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

[User]
RADIOLOGY NOTE:
A 25-year-old woman presented in 1994 to the ophthalmology department with sustained episodes of flashes affecting the vision in both eyes. She was morbidly obese weighing 140 kg and a smoker. On examination, her optic discs and fundi were normal, but she was noted to have a transient drop in her visual acuity that normalized over a few days. For the on-going troublesome migrainous phenomenon, she was referred to neurology where she reported episodes of blurred vision, paraesthesia in the left lower jaw, left arm and leg. She was experiencing monthly right-sided headaches, associated with photophobia, which resolved within 24 hours. Examination was normal with no evidence of focal neurological deficit. Multiple sclerosis was considered as a diagnosis but later deemed unlikely. She was thought to have complicated migraine, and she was discharged. In 1998, she was re-referred to the neurology department with intermittent tingling on both sides of her body. This was accompanied by a sensation of imbalance. She had some short lasting visual obscuration. Neurological examination was normal. A magnetic resonance imaging (MRI) of the brain was organized but could not be performed due to morbid obesity. In 2002, she presented to the emergency eye department with bilateral granulomatous uveitis. Retinal fundoscopy revealed multifocal retinal periphlebitis. The optic discs appeared healthy, and there was no retinal cystoid macular oedema. Blood tests showed a normal ANA, antiphospholipid screen, full blood count, an ESR of 28 mm/hour and the presence of an atypical ANCA. The ANCA prompted a referral to the rheumatology department. An MRI of the brain showed lesions that involved the deep white matter (Fig. ). Over the next few years, she was monitored in a combined rheumatology–neurology clinic. Neurological examination remained normal. A Lumbar Puncture (LP) was not performed due to the body habitus. Visual evoked potentials were normal. Between 2002 and 2004, she had episod

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


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

[User]
RADIOLOGY NOTE:
Our patient was a 57-year-old male who complained of weakness and pain in the lower extremities, as well as urinary retention. He had undergone transnasal surgery for ACTH-producing pituitary tumor in 1998. He subsequently experienced repeated episodes of residual tumor growth and underwent multiple sessions of tumor resection and radiotherapy. He developed urinary bladder dysfunction and pain/weakness in the lower extremities without a known cause. With gradual worsening of symptoms, the patient presented to our department on referral in 2009. On admission the physical examination revealed that the femoral nerve stretch test was positive only on the right side, and the straight leg-raising test was positive at 10 degrees for both legs. In the manual muscle test, reduced muscle strength was observed in the left gastrocnemius muscle and left extensor hallucis longus muscle, and a marked decrease in perception was noted in the L4, L5, and S1 regions on both sides. A urethral catheter was in place due to urinary retention. Neurological findings suggested damage to the cauda equina at L4 and lower levels. ACTH level was high at 356.8 pg/mL (). On magnetic resonance imaging (MRI), the signal intensity of the lesion was intermediate on T1-weighted images, low to intermediate on T2-weighted images and intermediate with partially high-intensity areas on short-inversion-time inversion recovery images. On a gadolinium-enhanced image, a neoplastic lesion was observed, whose content was slightly and irregularly enhanced by the contrast medium (). Given a diagnosis of cauda equina syndrome caused by a tumor in the cauda equina, laminectomy at L3-S2 followed by tumor removal was performed. The tumor was identified as an elastic, hard and clearly bordered mass entangled in several cauda equina nerves and encapsulated by a thin membrane. The tumor was detached from the nerves and as much of it was removed as possible. Two tumor masses were excised ().
On histopathology, H&

[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 59-year-old male patient, from Peru, with no relevant medical history, presented in September 2019 with a history of back pain, weight loss of about 5 kg, early feeling of fullness and night sweating of 8 months of evolution. His physical examination revealed a mobile mass without defined margins, located 12 cm from his left ribcage. The results of his routine haematology and biochemistry laboratory blood tests revealed moderate anaemia with a haemoglobin of 9.0 g/L and hyperkalaemia with a serum potassium of 5.8 mmol/L.
He had computed tomography (CT) scan of abdomen which showed a left renal mass of heterogeneous density of 19 × 12 × 9 cm, which had defined borders and contours and which was not associated with any nodal or vascular involvement (). Kidney cancer presumptive diagnosis was considered.
In October 2019, he underwent a surgery (left radical nephrectomy plus para-aortic lymphadenectomy), and during the procedure he was noted to have a left kidney dependent tumour that measured 20 × 19 cm with associated hilar and para-aortic lymph nodes.
Macroscopy pathology examination of the specimen was reported to have identified a left renal tumour that measured 23 × 12 × 10 cm which was noted to have a solid component, and which was soft in consistency, and which was light brown in colour and which contained areas of myxoid and haemorrhagic necrosis of 30% and 10%, respectively (). Microscopy pathology examination of the specimen detected a cell proliferation of tumour cells that were arranged in a storiform pattern which infiltrated the renal sinus, capsule and the perirenal fat, with pleomorphic nuclei and high mitotic index (). These findings were reported to be consistent with an undifferentiated liposarcoma of high histological grade, with 35 mitoses per ten high-power field (35/10 high-power field mitoses) and 30% of necrosis.
There was no evidence of metastatic spread to the Gerota’s fascia, renal pelvis, adrenal glands as well as there was no

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


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

[User]
RADIOLOGY NOTE:
A 33-year-old female patient who was still breastfeeding 10 months after her first natural delivery visited our outpatient clinic because of a left intertrochanteric fracture caused by falling from standing height. Before her pregnancy, the patient had no hypertension, diabetes mellitus, or other chronic diseases. She had no history of long-term drug use, smoking, or alcohol intake. She had not had any operations, did not suffer from hip or femur trauma, and had no family history of osteoporosis or hip fracture. During her pregnancy, the patient had no preeclampsia, eclampsia, gestational hyperthyroidism, or other metabolic diseases. She had no history of chronic diarrhea and never used glucocorticoids, heparin, or other drugs. Calcium 600 mg and vitamin D3 700 IU were supplemented every day during pregnancy, but she discontinued taking calcium and vitamin D after delivery. The patient had never complained about lower back or transient hip pain or a decrease in self-awareness of height during pregnancy and lactation. The patient experienced pain in the left hip after a fall, and could not stand on her left leg. At a physical examination, shortening deformity at the left leg was found, the range of motion in the left hip was restricted because of pain, and there was localized tenderness with palpation on the left hip. Percussion pain in the left lower limb was positive, but there was no tenderness in the spinal process in the thoracolumbar region and paravertebral muscles. Hip radiography () showed a left intertrochanteric fracture. Although the patient never complained about low back pain, magnetic resonance imaging of the thoracic and lumbar spine identified a new compression fracture in the L1 vertebra with marrow edema (). Laboratory test results are shown in . Serum calcium and parathyroid hormone concentrations were in the normal range, and 25-hydroxyvitamin D3 and albumin concentrations were low. BMD was measured with DXA, which showed a reduction in density i

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


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

[User]
RADIOLOGY NOTE:
A 58-year-old man was admitted to the emergency department with right upper quadrant pain and jaundice. Though gallbladder could not be demonstrated optimally, the ultrasonographic examination revealed an increase in gallbladder wall thickness but it was contracted. Dilatation of intra and extrahepatic bile duct was detected. As a result, 64-detector multidetector computed tomography (MDCT) was performed since we could not evaluate gallbladder and choledochus optimally with ultrasound. In MDCT, gallbladder was contracted and could not be demonstrated clearly. The enlargement of choledochus and multiple choledochus stones were determined. For a better evaluation of the biliary stones, T2 weighted (T2W) MRCP (NCE-MRCP) was performed. T2W images showed multiple stones in ductus choledochus and intrahepatic bile ducts. A 15×20 mm cystic lesion including thin septa was demonstrated at the head of pancreas at periampullary region (). There was no relationship between cystic lesion and pancreatic duct. Gadoxetic-acid enhanced MRCP (CE-MRCP) was performed at the same session to examine the bile duct obstruction and to evaluate the pancreatic cystic lesion (). A slight enhancement was detected at the wall and septi of the cystic lesion in CE-MRCP. There was no relationship between cyst and choledochus or pancreatic duct. There was no obstruction in the biliary tract as well. The transition of contrast material to the lumen of gallbladder was not seen at either early or late phase images. The patient was planned to undergo the surgical treatment according to these findings.
At surgical exploration, the size of gallbladder was significantly reduced. There were fibrotic adhesions between gallbladder, liver and transverse colon. Cholecystectomy was done; the pancreatic cystic lesion was aspirated and excised, as well. The histopathologic examination revealed a moderately differentiated adenocarcinoma of gallbladder with positive surgical margins and the pancreatic lesion was rep

