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

[User]
RADIOLOGY NOTE:
A 30-year-old gravida 2, para 2 woman admitted to our hospital with complaints of headache, nausea, vomiting, and right-sided blurred vision. She did not report any previous medical history or malignancy. Her neurologic examination revealed a right optic disc edema suggesting a posterior orbital mass. Her cranial computerized tomography (CT) scan showed multiple lesions that are a 6 mm mass on the right parietal lobe, a 16 mm mass on the left occipital, and another 7 mm mass on the left temporal lobe (Figures and ). All the lesions were hyperintense and surrounded by edema which suggests a metastatic cancer. Her cranial magnetic resonance imaging (MRI) also confirmed similar findings suggestive of a metastatic cancer to the brain.
For identification of the primary malignancy, she initially underwent thoracic and abdominopelvic CT. Upper abdominal CT scan revealed indistinctly bordered and heterogeneously contrast accumulating multiple lesions less than 15 mm in the liver. There was a pelvic tumor of 62 × 53 mm sized and solid cystic in nature located in the right adnexa. The pelvic mass was round shaped and thin capsulated that contains irregular septations and a solid component of 38 × 24 mm on MRI scan (). The right pelvic lymph nodes were slightly enlarged. No ascites were detected in the pelvic cavity. The endoscopic evaluation of the upper and the lower gastrointestinal tract and the ultrasonographic evaluation of the breast was found to be normal. The Pap test was reported to be negative for malignancy. Her serum tumor marker levels (CA 125, CA 15-3, CA 19-9, CEA, and AFP) were within normal limits.
The patient underwent a diagnostic laparoscopy for further evaluation of the adnexal mass. Biopsy of the adnexal mass and the liver was obtained and the pathologic examination revealed an ovarian mucinous cystadenocarcinoma with metastatic lesions of liver. The patient then was subjected to a laparotomy for a surgical staging procedure including total abdominal hys

[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 61-year-old male, ex-smoker, with a history of type 1 diabetes, was referred by his general practitioner (GP) to the ear, nose and throat (ENT) department with odynophagia, dysphonia, dysphagia and anterior neck swelling. The symptoms began while he was eating a cracker and, upon swallowing, he felt a painful crack in the right side of his neck. By the following day, the patient had developed hoarseness and pain on swallowing. He attended his GP five days later after developing neck swelling. At this point, it was thought the symptoms may represent an infection or a possible underlying malignancy; the patient was prescribed a course of oral antibiotics and referred urgently to the head & neck clinic. At subsequent review in clinic, the patient reported ongoing odynophagia, dysphonia and dysphagia. Examination noted some fullness of the anterior neck. Flexible nasendoscopy (FNE) showed pooling of saliva and swelling of the right supraglottis. The patient was otherwise systemically well and managing to maintain adequate oral intake despite his symptoms. An expedited outpatient CT scan of the neck was requested to investigate for possible laryngeal malignancy. While awaiting this investigation, the patient re-presented to his GP with rapidly progressing symptoms and was referred to the ENT on-call team for same-day review. The patient had worsening dysphagia, now only managing sips of water. The anterior neck swelling had increased significantly in size and was now indurated with a central area of fluctuance. He underwent urgent inpatient contrast-enhanced CT scan of the neck (Figures , ).
This demonstrated a vertical fracture of the thyroid cartilage to the right of the midline, with depression of the right thyroid lamina posteriorly causing mass effect on the trachea. There was also a large multiloculated collection in the midline just anterior to the thyroid cartilage. This extended superiorly up to the hyoid bone and inferiorly over the thyroid gland.

[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 Chinese man who had been experiencing chest pain for 10 years presented at our institution. He was moderately active, doing odd jobs around the house, and accelerating angina over the past 2 years. The patient had been taking aspirin, nifedipine for high blood pressure and metformin for diabetes mellitus type 2 for almost 10 years. He smoked one pack of cigarettes per day for about 40 years before quitting the previous year. His past history was remarkable for chronic obstructive pulmonary disease.
At the time of admission, the physical examination showed heart rate (HR), 67 beats/min (bpm); blood pressure (BP), 156/89 mmHg; and blood glucose, 6.85 mmol/L. An electrocardiogram (ECG) showed a sinus rhythm with ST depression and T-wave inversion when chest pain occurred. A complete blood count and a basal metabolic profile were examined; the evaluation of kidney function, blood acid, base balance, and blood sugar levels showed that there were all within a normal range. The treadmill exercise test was positive, and showed ST depression on the ECG when chest pain or shortness of breath occurred. The patient’s response to clopidogrel therapy was determined by testing for CYP450 genetic polymorphism, which showed non-resistance to such therapy. Testing for CYP450 genetic polymorphism was to predict response to clopidogrel
[].
The patient was prepared for coronary angiography (and stent placement if necessary). Before the procedure, the patient’s spontaneous baroreflex sensitivity (BRS), heart rate variability (HRV), and blood pressure variability (BPV) were measured (Table
). Six hours before the patient underwent coronary angiography, he was given 300 mg aspirin and 300 mg clopidogrel. An initial dose of heparin (100U/kg) was intravenously given before the procedure; an additional dose of heparin at 500U would be given if the procedure lasted 1 hour. The activated clotting time was maintained at 325 s.
The coronary angiogram was done through the

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


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

[User]
RADIOLOGY NOTE:
A 76-year-old Caucasian female with no psychiatric history presented to the emergency department with her family for a one-week history of unstable mood and psychosis following her third epidural steroid injection for low-back pain due to falls history. The chief complaint included altered mental status, agitation, and hallucinations. Table shows the admission lab values that were significant.
The patient was treated for hyponatremia given low serum sodium and transferred to neurology for further workup. Magnetic resonance imaging (MRI) of the head and lumbar puncture were unremarkable. However, the initial electroencephalogram (EEG) was consistent with a partial seizure disorder and focal clinical status epilepticus in the right temporoparietal region. The patient was treated with phenytoin 300 mg daily. The patient also received quetiapine and later olanzapine for psychosis. No seizure events were captured on EEG study one week later. Table lists the results of the initial and final EEG. The patient was also briefly treated with intravenous methylprednisolone for suspected autoimmune encephalitis without noted benefit. Despite treatment with antiepileptic medication, methylprednisolone, and sodium correction, the patient continued to exhibit symptoms of mania and psychosis and was transferred to the geriatric psychiatric inpatient unit 12 days after the initial presentation.
Upon psychiatric admission, the patient continued to identify her husband and daughter as demons. Her mental status exam was significant for disheveled appearance, uncooperative behavior, loud and disorganized speech with loose associations, grandiose, hyper-religious, and paranoid thought content. The patient was placed on one-to-one observation with assault precautions. Risperidone was initiated to target psychosis and mood and titrated to 1 mg twice daily; intramuscular (IM) haloperidol and lorazepam were also utilized during an event of acute agitation and assault on a healthcare staff mem

[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 82-year-old man with a history of hypertension was referred to our Department of Hepatobiliary Pancreatic Surgery with a persisting subxiphoid pain of 12 h duration. There was no positive sign, except for tenderness in the epigastric region. The results of the laboratory tests, including determination of blood glucose levels, were almost within the normal range. Computed tomography of the upper abdomen revealed an atrophic pancreas with a dilated pancreatic duct containing a single stone located at the pancreatic neck; no mass in the pancreatic gland head or biliary dilatation was detected (Figure ). The size of the stone was approximately 1.0 cm × 0.6 cm. Based on the clinical signs and test result, a diagnosis of pancreatic duct stone with CP was established.
Given the presence of only one stone in the pancreatic main duct, we elected to perform laparoscopic pancreatic duct incision and stone removal, followed by T-type tube drainage, under general anesthesia after obtaining informed consent from the patient.
During the operation, the patient received prophylactic antibiotics intravenously, and intermittent pneumatic compression therapy and graduated compression stockings were applied to the lower limbs. After catheterization of patient, he was installed in a flat Lloyd-Davies position. The patient was tilted in a 30-degrees reverse Trendelenberg position during the operation by the use of two 5-mm ports, two 10-mm ports, and one 12 mm port (Figure ).
By an ultrasonically activated scalpel, the lesser sac was opened via the gastrocolic omentum. Then, mobilization of the gastric antrum was performed, followed by upward retraction of the stomach to expose the front surface of the pancreatic head to the gland body. The duct of the pancreas was located by ultrasound laparoscopy and opened (Figure ). An initial opening was made above the gland neck by the joint use of an electrocoagulation and an ultrasonically activated scalpel, which was then prolonged further

