[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, para 5, postmenopausal black African woman who was human immunodeficiency virus (HIV)-negative presented to our casualty department with a 5-year history of progressive abdominal swelling. Five years prior to presenting, which was 1 year before she reached menopause, she had noticed that her abdomen was gradually distending. Her symptoms were associated with constipation, feeling of incomplete rectal emptying, early satiety, vomiting, and urinary frequency and urgency. She did not have any chronic illnesses and had a negative personal and family history of ovarian, uterine, bowel, and breast cancers. She was not receiving any medication prior to this presentation. She had delivered five children by cesarean section, and they were all alive and well. She lived in a rural area and was a subsistence farmer. She did not smoke and did not drink alcohol.
She had ascitic taps three times in 1 week at a district hospital before referral to a higher-level hospital because of recurrent reaccumulation of ascites. A transabdominal ultrasound scan (USS) showed generalized ascites with a thick fluid with septa, as well as bilateral mild hydroureter and hydronephrosis. Again, the ascites was drained twice. One month later, she underwent computed tomography (CT), which showed a large predominantly cystic lesion that occupied almost the entire abdominal and pelvic cavities, which were distended, causing a marked mass effect on surrounding organs and bowel. The lesion had areas of internal septation predominantly on the right flank with no features of metastatic disease. Tumor markers measured during this admission are shown in Table .
The patient was referred to a tertiary hospital but only went 5 years later. Upon admission, she had marked temporal wasting, with bilateral pitting lower limb edema extending to her sacrum. She had a normal breast examination. Her blood pressure was elevated at 167/93 mmHg, with tachycardia of 150 beats/min. Her body temperature was 36.

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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 71-year-old male presented with a history of AN lesions on the hands, feet, fold areas, face and oral cavity that had been present for approximately 4 months. The initial lesions appeared as hyperpigmentation, with a rough and thickened skin surface and mild pruritus, present on the hands, feet, axillary and inguinal regions. Subsequently, lesions also emerged on the face, neck, back of the ears and oral cavity. He was treated with an oral administration of avermectin A and traditional Chinese medicines along with topical steroids and urea vitamin E ointment with no clinical improvement. The skin lesions gradually thickened, developing into wart-like hyperplasias or tumor-like lesions and additional lesions associated with burning sensations surfaced on the buccal mucosa and tongue. According to the patient’s medical history, he was initially diagnosed with urinary bladder cancer in 2007. At that time, he received TUR-BT surgery followed by regular administrations of intravesical chemotherapy. In 2013, he was diagnosed with rectal cancer and underwent laparoscopic surgery followed by regular chemotherapy. He was then diagnosed with urinary bladder cancer in 2014, and again underwent TUR-BT surgery followed by intravesical chemotherapy. Additionally, the patient had a history of hypertension for more than 10 years. There was no history of steroid medication use, endocrine abnormalities, hepatitis, other autoimmune diseases or familial hereditary diseases. Family members were unaffected.
Physical examination revealed numerous grey and brown skin papillary papules or verrucous nodules observed in the axillary and inguinal areas, along with diffuse hyperkeratosis and waxy-yellow lesions in the palms and plantar surfaces. Clinical examination of the oral cavity revealed hypertrophic lesions and papillomatosis on the buccal mucosa, gingiva and a glossy tongue without moss (–). There were no apparent abnormalities in the toenails and hair.
Based on these findings and the

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


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

[User]
RADIOLOGY NOTE:
A 34 year old previously well lady from urban Sri Lanka presented to the Institute of Neurology at the National Hospital of Sri Lanka with a one month history of numbness of the right side of her face and difficulty chewing from the right side of her mouth. She described the onset of the symptoms as sudden as it was present on awakening from an uninterrupted sleep the previous night. The symptoms had persisted over a month without much progression. She had received treatment from a general practitioner but her symptoms had not improved. She did not have any diplopia or blurred vision, painful eye movements, hearing impairment, dysphagia or dysarthria. She did not complain of limb weakness or unsteadiness with tendency to fall. She did not complain of shooting pain on the right side of the face triggered by touch and has had no previous facial rashes. She denied sexual promiscuity. She had lived in Sri Lanka all her life and has not had any foreign travel.
Neurological examination revealed an alert lady who was oriented to time, place and person. There was no facial asymmetry or drooling of saliva and no obvious facial rashes. On asking the patient to open her mouth there was slight jaw deviation to the right side (Figure ). Palpation of the Temporalis and Masseters did not reveal any wasting. Sensory examination revealed impaired pain sensation on the right side of the face involving the Ophthalmic, Maxillary and Mandibular divisions of the trigeminal nerve conforming to the characteristic onion skin distribution. The corneal reflex on the right side was also absent. All other cranial nerve examination was normal including the adjacent nerves. Opthalmoscopic examination did no reveal optic atrophy or papillitis. There was no limb involvement with normal Corticospinal, Spinothalamic and Posterior column pathway examination including preserved reflexes and there were no demonstrable Cerebellar signs.
Magnetic Resonance Imaging (MRI)

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

[User]
RADIOLOGY NOTE:
A 72-year-old male with history of penile implant, hypertension, hyperlipidemia, severe peripheral vascular disease with extensive smoking history presented in clinic for severe bilateral lower extremities claudication. Doppler exam showed weak monophasic flow bilaterally. Patient also had a history of left popliteal stent placement and has been taking aspirin and Plavix since then. CT angiography of the lower extremities showed critical stenosis of superficial femoral artery of both lower extremities and a patent stent on the left popliteal artery. Decision was made to perform bilateral lower extremities angiograms via a transfemoral approach with possible revascularization of the right lower extremity (LE) first and then the left side on two different procedures one week apart. Both procedures were accessed through a transfemoral approach that involved balloon angioplasty of the left (L) and right (R) superficial femoral artery (SFA) and left proximal popliteal artery. No immediate post procedure complications were noted, VCDs were deployed and hemostasis was achieved on both occasions. Patient was discharged same day and aspirin and Plavix were resumed.
On the following day after the right transfemoral access approach, patient presents to ED with R groin and scrotal pain. On evaluation, severe tenderness on the R groin and scrotum was noted associated with worsening swelling and ecchymosis (Fig. ). Vitals were within normal limits and initial hemoglobin of 12 g/dl. Ultrasound of the right groin showed a 6.3 × 4.0 × 4.9 cm hematoma (Fig. ), his duplex ultrasound of bilateral testicle showed diminished blood flow on the right compared to the left (Fig. ). CT of the pelvis revealed a pseudo-aneurysm on the R groin originating from the common femoral artery (CFA) measuring 2.5 × 1.4 cm and extending into the R inguinal canal, filled with hemorrhage and extension into the R scrotum that measures 13.7 × 6.4 × 6.6 cm (Fig. ). During his clinical course, he has been hemo