[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 29-year-old man presented to the orthopedics department with progressive right wrist pain. He sustained a blunt injury caused by assault 3 days ago and initially evaluated in the emergency department. Radiographs of the wrist were obtained, and he was diagnosed with wrist sprain. He was prescribed with nonsteroidal anti-inflammatory and muscle relaxants drugs, and a volar short arm splint was applied. He was referred to the orthopedics clinics when his pain did not respond to treatment. The splint was removed, and inspection showed wrist edema along with loss of the dorsal ulnar styloid prominence ().
The wrist was tender to palpation, and the ulnar styloid process was not palpable at the dorsal aspect of the joint. He had mildly limited dorsiflexion and palmar flexion, and no forearm rotation. His previous X-rays, obtained 3 days ago in the emergency department, revealed an obvious UVD ().
Closed reduction was attempted under local anesthesia, however failed due to extreme pain. A computerized tomography (CT) was taken for possible locked dislocation. Axial views and volume-rendered images of the DRUJ revealed volar dislocation of the ulnar head engaged with the sigmoid notch ().
The patient was taken to the operating room and under general anesthesia, the ulnar head was reduced by forceful pronation. The DRUJ was stable during passive forearm rotation. A long arm cast was applied with the forearm in semi-prone position and kept for 3 weeks. Magnetic resonance imaging (MRI) was obtained to inspect possible injuries to the stabilizing soft tissues and showed incomplete triangular fibrocartilage complex (TFCC) tear and bone impaction injury caused by engagement of the ulnar head to the sigmoid notch (). The cast was removed at the 3 weeks, and rehabilitation was initiated. The 3-stage wrist rehabilitation program was prescribed for the patient: Progression to each stage was guided by pain response. The stages of rehabilitation were described as pain

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


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

[User]
RADIOLOGY NOTE:
A 14-year-old Thai girl was born via cesarean section due to premature rupture of the membrane with a birth weight of 2500 g. She is the first child of a consanguineous (second-degree relatives) couple. Both parents are healthy and have never had fractures. During her first year of life, she had delayed motor development and growth failure. At one year of age, she could not sit by herself and weighed 7.5 kg (< 3rd centile). She presented to our hospital at 14 months of age with fractures of both femora without a history of significant trauma. She was found to have ptosis of both eyes with normal teeth but no blue sclerae. She was small for her age. Her weight was 7.8 kg (3rd centile) and her length was 68 cm (< 3rd centile). Skeletal survey showed diffuse osteopenia, multiple healed fractures of the right humoral shaft, both tibiae and fibulae. Spine radiograph showed flattening and indentation of vertebral bodies (Fig. ). A diagnosis of OI was made and intravenous bisphosphonate therapy (pamidronate 1 mg/kg/dose for 3 days) was initiated and given every 3 months. However, she sustained 1–2 long bone fractures per year from minor trauma. She required multiple corrective osteotomies to correct her deformities. At the last follow-up, she was 14 years old, weighing 20 kg. She could not walk due to her long bone deformity (Fig. ). Remarkably, although she was in a special education class due to physical disabilities, her cognition was appropriate for age. She could talk fluently and do mathematics properly.
Prenatally, her younger sister was found to have a dilated fourth ventricle by an ultrasonography. She was born at term via cesarean section because of previous cesarean section and was diagnosed with hydrocephalus at birth. At 4 months of age, she had her first fracture without a history of a significant trauma, leading

[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 59 year-old Caucasian female with past medical history of migraines, presented to our emergency department as a transfer from another facility for further management of a non-ST elevation myocardial infarction. In the emergency room she presented with notable anterolateral T wave inversions on ECG as well as elevated troponin I of 2.5 ng/mL (reference range: 0.000–0.039 ng/mL). vThe patient was having continued chest pain at time of arrival and stated that she experienced her first acute episode of chest pain 1 day earlier, occurring at her home, while at rest. She stated that earlier in the day she was experiencing a migraine and took her home medication of Treximet 85/500 mg with good relief of her symptoms. The patient stated that she occasionally gets migraines and on occasion uses Treximet to relieve her symptoms, however has not had to take the medication in quite some time. The patient claimed that a few hours after her migraine had resolved she began to experience non-radiating, left sided, substernal chest pressure with associated paresthesia in the lower extremities and some non-descriptive nausea. This prompted her to seek medical attention at a local urgent care facility. She was seen and assessed by a physician and had an ECG performed which demonstrated no significant issues so she was discharged home with an antacid and told to follow up with her primary physician as an outpatient. The patient stated that the chest pain never really dissipated however she went to sleep that night without issues. The next morning, she woke up with continued chest pressure, yet, decreased in quality from the previous day. She went to work that day and while talking to her coworkers she immediately felt worsening of her chest pressure and was taken to a local hospital, without catheterization capabilities, where she was noted to have new ECG changes and elevated troponins. Upon transfer to our facility she was given 325 mg of aspirin by mouth and started on

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


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

[User]
RADIOLOGY NOTE:
An 80-year-old man was admitted to our hospital for the treatment of a rectal tumor found incidentally by rectal examination. The tumor, about 3 cm in diameter, was located on the right side of the lower rectum 3 cm above the anal verge. The pathological analysis of the biopsy sample revealed that the tumor was a moderately differentiated adenocarcinoma. Abdominal computed tomography (CT) and magnetic resonance imaging (MRI) indicated that the rectal cancer invaded into the muscularis propria without distant metastases and that lateral pelvic lymph node (LPLN) was not enlarged with a maximum long-axis diameter <3 mm. The most important problem was that the patient had a huge benign prostatic hypertrophy, the size of which was 85 × 80 × 70 mm (Fig. a–c). To achieve complete TME with negative CRM, a hybrid transabdominal-transanal approach for ISR was conducted.
First, vascular division and mobilization of the left colon were performed laparoscopically. The transabdominal approach was continued until the anterior dissection of the rectum became difficult due to a huge prostatic hypertrophy. Next, the circumferential rectal incision and subsequent intersphincteric dissection were performed under direct vision to enable attachment of a single port device (GelPoint Mini; Applied Medical). After closure of the anal orifice, the GelPoint Mini was placed to start the transanal approach. Posterior side of the rectum was first dissected until the transanal approach was connected to the dissection layer made by the transabdominal approach. The dissection procedure was extended to the lateral side. Bilateral pelvic splanchnic nerves were identified at the 5 and 7 o’clock positions. At the anterior side, the proper dissection layer cannot be easily identified because of the perineal body and the enlarged prostate. Once the dissection plane between the rectum and the prostate could be identified, it was relatively easy to continue along the same plane. The assistance provided by

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


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

[User]
RADIOLOGY NOTE:
A 52-year-old right-handed woman with no prior history of neurological symptoms was referred to our hospital with chief complaints of aphasia and headaches and no sign of both extremities weakness. These symptoms had developed suddenly 1 week before she was admitted to the hospital. CT images revealed intracerebral haemorrhage (maximum 3.5 cm in diameter) in the left frontal lobe (Figures and ).
Cerebral angiography revealed a contralateral unruptured aneurysm in the M1 region (not shown). On the basis of the preoperative MRI findings (Figures and ), the patient was diagnosed with intracerebral haemorrhage (ICH) caused by cerebral cavernous malformation. We recommended surgical intervention since the lesion was symptomatic and we thought that there would be a future risk of rebleeding. A preoperative 3D fusion image was then constructed to simulate surgical procedures (Figures –). From the results of the preoperative simulation, we determined that a straight skin incision and small craniotomy behind the hairline would be enough to remove the hematoma (). Using the simulated 3D image, Broca's area (the inferior frontal gyrus) was identified to be caudal to the hematoma cavity (). This information led the surgical team to avoid contact with the caudal wall of the hematoma cavity so that Broca's area was not damaged.
The patient underwent craniotomy under general anaesthesia 1 week after the onset of haemorrhage. A straight skin incision was made behind the hairline, and a bone flap was removed to reveal the preoperatively targeted sulcus (). A cross-shaped opening was made in the dura () followed by a large opening in the arachnoid membrane over and inside the targeted sulcus (). Inside the sulcus, a gyrus flattened by the hematoma was observed as indicated in the preoperative simulation. A minimal corticotomy (4 mm) was then made on the gyrus to reach the hematoma (). Most of the hematoma was liquid and was easily removed by suction; however, detachment of the solid

