[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 newborn male child, less than one day old, was found to be leaking clear fluid from the skull one hour after birth whilst the mother was holding the child. The child was born at forty-one weeks through a normal vaginal delivery with forceps assistance and no immediate complications. Prenatal screening was unremarkable. The mother was from an indigenous background and in good health and there was no family history of any other similar illnesses. She denied smoking and alcohol use during pregnancy. At birth, no issue with the skull was noted. On further inspection of the child, after the mother raised concerns about the clear fluid leaking from the skull, a 1.5 cm circular defect was identified in the area of the posterior fontanelle with macerated skin edges and underlying membranes and evidence of clear fluid flowing from it. The child had normal haemodynamic parameters throughout and was otherwise examined normally. Further testing of the fluid for beta-trace protein was positive for cerebrospinal fluid (CSF). The neurosurgery team at the tertiary referral centre was contacted at this stage for a suspected encephalomeningocele and the child was transferred there for further management. Further examination at this stage showed a child who was otherwise well, feeding normally, and with normal system review.
Further imaging with computed tomography (CT) scan of the head, magnetic resonance imaging (MRI) of the brain, magnetic resonance angiography (MRA), and magnetic resonance venography (MRV) identified a likely encephalomeningocele (Figures -). The defect was arising from the posterior fontanelle. Characterisation of the surrounding vasculature showed a persistent fetal vein and possibly an associated vein within the defect. An MRI spine to identify any associated NTD was unremarkable.
The child was booked in for emergent repair of the encephalocele. During the operation, a vertical incision with an elliptical extension around the defect was marked. Careful dissec

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


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

[User]
RADIOLOGY NOTE:
A 69-year-old male patient presented at our clinic complaining of dysphagia from eating and multiple cutaneous nodules.
One year earlier, the patient underwent remnant gastrectomy for gastric stump cancer. Postoperatively, due to the patient’s resistance to chemotherapy, he did not return to the hospital for postoperative adjuvant chemotherapy until 3 mo after the surgery. During the follow-up visit, the patient developed dysphagia from eating and also complained of some painless, red, skin nodules approximately 0.5-1.5 cm in diameter on his forehead, back, neck, and arms. Thus, the patient was readmitted to our hospital for a work up for his dysphagia and multiple cutaneous nodules. We consulted with our dermatologist, who suggested a re-biopsy of the cutaneous nodules, despite the negative pathological results for the subcutaneous nodule, when the patient had a remnant gastrectomy for his recurrent gastric cancer. Based on the medical history as well as pathological findings from the immunostaining study, the cutaneous malignancy was further confirmed to be of gastric origin.
The patient was initially admitted to our department for laparoscopic-assisted distal gastrectomy with D2 lymphadenectomy to surgically manage antral adenocarcinoma 3 years earlier, a pathological stage of pT4aN3bM0 for his antral ulcerated infiltrating gastric cancer with poorly differentiated tubular adenocarcinoma penetrating the serosal layer and invading the nerve (Figure ), and six cycles of postoperative adjuvant chemotherapy (fluorouracil, folic acid, and oxaliplatin). Additionally, the patient had type 2 diabetes and pneumoconiosis for many years.
He was admitted again 1 year ago for the treatment of gastric stump cancer. Following normal preoperative examinations, the patient underwent remnant gastrectomy, during which a single small subcutaneous nodule in the midline of his abdomen was considered suspicious and removed for a histopathological exam to diagnose the nature of the nodu

[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 Saudi Arabian girl weighing 520 g was born at 25 weeks gestational age to a 35-year-old, gravida 4, para 3 mother. There was no family or medical history of a thrombophilic disorder. The infant was a vaginal delivery with Apgar scores of 3 at 1 minute and 8 at 5 minutes. The birth weight was appropriate for gestational age with no dysmorphic features. The infant was immediately intubated, received surfactant, and was mechanically ventilated. The initial chest X-ray was compatible with respiratory distress syndrome. Shortly after birth, the baby developed hypotension. Umbilical venous and arterial lines were inserted, and a dopamine drip was started at 10 mcg/kg/minute with subsequent stability. A partial sepsis workup was performed, and the baby was started on ampicillin and gentamicin. Hyperglycemia on day 2 was managed with an insulin infusion. Cerebral ultrasound on day 3 of life was normal. The umbilical venous and arterial lines were removed on day 7 of life.
On day 14, the baby developed acute renal failure secondary to sepsis with poor urine output, hypotension, metabolic acidosis, hyperkalemia, and a raised creatinine. Numerous attempts were made to insert a peripheral arterial line for frequent blood sampling and blood pressure monitoring without success. Due to the severity of illness and need for arterial access, a decision was made to insert a right brachial artery catheter, but after 8 hours the middle, ring, and index fingers of the right hand were noted to be cold, and cyanosed, and the arterial line was immediately removed (). The hand was elevated, and warm compresses were applied to the contralateral limb. Ischemic changes soon became evident and 4 hours later progressed to involve the distal part of the fingers which started showing signs of probable early necrosis (). The international normalized ratio (INR) and partial thromboplastin time were normal. A complete prothrombotic screen was not performed because the event was not spontaneous, ther

[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 informed consent was provided by the patient, and ethical approval was warranted by the First People's Hospital of Huaihua.
A 49-year-old man presented with a 5-month history of back pain who was diagnosed with fourth thoracic vertebral body fracture caused by tumor cells based on pathology results. The tumor cells in the fourth thoracic vertebral body originated from hepatocellular carcinoma. The preoperative thoracic magnetic resonance imaging (MRI) showed a minor intraspinal space-occupying lesion in the fourth thoracic vertebra canal and found pathological fractures of the fourth vertebrae (). Back pain as the only clinical symptom without any weakness, numbness, or other symptoms of spinal cord injury in both lower extremities was reported to the physician. And then, he accepted the percutaneous vertebroplasty (PVP) plus interstitial implantation of 125I particles (10 particles) at a local county hospital (). Back pain was relieved postoperatively, 3 days after he received PVP combined with interstitial implantation of 125I seeds. However, back pain, bilateral lower extremity weakness, and loss of bladder control reoccurred on day 3 after surgery and got worse. A general physical examination and central nervous system examination upon patient admission revealed abnormal findings. The majority of symptoms encompassed pain and hypoesthesia below the processus xiphoideus. The abdominal reflex, the crissum and cremasteric reflex, and the knee and ankle reflex could not be induced. No pathological reflection of Babinski's sign was induced. The strengths of the major muscle of both lower limbs were 3 grades and progressively decreased in the postoperative period. The opiate drugs were used to control pain originating from the surgical site. He was admitted to our hospital after 44 postoperative days because of serious back pain. The postoperative transverse computed tomography (CT) revealed bone cements and metallic implants in T4 without any bone cement leakage,

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


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

[User]
RADIOLOGY NOTE:
The patient was a 41-year-old female with past medical history of appendectomy and dysmenorrhea. She presented to the emergency department with nausea, severe vomiting, and acute pain in the lower abdomen. She reported having experienced asthenia and weight loss for one month. On clinical examination, abdominal distension and tenderness were discovered. Blood tests revealed leukocytosis with neutrophilia, and a contrast-enhanced abdominal computed tomography (CT) showed a 7 × 7 × 4 cm hyperenhanced mass in the cecum that caused complete bowel obstruction (). Also, a 5 × 3 × 3 cm right adnexal mass that compromised the ovary with intimate contact with the uterus was found (). Furthermore, the CT showed dilated loops in the small bowel (>4 cm), some of which had an enlarged wall thickness and presence of intraluminal fluid stasis ().
With these findings, particularly the observation of a mass through the CT scan, and due to the evident weight loss that the patient had undergone, neoplasia could not be ruled out. Surgery was decided, and at laparotomy, a volume of 200 ml of inflammatory fluid was found in the cavity. Most of the loops of the distal ileum were dilated, and a 7 × 7 × 3 cm cecum mass was discovered, which compromised the ileocecal valve and caused complete bowel obstruction. Surgical decision was straightforward, the cecum mass was completely resected, and a right hemicolectomy was executed. An ileocolic anastomosis was also performed during the procedure. Furthermore, the right adnexal mass that was previously identified through the CT scan (measuring 4 × 3 × 2 cm) was observed to be firmly attached to the ovary and the fimbriae and displayed a pale external capsule surrounded by a cystic component. Gynecology consultation was required, and due to the size of the mass and its characteristics, surgical removal of the right adnexal mass was performed. After completion, closure of the abdominal wall was performed, and the remainder of the procedure continue

