[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 male was referred to his ophthalmologist regarding the complaint of sudden blurriness of vision in his right eye. He was diagnosed five months ago with a case of ENKTCL, nasal type, stage IV-B with testicular and central nervous system involvement with 23% natural killer (NK) cells on cerebrospinal fluid (CSF) flow cytometry. He was on an active therapeutic plan consisting of cycles of chemotherapy (i.e., SMILE protocol: dexamethasone, methotrexate, ifosfamide, L-asparaginase, etoposide), to which there was a complete response in the form of negative flow cytometry and computed tomography (CT) of the chest, abdomen, and pelvis. Five months after the initial diagnosis, prior to the fourth cycle of treatment, a complaint of blurriness of right eye vision was made. Brain CT was done aiming to rule out ocular involvement, which turned out to be unremarkable. At the time of the complaint, visual acuity was 20/30 -2 in the right eye as opposed to 20/20 in the left eye. The right eye showed relative afferent pupillary defect. Extraocular muscle movements were competent in both eyes. On examination of the anterior chamber, +1 cells were visualized in the right eye only. On dilated fundus examination, there was vitritis in the right eye which obscured the vision. Left eye examination was insignificant. B scan ocular ultrasonography revealed retinal detachment in the right eye. An optic CT revealed vitritis in the right eye; an impression of disease infiltration of the eye was made. The therapeutic plan was a diagnostic vitrectomy followed by systemic therapy. A pars plana vitrectomy was made and the vitreous specimen was sampled revealing the presence of 10% viable lymphoid cells expressing CD2 and CD56 on immunohistochemistry stain. An orbital magnetic resonance imaging (MRI) was ordered revealing evidence of an enhancing retinal lesion centered on the optic disc with diffuse restriction consistent with lymphomatous infiltration; minimal proptosis of

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


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

[User]
RADIOLOGY NOTE:
A 76-year-old man with severe chronic obstructive pulmonary disease (COPD) presented with a feeling of fatigue, weight loss, and reduced physical activities. He was diagnosed with COPD at the age of 69 years and had retired from work the following year. His smoking history included 40 cigarettes per day between the age of 14 and 69 years; his airflow limitation was classified as severe by the Global initiative for Chronic Obstructive Lung Disease; and a chest computed tomography (CT) scan showed severe emphysema. He had started long-term oxygen therapy at the age of 72 years and is currently inhaling 3 L/min of oxygen. Medical and family histories were otherwise unremarkable. Cardiac ultrasound excluded comorbid congestive heart failure or pulmonary hypertension, and CT pulmonary arteriography also excluded chronic pulmonary thromboembolism. As the patient had a history of acute exacerbations of COPD more than twice a year with extreme respiratory symptoms, he was prescribed a combination of inhaled long-acting antimuscarinic antagonist, long-acting beta2-agonist, corticosteroid, and oral carbocysteine, ambroxol, and theophylline. He reported symptoms of dyspnea on exertion, depression and anxiety, and a decrease in physical activity. He also experienced anorexia with a weight loss of more than 5 kg in a year, and no other possible causes of weight loss, such as tuberculosis and malignant tumor, were observed. Therefore, in addition to respiratory pharmacotherapy, we prescribed an antianxiety drug and provided nutritional supplement therapy, patient education, and pulmonary rehabilitation. However, the patient's mental and physical symptoms did not improve after 4 months. Furthermore, he exhibited deterioration in activities of daily living as well as physical and mental weakness; hospital visits were difficult and therefore, he considered home care. Persistent weight loss, poor endurance and energy, and low physical activity levels led to the diagnosis of physical

[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 man with known cervical canal stenosis due to ossification of the cervical posterior longitudinal ligament was transferred to an emergency room soon after a falling accident. The patient was alert and had complete tetraplegia, sensory deficits below the C4 cervical sensory level, and progressive restrictive respiratory failure that required assisted ventilation, and, eventually, a tracheostomy. Cervical spine magnetic resonance imaging showed cervical cord compression that was worse at the C3–C4 intervertebral level, and an intramedullary high signal at C3 and C4 vertebral levels, and the patient was managed conservatively. During the conventional weaning process of trials of intermittent spontaneous breathing in the ICU, an unexpected cardiac arrest made both the patient and medical staff reluctant to proceed with further weaning. Fifty-eight days after cervical cord injury, the patient was transferred to our hospital for further rehabilitation. He was fully conscious and received pressure-support mechanical ventilation with back-up rates of 16 breaths. He had total tetraplegia below shoulder girdle muscles with a preserved sensation from C2 to C3 on both sides, and a urinary obstruction. The limbs and trunk were stiff with contracture, and muscle stretch reflexes of the limbs were abolished. Neurological level of injury was C3 according to the ISNCSCI, with a total sensory score of four. There was no sensory sacral sparing, while the deep anal pressure was preserved, and the American Spinal Injury Association scale graded B. Chest roentgenogram and computerized tomography showed bilateral, widespread atelectasis. The patient occasionally showed signs of pulmonary infection. Intensive pulmonary care and rehabilitation, including physical support for expectoration, mechanically assisted removal of tracheal secretions (CoughAssist E70®, Philips Japan, Tokyo), ventilator muscle training, and management of the spasticity of the abdominal wall, resulted i

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


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

[User]
RADIOLOGY NOTE:
A 42-year-old female presented to the ENT department with a short history of severe breathlessness and stridor for 7 days with no history of hemoptysis, chest pain, or change in voice. She gave a history of being operated for uterine fibroids 2 months ago following which she had developed disseminated intravascular coagulation and septicaemia, for which she remained intubated and ventilated for 20 days. Indirect laryngoscopy showed normal vocal cords. Fibreoptic bronchoscopic examination under local anesthesia (performed in a reclining position) preoperatively revealed a tracheal stenosis and computerized tomographic scan (CT) confirmed it to be at the level of lower border of T3. The length of the narrowed segment was 8 mm with an anteroposterior diameter of 0.53 cm []. A diagnosis of tracheal stenosis following prolonged endotracheal intubation was made and anticipating the need for CPB during surgery, the patient was referred to the CTVS department for tracheal resection and end-to-end anastomosis.
Physical examination revealed severe respiratory distress. The respiratory rate was 35--40/min, patient had stridor, and was unable to lie supine. She was somewhat comfortable at a reclining position of 60--70°. There was no swelling in the neck, she had an adequate mouth opening with a Mallampati grade I. All routine hematological and biochemical laboratory tests were within normal limits. Arterial blood gas analysis (ABG) was also acceptable with oxygen saturation of 90% and respiratory alkalosis when breathing room air. Institution of CPB via femoral route under local anesthesia was considered necessary, but was not executed due to technical difficulty posed by the patient not being able to lie supine. Hence, as in the first patient, it was planned to perform sternotomy in the reclining position using inhalational anesthetics. A thoracic epidural catheter was inserted before anesthetic induction in the sitting position at the level of T3--T4 (0.2% of ropivacaine wit

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


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

[User]
RADIOLOGY NOTE:
A 7-year-old girl was referred to Mofid Children’s Hospital with a large necrotic ulcer on his left upper chest, and generalized lymphadenopathy since two months ago ().
The ulcer was begun with a small pruritic papule on the left upper chest, enlarged and extended to the neck, and then ulcerated.
She had a history of toxoplasmosis presenting with cervical lymphadenopathy, and positive IgM and IgG anti-toxoplasma antibodies, at least 10 months before this ulcer appearance. An excisional biopsy was performed at that time, with result of preserved nodal architecture, follicular hyperplasia and no malignant cells and positive PCR for Toxoplasma gondii infection, so, she underwent following up until the skin ulcer appeared, and then, she was referred for more extensive work up.
On physical examination she had a large necrotic ulcer (20 × 10 Cm) with a noma appearance on the chest, and a hyperpigmented plaque (2 × 1 cm) on the abdomen, along with generalized lymphadenopathy and mild splenomegaly.
After debridement of the chest wall ulcer and biopsies of abdominal skin and cervical lymph node, she was treated with ceftriaxone and clindamycin.
Several aerobic and anaerobic microorganisms such as Staphylococcus saprophyticus, Lactobacillus spp., enterococci spp., Staphylococcus aureus and Peptococus niger were isolated from the ulcer culture.
Further investigation showed normal bone survey and bone marrow aspiration.
Thoracic computed tomography (CT) without contrast revealed a large lobulated mass in the left anterior chest wall, with extension to the axillary area and several cervical and left supra clavicular lymphadenopathies. (The CT scan was not available in this article). Abdominal and pelvic CT scan revealed mildly enlarged spleen and para-aortic lymphadenopathies.
CT scan of the neck showed multiple extensive adenopathies predominantly in the left side of the neck and significant soft tissue swelling of the lower neck and chest wall. Brain CT scan was normal.
Routi