[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 case presents a 20-year-old German female patient diagnosed with a chronic wound infection caused by MFC following a traffic accident in Vietnam (see Fig. for a timeline). The patient was travelling through Vietnam when she was involved in a motorbike accident in February 2019. She was taken to the emergency department of a hospital in Hanoi where she presented with a large wound on the right leg. At the time of admission, she was complaining of severe pain in her back and right foreleg, as well as headache and nausea. The patient reported no other pre-existing medical conditions. Radiograph of the lower leg did not show any signs of fracture, and cranio-encephalic traumatic lesions were excluded in the cranial computed tomography (CT) scan. However, a lumbosacral spine CT scan revealed stable fractures of the thoracic vertebrae (T4 / 5). The patient underwent surgical debridement and suture of the leg wound the next day (see Fig. a for a representative photograph) and was treated with metronidazole and ceftriaxone over four days. She was discharged eight days after admission, transported to Germany and immediately admitted to a local hospital. At that time, her right lower leg was swollen, but lacked signs of surgical site infection. The patient was discharged three days afterwards, and dressing changes were subsequently performed in an outpatient-setting by her general practitioner and in local hospitals. Approximately five weeks after the accident, wound inflammation was observed for the first time, with redness and warmth around the suture site and dehiscent areas of the wound edges. However, no signs of systemic infection such as fever, increased leukocyte count, or C-reactive protein levels were apparent. Three days later, she was re-admitted to a local hospital with the diagnosis of wound infection. Surgeons described purulent exudate and a subcutaneous firm tumor measuring 2 × 4 cm in size (Fig. b) with spontaneous drainage (Fig. c). 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:
A 20-year-old woman presented to the emergency department with complaints of severe abdominal pain, multiple episodes of vomiting and obstipation for one day. She was a known case of abdominal tuberculosis and had received anti-tubercular treatment for two months. Vital signs showed a blood pressure of 100/64 mm Hg, heart rate of 110 per minute, respiratory rate of 18 per minute, oxygen saturation of 96% on room air and a temperature of 100.5°F. She was cachectic with a weight of 28 kg which was less than 5th percentile for gender and age matched normal population. Physical examination revealed diffuse abdominal tenderness and rigidity. Her erect abdominal radiography showed gas under right dome of the diaphragm. Clinical diagnosis of perforation peritonitis was made and the patient was wheeled to the operating room for emergent laparotomy. Intraoperatively, a 3 cm x 2 cm single ileal perforation was found 1 foot proximal to the ileocecal junction, with unhealthy bowel margins and multiple mesenteric lymphadenopathy. Resection of perforated bowel segment with proximal ileostomy and mucus fistula of distal ileum was performed. Later, histopathology report confirmed tubercular etiology showing caseous necrosis in mesenteric lymph nodes and epithelioid granuloma in ulcer edge biopsy. Two days after the surgery, the patient was started on oral feeds and was accepting meals orally subsequently. Ten days following surgery, the patient had multiple episodes of bilious vomiting with stoma output decreasing to less than 100 mL per day. Her abdomen remained flat with no increase in bowel sounds. Abdominal radiography showed dilated stomach with no air fluid levels. Oral feeds were stopped and a nasogastric tube was placed for drainage of gastric contents. A contrast enhanced computed tomography (CECT) abdomen was done to determine the cause of obstruction which revealed a decreased aortomesenteric angle of 15° (Figure ).
As a result of this decreased angle, an abrupt collapse

[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 with history of Protein C deficiency and recent right thoracic outlet decompression surgery and first right first rib resection 3 weeks prior presented to an internal medicine clinic with dyspnea on exertion of one day duration. The patient was in good health up until 8 months before presentation when she developed recurrent transient ichemic attacks (TIAs). She underwent extensive evaluation at several hospitals and eventually was found to have thoracic outlet syndrome of the left upper extremity and possible thrombus at the subclavian artery. She successfully underwent left-sided thoracic outlet decompression and left first rib resection 7 months prior to presentation. Her post-op period was complicated by a subocclusive left external iliac deep vein thrombosis (DVT), and she was treated with apixaban. She recovered over the next several months and continued anticoagulation for her prior TIAsand DVT in the setting of Protein C deficiency. Two months prior to presentation, she developed right arm symptoms consistent with thoracic artery outlet syndrome on the contralateral side. She ultimately underwent thoracic outlet decompression surgery and right first rib resection 3 weeks prior to presentation, only missing full anticoagulation for 2 days. She was recovering as expected until she began to notice dyspnea on exertion 1 day prior to presentation.
Her vitals were within normal limits. Her physical exam was notable for decreased breath sounds and dullness to percussion in the right lung base. To evaluate her complaints further, a Cardiac Limited Ultrasound Exam (CLUE) was performed with the phased array probe and revealed the right hemidiaphragm had decreased movement compared to the left hemidiaphragm with a normal CLUE exam otherwise ( and ; Supplement Videos 1 and 2) [].
Labwork including troponin was normal, and electrocardigram revealed a new right bundle branch block but no evidence of ischemia. CT angiography of the chest was pursued du

[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 healthy, 10-year-old boy was admitted to pediatric dentistry clinic for the management of crowding associated with a large tooth present in the upper jaw. On intraoral examination, the patient's chief complaint was confirmed by the presence of a misaligned maxillary right central incisor. The tooth had a talon cusp-like enamel projection on the labial aspect of the crown and had a large mesiodistal dimension. Owing to the patient's gagging reflex, a proper radiographic examination of the incisor could not be made. However, the occlusal and periapical radiographs were highly suggestive of a large pulp chamber, and even of the possibility of a fused tooth. The occlusal radiograph also indicated an unerupted supernumerary incisor located on the contralateral side between the central and lateral incisors. The supernumerary incisor had a well-shaped crown and showed advanced root formation with incomplete apical closure ().
Among possible treatment options, esthetic reduction of the crown in both the proximal and labial aspects was considered unfavorable due to the presence of a large pulp chamber. Extraction of the tooth and consequent orthodontic correction were also discarded as a treatment alternative, since orthodontic movement of the supernumerary tooth over the midline could result in resorption of the alveolar bone. Finally, the use of the contralateral supernumerary incisor as a replacement for the existing large incisor was considered the best treatment option, since both the radiographic crown dimensions and presence of the immature apex favored the possibility for autotransplantation. The patient and his parents were informed about the treatment options and their possible outcomes. The patient showed up four months later, approving the treatment plan of autotransplantation. During the time, the supernumerary incisor erupted into the crowded maxillary arch in a rotated fashion (). Extraction of the large incisor and autotransplantation of the supernumerary t

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


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

[User]
RADIOLOGY NOTE:
A 51 year old man presented to our outpatient department with an increasing swelling in the right distal upper arm. He reported about local pain without radiation. The patient´s medical history was without previous infections, surgeries or other diseases. The mass in the arm presented solid and relocatable. The examination showed full strength in all upper extremity muscles, especially in the forearm flexors, in M. pronator, M. abductor pollicis brevis, M. flexor pollcis brevis, M. opponens pollcis and Mm. lumbricales I and II. No sensory loss in the upper arm, the forearm, the palm and dorsum of the hand and the fingers could be found.
MRI of the upper arm showed a spindle-shaped homogeneously contrast enhancing mass. It was located some centimeters above the crook of the arm within the medial sulcus bicipitalis. In the imaging it showed a relationship to the median nerve main branch of the forearm or seemed to originate from part of its fibres, respectively. Its diameter was about 11 × 4 centimeters (). The primary diagnosis from the radiologist was schwannoma.
Surgical extirpation was indicated and performed. In its middle part the exposed tumour had a smooth capsule which was opened (). In its equator the surface had a good boundary to the surrounding tissue (). It did not extend to the muscles or tendons. In its distal and especially in its proximal ending the tumour showed a more infiltrative growth (). A feeding fascicle could be identified and was cut after ensuring by electric stimulation that it had no motor function. But with the intention to set no damage at the main nerve trunk approximately twenty percent residual tumour was left ().
The postoperative course was uneventful. The patient suffered a light hypesthesia in the forearm. This did not match to the supply territory of the median nerve which is the palmar hand. It rather corresponded to another skin nerve, possibly damaged by the approach. There was no

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


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

[User]
RADIOLOGY NOTE:
A 19 year old nulliparous, British Caucasian woman was admitted with a sudden onset of right iliac fossa pain. Urine pregnancy test was negative. This pain was sharp and stabbing in nature with no radiation. There was no associated vomiting or fever. She denied any urinary urgency, frequency or dysuria and her bowels were normal. On examination there was minimal guarding and no rebound tenderness. No distension was seen and bowel sounds were heard. Transvaginal pelvic ultrasound demonstrated two small simple cysts within the right ovary. She was managed conservatively with analgesics only and the pain resolved within 24 hours. Following this acute episode she developed intermittent pelvic pain. Her subsequent scan showed 9.8 × 4.5 cm complex cystic mass in right adnexa with features suggestive of a dermoid cyst with no colour flow on Doppler examination. Interestingly her CA 125 was markedly elevated at 657; CEA, ∝ FP, HCG, white cell count (WCC) and CRP were all within normal limits. Her periods were regular and she was using condoms for contraception. She was in a new relationship and they had been together for the last 4 months.
Past medical history included well controlled asthma, a negative laparotomy at the age of seven for abdominal pain but no previous pelvic infections. Pelvic examination revealed a normal size uterus with a right adnexal mass which appeared fixed to the pelvic side wall.
A subsequent CT scan one week later suggested a right adnexal dermoid cyst 5.4 × 4.8 cm with abnormal soft tissue 3.0 × 2.6 cm deep to right rectus muscle and abnormal irregular soft tissue along pelvic side wall extending from left common iliac bifurcation to left adnexa and an enlarged 10 mm precaval lymph node was also seen. These features were thought to be highly suspicious of malignancy during the case review at the Gynaecology oncology Multidisciplinary Team (MDT) meeting.
A further CA 125 level was measured pre-operatively and had fall