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


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

[User]
RADIOLOGY NOTE:
A 28-year-old woman initially presented with blurry vision that developed over the span of approximately one month. The blurry vision was initially most prevalent on horizontal gaze but progressed to include vertical gaze. It resolved with closure of one eye. She reported a history of gradually worsening headache over the past several years. Her headaches both worsened in intensity and increased in frequency, until it was quite debilitating and occurred daily. She described the headache as an intense pressure in both the front and back of her head. She also noted a “whooshing” sound in her right ear. She denied any nausea or vomiting and had not had any syncope, numbness, weakness, facial droop or slurred speech. Furthermore, she had no history of bladder or bowel dysfunction.
Her medical history was pertinent only for obesity with a body mass index (BMI) of 39. On physical exam she was noted to have papilledema. Her neurological exam was unrevealing with the exception of a subtle sixth cranial palsy.
A magnetic resonance image (MRI) was obtained which showed a T1 hypointense and T2 hyperintense cystic lesion arising from the pineal gland measuring 2.0 x 1.1 cm in the sagittal plane with mild mass effect on the tectum and partial effacement of the cerebral aqueduct (Figures , ). The lesion demonstrated a thin rind of contrast enhancement and had thin enhancing internal septations. The lateral ventricles were mildly enlarged. There was no restricted diffusion and no loss of gray white differentiation. Cine flow study noted cerebral spinal fluid (CSF) flow through the cerebral aqueduct. Based on the radiographic images, the most likely diagnosis was an atypical pineal cyst.
Given the rapidity of the vision changes, the decision was made to pursue surgical intervention. An endoscopic third ventriculostomy (ETV) with pineal cyst fenestration was performed without complication. A computed tomography (CT) scan obtained post

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

[User]
RADIOLOGY NOTE:
A 36-year-old male patient, presented to the emergency department on the 10th of January 2014, with intermittent right sided abdominal pain for the past few months that was becoming severe in the preceding few days. The nature of pain was nonspecific and the location was diffuse. There were no associated lower urinary tract symptoms or fever. He has no comorbidities or history of urolithiasis. He was a smoker for the last 20 years. Physical examination revealed right-sided renal angle fullness. Rest of abdominal examination was unremarkable.
Urinalysis showed microscopic hematuria with some proteinuria. Full blood count was within normal limits, whereas renal function test showed an elevated creatinine of 150 µmol/L. A plain abdominal film showed; a large, well-defined soft tissue swelling in the right hypochondrium and lumbar region. The patient was initially seen by the nephrology services, who arranged renal tract ultrasound (US), which showed a large clear cystic lesion measuring 20 cm × 16 cm in the right subhepatic region occupying the entire right lumbar quadrant. No contents seen with no septation. The right kidney was compressed by the cyst and could not be separately imaged from this lesion. The contralateral kidney was unremarkable. He was referred to urology clinic, where he was found to have a palpable mass that was dull to percussion occupying the right renal angle. After taking necessary measures against contrast nephropathy, the patient had a CT scan with intravenous and oral contrast of the abdomen and pelvis that showed a large thick-walled nonseptated noncalcific right renal cortical cyst (23 cm × 16 cm × 15 cm) showing enhancement of its thick walls, no right perinephric/pericystic fat stranding, preserved tissue planes with surrounding related organs.
For further assessment of drainage and function, the patient had an MAG3 renogram that showed a small right kidney with poor perfusion and excretion of the tracer. It contributed around 9% to the

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


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

[User]
RADIOLOGY NOTE:
A 38-year-old man of Korean descend and now living in Japan presented to the outpatient clinic of a local hospital with abdominal pain, melena and dizziness. Laboratory test showed that he had microcytic anaemia (haemoglobin 8.7 g/dL and mean corpuscular volume 71.7 fL). Faecal occult blood test was positive. His medical history included a previous duodenal bulb perforation which required surgery in his teens. Oesophagogastroduodenal endoscopy (OGD) and colonoscopy was subsequently performed, revealing no active bleeding but slightly deformity and linear scares in duodenal bulb. A plain CT scan later performed revealing no abdominal or pelvic masses. The patient received transfusion of two units of red blood cells which restored his haemoglobin to 11.5 g/dL, relieving his symptoms significantly. He was discharged on day 12 and later referred to our hospital, a metropolitan centre in central Tokyo, for further workup and treatment.
In the diagnostic workup, chronic iron deficiency anaemia caused by small intestinal bleeding was considered. BAE (single balloon, rectal approach) was hence performed in search of the culprit lesion. However, the scope failed to advance to the jejunum; mild inflammatory changes were found in the proximal ileum. Capsule endoscopy was further performed to inspect the small intestine. There was initially a delayed pylorus passing of the capsule endoscope due to stenosis in the duodenal bulb, but the capsule eventually reached to the small intestine. Images from the capsule showed small intestinal ulceration with surrounding erythematous mucosal changes in jejunum, which were likely to be the cause of the recent bleed (). Several days later, a plain abdominal X-ray was performed confirming capsule retention in distal small intestine. As a result, a secondary BAE (single balloon, rectal approach) was performed to retrieve the capsule. Despite the stenosis in area surrounding the jejunum–ileac junction, the scope was successfully inserted to th

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


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

[User]
RADIOLOGY NOTE:
A 67-year-old lady was admitted via the emergency department after being found unresponsive at home by her husband early in the morning. On presentation, her GCS was 9 with normal vital signs. Her glucose level was 8 mmol/L, and the blood gases were normal. On observation an hour later, her dextrose test was rechecked and fell to 1.5 mmol/L with blood glucose of 0.9 mmol/L. She was given intravenous dextrose and her condition improved.
Of note, her past medical history included a two-year history of type 2 diabetes mellitus, recently diagnosed depression, and osteoporosis. Her oral hypoglycemic agents had been recently withdrawn as her blood sugar levels were well controlled on dietary changes she had made. Her family reports that she was increasingly anxious over the last few months with occasional confused periods. She also had a 4 kg weight loss over the last 12 months (10% body weight). Her daily medications include citalopram, bromazepam, and weekly bisphosphonate. There was no family history of diabetes mellitus, hypertension, or hyperparathyroidism. The patient denied taking any excess medication or oral hypoglycemic agents.
On examination, the patient was alert but appeared very anxious; her GCS returned rapidly to normal on intravenous dextrose. Cardiovascular, gastrointestinal, and neurological examinations were normal as well as her other laboratory investigations.
The patient underwent a 72-hour fast as part of the investigation but was interrupted at 2 hours due to hypoglycemic symptoms (sweating, feeling drowsy and unwell). During this episode, her blood glucose level was confirmed to be low (1.1 mmol/L), C peptide was elevated at 8.2 and insulin levels at 91. Her sulfonylurea screen was negative and her other pancreatic endocrine hormones were sent and came back as within normal limits.
CT scan of abdomen revealed a 2.6 cm by 2.0 cm hypodense mass containing peripheral calcifications in the body of the pancreas (). Multiple low attenuation liver