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


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

[User]
RADIOLOGY NOTE:
This is a 60-year-old right-handed man with past medical history of relapsing-remitting multiple sclerosis diagnosed 20 years ago with prior beta interferon treatment for 8 years and with chronic left residual hemiparesis who presented to the emergency room after experiencing generalized weakness followed by a fall to the ground with apparent loss of consciousness. While the patient reported no loss of consciousness, he did not have memory of the events surrounding the fall. EMS was called and patient was airlifted to the nearest percutaneous intervention-capable center after the ECG showed a ST segment elevation in the leads V1 to V3, so the ST segment elevation myocardial infarction (STEMI) alert was activated. In the emergency department, the patient was without chest pain. Upon further questioning, he denied any family history of heart disease including no cardiomyopathy, heart failure, arrhythmias, or premature or sudden cardiac death. Vitals demonstrated mild tachycardia to 105 beats per minute and a temperature of 38 degrees Celsius, and labs revealed a negative troponin level. Ultimately, the ST segment elevation myocardial infarction (STEMI) alert was cancelled due to the high clinical suspicion of the type 1 Brugada pattern in a syncopal patient with anteroseptal ST elevations without chest pain. Workup for the febrile episode revealed positive serology for influenza B. Oseltamivir was started and the patient completed 5 days of treatment. The patient was no longer febrile and his tachycardia had resolved, but he continued to show a persistent type 1 Brugada pattern on the ECG during the entire hospitalization course as seen below (). The patient subsequently went for a transthoracic echocardiogram which demonstrated a normal left and right ventricular function and no structural abnormalities. He also underwent coronary angiography, which revealed nonobstructive coronary artery disease.
Ultimately, the primary concern was to elucidate, whether the patient'

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


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

[User]
RADIOLOGY NOTE:
An 88-year-old male presented in the outpatient surgical setting with a chief complaint of a right groin bulge that had been present for 6 weeks. He had sharp pain initially when he first developed the abnormality but had been asymptomatic ever since. He did not recall any inciting factors. He was concerned that a previously repaired right inguinal hernia had recurred from its original tissue repair in 1977. Details of the original right inguinal hernia repair were unknown to the patient, other than no implantation of mesh occurred. On physical examination, a 3 cm × 3 cm firm, nontender mass was palpable in the right groin just lateral to the pubic tubercle. A computed tomography scan of the abdomen and pelvis was performed to elucidate the cause of the mass in his groin (Figs. , , and ). The imaging was relevant for a right inguinal hernia with the appendix present within the sac. Preoperative laboratory testing revealed a white blood cell count of 4.7 × 109/L. The patient elected to proceed with surgical intervention for hernia repair.
The patient presented to the hospital setting for his elective right inguinal hernia repair. A classic oblique incision was made in the right groin using the anterior superior iliac spine and pubic tubercle as landmarks. The external oblique aponeurosis was opened and the hernia isolated and examined. The hernia was noted to be comprised of an extremely hard and dense amount of omentum that had a chronic, scarred appearance. The base of the appendix could be seen exiting the internal inguinal ring, but the densely adhered omentum prevented reduction of the appendix back into the peritoneal cavity. Initially, there was no indication to perform an appendectomy at the time of the procedure if the appendix could be successfully reduced into the abdominal cavity. However, the chronic appearing adhesions in the area prevented this step. In order to reduce the appendix at that point, a relaxing incision was then made in the typical transve

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


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

[User]
RADIOLOGY NOTE:
A 75-year-old Caucasian man was admitted for an elective balloon aortic valvuloplasty for critical aortic stenosis. He had a significant cardiac history including congestive cardiac failure, permanent pacemaker and mitral valve replacement and was on subsequent long-term warfarin anticoagulation. Interestingly, he had a prior left ICS from a spontaneous iliolumbar branch artery bleed that was treated with embolization and fasciotomy from which he made a complete recovery.
During this admission, balloon aortic valvuloplasty was attempted with right femoral artery access obtained via a right groin puncture; unfortunately, the patient became hemodynamically unstable and the procedure was abandoned. Two weeks later, the patient started complaining of severe pain in the right hip. Examination revealed extensive bruising overlying the right groin and decreased hip flexion on the right side with diminished power in the L3–S1 myotomes. Additionally, there was patchy loss of sensation to the anterior right thigh and the dorsum of the right foot. A Doppler ultrasound of the right groin was performed which revealed a 2 cm false aneurysm in the right groin medial to the right common femoral artery. A non-contrast computed tomography (CT) scan was also performed which revealed areas of mesenteric stranding in the right iliac fossa with an enlarged right iliacus muscle measuring 7 × 6.5 cm. The iliacus muscle demonstrated subtle low-attenuation areas in keeping with an iliacus hematoma (Fig. a and b).
Ultrasound guided thrombin injection was performed to treat the pseudoaneurysm. A follow-up CT angiogram demonstrated successful thrombosis of the right CFA pseudoaneurysm and a stable iliacus hematoma with no active iliac arterial extravasation. The patient was taken to the operating theater for an iliacus fasciotomy and hematoma evacuation.
On exposure, the retroperitoneal layer was reflected medially and the neurovascular structures were identified and protected. The right iliac

[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 21-year-old primigavida with 29.3 weeks of gestation was admitted in our institute for termination of pregnancy, as her routine anomalous ultrasonogram (USG) done at a primary center revealed defective development of spine, atrial septal defect (ASD), aplasia of the right kidney, and encephalocele. The mother's routine blood and biochemical investigations were within normal limits. She was not a known diabetic or hypertensive and had a history of nonconsanguineous marriage. She gave a history of iron and folic acid tablets supplementation. A repeat USG done at our institute confirmed the above-mentioned anomalies. In view of multiple nonviable anomalies, with the informed consent of the parents, the pregnancy was terminated and abortus was sent for pathological examination.
At autopsy it was a fetus of ambiguous genitalia, weighed 900 g. The head was enlarged, severely retroflexed, and there was no neck. Head was seen directly resting on the chest and mandibular skin in continuous with chest skin surface. The ears were low set [] and the vertebral column was short and irregular. There was an omphalocele with partly covered membrane containing liver, bladder, and intestine as contents. Lower limbs showed bilateral clubfoot. There was overgrowth of upper limbs compared with lower limbs []. Posteriorly the skin of the scalp was thick and extended up to lumbar region [] Radiograph of the abortus revealed hyperextension of the neck with occiput touching the cervicodorsal vertebra with soft tissue continuation on the dorsal aspect of the neck. Cervical and thoracic vertebra showed defective block vertebra with thoracolumbar lordosis suggestive of iniencephaly []. Autopsy of the fetus revealed two lobes in the right lung with hypoplasia of both the lungs []. Cardia showed ASD [Figure and ]. There was an accessory spleen in the greater omentum []. Both the testes were seen in the inguinal canal. On opening the cranial cavity, there was defect in the development

[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 African–American male presented with a gunshot wound through the left face and neck. On exam the patient was noted to be pulseless and apneic. After resuscitation, initiation of a mass transfusion protocol and return of spontaneous circulation, the patient was GCS 11 (E4V1TM6) and was noted to have no movement in any extremities. A computed tomographic (CT) cervical spine scan and CT angiography of the neck revealed a bullet trajectory through the left C2–3 facet with fractured c3 posterior elements and a bullet fragment at the C3 level, a left vertebral artery dissection, and left internal and external carotid artery transections (). The patient underwent an emergent tracheostomy, neck exploration, left ICA/ECA ligation and partial wound closure. This was followed by endovascular embolization of the left vertebral artery. The patient was noted to have serosanginous drainage from the neck wound consistent with a CSF leak. After an unsuccessful trail of conservative management, a lumbar drain was placed and confirmed with fluoroscopic guidance without CSF egress. A magnetic resonance imaging (MRI) scan of the cervical spine was obtained which demonstrated a pronounced CSF fistula and a complete obstruction of the CSF space at the C3–6 levels ().
An EVD was placed in the intensive care unit after informed consent was obtained. The EVD was placed under sterile conditions using local anesthesia consisting of lidocaine with 1% epinepherine and mild conscious sedation consisting of 5 mg of diazepam, and 2 mg of morphine. Ten milliliter of CSF was drained every hour. The EVD was exchanged on Day 14 as customary at our institution due minimal but persistent CSF leak. CSF diversion was continued for a total of 25 days due to the large size of the wound and the initial partial closure. The external drain was removed after a successful 48-hour clamp trial. There were no complications associated with the csf diversion. The patient remained free of CSF