[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 a medical history of hypertension, atrial fibrillation, type 2 diabetes mellitus, and mild chronic renal impairment with a single functional kidney was referred to our hospital because of a Crawford type 3 thoracoabdominal aneurysm with a diameter of 6.4 cm. There was a preexisting occlusion of the left renal artery. Baseline serum creatinine was 1.81 mg/dL. The estimated glomerular filtration rate (eGFR) using the modified diet and renal disease study equation (MDRD) was 37 mL/min/1.73 m2.
Endovascular repair was performed with an aortic branch graft including side branches for the celiac trunk, superior mesenteric artery (SMA), and the right renal artery. Covered stents were placed through the side branches in the target vessels and these were relined with nitinol self-expanding stents. The procedure was complicated by diplopia caused by occipital infarction, despite intraoperative heparinisation and immediate postoperative readministration of anticoagulant therapy (coumarin and clopidogrel). Postoperative serum creatinine remained unchanged. Three weeks after surgery, clopidogrel was discontinued because of side effects. Follow-up CT-angiography 6 weeks after discharge showed adequate position of the aortic branch graft (), patency of the visceral side branches, and target vessels without kinking of the (covered) stents. However, a mass in the left mamma was found. Additional diagnostic tests showed an invasive ductal carcinoma. Subsequently the patient was planned for mastectomy with sentinel node procedure. Anticoagulant therapy was discontinued 3 days before surgery. Upon admission for the planned surgery, the patient reported anuria for approximately 12 hours and right flank pain that had started early that morning. Blood test showed an increase in serum creatinine to 5.37 mg/dL. Ultrasound investigation showed an occlusion of the stents in the right renal artery side branch and minimal venous flow suggesting acute ischemic kidney injur

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


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

[User]
RADIOLOGY NOTE:
A 47-year-old white male presented with recurrent severe dizziness, chest tightness, shortness of breath, left upper back pain, night sweats, and chills of three weeks duration. His past medical history consisted of a 20 pack/year history of smoking and squamous cell carcinoma of the tongue, status-post excision with subsequent radiation and chemotherapy a year and a half prior to his presentation. He also had recurrent disease with biopsy-proven metastatic disease in the cervical lymph nodes nine months after the initial diagnosis and multiple lung nodules on CT and PET scans six months thereafter. He was continued on immunotherapy with nivolumab with subsequent cycles planned.
He was admitted for workup of the near syncope. A CT of the chest on admission revealed a filling defect in the left brachiocephalic vein extending into the right atrium and a filling defect in the right ventricle believed to be a thrombus. Heparin anticoagulation was initiated for possible thrombus in transit and a suspected pulmonary embolus (PE). Ten hours later, the patient developed severe diaphoresis, associated with inspiratory chest pain and shortness of breath. An electrocardiogram (ECG) revealed diffuse ST elevation, and a stat TTE revealed a large pericardial effusion with tamponade physiology. Emergent pericardiocentesis was performed and 1,600 cc bloody pericardial fluid was drained; the pericardial drain was left in for 24 hours with no significant additional drainage. Cytology of the pericardial fluid was negative. The patient’s shortness of breath persisted at rest and was associated with a low-grade fever (100.2° F). He experienced repeated episodes of hypotension and tachycardia, requiring intermittent fluid resuscitation and pressor support.
A follow-up TTE (Figure ) and TEE (Figure ) revealed a growing right-sided mobile mass in the right atrium, right ventricle, and pulmonary artery (PA), which was believed to be a large thrombus.
In view of cardiac tamponade with a rapi

[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 seven and half year-old boy visited the outpatient clinic of Pediatric Dentistry Department, Faculty of Dentistry, Cairo University in June 2015 with a chief complaint of pain on the lower right molar area. The patient’s mother stated that the pain was at times throbbing in nature, and child is not able to chew on this side.
Clinical examination showed a badly decayed, lower second primary molar with related localized intraoral abscess, where the lower first primary molar was intact. The patient had poor oral hygiene; he had not received any professional dental care, and was very apprehensive.
Radiographic examination revealed root resorption and bone rarefaction related to lower second primary molar. The interesting finding was a considerable amount of root resorption of the distal root of the adjacent lower first primary molar (
).
The case was managed by performing pulpectomy
 to the lower second primary molar, with root canals filled with calcium hydroxide paste with iodoform (Metapex, Meta Biomed, Republic of Korea). The tooth was then restored with high viscosity glass ionomer (GC Fuji IX GP capsule, GC corporation, Tokyo, Japan) (
). The lower first primary molar was not touched and instead monitored. No antibiotics or analgesics was prescribed.
Unfortunately, the patient’s mother did not want follow-up appointments in person, however, she was contacted on the phone, after 2 weeks, 3 months and 6 months, and she said everything was fine and there was no swelling or pain.
At about 8 months from the treatment appointment, the patient’s mother visited the outpatient clinic with the patient for other reasons, and decided to pass by the Pediatric Dentistry Department for patient follow-up. Clinical examination showed no signs or symptoms, occlusal restoration was intact, and radiographic examination revealed arrested root resorption, on both molars, and an increase in the density of bone although this was not at a

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


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

[User]
RADIOLOGY NOTE:
A 33 years old female noted abnormal sensations in her left upper limb of two months duration. She was evaluated by neurologists and was believed to have psychiatric illness. She was then referred to a psychiatrist and was treated for somatoform disorder for two years when she complained of worsening of sensory disturbances in the form of sensory loss in a “cape-like” distribution along with painless ulcers in the left hand. At this time, the imaging of the cervical spine was done and she was found to have chiari I malformation and syringomyelia. She was later referred to neurosurgery for further management. On admission to neurosurgery department, she had normal optic fundi, sensory impairment from C4 to T8 on the left side with small, trophic ulcers in the left hand. Her left hand grip was weak. MRI examination revealed panventricular hydrocephalus with chiari I malformation along with syringomyelia extending from C1 to lower thoracic region. There was evidence of communication of fourth ventricle with the syrinx [Figure and ]. The patient underwent a right ventriculoperitoneal shunt. Following shunt insertion, there was no change in the patient's neurological status. CT scan showed decompression of the supratentorial ventricles with persistent dilatation of the fourth ventricle [] and hence, the patient underwent foramen magnum decompression and intradural exploration. An upper cervical laminectomy was also done for a possible syringopleural shunt, if necessary. During intradural exploration, an arachnoid veil was found to be covering the foramen of Magendie. The arachnoid veil was opened which revealed a gush of CSF. Following this the cervical cord size was found to decrease intraopertively and hence the planned syringopleural shunt was not done. Following foramen magnum decompression, the patient's neurological status improved with significant improvement in sensations and healing of trophic ulcers. Two months after surgery, she went back to work as a school 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:
An 82-year-old female presented to our hospital with fever, dry cough, shortness of breath, and poor appetite for three days. She was treated for pneumonia two weeks prior to hospitalization by her primary doctor and had completed a 10-day course of an oral antibiotic. There was no previously reported history of Clostridium difficile infection. She had moved to the United States two years prior. She was ambulatory and functional at baseline.
At the time of presentation, her blood pressure was 89/48 mmHg, pulse rate was 101 beats per minute, respiratory rate was 40 breaths per minute and temperature was 101 ° Fahrenheit. On examination, she was found to be obtunded and not moving any extremities. Her abdomen was soft and distended with reduced bowel sounds. Her peripheral pulses were palpable and her pupils were reactive bilaterally. Her trachea was cannulated for acute respiratory failure. Despite intravenous fluid challenge, she remained hypotensive and was started on norepinephrine for suspected septic shock and admitted to the intensive care unit. She was started on intravenous vancomycin, piperacillin-tazobactam, and azithromycin. Her initial laboratory findings have been mentioned in Table .
X-ray imaging of the chest showed diffuse bilateral pulmonary infiltrates. Computed tomography (CT) imaging of her brain showed no acute large vessel distribution infarction, hemorrhage, mass, or mass effect. Venous Doppler ultrasound of her lower extremities showed bilateral deep venous thrombosis and therapeutic subcutaneous enoxaparin was started. She had multiple episodes of watery diarrhea since arrival in the ICU and she was started on oral vancomycin. The stool was sent for analysis and was found to be positive for the glutamate dehydrogenase (GDH) antigen and Clostridium difficile toxin B. She was noticed to have cold mottled skin and decreased peripheral pulses, first in the right upper extremity followed by the right lower extremity. This has been presented in Fig

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


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

[User]
RADIOLOGY NOTE:
A 73-year-old woman presented with dyspnea on exertion. Chest radiography showed an enlarged mediastinal silhouette. Preoperative computed tomography (CT) and echocardiography revealed a giant cyst (12 × 10 cm in diameter) occupying a large area around the left atrium and ventricle, and it was present behind the pulmonary artery. Based on the preoperative CT findings, a pericardial or an epicardial cyst was suspected. Additionally, attachment of the cyst to the left atrium, left ventricle, pulmonary artery, and pulmonary vein was suspected (Fig. ). Compression of the left atrium and ventricle was considered to be the cause of her symptoms. Her hemodynamic condition was stable. Percutaneous cystocentesis was performed, and 800 ml of serous liquid was aspirated. However, 1 week after cystocentesis, the cyst recurred, and its size was the same as that before the procedure. Therefore, resection was planned.
If the cyst was an epicardial cyst, tight adhesion of the cyst to the left atrium, left ventricle, pulmonary artery, and pulmonary vein was considered possible. However, we believed that the cyst was more likely a pericardial cyst because a pericardial cyst is more common than an epicardial cyst. Therefore, resection involving video-assisted thoracoscopic surgery (VATS) was planned initially. However, the pericardium was intact and an epicardial cyst was diagnosed intraoperatively. As preoperative CT showed compression of the left atrium, ventricle, pulmonary artery, and pulmonary vein, adhesion was suspected. Additionally, the possibility of cardiopulmonary bypass (CPB) was considered. Therefore, open surgery through median sternotomy was performed. The cyst was found to be attached to the visceral pericardium involving the left atrium and pulmonary artery. Contrary to our expectation, the left ventricle was not involved. Additionally, coronary vessels were not involved. The cyst was most tightly attached to the main pulmonary artery. Thus, it was thought to have or