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


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

[User]
RADIOLOGY NOTE:
A 12-year-old female patient with Down syndrome (weight 35 kg, height 135 cm) was referred to the department of dental anesthesia for behavioral management. Behavioral management was difficult because of her congenital heart condition, and uncooperativeness due to intellectual disability and dental phobia. Her chief complaints were pulp exposure, necrotic change, and pus discharge in the right mandibular first molar. Meanwhile, a root canal procedure was planned with a pediatric dentist.
The patient was given birth by normal spontaneous vaginal delivery with birth weight of 3.0 kg, and was diagnosed with chromosome 47XX + 21 Down syndrome. Immediately upon birth, she was also diagnosed with ventricular septal defect, for which she underwent regular examinations without any surgical intervention. At age 5, cardiac catheterization found severe pulmonary hypertension, based on which a diagnosis of ES was made ().
Echocardiography results indicated bidirectional shunt due to large perimembranous ventricular septal defect, resulting in severe pulmonary hypertension. A chest radiograph showed no significant interval changes, while laboratory test results showed hemoglobin and hematocrit level of 14.2 g/dl and 41.2%, respectively. Other laboratory findings were unremarkable.
Preoperative physical examination results showed blood pressure of 110/70 mmHg, heart rate of 100 beats/min, and oxygen saturation of 91%. Her physical activity was identified as NYHA (New York Heart Association) class II, meaning mild symptoms (mild shortness of breath and/or angina, and slight limitation during ordinary activity). A pediatric cardiologist recommended avoiding general anesthesia since it could threaten her life, and instead, recommended the use of antibiotics (bacterial endocarditis) and lidocaine without epinephrine, prevention of air embolism, and prevention of an increase in PVR during anesthesia and recovery period.
A pediatric dentist had planned to perform root canal treatment o

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


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

[User]
RADIOLOGY NOTE:
A 59-year-old male patient presented after a motorcycle accident with fractures of the left distal radius, left fifth metacarpus, left tibial plateau, and left second and third metatarsi, as well as wounds on the anterior surface of the left tibia and the dorsal surface of the left foot. The patient underwent emergency surgery to repair the lacerated extensor tendons in his left foot and injured dorsalis pedis artery was ligated. He underwent another operation three days after admission to repair his left distal radius fracture and metatarsal fractures. In the third week, the left tibia plateau fracture was fixed with a hybrid Ilizarov ring and monolateral Schanz screws to tibial shaft and the necrotic tissue was debrided. Extensive necrotic lesions formed in the wounds on the dorsum of the patient’s left foot and his anterior tibia. Empirical treatment with tigecycline and ciprofloxacin was initiated based on a diagnosis of complicated skin/soft tissue infection. Tissue cultures were obtained from the wound on the fifth day of antibiotic therapy. Due to the persistence of extensive necrosis after nine days of antibiotherapy, tigecycline and ciprofloxacin were replaced with imipenem and teicoplanin. On the same day, wound debridement was performed in the operating room and tissue culture samples were obtained intraoperatively. A. flavus growth was observed in the initial tissue culture, and A. flavus and A. fumigatus growth was observed in the tissue cultures obtained intraoperatively. Based on the diagnosis of PCA, intravenous voriconazole at a loading dose of 6 mg/kg twice daily and maintenance dose of 4 mg/kg twice daily was added to the patient’s treatment. Debridement was repeated after 10 days and tissue cultures were obtained. Tissue culture was again positive for A. flavus. VAC treatment was started after a second debridement. No growth was observed in tissue cultures obtained on day 10 and day 17 of antifungal therapy. The wounds turned to healthy granulati

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


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

[User]
RADIOLOGY NOTE:
A 57-year-old man presented with a long history of groin pain for several years. There was no history of trauma or injury to groin. The pain exacerbated by walking and prolonged sitting. Since last few months his pain had increased with loss of movement at the hip. Physical examination revealed slight asymmetry in the region of the iliac bone compared with the contralateral side, with no signs of inflammation or palpable mass. Hip range of motion was decreased with flexion limited to 90°, and abduction of 15°. Patient walked with Trendelenburg gait possibly because of pain. Conventional radiographs of the hip () revealed the presence of a bony protuberance at the right anterior inferior iliac spine, several centimeters in length close to the right acetabulum, with no signs ofjoint degeneration. Suspecting a giant osteochondroma which could be in the process of malignant transformation we performed a magnetic resonance imaging (MRI) which showed the existence of a bone tumor with benign appearance, but excluding the osteochondroma as a diagnostic possibility, because there was no peripheral cartilage. Subsequently a CT scan () revealed a bony lesion (6 cm long and 3 cm thick) with a well-defined cortical bone and a heterogeneous zone in the junction with the ilium suggesting a pseudo- articulation. With these studies we could establish the diagnosis of pelvic digit instead of an osteochondroma.
Initially, non-steroidal anti-inflammatory medications were prescribed with no symptomatic improvement. Surgical excision of the pelvic rib was planned with consent of the patient. Anterior approach to the hip (Smith-Petersen) was used. Tensor fascia latae and gluteus minimus required to be partially detached to completely expose the ‘rib’ till the base. The ‘rib’ was resected from its base and samples send for histopathology (). Histopathological examination showed the presence of corticomedullary structure similar to a rib, with no accompanying cartilage; this finding was co

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


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

[User]
RADIOLOGY NOTE:
A 65-year-old nondiabetic male presented to us with history of chest pain of 3-hour duration two days ago, associated with vomiting and one episode of syncope. For these complaints, he had been evaluated at a local hospital and diagnosed as acute inferior wall with posterior wall MI with atrioventricular (AV) dissociation, for which he was managed medically, and transvenous right ventricular apical temporary pacing was done. Due to persistent hypotension and recurrent rest pain, the patient was referred to us on the third day of the index event. His presentation ECG at our centre showed evidence of inferior wall MI with 2 : 1 AV block (). Echocardiogram showed hypokinesia in the left circumflex (LCx) territory, with an ejection fraction of 50% and moderate mitral regurgitation. Pacing threshold was normal and remained so throughout the observation period. In view of postinfarction angina, hypotension, and persistent AV block, the patient was taken up for coronary angiography with an intent to revascularise. His coronary angiography showed a left dominant circulation with 90% stenosis in proximal segment of left circumflex artery and 70% stenosis in the middle segment of the left anterior descending (LAD) artery. The LCx was balloon dilated followed by deployment of a drug eluting stent; the LAD was planned for a staged procedure. The angioplasty was uneventful and the patient was shifted to ICCU.
After four hours of percutaneous coronary intervention (PCI), the patient suddenly developed palpitations and ECG showed monomorphic ventricular tachycardia (). He was managed with 150 J biphasic DC cardioversion followed by intravenous amiodarone bolus and infusion, considering it to be secondary VT. The serum electrolytes were within normal limits. There were multiple hemodynamically significant episodes of both monomorphic () and polymorphic VT () over the next few hours. Significant ischemia was effectively ruled out by a check angiography that showed patent LCx stent w

[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 injured her right ankle joint after falling from a bicycle in January 2013. One week later, ORIF was performed at the initial emergency hospital. One month postoperatively, the patient was permitted to walk with weight-bearing but was unable to do so due to sustained ankle pain on the lateral and posterior aspect. After follow-up, including rehabilitation for 7 months, all screws were removed under the assumption that bone union had been obtained. However, ankle pain remained and the patient still could not walk with weight-bearing and was referred to our hospital in December 2013.
On initial plain radiographs, Weber type B and Lauge-Hansen classification SE type stage 4 fractures were revealed (). The medial and lateral malleoli were fixed using Acutrak 2 screws (Acumed, Hillsboro, OR) at the time of initial operation in February 2013 (). After the removal of those screws, a medial clear space was opened (). Computed tomography at our hospital revealed bone union of the posterior and medial malleoli but malunion of the lateral malleolus ().
Ankle arthrodesis is considered one form of salvage when a long time has elapsed since the first operation. However, reconstructive osteotomy was selected in this case because of the young age of the patient and the relatively smooth joint surface on radiography. In this case, shortening of the fibula because of posterolateral rotation of the distal fragment and widening of the ankle fork because of concomitant syndesmotic injury was present. As a result, the surgical plan involved fibular osteotomy through the initial fracture plane with fibular lengthening and internal rotation of the distal fragment until the ankle fork had been reconstructed anatomically. In addition, syndesmotic stabilization was planned by screw fixation.
We also evaluated preoperative foot function before reconstructive osteotomy using the self-administered foot evaluation questionnaire (SAFE-Q) () []. Despite poor results, ankle range