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


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

[User]
RADIOLOGY NOTE:
A 68-year-old Japanese man with a history of distal partial gastrectomy for gastric cancer 10 years earlier was admitted for surgical treatment of intrathoracic esophageal cancer (T3, N2, M0, stage III). He underwent subtotal esophagectomy with three-field lymph node dissection and removal of the remnant stomach with the abdominal lymph nodes. The alimentary continuity was reconstructed with a pedicled jejunal limb through the antethoracic route. When we separated the diaphragm from the esophagus and removed xiphoid surgically to prevent a pedicled jejunal limb injury, the pericardium was opened. Anastomosis of the esophagus and jejunum was carried out instrumentally with a circular stapler. A postoperative enteral contrast examination showed smooth passage and no deformity of the reconstructed jejunum. The patient was discharged about 4 weeks postoperatively. About 6 months after the esophagectomy, the patient was readmitted to our hospital because of abdominal discomfort and vomiting. His vital signs were stable and unremarkable. He was thin, with a body mass index of 18.6 kg/m2. Physical examination revealed that the pedicled jejunum through the antethoracic space was markedly dilated and the abdomen was soft and flat (Fig. ). Laboratory data showed only leukocytosis with no other remarkable findings. A chest roentgenogram revealed an increased cardiothoracic ratio of 70%, and an enteral contrast study showed a bird’s beak deformity. The swallowed barium remained static in the reconstructed jejunum. Computed tomography of the thoracoabdominal region showed the reconstructed jejunum within the pericardium anterior to the heart (Fig. ). We diagnosed the patient with IPDH after esophagectomy and performed an emergency laparotomy. Upon opening the abdominal cavity, we found that the reconstructed jejunum had herniated into the pericardium through an approximately 4-cm-diameter diaphragmatic defect without a hernia sac (Fig. ). The herniation was easily reduced, and t

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


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

[User]
RADIOLOGY NOTE:
A 60-year-old female known case of hypertension and diabetes on treatment had undergone bilateral total knee replacement in 2002. The patient was treated with oral bisphosphonate therapy for osteoporosis, 70mg alendronate once a week orally from 2003 to 2007 (4 years) and then from 2009 to 2013 (4 years). The patient presented to the hospital in January 2013 with pain in the right side of the jaw and pain during mastication since 6 months. From her history, clinical examination and radiological findings she was diagnosed to have osteonecrosis of her right posterior body mandible (). This was treated by way of sequestrectomy and saucerization in January 2013 () and stoppage of Alendronate. There was no history of the patient having any dental procedure while on alendronate. In March 2013, she was admitted with complaints of pain and swelling over the right thigh following a history of trivial fall, and after clinical examination and history taking, X-rays were done which showed an atypical right displaced subtrochanteric fracture through the focally thickened lateral cortex of proximal femur (). The fracture was managed surgically with proximal femoral nailing (). The knee replacement was unrelated to the sub-trochanteric fracture. For the subtrochanteric fracture of femur, regular follow-ups were done postoperatively with serial X-rays. Blood investigations were done, and serum calcium was 9.5mg/dl, and serum Vitamin D3 was 20ng/ml which was optimized with 6,00,000 IU of intramuscular Vitamin D3 and maintained by oral Vitamin D3 medications. At 3 months, the fracture was in delayed union (), and hence, the patient was started on injection Teriparatide 20mcg subcutaneous for a period of 18 months. The patient was kept non-weight bearing. The 6 months X-ray showed further progression in fracture healing (), and the patient was allowed partial weight bearing. In October 2013, 10 months after stopping Alendronate, she again came with the complaint of pain 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:
An 85-year-old female arrived to the emergency room after experiencing a ground-level fall. The initial physical examination revealed that the patient had a left upper limb abduction 4/5 weakness with mild C5 dermatome hypoesthesia. Vitals were found to be stable, and other than a previously diagnosed essential tremor, the patient was found in her usual state of health. Initial neck computed tomography (CT) revealed a C5 fracture involving the body, left traverse process and transverse foramen, and mild anterolisthesis as well as C6 left transverse process comminuted fracture. Neck CT angiography revealed slight contrast extravasation at C6 transverse process region with normal vascular reconstitution above and below the injury level. Cervical spine magnetic resonance imaging disclosed a C4-5 disc bulging with concomitant T2 cord hyperintensity and soft tissue enhancement which in the setting of acute trauma was believed to correlate with spinal cord contusion and an associated ligamentous injury [].
Due to the high suspicion of instability, the patient was admitted for emergency spinal stabilization surgery. Soon after admission, the patient's hemodynamic status was compromised due to an unstable supraventricular tachycardia that required aggressive medical management and prevented from pursuing surgical stabilization due to the high cardiac risk associated. The patient's family was oriented regarding the related risks and at that time family refused surgical treatment.
Soon after the patient's recovery, she was discharged home with a rigid cervical orthosis for conservative management and was subsequently followed in sequential outpatient visits. The patient's clinical course was marked by deterioration of the left upper limb weakness, mainly abduction and handgrip as well as anesthesia. Follow-up imaging revealed worsening of C4-5 anterolisthesis due to vertebral subluxation []. After proper medical and cardiac risk assessment, a decision was made to admit the pa

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


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

[User]
RADIOLOGY NOTE:
A 25 year old female was diagnosed of CVID in 2006 (at age of 18) with initial presentation of recurrent episodes of bacterial sinusitis and outbreaks of genital herpes. Laboratory work revealed hypogammaglobulinemia with poor antibody responses to both polysaccharide and protein antigens. She was found to have IL-2-Inducible T-cell kinase (ITK) mutation, which is potentially involved in the pathogenesis of her CVID. She was started on IVIG and has been receiving it every month.
The patient has additional history of type 1 diabetes diagnosed at 18 months of age, for which she has been depending on insulin, as well as immune thrombocytopenia purpura (ITP) diagnosed at age of 11. She had multiple episodes of recurrent thrombocytopenia managed with IVIG and corticosteroids. In 2002, at the age of 14, she was hospitalized with a presentation of fever and pain, and found to have lymphadenopathy, lymphopenia, neutropenia, and thrombocytopenia. An extensive infectious workup was negative. She had bone marrow biopsy, which was unremarkable with the exception of findings consistent with cytopenias. She ultimately underwent a splenectomy and lymph node resection in 2002. Lymph node and spleen pathology revealed noncaseating granuloma. After the splenectomy, her fevers and pain resolved. Her blood counts have remained relatively normal since splenectomy.
In June 2013 when she was 25 year old, she presented with left flank pain and fever. A CT scan showed diffuse lymphadenopathy in chest, abdomen, and pelvis with the largest node measuring 4.7 × 2.9 cm in the mid abdomen. A biopsy of left peri-aortic lymph node showed non-necrotizing granulomatous inflammation. Extensive infectious disease and rheumatology workup were all negative. She was started with prednisone 60 mg daily for 7 days before being tapered down, with clinical improvement. In September 2013, she was hospitalized again with abdominal pain and fever. A PET scan was done and showed extensive hypermetabolic lymphade

[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 85-year-old female with known history of anxiety disorder, coronary artery disease, diabetes, hypertension, hyperlipidemia, coronary artery disease, cerebrovascular accident (CVA) and chronic anemia was sent to the emergency department by the family for acute encephalopathy. Patient was diagnosed with a UTI 3 weeks prior to presenting to the emergency department and finished a course of antibiotics but was still feeling weak. Hence, a chest x-ray was done by the primary care provider during the follow- up appointment which showed findings concerning for pneumonia and a CT of the chest was done along with a SARS-CoV-2 PCR test. Patient had a positive SARS-CoV-2 PCR test 2 days prior to presenting to the emergency department. Patient had mild cognitive impairment at baseline as noted by the family and was currently being worked up by the primary care provider as an outpatient. According to the patient’s daughter, they were able to notice some personality changes going on for at least 4 to 5 months prior to her admission. Patient was alert and awake but was not oriented to time, place, person and situation. She was not in any acute cardiorespiratory distress. She denied to have fever, chills, chest pain, chest pressure, shortness of breath, abdominal pain, nausea, recent changes in bowel or bladder habits. She was only able to recall her first name and could not recall her last name or date of birth. A thorough investigation was done in the emergency department and laboratory work up of note showed hyponatremia, hyperglycemia, elevated CRP,elevated erythrocyte sedimentation rate (ESR),elevated procalcitonin, microcytosis with hypochromia with mild anemia and thrombocytosis and elevated D-dimer (Table ).
Urinalysis was done in the emergency department which did not indicate an infection. CT of the head without contrast showed no acute intracranial process, cortical atrophy and mild chronic small vessel white matter ischemic disease; old infarct in the right posterior

[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-year-old woman was admitted with acute onset of short-term memory loss, intermittent headaches, dizzy spells and an obvious change in personality which had progressed over a ten day period. Intermittent vomiting, confusion and unsteadiness were also reported. These symptoms worsened over the three days prior to admission. Her past medical history included an episode of herpes simplex virus infection about one month earlier. A non-smoker, she consumed alcohol in moderation.
On examination, she had disorientation of time and place and her mini mental score was found to be 2/10. Confusion with nominal aphasia was also noted. She was apyrexial. Cardiovascular, respiratory and gastrointestinal system examination was unremarkable. Neurological examination showed normal power and tone in both arms and legs with normal symmetrical deep tendon reflexes. Her gait, coordination, cranial nerve and fundus examination were normal.
Investigations revealed a normal full blood count and unremarkable routine biochemical tests and inflammatory markers. Contrast enhanced CT of the brain showed low attenuation areas adjacent to the anterior ends of both thalami. Appearances were reported as an unusual form of cerebral infarctions and it was suggested that other pathology could not be ruled out.
Examination of CSF revealed isolated lymphocytosis. Glucose and protein were normal. Polymerase Chain Reaction (PCR) tests for herpes simplex virus and varicella zoster were negative.
Electroencephalogram (EEG) recordings showed intermittent low frequency activity suggesting focal abnormality of cortical function, probably associated with a vascular or structural lesion but no clear evidence of encephalitis or epileptiform activity. On MRI scan (Figure ) of the head there were bilateral symmetrical lesions in both thalami giving high signal changes on the T2 weighted and proton density images. In addition there were asymmetrical multiple high signal areas on T2 weighted images in both cerebe