[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 72-year-old man who had type 2 diabetes and was toothless visited our hospital because of anal pain that had started a week before. Swelling and redness were observed on his left-side buttock. Digital examination revealed swelling of the left-side anal canal. The blood examination test result showed elevated white blood cell count and C-reactive protein level. The computed tomography (CT) revealed a fluid cavity containing air in his left-side buttock and a high-density linear structure in the cavity (). Furthermore, we found several linear structures in the gastrointestinal tract (). We made a diagnosis of perianal abscess due to a foreign body and performed an emergency operation. We especially suspected a foreign body, particularly a fish bone, in the abscess cavity on the basis of the CT scan findings.
We performed an operation under lumbar anesthesia in the jackknife position. We cut on the swollen site on the left-side buttock and drained purulent discharge. We also found and extracted from the abscess cavity foreign bodies, including the fish bone, which were detected on the preoperative CT scan. The foreign body was 5 cm long (). We irrigated the abscess cavity with saline and placed an 8 mm Penrose drain. We did not close the wound to drain discharge after the surgery. The bacterial culture of the sample taken from the abscess cavity showed Escherichia coli. Accordingly, the patient received tazobactam/piperacillin until day 3 and clavulanic acid/amoxicillin between days 4 and 11. In the postoperative course, the amount of discharge from the drain decreased day by day. The findings from the buttocks and the white blood cell count and C-reactive protein level were improved. The drain was removed on day 6, and the patient was discharged from the hospital on day 8. After the operation, the patient remembered that he ate fish (barracuda) before the onset of his symptoms and ate food without his denture because it

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


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

[User]
RADIOLOGY NOTE:
The patient is a 25-year-old male with a past medical history of chronic sinusitis who was brought to our emergency department by EMS for new-onset seizures. The patient had been complaining of weakness, frontal headache, sinus pain, and nasal congestion for the last 5 days. He was seen at a different emergency department three days before and discharged with a diagnosis of viral syndrome. On presentation to our department the patient was postictal and complained of neck stiffness, headache, congestion, and fever; he was placed in isolation due to concern for meningitis. Initial vital signs included a temperature of 103°F, heart rate of 112 beats per minute, 20 breaths per minute, and blood pressure of 116/61 mmHg. On examination he was diaphoretic and lethargic but was fully oriented and able to answer questions. Cranial nerves two to twelve were intact with no focal neurologic deficits; the remainder of the physical examination was unremarkable except for bilateral frontal sinus tenderness to palpation.
Point-of-care glucose, complete blood count with differential, and basic metabolic panel were obtained, all within normal limits. Computed tomography (CT) of the head without contrast was ordered to evaluate for suspicion of intracranial pathology, revealing 1.3 cm attenuation behind the frontal bone and severe frontal sinusitis (). At this point both neurosurgery and otolaryngology specialists were consulted. MRI with and without contrast were subsequently ordered, showing a 2.1 cm epidural lesion in the left frontal region producing minimal mass effect on the left frontal lobe ().
While in the emergency department, the patient received Tylenol, empiric vancomycin, ceftriaxone, levetiracetam for primary seizure prevention, and dexamethasone to decrease intracranial edema. Over the next several hours the patient's fever decreased to 99°F and tachycardia resolved. However he still complained of frontal sinus pain and headache. The patient was admitted to the surgica

[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 26-year-old African American woman presented for an orthotopic heart transplantation following staged resection for a cardiac paraganglioma. The oncologic treatment included an en bloc resection of the heart, portions of the great vessels, several ribs and a portion of pectoralis major muscle (Fig ). The plastic surgery department evaluated the patient intraoperatively for chest wall reconstruction. It was noted that the sternum was divided in the midline and a large portion of the left sternal body, along with 4 ribs to the anterior axillary line, had been resected en bloc with the specimen. This resulted in a 10 × 10 cm2 chest wall defect (Fig ), and a decision was made to proceed with Strattice for chest wall reconstruction. Multiple interrupted 0 polydioxanone suture (PDS) sutures were placed in horizontal mattress fashion 270° around the defect through the ribs and intercostal musculature. The Strattice was trimmed to fit the chest wall defect and was parachuted underneath the rib edges to minimize contact between the bony edges and the heart. The Strattice was then serially secured in place, creating a tight construct to replace the missing segment of chest wall (Fig ). Bone reduction clamps were used to reduce and align the manubrium and residual body of the sternum. Rigid fixation was provided with a locking sternal plating system. The medial edge of the Strattice was then aligned with the contralateral sternum/ribs and this was secured with interrupted figure of eight 0 PDS sutures.
Muscle coverage for the implants was obtained by elevating the residual pectoralis muscle on the left and approximating this to a composite pectoralis myocutaneous flap that was elevated from the right chest. The patient did well postoperatively and was discharged home on postoperative day 16. A 9-month computed tomographic scan shows stable internal reconstruction and no fluid collection around the graft (Fig ). At a 14-month postoperative visit, her chest wall

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


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

[User]
RADIOLOGY NOTE:
The patient is a 74-year-old, left-handed man who was a retired upholsterer with just four years of schooling. He reported that he always used his left hand for everyday tasks including writing and doing his work. Family sinistrality could not be corroborated.
He reported that about one month and a half before his current hospitalization he began to experience loss of strength in his right leg associated with difficulty in walking. Additionally, he mentioned that he had no control over his right hand and when walking in the street that hand would touch other people without him being aware of it; apparently he would make hand or foot movements without being aware of what was happening and with no control over those actions. Similarly, he sometimes lost his right shoe with no direct knowledge of any movement. One month earlier, after a fall, he had been taken to a hospital.
There, the preoperative neurological examination reported headache, disorientation, incomprehensible speech, and right hemiparesis. Three days after admission to the hospital, neurosurgery was performed. Preoperative neuropsychological evaluation could not be conducted due to his neurological status and the limited time before surgery.
A preoperative MRI () revealed a lesion in the left hemisphere that involved the frontal and parietal lobes and had collapsed the ventricle. It was a hyperdense lesion with significant brain edema that suggested a space-occupying lesion. A brain tumor with a high level of malignancy that was interpreted as a probable glioblastoma multiforme was also found. The lesion was deforming the Sylvian fissure and affecting Brodmann areas 39 and 40, with an extension towards the temporal lobe.
The patient was taken to surgery to remove the tumor. A first subtotal resection (80%) of the tumor via craniostomy was performed. Two days after this surgery, neurological examination revealed Glasgow = 15, spontaneous ocular opening, isochoric pupils, photomotor and consensual reflexes

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


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

[User]
RADIOLOGY NOTE:
A 3-year-old boy presented with a large bosselated swelling over the cheek extending to the submandibular, submental, postauricular region and which was still further increasing in size (Figure ). A trucut® biopsy was suggestive of fibromatosis. Computerized tomogram (CT) scan revealed a large soft tissue mass infiltrating the massetter, parotid gland, floor mouth, submandibular gland, the lateral oro-nasopharyngeal wall and the pterygoid muscle. The horizontal ramus of mandible was eroded and the mass extended across the midline. Excision of the mass with segmental mandibulectomy was performed. Reconstruction with a free fibula was deferred for a later stage in view of the young age, large mass and concern of recurrent disease. Since the mucosal defect following excision was not large enough primary closure was performed. Histopathology confirmed juvenile fibromatosis and all cut margins of resection were free of tumour. The patient presented after 13 months with recurrent swelling over the cheek with significant difficulty in swallowing and constant dribbling of saliva due to inadequate mouth closure (Figure ). A CT scan revealed presence of a large recurrent mass in the floor of mouth, infiltrating the infratemporal fossa (ITF) and reaching up to the base of skull (Figure ). In view of the extensive recurrence low dose chemotherapy (weekly vinblastine, methotrexate and tamoxifen) was started. After completion of 12 weeks of chemotherapy, a partial response was achieved. Excision of the mass with ITF clearance was performed subsequently. A portion of tongue and its base along with the lateral oropharyngeal and the soft palate was also excised (Figure. ) The defect following resection was large and a free flap was not feasible as the external carotid artery was ligated at previous surgery. Reconstruction with a PMMC flap for providing mucosal cover and soft tissue bulk for defect was considered. In view of the large mucosal defect a large skin paddle was taken inco

[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 female patient presented with a locally advanced tumor of the proximal pancreatic body. The patient showed no signs of obstructive jaundice and did not require biliary stenting. Initially, her tumor was noted to involve the major visceral vessels, including the celiac artery, portal vein, and splenic artery and vein (). The tumor was deemed unresectable and the patient underwent extensive chemotherapy with multiple cycles of gemcitabine, Abraxane, 5-fluorouracil, Alloxantin, Avastin, and Xeloda. After showing a favorable response, she was referred for surgical re-evaluation. The post neoadjuvant chemotherapy CT scan () showed a poorly defined infiltrative pancreatic neck and body mass measuring ∼25 × 15 mm with ill-defined soft tissue encasing the proximal splenic artery, common hepatic artery (CHA), distal celiac axis, and superior mesenteric artery (SMA). The mass also partially encased the portal vein and superior mesenteric vein (SMV). There was no radiologic evidence of hepatic metastasis and there was mild pancreatic duct dilatation. Pre-treatment and post-treatment serum CA 19–9 levels were 46 and 9, respectively. The patient did not receive any additional studies to assess GDA flow or the need for preoperative coiling/embolization. The absolute need for resection of the celiac axis was not determined until the time of the operation. The patient's functional status, perioperative risk, and likelihood of response were weighed and she was determined to be a candidate for an attempt at a modified Appleby procedure. After being properly informed of her various treatment options, she elected to undergo the operation.
Exploration of the duodenum and pancreas revealed a firm mass in the body of the pancreas with a soft pancreatic neck. No gross evidence of metastatic disease was present. There was a benign appearing lesion in the superior aspect of liver segment II, which was excised in its entirety and confirmed to be benign. Cholecystectomy was perfo