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


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

[User]
RADIOLOGY NOTE:
An 85-year-old female with a past medical history of diabetes mellitus, hypertension, and hyperlipidemia underwent surgical consultation in October 2015 for an incidentally found right foot mass subsequent to an elective gynecologic procedure. The patient first noticed a small lesion on the dorsum of her right foot approximately 12 years ago. She never sought medical attention for this slowly growing and asymptomatic lesion. However, this lesion had been growing more rapidly and had become foul smelling over the past 3 weeks. She denied any pain, paresthesias, weight loss, or recent trauma to the foot. She also denied any history of smoking or significant sun exposure. Her only surgical history included a recent total abdominal hysterectomy and left salpingo-ophorectomy. On physical examination, she was a well-nourished Caucasian female who was found to have a large exophytic, fungating 8.0 × 8.0 × 0.6 cm malodorous mass on the dorsum of her right foot (Figure ). This mass was insensate to light touch with no surrounding erythema. She had palpable dorsalis pedis and posterior tibial pulses with full range of motion of that foot. The left lower extremity was benign in examination, with no masses or lesions. A thorough dermatologic examination did not reveal any other concerning lesions. A punch biopsy of this mass was consistent with BCC. Subsequent magnetic resonance imaging (MRI) showed a large soft tissue irregularity surrounding the second to fifth extensor tendons (Figure ). Given these findings, the patient underwent a wide local excision of this BCC with full-thickness skin graft for coverage.
The lesion was excised in its entirety with a 5-mm circumferential margin beyond the extent of visible tumor. This incision was carried down directly to the fascia overlying the extensor digitorum longus tendons. Intraoperative pathologic evaluation noted a negative deep margin; therefore, resection of extensor tendons was not required. The specimen was sent to pathology

[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 was incidentally diagnosed with a left CIAA by abdominal ultrasonography, with computed tomography (CT) demonstrating a left CIAA measuring 4.5 cm in diameter (). The patient was referred to our hospital for surgical treatment. He had a medical history of liver cirrhosis and traumatic abdominal injury. Thus, he underwent EVAR using a GORE EXCLUDER AAA Endoprosthesis to embolize the left internal iliac artery. The postoperative course was uneventful, and postoperative CT showed no endoleak (). Follow-up CT scans at 6-month, 1-year and 2-year intervals post-EVAR revealed a reduction in the size of the aneurysmal sac. However, the 3-year interval CT demonstrated an increase in the sac size (). Contrast-enhanced CT and angiography revealed no endoleak but showed a dilatation of the CIAA. Therefore, the patient underwent open aortic repair of the CIAA.
The infrarenal aorta up to the right common iliac artery and the left external iliac artery were exposed via a retroperitoneal approach. Proximal control was achieved by clamping midway between the renal arteries and the aortic bifurcation, and distal control was achieved by inserting an occlusion balloon into the right common iliac artery and clamping the left external iliac artery. The sac of the CIAA was opened, and many thrombi were noted around the stent graft. No backbleeding of the lumbar arteries or junctional bleeding of the stent was detected, and the entire endograft was removed easily. Abdominal aortic replacement with a Y-shaped vascular prosthesis (J Graft SHIELD NEO, bifurcated vascular prosthesis) was performed (). Proximal and distal anastomoses were performed at the level of midway between the renal arteries and the aortic bifurcation where the endograft was fixed, and at the level of the right common and left external iliac arteries, respectively.
The patient recovered uneventfully, however, 1 year after open conversion, CT revealed a significant increase in the size of the unreplaced i

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

[User]
RADIOLOGY NOTE:
A 77 year old male was treated at a chiropractic clinic for low back pain resulting from lumbar facet arthrosis and lateral canal stenosis. On a subsequent visit he reported right wrist pain which began while lifting a heavy box. On examination, redness and swelling was noted on the dorsal aspect of his right wrist. Range of motion was full with pain at end range of flexion and extension. His health history included two hip replacements, two previous episodes of gout in both first metatarsophalangeal joints (2 and 5 years prior), and hypertension. Medications for hypertension included perindopril (4 mg), hydrochlorothiazide (25 mg), and Norvasc (10 mg). In addition, he was prescribed 80 mg of aspirin/day and took a daily multivitamin. One week prior, the patient's general practitioner had increased his Norvasc dosage and also prescribed Tylenol 3 to be taken as needed for his back pain.
Two days later the swelling had increased in the dorsal aspect of his right wrist and hand. Wrist flexion was limited by 80% with severe pain. Pain was present on palpation of the scaphoid bone. Due to the suspicion of fracture, the patient was referred to his general practitioner for radiographs. The radiologist who read the films described tiny cysts at the distal radius and concluded that these were most likely due to old trauma. Mild osteoarthritic changes were noted at the carpal-metacarpal joint at the base of the thumb. The report stated that the radiographs were otherwise normal.
The patient's symptoms worsened with increased pain and swelling over the next few days. Due to the worsening symptoms, repeat radiographs were performed five days later and were read by a radiologist. The radiographs revealed well-marginated juxta-articular bony erosions at the radial styloid process and the dorsal rim of the distal radius with soft tissue swelling. These findings were deemed to be consistent with gouty arthritis. (See figure ).
The patient was referred

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

[User]
RADIOLOGY NOTE:
A 35 years old (height, 159 cm; weight, 85 kg; gravida 3, para 1) pregnant woman with SAS presented to our hospital and was scheduled to undergo elective CS under epidural anesthesia at 36 weeks of gestation. An echocardiographic examination at 34 weeks of gestation revealed that the diameter of the beginning portion of the aorta (under the aortic valve) was narrowed by about 17 mm. The diameter of the ascending aorta was normal, the average pressure gradient was 40 mmHg, and the ejection fraction was 67%.
In the operation room, her baseline vital signs were as follows: heart rate (HR), 82 bpm with normal sinus rhythm; noninvasive blood pressure (BP), 130/76 mmHg; and oxygen saturation (SpO2), 96%. Supplemental oxygen was administrated by a face mask at the rate of 3 L/min. Traditional epidural puncture was performed at the L1–2 and L3–4 interspaces in the left lateral position, and a catheter was inserted to a depth of 4 cm into the epidural space at the cranial and caudal ends of the surgical field. The patient was then placed supine in a left-tilt position; 3 mL of 2% lidocaine was injected as a test dose, and another 7 mL was injected 5 min later through the cranial catheter. Additionally, 3 mL of 1.5% lidocaine was injected through the caudal catheter. At 20 min after the lidocaine injection, the sensory block had reached T6. The patient had no discomfort, and her hemodynamic parameters were stable. The operating bed was adjusted from the left-tilt to horizontal position, and the operation was allowed. Two minutes later, the patient reported chest distress and difficulty breathing (HR, 110 bpm; BP, 80/69 mmHg; SpO2, 96%), and 3 mg of intravenous ephedrine was promptly administered. The patient immediately lost consciousness with no response (HR and BP were depressed to 40 bpm and 53/15 mmHg, respectively). The lowest BP at

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

[User]
RADIOLOGY NOTE:
A 36-year-old G3P0111 with a past medical history significant for seizure disorder and morbid obesity (Body Mass Index 33 kg/m2) presented with a chief complaint of progressively worsening abdominopelvic pain, nausea, and vomiting for one day. Two weeks prior she presented to an outside facility for right-sided abdominopelvic pain and dyspareunia at which time her intrauterine device was found to be malpositioned with the IUD was low lying and predominantly in the cervix but otherwise there was no evidence of pelvic pathology on transvaginal ultrasound imaging. She subsequently had the intrauterine device removed by an outside gynecologist prior to her presentation to our facility. On presentation to the emergency room, she was found to be tachycardic but normotensive and afebrile. Her laboratory values were significant for white blood cell count of 18.4-cells/mm3 and a glucose level of 443 mg/dL. Computed tomography (CT) scan of the abdomen and pelvis demonstrated a right-sided tubo-ovarian abscess that was 8 cm in diameter with foci of internal air and extensive surrounding inflammatory changes ().
The patient had not received primary care for a prolonged period of time. She was subsequently found to be in diabetic ketoacidosis with newly diagnosed type 2 diabetes mellitus and a hemoglobin A1c level of 14% requiring aggressive intravenous fluid hydration and insulin. She also had a low grade temperature so one set of blood cultures were obtained and she was initiated on empiric antibiotics with intravenous gentamicin and clindamycin pending complete work-up. Interventional radiology (IR) was consulted for possible drainage of the tubo-ovarian abscess but the location of the abscess was not amenable for a safe percutaneous approach secondary to bowel loops and major arteries being in close proximity to the abscess. While she initially had mild improvement of her abdominal pain with downtrending fever curve and leukocytosis, her clinical course was complicated by ol