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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:
We present a 40-year-old male with a history of chronic back pain and a recent, acute progression of bilateral lower extremity paresthesias and weakness. Over a seven-day period prior to presentation, the patient experienced a sudden onset of bilateral leg numbness, with no history of trauma or another precipitating event. The right leg was affected more severely than the left, traveling primarily in a distribution down the lateral leg into the dorsum of the foot and great toe. He eventually began having a shooting pain in this same distribution. He also reported a progressive weakness with bilateral ankle and toe dorsiflexion and five days duration of perineal numbness and mild urinary retention. On exam, he was unable to dorsiflex his ankles or great toes against gravity and had reduced sensation in the lateral aspect of both lower legs and the dorsum of bilateral feet. The patient’s Achilles reflexes were also diminished bilaterally, though reflexes were present and brisk at the knee. It is also pertinent that no upper motor neuron signs were present.
Magnetic resonance imaging (MRI) of the lumbar spine revealed a somewhat heterogeneous, but predominately T2-weighted, hyperintense mass in the left lateral and dorsal epidural spaces (Figure ). There was significant lumbar stenosis present at the level of L4-5 secondary to the mass, with the rightward displacement of the thecal sac. There was no clear connection to the adjacent facet joint although the dorsal mass did seem to be contiguous with the dorsal aspect of the L4-5 disc (Figure ).
Due to the acute onset of symptoms, as well as the severity of neurologic involvement, the patient was taken to surgery for exploration and removal of the epidural mass. An L4-5 laminectomy was performed, which revealed a very large dorsally migrated disc fragment that erupted as soon as the ligamentum flavum was removed. The large mass, which was displacing the thecal sac

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


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

[User]
RADIOLOGY NOTE:
We present a clinical case report of a 34-years-old pregnant woman with a single gestation. An omphalocele enclosing mixed intestinal and hepatic content was diagnosed at 12th week (). Nuchal translucency (NT) was normal, and no other associated malformations were observed. Parents were counseled regarding ultrasound findings. A genetic study was performed including karyotype, 60K Array-CGH, and methylation-sensitive multiplex ligation probe analysis to analyze the presence of epigenetic and genetic changes related to BeckwithWiedemann Syndrome (BWS), all of them being negative. Parents were informed of the results, as well as the impossibility of ruling out BWS completely despite the negativity of the genetic study, since this disorder is caused by epigenetic defects and there are up to 20% of cases whose diagnosis is clinical and therefore postnatal. After counseling, the patient decided to continue with gestation. The 20th week anomaly scan showed no associated malformations, except a slight upward and leftward heart displacement due to diaphragm elevation. Cardiac function and ductal venosus flow were normal throughout gestation and the heart was structurally normal. At 21st week, the omphalocele content became only hepatic (). Ultrasound controls were scheduled every 4 weeks to rule out the early onset of fetal growth restriction, as well as other disorders. At 37th week the estimated bag size was 51 × 56 mm (). At 38.3 weeks, the patient was admitted because of mild but regular contractions. At 38.4 weeks, a caesarean section was performed with the coordination of the Obstetrics, Neonatology, Anesthesiology, and Pediatric Surgery teams. The newborn weighed 3540 g, Apgar Test 9-10, and pH 7.32 (). A thermal bag covering the whole baby's body was placed immediately after the birth to maintain body heat and reduce the risk of infection (). The baby was admitted in the Neonatal Ward for management and surgical preparation in the first hours, starting parenteral nu

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


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

[User]
RADIOLOGY NOTE:
A 55-year-old Caucasian male, with a past medical history significant for tobacco abuse (41 pack-years), presented with shortness of breath accompanied by chest and back pain for two months. Blood workup showed a WBC count of 68,400 cells/µL, with an AEC of 27,360 cells/µL. A computed tomography (CT) pulmonary angiogram was performed, as he was hypoxic, and revealed a 3.6-cm speculated mass within the anterior right upper lobe, partially invading the anterior chest wall. It also revealed mediastinal and hilar adenopathy, an extensive osseous lesion (including compression fracture at T7), and a small pericardial effusion (Figure ). A CT of the abdomen and pelvis with contrast was performed and revealed a diffuse metastatic disease involving the liver, adrenal glands, spleen, and the bones. Magnetic resonance imaging (MRI) of the thoracic spine did not reveal spinal cord compression, but it did show the compression fracture at T7 and multilevel thoracic spondylosis. An MRI of the brain revealed a 5-mm lesion in the left occipital lobe, without edema or mass effect.
The hematology-oncology team was consulted for an evaluation of the metastatic disease and the eosinophilia. A core needle biopsy was obtained from a liver lesion and the result came back as poorly differentiated adenocarcinoma of the lung (cytokeratin 7, TTF1, and napsin-A were positive, while cytokeratin 2 and CDX2 were negative). Given his functional status, the decision was made to hold on systemic therapy and start on palliative radiation to the spine for pain control. The plan was to complete radiation sessions and then evaluate his functional status before starting systemic therapy.
He continued to have a high WBC count during the admission (Figure ). Therefore, a bone marrow biopsy was performed to rule out a hematologic malignancy and it revealed metastatic adenocarcinoma of the lung with no evidence of a myeloproliferative disorder. The flow cytometry from the bone marrow showed

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


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

[User]
RADIOLOGY NOTE:
A 57-year-old female with a past medical history significant for polyarteritis nodosa on immunosuppression with Azathioprine presented to the neurosurgery clinic with progressive right lower extremity shooting pain, numbness and tingling over the past six months. On physical examination, she had trace weakness in right lower extremity dorsiflexion as well as right foot eversion with diminished vibratory and pin-prick sensation in her bilateral lower extremities. Magnetic resonance imaging (MRI) of the thoracic and lumbar spine with and without contrast was obtained which demonstrated a cystic lesion in the conus medullaris spanning the thoracic 11 to thoracic 12 levels (Figure ). This cystic lesion was first identified nine years prior in 2011 (Figure ). At the time of initial imaging in 2011, the patient did not have any neurologic complaints nor did she have any appreciable neurologic deficits on physical examination. A dedicated MRI of the thoracolumbar spine was obtained in 2011 due to an indeterminate finding observed in the conus medullaris on abdominal MRI for workup of abdominal pain. At the time of initial identification in 2011, due to the lack of neurologic symptoms and neurologic deficits, the cystic mass was determined to be an incidental finding with no further intervention pursued. On MRI thoracic spine with and without contrast at the time of her subsequent presentation in 2020, she was found to have interval enlargement (Figure ) of the previously imaged conus medullaris cystic mass (Figure ) which had enlarged over the course of the past nine years. Electromyography (EMG) and nerve conduction velocities (NCV) were obtained with normal results, making a peripheral neurologic process such as neuropathy or radiculopathy less likely. Based on the interval increase in the size of the conus medullaris lesion in the setting of normal EMG and NCV, it was felt the etiology of her current symptomatology and neurologic examination findings were related to the

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


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

[User]
RADIOLOGY NOTE:
In May 2006, a 25-year-old man, who had sustained a complete left brachial plexus injury with cervical root avulsion and subclavian artery lesion in a motorcycle accident, came to our attention. An exposed distal humeral shaft fracture at the level of the elbow with median and ulnar nerve transection was also identified.
The patient was treated in an emergency department with humeral fracture stabilization (Synthes locking compression plate; Synthes, West Chester, PA, USA) and revascularization of the left arm. In July 2006 he underwent surgery of the brachial plexus lesion, with nerve transfers of the distal spinal accessory to axillary nerve and the phrenic to musculocutaneous nerve. Unfortunately he did not show any sign of recovery of the motor function in the left upper limb, and in August 2008 a functional transfer of a gracilis free flap to brachial biceps and a wrist arthrodesis were performed. Over the last 6 years the patient has undergone surgery 3 times and has followed a rehabilitation program.
From the outset, the patient has been treated by searching for symmetry in orthostatic posture. The Global Postural Rehabilitation technique has been used thus far in the course of rehabilitation. Three times per week the patient sustains passive mobilization of each upper limb joint to maintain articular suppleness and prevent stiffness. During the session, the physiotherapist also administers sensitive stimulation to maintain afferent channels.
At all times the patient wears splints to place the distal extremity in an intrinsic position for correct articular and muscle length. The whole upper limb is supported by a sling. Postural control, splinting, mobilization, and sensibility rehabilitation have all been included in the rehabilitation program.
Since 2007 the patient has suffered from neuropathic pain (NP) involving the ulnar side of the forearm, the proximal third of the forearm, and the thumb in both radial (dorsal) and median (volar) regions.
From the out