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


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

[User]
RADIOLOGY NOTE:
A 70-year-old man had visited our hospital with a chief complaint of dyspnea in 2004, and at that time, a 3.9 × 3.6-cm tumor in the right hemithorax was detected The tumor was diagnosed as a pulmonary solitary fibrous tumor by transthoracic needle biopsy (Fig. a-c). However, the patient was lost to follow-up. In April 2011, he visited our hospital again with complaints of acute shortness of breath. At that time, a large amount of pleural effusion and a 17 × 15-cm huge mass were observed on the chest radiograph, and a transthoracic needle biopsy and thoracentesis were performed accordingly. The tumor was diagnosed again as a solitary fibrous tumor, and surgical resection of the tumor was recommended. However, the patient refused to undergo the operation. When he visited our hospital to undergo positron emission tomography/computed tomography (CT), loss of consciousness developed suddenly while a blood sample was taken in the fasting state. Thus, he was admitted to the emergency room, and his blood glucose level was 38 mg/dL on admission. An examination of his medical history showed that the medication for diabetes mellitus was started 4 years ago, and this medication was stopped 2 years ago. According to the most recent chest CT scan, the size of the solitary fibrous tumor in the right hemithorax had increased to 18.5 × 14.5 cm, and a large amount of pleural effusion was observed (Fig. a-b). After injecting 50 cm3 of 50% dextrose/water (D/W), his blood glucose level increased and consciousness recovered. To prevent the recurrence of hypoglycemia, 10% D/W was continuously injected, but hypoglycemia and loss of consciousness developed three more times over 3 days after admission to an inpatient ward. A hormone test was conducted to differentiate the cause of hypoglycemia. Although, no abnormal findings were observed and the tumor had enlarged and the blood glucose level decreased despite the patient’s history of diabetes, so

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


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

[User]
RADIOLOGY NOTE:
We present a primigravid, 33-year old European woman, who was admitted to the emergency department for obstetrics in her 34th week of pregnancy, due to a symptomatic but compensated anemia, which clinically has been manifesting in a 3-week history of fatigue, mild circulatory insufficiency and a hemoglobin level of 4.8 g/dL. The patient negated vaginal or rectal bleedings but mentioned a blackening of stool during the last three weeks, which she attributed to the intake of iron supplements. There were no abnormal findings considering the pregnancy. After transfusion of three packed red blood cells, only a marginal increase in hemoglobin level (5.9 g/dL) was recorded. Considering the symptoms and insufficient increase in hemoglobin levels, a gastrointestinal bleeding was assumed and gastrointestinal endoscopy was advised. Gastroscopy revealed a posterior wall-sided mobile conglomerate tumor in the corpus and antrum with an ulcerated and hypervascularized surface leading to severe hemorrhage. Proximal to the tumor, the posterior wall of the gastric corpus was impressed extraluminally. According to its endoscopic appearance, the tumorous mass was assumed as a highly suspicious finding with the suggestion of an ulcerated malignant gastric tumor or gastrointestinal stromal tumor (GIST) of the stomach. Biopsy or intervention measures were not performed due to the risk of further uncontrollable bleeding. The extent of the tumor was additionally determined by transabdominal ultrasound, which showed an 11 cm mostly cystic tumor mass presumably arising from the pancreatic tissue. At this point, the entity was still not clear. An interdisciplinary team of gynecologists, visceral surgeons and gastroenterologists evaluated these clinical findings with regard to the gestational age and decided to refrain from further diagnostics (magnetic resonance imaging (MRI)/computed tomography (CT)/biopsy/blood tests) and conservative therapy because of the urgent need of maternal treatment.

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


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

[User]
RADIOLOGY NOTE:
An 87-year-old woman was referred to our department for otalgia, yellowish discharge, itching, and hearing loss of the left ear recurring over the last three months. She reported intermittent fever, but neither tinnitus nor vertigo. She denied previous trauma or surgery in this region and was not using a hearing aid. Her past history included atrial fibrillation, diabetes mellitus, arterial hypertension, and glaucoma. Oral antibiotics and anti-inflammatory medications, prescribed elsewhere, were not effective.
Physical examination revealed a reddish, round, tender soft mass of the outer third of the inferior wall of the left EAC, discharging a yellowish fluid upon pressure; however, a concomitant ruptured tympanic membrane and otorrhea through this perforation were also found. No cranial nerve palsy was detected. Swelling of the left parotid region and bilateral cervical lymphadenopathy were also present. CT scan of the temporal bone showed a cystic lesion on the inferior cartilaginous part of the EAC but no temporal bone lysis; the middle ear appeared to contain fluid and swelling of the parotid gland and cervical lymph nodes bilaterally were also seen (). The audiogram revealed conductive hearing loss of the left ear. The patient was treated with intravenous cefuroxime. A specimen of the discharge was sent for bacteriological evaluation and turned out to be negative for bacteria.
The patient underwent excision of one cervical lymph node and fine needle aspiration (FNA) of the left parotid. Histopathological examination of the lymph node ruled out malignancy, being consistent with a granulomatous process; however blood tests and thorough immunological and rheumatological examination failed to confirm this hypothesis. The FNA examination was nondiagnostic as it showed normal salivary glands.
The EAC lesion was surgically excised under general anesthesia, utilizing a transmeatal approach. Macroscopically the resection specimen was a fusiform skin sample measuring 1.9

[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 31-year-old African man presented to our emergency unit with a four-hour history of penile swelling and voiding difficulty. He had earlier tried to suppress an erection before his routine morning religious rituals by kneading on his erect penis. He heard a popping sound with associated minimal pain and sudden detumescence. He noticed no bleeding per urethra but subsequently had difficulty with voiding and urinary frequency. On physical examination, he had a grossly swollen and deformed penis with deviation to the right side (Figure ). A diagnosis of penile fracture with probable associated urethral injury was made. Bedside urine analysis results were negative for blood and he was taken for penile ultrasound and sonourethrography about an hour after presentation to the emergency unit. This was performed using a high-frequency 7.5MHz transducer with our patient in a supine position and the penis supported with towels between the thighs. A generous amount of sonographic acoustic gel was applied on the dorsum of the penis and images were obtained both in longitudinal and transverse planes beginning at the glans and proceeding proximally to the root of the penis. This was performed initially without urethral distension. A 16Fr Foley catheter was then placed at the urethral meatus with its balloon inflated with 2mL of water at the fossa navicularis. Retrograde urethral distension using normal saline was achieved via the catheter and sonographic images were obtained as above. The penile ultrasound showed a tear of the TA covering the ventrolateral aspect of left CC with associated hematoma in the proximal third of the penile shaft, and the real-time sonourethrography additionally revealed an intact urethra (Figures and A,B). He also had retrograde urethrography performed, which also showed an intact urethra (Additional file 1). Three hours after presenting to the hospital he had penile surgery via a subcoronal circumferential degloving incision. A Foley urethral catheter

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


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

[User]
RADIOLOGY NOTE:
A 45-year-old Caucasian lady having a past medical history of obesity, type II diabetes and hypertension presented with bleeding per vagina, hematuria, low urine output, intermittent headache, ataxia, diplopia and blurring of vision. She also experienced a weight loss of 60 pounds over 1 year, shortness of breath on exertion and a dry cough. The patient was treated with multiple antibiotics for a suspected urinary tract infection (UTI). Following an abnormal Pap smear, her vaginal examination revealed a hard mass in the cervix extending to the left vaginal wall, left pelvic wall and inferiorly to the lower vagina and introitus, suspicious of a cervical primary. Cervical biopsy revealed multiple nests of markedly atypical squamous cells and an ulcer bed with numerous deep nests of atypical squamous cells amidst extensive necrosis consistent with invasive poorly differentiated squamous cell carcinoma. Immunohistochemical study showed the tumor cells to be P16-positive and the nests of the invasive tumor were highlighted by pancytokeratin immunostain.
Physical examination revealed a pale appearing lady with an ECOG performance status of 2. Neurological evaluation revealed complete restriction of abduction in the right eye indicating sixth cranial nerve palsy and gait ataxia. In addition, there was a 2 cm × 1.5 cm firm, palpable, ovoid mass on the right side of her scalp, which on biopsy showed metastatic poorly differentiated squamous cell carcinoma consistent with origin from the uterine cervix.
Laboratory analysis showed leukocytosis, a low hematocrit and acute renal failure with creatinine of 3.4 and UTI. She was given intravenous fluids, blood transfusion and antibiotics.
Subsequently, an MRI of the brain showed multiple intraaxial enhancing lesions involving the frontal lobes, cerebellar hemispheres, right occipital lobe in addition to an enhancing, expansile mass in the clivus with soft tissue component in the right cavernous sinus extending anteriorly into the s