[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 woman with renal insufficiency (GFR 16 mL/minute/1.73 m2) and known kidney stones, who had deferred definitive stone management for nearly 5 years, presented to our clinic in June of 2015 with left flank pain. A CT scan of the abdomen demonstrated bilateral staghorn calculi, severe bilateral hydronephrosis, and minimal right renal parenchyma with thinned left sided parenchyma. Compared to prior CT in 2013, there was an additional finding of a new hyperdensity within the left lower pole suggestive of hemorrhagic or proteinaceous debris (). She complained of increased fatigue and pain, however, denied weight loss or hematuria. She was desirous of definitive left stone removal for renal preservation and pain control and was counseled toward a staged PCNL.
After gaining percutaneous access and removing a moderate volume of stone, we noted abnormal shaggy appearing urothelium of the collecting system, which was biopsied. The intraoperative course was complicated by moderate blood loss hypotension. The patient required postoperative blood transfusions and inotropic support and, ultimately, required interventional radiology guided angiogram and selective renal artery embolization to cease blood loss. Renal function declined as a result of the embolization, intravenous contrast nephropathy, and acute blood loss anemia and the patient ultimately required hemodialysis. After stabilization, she was discharged on postoperative day 13.
Histologic assessment of the inflammatory tissue revealed papillary proliferation with squamous metaplasia and moderate atypia, interpreted as reactive urothelium given long-standing stone history. At 1-month follow-up, physical examination revealed a tender cutaneous bulge on her left flank, at the site of her previous nephrostomy, concerned for hematoma or abscess. A CT of the abdomen favored hematoma extending to the skin () and also noted nonspecific para-aortic lymph node enlargement. Shortly after, the collection was noted to e

[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 33-year-old Asian woman returned for a frozen embryo transfer (FET) cycle three years following an uncomplicated pregnancy and birth that resulted from a previous successful attempt at ovulation induction with gonadotropins and IVF. She had been placed on an antagonist protocol and her stimulation was unremarkable. Her medical history was significant for hyperlipidemia and oligoovulation secondary to PCOS, which was diagnosed at the time of her initial presentation. At that time, she had irregular menses occurring every 1–4 months and evidence of bilateral polycystic ovaries on ultrasound. Her androgen levels were normal and she did not exhibit any evidence of clinical hyperandrogenism. Prior to returning for FET, her menses remained irregular; however she denied the use of any hormonal agents. There was no personal or familial history of endometriosis or gynecologic malignancies. Pelvic ultrasounds (PUs) performed at her initial infertility consult as well as during treatment and in the early stages of pregnancy revealed polycystic-appearing ovaries, but were otherwise normal.
Prior to the commencement of a FET cycle, the patient had a baseline PU, which revealed a complex ovarian cyst with layered low level echoes measuring 5.1 × 3.8 cm (). One area at the base of the cyst had a papillary growth (), while color Doppler revealed venous flow within the growth suggesting malignancy. Tumor markers including CA125 (21 U/mL) were within normal range. A repeat PU and a subsequent CT scan confirmed the previous ultrasound findings.
At exploratory laparotomy by gynecological oncologist, an enlarged fluctuant and cystic left ovary adherent to the rectosigmoid was found. The pelvis was otherwise normal. After obtaining peritoneal washings, the patient underwent a left salpingo-oophorectomy and omental biopsy but the cyst inadvertently ruptured during the procedure. Gross examination showed a 5 cm cyst with a 2.5 cm papillary lesion arising from the cyst wall. Final patholo

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


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

[User]
RADIOLOGY NOTE:
The patient is an elderly woman, 82 years old this year. She went to the hospital for abdominal pain in May 2000. Color Doppler ultrasound showed moderate ascites and right ovarian accessory mass. Abdominal aspiration was taken as bloody osmotic fluid, and pathological smears found adenocarcinoma cells. She was then given preoperative neoadjuvant chemotherapy: intraperitoneal perfusion (cisplatin 120 mg) and systemic chemotherapy (cyclophosphamide 700 mg, pirarubicin 60 mg), every 3 weeks for 3 cycles.
On July 11, 2001, the patient underwent total uterine attachment, omentum, pelvic lymphadenectomy, and pelvic floor tumor reduction under general anesthesia. The postoperative examination was ovarian cancer. Adjuvant chemotherapy was performed after surgery: intraperitoneal perfusion (cisplatin 120 mg) and systemic chemotherapy (cyclophosphamide 700 mg, pirarubicin 60 mg), every 3 weeks for 3 cycles.
The patient was taken to the hospital because of the left breast mass on November 20, 2018. Physical examination showed that there was a hard mass in the left breast, which was not movable and painless, with a diameter of about 2 × 2 cm. The right breast and bilateral axillary fossa were normal. Molybdenum target showed a mass lesion in the lower quadrant of the left breast, which may be malignant. Doppler color Doppler showed that the low-echo nodules were found at 5 o’clock in the left breast. The shape was irregular, the edges were irregular, the right breast was not abnormal, and the bilateral lymph nodes were negative. Computed Tomography (CT) showed a small amount of effusion in the bilateral thoracic cavity; bilateral lungs were scattered in the nodules, with a maximum of 0. 7 × 0. 5 cm in the lateral segment of the right middle lobe.
On November 21, 2018, she underwent general anesthesia for left breast cancer breast-conserving surgery and sentinel lymph node biopsy (SLNB). The pathological results were malignant, and no tumor metastasis was observed in peripheral

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


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

[User]
RADIOLOGY NOTE:
A 32-year-old man with SB developed ESKD due to reflux nephropathy and enrolled in a maintenance HD programme. After 1 year, he developed recurrent syncopal events with each HD treatment. Syncope would predictably occur 1–2 h into HD. He suffered light-headedness prior to each event and an occipital headache subsequently. He returned to normal each time over a variable period from 10 to 30 min after termination of HD. He was completely asymptomatic in the time between each HD session.
He had a ventriculo-atrial shunt due to hydrocephalus. This shunt was assessed by the neurosurgical service and found it to be functioning entirely normally. He had the cerebrospinal fluid (CSF) removed from the shunt reservoir pre-HD to increase pressure accommodation. Cardiac telemetry during the syncopal episodes demonstrated that sinus tachycardia and echocardiography were normal. Video-electroencephalography (EEG) during syncope showed a pattern consistent with the sleeping state, but no seizure activity or signs of encephalopathy.
Reducing the size of the dialysis filter, the blood flow rate and the duration of dialysis treatment in an attempt to reduce osmotic shifts were unsuccessful, however, this did reduce the severity of events and the recovery time, suggesting some benefit.
Magnetic resonance imaging (MRI) of the brain revealed CM II with severe herniation of the cerebellar tonsils through the foramen magnum, as shown in .
We theorize that the severity of compression of the reticular activating system was such that very minor increases in cerebral volume were enough to cause syncope and could not be compensated for by the functioning ventriculo-atrial shunt. The EEG pattern consistent with the sleeping state adds further to the evidence of compression on the reticular activating system by the herniating cerebellar tonsils.
In an attempt to reduce intra-cerebral pressure, we gave a trial of 50 g of mannitol immediately before dialysis and an additional dose at the midpoint

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


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

[User]
RADIOLOGY NOTE:
A 40-year-old woman presented with a slowly growing asymptomatic mass over the scalp in the right parieto-occipital region. Clinical history revealed that there was no trauma or fracture in the past. There was no history of headache or convulsion. The patient did not have weight loss or loss of appetite. Her menstrual cycles were normal. The mass had been progressively increasing in size over the last 4 years. On examination, the swelling measured approximately 2 cm × 2 cm, was firm, slightly fixed, nontender, and covered by normal skin []. It was non-fluctuant. There was no discharge or punctum associated with the swelling. There was no evidence of cervical lymphadenopathy on palpation. Further systemic and bilateral breasts examination revealed no abnormality in any of the systems.
X-ray of the skull showed bony calvaria with no evidence of any bony abnormality or fracture. Laboratory investigations revealed normal hematological parameters such as complete blood counts and peripheral smear examination. Biochemical tests such as thyroid, kidney, and liver function tests, as well as lipid profile of the patient were normal.
FNAC was performed and blood mixed cellular aspirate was obtained. Papanicolaou and Giemsa stains were applied. Smears prepared showed high cellularity comprising of clusters, sheets, whorls, and singly scattered epithelial cells. These cells showed mild pleomorphism and were round to oval with eccentric nuclei, fine granular chromatin, and moderate amount of cytoplasm [Figure ]. Few of the cells showed intranuclear inclusions []. Many tight whorls of such cells were also noted [, inset]. No necrosis or any mitotic figures were seen, and the background showed blood. Finally, an impression of cutaneous meningioma was made based on the cytomorphological features. The patient was advised radiological investigations and neurosurgical intervention.
CECT brain showed evidence of soft tissue enhancing swelling over the right parieto-occipital region [].