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


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

[User]
RADIOLOGY NOTE:
A 69-year-old female was referred to our clinic for an incidental finding of a large Morgagni hernia found on a recent CT chest scan for lung cancer screening. Patient reported occasional shortness of breath after prolonged ambulation but denied chest pain. She did have remote history of acid reflux symptoms but nothing recently. She denied issues with prematurity or issues with development as an infant, chest trauma, or MVA history. She did complain of occasional right shoulder pain but attributed this to arthritis. Denied history of heart attack, stroke, DVT, or PE. She had a 30-pack-year smoking history but quit a year prior. She was up-to-date on her colonoscopy, current within the past year. She denied hematochezia and melena, bowel habit changes or major body weight changes as well as any current abdominal pain. On examination her vitals were within normal parameters. Heart and lungs were unremarkable. Abdominal examination was soft with normal bowel sounds and nontender. Remainder of examination was unremarkable. Laboratory values included a normal CBC and BMP. A CT chest scan had demonstrated a large retroxyphoid hernia of Morgagni involving several loops of small bowel and transverse colon located in the right inferior hemithorax (Figs and ). No evidence of acute incarceration or strangulation were noted. A detailed discussion was undertaken with the patient regarding her hernia and she was consented for a laparoscopic repair with mesh.
Patient underwent a laparoscopic approach in lithotomy positioning with the primary surgeon working between the legs. Three working ports were used, a 12 mm port at the umbilicus and two 5 mm ports; one in the LUQ and one in the RUQ. Upon initial laparoscopy multiple loops of small bowel were progressively reduced out of the hernia sac which also included the ascending colon and part of the transverse colon (Figs and ). All the small bowel and the colon

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


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

[User]
RADIOLOGY NOTE:
A 54-year-old male patient presented with febrile sensation and anterior chest wall pain with an erythematous ulcerative plaque in the right parasternal area that had become aggravated over a month despite antibiotic treatment prescribed at a local clinic. A swab culture was done, which led to the identification of Citrobacter koseri. The patient was admitted to the general ward for further workup and initiated on intravenous (IV) ciprofloxacin (400 mg every 12 hours).
The patient had undergone right upper lobectomy and thymectomy 35 years ago via posterolateral thoracotomy followed by adjuvant radiotherapy. A chest computed tomography scan revealed chronic empyema with a right apical calcified sac with an air-fluid level and chest wall abscess, for which continuity to the pleural space could not be excluded ().
An elliptical skin incision was made around the fistula orifice at the second and third intercostal spaces (ICSs) along the right side of the sternum at the costosternal junction. After removing the infected bony chest wall, we entered the empyema cavity and evacuated the pus and necrotic materials. A sump drainage tube was inserted into the cavity for subsequent irrigation and drainage.
Treatment with IV antibiotics was continued, and daily chest tube irrigation with 1 L of taurolidine-mixed purified water was performed for local infection control. Subsequently, a pleural fluid culture study was performed every 5 days, and no bacterial growth was observed. However, the patient remained febrile for 36 days after the initial operation; thus, we delayed the second stage of the operation. After discontinuing the irrigation using the chemical agent, the patient was afebrile and in a suitable condition for thoracomyoplasty. The first stage of the operation included full thoracotomy and resection of the second to fifth ribs. The thoracic cavity was entered and inspected through the fourth ICS periosteal bed. Severe visceral pleural adhesion to the chest wall was s

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


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

[User]
RADIOLOGY NOTE:
A 48 year old male patient presented to the emergency department with a one hour history of epigastric pain, vomiting and profuse sweating. The patient's medical history was significant for long standing hypertension and chronic heavy cigarette smoking as well as recurrent attacks of chest pains related mainly to exertion and relieved by rest.
Clinical examination revealed an obese restless patient with a blood pressure of 90/60 bilaterally and a regular pulse at 110 beats per minute. The jugular veins were congested with a venous pressure of 15 mmHg above the sternal angle and positive Kussmaul's sign. Cardiac examination revealed normal first and second heart sounds and an S3 gallop but no murmurs or pericardial rub. Chest examination revealed bilaterally equal air entry with normal vesicular breathing and no rhonchi or crepitations.
Electrocardiogram was performed in the emergency room and revealed Q waves and ST segment elevation in the inferior leads as well as tall R wave and ST segment depression in lead V2 as shown in figure . Right chest leads showed ST segment elevation in lead V3R and V4R as shown in figure . The clinical picture together with electrocardiographic finding suggested a diagnosis of acute transmural infero-posterior associated with right ventricular myocardial infarction.
Immediately after admission to the emergency room, the patient's conscious level ran a downhill course and he went into deep coma with a GCS of 3/15 and pinpoint pupils. A computed tomography of the brain was performed and revealed no abnormalities. This deterioration was presumed to be due to acute ischemic stroke not yet evident in the initial CT scan. Taking into consideration this sudden worsening of his conscious level and a calculated NIHSS score (National Institute of Health Stroke Scale) of >25 indicating a massive cerebral infarction, it was decided not to administer thrombolytic therapy. We also decided not to undergo primary percutaneous transluminal coronary ang

[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, white male of Greek origin, was admitted in our hospital in December 2008 in order to be treated for a large mass located in the head of the pancreas. The patient had been originally subjected to a routine blood check up, which revealed mildly elevated transaminase levels. He was then referred for an abdominal U/S and eventually for a CT scan on an outpatient basis. Both revealed a large, well circumscribed mass of 6.8 cm in diameter, which seemed to be in direct contact with the head of the pancreas and the inferior vena cava (Figure ). A subsequent MRI of the abdomen showed the mass to measure about 7.3 cm, to have irregular borders and to be located posterolaterally to the pancreatic head. The inferior vena cava was located directly behind the mass, and seemed to be slightly displaced by the tumor. The portal vein was located directly above the mass. Both these vessels did not appear to be directly invaded by the mass.
Endoscopic ultrasound scan was performed which allowed FNA of the mass. The cytology revealed cells morphologically and immunogistologically indicative of a neuroendocrine pancreatic neoplasm. Subsequently, the patient was referred to our hospital for further surgical and possible antiproliferative therapy.
On physical examination the patient was found to manifest periodic choreo - athetosic movements that had appeared in the 3 months that preceded the diagnosis of his pancreatic tumor, to together with polyarthralgia of his limbsâ€™ large joints. The rest of his neurological clinical examination as well as an MRI of the brain were normal. Serum amylase, bilirubin and transaminase levels and all serum tumor markers were within normal range.
The patient underwent surgical resection of the tumor by means of a modified Whippleâ€™s procedure and Roux-n-Y reconstruction of the gastrointestinal tract (Figure ). His recovery was uneventful and he was discharged from the hospital 10 days after the operation.
Pathological examination of the s

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


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

[User]
RADIOLOGY NOTE:
A 70-year-old man presented with an incidental right renal mass after magnetic resonance cholangiopancreatography (MRCP) for investigation of abnormal results of liver function tests (LFTs), which suggested an obstructed biliary tree. The patient had undergone OLT in 2000 after extensive preoperative investigations for cryptogenic liver cirrhosis including serology and radiology. Post-OLT histopathology showed that the native liver had nodules of varying sizes consistent with cirrhosis with no evidence of carcinoma. The patient was started on immunosuppressive therapy with tacrolimus, which was subsequently changed to sirolimus in 2005, and he was followed up quarterly by the liver transplant service at our center.
On routine follow-up, the patient was found to have obstructive (cholestatic) LFT results in late 2009. An MRCP was performed and a diagnosis of choledocholithiasis was made, but incidentally a right renal mass was also found. No biliary tree obstruction or liver lesions were noted on this scan. A triple-phase computed tomographic (CT) scan of his abdomen and pelvis further confirmed the presence of a lobulated enhancing mass (55 mm×45 mm in diameter) in the right upper pole extending into the perinephric fat and abutting the right hemidiaphragm () but with a clear plane between the liver and the mass. Again, the hepatobiliary system had no lesions present. He was otherwise asymptomatic with all staging negative for metastatic disease. His case was reviewed at a multidisciplinary meeting where consensus dictated that the mass was likely to represent a primary renal tumor that should be resected. Partial nephrectomy was offered but declined by the patient.
The patient underwent a right open radical nephrectomy via a flank approach and resection of part of the hemidiaphragm requiring repair with a synthetic mesh (Gore-Tex patch). There were no obvious liver lesions on careful inspection and palpation. The procedure resulted in 500 mL of blood loss and no pe

