm []. The lateral rim of eyelid was closed primarily in continuity with the flap. 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 12-year-old healthy boy was referred from the Public Dental Health Services (PDHS) to a prosthodontist at the Oral Health Centre of Expertise (specialist dental care) for treatment of the maxillary incisors. The boy's chief complain was the appearance of his upper front teeth. A history of multiple traumas at the primary teeth was revealed. The first at the age of 1½ years was perceived by the parents as not significant, whereas the second at the age of 2½ years was severe. The boy had fallen off his bicycle against a fence outside the family's house. Trauma was recorded in PDHS with the diagnoses of avulsed teeth #51 and 61 and uncomplicated crown fracture tooth #52. Three weeks after trauma, delayed intraoral wound healing was recorded with gingival retraction buccal for tooth #62 and alveolar fracture at the area was suspected. At the age of 7, teeth #11 and 21 had not erupted. One year later, it was noted that the erupted tooth #11 had atypical crown shape and enamel hypoplasia whereas tooth #21 had not erupted yet. Periapical radiograph showed that tooth #21 had aberrant crown anatomy similar to the erupted tooth #11 (). At the age of 9, the boy was referred to a private orthodontist due to delayed eruption of tooth #21 (). The orthodontist perceived the delayed eruption as a result of a supernumerary tooth and referred the patient to an oral surgeon at the university dental clinic for examination and surgical removal of the supernumerary tooth. Small-volume cone-beam computed tomography (CBCT) revealed atypical morphology of tooth #21 with the root forming a 90° angle to the longitudinal axis of the crown. The root was located parallel to the nasal floor in anterior dorsal direction. It was further described that the crown had an irregular and atypical shape. In addition, CBCT showed that teeth #12, 11, and 22 had varying degrees

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


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

[User]
RADIOLOGY NOTE:
A 39-year old woman, with a medical history of 20 pack-years of smoking, was diagnosed lung adenocarcinoma with liver metastasis in September 2009. Molecular analysis of the tumor revealed no EGFR mutation. She was treated with cycles of permetrexed (500 mg/m2) and cisplatinum (75 mg/m2) every 21 days from September 2009 to January 2010, with a stable disease on CT scan evaluation after 6 cycles of chemotherapy.
In January 2010, she had a persistent headache associated with photophobia and a progressive decrease of her performance status. Radiological explorations included a CT and a MRI of the brain and were considered normal. A cerebrospinal fluid (CSF) exploration was then performed, revealing the presence of carcinomatous cells, compatible with an adecarcinoma of the lung. The CSF protein level was slightly increased (0.47 g/L), whereas CSF glucose level was normal. Intrathecal DepoCyt® (50 mg) was delivered the 17th of February 2010, followed by marked aggravation of clinical symptoms and worsened performance status, despite oral prednisone intake at 1 mg/kg.
The patient was then treated with intrathecal injections of methotrexate (15 mg, day 1-5) and prednisolone 30 mg (day 1) with oral folinic acid rescue (25 mg 12 h after methotrexate, day 1-5) []. A cycle was performed every 2 weeks with repeated lumbar punctures. Four cycles of high dose methotrexate were administered between March and April. A clinical improvement was noticed after the first cycle of chemotherapy, with decrease in headaches, improvement of performance status, allowing the diminution of prednisone intake. Clearance of carcinomatous cells was observed on CSF exploration after the second cycle of chemotherapy and confirmed until the end of intrathecal injections. Treatment was well tolerated and no clinical or biological toxicity was noticed. Interruption of intrathecal treatment was decided with regards to clinical and cytological response after four intrathecal treatment injections.
At 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 42-year-old female presented to the Emergency Department with a complaint of left lower quadrant abdominal pain and cramping that she reported began 2 days prior. Pain onset was followed by bloody stools, both of which resolved the following day aside with only some residual nausea. Abdominal cramping recurred early on in the morning of admission. The patient denied any ingestion of potentially contaminated water or unusual food. The patient history was also negative for recent surgeries, travel, or sick contacts. The patient reported no family or personal history of inflammatory bowel disease and had no other concerns aside from the left lower abdominal pain and bloody stools.
Upon examination, her vital signs revealed an elevated heart rate of 118 and a slight elevation in blood pressure at 134/88. Her abdominal exam showed normal bowel sounds and a soft abdomen but with mild diffuse tenderness. No rebound or guarding was noted.
Laboratory testing was largely unremarkable. CT abdomen pelvis with intravenous contrast revealed findings consistent with an ileocolic intussusception (). A tubular structure was seen within the lumen of the intussusception which was determined to be a distended appendix potentially serving as the lead point. No indication of obstruction or bowel perforation was seen, but there was a small amount of intraperitoneal fluid. All organs were unremarkable aside from a non-obstructing stone seen in the right kidney.
The patient was admitted to general surgery for further evaluation and management. It was discovered that right colon and distal ileum had intussuscepted into the transverse colon, but it was unable to be reduced laparoscopically and therefore the procedure was converted to open laparotomy. After converting to an open procedure and mobilizing the colon, it was noted that a very long segment of colon had intussuscepted with a firm mass and lead point that had travelled into the transverse colon. The bowel was manually manipulated b