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


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

[User]
RADIOLOGY NOTE:
A 66-year-old man with no history of concomitant conditions was admitted to our hospital. He had been operated on due to a tumour on the distal third of the left arm as a result of a closed trauma without fracture 20 years before. Several debridement surgeries were also performed on his lesion, but no detailed information is available. Physical examination revealed new lumps with seropurulent discharge 7 years after the first surgery. Subsequent blood analysis did not show alteration in acute phase reactants, and hematimetric indexes were within normal ranges. For the next 20 years, he continued to experience similar episodes of sporadic reactivation of the lumps.
Before 4 years, he was admitted to our hospital due to painless lumps fixed on the subcutaneous tissue of the left arm (). Radiographs of the left humerus revealed an alteration of the bone structure with distal diaphyseal involvement and thickening and cortical irregularity, which extended up to the metaphysis (). A computed tomography (CT) scan disclosed an alteration in the osseous morphology of the metaphysis–diaphysis in the distal third of the humerus at an intramedullary and cortical level, with osteolysis, periosteal reaction, diffuse involvement of adjacent soft tissues and several lower density, superficial, poorly defined liquid areas (). A magnetic resonance imaging (MRI) scan confirmed the multiple liquid deposits on the thick walls of the soft tissues and muscular oedema related to joint effusion ().
Aspiration was performed, and the extended coloured (Diff-Quick) haematoxylin–eosin, pap-test showed lymphocytes, leukocytes, macrophages, multinucleated giant cells and accumulations of bacillary structures (Actinomyces), consistent with a granulomatous inflammatory process (). Cultures (glucose asparagine agar, arginine-glycerol and tyrosine agar mediums) were subjected to a prolonged incubation of 21 days under aerobic and anaerobic conditions and were negative.
The patient underwent a surgica

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

[User]
RADIOLOGY NOTE:
A 48-year-old Japanese man noticed a slightly tender soft tissue mass on the anterolateral aspect of the lower part of his left chest wall, six months prior to his first visit to our hospital. When the tumor became slightly enlarged, he visited his previous orthopedist. A soft tissue tumor was suspected and an incisional biopsy was performed. However, a definite pathological diagnosis could not be made due to the small amount of biopsy specimen. He was referred to our hospital for further examination and treatment. On inspection, the anterolateral surface of the lower part of his left chest wall was swollen. On palpation, a fibrously hard tumor, measuring 5 × 6 cm, was palpable. It adhered firmly to the chest wall. He was experiencing mild pain. There was no localized heat or redness. Chest radiographs showed no abnormal findings. A magnetic resonance imaging (MRI) scan showed that the soft tissue tumor (measuring 6 × 5.5 × 5 cm) was located beneath his external oblique muscle and permeated into his intercostal muscles, causing the peritoneum to protrude towards his abdominal space (Figure ). The signal intensity of the lesion was isointense to skeletal muscle on T1-weighted images (Figure ) and heterogeneously high on T2-weighted images with some areas of low intensity (Figure ). The lesion was strongly enhanced by the administration of a contrast medium (Figure ). As a result of these physical and MRI findings, we suspected a soft tissue tumor rich in collagen fibers and blood vessels, such as desmoid tumor, fibrosarcoma or malignant fibrous histiocytoma. He was unwilling to take a second biopsy and a natural course was observed. The tumor gradually enlarged, becoming 8 × 6 cm on palpation ten months after his first visit. At this time, a second incisional biopsy was performed. Macroscopically, the tumor was whitish and fibrous. Histologically, the tumor was poorly circumscribed and infiltrated into his surrounding soft tissue. Spindle

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

[User]
RADIOLOGY NOTE:
A 35-year-old female presented to a local hospital with a 3-month history of intermittent abdominal pain. Initial abdominal ultrasonography revealed cystic dilatation of the extrahepatic bile duct. A suspicion of choledochal cyst was made and was referred for surgical management. Her past medical history was unremarkable. She weighed 83 kg and was 164 cm tall, with body mass index of 30.9 kg/m2. Apart from mild right upper quadrant tenderness, her physical examination was unremarkable. Laboratory tests including liver and renal function tests, serum and urine amylase levels were normal. A magnetic resonance cholangio-pancreatography (MRCP) done showed a cystic fusiform dilatation of the common bile duct (CBD) extending into the right and left hepatic ducts (). No PBM was observed. The MRCP findings suggested type Ic CC. Without any further imaging, patient was scheduled for complete cyst excision with cholecystectomy and hepaticoenterostomy surgery. At laparotomy, the CBD was found to be fusiformly dilated. Bile samples were taken from the cyst and the gallbladder (GB) for amylase level essays. The GB was dissected from the liver bed and the cystic duct opened into the midportion of the cyst. After careful dissected of the cyst from surrounding vascular structures, the distal part entering the head of pancreas was noticed to be unaffected (). The distal part was transected just at the level of the head of pancreas and samples were taken for frozen section. Dissection at the hepatic hilum revealed two separate dilated ducts originating from the confluence of the left and right hepatic ducts and both entering into the cyst (). The two ducts were transected just distal to their origin from hepatic confluence to avoid confusing them as true right and left hepatic ducts (). The hepatic confluence was then opened to expose the true left and right hepatic ducts (). The dilated portions of the both hepatic ducts were transected and samples were taken for frozen section. A

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


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

[User]
RADIOLOGY NOTE:
A 25-year-old lady presented to hospital 36 days after giving birth via an uncomplicated lower segment caesarean section. She stated that the scar was well healed since the fifth day post-surgery and she had begun breast feeding. There was no history of nipple trauma or mastitis. She complained of a 15 day history of progressive pain, swelling and decreased range of motion in her right knee. Systemic examination revealed pyrexia of 38.5 degrees Celsius and a tachycardia of 120 beats per minute. Examination of the knee demonstrated a red, hot, swollen, tender joint with minimal range of motion. Radiographs of the knee were unremarkable. The knee was aspirated under aseptic conditions and 35 mls of turbid fluid was collected.
Blood laboratory results were as follows: white cell count 15.8 × 109/L, CRP > 250 and ESR 75. Initial gram stain of the aspirate showed 3+ of white cells but no organisms.
In view of the clinical picture, the patient underwent urgent arthroscopic washout of the knee. It was noted that the synovium was thickened and inflamed, and biopsies were taken. Furthermore, there was a significant amount of pus in the suprapatellar pouch. The knee was washed out with nine litres of normal saline.
Cultures of the pus taken from the knee subsequently grew Staphylococcus aureus sensitive to flucloxacillin. Cytology of the fluid was negative for crystals. The biopsies taken revealed acute synovitis with extensive ulceration of the synovial lining lined by inflammatory exudate composed of fibrin, polymorphs and scattered macrophages.
The patient was given intravenous benzylpenicillin (1.2 g QDS) and flucloxacillin (1 g QDS) post-operatively and the patient clinically improved. She underwent a further arthroscopic washout of the knee three days after the original procedure. It was found at the second operation that there was some pus in the lateral arthroscopy portal wound though no pus within the knee joint