[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 proband is a 43-year-old male of northern European descent who initially presented with acute onset left leg cramping pain that lasted for several days. The pain was associated with numbness in his left leg and nausea. His past medical history was significant for mitral valve prolapse, aortic root dilation umbilical hernia left anterior cruciate ligament (ACL) rupture, and severe myopia corrected with LASIK surgery. Family history revealed rheumatic heart disease in his mother, necessitating mitral valve repair due to mitral valve prolapse with severe regurgitation. Upon examination, his popliteal arterial pulses were 4+ bilateral, bounding. His height was 196 cm, with an increased arm span-height ratio of 1.07. He had a mild pectus carinatum deformity, mild scoliosis positive wrist and thumb sign, pes planus, and mild skin striae. A Doppler ultrasound was performed by his primary care physician (PCP), which ruled out deep venous thrombosis (DVT); however, it revealed a large left popliteal artery aneurysm with thrombus that measured 6.3 × 3.1 × 3.4 cm. He underwent a CT angiogram that showed normal abdominal aorta as well as common iliac arteries. However it showed bilateral popliteal artery aneurysms measuring 3.6 × 4 cm in the left side and 3 × 2.8 cm in the right side (). After repairing of his left popliteal artery aneurysm with bovine carotid interposition via posterior approach, he was sent for cardiac and genetic evaluations. He underwent a MRI exam of the heart with and without intravenous gadolinium contrast administration () which showed mild bileaflet mitral valve prolapse and aortic root dilation (measuring 46 mm at the level of the sinuses of Valsalva). The patient has been prescribed metoprolol tartrate and losartan to control his aortic root disease and was to undergo elective aortic repair when the aortic dimension becomes near to or reaches 50 mm. A diagnosis of Marfan syndrome was made based on the revised Ghent criteria as the proband had aor

[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 47-year-old male police officer who sought care at a consulting office and had been the victim of a perforating firearm wound to the right infraclavicular region 7 months prior to presentation. At the time of wounding he had been treated conservatively.
The patient complained of exertional dyspnea and considerable edema and pain in the right arm. He had brought the results of a chest tomography conducted some weeks before which showed considerable dilatation of the right subclavian vein and the cervical veins of the right upper limb.
Physical examination revealed significant edema of the right upper limb, with pain on palpation and holosystolic murmur in the topography of the right pulmonary apex. Right radial, ulnar, and brachial pulses were all reduced in comparison with those of the contralateral limb.
Two weeks after this consultation, the patient presented at an emergency room with exacerbation of the dyspnea, symptomatic ventricular tachycardia, and frequent premature ventricular contractions and was admitted to the hospital.
Supplementary cardiac tests were then conducted. The echocardiogram showed dilatation of the left cardiac chambers and an ejection fraction of 63%. Myocardial scintigraphy showed signs of dilated cardiomyopathy.
After clinical and cardiac stabilization, the patient underwent arteriography of the right upper limb, which showed a large arteriovenous fistula between the right subclavian vessels and a pseudoaneurysm of the subclavian artery ( ).
The treatment chosen was endovascular repair under local anesthesia with sedation. The technique employed was via puncture of the right common femoral artery with a 7F introducer and puncture of the right brachial artery with a 5F introducer. The subclavian artery was catheterized via the brachial access and the guidewire was snared and a through-and-through system constructed via the femoral access, due to difficulty in advancing the guidewire via the subclavian artery. The injury w

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


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

[User]
RADIOLOGY NOTE:
A 32 year-old woman with a history of hypothyroidism and pre-eclampsia initially presented to an outside hospital with acute onset dense left hemiplegia, right gaze preference, and left-sided neglect. Her initial National Institute of Health Stroke Scale (NIHSS) was 14 and she had an admission Glasgow Coma Scale (GCS) of 10. A computed tomography (CT) angiogram of her neck revealed complete occlusion of the right cervical internal carotid artery (ICA). She was outside the time window for intravenous thrombolysis; however, she underwent mechanical thrombectomy using a stent retreiver device and aspiration (Penumbra System®, Alameda, CA). Immediately after the procedure, there was a successful restoration of the blood flow to the distal ICA, proximal middle cerebral artery (MCA), and to the anterior cerebral artery (ACA), with residual distal M2 occlusion. She was intubated for the procedure and was extubated in the following days. Her left-sided weakness persisted and a repeat CTA showed re-occlusion of the right cervical ICA. No further intervention was done and she was treated with aspirin and statin for secondary stroke prophylaxis. The stroke was deemed cryptogenic after work-up for a potential source was negative including an echocardiogram which demonstrated a normal ejection fraction, normal left atrial size, and negative bubble study. A workup for prothrombotic and hypercoagulable states were negative as well. Magnetic resonance imaging (MRI) of the brain was done which showed a large area of diffusion restriction with corresponding decreased apparent diffusion coefficient (ADC) and T2 hyperintensity in the right frontal, parietal, temporal lobes and in the basal ganglia with areas of hypointensities on gradient echo sequencing, which suggested infarction in these areas with some areas of hemorrhagic conversion (Figure ).
Subsequently, she was discharged to an inpatient rehabilitation center. While at the rehabilitation center, about four weeks after her stro

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


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

[User]
RADIOLOGY NOTE:
A 38-year-old Caucasian woman who had no medical history presented with a headache of 2 months’ duration in August 2012. There was a family history of malignancies. She had no psychosocial history. She did not take any medications. She was a housewife. She lived with her husband and three children in a flat in the city center of Istanbul. She never smoked tobacco and did not consume alcohol. Her vital signs were stable with blood pressure 110/70 mmHg, pulse rate 82/minute, and temperature 36.5 °C. On neurological examination, there was a limitation of temporal movement in her right eye. There were no signs of paresthesia or hypoesthesia. A general examination showed no other abnormality. Brain MRI showed 34 mm × 10 mm and 20 mm × 19 mm masses in her clivus. She was operated on and a pathology examination showed chordoma. Postoperative stereotactic radiotherapy to clivus at a total dose of 24 Gray in one fraction with gamma-knife was performed. In March 2014, she had a recurrence in her clivus and then she underwent another operation. A pathology examination revealed chordoma. She presented with diplopia for 1 month in January 2015. Brain MRI detected a recurrent mass in her clivus and invasion to the pons. She was treated with external cranial radiotherapy for palliative intent. She received a total of 30 Gray to recurrent mass in ten fractions during 10 days. In March 2015, a residual mass in her clivus was seen in MRI. She was started on daily 400 mg of imatinib in April 2015. The best response to imatinib was stable disease. Overall, imatinib was well tolerated; she reported periorbital edema, grade 1 skin rash on her legs, and nausea grade 2. She complained of visual loss in her left eye in May 2017. Brain MRI confirmed progressive disease (Fig. ). Imatinib was stopped and sunitinib 37.5 mg per day was started in

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


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

[User]
RADIOLOGY NOTE:
We report the case of a 37-year-old male with a past medical history of essential hypertension and hyperlipidemia who was transferred to our hospital for further ongoing care for colitis and hematochezia in settings of possible bleeding disorder. The patient was initially presented to another hospital with a one-week history of diffuse abdominal pain, bloating, and a three-day history of bright red blood per rectum. He also reported multiple episodes of vomiting and one episode of gross hematuria. The patient also reported a six-month history of fatigue, generalized body weakness, cold intolerance, swelling in his arms and legs, easy bruising, and unintentional weight loss of 20 pounds over six months duration. In October 2020, he had an episode of profuse gum bleeding after a dental procedure, and he has been currently being worked up by hematology as an outpatient for von Willebrand disease (VWD) versus hemophilia. He had a remote history of proteinuria and was following by nephrology outpatient, but a biopsy was not pursued in the setting of bleeding disorder workup. We were consulted as he was found to have nephrotic range proteinuria with a 24 hr urine protein of 4.61 gm.
On examination, he was afebrile with a blood pressure of 105/64, tachycardia with a heart rate of 112, and normal oxygen saturation on room air. He was in no acute distress. His cardiac and pulmonary exam was unremarkable. Abdominal examination revealed mild diffuse tenderness and dullness on percussion. He had +2 non-pitting edema in the lower extremities. The skin was dry, and no rash was noted. Ultrasound abdomen was done, which showed hepatomegaly with findings of portal hypertension with the slow flow in the main portal veins, recanalized umbilical vein, pericholecystic edema, reversal flow within the splenic vein at pancreas, splenic siderosis, splenic varices, and moderate ascites.
Laboratory workup (Table ) revealed acute kidney injury (

