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

[User]
RADIOLOGY NOTE:
A 67-year-old Caucasian male presented to the emergency department at a local hospital for left lower abdominal tenderness. The patient had undergone a living unrelated kidney transplant into his left iliac fossa 12 years prior due to chronic glomerulonephritis. His stable immunosuppression regimen included tacrolimus (1 mg every 12 h), mycophenolate mofetil (500 mg every 12 h), and prednisone (5 mg daily). Except for one episode of acute cellar rejection a month after kidney transplantation, he had been doing well with a baseline serum creatinine level of 2.0 mg/dL. On arrival, his body temperature was 36.6 °C, blood pressure was 163/54 mmHg, and pulse was 61 beats/min. He reported that he had been active until the day before without noticing any injuries, but he recalled his cat, weighing 15 lbs, jumped on his abdomen seven days prior. On physical examination, his abdomen was soft and flat without rebound or guarding, except for a small tender mass noticed at the incisional site of the kidney transplant. His hemoglobin was 7.1 g/dL. His serum creatinine level was elevated from his baseline to 2.5 mg/dL. He was producing a normal amount of urine without hematuria. Computed tomography (CT) without intravenous contrast revealed a 12 cm × 2.5 cm subcapsular hematoma around the transplanted kidney (Figure ). Urology was consulted, and the decision was made to conservatively observe the patient, as he met criteria of a renal trauma grade II according to the renal trauma grading system by the American Association for the Surgery of Trauma.
On admission, the patient received a red blood cell transfusion and was started on labetalol for hypertension. His systolic blood pressure was controlled within a range of 110-140. Within three days, his serum creatinine level increased to 5.4 mg/dL and his urine output decreased. His blood pressure was elevated up to 156/80 mmHg. The patient was transferred to a transplant center for further 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 69-year-old Filipino man with history significant for hypertension and hyperlipidemia presented to his primary care physician with hematuria with weight loss of 1 month’s duration. He did not have any flank pain, burning on urination, or increased urinary frequency. He did not endorse any symptoms of fatigue or night sweats. His only medication was atenolol for his hypertension. He did not smoke tobacco, drink alcohol, or do any recreational drugs. He was unemployed at time of interview. He did not have any family history of cancer. His vital signs were within normal limits. On physical examination, he was well appearing and in no acute distress. He had no palpable mass and had an otherwise normal cardiovascular, respiratory, and neurologic examination. Laboratory work showed normal cell counts and normal electrolytes; the results of his kidney and liver function tests were normal. A computed tomography (CT) – intravenous pyelogram was performed as a diagnostic work-up for his hematuria, which demonstrated a large mass in the left collecting system and proximal ureter. He was seen by urology with plans for surgical resection 1 month later. Three weeks later he was admitted to the Emergency Department with nausea and vomiting. He was tachycardic to 110 beats per minute but maintained a normal blood pressure. His laboratory results were notable for hemoglobin to 12.1. His sodium was 134. At that time, a CT scan of his abdomen and pelvis showed interval enlargement of the left renal mass. An ureteroscopy with biopsy was performed, which showed necrotic tissue with rare crushed degenerating atypical cells. A screening chest CT scan was also obtained which showed a small 3 mm nodule in the lower lobe of his left lung. A follow-up interventional radiology-guided left kidney biopsy showed a cellular neoplasm with sheets of pleomorphic round cells with hyperchromatic nuclei, irregular nuclear outlines, and inconspicuous nucleoli with scant and delicate cytoplasm which is

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


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

[User]
RADIOLOGY NOTE:
A 38-year-old female patient, gravid 3 para 2 abortion 1 was referred to our hospital with a one-year history of vaginal mass. One year before admission, the patient felt vaginal uncomfortable and found a mass in her vagina. The patient, lived in a remote rural area, did not go to the hospital for further examination due to her poor economic condition. She experienced discomfort in the vagina and felt the vaginal mass was growing progressively in the past year before admission. Her general medical history revealed no surgery and disease. At the time of consultation, vaginal examination demonstrated a large fixed mass was located in the right lateral wall of the vagina and occupied the upper and middle third of the vagina. Laboratory blood test results, including serum tumor markers, were all within the normal ranges. Abdominal computed tomography (CT) showed a 17.6 cm× 10.4 cm solid mass in pelvic cavity (Fig. ). The urinary bladder, rectum and uterus were displaced to the left side of the pelvic cavity, but there was no ascites and enlargement of pelvic and para-aortic lymph nodes. Transverse (Fig. a), sagittal (Fig. b) and coronal (Fig. c) CT images revealed the tumor mass was highly suspected to originate from vagina.
Exploratory laparotomy was carried out to remove the mass after adequate preoperative preparation. Intraoperatively, a solid mass with the size of about 18 cm in diameter was found from pelvic floor to pelvic cavity. The lower boundary of the tumor mass was at the level of vaginal orifice. The urinary bladder, rectum, uterus and bilateral adnexa were separate from the mass and displaced to the left side of the pelvic cavity. The boundary between the mass and the surrounding urethra and bladder was clear, and there was no invasion to adjacent organ or metastasis. After Separating the tumor from the surrounding tissue, we found the tumor had a thin, fibrous capsule and originated from the right lateral wall of vagina. The tumor mass was completely rem