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


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

[User]
RADIOLOGY NOTE:
A 32-year-old man injured his dominant right hand by striking a punching bag machine with a clenched fist. Clinical examination revealed that his right hand was markedly deformed and swollen. The range of motion was limited due to pain. He had small bulla formation on the dorsal aspect of the hand. There was no neurovascular deficit.
Plain radiography and computed tomography revealed dorsal dislocations of the index, middle, ring, and little fingers at the CMC joints and simultaneous fractures of the dorsal aspect of the trapezoid and hamate []. An initial attempt of closed reduction under conscious sedation in the emergency room was unsuccessful.
The surgery was performed through the dorsal aspect of carpus in a zigzag fashion from proximal part of the wrist to the middle part of the metacarpal bone. An interposed dorsal joint capsule in the CMC joints was found which might prevent the initial closed reduction of these joints. After removing the interposed joint capsule, CMC joint reduction was easily achieved under fluoroscopy.
However, we could not achieve stable reduction without fixation. The Kirschner wire fixation was performed while the CMC joints reduced. Under fluoroscopic vision, the first Kirschner wire was inserted retrograde from the base of the fifth metacarpal bone to the hamate. The second Kirschner wire was inserted antegrade from the hamate to the fourth metacarpal bone. The third Kirschner wire was inserted antegrade from the trapezoid toward the second metacarpal bone. The fourth Kirschner wire was inserted retrograde from the third metacarpal bone to the capitate. Finally, dorsal fractures of the trapezoid and hamate bone were reduced and each fracture was fixed with a mini screw (1.5-mm cortical screw, Synthes, West Chester, PA, USA).
After bony fixation, the ruptured dorsal capsule and ligaments of the CMC joint were repaired with absorbable sutures. Postoperatively, the patient remained in a volar above elbow spl

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


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

[User]
RADIOLOGY NOTE:
A 70-year-old woman, hailing from Kashmir in India, presented to us with progressively increasing abdominal mass since 11 years. This was associated with progressive appearance of jaundice and dull aching pain in abdomen since 3 months with pruritus for one month that worsened nocturnally. She neither complained of fever, bleeding diathesis, chest pain, cough or palpitations, and altered bowel habits nor did she suffer from anorexia. There was significant unintentional weight loss secondary to early satiety since last one year. There was no history of swelling of legs or puffiness of face during this period. There was no history of swelling over other parts of the body or associated skin changes. The patient is a known case of diabetes mellitus on oral hypoglycemic agents with adequate glycemic control since the last 20 years. Eleven years ago, the patient underwent an open laparotomy for complicated symptomatic gall stone disease and was incidentally detected to have a space occupying lesion of the head of pancreas. The lesion was highly vascular on intraoperative analysis and was left alone at that time with a fine needle aspiration cytology evaluation, which was later confirmed to be that of benign microcystic adenoma. The patient thereafter started noticing progressive enlargement of an epigastric mass which was initially seen 8 years ago. This mass progressed to involve the whole of the abdomen with associated lethargy and early satiety and difficulty in performing routine works. Multiple fine needle aspiration cytology of the mass lesion was done at various hospitals outside, before presentation to our facility. All those reports were noncontributory and confirmed the presence of only blood and cystic elements. On examination, at our center, the patient was found to be conscious and alert but emaciated with temporal hollowing and facial muscle wasting, with good performance status (ECOG-PS 0). Pallor was evident, as were icterus and scratch marks over the abdo

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


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

[User]
RADIOLOGY NOTE:
An 80-year-old woman presented to the authors' hospital emergency department complaining of right hip pain after sustaining a fall in her own home. Prior to injury she could walk normally. She had a normal body mass index and did not suffer from any other comorbidities. Clinical and radiographic evaluation of the right hip demonstrated an AO type 31.A2 intertrochanteric fracture.
The femur fracture was treated with intramedullary fixation the following day (). The patient tolerated the procedure well and the immediate postoperative period was completely uneventful. She was instructed not to bear weight for two weeks, but a range of motion exercises were started on postoperative day one. After an unremarkable hospital stay she was transferred to a rehabilitation facility on postoperative day four. Two weeks following surgical fixation of the femur fracture the patient started progressive weight-bearing and gait training. However, on postoperative day 20 the patient complained of a sudden onset pain at the right groin, over the femoral triangle of Scarpa. On physical examination the patient presented with a palpable and visible mass of about 3 × 3 cm, hard and tender to palpation (). Arterial pulses, strength, and sensation of the right lower extremity were unaffected. The pain was poorly controlled by rest and pain medication.
On postoperative day 40 anteroposterior and lateral X-rays were obtained demonstrating cephalad migration of the lesser trochanter (). For such reason an angio-computed tomography (CT) was obtained to assess fragment location and femoral vascular involvement (). The study demonstrated the migration of the lesser trochanter over the femoral triangle of Scarpa with no apparent neurovascular injury. On postoperative day 45 the patient underwent surgery for removal of the dislocated lesser trochanter. Intraoperatively the ascending branch of the lateral circumflex artery was isolated and retracted to access and remove the bony fragment. The apex of