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


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

[User]
RADIOLOGY NOTE:
We report on a case of a 16-year old male patient who was diagnosed with DF of the right upper thorax in 2011 (Fig. ). The primary approach consisted of partial tumor resection for functional preservation. Systemic therapy with MTX/VBL was started after completion of surgery in order to maintain tumor control. However, MTX-associated nausea and fatigue led to discontinuation of MTX after 6 months of treatment. Instead, sulfonylurea had been added to VBL, but again, nausea limited the applicability of this combination and treatment was provided as single agent sulfonylurea.
Two years after the initial resection, a symptomatic tumor recurrence was detected while receiving medical treatment. Local recurrence involved the right brachial plexus, which was incompletely resected for the purpose of function preservation.
Systemic therapy was reconvened with MTX and vinorelbine, which achieved symptomatic improvement of pain with disease stabilization as best response on MRI. However, the treatment was not sustainable because of grade 1 nausea and fatigue and led to treatment discontinuation after 4 months.
Within 4 months, the patient complained of recurrence of grade 1 tumor pain and the MRI showed gradual tumor growth. At this time, radiotherapy was not considered appropriate given the young age and the proximity to the plexus nerves, instead medical treatment was discussed with the patient. Re-challenge with chemotherapy was not preferred by the patient, and an individual approach to medical treatment was sought. Based on the hyperperfusion of the patient’s tumor and the promising results of sorafenib in DF, we implied future treatment with bevacizumab 15 mg/kg q3wks., given the excellent tolerability profile of this agent.
During the course of treatment, tumor pain disappeared and the patient experienced functional improvement. Initial radiological response was detected after 1 month, with a tumorshrinkage of 16 %. Treatment was continued for a total duration of 12 mont

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


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

[User]
RADIOLOGY NOTE:
A 45 year old female presented to our institution with a diffuse swelling of the left maxilla which caused a mild tumefaction of the left cheek and obliteration of the buccal vestibule, left cheek pain during chewing with auricular and temporal irradiation, and masticatory disorders. The patient reported the onset of symptoms about 3 weeks before, but the exact duration of the swelling is not known. However, the patient remembered that about 3 years ago she was complaining of pain in the molar region of left maxilla and she addressed to her dentist. Without X-ray examination it was decided for extraction of the 2nd molar which presented palatal ectopia, but without caries and no abnormal mobility. Personal or family records were not significant, but noteworthy is that she worked about 10 years as an industrial dyer.
Extraoral examination revealed a mild diffuse swelling of the left cheek, most obvious at the posterior side of the zygomatic region. It was painless and hard in consistency on palpation. Intraoral examination revealed a diffuse swelling extending from the maxillary left first premolar to the tuberosity and retromolar regions that obliterated the buccal vestibule (Fig. ). The overlying mucosa was stretched but intact. On palpation, at the level of maxillary alveolar process the swelling was hard and painless but became fluctuating and slightly tender in the retromolar region.
Orthopantomogram showed a radiolucent lesion involving the left maxillary tuberosity, alveolar process, and the maxillary sinus with erosion of lateral wall and floor of the sinus (Fig. ). On computed tomography scan it was noticed an expansile, radiolucent lesion of the left maxilla (about 4 cm in diameter) with scattered areas of calcification which completely obliterated the left maxillary sinus (Fig. ). The scan showed tumor extension and involvement of the alveolar process (behind the first premolar with buccal cortical thinning, erosion and invasion of the soft tissue from ret

[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 44-year-old woman with a six-month history of progressive hoarseness and an abnormal sensation in the throat was referred to the Nanjing Drum Tower Hospital (Nanjing, China). The patient had no history of smoking, coughing, dyspnea or dysphagia; however, it is worth noting that the patient was exposed to iron ore and coal dust for several years in the work place. In addition, the patient had a history of over five years of second-hand smoke inhalation.
Fiberoptic laryngoscopy revealed swelling of the left ventricular fold and laryngeal ventricle that extended backwards to the left aryepiglottic fold. The bilateral vocal cords appeared normal and there was no vocal cord paralysis (). The patient subsequently refused any further examinations. The laryngeal abnormal sensation gradually progressed, and after 18 months the patient underwent a second laryngoscopy, which revealed similar findings to the first without obvious progression (). Computed tomography (CT) revealed a mass involving the left ventricular fold and anterior commissure. The left pyriform sinus was not distinguished (). Neither physical examination or neck CT detected any tumescent lymph nodes in the neck, and the chest X-ray was normal.
The preoperative diagnosis that was deemed most likely was that of a laryngeal neoplasm with laryngeal amyloidosis. The subsequent frozen section biopsy of the lesion taken during laryngofissure revealed the nature of the neoplasm. As the patient refused to undergo an expanded total laryngectomy, which is indicated for a locally advanced laryngeal tumor (), local resection of the left ventricular fold, laryngeal ventricle and aryepiglottic fold was performed only (). The margin of the biopsied tissue surrounding the lesion was negative. Although there was no sign of lymphatic spreading, perineural invasion existed, therefore, it was suggested that radiotherapy be performed at one month post-surgery (). However, one month later and prior to this radiotherapy, regional

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


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

[User]
RADIOLOGY NOTE:
An 8-year-old thin built Indian boy belonging to lower socio-economic group presented to the orthopedic department with the chief complaints of pain in the left leg for the last 3 months. There was no fever at presentation. On examination there were three small and scantily draining sinuses in the proximal and middle third of his left leg. The ipsilateral inguinal lymph nodes were not significantly enlarged. There was history of high grade fever for a few days three months back with spontaneous acute onset pain and swelling around the upper left leg with inability to walk, which was managed by a local doctor with some medication that provided some symptomatic relief within a matter of a few days time. The three small non-healing wounds however persisted. After three months the patient attended our hospital for further treatment.
The child had no fever or palpable abscess on examination. Clinically, swelling was minimal in the affected site of the leg. Radiograph of the affected limb showed features of chronic osteomyelitis with a large diaphyseal sequestrum on the medial cortex of tibia with incomplete involucrum []. The total lymphocytic count was within normal limits and differential counts were unremarkable. Sedimentation rate was 38 mm per hour. Tuberculin test and fungal smears were negative. The patient could not afford to do magnetic resonance (MR) imaging or a computerized tomography (CT). Wound swab taken from the proximal draining sinus yielded methicillin sensitive Staphylococcus aureus (MSSA) sensitive to 3rd generation of cepahalosporin and aminoglycoside (Amikacin), which were started and continued for a period of six weeks. No surgery was performed; not even incision and drainage. The sinuses healed completely in 6 weeks time. Gradually, over a period of 8 months, the large tibial diaphyseal sequestrum got fully incorporated into the healthy diaphyseal bone indistinguishable from normal bony architecture [Figures and ]. The functional outcome also was

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


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

[User]
RADIOLOGY NOTE:
In October 2014, a 46-year-old White male presented to clinic with recent history of rapidly growing, painful swelling in left axilla. He was referred by his GP to Melanoma clinic in view that in February 2010 he had a wide local excision of malignant melanoma on his right upper back with 0.72mm Breslow thickness. Swelling in the axilla has been present for 3 months, and he first noticed it during game of tennis. On presentation the patient was systemically well and had no co-morbidities, no other past medical history and no family history of melanoma, however he reported occasional prolonged sun exposure during holidays and mild sun burns in the past. He is a non-smoker and alcohol consumption was mild.
On examination he had a 10 cm firm swelling under left axilla with no obvious surface skin changes. There was no other palpable lymphadenopathy.
An ultrasound and fine needle aspiration (FNA) of the mass, confirmed metastatic melanoma with a BRAF V600E mutation. He underwent further scanning to identify any other lesions. Results of brain MRI were normal and PET-CT showed a large FDG avid axillary mass () likely to represent a lymph node with no metabolically active primary lesion.
Given the size and location of the mass, it was not amenable for safe surgical resection without significant risk of morbidity. It was decided to commence systemic treatment with the BRAF inhibitor, Dabrafenib.
Four month following commencement of systemic therapy there was a significant reduction in size of the lesion that made it suitable and safe for surgical resection. Patient was scheduled on the elective list for axillary node clearance and was operated by Consultant Plastic surgeon, procedure was uncomplicated and patient was discharged home the following day. Specimen was sent to histopathology laboratory and subsequently been reported as no malignancy. This was a complete response to Dabrafenib. It was decided to continue with Dabrafenib to complete a full year of therapy