[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 79-year-old man presented with high-grade muscle-invasive bladder cancer and underwent robot-assisted laparoscopic radical cystoprostatectomy with urethrectomy, extended pelvic lymph node dissection, and intracorporeal urinary diversion. One week after surgery, clear fluid started leaking from the external urethral orifice. The leakage output was 300 mL per day. CT revealed a medium amount of ascites. Biochemical examination of the ascitic fluid was suggestive of lymphorrhea. A low-fat diet was started, but the leakage output did not decrease. Two months after surgery, intranodal lymphangiography was performed to detect the site of leakage and reduce the amount of lymphatic leakage. Under local anesthesia, bilateral inguinal lymph nodes were punctured with a 23-gauge cathelin needle under ultrasound guidance (). Lipiodol was injected slowly under fluoroscopy, showing a network of lymphatic vessels in the pelvis. Lymphatic leakage from the left pelvic wall into the peritoneal cavity was detected (). Although the therapeutic effect of lipiodol lymphangiography was expected, the amount of lymphatic leakage did not change after lymphangiography. Thus, laparoscopic surgical repair of lymphorrhea was performed two weeks later. During the repair, a dent was found on the left wall of the pelvis just above the external iliac artery, from which the serous fluid slowly leaked into the peritoneal cavity. Although the dent was suspected to be the lymphatic leakage point, the laparoscopic findings alone were not conclusive. We decided to perform intraoperative lymphangiography to confirm that the dent was the leakage point and to exclude other sites of leakage. A left inguinal lymph node was punctured under ultrasound guidance and lipiodol was slowly injected, showing leakage from the left wall of the pelvis. Then, indigo carmine diluted 10-fold with normal saline was slowly injected. In total, 1 mL of lipiodol and 1 mL of diluted indigo carmine were used. Three minutes after a

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


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

[User]
RADIOLOGY NOTE:
A 79-year-old woman presented with post-menopausal bleeding and pain in lower abdomen for 2 months. The obstetric history of the patient was P2L2 and the patient had attained menopause 30 years back. The age of menarche was 14 years. On examination, a firm mass was palpable in lower abdomen extending upto umbilicus. On vaginal examination, uterus size could not be made out and a large abdomino pelvic mass was palpable. Abdominal ultrasonography revealed a normal-sized uterus with endometrial thickness of 7 mm and a 20 × 10 cm solid mass in pelvis and lower abdomen. Left ovary was not seen separately and there was minimal ascites. Patient underwent endometrial aspiration and it was reported as endometrioid adenocarcinoma (Grade 1). Patient underwent staging laparotomy which revealed a 20 × 10 cm solid left ovarian tumor. The right ovary was normal and there was minimal ascites which was sent for cytology. On exploration, intestines, liver and biliary tract, pancreas, omentum, and fallopian tubes were without lesions and the uterus was of normal size. The patient underwent total abdominal hysterectomy with bilateral salpingo-oophorectomy, infra-colic omentectomy, and pelvic lymphadenectomy and the specimen was submitted for histopathological examination.
Left ovary measured 21 × 14 × 10 cm and the cut section was homogenously fleshy with areas showing yellowish discoloration. Cut section of the uterus revealed a 4 × 3 cm exophytic fundal growth in the endometrial cavity infiltrating less than one-third of the myometrium. The right ovary, omentum, and bilateral fallopian tubes were grossly normal. On microscopic examination, left ovary showed features of a stromal tumor with minor sex cord elements []. The tumor comprised mainly of fibroma-thecoma component (more than 90%) with few aggregates of granulosa cells []. These granulosa cell aggregates were immunoreactive for inhibin [] and calretinin [].
Multiple sections from the endometrial growth showed features of a wel

[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 49-year-old man with no medical history presented to our hospital with a 2-week history of the left low back pain. He reported a unilateral lower lumbar and buttock pain below the L5 spinous process that increased while sitting, particularly on a chair without a back rest. His physical examination revealed normal neurological findings, and tenderness on posterior iliac spine was reported. Moreover, provocation tests (Patrick’s test, Gaenslen’s test, and the SIJ shear test) indicated positive results on the left side. There were no specific findings in plain radiography of the lumbar spine and pelvis or magnetic resonance imaging (MRI) of the lumbar spine. In addition, blood chemistry test findings were normal. From the physical examination, SIJ pain was strongly suspected. However, the SIJ block under fluoroscopic guidance was ineffective. We prescribed nonsteroidal anti-inflammatory drugs (NSAIDs) and observed the patient through follow-up. We performed MRI of the pelvis 2 weeks later. MRI of the left SIJ revealed low signal intensity on T-1 weighted images and high signal intensity on T-2 weighted images. It revealed a diffuse bone marrow edema in the left SIJ (). Computed tomography scan of the pelvis was then performed for differential diagnoses of the lesion, however, neither tumors lesions nor fractures were detected. The treatment course was local rest and continued NSAIDs administration, and the pain resolved within 3 months. However, 2 months later, he was referred to our hospital again with right low back pain. The physical findings and examination were similar to the initial consultation. MRI revealed a diffuse bone marrow edema at the right SIJ; the left SIJ bone marrow edema had disappeared (). The patient was administered the same treatment course of local rest and NSAIDs. After 5 months, his symptom disappeared, and the MRI revealed a disappearing bone marrow edema with normal findings (). During the 2 years of follow-up, there has been no recurrenc

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


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

[User]
RADIOLOGY NOTE:
We describe the case of a 93-year-old woman who came to the ED with two days of syncopal episodes, altered mental status, and chest pain. The patient had a past medical history of hypertension, renal cell carcinoma requiring left nephrectomy, thyroid cancer requiring thyroidectomy, and subsequent hypothyroidism. The patient was evaluated by the Internal Medicine team and was found to be very weak and confused with a heart rate (beats per minute) ranging from the 120s to 130s. She also had episodes of sinus arrest and elevated troponins. She was admitted to the medical intensive care unit (ICU) with symptomatic sinus node dysfunction and tachycardia-bradycardia syndrome.
Upon admission, an ultrasound-guided right internal jugular catheter was placed without any reported complications or difficulties. Cardiology was consulted and the patient was started on an isoproterenol drip with plans for pacemaker placement. During the procedure, the central line was noted to be pulsatile and crossing the midline. Immediately after pacemaker placement, the Vascular Surgery team was consulted for evaluation and management of iatrogenic intra-arterial central catheter placement.
Upon vascular evaluation, a chest X-ray (CXR) was reviewed (Figure ); and the central line was noted to have an unusual track with the tip projecting medially. To confirm the diagnosis of intra-arterial catheter placement, blood gases were obtained; and the line was evaluated for waveform and blood pressure. These studies showed clear arterial parameters confirming the presumed diagnosis. Ultrasound evaluation was inconclusive due to patient habitus. After discussing the risks and benefits of removing the line at the bedside versus in the operating room (OR), the patient was immediately taken to the OR.
The patient was placed under general anesthesia and intubated. The patient's position was similar to that used for a carotid endarterectomy with the head slightly extended and turned towards the left. The ca

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


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

[User]
RADIOLOGY NOTE:
A 66 year-old Japanese male underwent upper gastrointestinal endoscopy by his practitioner for complaints of dysphagia, which revealed an esophageal submucosal tumor. He was referred to the National Hospital Organization Mito Medical Center in 2006 for treatment. He did not complain of fever, weight loss, or night sweating. On admission, physical examination revealed no remarkable features; the liver, spleen, and superficial nodes were not palpable. His laboratory data showed no abnormalities except a 10-year history of abnormal glucose tolerance treated by his primary physician. No elevated tumor markers or autoimmune antibodies were observed. A barium esophagogram, CT, and upper GI endoscope showed an esophageal submucosal polypoid lesion at the cervical esophagus (). Its location close to the esophageal orifice and large size (4 × 2 cm) made an endoscopic resection technically difficult, and the patient was enrolled in the Department of Surgery. As the tumor was endoscopically diagnosed as benign leiomyoma or lipoma, we decided to perform a tumor resection because of the patient's complaints of dysphagia and because the cervical esophagus is relatively approachable compared with the thoracic esophagus, even without pathological diagnosis. The tumor was removed through a cervical esophagotomy under a cervical collar incision.
The tumor macroscopically showed a submucosal polypoid appearance (). Resected tissue was fixed in 20% formalin, embedded in paraffin, and routinely stained with hematoxylin and eosin, followed by immunohistochemical analyses with monoclonal antibodies, as summarized in (supplement). The tumor was composed of multiple, vague nodules (,) that contained abortive CD10+Ki67+ germinal centers surrounded by a regular proliferation of CD3-CD20+CD79a+bcl2+ small lymphoid cells without immunoblastic large cells (). These areas corresponded to the mantle zone, with no definite formation of the marginal zone observed. No lymphoepithelial lesions (intrae