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


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

[User]
RADIOLOGY NOTE:
A 16-year-old male Japanese patient presented to our clinic with an inability to extend his left knee. He had injured his left knee during a jump while playing handball and sustained an avulsion fracture of the tibial tubercle Open reduction and cannulated screw fixation for the tibial plateau fracture had been performed at another institution 10 months before he visited our hospital. However, the rupture of the patellar tendon had been missed during the initial emergency treatment. He complained of patellar dislocation, an inability to run, and difficulty in walking up and down stairs. An examination indicated that his left patella had migrated proximally and was higher than the right (Figure
). There was evidence of quadriceps wasting, and a palpable gap below the patella was noted. The range of movement was from 0 to 130°; however, there was no active knee extension. The preoperative Lysholm knee-score
[] was 65 points. Both plain radiography and computed tomography with three-dimensional reconstruction confirmed that there was massive ectopic calcification along the patellar tendon and severe patella alta (Insall-Salvati index, 1.6) (Figure
). Magnetic resonance imaging indicated the absence of continuity in the patellar tendon and an irregularity in the tibial tuberosity.
During surgery, two-thirds of the patellar tendon mass was found to have been replaced by bone. The bony mass, which was 5.5 × 3.0 × 2.0 cm in size, was removed. Rupture of the patellar tendon from the inferior pole of the patella was identified during the operation. The semitendinosus and gracilis tendons were used to reconstruct the patellar tendon, as described. The ruptured patellar tendon remnant was sutured to strengthen the reconstruction, and the course of rehabilitation proceeded, as described. His knee functions gradually returned to normal, and no pain was reported. He was able to resume his sports activities 6 months after surgery and returned to full training 8 months after surg

[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 boy presented to THP with a history of fever for 2 days along with headache, arthralgia and myalgia. He did not complain of abdominal pain and did not have bleeding manifestations or any other warning symptoms. On examination, blood pressure was 110/70 mmHg and pulse rate was 100 beat per minute and capillary refilling time was less than 2 s. The abdomen was soft and non-tender and there was no free fluid. Lung fields were clear on respiratory system examination. Rest of the examination was normal. His NS-1 was positive and the PCR appeared as DEN 2 serotype. The patient was managed as having dengue fever. He continued to have fever spikes for 4 days following admission. On the 5th day following admission, he developed postural dizziness, vomiting and heavy diarrhoea. On examination, he was febrile, dehydrated, flushed and had warm peripheries. Blood pressure was 90/60 mmHg, pulse rate was 130 beats per minute and a capillary refilling time of 2 s. Ultrasound examination of abdomen revealed free fluid in the hepato-renal pouch with increased gall bladder wall thickness. He was clinically diagnosed as having DHF complicated with septic shock and gastroenteritis. He was taken to HDU and critical phase monitoring commenced. His c-reactive protein was high 112 mg/dl. Broad-spectrum intravenous antibiotics (ceftriaxone and metronidazole) were started cover the sepsis after taking blood and urine cultures. Within about 1 h, the patient deteriorated significantly and continued to have vomiting and diarrhoea. Blood pressure dropped to 60/30 mmHg and the pulse rate increased to 120 beats/min. Several fluid boluses were given including normal saline and IV Dextran 40. The haematocrit value dropped from 36 to 30 and patient went into decompensated shock with no urine output. He needed continuous transfusion of whole blood amounting to 9 pints over 20 h to maintain blood pressure and urine output. However, there were no obvious bleeding sites.

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


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

[User]
RADIOLOGY NOTE:
This is a case of EA, a 77-year-old Filipino female, diabetic, hypertensive with a history of coronary artery disease who underwent percutaneous coronary angioplasty of the right coronary artery (RCA) in 2000. One week prior to consult, she complained of occasional chest heaviness aggravated by effort and worsening shortness of breath. She was admitted in the wards and initially managed as a case of acute coronary syndrome and community-acquired pneumonia. Pertinent physical examination findings included the following: BP 100/60 mm Hg, cardiac rate of 77 beats per minute (bpm), respiratory rate of 22 cycles per minute, no neck vein engorgement, bibasal rales, with a systolic ejection murmur heard over the lower left sternal border with no radiation to the carotids. The 12-lead electrocardiography showed sinus rhythm, normal axis, with left atrial abnormality, and LV hypertrophy with secondary ST-T wave abnormalities; chest radiography revealed enlarged heart with LV prominence with mild congestion. Two-dimensional transthoracic echocardiogram was done which showed markedly thickened walls of the left ventricle ( and ) with a peak instantaneous continuous wave Doppler gradient across the basal LV segment of 194 mm Hg, and concentric LV remodeling with segmental wall motion abnormality with preserved systolic function and presence of SAM of the mitral valve with an LV ejection fraction of 57% by Simpson’s. Surgical myectomy was advised but she refused any surgical treatment. ASA was then the treatment option.
On the second hospital day, she underwent coronary angiogram which showed patent stent on the RCA with absence of a major septal perforator branch of the LAD artery (). shows how a normal major septal perforator appears on angiogram as it originates from the proximal LAD. This was taken from another patient, a 52-year-old female []. Septal ablation was deferred and she was referred to electrophysiology for evaluation. On the third day, electrophysiologic/ventricu

[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 58-year-old male patient presented with a one-week history of bloody otorrhea from the right side. In the past 34 years, the patient had undergone four surgeries to remove the masses from his right parotid gland. Histopathologic examinations performed after the first three surgeries indicated the presence of benign pleomorphic adenomas. The latest surgery was performed nine months ago to remove a 3.3 cm mass from the parotid gland. Following this surgery however, a histopathologic examination revealed a true malignant mixed tumor (carcinosarcoma) composed of poorly differentiated carcinoma and osteosarcoma. Immunohistochemical studies were positive for P53, Ki67, and vimentin, weakly positive for cytokeratin, and negative for Actin and the S100 protein. The patient was given adjuvant radiotherapy after the latest surgery and was doing well except for symptoms associated with irradiation.
The patient underwent a follow-up high-resolution CT scan of the temporal bone for the presented symptoms and showed extensive opacification of the right mastoid air cells, posterior petrous bone, middle ear, and the external auditory canal. The imaging appearance raised the suspicion of a recurrent tumor. Excisional biopsy of the external auditory canal mass was performed and confirmed the diagnosis of a recurrent true malignant mixed tumor.
During this hospitalization, a chest radiograph indicated the presence of patchy opacities in his left lower lung field () not seen in previous chest radiographs; this warranted a CT scan for further characterization. A CT scan of the chest showed parenchymal consolidation with some amorphous calcifications (); hence, the possibilities of fungal infection or granulomatous disease were considered initially. This patient had no fever and did not report associated symptoms of infectious or inflammatory respiratory tract diseases; therefore, a CT-guided biopsy of the pulmonary lesion was performed because of the concern of atypical pulmonary meta

[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 female without significant past medical history presented to the clinic after the results of a routine mammogram revealed the continued presence of a small mass in her right breast. A mammogram dated 3 years prior detected this mass and reported it as small and benign, located inferior to an implant of her right breast. The more recent mammogram findings reported no change in size. The patient was asymptomatic and denied previous history of cancer and no family history of breast cancer, or other malignancies. She denied weight loss, fever, night sweats, or change in appetite. However, she did report mild discomfort with self-palpation to her lower right breast. Her breast implants were placed 28 years ago in Argentina for cosmetic reasons and have not since been revised. Additionally, she reported a long history of smoking tobacco daily.
To rule out malignancy, an ultrasound was performed and confirmed the presence of an elongated nodular density benign in appearance. The mass had multiple areas of hyperechoic densities within it and was located at the 8 o'clock position 10 cm from the right nipple. The size was measured to be 3.4 × 1.3 × 3.2 cm, with no evidence of shadowing or implant rupture reported (). The impression of the ultrasound was the presence of a hamartoma, a benign lesion of the breast that corresponded with previous mammogram results. Despite recommendations for a follow-up mammogram at a later date, the patient was referred by her primary care provider for fine-needle biopsy and samples were sent for evaluation.
Biopsy samples were sent to pathology for analysis using histology, immunohistochemistry, and FISH studies. Histologic sections of the core biopsy fragments showed malignant lymphoma of diffuse pattern. The tumor cells were large in size with anaplastic and focally spindled morphology. Additionally, there were increased mitotic figures and cellular apoptosis. Immunohistochemistry revealed lymphoma cells positive for CD20, PAX5

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


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

[User]
RADIOLOGY NOTE:
A 38-year-old woman with a medical history of hypertension, chronic obstructive pulmonary disease, osteoarthritis of knees, chronic smoker, and cocaine abuser presented to the emergency department with complaints of painful body rash which appeared within some hours after smoking cocaine. The rash first appeared on her right arm, followed by rash on the right thigh, left thigh, and left arm. This rash was associated with a burning pain, ten out of ten in intensity without radiation and mostly located on her right arm and right thigh. There was no skin peeling or purulent discharge noted. She denied having any oral or genital mucosal ulcer. She denied any physical injury, fall, pruritus, gastrointestinal symptoms, genitourinary symptoms, fever, chills, chest pain, dyspnea, headache, blurring of vision, dizziness or urinary symptoms. She denied any other systemic complaint. Her home medications include amlodipine, albuterol inhaler as needed, and acetaminophen as needed. She has never been prescribed any anticoagulant including warfarin.
Although she has been smoking cocaine for more than 20 years, the first episode of skin rash post cocaine use did not occur until 3 years ago. At that time, the rash also occurred on bilateral legs and she was admitted to a local hospital. She underwent skin biopsy and it revealed vasculitis with fibrin-platelet thrombi consistent with levamisole-induced vasculitis. She was counseled to stop using cocaine and was treated with intravenous steroid followed by tapered dose of prednisone. The next episode of similar rash lesions of bilateral legs developed in 2014 after smoking cocaine and she again responded to steroids treatment. Six days prior admission to our hospital, she used a larger amount of cocaine than usual (200 dollar-worth). She denied any allergy to cold weather, food, or medications.
Initial vital signs included a temperature of 98°F, pulse rate 98 beats/min, respiratory rate 18 breaths/min, blood pressure 105/72 mmHg, and