[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 Caucasian man presented with intermittent upper abdominal pain, nausea and bloating for the previous 12 months. There was no history of fever, jaundice, pale stools or dark urine. His past medical history included a Billroth II gastrectomy and Roux-en-Y reconstruction for peptic ulcer disease 11 years earlier. On examination, he was haemodynamically stable and afebrile. Abdominal examination was unremarkable. Laboratory tests, including liver function tests and inflammatory markers were all normal. Transabdominal ultrasound examination revealed gallstones and intra- and extrahepatic biliary dilatation. Endoscopic retrograde cholangiopancreatography (ERCP) was unsuccessful. Magnetic resonance cholangiopancreatogram (MRCP) and computed tomography (CT) confirmed gallstones within the gallbladder and biliary dilatation to the level of the ampulla, and demonstrated a 4 × 3 cm low density filling defect in the second part of the duodenum (Figure ).
After he was admitted to a specialist centre, endoscopic ultrasonography and repeat ERCP were attempted but failed due to inability to cannulate the duodenal limb of the Roux-en-Y. Two hours after the procedure he developed severe, generalized abdominal pain and hypotension. This raised the possibility of iatrogenic intestinal perforation. However, it was decided to proceed directly to laparotomy rather than repeat imaging, since it was apparent that surgical exploration would be required in the event of unsuccessful ERCP. During the operation, there was no evidence of intestinal perforation. A 3.5 cm gallstone was found proximal to a stricture in the second part of the duodenum. There was no evidence of a cholecystoduodenal fistula. The duodenal papilla and pancreas were normal. The common bile duct, which was dilated due to extrinsic compression by the intraduodenal gallstone, was explored and found to be normal, and contained no stones. The gallstone in the duodenum was extracted via a duodenotomy, the duodenal

[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 63-year-old Hispanic woman with a history of peptic ulcer disease with dyspepsia and was treated with a proton pump inhibitor (PPI). She was diagnosed with Helicobacter pylori infection and received a triple drug therapy. Subsequently she experienced weight loss of approximately 14 kg over 2 months (BMI = 18.4; previous weight 64 kg, BMI = 23.5), and her dyspepsia did not improve. Colonoscopy and esophagogastroduodenoscopy (EGD) were performed and revealed a 4 cm pyloric ulcer and 70% pyloric stenosis; biopsies were taken at the time of the EGD. The biopsy demonstrated adenocarcinoma in signet ring cells. She was referred to the General Ignacio Zaragoza Regional Hospital Surgery Department for further evaluation. Social history was significant for an 18-pack-year smoking history. Her family history was significant for first-degree relatives with a history of cancer: one with bladder carcinoma and the other with prostate carcinoma. Her physical examination was within normal limits. Laboratory tests demonstrated normal hemoglobin and hematocrit levels, normal liver enzymes, and normal renal function; however, urinalysis was significant for both proteinuria and hematuria, and her blood type is A positive. Carbohydrate antigen (CA)125 and CA19-9 were normal. Her chest X-ray was normal for her age. A computed tomography (CT) scan of her abdomen and pelvis showed a tumor in her left kidney of approximately 140 × 97 × 85 mm with homogeneous enhancement in its upper pole. No distant metastases were evident. Surgical intervention with an exploratory laparotomy was undertaken, where a partial gastrectomy was performed with gastrojejunal anastomosis with omega of Braun reconstruction and left radical nephrectomy. Interoperative cryosections were evaluated by pathology. She had an estimated blood loss of 850 cc, with an estimated surgical time of 210 minutes. The postsurgical course was without complications. The histopathological report describes the left kidn

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


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

[User]
RADIOLOGY NOTE:
A 32-year-old female patient with a history of bronchial asthma of two-year duration came to our hospital for evaluation of uncontrolled asthma. Since her diagnosis, she was started on short acting β-agonists followed by inhaled steroids.
Not long after, long acting β-agonists and Montelukast were added to the treatment because of persistent asthma consisting of a persistent cough, shortness of breath and wheezes that were not responding to the treatment previously prescribed. She also was prescribed steroids as needed for relapses which happened frequently.
She sought help by multiple pulmonologists and internists, because it was interfering with her life activities, who prescribed her the same treatment and would put her on oral steroids which would improve the patient's condition partially but not completely.
Frequent exacerbations were noticed but since she was already taking the maximal optimal dose for asthma medications, nothing else could be done.
In our hospital, the patient was reevaluated with a detailed history focusing on the place of residence, degree of ventilation of her house (which was well ventilated) and exposure to allergens and animals at home. There was nothing of significant value with no allergen exposure, no history of NSAIDs or β-blockers use and no heart burn. She did however mention a brownish colored sputum with a plug like consistency and multiple courses of antibiotics.
She also mentioned that her husband is an avid smoker but not in front of her and her past medical and surgical history was unremarkable despite the asthma. She affirmed to be compliant with her medication but still suffering from frequent exacerbations that were partially relived by oral or IV steroids.
This led to the suspicion of allergic bronchopulmonary aspergillosis and thus further investigations were done which included:
A chest-CT scan that showed atelectatic bands. Blood and sputum samples that showed increased IgE levels (450 kU/L), increased eosinophils cou

[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 71-year-old female with a pertinent history of essential hypertension, anxiety, and hypothyroidism presented with acute-onset abdominal pain. The pain described the typical characteristics of pancreatitis, with sharp mid-gastric pain radiating towards the back, without any significant relieving factors, accompanied by unremitting nausea and vomiting. The patient did not have any recent history of smoking, drinking, or any recreational drug use. Her home medications included losartan, Synthroid, Xanax, and bupropion.
Clinical history did not yield any relevant information, apart from the fact that the patient had presented with similar acute symptoms of pancreatitis approximately four weeks prior to this episode. She was conservatively managed with intravenous fluids and pain control with the resolution of symptoms. The patient was investigated for common causes of pancreatitis, including ultrasound and computed tomography (CT) of the abdomen, lipid profile, drug screen, and hepatitis panel. The workup to rule out the common causes of pancreatitis was negative.
The patient subsequently improved and was discharged home to be followed by the gastroenterology for further investigations, including magnetic resonance imaging (MRI) of the abdomen and immunoglobulin (IgG4) levels, to rule out uncommon causes of pancreatitis. Of note, before discharge home, she was resumed on losartan at the same dose.
In this admission, the patient presented with similar complains and the repeat CT abdomen with intravenous (IV) contrast redemonstrated acute pancreatic inflammation with mild peri-pancreatic fluid accumulation without any evidence of necrosis and ductal dilatation (Figure ). The ultrasound of the abdomen was also repeated, which did not yield any evidence of cholelithiasis and the common bile duct measured 4 mm in size. The patient was evaluated by gastroenterology and was managed symptomatically. MRI the abdomen did not demonstrate intra or extrahepatic biliary ductal path

[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 81-year-old man visited the gastroenterologist because he had been suffering from iron deficiency anaemia without obvious blood loss for a few months. Apart from intermittent pain in the right upper abdominal region, there were no other symptoms. His weight remained constant and he did not lose his appetite. Defecation was regular, once a day. His medical record consisted of diabetes mellitus type II, hypertension, impaired renal function and an ear operation many years before. He had no history of gastrointestinal problems. Family history revealed two brothers who had died of colorectal cancer at old age. With a body mass index of 28 he was overweight. Examination of the abdomen did not reveal any unusual findings. No abnormality was palpated during digital rectal examination. A complete blood count revealed anaemia (Hb 6.7 mmol/l) and iron deficiency (9 µmol/l).
The patient underwent colonoscopy. Diverticulosis was seen in the sigmoid. Three polyps were removed during the colonoscopy. A bleeding tumour was found in the ascending colon, 80 cm from the anal sphincter. Definitive pathology revealed an adenocarcinoma in the ascending colon. An abdominal CT scan confirmed the presence of a process in the ascending colon. It also showed a liver lesion with a diameter of 9 mm, suspicious of liver metastasis. The CT scan did not reveal any other unusual findings. Ultrasonography of the upper abdomen confirmed a liver lesion, with a diameter of 13 mm, suspicious of liver metastasis with an atypical hepatic haemangioma in the differential diagnosis. MRI scan showed a liver lesion in segment V, suspicious of liver metastasis.
The patient underwent simultaneous right hemicolectomy and wedge resection of the liver lesion. During perioperative inspection of the upper abdomen, a gallbladder deformity was seen (fig. ). The fundus of the gallbladder was folded like a cap. The patient underwent cholecystectomy to make the wedge resection of the liver metastasis in segment V easi

[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-years-old male during an ordinary visit for drug prescription due to his chronic health problems, described his complaints (voice alteration, dysphagia and saliva drooling progressively worsening during the last few weeks) and his general physician referred him for an E.N.T. evaluation. The lack of any pain sensation was the reason for the delay of seeing a physician. His medical history was significant for severe benign prostatic hyperplasia, hypertension and chronic obstructive pulmonary disease. He was heavy tobacco smoker until recently. No history of alcohol intake was referred.
Clinical examination of the oral cavity revealed an oversized pigmented soft mass arising from the left half of his hard palate involving the soft palate and the ipsilateral palatine tonsil causing partial obstruction of the oral cavity and the oropharynx (Figure ). Some pigmented macules of various sizes were also noted growing at the periphery of the tumor. During neck palpation a 2 × 3 cm firm mobile non-tender mass was palpated at the left upper jugular region. A punch biopsy of the oral mass was performed.
A complete blood cell count, biochemical profile, and urinalysis were ordered without significant findings. A chest x ray was normal.
Histological examination of the specimen demonstrated extensive infiltration of the ulcerated mucosa by neoplastic predominantly epithelioid cells, in a solid, nested, trabecular or alveolar pattern. The cells were round to oval, having prominent eosinophilic nucleoli and atypical mitotic figures. In areas with intact surface epithelium was identified continuity of the tumor with the epithelium. There were also brown pigment deposition and neoplastic giant cells (figure ).
A computer tomography with contrast revealed pathologically enlarged cervical lymph nodes of the left neck. Signs of infiltration of the ipsilateral medial pterygoid muscle were also observed (figure ).
Work up for distant metastases (CT scan of chest, brain and abdomen plus