[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 of north Indian origin, reported to the OPD of GMC, Patiala, on 2 April 2013 with the complaint of postmenopausal bleeding since six months. Bleeding was off and on and irregular in nature. She also had lower abdominal pain, which was mild in intensity, non-radiating and having no variability with change of posture or respiration. There was also a history of weight loss and decreased appetite over the last two months. There were no associated bowel or bladder complaints. There was no history of any long-term illness or any chronic disease or any prior hospitalization.
Patient was moderately built. Vitals were stable with blood pressure 136/88mm Hg, pulse rate 76/min and respiratory rate 18/min; no pallor was present.
On per abdominal examination, a soft to firm midline mass was palpable, which was about 20 weeks as compared to a pregnant uterus and had smooth surface. The mass was mobile from side to side, with no tenderness or any changes in the overlying skin.
On per vaginal examination, the cervix was directed backward, uterus was anteverted, around 20 weeks size and mobile, B/L fornices were clear, and no tenderness was observed.
Patient had already undergone an endometrial biopsy and cervical biopsy on 8 March 2013 at a private nursing home, which showed malignant mesenchymal lesion and features suggestive of chronic cervicitis. On computed tomography dated 22 March 2013, there was a large, well-defined heterogeneous enhancing mass of approximately 14 × 12 cm size seen arising from uterus with thinned out peripheral rim of normal myometrial tissue with possible infiltration into myometrial wall anteriorly with few nodular calcifications seen in the peripheral and central regions. Both the ovaries were normal looking. The pelvic fat planes were well maintained and appeared normal. Muscular and bony walls had normal outline. There was no lymphadenopathy.
Probable diagnosis of endometrial growth was made and the patient was advised surgery. Al

[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 20-year-old female patient with hemoglobin-SS sickle cell disease, osteonecrosis of the right hip with chronic right hip pain, and asthma presented complaining of pain in both thighs for 5 days. The pain began after ice-skating but she denied any direct trauma to her limbs. On presentation, she was febrile and tachycardic, with leukocyte count of 25.3 × 109/L and hemoglobin of 7.0 g/dL. There was no tenderness to palpation of the hips bilaterally and no tenderness to palpation of the joints, but an ill-defined swelling to the right anterior thigh was noted which the patient reported was chronic.
An initial diagnosis of sickle cell vasoocclusive painful crisis with systemic inflammatory response syndrome was made, and sepsis work-up was done. She was started on analgesics and intravenous fluids and also received a simple blood transfusion. On hospital day (HD) 2, she was noted to have persistent fever and leukocytosis and so was started on intravenous Levofloxacin empirically. At that time, her left thigh pain appeared to be worsening, with a new area of swelling and warmth but no tenderness. X-rays of the left hip and left thigh were done, which showed heterogeneous appearance of the proximal left femoral shaft, which was thought to be likely secondary to sickle cell osteodystrophy, infarct, or infection.
The patient's blood cultures obtained on admission had shown no growth and her urine culture was negative. Her chest X-ray showed no evidence of pneumonia. However, clinically, she did not appear to be improving, with persistent pyrexia and leukocytosis. Her C-reactive protein levels were elevated at 7.8 mg/dL, for which her dose of Levofloxacin was increased and Vancomycin was added. Due to increasing suspicion for osteomyelitis, an MRI of the left lower extremity was done. It demonstrated 2 areas of loculated fluid collection: the first was in the proximal left thigh anteriorly, in the quadriceps

[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 68-year-old male underwent pelvic exenteration, right lower quadrant ileal conduit creation, and left lower quadrant colostomy for the treatment of rectal carcinoma. Four years after these surgical procedures, the patient presented with vague lower abdominal and perineal pain and decreased ileal conduit output for four days. In addition, he related that he was experiencing persistent drainage of cloudy, yellow fluid from the perineum for four weeks.
On physical examination, the patient was found to have a wet perineum with a visible draining sinus in the ventral aspect of the anal scar.
Renal ultrasound was performed and revealed normal kidneys with no evidence of hydronephrosis. A nuclear medicine bone scan was negative for metastatic disease, but it was evident that the ileal conduit was leaking urine into the deep pelvis (). A retrograde ileal conduit examination, with water soluble contrast, revealed contrast flowed promptly from an open end of the conduit intoa pelvic fluid collection. Neither ureter could be visualized as the contrast preferentially flowed into the pelvis (). The findings were considered to be consistent with a proximal ileal conduit dehiscence and extravasation of contrast into a pelvic cavity.
Urology consulted interventional radiology to discuss placement of bilateral nephrostomy catheters, followed by antegrade ureteric stents, in an attempt to divert urine away from the conduit dehiscence.
In the absence of hydronephrosis, nephrostomy insertion was deemed to be too technically difficult and would require multiple needle punctures of the kidneys while attempting to gain access to the collecting system. In addition, the collapsed collecting systems would present a very confined space in which to attempt to maneuver needles, guide wires, and catheters. Because of the probability of procedure technical failure, and heightened concerns about procedural complications, another treatment option was felt to be necessary. It was decided that a

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


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

[User]
RADIOLOGY NOTE:
A 23-year-old male was taken to a general hospital after the car he was travelling in collided with a tree at fifty miles per hour. CT demonstrated free fluid in the pelvis, likely from a mesenteric bleed, but no free air and no solid organ damage (). He was transferred to a major trauma centre where he was managed conservatively and discharged the next day.
Five days later he represented to a third hospital with severe abdominal pain. A repeat CT showed an increase in the volume of pelvic free fluid and he was immediately taken to theatre for exploratory laparotomy. This revealed a mid-small bowel point of obstruction caused by adhesion to a mesenteric haematoma. Extensive adhesions were evident (the patient had an appendicectomy age nine), but there was no prior history of symptoms of obstruction. Proximal adhesiolysis was performed to allow mobilisation of bowel but this was limited by extensive peritoneal contamination and patient stability; distal and pelvic adhesions therefore remained.
Although there was no full thickness or serosal injuries to the small bowel, it was completely detached from the mesentery and showed signs of ischaemia. A 20 cm section of small bowel was resected, with a side-by-side anastomosis fashioned. Histology from the resected section of small bowel showed only inflammatory and fibrotic changes compatible with trauma.
After four days in ITU, a repeat CT scan was performed as NG aspirate volumes and inflammatory markers remained high. This showed a small left iliac fossa collection with no clear features of perforation. There was small bowel dilatation with a change of calibre in the region of the anastomosis, raising the possibility of obstruction (Figures and ). This most likely represented a paralytic ileus and it resolved without further intervention. The patient was discharged twelve days after surgery.
However, he represented later that day with a leaking abdominal surgical wound. The fluid had the appearance of undigested food, r

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


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

[User]
RADIOLOGY NOTE:
A 74-year-old man underwent a computed tomographic (CT) scan to determine the status of cervical lymph node involvement and discrete swelling of the right parotid gland. One year before, the patient had undergone partial resection of soft palate for mucoepidermoid carcinoma. Neck lymph node involvement was negative, but 32 x 24 mm well-circumscribed mass was incidentally detected in the deep lobe of the right parotid gland []. MRI of oropharyngeal and neck region was performed. The MR images showed a well-circumscribed mass in the deep lobe of the right parotid gland with extension to para pharyngeal space [].
The mass showed low-signal intensity to parotid gland parenchyma on T1- and T2-weighted images and homogeneous enhancement after intravenous gadolinium-based contrast medium administration. On the basis of these findings, the lesion was diagnosed as a deep lobe parotid tumour. FNAC with screening performance was applied immediately prior to operative treatment. A parotidectomy was performed with mandibular osteotomy, selectively excising a portion of a deep lobe of the right parotid gland []. Postoperatively, an operative specimen with the tumour was examined macroscopically and histologically. Tumour was 32 x 24 mm in size, was resilient, soft, and surrounded by a capsule. It did not adhere to the surrounding tissues. The surface of the tumour was soft, homogeneous, and yellowish brown []. Microscopic examination showed large cells separated by exceedingly obscure stroma []. The cytoplasm was bright eosinophilic with eosinophilic granules. The cells contained relatively small, round, vesicular nuclei with no or more nucleoli. Mitotic figures were absent. There was a scattering of ducts, suggesting remnants of a duct system. The final histological diagnosis was an oncocytoma. No capsule is discernible in microscopic features. PTAH stain was done to confirm that the eosinophilic granules were mitochondria.
Postoperative period was uneventful. The patient was tr

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


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

[User]
RADIOLOGY NOTE:
A 22-year-old man was being referred to our hospital due to hemoptysis. He experienced hemoptysis 16 months ago. The non-contrast outside chest computed tomography (CT) missed the anomaly thereafter. Otherwise, his past medical history and family history were not remarkable. Physical and laboratory findings were within normal limits. A chest radiograph demonstrated no active lung lesions. Chest CT with contrast enhancement showed a ground-glass attenuation and consolidation in the right lower lobe posterior basal segment and a large anomalous artery from the distal descending thoracic aorta supplying basal segment of right lower lobe (). The diameter of the feeding artery was about 10 mm. Bronchoscopy revealed that the major bronchial branches were normal and at the right 2nd carina there were bleeding evidences and woozing on saline washing (). Angiography showed about 10 mm diameter feeding artery to basal segment of right lower lobe, enlarged arteriovenous vessels and draining vein. On diagnosis of anomalous systemic arterial supply to the basal segments of right lower lobe from descending aorta without sequestration, the therapeutic embolization was performed with Amplatzer Vascular Plug (two 12 mm; AGA Medical, Golden Valley, MN, USA) ().
After the embolization, the patient suffered from fever. At 2 days after embolization, chest X-ray revealed hazy and nodular opacities at right lower lobe (RLL). With a suspected diagnosis of post-embolization syndrome with pneumonia, the patient was prescribed to empirical antibiotics. Although the fever subsided 5 days later, his chest X-ray showed pleural effusion in the right lung (). A diagnostic thoracentesis revealed amber colored fluids, which was found to be neutrophil-predominant exudates. At 14 days after the antibiotics application, he was discharged when symptoms and conditions had improved, but pleural effusion sustained. Twenty-two days later, his chest CT revealed vascular plugs, anomalous systemic artery from