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


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

[User]
RADIOLOGY NOTE:
A 68-year-old male presented with chest pain similar to acute coronary syndrome. The patient had felt a substernal pain from a period of four days prior to examination, which had begun while carrying out farm work in a squatting position. The severity of the chest pain had fluctuated, and then the patient felt intolerable chest pain that lasted for two hours. An electrocardiogram showed normal sinus rhythm, and cardiac enzymes were normal. However, compared with another chest X-ray four months earlier (), a second chest X-ray revealed left diaphragmatic hernia with a markedly distended stomach and passive atelectasis of the left lower lung (). An abdomen computed tomography showed that the herniated stomach was significantly distended by ingested air due to severe pyloric compression. The diaphragmatic defect was approximately 5 cm in diameter ().
We performed an emergency operation because the patient suffered from continuing chest pain, which suggested a strangulation of the stomach. A left lateral thoracotomy was performed through the eighth intercostal space after intubation with a double-lumen endotracheal tube and insertion of a nasogastric tube for decompressing the stomach. We carefully inspected the stomach, which was entirely displaced into the thoracic cavity, including the greater omentum (), and we then reduced the stomach into the peritoneal cavity. A diaphragmatic defect was identified on the highest central tendon and had a round shape, half of which had a well-demarcated margin (). The diaphragm was thinned and unevenly rough owing to senile change. The remaining tissue of the fragile margin was completely excised () and was closed primarily using continuous running sutures and multiple interrupted sutures (). The patient was extubated before leaving the operating room. The chest X-rays before discharge showed complete reduction of the stomach and full re-expansion of the left lung (). The patient was uneventfully discharged and resumed a normal die

[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 case began with a 79-year-old female who called 911 from her home for transport to the emergency department (ED) for evaluation of abdominal pain in her left upper quadrant with radiation through to her back and left shoulder, which had been present for approximately three hours. The patient had a past medical history significant for hypertension and hypercholesterolemia for which she took lisinopril and rosuvastatin daily.
Upon arrival at the patient’s home, the emergency medical services (EMS) team reported that the patient initially appeared well with normal vital signs but then began to deteriorate. The patient’s blood pressure fell to 61/38 mmHg and she had a near syncopal episode prompting EMS to administer intravenous (IV) fluids and commence transport to the ED for further evaluation.
When the patient arrived to the ED she was awake and alert with mild distress from her pain but interacting appropriately. Her vital signs were blood pressure of 101/56 mmHg, pulse rate of 74 beats per minute and an oxygen saturation of 100% on room air. Her physical exam was positive for tenderness in the left upper quadrant of her abdomen, but it was soft with no guarding or rigidity. She showed no signs of focal neurologic deficit, jugular venous distension, heart murmurs or abnormal lung sounds. Her extremities had equal distal pulses with good capillary refill. Her medical history provided no identifiable explanation for her pain. The patient denied any history of trauma but reported she “did sneeze three times” just prior to the onset of her pain. Given the patient’s symptom of sudden onset abdominal pain with radiation to her back accompanied by hypotension, abdominal aortic aneurysm (AAA) was immediately considered. A bedside ultrasound was then performed but results were limited due to bowel gas present. Initial interpretation of her exam showed no obvious AAA, no definite free fluid and no evidence of pericardial tamponade. In the meantime vascular and general sur

[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 15-year-old female presented with complaints of pain in the right lower limb and back for 1 month. Ultrasound revealed a retroperitoneal mass adjacent to the lower pole of the right kidney. CT scan revealed a large heterogeneous lobulated mass with intralesional cystic areas of necrosis and heterogeneous postcontrast enhancement in the retroperitoneum measuring 11 × 5.5 × 6 cm in size on the right side at the level of mid and lower pole of the kidney. There was no evidence of calcification in the lesion. The mass had extraneous indentation of the inferomedial cortex of the right kidney. The mass displaced the right renal vein anteriorly and the right proximal ureter anterolaterally with compression of the inferior vena cava anteromedially. Medially, the mass was seen to be infiltrating the psoas muscle and abutting the right lateral cortical margin of the L4 vertebra. The right adrenal gland was seen separately and appeared normal (). 3D reconstruction of the imaging was done to assess the relation of the mass with the surrounding structures.
Serum cortisol and serum and urine normetanephrines were normal, ruling out a functional tumor. The patient underwent USG-guided core needle biopsy which revealed retroperitoneal ganglioneuroma as presence of mature ganglion cells in a Schwannian stroma with no evidence of mitosis/necrosis.
The patient underwent exploratory laparotomy through anterior subcostal incision. The mass was found to be displacing the right kidney and proximal ureter laterally with anterior displacement of right renal vein. The right ureter was looped using a vascular sling and traced upwards to identify the right kidney and the right renal vein. The mass was carefully dissected from the surrounding structures using electrocautery and the base of the mass infiltrating the psoas muscle was fulgurated.
The mass was encapsulated and measured 11 × 6 × 5 cm in size. It had a bosselated surface. The cut surface was homogeneous and soft to firm in consisten

[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 woman with a previous history of long-term peptic ulcer, under proton pump inhibitor therapy, and hypertensive arterial disease, was admitted to our emergency department with complaints of abdominal distension, upper abdominal pain and alimentary vomit for the last 12 h.
On physical examination, she had tenderness and guarding in all abdominal quadrants. All vital signs were within normal range. The laboratorial tests revealed only a mild increase in systemic inflammatory parameters but with no organ failure.
The patient underwent an abdominal plain film, which identified a massive gastric dilation and a pneumoperitoneum was suspected (Fig. ). In order to confirm these findings, an abdominal computed tomography (CT) was performed, which clearly identified a massive gastric dilation. The stomach reached the pelvis and had an abrupt stricture at the level of the pylorus. A large pneumoperitoneum was also confirmed (Fig. ).
An urgent laparotomy was performed, and intraoperatively an exuberant gastric dilation was detected, with only a small amount of seropurulent free peritoneal fluid. On abdominal exploration, a limited area of necrosis with ∼2 cm was detected in the lesser curvature of the stomach. After inspection, an anterior gastrotomy was performed to empty the stomach (a total of 4 l of fluid was aspirated) and to access the area of mucosal necrosis. At last, an affected area of 3 cm × 2 cm close to the lesser curvature was identified, and an atypical gastrectomy was performed, using a linear stapler. An underlying pyloric stenosis was identified, which was circular and that seemed not to be malignant. Therefore, a Heineke–Mikulicz pyloroplasty was performed besides the partial gastrectomy. During the surgery, it was decided not to perform a vagotomy, considering the patient age and to prevent gastric emptying impairment in a patient who had already a certain degree of gastroparesis.
The postoperative period was event free, and the patient was dis

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


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

[User]
RADIOLOGY NOTE:
We present a case of a 21-year-old female who, in the month prior to admission to our institution, had been treated multiple times in emergency departments at various hospitals referring epigastric abdominal pain and constipation. The treatment she received was based on the resolution of constipation, antacids and dietary recommendations. The patient was admitted to our emergency department after 1-month of upper quad-rant abdominal pain radiating to the left upper quad-rant, additionally she cited a weight loss of 5 kg in the last month. Her symptoms had become more aggravated two days prior to admission with unquantified fever, chills and night sweats. She had no history of previous peptic ulcer disease or surgical procedures. A review of the family history revealed no significant disease. A physical examination revealed vital sings with a heart rate of 102 beats per minute, respiratory rate 16 breaths per minute, temperature of 37°C, blood pressure of 110/56mmHg, the abdomen was distended, the percussion was tympanic, the bowel sounds were de-creased. Additionally we found a painful, not well limited, mass adhered to deep planes in the abdominal palpation without peritoneal irritation or other alterations. A work-up started with blood chemistry, CBC, and we requested a CT of the abdomen due to clinical examination findings. The preclinical showed no elevation of acute phase reactants and no electrolyte disturbance, the CT scan evidenced an irregular, small collection in the gastric antrum and behind the left rectus muscle of approximately 30x11x16mm, which was associated with increased density of the surrounding fat. Inside this area, the end of a tubular, hypodense structure (compatible with foreign body) was visible coming out from the gastric lumen through the wall, which was perforated ( and ). The findings on CT were dis-cussed with the patient who was questioned again for further information to determine the origin of the foreign body. The patient agreed to