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


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

[User]
RADIOLOGY NOTE:
In May 2007, a 71-year-old woman was diagnosed with DM because of heliotropic rash over the upper eyelids, edema and erythema at the face and the upper extremities, skeletal muscle pain, and progressive weakness of the proximal muscles of her upper and lower limbs. Laboratory tests showed significant elevation of creatine kinase (3.7 times the normal levels) and anti-Jo1 antibodies positivity. Electromyography findings indicated myositis of the proximal muscles, and the muscle biopsy showed perimysial inflammation. She had been a heavy smoker until the age of fifty (more than 20 cigarettes per day), not addicted to alcohol, and she had a history of hypertensive cardiomyopathy. The patient was treated with systemic steroid therapy with good control of muscle pain and weakness and partial remission of skin rash. In July 2008, she was diagnosed with a carcinoma of the right colon with locoregional lymph node involvement and three liver metastases, all localized in the left lobe. Tumor genetic evaluation showed the presence of the BRAF V600E mutation. She underwent right hemicolectomy, subsequent systemic neoadjuvant chemotherapy with oxaliplatin and capecitabine (XELOX regimen) for 4 cycles with significant shrinkage of liver nodules and, in February 2009, resection of hepatic metastases. Systemic chemotherapy with the same agents was administered for additional 4 cycles after radical hepatectomy. A complete remission of clinical and laboratory signs of DM was also observed upon liver surgery.
The patient had a relapse-free survival of 7 months, until September 2009, when a computed tomography (CT) scan revealed multiple lung metastases. A parallel recurrence of facial erythema, skeletal muscle pain, and weakness of the proximal muscles was observed. Laboratory tests exhibited also elevation of creatine kinase levels and anti-Jo1 antibodies. A 2nd line chemotherapy with 5-fluorouracil, folinic acid, and irinotecan (FOLFIRI regimen) was administered for 5 months with co

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


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

[User]
RADIOLOGY NOTE:
A 16-year-old male, prior to his presentation at our clinical setting, was diagnosed with an osteosarcoma in his left fibula. At the time of the diagnosis, he presented with a painful and progressively enlarging mass over the left ankle which restricted any weight bearing on the affected leg. A contrast-enhanced magnetic resonance imaging (MRI) scan of the lower extremities revealed a well-defined multicystic mass arising from the distal metaphyseal region of the left fibula (Figure ).
The mass was subjected to a core needle biopsy and subsequent histological evaluation of the biopsy specimen revealed a collection of hypercellular, spindle polygonal cells with an abundance of osteoclastic giant cells; which provided the tissue diagnosis of an osteosarcoma. Following this diagnosis, the patient presented to our clinical setting for further management. He underwent surgical excision of the tumor followed by the placement of a vascularized fibular bone graft. Following the surgery, the patient was provided with a total of 32 cycles of adjuvant chemotherapy with cisplatin, methotrexate, and leucovorin. He subsequently went into remission. After six months, he presented again with complaints of resurfaced pain in his left leg. A bone scan was performed due to the suspicion of tumor recurrence, which revealed an intense and irregular uptake in the distal segment of the left leg; confirming the reemergence of his primary pathology. The bone scan also showed areas of bony metastasis (evidenced by multiple areas of moderate tracer uptake) in the left maxilla, left parietal bone of the skull and greater trochanter of the left femur (figure ).
Further assessment with a contrast-enhanced high-resolution computed tomography (HRCT) scan of the lungs revealed multiple soft tissue nodules of differing sizes in both lungs. Some of these nodules were pleural-based and some showed internal cavitations (with the largest in the right upper lobe measuring 1.8 cm in diameter), which 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 14 years old girl was brought to our pediatric emergency unit because of severe hypocromic microcytic anemia detected by her primary care physician who had required blood tests to investigate the cause of reported asthenia and weight loss. Her mother reported that the patient had experienced early satiety and abdominal pain for several months. No history of fever or trauma as well as no dysuria, gross hematuria or recent travel abroad. Reported regular menstrual cycles until 2 months before admission.
With regards to the past medical history, a neurosurgical intervention for cranial meningocele of the bregmatic region at the age of 6 years and laparoscopic cholecystectomy for gallstones at the age of 13 years have been reported. At the time of cholecystectomy, hemoglobin was normal as well as hemoglobin electrophoresis. Initially, parents denied that their daughter had any history of eating disorder such as PICA, though alopecia was reported.
At physical examination: anorexic habitus, pulse rate of 88 beats/min, respiratory rate of 28/min, very pale skin and mucosae, no evident bleeding nor icterus. Her abdomen was rigid under palpation with a non- compressible mass in the left upper quadrant.
Laboratory tests, including erythrocyte morphology, confirmed a severe IDA, with normal Serum electrolytes, amylase, thyroid and liver function tests and vitamin B6, B12 and folate at the lower range of norm. Fecal occult blood test was positive.
Abdominal ultrasound (US) showed perihepatic free fluid and mild splenomegaly (10.5 cm diameter) and computed tomography (CT) scan reported severe gastric dilatation due to organic matter accumulation. The mass completely filled the gastric fundus and antrum and extended into duodenum. Also, small bowel dilatation and air-fluid levels were present (Fig. ). A gastric bezoar was therefore suspected.
After appropriate transfusion of erythrocytes and plasma, endoscopist evaluation was requested. In the light of the large size of the mas

[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 34-year-old female who presented to the ED with a one-day history of severe right breast pain with a mass. The patient noted a pea sized mass four months ago. Attributing the mass to her menstrual cycle, she did not seek medical attention until this ED encounter. The patient is not currently on birth control but has taken oral contraceptives in the past. She has never been pregnant and is a nonsmoker with no family history of breast or ovarian cancer. She has no history of breast surgery and menarche was at 13 years old. On exam, there was a palpable, dominant mass in the right breast at the 12 o'clock position measuring 4 cm by 2.5 cm in greatest dimension. The mass was mobile and there was no induration, drainage, fluctuance, erythema skin dimpling, nipple retraction, nipple discharge, peau d'orange, palpable lymphadenopathy in the bilateral axilla(s), lymphedema of the bilateral arm, or palpable masses in the left breast. The ED physician attempted to aspirate and drain the mass, which was unsuccessful. She was then given Motrin and clindamycin for suspected abscess and told to follow up at a breast center for imaging. No imaging was done in the ED. Three weeks later the patient was seen at a breast health and imaging center and completed a mammogram, ultrasound, and biopsy.
Mammogram demonstrated an irregular mass measuring 29 mm in longest dimension at 12 o'clock at a distance of 7 cm from the nipple at the site of palpable mass (Figure and Figure ). Coarse heterogeneous calcifications were noted in the mass. The breast was heterogeneously dense which may have lowered the sensitivity of mammography.
Right breast ultrasound demonstrated a solid mass measuring 29 x 17 x 28 mm at the site of the clinically palpable mass at 12 o'clock at a distance of 7 cm from the nipple (Figure and Figure ). The characteristics of

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


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

[User]
RADIOLOGY NOTE:
A 3-month-old girl was referred to a tertiary eye hospital for management of her left microphthalmos. She was born at 37 weeks by caesarean section weighing 1.26 kg following a complicated pregnancy. Her mother had experienced moderate reflux and recurrent gastritis as well as one episode of gastroenteritis during the tenth week of pregnancy; she did not suffer infection or nutritional deficiency. There was no history of medication use during pregnancy. The mother was monitored intensively during the third trimester for intrauterine growth retardation. The patient spent 3 weeks of the post-natal period in a special care baby unit for weight gain, requiring minimal respiratory support and an incubator for 3 days.
At term corrected age, her left eye appeared microphthalmic with an unusual fundal appearance, whilst her right eye appeared normal. Three months later, she was not showing any reproducible fix and follow responses with either eye, she had a reduced gaze preference to the left, but no abnormal eye movements were noted. There was an afferent pupil defect of the microphthalmic left eye with minimal pupil constriction to light. Both corneas and lenses were clear; irides were brown and well pigmented. Her skin and fundus were also appropriately pigmented. Her left eye appeared clinically microphthalmic with a microcornea as the central horizontal corneal diameter measured 7.5 mm (reference range of 9.0–10.5 mm []).
Dilated fundus examination of the left eye revealed a large nasal chorio-retinal coloboma, a rudimentary ‘optic nerve head' and no discernible macular reflex or foveal pit. The right eye appeared structurally normal with a healthy disc, normal macular appearance, and normal horizontal corneal diameter.
Unexpectedly, the ultrasound b-scan measured an axial length of 15.3 mm right eye and 15.7 mm left eye. This was supported by the MRI of the brain and orbits (Fig. ), which showed a longer globe length of the left compared to the right