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


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

[User]
RADIOLOGY NOTE:
The patient is a 57-year-old female who underwent cardiac catheterization via the right common femoral artery two weeks prior to developing a large, symptomatic right common femoral artery pseudoaneurysm ().
The patient began complaining of groin pain two weeks after cardiac catheterization. She has a past medical history of aortic valve replacement secondary to aortic valve infective endocarditis, hyperlipidemia, and hypertension.
She underwent two attempts of ultrasound-guided thrombin injection of the pseudoaneurysm. On ultrasound, the size of the pseudoaneurysm was found to be 5 cm × 3 cm × 4.6 cm. The neck of the pseudoaneurysm was measured to be 0.8 cm long. The two attempts involved using a 21 gauge needle to administer 1000 units and 2000 units of thrombin, respectively, into the pseudoaneurysm under ultrasound guidance and with the assistance of compression. Due to the size of the aneurysmal cavity and a relatively large pseudoaneurysm neck, injections were found to be unsuccessful on follow-up ultrasound (Figures and ). It was then decided to attempt endovascular closure of the neck of the pseudoaneurysm. All risks were discussed with the patient.
After identification by the attending surgeon, the patient was transferred to the procedure room table in the catheterization lab. The patient received IV sedation, and local anesthesia was used prior to ultrasound-guided percutaneous access to the left common femoral artery. During the procedure, vital signs, including blood pressure, heart rate, respiratory rate, and oxygen saturation, were monitored by an ACLS certified nurse.
After a 21 gauge needle was placed into the projection of the vessel lumen, a guidewire was placed into the left iliac artery. An angiographic catheter and guidewire were used to perform selective cannulation of the contralateral right common iliac artery. Then, a 6 French long access sheath was placed to perform an angiogram. The neck of the pseudoaneurysm was visualized (), and a 0.014

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


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

[User]
RADIOLOGY NOTE:
A 50-year-old male physician, with no medical comorbidities, presented to the emergency room with history of forceful unrelenting vomiting associated with moderate nausea that had progressed over the past 2 weeks. Initially attributed to gastritis, his symptoms did not improve with proton pump inhibitor and antiemetic medications.
His level of consciousness had started to drop over the preceding 24 hours with significant increase in the severity of his headache. Physical exam showed a depressed Glasgow coma score (GCS) of 12 equally reactive pupils with no focal neurological deficit.
An urgent brain computed tomography (CT) scan revealed obstructive hydrocephalus with an infratentorial somewhat hyperdense lesion in the fourth ventricular that enhanced homogeneously ().
The patient was admitted and urgent endoscopic third ventriculostomy was performed, with rapid recovery of his level of consciousness postoperatively. Cerebrospinal fluid (CSF) analysis and cytology results were within normal and negative for malignant cells.
Further brain and spine imaging with magnetic resonance (MR) scan demonstrated a 20 × 25 × 30 mm strongly enhancing mass occupying the inferior half of the fourth ventricle (Figures and ). The mass acquired the shape of the ventricular cavity, extended towards the lateral foramina of Luschka and inferiorly towards the obex without evidence of fourth ventricular dilation. No evidence of parenchymal invasion or drop metastases was seen on imaging of the whole spine. The radiologist's impression was that of an ependymoma or possibly a subependymoma.
The patient was then shifted, 2 days later, to the operating theatre for resection of a tumor of the fourth ventricle. Midline posterior fossa craniotomy was performed and the tumor was accessed through a transvermian approach. The tumor was exophytic, grayish in color, firm, and fairly vascular, being fed by leptomeningeal vessels arising from top of the brainstem. Invasion of the lower pons and upper 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:
An 85-year-old man was presented by his general practitioner complaining of the presence of an erythematous round lesion that was protruding from the surgical scar of his previous sternotomy. He mentioned that the lesion has been growing slowly over time and that lately was also associated with pain in the area. The patient has undergone aortic valve and aortic root replacement with the use of a prosthetic tube graft 7 years ago. The general practitioner referred him to the cardiothoracic unit of our hospital; physical examination confirmed the presence of a non-pulsatile, erythematous round lesion in the cranial third of the previous sternotomy scar with a surrounding bruise (Fig.
and .
Contrast-enhanced computed tomography (CECT) scan was performed and revealed a 7-cm pseudoaneurysm arising from a 5-mm fenestration of the distal suture line of the Dacron graft with significant amount of thrombus. The pseudoaneurysm was pushing the sutured sternum forward causing diastasis of the sternotomy and was extending anteriorly to the sternum in the subcutaneous tissue (Fig.
and .
The patient was discussed in the aortic multidisciplinary meeting and was considered as of high risk for surgical revision; an endovascular approach was suggested as an alternative option and was referred to interventional radiology.
The procedure was performed under local anesthesia. Written informed consent was obtained explaining the risks and benefits of the procedure, including the risk of potential pseudoaneurysm rupture during manipulation and potential embolic material migration in the cerebral circulation. A retrograde left femoral artery access was obtained and a 5F sheath was inserted. Through a pigtail catheter, angiographic evaluation of the ascending aorta in anteroposterior and oblique views was followed in order to delineate the neck of the pseudoaneurysm. A second arterial access through the left axillary artery followed by another 5F sheath was inserted. Using this access, 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 10-year-old boy was referred for management of malposition left maxillary permanent lateral incisor (tooth 22). Tooth 22 was in crossbite to the left mandibular permanent lateral incisor (tooth 32) and permanent canine (tooth 33) (). According to the boy's mother, the boy had a small pointed tooth between the right and left maxillary permanent central incisors (tooth 11 and tooth 21) extracted two months ago at a private dental clinic. The attending dentist informed them it was an additional tooth. However, no X-ray was available to verify their account. On examination, tooth 21 appeared malposition labial and inferior in relation to the maxillary alveolar ridge.
The first stage of the treatment was to get tooth 21 closer to the arch alignment. We bonded orthodontic brackets (022 × 028 slots, American Orthodontics) on teeth 12, 11, and 21 and used a sectional orthodontic appliance technique to align the teeth. It took over 4 months to achieve the desired result (). A 014 round nickel titanium (NiTi) wire was used to align tooth 22 through deflection method. Once tooth 21 had been moved inferiorly towards the arch alignment, we placed molar bands around the maxillary permanent first molars (teeth 16 and 26). However, the mesial-distal width space between tooth 21 and the left maxillary left primary canine (tooth 63) was narrow (6 mm) and inadequate to move tooth 22 into the arch alignment.
In the second stage, we used a 2 × 4 fixed orthodontic appliance to close the space between tooth 11 and tooth 21. We passed a 018 stainless steel round wire through the brackets and bands. We ligated both the brackets on teeth 12 and 11 over the arch wire using a ligature wire to act as an anchor unit. A 3-unit power chain was placed over the brackets on tooth 12, tooth 11, and tooth 21 to gain space closure. The space closure took approximately