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


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

[User]
RADIOLOGY NOTE:
A 31-year-old healthy female suddenly collapsed with short lasting convulsions in January 2015. Patient’s second pregnancy was at gestational weeks 26 + 5. Her first pregnancy had been uneventful and had ended in normal childbirth. At the time of collapse patient was at home with her spouse who immediately called emergency response center. Dispatcher alerted nearest ambulance capable for basic life support within 60 s from beginning of the emergency call. A cardiac arrest was not identified during the emergency call, but after six minutes from beginning of the call the dispatcher alerted the mobile intensive care unit (MICU) according to the alert protocol of unconscious patient. MICU is normally staffed by two paramedics and an emergency physician. However, there was also an extra paramedic in MICU due to rotation of ambulance staff. The emergency physician on duty was a resident of anesthesiology and intensive care.
The first ambulance reached the patient 10 min from beginning of the emergency call. Patient was lying on a couch unconscious and not breathing. No CPR was performed by bystander. Patient was moved to the floor by the EMS personnel. The primary rhythm was ventricular fibrillation and cardiopulmonary resuscitation was carried out according to the shockable rhythm protocol. Before arriving to the scene, the MICU emergency physician was informed about the cardiac arrest of a pregnant patient. A plan of first establishing advanced life support and then deciding on the need for prehospital emergency hysterotomy was made. Emergency physician on duty had no previous experience from caesarean sections.
MICU reached the patient 15 min from beginning of the emergency call. VF had been defibrillated two times and second two minute cycle of compression was going on. A left lateral tilt of uterus was performed. Patient was intubated and intravenous line was established by the MICU staff. Because of long delay of ALS and no bystander CPR fetal heart beats were check

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


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

[User]
RADIOLOGY NOTE:
A 58-year-old man presented with fever and malaise from SAB with no obvious source of infection on examination. He had a background of hypertension and type 2 diabetes mellitus. CT of the thorax, abdomen, and pelvis was not able to elucidate the source of the infection. TOE showed a thickened aortic valve with calcification of the noncoronary cusp but no overt signs of IE (no vegetations or significant valvular regurgitation). Due to a lack of an infective source, he was treated as presumed IE in view of abnormal aortic valve with 6 weeks of antibiotics, and he remained well immediately on discharge.
Two years later, he had an ST-segment elevation myocardial infarction (STEMI), for which he underwent primary percutaneous coronary intervention (PCI) with stent to distal right coronary artery. A small aneurysm at the origin of the right coronary artery was noted which was attributed to atherosclerotic disease []. He made an uneventful recovery and was discharged; however, 2 weeks after the STEMI, he represented with fever and chest pain. Two positive blood cultures showed SAB. TTE and TOE again showed thickened abnormal aortic valve but no evidence of IE. However, no other source of infection was identified, and he was again treated as suspected IE and discharged to finish his course of antibiotics.
He returned a month later with rigors and joint pains. Again, positive blood cultures revealed SAB. Repeat TTE; CT of the thorax, abdomen, and pelvis; and FDG-PET were all negative. He completed 6 weeks of inpatient intravenous antibiotics and was discharged home.
Three months after, he presented with nausea, epigastric pain, and a high-grade fever. Three sets of positive blood cultures grew S. aureus (MLST clonal complex 22). WBC-SPECT of the lower chest and abdomen demonstrated a focus of low-to-moderate grade uptake at the root of the aorta, which was suspicious of IE [].
Following this, CT of the thorax with contrast

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


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

[User]
RADIOLOGY NOTE:
A 28-year old Caucasian woman without significant risk factors for atherosclerosis presented with headache, right hemiplegia, and right visual impairment. Magnetic resonance imaging revealed a fresh left posterior brain infarction. A duplex ultrasound showed no cerebrovascular stenosis or occlusion, but an echocardiogram revealed a left ventricle pedunculated mobile mass (5 mm in diameter) that was attached to the mitral valve chordae tendineae (Figure ). Left and right ventricular functions were normal, and mitral valve regurgitation was mild. Because the patient did not exhibit findings indicative of having an embolic source, we elected cardiac surgery to resect the cardiac tumor and to avoid further embolic events.
A CPB was instituted via the femoral arterial and venous cannulation through a 3 cm transverse incision in the right groin. The tip of the venous cannula was positioned under transesophageal echocardiographic guidance in the superior vena cava. The temperature of the patient was cooled to 34°C, and vacuum-assisted CPB was used throughout the procedure. A right lateral mini-thoracotomy (length, 5 cm) was performed via the 4th intercostal space, and the incision was placed in the submammary crease. A video camera was inserted through a 10 mm port in the right 3rd intercostal space and a transthoracic aortic cross-clamp was inserted through the 3rd intercostal space. Antegrade cold blood cardioplegia was administered directly into the aortic root and repeated every 20 min. throughout the procedure, the surgical field was flooded with carbon dioxide via the camera-port. The left atrium was opened posterior to the interatrial groove. Exploration of the mitral valve showed a globular tumor involving the anterior mitral leaflet chordae tendineae (Figure ), which was removed along with the involved chordae tendineae. Neochordae were implanted using the loop technique. The required length of the loop was determined by measuring the distance between the correct

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


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

[User]
RADIOLOGY NOTE:
The patient was a 32-year-old Korean woman referred because of a cystic lesion below the mandibular right first molar at a local dental clinic. She had no pain or significant systemic disease. Several clinical tests, including electric pulp test, were performed and the affected tooth showed the presence of pulp vitality. There was no tooth mobility.
Panoramic radiography revealed a round, mixed lesion below the mandibular right first molar (Fig. ). The border of the lesion was clear, but no clear cortication was observed. The effects on the adjacent teeth and inferior alveolar canal were unclear. The lesion was generally radiolucent, but a mixed radiopaque portion was seen adjacent to the anterior boundary of the lesion, resembling the shape of a mixed lesion.
In the additionally obtained cone-beam computed tomography scan, a slightly ovoid lesion was observed anteriorly and backwards (Fig. ). Likewise, the boundaries were clear, but no clear cortication was observed. Although thinning of the adjacent cortical bone was observed, no apparent expansion pattern was observed. The radiopaque portion inside the radiolucent portion was mixed at the anterior site of the lesion. The anterior part of the lesion showed the characteristics of COD. The middle and posterior parts of the lesion were suspected of cystic changes, showing low attenuation. The size of the area considered as a cystic portion was not sufficiently large, so it was difficult to distinguish it as a secondary cystic lesion. Considering all radiologic findings, the imaging diagnosis was COD with a cystic lesion, such as ABC or SBC.
Surgical excision and histopathologic examination were performed. Histopathologically, stromal tissue was composed of spindle-shaped fibroblasts with small blood vessels (Fig. ). Cystic aneurysmal components showed blood-filled cystic cavities lined with a thick membranous structure that comprised multinucleated giant cells and mononuclear cells (Fig. ). The anterior part of the l

[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 78-year-old woman presented after falling from an upright position on her left hand and then experiencing difficulty elevating her left arm. She had a six-month history of mild pain in her left elbow after agricultural work for which she used a hoe and a 10-year history of medication with bisphosphonate (alendronate), to treat osteoporosis that was diagnosed after a thoracic vertebral fracture.
A lateral radiograph of the left forearm upon presentation revealed a transverse fracture at the posterolateral aspect of the proximal ulna (). Computed tomography of the left ulna showed cortical thickening, with transverse fractures and spike formation on the volar side (). X-rays did not reveal any abnormalities of the contralateral side. Biochemical findings showed normal serum calcium, phosphate, alkaline phosphatase, and thyroid hormone values. The mineral density of the distal radius had a T score with a standard deviation (SD) of -1.9 on dual-energy X-ray absorptiometry. The fracture was diagnosed as atypical, and bisphosphonate therapy was stopped. The patient underwent open reduction with internal fixation (ORIF) using a 3.5 mm locking compression plate (DePuy Synthes, Zeist, Netherlands) for the ulnar fracture (). A transverse fracture with cortical thickening was evident during the procedure. Plain radiography showed no signs of fracture healing at three months postoperatively (), when the patient complained of pain at the fracture site. The results of a physical examination and laboratory tests, including white blood cell counts, C-reactive protein, and erythrocyte sedimentation rate, were normal, which ruled out an underlying infection of the surgical site. We diagnosed the fracture site as nonunion; thus, we performed the revision surgery to stabilize and to achieve a union of the fracture site at 4 months after the first operation. Scar tissue and the osteosclerotic lesion from the fracture site were excised under general anesthesia, and the fracture surface