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


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

[User]
RADIOLOGY NOTE:
A 6-year-old girl with the complaint of vague periodic abdominal pains mainly in the epigastrium and periumbilical region is referred to the children's hospital. There was not any correlation with feeding and almost having discomfort at night times. She had periods of constipation and diarrhea and symptoms of leg pains. She also used to take Propranolol for early morning headaches mostly in the frontal region for 2 years. The patient with a probable diagnosis of Familial Mediterranean Fever (FMF) was referred to the pediatric rheumatology clinic for further surveys when 0.5 milligram daily colchicine was taken without considerable clinical response. She also had both an intussusception experiment and a history of negative appendectomy since she was 2 years old and the initiation of abdominal pain since that time. She was never febrile during abdominal pains. General examination revealed a thin hemodynamically stable girl with no signs of acute abdomen; the weight and the length were 15 kg and 105 cm [body mass index (BMI): 14.5 kg/m2].
She had second admission within previous 15 days with similar complaints. The grey scale and color Doppler abdominal ultrasonography showed normal portal and splenic veins and there were no evidences of thrombosis. Stool calprotectin test was also requested for a probable inflammatory condition in the gastrointestinal tract. However, because of persistent symptoms, abdominal CT angiography was obtained, which revealed a decrease in aortic and superior mesenteric artery and aortomesenteric angle consequently to 5 mm and 14 degrees suggestive for superior mesenteric syndrome along with a gastric and duodenal dilation [].
Another confirmatory spiral CT scan of abdominopelvic region also marked distended stomach and the proximal part of duodenum which in context of CT angiography proposing SMA syndrome. In addition, she was in a malnourished state without adequate evidences supporting an autoimmune condition. Thus, according to persistent

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


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

[User]
RADIOLOGY NOTE:
A 78-year-old male patient presented in April 2015 with suspected lung cancer. Chest CT examination revealed a pulmonary space-occupying lesion in the left upper lobe of the lung (Fig. ). Following fine needle biopsy, pathology confirmed the patient had lung adenocarcinoma and EGFR (Fig. ), ALK and ROS1 were negative (Fig. ). Due to the advanced age of the patient (78) together with a diagnosis of atrial fibrillation, EGFR-TKIs was recommended as the treatment of choice. From 23 October 2015, the patient commenced gefitinib 250 mg orally once a day until the disease progressed in July 2016 when CT scan of the chest indicated metastasis in the lung. The gefitinib, everolimus combined therapy was subsequently recommended because of disease progression. However, after a few months of combined treatment, everolimus had to be withdrawn because the patient experienced severe breathlessness, cough and mouth ulcers. At that time, the patient had been taking gefitinib for 16 months until drug resistance developed on 16 February 2017 (Fig. (a)).
The patient had second gene mutation testing at this time which indicated EGFR T790M mutation. Osimertinib 80 mg/day orally was subsequently recommended from March 2017. After only one month of treatment, chest CT scan revealed the disease had almost completely resolved (Fig. (b)). However, severe interstitial lung disease was also confirmed (Fig. (b)). The patient was found to have severe cough and difficulty in breathing at this time and the symptoms did not resolve, even after anti-infection and anti-cough treatments were administered. The patient attended our hospital for further treatment. After reviewing his treatment history and chest xray, we considered that he was suffering from severe drug-induced interstitial lung disease and advised him to cease taking the osimertinib immediately. Unfortunately, he still continued to take the osimertinib as he considered the medicine to be effective for his tumor, and refused to tell the d

[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 healthy male presented for an assessment of nonhealing painful necrotic lesions of the left leg. His past medical history included anemia with intermittent pancytopenia diagnosed 10 years ago. Previous specialist hematologic assessment did not reveal an etiology. Two weeks prior, he believed that he sustained a spider bite while mowing the lawn during the month of August. The lesion began as a small papule less than 1 cm and then developed into a large blister on the left lower calf. Oral cloxacillin was initiated for one week; however, the lesion rapidly increased in size, began to ulcerate, and was extremely painful. He presented to the emergency room at a community hospital, febrile (38 degrees Celsius) with otherwise stable vitals. The documented area of necrosis measured 10 cm × 13 cm. Blood work showed ongoing pancytopenia (white blood cell count of 1.8 × 109/L, hemoglobin 100 g/L, platelets 88 × 109/L). He underwent urgent surgical debridement due to clinical concerns of a necrotizing process. Empiric ceftriaxone, metronidazole, and clindamycin were initiated. There was no intraoperative evidence of necrotizing fasciitis, purulence, or foul odour. Tissue cultures yielded methicillin-susceptible Staphylococcus aureus (MSSA), and the antibiotics were narrowed to cefazolin. Necrosis developed at the surgical margins and rapidly extended a further 3 cm over the next 3 days. A second surgical debridement was completed with the addition of a negative pressure dressing over the wound. The intraoperative tissue cultures yielded MSSA and Pseudomonas aeruginosa. Ciprofloxacin was added to cefazolin. During the subsequent three days, the patient developed severe calf pain with an expanding hematoma and required urgent surgical exploration. No significant abnormalities were noted. Tissue cultures yielded the same mixture of organisms. Further extension of necrosis again was observed at the surgical margin, and a fourth surgical debridement extended his woun