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


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

[User]
RADIOLOGY NOTE:
The present case report is about a 34-year-old gentleman who presented with a painful swelling behind the angle of left mandible of 5 months duration. He also complained of change in character of voice, dysphagia and weakness of left upper limb for 3 months prior to admission.
On neurologic examination, he had IX, X and XI cranial nerve palsy on the left side. There was a 3.5 cm × 3.0 cm bony hard swelling underneath the angle of left mandible leading to obliteration of post auricular groove. It was extremely tender. On examination of the oral cavity, the swelling was bulging into the tonsillar fossa and compressing the palatal arches.
Since, the mass was palpable externally, fine-needle aspiration was attempted pre-operatively (twice) and on both occasions, but it was found to be inconclusive.
The axial and reformatted sagittal computed tomography showed a large expansile and destructive bony lesion involving the foramen magnum on the left side from lower clivus up to the axis. There were calcifications seen within the tumor. Thin sclerotic rim was visible around most of the periphery of the lesion [Figure –]. The lesion had involved the lateral masses and part of anterior and posterior elements of upper 2 cervical vertebrae.
Magnetic resonance imaging showed a heterogenous mass (size approximately 5.3 cm × 6.2 cm × 5.5 cm) with strong post contrast enhancement. The lesion was displacing left internal carotid artery peripherally causing mild compression and had involved the left vertebral artery, the oblique part of V3 segment [Figure –].
With pre-operative impression of a high grade bony lesion, the patient was planned for surgical decompression of the mass through left sided far lateral approach. At surgery, near total excision of the tumor was achieved, deliberately leaving a thin rim of tumor tissue attached to posterior pharyngeal wall to prevent opening the oral cavity [Figure and

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


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

[User]
RADIOLOGY NOTE:
A 58-year-old woman presented with dyspnea on exertion of 2 months’ duration and 2 episodes of syncope on January 20, 2020. Transthoracic echocardiography showed a well-defined heterogeneous, large, round mobile mass with attachments to the atrial side of the anterior mitral valve leaflet (26 × 20 mm), suggestive of an atypical myxoma (Fig. ). In addition, the patient had a left ventricular ejection fraction (LVEF) of 55%, severe mitral stenosis, severe mitral regurgitation, mild-to-moderate tricuspid regurgitation, and a pulmonary arterial systolic pressure (PASP) of 42 mm Hg. Coronary angiography revealed normal epicardial coronary arteries. Brain computed tomography (CT) and neurologic evaluations were unremarkable.
The patient was scheduled for surgical mass excision. On January 24, the LA mass (20 × 25 mm) was removed completely, and the mitral valve was replaced with a St Jude Medical prosthetic valve given the destruction of the anterior mitral valve leaflet and chordal involvement. The histopathological examination illustrated diffuse fibrosis in the mitral valve, as well as cellular pleomorphism and high mitotic activity in the removed cardiac tumor. The evaluation of the surgical margin was rendered impossible by the fragmentation of the specimen. Postoperative echocardiography revealed that the prosthetic valve had good leaflet motion with an acceptable gradient. An LVEF of 45%, mild tricuspid regurgitation, and a PASP of 28 mm Hg were also reported. No residual mass was detected. The patient was discharged thereafter on February 3.
Seventy-nine days later, on April 22, 2020, the patient was readmitted with a 1-week history of dyspnea, palpitation, fever (body temperature = 38 °C), and a sore throat. The time in therapeutic range assessment revealed that the international normalized ratio was acceptable during the mentioned period. In the emergency department, transthoracic echocardiography demonstrated the fixation of the prosthetic mitral valve in 1 lea

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

[User]
RADIOLOGY NOTE:
The patient was an 11-year-old boy with no family history of optic neuropathy or dystonia. He presented with focal dystonia in the right upper limb at 3 years of age, and his disease progressed over 4 years to dystonia in both the upper and the lower limbs on his dominant right side. At 5 years of age, he was able to walk slowly without holding a handrail. However, at 7 years of age, he had severe dysarthria and was unable to walk without support owing to dystonia and spasticity. He had neither mental retardation (verbal IQ, 129; performance IQ, 97; full-scale IQ, 115 by the Weschler Intelligence Scale for Children) nor short stature. Ophthalmologic examination showed no remarkable findings indicative of optic neuropathy. Magnetic resonance imaging findings at 3 years of age showed high signal intensity lesions in bilateral putamina on fluid-attenuated inversion recovery images () and diffusion-weighted images (). With time, the high signal intensity lesions on diffusion-weighted images migrated from the putamina to the caudate nuclei (). The MRI findings obtained at 6 years of age showed that the high signal intensity lesions had spread to the bilateral caudate nuclei and the midbrain on fluid-attenuated inversion recovery images () and diffusion-weighted images (). On laboratory examination at 7 years of age, blood cell counts were normal, and the concentrations of lactate and pyruvate were not elevated in serum and cerebrospinal fluid. The serum concentrations of copper and ceruloplasmin were normal. In the serum Amino acid analysis, organic acid level in urine, and levels of lysosomal enzyme in white blood cells were found to be normal. Sequence analysis of the white blood cell mitochondrial DNA from this patient showed the presence of a homoplasmic G>A transition mutation at nucleotide position 14 459 in the reduced nicotinamide adenine dinucleotide dehydrogenase subunit 6 gene ().
The patient had been treated with coenzyme Q10 (2 mg/kg/d), l-carnitine (90 mg/k

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

[User]
RADIOLOGY NOTE:
An 18-year-old female presented to the Department of Plastic Surgery in surgical super specialty block. History revealed repeated administration of intramuscular injections at bilateral gluteal regions. Clinical examination showed hard mass in bilateral gluteal area. Ultrasound scan of the gluteal areas showed hard lesions with pockets of necrosis within. Biopsy revealed calcified tissue. Patient was further evaluated by dermatologists for connective tissue disorders and muscular dystrophies. Laboratory investigations for rheumatoid arthritis, systemic lupus erythematousus (SLE) were done. Patient's clinical examination, blood investigations for connective tissue disorders and muscular dystrophies were negative.
The lady was posted for bilateral gluteal mass excision and flap cover procedure under anesthesia. Patient's preanesthesia check-up was done a day prior to surgery. Lady gave a history of getting intramuscular injections for fever and body ache from adolescence. Lady weighed 40 kilos and height of 150 cm. General physical examination showed thickened skin and small discrete bony masses beneath the skin in areas like face, elbows, knees and surgical site. Airway examination-mouth opening vertically allowed three fingers. Angles of the mouth were inelastic and allowed three fingers with difficulty. Jaw and neck were normal with a normal range of neck movements. Systemic examination was normal. There was restriction in the movement of the hip joint due to hard mass over gluteals. Fungal infection was present on the back till lumbar region. Anesthesia technique planned was general anesthesia with the endotracheal tube as position needed for surgery was the prone position.
Nil per oral guidelines were advised, and a written informed consent was taken from the patient Tablet Ranitidine 150 mg and Tablet Alpralozam 0.5 mg was advised for the night. On the day of surgery intravenous line was secured in preoperative holdup area and intravenous premedication of inject

[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:
Eleven years ago, when our patient was a 33-year-old unmarried nulligravida, she developed CCC of the ovary for the first time. At that time, her menstrual cycle was regular and 30 days long, with dysmenorrhea, manifesting as lower abdominal and lumbar pain, persisting for 5–7 days. There was no family or medical history of note. She had visited a local clinic with the chief complaint of lumbar pain, where a right ovarian tumor 8 cm in size that included solid internal components, was identified, and she was referred to the University of Tsukuba Hospital. Transvaginal ultrasound had revealed a right adnexal mass with solid components, 68 mm × 53 mm in size, and an intramural uterine fibroid 23 mm × 27 mm, with no hypertrophy of the endometrium, which measured 2.1 mm. Blood counts and blood biochemistry test results revealed no abnormalities. Her serum CA19-9 level was 45.9 U/ml, CA125 was 22 U/ml, and CEA level was 1.3 ng/ml. Abdominal computed tomography (CT) and magnetic resonance imaging (MRI) revealed an 80-mm unilocular cystic mass in the right ovary with a papillary protrusion of longest diameter 45 mm. The left ovary was not enlarged, and there was no obvious peritoneal dissemination or enlarged lymph nodes. Surgery, comprising right adnexectomy, left ovarian biopsy, partial omentectomy and uterine fibroid removal, was performed. The right ovary was enlarged to 8 cm in size, and it was removed without intraoperative rupture and with its capsule intact. The left ovary was not enlarged, but was seen to have a small endometrial cyst, which was resected. The absence of peritoneal dissemination and enlarged lymph nodes was confirmed during surgery. The pathological diagnosis was CCC localized to the right ovary and endometriosis was observed in the left ovary, with ascites cytology Class III. The cytology was composed of clusters that include atypical cells having somewhat nuclear enlargement, and