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


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

[User]
RADIOLOGY NOTE:
A 4-year-old boy visited a local hospital due to repeated episodes of pneumonia since the age of three months. A chest radiograph and CT revealed an abnormal mass-like lesion in the right lower pulmonary lobe. An attempted total excision was unsuccessful, and only a biopsy was performed in the local hospital. The precise pathologic report of the outside hospital was not available except for information of a kind of vascular mass. Because the boy had long-standing and recurrent symptoms, he was referred to our vascular center for further evaluation and treatment. A plain radiograph showed increased right infrahilar opacity overlapping the cardiac shadow. The right lung was more lucent and smaller than the left one, suggesting an airway problem (). A precontrast CT scan revealed a soft tissue mass containing multiple and well-defined small calcific foci in the right lower lobe of the lung, which were suggested to be phleboliths (). After injecting the contrast material, the anterolateral portion of the mass was intensely enhanced without enhancement of the surrounding region (). The lesion was encasing the right bronchus intermedius and the right lower lobar bronchus, resulting in decreased caliber. The right inferior pulmonary vein was also narrowed by the encasing mass (). The mass abutted the posterior margin of the heart and superior pulmonary vein. Before surgery, an MRI was performed in our hospital three months after the CT scan performed at the outside hospital to further evaluate the mass demarcation with the surrounding tissues; especially in the airway and large vessels. The lesion was found to be isointense with the muscles on T1-weighted images and hyperintense on the T2-weighted images (). There were no signal differences between the enhancing and the non-enhancing part on a contrast enhanced CT on MRI. Because the intravenous administration of MRI contrast agent was not performed during MRI, the comparison of the enhancing pattern between the CT and MRI

[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 male visited the outpatient department presenting a one-week history of right-side foot drop. The patient had no history of hypertension, diabetes, hypothyroidism, arthritis, cancer, hepatitis or stroke. He denied any recent traumatic accidents to the right leg. The complete physical evaluation was conducted, showing no abnormalities such as visual changes, fever, chills, dizziness, headache, or bowel or bladder problems. In the detailed neurological examination, he was well oriented and exhibited no signs of cranial nerve function disorders such as dysarthria, dysphagia or facial palsy. Distal pulse and sensation were intact in all extremities including the dorsal aspect of the right foot. Passive range of motion was in a normal range in every peripheral joint. The patient was also negative for the straight leg raise test and femoral nerve stretch test. No pathological reflexes were found bilaterally such as Babinski and ankle clonus, with normal deep tendon reflexes. Individual muscle strength tests were normal for all extremities except for the right tibialis anterior and the extensor digitorum. Muscle tone grades in the right tibialis anterior and extensor digitorum were 0/5 when measured by Modified Ashworth Scale.
Electromyogram (EMG) and magnetic resonance imaging (MRI) were performed. EMG showed no remarkable findings and lumbar spinal MRI revealed a diffuse bulging disc at the L4-5 disc space level. However, there was no evidence of severe nerve root compression that was susceptible to current condition. Since the lumbar spinal lesions were ruled out for the patient's symptom, a brain MRI was performed to investigate any potential central lesions. Diffusion-weighted imaging (DWI) showed focal high signal intensity on the left upper motor cortex (). An afferent diffusion coefficient (ADC) map revealed low signal intensity on the same area (). Subsequently, the patient was diagnosed with subacute cerebral infarction. After one week of treatment

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


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

[User]
RADIOLOGY NOTE:
A 51-year-old woman with a one-month history of redness and swollen left knee joint was transferred to our general intensive care unit (ICU) due to persistent high fever (up to 39.5°C) and sudden hypotension. After being diagnosed with dermatomyositis 2 years ago, she continued medication treatment on prednisone tablets with a 25 mg daily dose and cyclosporine capsule with a 75 mg dose twice per day. Last month, the results of blood culture and bacterial culture of joint cavity pus as obtained from other medical institutions were shown to be negative, with no special microbiological examination performed.
When the patient visited the rheumatology department for appointment with a doctor, she coughed up sputum intermittently and her body temperature reached up to 40°C. Physical examination revealed that the left knee was red and swollen with positive floating patellar test, along with red rash in the V area of face and neck. The right dark yellow pleural effusion displayed exudate and negative bacterial culture. Vancomycin was thus prescribed to reduce infection, and 20 mg of methylprednisolone was applied twice a day. Four days later, she was transferred to ICU due to hypotension (the detailed clinical course is shown in ). The patient exhibited low blood pressure and high heart rate, which was accompanied by elevated procalcitonin and multiple organ failure. Broad-spectrum anti-infective therapy (imipenem/cilastatin + linezolid) was initiated within the first hour of highly suspected septic shock. ECG suggested cardiac infarction and high myocardial enzyme index. In order to rule out the occurrence of acute cardiovascular event, no infarction was detected immediately after coronary angiography. Given the EF value of 30% for the patient, septic heart disease was suspected. At the same time, the patient suffered acute liver injury, acute renal injury and thrombocytopenia.
After the patient was transferred to ICU, joint cavity pus was also taken for culture in additio

[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.