[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 male noticed something coming out of his skull while he was combing his hair which he tried to pull out a bit (). The patient had no complaints of pain at that site in the scalp, headache, fever, nausea, convulsions, altered sensorium, loss of consciousness, oliguria, or hematuria. He is a known case of hypertension and diabetes mellitus with a history of alcohol addiction since 36 years. The patient had a past history of hemodialysis in view of leptospirosis-induced acute kidney injury with uremic encephalopathy three years back.
A CT scan of the head was performed in view of a foreign body coming out of skull. A hyperdense linear foreign body was seen extending from the upper part of the right internal jugular vein, coursing cranially, piercing the right tentorial leaflet, traversing through the right posterior parieto-occipital parenchyma, and exiting extracranially through the right parietal bone. Similar smaller variable-sized metallic structures continued with the aforementioned foreign body, in the right half of posterior fossa and right occipital region were also seen. A small peripherally enhancing hypodense area was seen along the catheter in the right posterior parieto-occipital region, representing a focal-forming abscess. Partial thrombosis of the internal jugular vein was seen (). The patient was taken up for emergency surgery for the removal of the foreign body. In the left lateral position, a skin incision was taken at the exit point and flap was raised. There was a small 0.2 × 0.1 mm-sized opening in the right posterior parietal bone. The wire was gently pulled out as much as possible. Bone wax was applied over a small defect in the bone. Hemostasis was done. The incision was closed over a suction drain. The procedure was uneventful and the patient was apparently all right after regaining consciousness. A postoperative CT head was performed which revealed few (at least four) fragments of retained catheter seen in 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 man visited emergency room with right upper quadrant and flank pain. CT revealed calculous cholecystitis without common or intrahepatic bile duct stones. He had not viral hepatitis or previous abdominal pain history. He showed mild fever and normal limit of blood chemistry except leukocystosis with white blood cell count was 13,000. We decided the cholecystostomy for initial treatment of cholecsytitis, after making patient stable and afebrile.
Initial CT scan showed small mass-like lesion of severely shrunken right hepatic lobe and hypertrophy of the left hepatic lobe (). Right hepatic vein was normally drained to inferior vena cava (), and intrahepatic duct was not dilated. Right hepatic artery and portal vein were not visualized distinctly in CT. GB was identified in a retrohepatic position, and located in beneath the diaphragm with wall thickening demonstrating cholecystitis (). One week after cholecystostomy, cholecystectomy was done. We tried laparoscopic approach with routine 4 port methods, however we could not approach the GB without liver mobilization and position change. Because of severe adhesion of GB with omentum and mesocolon, we decided the open conversion procedure. During the cholecystectomy, excessive bleeding and bile leakage occurred in GB bed requiring two pint of packed red blood cell transfusion. However we could not be sure of hepatic artery or portal vein bleeding. We did not perform liver resection due to absence of pathologic condition of liver parenchyma, and perform bleeding and leakage control by suture ligation. A drain was left in GB fossa and liver dome. On 3rd day after operation, 50 to 100 mL/day of bile drainage was detected in Jackson-Pratt drain. We decided conservative management for bile fistula. CT showed small amount of biloma in GB fossa. Ten day after surgery, the amount of bile drainage increased up to 200 mL/day, and so we decided to perform endoscopic retrograde cholangiopancreatography for therapeutic bil

[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 study was conducted in accordance with the ethical standards of the Institutional Review Board of our institution, Des Moines University College of Osteopathic Medicine.
A 61-year-old male patient presented with progressive pain in his medial left hamstring as well as weakness with left-sided foot drop and paresthesias in the plantar aspect of his foot. Symptoms first presented as impairments in his ability to push off with his left foot during moderate exercise. He did not present with radicular symptoms but did have a previous X-ray of the lumbar spine, which showed no signs of stenosis or compression.
Upon initial physical examination, the patient was found to have no tenderness to palpation of his lumbar spine. Tenderness was appreciated in the medial left glute and left posterior medial thigh down to the knee. No reproducible pain was noted below the knee, and no obvious foot deformity, erythema, or edema were present. He did endorse decreased sensation in the distal third of the plantar foot including the first metatarsal. The patient was unable to flex or extend his left first metatarsal. Left Achilles tendon reflex was 0/5, with a contralateral reflex of 5/5.
The patient was subsequently evaluated by a physical medicine and rehabilitation specialist, who noted diminished left S1 reflex. He was able to stand in plantarflexion on the right, but was unable to flex to full height on the left. Also, weakness of the left flexor hallucis longus and digitorum longus with absent sensation on the plantar surface of the first metatarsal to pinprick and light touch was noted. He was then referred for osteopathic manipulative therapy (OMT). Initial treatments with OMT did offer some relief, but his symptoms persisted. An electromyogram (EMG) was performed, which showed evidence of peroneal nerve injury in the absence of a superficial peroneal sensory response, temporal dispersion when stimulating across the knee, and tibial nerve injury.
Magnetic resonance imaging (

[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 report the case of a 40-year old male patient who was referred to our department complaining of a slowly growing mass of the right neck. Previous medical history was nonrevealing except from a trauma to the right neck about 9 years ago. At that point, the patient had noticed the swelling for the first time. However, he did not seek further medical attention since the mass did not cause any symptoms. Thorough physical examination was unremarkable besides the substantial mass of the right lateral neck (Fig. ). Subsequent imaging with ultrasound revealed a septate, cystic formation comprising the entire right cervical region. The septa were partly calcified and showed moderate blood perfusion. Based on these ultrasound findings, a diagnosis of lymphangioma was considered. However, an additional magnet resonance imaging (MRI) was recommended for appropriate assessment of the masses’ size and potential invasion of the surrounding tissue.
MRI revealed a massive, polycystic formation located right beneath the sternocleidomastoid muscle. The mass had a craniocaudal diameter of 13 cm with a maximum width and depth of 10 cm and 5 cm, respectively. The caudal part surrounded the brachiocephalic trunk and extended down to the upper mediastinum as well as the thyroid isthmus. However, direct communication with the thyroid gland was not reported. Distinct septa displayed slight contrast enhancement, abnormal lymph nodes were not found. These MRI findings were also considered consistent with a lymphangioma.
Consequently, surgical resection of the presumed lymphangioma was pursued. While the major part of the mass could be successfully resected, intraoperatively (Fig. ), the decision was made to leave the masses’ segment which surrounded the brachiocephalic trunk to avoid potentially fatal injuries.
The specimen was sent for histologic assessment to verify the presumptive diagnosis. Microscopic evaluation revealed psammoma body-like calcifications and expression of thyroglobulin

[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 50-year-old male presented with hematuria, increased frequency, and burning sensation during micturition along with left flank pain for 2 months. There was a history of generalized weakness, weight loss, and loss of appetite during this period. On examination, the patient was poorly nourished with the presence of a palpable left-sided abdominal mass.
Ultrasonography (USG) of the abdomen showed the presence of right ectopic kidney and left-sided hydronephrosis. A heterogeneous mass was noted in the left kidney. Another polypoidal mass was also seen in the lumen of the urinary bladder, attached to its posterolateral wall.
Contrast-enhanced computerized tomography (CECT) of the abdomen helped in the renal anatomy and characterization of the mass, which revealed L-shaped crossed fused renal ectopia. The right kidney was not present in the right renal fossa and was in the midline, anterior to the aortic bifurcation at the L4-L5 level. It was malrotated and fused with the lower pole of the left kidney. The left kidney was enlarged, with a large soft heterogeneous tissue density mass involving the interpolar and lower pole regions that exhibited heterogeneous enhancement with central non-enhancing areas. Few calcified foci were seen in the mass, along with moderate hydronephrosis. In the delayed phase (15 minutes), no contrast excretion from the left kidney was recorded. The interpolar region of the right kidney was contiguously infiltrated by the left lower pole renal mass. Small tumor thrombi were present in the segmental right renal veins draining the interpolar region. Aortocaval, para-aortic and left renal hilar lymphadenopathy were also noted.
Along with these findings, a well-defined polypoidal mass was seen in the left posterolateral wall of the urinary bladder, infiltrating the left vesicoureteral junction. The middle and distal parts of the left ureter were contiguously involved by this urinary bladder mass. A peripheral rim of calcification was present.
Becaus

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


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

[User]
RADIOLOGY NOTE:
A 28-year-old, Jamaican female, gravida 7 para 3 presented to the clinic at 8-week gestation for her first prenatal visit. Her first pregnancy was complicated with uncontrolled hypertension resulting in a term primary cesarean delivery. Prior to this pregnancy she was normotensive. As this pregnancy occurred in Jamaica, medical records regarding the details of her care were not available. The indication for the cesarean delivery was not known to the patient. However, the patient reported that her blood pressure normalized after this delivery. This was followed by an uncomplicated pregnancy and repeat cesarean delivery at term three years later. Over the next three years, she had three elective terminations of pregnancy. A year thereafter, she had another pregnancy that was complicated by proteinuria and elevated blood pressure that resulted in a fetal demise at 29-week gestation. After delivery, her blood pressure normalized and she remained asymptomatic. The presumptive diagnosis by the medical team was early onset severe preeclampsia, and therefore no renal biopsy or subsequent workup was undertaken at the time.
A year after the last pregnancy she emigrated to the United States and presented to our clinic for prenatal care at 8-week gestation. She denied any medical problems and was not using any medications. She smoked one pack of cigarettes per day and denied the use of alcohol or other illicit drugs. Her initial blood pressure was 96/60 mmHg. Prenatal labs, initial complete blood count, and BUN and creatinine levels were normal ( and ).
At 12-week gestation, she returned to clinic for follow-up. Physical examination was positive for 1+ bilateral lower extremity edema. Her blood pressure was 102/64 mmHg. A baseline 24-hour urine collection revealed 5047 g of protein excretion. Subsequent workup with renal ultrasound, microscopic urine analysis, urine electrolytes, and a rheumatology panel consisting of anti-nuclear antibody (ANA), CRP, anti-double stranded DNA,