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


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

[User]
RADIOLOGY NOTE:
A previously healthy 48 year old male presented to our surgical out-patient service complaining of a 3 month history of progressively worsening dysphagia for solids with associated regurgitation and unintentional weight loss of 14 kg. Physical examination was unremarkable and there was no evidence of organomegaly or lymphadenopathy. Subsequent oesophagoscopy revealed a large polypoid pigmented lesion at 30 cm. The lesion did not impede the passage of the scope. Multiple biopsies were taken. Two pigmented cutaneous lesions (no sinister features present in either lesion) were also excised – histology showed benign lesions. No evidence of melanoma was found.
A staging CT scan of his thorax, abdomen and pelvis showed a well-defined eccentric mass in the mid-lower oesophagus. There was no apparent local invasion or regional lymphadenopathy.
Whole body FDG PET/CT body scan confirmed the mass in the oesophagus with increased uptake in a high abdominal pre-aortic and high right paratracheal node consistent with metastasis. (see figure ).
Biopsy results from the oesophagoscopy showed an infiltrating malignant tumour with prominent nucleoli and cells prominent in the submucosa and also in the basal layer of the squamous mucosa. S100 stain was positive. Features were consistent with malignant melanoma. The features that confirmed the primary nature of the neoplasm were the junctional change, multi-pleomorphic spindle shaped cells with prominent nucleoli and some lymphocytic infiltrate. (see figures &).
The absence of cutaneous, ocular, or mucosal melanoma elsewhere also supported a diagnosis of primary rather than secondary melanoma.
He underwent a three stage oesophagectomy with mediastinal lymphadenectomy. Seven of the twenty six lymph nodes were postitive for melanoma, including the two nodes highlighted by the FDG-PET scan. The remainder of his post-operative stay was unremarkable and he was discharged home.
He underwent a course of immunomodulatory therapy, consisting of

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


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

[User]
RADIOLOGY NOTE:
A 90-year-old woman visited our hospital due to a large area of erythema and localized skin ulceration with hemorrhage of her right breast. Her breast symptoms arose 5 years ago and had been worsening. She could not visit a hospital because she expected for naturally healing and feared noticing cancer and death. She had a history of atrial fibrillation and cerebral infarction 2 months earlier, then her breast lesion was found out. The area of erythema was 15 × 15 cm2. Her nipple and alveolar complex were destroyed and had an uncertain shape. Her skin erythema was soft, and no tumor was palpable (Fig. ). Her quality of life had got worse by hemorrhage and exudate from the tumor, and she felt strong anxiety about getting more worse and death from the cancer.
A punch biopsy indicated mammary Paget’s disease. Computed tomography showed that the tumor was only on the surface of the breast, with no metastasis including of the axillar lymph nodes. There was no underlying tumor in the breast (Fig. ).
Even though our patient was a very elderly woman with comorbidities and her prognosis was relatively good, her symptoms were intolerable. By the request of her and her family, we decided to perform surgery to eliminate the area of erythema after receiving sufficient informed consent. The surgical treatment was performed by two teams that included surgeons and dermatologists. We drew a resection line 1 cm from the skin erythema. Dermatologists were on standby in case a skin graft was needed. We performed muscle-sparing mastectomy with sampling of an axillar lymph node. We added two stress-relaxation sutures to avoid diastasis because the excision area was very large and the tension of the skin flap was strong (Fig. a, b). Fortunately, a skin graft was not necessary and her postoperative course was good. The skin flap did not develop major complications such as necrosis, seroma, wound infection, and highly disturbance of moving the right upper limb. We removed the stress

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


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

[User]
RADIOLOGY NOTE:
A 77-year-old man with no history of skin cancer presented to the outpatient dermatology clinic for a scalp lesion of three weeks duration. He reported rapid lesion growth, but no change in the overall appearance nor any associated symptoms. Examination revealed a mobile, round, exophytic nodule with overlying ulceration and hemorrhagic crust, approximately 1.5 cm in diameter (Figure ). Given a high clinical suspicion of malignancy, the lesion was excised three weeks following the initial visit using a fusiform (elliptical) incision with 1 cm margins. The lesion immediately prior to the procedure is seen in Figure .
A histopathologic examination of an excisional biopsy of the cutaneous lesion revealed a proliferation of spindle and pleomorphic tumor cells, which flattened the overlying epidermis (Figure ) and extended to the subcutaneous tissue (Figure ). The tumor cells were large and polygonal and contained eosinophilic cytoplasm. They expressed diffuse CD10 positivity (Figure ) and focal CD68 positivity. The tumor cells were negative for p40 and SOX10, excluding the possibility of sarcomatoid carcinoma and melanoma, respectively. The histopathologic findings were found to be consistent with invasive pleomorphic dermal sarcoma. The tumor measured 3.3 cm at the largest dimension, and tumor cells were found to be present at the surgical margin. There was no evidence of lymphovascular or perineural invasion.
A surgical, wide, local excision was planned. Preparatory computed tomography (CT) imaging revealed an approximately 3.9 cm focus of enhancement with central ulceration in the soft tissue of the posterior scalp and confirmed a lack of bony erosion in the underlying calvarium. No metastatic adenopathy was appreciated. Figure demonstrates the scalp vertex prior to surgery. A wide local excision was performed using a 2 cm margin around the remaining tumor for a 7.5 cm area of planned excision. The repair utilized a 7x3.5 cm full-thickness skin graft from the left up

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


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

[User]
RADIOLOGY NOTE:
A 47-year-old female with renal failure secondary to adult polycystic kidney disease had repeatedly refused the formation of an AV fistula for haemodialysis due to severe needle phobia. She was commenced on peritoneal dialysis in 2008, which became inadequate as a result of membrane failure in 2010. She was commenced on haemodialysis via twin tunnelled Tesio® (Medcomp, PA, USA) lines inserted via a left internal jugular approach having had temporary right internal jugular access previously.
She was referred to the vascular surgery unit with the line in situ for 2 years following a failed attempt to remove the malfunctioning venous limb of the catheter on the renal unit. A chest X-ray showed the tip of the catheter at the level of the right atrium (Fig. ). Following discussion at the multi-disciplinary meeting, the decision was made to attempt removal of the line by a combined endovascular and surgical approach under general anaesthesia.
Under general anaesthesia, a cut down was performed onto the left internal jugular vein at the entry point of the catheter. The fibrin sheath was incised and traction on the catheter failed to release it. Simultaneous traction and snaring of the catheter tip via a femoral venous approach was failed. A hydrophilic guide-wire was passed through the catheter and out of a side hole of the line, which was then snared in the right atrium. Synchronous traction was applied to both ends of the line via the snare and the external portion of the line, but the line could not be freed. Balloon angioplasty within the lumen of the line was performed in order to attempt splitting of the surrounding fibrin sheath. Furthermore, upon traction of the external portion of the line, the unusual finding of a palpable transmitted pulse via the catheter was noted. In order to investigate this further, a trans-oesophageal echocardiogram was performed intra-operatively. This showed the proximal portion of the line passing through the tricuspid valve, with its t

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


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

[User]
RADIOLOGY NOTE:
An 87-year-old woman with an intractable pain radiating over the left chest, suggestive of intercostal neuralgia, was referred to our spine center for further evaluation and management. Five weeks earlier, she experienced a ground-level fall, causing severe back pain. According to the initial evaluation conducted elsewhere, she was diagnosed as having OVF of the T10 vertebral body and managed conservatively with a brace and pain medication for one month. Her chief complaint gradually changed from bilateral back pain to an aching pain extending to the left thorax before her first visit to our hospital. What is noteworthy about the history of this case is that 8 years previously, she had had a painful OVF of the T12 vertebral body at the age of 79 years, which was treated with vertebroplasty using hydroxyapatite (HA) blocks and posterior pedicle screw instrumentation followed by iliac bone graft fusion from T11 to L1 at another hospital [].
On clinical examination at our hospital, the patient had no neurologic deficits, complaining of nothing but reporting a position-dependent severe chest pain on the left side, which intensified when sitting up from a supine position. Imaging studies revealed neither rib fractures nor abnormal findings of the chest cavity as a possible cause of the chest pain.
On the plain radiographs of the thoracic spine (), the anteroposterior (AP) views and the lateral views taken in the supine position showed the IVC within the T10 collapsed vertebral body as a gas-like radiolucent area, which disappeared on the lateral view obtained in the sitting position (i.e., the opening-closing phenomenon) most likely indicating an OVF of nonneoplastic and noninfectious origin [, ]. The lateral radiograph in the sitting position also demonstrated that the fracture line extended through the posterior fusion mass bone, grafted 8 years ago, indicating a potentially unstable flexion-distraction injury. Close observation of the AP radiograph obtained in the sup