[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:
Due to persistent headaches and the qualitative alteration of consciousness in a woman aged 58 years, on 11 July 2011, a head NMRI was performed, and it showed an expansive lesion in the left frontal portion of the brain, measuring 60 × 50 × 40 mm (Fig. ). The tumor was accompanied by a large edema (Fig. ). As the first step, dexamethasone was included with a dose of 8 mg/day. The surgical procedure was performed on 25 August 2011, and a maximum tumor resection was performed on that occasion.
In the period between 08 November and 23 December 2011, the patient underwent radiation with 46 Gy, followed by radiation of the tumor base with 14 Gy in 14 fractions. During radiation, the patient had been receiving TMZ in a dose of 120 mg daily for 42 days. Afterwards, 6 cycles of TMZ (240 mg during each cycle) were administered.
The patient started to use standard phytotherapy together with combined RT/CT, and then together with monotherapy with TMZ, and continued to use it after the completion of the oncological treatment. She had been taking PT at full capacity and without interruption for 24 months. Five months after the completion of PT, the patient began to complain of an intense headache; so in April 2014, a control NMRI was performed, and a recurrence of the underlying disease in the frontal portion of the head on both sides, in the shape of a butterfly, was found on that occasion. On the right side, prominent was a larger area of 56 × 47 × 43 mm in diameter that occupied the front third of the corpus callosum (Fig. ).
After these findings, the patient was reintroduced to oncological treatment, which consisted of the combined RT/CT followed by planned 6 cycles of monotherapy with TZM in a daily dose of 260 mg for 5 days during a cycle of 28 days. After the third cycle of the treatment with TZM, a control MRI was

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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 man underwent percutaneous angioplasty due to unstable angina CCS III-IV. He had a history of mild chest pain for the last 20 years with a crescendo pattern in the early past. No pathological findings were detectable in electrocardiography. His cardiovascular risk factors included history of nicotine abuse, hypertension, as well as hyperlipidemia. Due to the severity of the angina an elective catheterization via the right radial artery was planned. Mecain 1% injection solution was used as a local anesthetic and verapamil was administered as an intra-arterial vasodilatory agent. For anticoagulation 5.000 IE heparin and 150 mg clopidogrel were applied.
The process of advancing the guide wire toward the ascending aorta has been described as difficult due to a kinking of the brachiocephalic trunk. As in the first case, the procedure was performed by an experienced cardiologist with a large number of transradial catheterizations performed. During the procedure the wire was not forced and a polymer-jacketed guidewire was used.
His coronary angiography revealed the presence of a chronic collateralized stenosis in the proximal third of the right coronary artery, diffuse sclerosis, and calcifications with high degree stenoses of the ramus circumflexus and the proximal left anterior descending coronary artery. After an extensive interdisciplinary discussion of the diagnostic findings it was decided to perform interventional treatment. During the switch to a guide catheter (Braun; Serpia; XB 3,5; 6 French) advancing the guide wire into the ascending aorta again appeared to be difficult and ultimately frustrating. The subsequent angiography demonstrated a strong suspicion of a dissection of the brachiocephalic trunk. A subsequent CT angiography confirmed a dissection of both the brachiocephalic trunk as well as the aortic arch (). The patient was referred to the Department of Cardiac Surgery for further conservative treatment and coronary artery bypass grafting. N

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


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

[User]
RADIOLOGY NOTE:
A 77-year-old female began feeling discomfort in her abdomen around the beginning of September 2019. She also developed night sweats and fever, with little improvement in symptoms. On September 30, she had acute severe abdominal pain and was taken to the emergency room in the previous hospital. On examination, the patient presented with a fever of 38 degrees, rebound pain in the lower abdomen, and muscular defenses. CT scans showed jejunum and ileum wall thickening. It showed fatty deposits around the small intestinal tract and thickening of the nearby intestinal wall, and gastrointestinal perforation could not be ruled out. CT scans also showed adhesions due to inflammation of the sigmoid colon and small intestine (part of the ileum) (Fig. ). She was guided to our hospital for further investigation. The laboratory tests revealed a C-reactive protein (CRP) level of 6.80 mg/dL (normal range: 0–0.14 mg/dL) and an interleukin 2 receptor (IL2R) level of 3,652 (normal range: 121–613 U/mL) (Table ). Transanal small bowel balloon endoscopy revealed mild edema with petechial erythema, which was thought to be lymphatic follicular hyperplasia around 100 cm the oral side from the Bauhin valve. There were no abnormal findings in the colon. Biopsies were taken from the site of the suspected lymphatic follicle hyperplasia (Fig. ). Transoral small bowel balloon endoscopy revealed shallow erosions and edematous mucosa which were detected around 200 cm from the anal side at the vicinity of the Trites ligament. We found ulcers with surrounded disrupted villous structures around the anal side where erosion with edematous mucosa were noticed. We obtained one specimen from the erosion site and the other from the ulcer site (Fig. ). All specimen showed atypical lymphocytes infiltrating the small intestinal mucosa demonstrating intraepithelial lymphocytosis. Immunohistochemical staining showed that infiltrated lymphocytes were positive for CD3, CD7, and CD56, but negative for CD4, CD5, an

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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 61-year-old man was involved in a motor vehicle accident at the age of 31. He sustained a left open femoral shaft fracture, and was treated with open reduction and internal fixation. Despite the treatment, the fracture was malunited and valgus deformity of the femoral shaft remained. Progressive left knee pain appeared 3 years before presentation. He was referred to us for surgery. Radiographs showed advanced degenerative arthritis of the left knee and malunited left femoral shaft fracture (Figures and ). There was a 11° valgus in coronal plane and 23° antecurvatum deformity in sagittal plane preoperatively.
Extra-articular deformity and canal sclerosis precluded the use of a conventional intramedullary alignment guide; therefore, we performed navigation-assisted TKA.
Preoperative planning revealed that the estimated distal femoral cut line does not compromise MCL insertion site (). The distal femoral cut line was set 13° flexion to the mechanical axis in the sagittal plane () to avoid notching of the anterior femoral cortex. According to the intraoperative assessment, the estimated thickness of distal femoral resection was 12 mm for the medial condyle and 6 mm for the lateral condyle ().
Postoperative radiographs showed well-restored coronal limb alignment. Coronal alignment of the femoral component was 90° to the mechanical axis (). Sagittal alignment was 13° flexion to the mechanical axis that is parallel to the anatomical axis of the distal femur (). The femoral component was placed according to the intraoperative navigation data. Mechanical axis of the lower limb improved from 9° valgus preoperatively to 1° varus postoperatively.
Range of motion improved from 15°–105° to 10°–120°. Knee score increased from 36 to 92, and function score increased from 50 to 90 at the latest follow-up. Soft tissue balance was well coordinated. No complications, such as infection, deep venous thrombosis, PF problems, or aseptic loosening, were seen postoperatively. As a result, t