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


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

[User]
RADIOLOGY NOTE:
A 48-year-old male presented in emergency with a history of abdominal mass since childhood. The abdominal mass was gradually progressive in size and rapidly increased in the last two weeks. He also complained of breathlessness for one week associated with abdominal pain. The patient never went to any hospital for the abdominal mass. There was no history of vomiting, altered bowel habits, trauma to the abdomen, melena, and passage of any membranes in the stools. There was no history of cough with sputum. On examination, the patient had tachycardia with normal blood pressure. There was no pallor or jaundice. Abdominal examination showed a large mass of almost 20cm x 20cm occupying the epigastrium, right hypochondrium, left hypochondrium, and umbilical region. It had varying consistency - soft in the upper part and firm in the lower and lateral parts.
Routine blood investigations, including complete blood counts and renal function tests, were normal. A liver function test revealed mild elevation (174 IU/L) of alkaline phosphatase (ALP). Hydatid serology was positive. Abdominal USG showed the presence of a large hypoechoic cyst with air and debris. Contrast-enhanced CT of the abdomen showed a 20cm x 18cm cyst, arising from the left lobe of the liver having an air-fluid level and few septations or membranes at the inferior aspect of the cyst with debris. The left portal vein was compressed, and the left bile duct was not visualized. The gallbladder had air within it. The common bile duct (CBD) was normal in caliber, and there was no air within it (Figure ).
The cyst's fistulous communication with the duodenum was demonstrated with oral contrast CT scan (Figure ). The cyst was closely related to the stomach and had displaced the stomach and spleen laterally. The pancreas appeared normal.
As the patient was breathless, a decision was made to put a percutaneous pigtail drain within the cyst to decompress.

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


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

[User]
RADIOLOGY NOTE:
A 53-year-old white woman diagnosed with a triple-negative basal-like invasive ductal carcinoma located at the intersection of upper quadrants of the right breast was treated with breast-conserving surgery having free surgical margins (>1.5 cm) and sentinel lymph node biopsy. Pathologic stage of the tumor was pT1N0M0. Adjuvant chemotherapy and radiotherapy were given.
Seventeen months after the end of the radiotherapy, she presented with a painful mass in her right breast at the surgical bed. There were neither palpable axillary lymph nodes nor elevation of tumor markers. The imaging study with mammography and magnetic resonance imaging (MRI) showed a right breast mass whose pathological study comprising seven breast tissue fragments obtained by vacuum-assisted percutaneous biopsy revealed fat necrosis and fibrosis. These findings were interpreted as sequelae of breast-conserving treatment. Anti-inflammatory treatment was given and close follow-up was recommended.
After three months, the mass had increased in size and patient complaints had also increased. Complimentary mammography and MRI-guided vacuum-assisted biopsy were performed at the core and at the peripheral enhancement of the mass. Twenty-one breast tissue fragments were obtained and, as with previous biopsies, pathologic diagnosis was confirmed with exclusion of malignancy (Figure ). Three months later, the clinical situation was worse with edema and slurring, and skin biopsy was performed excluding malignancy again. One year later, another biopsy comprising twenty fragments of nonmalignant breast tissue was carried out. At this time, the patient suffered from an unmanageable constant breast pain, and a new mammogram showed a diffuse affectation of the right breast. The progression of the mass in different mammography images is shown sequentially from left to right in Figure . Given these clinical facts, a radical mastectomy was indicated with two possible diagnoses: breast cancer recurrence or radio-indu

[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 35 years old indigenous man, with no stable accommodation for 10 years, identified the street as where he most frequently sleeps. His highest level of schooling was year 8. His first contact with the adult hospital healthcare system was in 2005 when he was hit by a car at the age of 22 years old, causing severe injuries. By this time, he already had severe ataxia (unsteady gait) and intellectual impairment from heavy solvent and alcohol abuse during his teenage years. In 2012 he had a further major car accident causing multiple leg fractures and by 2013, he was permanently wheelchair bound, homeless and a frequent user of street drugs, solvents and alcohol. He reports being regularly assaulted and having had multiple interactions with police, at the age of 30 years old, he was approved for permanent supported care but always left hospital to return to the streets before this could be found. His combination of permanent physical disability, lack of mobility, brain injury and vulnerability to attack and coercion resulted in him scoring 14 on the VI-SPDAT questionnaire in August 2016, reflecting high vulnerability. When asked ‘what do you need to be safe and well’ he simply answered ‘a house’.
Hospital use by this patient for a 27 months period (January 2015 to March 2017) is summarised in and the costs of these ED presentations and inpatient admissions have been computed using the sources described in the methods section. His total estimated costs for the 51 ED presentations over the 27 months period January 2015 to March 2017 was $33,456, and the cost of the 28 inpatient admissions amounted to $299,460. In total, this represents a cost to the health system of almost $333,000 or $12,333 per month over a 27 months period.
In early April 2017, this patient was found a place in a supported psychiatric care facility. Since then, he has not presented to any hospital or been

[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 72-year-old African American male presented to the emergency department from the outpatient oncology office with a week of mild abdominal pain, which was not life-threatening. His past medical history was notable for metastatic pancreatic adenocarcinoma, which had been diagnosed one year earlier, from endoscopic retrograde cholangiopancreatography (ERCP) brushings when he presented with obstructive jaundice and required biliary and duodenal stent placement at the time. He had undergone a routine CT scan of his abdomen and pelvis for disease progression two days prior to admission, which revealed a massive pneumoperitoneum (Figures , ). The ominous imaging prompted his admission to the hospital. On presentation to the emergency department, he was in no distress with a blood pressure of 126/85 mm Hg, pulse rate of 93 beats per minute, respiration rate of 18 breaths per minute, and a temperature of 36.9° C. Physical examination was significant for marked abdominal distension with a benign non-peritonitic exam and mild tenderness on palpation. Laboratory tests were unremarkable, except for a white blood cell count of 10.5 x 103/uL with neutrophil predominance (83%). A repeat CT scan showed patent biliary and duodenal stents without a definite source of perforation; however, three suspicious locations were noted by the radiologist containing small foci of free air adjacent to the bowel.
Given the initial concern for perforated viscus, the patient was started on broad-spectrum antibiotics and antifungals. He was managed conservatively with intravenous hydration and strict bowel rest. He remained hemodynamically stable and non-septic throughout his hospitalization and continued to have flatus and intact gastrointestinal function. General surgery recommended no acute surgical intervention. In a few days, he was started on a clear liquid diet which he tolerated well. His abdominal distension gradually improved without any surgical intervention, and he was discharged home 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 60-year old man was admitted to the hospital after falling off an electric scooter. He fell on outstretched hands and knees and did not sustain a head injury. He immediately noticed loss of sensation in all four limbs and the abdomen.
On admission to the emergency department, he did not have motor or sensory (light touch or pain) deficits on physical examination. Deep tendon reflexes were intact. Deep anal pressure was intact. Anal tone was preserved with normal voluntary anal contraction. Computed tomography (CT) brain at that time did not show any evidence of fracture or haemorrhage.
However, on review 2 hours later, wrist flexion and extension were noted to have dropped to a power of 2/5, and his grip 3/5 based on the Medical Research Council (MRC) manual muscle testing scale. He was also complaining of a tingling sensation throughout his body. Anal tone and sensation remained normal. The neurological level of injury was C5 ASIA Impairment Scale (AIS) D based on the International Standards for Neurological Classification of Spinal Cord Injury. Please see . CT cervical spine showed multilevel cervical spondylosis with marginal osteophytosis and uncovertebral hypertrophy. There was mild central canal stenosis noted at C6/7 and bilateral exit foramina narrowing.
He was admitted for observation. Magnetic resonance imaging (MRI) of the cervical spine confirmed the presence of severe cervical spondylosis causing cord compression at C4/5 with associated cord oedema. He was kept in a hard Aspen collar. His symptoms fluctuated minimally over the next few days and his neurological level of injury was C4 AIS D prior to surgery. He underwent C3-C6 posterior decompression and instrumented fusion to stabilise the spine and to prevent further deterioration.There were no intraoperative complications and neuromonitoring of both the motor evoked potentials and somatosensory evoked potentials remained stable throughout the procedure. The cord was well decompressed and noted to be

[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.