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


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

[User]
RADIOLOGY NOTE:
A 32-year-old male was referred to the endocrine surgery team with hypercalcemia and a history of several years of kidney stones. He had first been diagnosed with elevated serum calcium ∼6months prior to his visit in the endocrine surgery clinic but had experienced recurrent problems with nephrolithiasis for several years prior to this. He underwent three lithotripsy procedures and multiple urologic stent placements during this time. Additional symptoms included severe fatigue, weakness and joint pain. Aside from his nephrolithiasis and subsequent renal failure, the patient was otherwise healthy, with no medication use, no allergies, and no history of tobacco or alcohol use.
Six months prior to our evaluation, at another hospital, the patient underwent failed neck exploration for primary hyperparathyroidism. Pre-operative imaging suggested a right inferior parathyroid adenoma, but bilateral neck exploration including a right thyroid lobectomy was unsuccessful. The initial operation was complicated by transient bilateral vocal cord palsies. The patient was evaluated by an otolaryngologist, and his weak voice and vocal cord palsies resolved without any further intervention.
His hypercalcemia persisted and the patient continued to suffer from nephrolithiasis. Despite his multiple urologic interventions, he developed renal failure with a creatinine peaking at 13.5 and requiring temporary dialysis. Parathyroid imaging, including sestamibi/SPECT scan as well as MRI/MRA of the neck and chest suggested an ectopic parathyroid adenoma in the aortopulmonary window (Fig. ). Following consultation with cardiothoracic surgery, the patient underwent a minimally invasive thoracic approach to the mediastinum, followed by conversion to a left posterolateral thoracotomy. Neither approach located the suspected mediastinal adenoma. A median sternotomy was then performed. The entire thymus and all mediastinal fatty tissues were removed without evidence of any abnormality. Finally, the pe

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


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

[User]
RADIOLOGY NOTE:
A 32-year-old, Australian Caucasian man who was a national competing power lifter was referred to our specialist sports clinic 8 weeks after experiencing sudden intractable pain in his left knee, accompanied by a loud popping sound, whilst leg pressing 300 kg. Weight bearing and extension of his left leg were subsequently limited as a result of pain. Prior to attending our clinic, he had been managed non-operatively by his General Practitioner and a Physiotherapist, who had provided him with a knee brace for support. Despite this, he suffered continued pain and weakness, but denied any locking, giving way or instability.
He was a non-smoker, with no past medical problems and expressly denied using systemic steroids. He had not previously experienced any knee problems. Clinical examination revealed left quadriceps wasting in comparison to the contra-lateral leg with a palpable gap over the superior-lateral aspect of his patella. Knee flexion, in particular squatting, evoked pain and accentuated the gap. This also further demarcated the prominent, retracted vastus lateralis muscle belly (). A normal range of active movement was retained; however power in extension was diminished in comparison with the other leg. There was no extension lag and no clinical evidence of ligamentous or meniscal pathology within the knee joint.
Blood tests showed no evidence of haematological or metabolic abnormality.
Anterior-posterior, lateral and skyline patella radiographs of the knee showed no diagnostic irregularity and no evidence of femoral trochlea dysplasia or variation in patella height or tilt. MRI demonstrated a complete and isolated avulsion of the vastus lateralis component of the quadriceps tendon in the osteotendinous region at its patella insertion (). The patient was keen for operative intervention as he had already undertaken a course of unsuccessful conservative therapy and was anxious to expedite his return to training.
Intra-operative findings confirmed an avulsion of

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


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

[User]
RADIOLOGY NOTE:
A 24-year-old female patient presented to the emergency department complaining of severe pain and redness in both eyes.
The patient had a clear medical record. She mentioned that she is a regular contact lens user due to myopia and had never experienced problems with her eyes. She had been wearing soft contact lenses for the last six years on a daily wear basis for eight hours per day, seven days per week and used OptiFree Express (Alcon, Fort Worth, Texas) as a disinfecting solution. She claimed to never wear her contact lenses overnight. The patient also mentioned that she had recently switched to a different contact lens disinfecting solution. She started to use Renu fresh multipurpose solution (Bausch & Lomb, Rochester, New York) based on the recommendation of her optician. Finally she mentioned that her lenses, suitable for use for one month, were not used for more than one week, and that the pair currently in use were in fine condition.
Best corrected visual acuity was 20/20 on both eyes despite the fact that a sense of blurred vision was reported.
Slit-lamp examination revealed two infiltrates, approximately 1,5 mm in size, at 4 and 7 o'clock in the inferior part of the cornea in the right eye and five smaller infiltrates in the superior half of the left cornea. The infiltrates appeared to extend to the middle stroma. Furthermore, conjunctival redness and moderate anterior chamber inflammation were observed in both eyes.
Regarding management, the appropriate guidelines were applied [].
Immediately, prior to any action, the infected contact lenses and a specimen of the disinfecting solution were taken and sent in for culture [].
Initially, although the patient was informed of her condition and advised to follow the appropriate treatment in her own house, she demonstrated significant anxiety about the way she should administer the medication and subsequently was advised to remain in the clinic for treatment.

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


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

[User]
RADIOLOGY NOTE:
A 72-year-old man presented with left hip pain and intermittent low grade fever, as well as occasional yellowish drainage from a sinus tract at the surgical incision of a cementless THA performed 4 years before at another hospital. Patient's past medical history was also significant for a 2-vessel coronary artery bypass graft (CABG), performed one year prior to the current presentation. Prior use of steroids, a previous state of immunosuppression, or recent travel was not reported. The patient reported multiple prior hospital admissions due to drainage, allegedly attributed to a superficial infection and suppressed multiple times with multiple courses of per os and/or intravenous antibiotics including vancomycin, clindamycin, ciprofloxacin and cotrimoxazole, only to recur a few months after each episode and antibiotics regimen. Anteroposterior (AP) pelvis, AP and lateral hip radiographs as well as laboratory findings were consistent with PJI, as well as heterotopic ossification adjacent to the left hip joint (Fig. ). Preoperative cultures collected with wound swabs showed Staphylococcus hominis and Staphylococcus capitis isolates of debatable clinical significance; cultures of synovial fluid aspiration were negative. With the assumptive diagnosis of PJI and septic loosening of the implants a joint decision was obtained for a staged THA revision.
The patient was scheduled for the first stage THA revision 4 weeks after cessation of any antibiotics. Through a posterior hip approach, the femoral component was removed via a Paprosky-style extended proximal femoral osteotomy . Next, the acetabular cup and supporting screw were removed (Fig. ). Eight tissue samples were obtained from the bone, joint capsule and femoral canal for cultures, and the implants were sent for sonication. We routinely use sonication to identify bacteria in the biofilm on explanted implants, as this method has been found to be significantly more sensitive than tissue biopsy, while maintaining almos

[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 female patient presented with cough and mild dyspnea to the outpatient department. She had a history of being diagnosed with pulmonary tuberculosis 7 years ago, which she had completely recovered after 6 months of antituberculosis drug regimen. There was no other notable history. Dullness and decreased breathing sound at the left side was noted after auscultation. Complete blood count revealed no abnormal finding, and no acid-fast bacilli was discovered on the sputum culture test. Plain chest radiography showed giant bulla in the left lung and subsegmental consolidation in the left lower lung field. Chest computed tomography (CT) scan revealed the left upper lobe of the lung being replaced by bullae of various sizes, and subsegmental consolidation had broad contacted with bullae at the lingular segment of the left upper lobe (). The right lung showed no abnormality. The patient's pulmonary function test signified moderate obstructive respiratory failure. Wedge resection of the left lung using video-assisted thoracoscopy was performed under the preoperative diagnoses of giant bullae and pulmonary emphysema. During operation, the left lower lobe was found to be severely compressed by the bullae. Gross examination of the wedge resected lung was 15 × 9 × 4 cm in size with dilated giant bullae (). Spongiform emphysema was observed at the cut surface, and there were partial solid changes and fibrotic progression. Examination of the solidified sites by light microscope indicated general emphysematous changes with destruction of the alveolar wall in addition to numerous tissues replaced by structures similar to the chorionic villi. The villous structure was adjacent to, or in some cases adhered to, the destroyed alveolar wall and interlobular septa. Immunohistochemical staining of the epithelium lining the villous structure was partly positive for thyroid transcription factor-1, and the interstitial cells at the core was positive for CD-10, D2-40 and vimentin

[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.