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

[User]
RADIOLOGY NOTE:
A 17-year-old female patient was presented to our institute on April 2016 complaining of occasional back pain and spinal deformity. On examination, the patient had no limitation of physical activity, occasional pain, no neurological deficits with mild thoracic scoliosis. Reassurance of the patient and her family was done with conservative treatment. Six months later, the patient presented back with worse pain, numbness of both lower limbs, progressive deformity, and shortness of breath. MRI was ordered for her, and revealed a giant extra pulmonary mass shifting the mediastinum to the opposite side, extending opposite T6 to the lower border of T10 with intra spinal extension through the left neural foramina compressing the spinal cord. Full-length spinal PA and lateral X-rays showed left thoracic scoliotic curve extending from T5 to T9 with apex at T7 and measuring about 50° with Cobb method with thoracic kyphosis of 65° (–).
Percutaneous US-guided needle biopsy was done, and the histopathological report confirmed the diagnosis of ganglioneuroma. One-stage posterior instrumented correction of scoliosis, spinal cord decompression, and excision of the whole mass through posterior approach was planned for the patient after a multidisciplinary team approval in our institute comprising spine surgeon, anesthesiologist, and cardiothoracic surgeon.
The patient was operated under general anesthesia in prone position over a radiolucent table. Standard posterior approach to the thoracic spine was done exposing the posterior elements subperiosteally. Then pedicle screws were inserted using the free hand technique from T3 to T11 and their position was checked by intra operative radiograph. A rod was connected to the screws on the right side and then wide microscopic decompression of the spinal canal was done exposing the mass and the spinal cord. Careful dissection of the mass from the spinal cord was done and the nerve root connecting the mass to the cord was identified and liga

[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:
History
A 27-year-old Caucasian male presented to the emergency department with an open right tibia and fibula shaft fractures following a high-speed motorcycle crash. The patient was helmeted at the time of the crash and there was no reported loss of consciousness. He reported isolated right lower extremity pain without neurologic complaints.
Exam and diagnostics
This was an isolated injury with no clinical or radiographic evidence of intracranial, -thoracic, -abdominal, or -pelvic injury. A FAST exam (Focused Assessment with Sonography in Trauma) was performed prior to our orthopaedic exam, which demonstrated no signs of hemorrhage.
Inspection of the right lower extremity revealed two large wounds to the anterolateral and anteromedial tibial diaphysis. The anterolateral and anteromedial wounds measured approximately 20 cm and 12 cm in length, respectively. Both wounds exhibited gross contamination with road debris as well as exposed muscle and fracture fragments (Figure ). There was no clinical evidence of compartment syndrome. There were no sensory or motor deficits involving the superficial peroneal, deep peroneal, or tibial nerves. A strong dorsalis pedis pulse was palpable, however the posterior tibial pulse was unidentifiable on palpation or Doppler ultrasound. A computed tomography (CT) angiogram was obtained which demonstrated vascular stenosis of the posterior tibial artery at the level of the fracture. All hematologic and metabolic labs were within normal ranges.
Time from the emergency department to the initial operative encounter
Dual antibiotic prophylaxis, consisting of cefazolin and gentamycin, was administered promptly upon arrival to the emergency department. Antibiotic administration was estimated to be within three hours from the time of injury. A brief bedside irrigation with 3 L of sterile saline was performed and the wounds were dressed with moist gauze. The patient was then provisionally stabilized with a moldable long leg fiberglass splint a

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


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

[User]
RADIOLOGY NOTE:
A previously healthy 35-year-old African American male presented with a one-month history of worsening lower back and bilateral lower extremity pain, intermittent night sweats, and 32 kg unintentional weight loss over the course of a year. He did not have saddle anesthesia or urinary or fecal incontinence. He was initially seen in a primary care clinic and was diagnosed with sciatica. As symptoms continued to worsen, he underwent a computed tomography (CT) scan of the lumbar scan as an outpatient that was concerning osseous spinal metastasis. He was started on prednisone 10 mg daily and was referred to the oncology clinic at our center. Prednisone gave him minimal symptomatic relief. While waiting to be seen in the oncology clinic, the patient had an episode of leg weakness with near-fall prompting him to present to the emergency department of our hospital and was admitted for further evaluation. His vital signs were stable. He had no palpable cervical, supraclavicular, axillary, or inguinal lymph nodes. Neurological exam was normal with intact strength and sensation in both lower extremities.
His complete blood count and serum electrolytes were normal including a normal serum calcium level at 8.1 mg/dL. He tested negative for human immunodeficiency virus 1 and 2 antibodies. Magnetic resonance imaging (MRI) of the cervical, thoracic, and lumbar spine showed several enhancing lesions in T11, T12, L3, L4 vertebral bodies, right sacrum, and ilium that were concerning metastatic disease. There was effacement of the right lateral recess and right neural foramen at the L3-L4 and effacement of the left lateral recess and left neural foramen at the L4-L5 due to tumor retropulsion (Figures –). In addition, a small epidural tumor was noted at the T5 vertebral level without significant spinal canal stenosis or cord compression. Imaging was also concerning osseous metastasis involving the sternum and multiple ribs. Incidentally, narrowing of the neural foramen at

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


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

[User]
RADIOLOGY NOTE:
A 1-month-old male child was brought with a translucent swelling at the back since birth. On magnetic resonance imaging (MRI), there was evidence of a sacral spinal dysraphism with cerebrospinal fluid outpouching suggestive of a sacral myelomeningocele with tethering noted at the lower end of the cord (). The child underwent repair of the sacral myelomeningocele with sac excision and detethering of cord at the age of 1 month. Closure of the defect was done with advancement flaps using multiple Z plasty technique. Postoperatively, child developed pyogenic meningitis and urinary tract infection which was treated with intravenous antibiotics. The child recovered completely and had normal developmental milestones and could walk normally and was on regular follow-up for 1 year.
The child now presented at the age of 4 years with complaints of fever since 7 days, weakness of both lower limbs with difficulty in walking and urinary disturbance for 4 days. On examination, tone was decreased in both lower limbs with decreased deep tendon reflexes. On evaluation for fever, the child was diagnosed to have urinary tract infection and was started with appropriate antibiotics. On ultrasonogram, child had a significant postvoid residual urine volume of 73 mL. On further evaluation with an MRI, bulbous dilatation of the lower end of spinal cord was present with 3 well defined peripherally enhancing septated cystic lesions at L3–5 levels. Lower end of the cord could not be identified separately from the upper 2 cystic lesions, which thus appeared to be intramedullary. The intramedullary component showed greater peripheral enhancement indicating a thicker capsule with greater adhesions as per the senior author. There was a syrinx from D6–9 levels (). In view of fever and short duration of symptoms, we considered the possibilities of an abscess or an infected dermoid/epidermoid cyst.
The patient underwent L3–5 suspension laminoplasty and excision of intradural lesion. The cystic lesions

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


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

[User]
RADIOLOGY NOTE:
Our patient is a 57-year-old Caucasian postmenopausal female who presented with dyspnea, shortness of breath, and fatigue. Echocardiography was performed that showed a mass in the left atrium which was presumably a myxoma or a thrombus. The patient was then transferred to a more specialized hospital in the capital city. After transportation, the patient was admitted to the hospital with the same symptoms of shortness of breath and fatigue. Echocardiography confirmed the presence of a mass in the left atrium (). ECG did not reveal any abnormalities. The patient's condition started to deteriorate. Hemoptysis and nasal bleeding were present. The patient's extremities were cold with a capillary refill of >3 sec, and the jugular veins were distended. The patient was sitting in bed because of shortness of breath. A diagnosis of bilateral pneumonia was made. Vital signs at that moment were heart rate, 125 beats per minute without any signs of arrhythmia; blood pressure, 120/80 mmHg; respiratory rate, 32–28 BMP; and SPO2, 93–94% on an O2 cannula of 15 L/min; and bilateral crackles were noted on chest auscultation. The patient's condition started to deteriorate quickly, and it was decided to intubate the patient and start mechanical ventilation because of progressive and rapid respiratory distress that involved extra muscle groups for respiration. Vital signs before intubation and mechanical ventilation were respiratory rate 44 BMP and SPO2, 86–87%. Before intubation echocardiography was performed again, it showed a mass causing blood flow obstruction at the level of the mitral valve, which resulted in blood stasis in the pulmonary system and led to pulmonary edema (mean pressure gradient across the mitral valve, 27 mmHg). It was decided to operate immediately and remove the tumor as fast as possible because cardiogenic shock had developed. Additionally, the patient had a previous mitral valve replacement because of mitral regurgitation and a mechanical valve and tricuspid v

[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.