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


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

[User]
RADIOLOGY NOTE:
A previously healthy 29-year-old female patient was admitted to the emergency room of Santa Paula Hospital, Sao Paulo, reporting a sudden headache and syncope associated with mild dysphasia and weakness of right arm and leg. Upon admission, she was graded a Glasgow Coma Scale of 13 and a Grade 4 right hemiparesis. According to her husband, she had not suffered any trauma. The patient was hemodynamically stable and reported on regular use of oral contraceptive.
When the patient was submitted to a computed tomography (CT) scan, the following were detected: A nodular hyperdense frontotemporal image anterior to a large left side predominantly temporal hematoma associated to edema and signs of subfalcine and transtentorial herniation, and a midline shift of approximately 6 mm []. An urgent magnetic resonance imaging (MRI) revealed aneurysm of 2, 5 cm in diameter, with partially thrombosed content associated to a large left temporal hematoma []. Digital subtraction angiography revealed dissection of the parietal-occipital branch of the left MCA and large pseudoaneurysm []. Terminal branches of distal MCA were seen emerging from the aneurysm base. In addition, a routine laboratory and cardiologic examination were conducted, yet the results were unrevealing.
Surgery under sensitive evoked potential (SEP) and motor evoked potential (MEP) monitoring was performed on an urgent basis given the risk of further neurological worsening.
A left side large frontotemporal craniotomy was performed along with wide Sylvian fissure opening and complete aneurysm dome and neck dissection. Aneurysm was trapped, and no reduction on neurophysiological parameters from baseline could be noted afterward, thus prompting us not to do a bypass. After the opening of the lesion wall, no bleeding was noted and aneurysmectomy was conducted given the large dome had considerable mass effect on the adjacent brain. Draining of the temporal hemorrhage considerably alleviated regional cerebral edema. Immediat

[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 female patient had upper gastrointestinal bleeding with haematemesis and melena in the context of an altered general condition. The physical examination revealed weight loss (15 kg) and an abdominal mass of approximately 20 cm in size on the major axis, located in the epigastrium and left hypochondrium. The mass was not very mobile and was poorly limited. A blood test showed anaemia (8 g/dl). A computed tomography (CT) scan revealed a voluminous mass of approximately 22 cm in size from the rear cavity of the epiploon with a predominant mix of aerobic and fluid components. The mass had a thickened and irregular wall and pushed back the stomach (Fig. ). This observation was suggestive of a gastric duplication with blocked communication. An oesophagogastroduodenoscopy did not reveal any lesion up to the 3rd duodenum apart from an aspect of extrinsic compression of the anterior side of the cardio-tuberosity junction. An exploratory laparotomy was decided upon, as the ultrasound endoscopy was not available. During this exploration, a large tumour of a suspicious nature was found at the expense of the posterior gastric wall extending from the spleen to the left hepatic lobe and left diaphragmatic cupola. There was no hepatic metastasis, suspicious adenopathy or peritoneal carcinosis. Nevertheless, the lesion seemed to be inextirpable. We therefore ended the procedure by performing, via a short gastrotomy, four biopsies of the lesion that communicated with the gastric lumen through an orifice admitting a finger. The postoperative outcomes were simple. The biopsy results were in favour of a stromal tumour, with positive CD117, CD34 and Dog1 antibodies (Figs. , S1, S2 and S3). The Ki-67 index was positive at 4%.
A treatment with imatinib at the initial dosage of 800 mg twice daily was initiated. Poor tolerance to treatment (i.e., severe asthenia and aggravation of anaemia following repeated digestive bleeding) required 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:
Our patient is a 55-year-old Ethiopian woman, gravida IV para III abortion 0, who gave birth to three children at home by spontaneous vaginal delivery. She presented to our hospital claiming she was carrying a dead fetus in her womb from a pregnancy that had been there for 22 years. The pregnancy lasted up to nine months uneventfully at which time the membrane ruptured and she went into labor. After 3 days of labor at home, she developed vaginal bleeding and visited a nearby hospital where she was informed that she had a uterine rupture which had to be operated on. However, she refused the surgery and went home. Over time she developed urinary incontinence.
She lost all her three children from an unspecified medical illness before their first birthday, although she claimed all the pregnancies and the labor were uneventful. Since the incident, she is divorced and lives alone supported by her sister.
At her current presentation, she had lower abdominal pain which had increased in severity, vaginal discharge, and urine per vagina since the onset of the condition. She had no other known medical illness.
On physical examination there was a gravid uterus of 20-week size and a non-tender, fixed, and firm abdominopelvic mass with no signs of fluid collection in her peritoneal cavity. There was a continuous leakage of urine through her vagina but a leak point was unidentified. Her vaginal canal was filled with a 4 cm by 5 cm, oval and stony hard mass.
Laboratory findings, complete blood count, and organ function tests were in the normal range. An abdominal ultrasound was difficult to perform as there was only shadowing in her pelvis from the bony structures and our patient was incontinent, therefore, she was unable to retain urine.
Abdominopelvic computed tomography (CT) findings: On the scanogram, multiple calcified tubular fetal parts were demonstrated in the pelvis of our patient (Fig. ). On the post-contrast images,

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


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

[User]
RADIOLOGY NOTE:
A 28-year-old man without any underlying diseases had suffered from left side weakness and clonic–tonic seizures for 12 days. Computed tomography (CT) of the patient's head revealed a hypodensed mass with the size of 3 × 3 × 2.4 cm of the right temporal lobe. He was then admitted, and the magnetic resonance imaging (MRI) of his brain showed cystic astrocytoma in the right parietal lobe without midline shifting. A craniotomy was performed, and the pathology showed astrocytoma (World Health Organization (WHO) grade III). After operation, he received 2-dimensional conformal RT with a total dose of 45 Gy in 25 fractions to the whole brain. Mild skin erythematous change was noted after the completion of RT.
During a regular follow-up of 14 years after postoperative adjuvant RT, a small red nodule was noted at the patient's right scalp. The size of the nodule increased overtime and the color eventually turned to black within a year. This gray-colored skin papule with a diameter of 2.5 cm has an ulcerative center. He received skin tumor excision at the age of 42. The skin tumor was totally removed with an adequate margin. The pathology revealed BCC. The morphology of the tumor featured basaloid cells which extended into the dermis with elongated nuclei and little cytoplasm. The peripheral cell layer of the tumor masses showed a palisade arrangement of the nuclei (Fig. ). No skin tumor recurrence has been noted to date.
Two years later, the patient developed headache, left side weakness with unsteady gait at the age of 44. His brain MRI revealed a huge cystic lesion with fluid-fluid level in the patient's right frontal lobe. There were hemorrhage, perifocal edema, mass effect causing mild midline shift. Second craniotomy was performed, and there was presence of microvascular of festoons gliosis, microcalcification and tiny foci of necrosis in the specimen, which favored the diagnosis of glioblastoma (WHO grade IV).