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


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

[User]
RADIOLOGY NOTE:
A 52-year-old woman (gravida 1, para 1, and abortion 1) was referred due to the pelvic mass which was found by the transvaginal ultrasound in private clinic. Transvaginal ultrasound demonstrated a large irregularly marginated solid mass in the pelvic cavity. She denied the abdominal bloating and the pain except for the vaginal discharge. Her appetite, bowel and urinary function were normal with no recent weight loss. The medical history was unremarkable; there was no history of the abdominal surgery, gynecologic disorders, and family history was not notable. On the physical examination, there was no palpable mass in the abdomen and the cervix appeared normal. Laboratory tests, including tumor markers (CA-125, CEA, and CA-19-9) were within the normal range. Pelvic computed tomography (CT) revealed a 12×9 cm2, lobulated and well-enhanced mass (). Expected origin was the left ovary and the patient was underwent laparoscopic surgery. On the laparoscopy, the uterus and both sides of adnexa were appeared normal. The tumor was not originated from ovary and located in the presacral retroperitoneal space. The tumor was bluish-colored, and adhered densely to the adjacent tissues. The surface of tumor was fragile to bleed easily during dissection (). Since the mass was large and fixed with adjacent tissue, the mass was removed with several pieces. The frozen section biopsy (FSB) was conducted with those pieces. The FSB test result revealed the stromal tumor which cannot be excluded the chance of malignancy. We decided to the laparotomy considering result of FSB. After midline incision, the whole abdomen, including appendix, liver, and diaphragm, were explored carefully and revealed no other abnormalities. Tumor was adhered to the sigmoid colon on the right side of the pelvis and to the iliac vessels and the ovary on the left side of the pelvis. During the sharp dissection around tumor, the left internal iliac vein was injured. It caused fatally massive hemorrhage

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


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

[User]
RADIOLOGY NOTE:
A 34-year-old woman presented with multiple episodes of recurrent upper abdominal pain associated with retching and vomiting. All episodes were treated at home with intramuscular metoclopramide, not requiring hospitalization. Her clinical examination noted only mild tenderness on upper abdominal examination. Haematological and biochemical profiling was performed, as were plain abdominal X-ray and abdominal sonography, and all were normal. She also underwent an endoscopic examination of the upper digestive tract, which revealed a suspected stomach rotation. Following this, the patient ingested a barium meal that showed an organo-axial rotation of this organ, confirming the presence of a volvulus. The patient was treated with nasogastric drainage, intravenous fluids and proton pump inhibitors. She was offered definitive surgical treatment for her condition by laparoscopic gastropexy.
Laparoscopy was performed under general endotracheal anaesthesia. A carboperitoneum of 12 to 14 mmHg was created through umbilical Veress needle insertion. A number 10 trocar was placed here for camera passage. A number 10 trocar was inserted in the right iliac fossa and a number 5 trocar was inserted in the left iliac fossa. A great number of peritoneal adhesions were found on examination of the abdominal cavity. No macroscopic diaphragmatic defect was found. A laxity of gastrocolic and gastrophrenic ligaments was found, associated with a medium-grade gastrectasis.
The major curve was approached by making an opening into the gastrocolic omentum, which was divided from the antrum to the fundus and skeletonised using an ultracision harmonic scalpel. Four Ethibond 2/0 seromuscular sutures were later placed, using the trocar ports to introduce the strands. The sutures were placed on the anterior wall of the stomach (two near the fundus on the major and lesser curve side and two on the gastric body on the major and lesser curve side). The needles were cut off, retrieved and both ends of the s

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


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

[User]
RADIOLOGY NOTE:
62-year-old woman with medical history significant for aortic stenosis and chronic atrial fibrillation presented to the emergency department with fatigue and progressively worsening shortness of breath with minimal exertion. She was asymptomatic at rest and denied chest pain, orthopnea, paroxysmal nocturnal dyspnea, leg swelling, presyncope, or syncope. She was incidentally found to have a systolic murmur during her pregnancy 20 years prior to this presentation. Notably, she had been offered aortic valve replacement in the past but declined.
Vital signs were normal with blood pressure of 110/60 mmHg, pulse rate of 79/min, temperature of 97.2°F, and respiratory rate of 16 breaths/min with normal oxygen saturation of 100% on ambient air. Physical examination was significant for irregularly irregular heart rhythm, and ejection systolic murmur was loudest in the aortic area with radiation to the carotids. Her lungs were clear to auscultation, and no pedal edema was noted. Electrocardiogram revealed atrial fibrillation with voltage criteria for left ventricular hypertrophy. Her most recent transthoracic echocardiogram revealed a thickened calcified aortic valve with decreased excursion with 4.6 m/s velocity suggesting a peak of 86 mmHg and mean of 36 mmHg suggestive of severe aortic stenosis. No other significant valvular abnormalities noted. Cardiac catheterization revealed widely patent coronary arteries.
Based on the presence of worsening symptoms and the risk of sudden cardiac death, the decision was made to proceed with surgical aortic valve replacement. Given her history of chronic atrial fibrillation, she was also planned for left atrial appendage exclusion and Cox Maze IV procedure simultaneously with the aortic valve replacement. Intraoperative transesophageal echocardiogram revealed quadricuspid aortic valves confirmed during surgical exploration (). The native stenotic quadricuspid aortic valve leaflets were excised, and a 21 mm Saint Jude Medical Trifecta val

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


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

[User]
RADIOLOGY NOTE:
A 34-year-old primigravida was referred to our tertiary care hospital with a suspicion of either a chorioangioma of the placenta or a placental teratoma on the second-trimester anomaly scan performed from a secondary care hospital. The patient had no known comorbidities apart from being diagnosed with pregnancy-induced hypertension. The conception was planned and was not assisted by any interventional or medical means. There was no history of congenital anomalies in the family or of twin pregnancies. Ultrasonography at our institution revealed a single intrauterine fetus, corresponding to 27 weeks and two days of gestation, displaying a normal interval growth from the previous ultrasound. The presence of a multiloculated cystic mass with septations and calcifications was also noted. This mass was devoid of any vascularity (Figure ).
On color Doppler examination, no vascularity was noted and the mass, reported as measuring 104 x 53 mm, appeared as arising from the anterior wall of the uterus. The differential diagnosis of placental teratoma, chorioangioma, hemorrhagic placental degeneration, or degenerating fibroid was considered. A repeat scan in the third trimester revealed the same findings.
At 36 weeks and five days of gestation, the patient gave birth, via C-section, to a fetus with good Apgar scores (9/1, 9/5). A second congenitally malformed fetus was also delivered, which was devoid of cephalic end structures. Only the feet and lower limbs of the fetus were discernable (Figure ). A single placenta measuring 515 grams was also delivered, containing two umbilical cords. The patient was discharged in a stable condition on the sixth day of admission.
A histopathological examination of the placenta revealed placental discs measuring up to 19.5 x 14 x 4 cm. The placental membrane measured 30 x 16 cm, with two umbilical cords. The separately lying fetus showed gross malformation with the absence of the head and both upper limbs. However, both lower limbs were partia

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


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

[User]
RADIOLOGY NOTE:
A 54-year-old Caucasian male with past medical history positive only for diverticulitis with a resultant sigmoidectomy presented to a pain management specialist with progressively worsening bilateral low back, buttock, and radicular leg pain, weakness, and numbness for five weeks after falling from an 8 ft. ladder onto concrete. At the time of the fall, no notable injury was sustained and the patient reported only minimal low back pain without radiculopathy. Over the next several days, the patient began to experience numbness and weakness of the bilateral lower extremities. Evaluation in the ER, which included a hip X-ray and MRI of the lumbar spine (seen in ), revealed only mild lumbar facet arthropathy and moderate left neural foraminal stenosis at L3-L4 without any concomitant hip or spine fracture.
Following discharge, the patient reported worsening low back pain and bilateral lower extremity weakness in both L5 and S1 distributions. Several weeks after the initial fall, the patient was referred to pain management where he was evaluated and eventually underwent a radionuclide bone scan. This revealed mildly increased uptake at L5/S1 but was suspected to be a result of facet osteoarthritis. The patient denied any fever at this time, constitutional symptoms, or recent illness. Review of symptoms and physical exam were unremarkable aside from mild paraspinal tenderness and lumbosacral radiculopathy. The rest of the patient's neurologic exam was normal. The patient was instructed to follow up in one week's time. At the return visit, he reported continued worsening of symptoms with no relief. At this point in time, the patient mentioned that he had been experiencing shaking chills at night. Other review of symptoms and physical exam remained unchanged, and the patient was noted to be afebrile. A CT scan () and subsequent MRI of the lumbar spine () were conducted which revealed extensive findings of discitis/osteomyelitis at L5–S1 as well as an epidural abscess result

[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.