[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 90-year-old man was brought to the emergency room due to acute onset of severe generalized weakness, sudden onset of dyspnea, pleasure whistling in respiration, acute dysphagia to both liquids and specially solids and inability to speak, from 2 days ago. He had one time vomiting at onset of the symptoms. He had medical history of achalasia, recurrent pneumonia in last months and head trauma 2 months ago with sub-arachnoids hemorrhage and several convulsions. On arrival to hospital, his vital sign were as oral temperature: 37.8°C, heart rate: 100/minute, respiratory rate: 16/minute, blood pressure: 100/80 mmHg with 95% oxygen saturation on room air. He was completely alert but could not talk. In physical exam except for severe cachexia and superficial ulcers on two forearms, there was no other finding. Lung exam was incomplete due to severe illness and superficial respiration. He did not have stridor and wheezing! None of examiners noticed to his respiration with pleasure whistling and the history of losing his upper dental prosthesis from two days ago. Posterior-anterior chest x-ray revealed bilateral consolidations with the most prominence in the right middle lobe (). Chest computed tomography (CT) scan revealed the same finding as well as bilateral pleural effusion (). He was admitted to the Infectious Disease ward with diagnosis of aspiration pneumonia. In next day, his dyspnea guts worst so made the corresponding physician to take a lateral neck radiography (). A large foreign body was lodged above epiglottis between oropharynx and hypopharynx. On physical examination, his lost upper complete upper denture with 5 x 5 centimeter size was seen in his pharynx behind the tongue and was manually extracted with fingers. His three days dyspnea, whistling, inability to talk and dysphagia was dramatically improved. He was treated for aspiration pneumonia due to last convulsions and was discharged in a stable condition after one week. In third

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

[User]
RADIOLOGY NOTE:
A 45-year-old man presented with a one-month history of progressive back pain and hypesthesia in both L3 dermatomes. There were no motor weakness. He had undergone a right temporo-occipital craniotomy and partial removal of a huge HPC followed by whole brain radiotherapy at other university hospital in 2003 (). He underwent two more craniotomies with recurrent tumors removal at our institute in 2012 and 2013 (). Thereafter, he has been treated by gamma knife radiosurgery three times successfully for local recurrent and residual HPC. Since then, no local recurrence has been found. In March 2016, however, the first extracranial metastasis was found in the L2 vertebral body. Diagnostic workup including thoracolumbar magnetic resonance imaging (MRI), bone scintigraphy and thoracolumbar computed tomography (CT) revealed a solitary L2 body lesion. CT scans showed well demarcated osteolytic mass in the posterior aspect of L2 vertebral body with retropulsion to anterior epidural space (). T1- and T2-weighted MRIs showed an isointense tumor with strong contrast enhancement compressing the spinal cord (). Bone scintigraphy also showed hot uptake in L2 body. In consideration of the patient's relatively young age and a solitary lesion at the L2 body, we planned subtotal en bloc corpectomy and radical removal of the tumor via a transpedicular approach. Angiography performed prior to surgery revealed hypervascular tumor supplied by multiple arteries from the bilateral L2 and right L1 segmental arteries. Preoperative embolization of the feeders was done successfully through a super-selection of bilateral L2 segmental arteries using gelform particles one day prior to surgery. The patient underwent a L2 total laminectomy and radical total removal of the tumor with subtotal corpectomy. At surgery, a gray and reddish tumor filled the L2 vertebral body, which was curetted and drilled out easily under surgical microscope, and the tumor cavity filled with minced autologous bone. There wa

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


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

[User]
RADIOLOGY NOTE:
A 41 year old male presented at the emergency room reporting abdominal pain in the hypogastric region and in the lower right limb with neurogenic characteristics (paresthesia and burning mainly in the L2 dermatome) one week prior to admission. The patient had a history of papilliferous tumor of the thyroid, resected two years previously without need for complementary therapy. The patient underwent computerized tomography (CT) of the abdomen (Figs. and ), which revealed a hypodense and circumscript nodular formation, located in the right median presacral region, at the level of vertebrae S1 and S2, measuring approximately 4.4 × 3.9 × 3.4 cm. There were no other abdominal abnormalities. The decision to perform an excision surgery was based on the symptoms (associated with the topography of the tumor) and the need of diagnosis since the CT was inconclusive. There was no suspicious diagnosis related to the previous tumor.
The tumor found in laparoscopic surgery was a hardened nodular mass with a yellow surface and a elastic consistency. Its capsule was thickened by a significant adipose tissue layer firmly adhered to its surroundings. A colon liberation and meticulous dissection was performed in order to expose the tumor and to remove the adherences without harming important structures as the iliac vessels and the inferior hypogastric plexus (Fig. ).
The lesion was completely removed, without signs of bleeding or remaning lesions. Histopathological examination revealed dimensions of 5.0 × 3.5 × 2.6 cm (Fig. ). The surgery lasted 260 min and was performed through 4 incisions (right lumbar region, left and right iliac regions and infra-umbilical). The discharge was made after less than 24 h of hospitalization. The patient reported alteration in intestinal routine, retrograde ejaculation and pain in the lower right limb in the immediate postoperative phase, with spontaneous resolution after approximately one month. The patient was followed up for 4 months and there were no

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


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

[User]
RADIOLOGY NOTE:
A patient in her late seventies was incidentally found to have a large infrarenal abdominal aortic aneurysm in 2013 for which she had undergone an uneventful percutaneous endovascular aortic repair with left chimney. She lived alone, remained independent in her activities of daily living, and was community ambulant without aid.
She was electively admitted in September 2019 for embolization of a type 2 endoleak by the interventional radiologist. Super selective cannulation of the distal aspect of the iliolumbar branch supplying the nidus with a micro catheter was performed. Embolization was carried out using Onyx® until complete exclusion of the nidus. This was followed by repeat aortogram, which showed complete exclusion of the nidus from right-sided branches. However, there was continued filling of the nidus from the left lumbar branches. It was therefore decided to embolize the left side. After embolization, angiogram showed complete exclusion of the endoleak and the left-sided branches supplying the endo leak.
Five hours after the procedure the patient complained of bilateral lower limb weakness and numbness, right more than left. Physical examination revealed lower motor neurone pattern of weakness over bilateral lower limbs, right worse than left (Table ). Sensation testing revealed normal sensation over left, impaired sensation for right L2 to S1. Proprioception at bilateral big toes was intact. Reflexes were absent in bilateral lower limbs.
Lumbar spinal drain was inserted to decompress the spinal cord to allow more arterial flow as there was concern with spinal cord ischemia. The patient was started on fluid replacement to maintain the mean arterial pressure above 80 mm Hg. Urgent CT aortogram followed by MRI thoracolumbar spine was performed. Aortogram showed postinterval embolization of bilateral feeding arteries. Onyx material was seen within a branch of the embolized right iliolumbar artery, which extends into the spinal canal at the level of L3 and appe

[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.