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


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

[User]
RADIOLOGY NOTE:
In January 2018, a 70-year-old man residing in South Korea was admitted to Chosun University Hospital with reported consistent low back pain. At first, he had been admitted to a local hospital on 24 November 2017, a month before visiting Chosun University Hospital with a history of 5 days of chills and fever. In the local hospital, in view of the possibility of acute pyelonephritis, he was first treated with intravenous ceftriaxone at a dosage of 2 g daily. Two days after admission, back pain started. During antibiotic treatment, blood cultures taken on admission yielded Salmonella enterica. He remained on ceftriaxone (2 g daily) for 18 days including initial treatment to cover S. enterica. Upon follow-up blood culture, no bacteria were detected on the 8th and 25th days after starting treatment, and the patient no longer had fever; he was subsequently discharged from the local hospital on 19 December 2017. However, he consistently suffered from lower back pain, nausea, and vomiting; he was re-admitted to the same local hospital 9 days after his discharge. When he was re-admitted to the local hospital again on 30 December 2017, magnetic resonance imaging (MRI) was performed and L1 spondylitis was demonstrated. MRI revealed whole bone marrow oedema with endplate lytic changes in the L1 body and focal marrow oedema in the upper endplate of L2 bodies. Additionally, mild destruction of intervertebral disc at L1–2 was shown. These findings were considered to be indicative of pyogenic spondylitis (Fig. a, b, c). He was empirically treated with cefazolin (1 g, 3 times a day) for 10 days to cover the possibility of Staphylococcus aureus infection, which is a common cause of pyogenic spondylitis. Then, blood cultures were tested and yielded S. enterica again. Finally, he was transferred to Chosun University Hospital, and bone biopsy of L spine was performed on 3 January 2018. He had no fever, and the initial blood test was

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


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

[User]
RADIOLOGY NOTE:
A 18-year-old male patient reported to our center with a chief complaint of pain and swelling of the left maxilla since 6 months. On extraoral examination, there was a diffuse bony swelling of the left maxilla which was slightly tender on palpation. Intraoral examination revealed bicortical expansion of the left maxillary alveolar ridge with the swelling extending from left first premolar to the first molar which was roughly elliptical in outline and nontender (). The swelling was hard in consistency and measured approximately 3∗2 centimeters in greatest dimension. No mobility of the teeth in the region was elicited and there was obliteration of the buccal vestibule. Mucosa over the swelling was normal with absence of any ulcerations or sinus discharge. There were no other secondary changes involved like paresthesia or cervical lymphadenopathy.
Radiographic examination revealed a well-circumscribed, radio-opaque lesion mixed with areas of radiolucency. The lesion was roughly round to oval in outline and measured around 3∗3.5 cm in diameter. The periphery of the lesion was surrounded by a well-defined radiolucent rim (). There was no reactive bone forming rim at the periphery. Radiographically, the lesion was extending from distal surface of canine root anteriorly to the mesial surface of second molar posteriorly. Superiorly, the lesion was invading into the maxillary sinus and the inferior extent was almost till the alveolar ridge ().
Incisional biopsy was performed under local anesthesia. Access to the lesion was gained through a buccal crevicular incision. A diagnosis of benign bone tumor was then made based on the histological, radiological, and clinical findings. Complete excision of the tumor mass was planned under general anesthesia. Under strict aseptic precautions, complete excision of the tumor was performed through a buccal vestibular incision extending from canine to the second molar (). Intraoperatively, the tumor was not very vascular and as it was well

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

[User]
RADIOLOGY NOTE:
A 49-year-old man was referred to our hospital for lower abdominal pain. Colonoscopy showed a circumferential tumor in the sigmoid colon, and histopathological examination revealed moderately differentiated adenocarcinoma. Enhanced computed tomography (CT) and magnetic resonance imaging (MRI) showed a large tumor directly invading into the urinary bladder and the left ureter. Besides, an abscess was formed between the tumor and the urinary bladder (Figures and ). Cystoscopy showed no definitive tumor exposed in the mucous membrane, and urine cytology was also negative for cancer. Preoperative staging was cT4bN0M0 cStage IIC locally advanced sigmoid colon cancer. Neoadjuvant therapy was considered; however, because the patient had continuous lower abdominal pain with a high C-reactive protein level of 6.1 mg/L, we decided against neoadjuvant therapy. We then planned laparoscopic anterior resection with en bloc partial resection of the urinary bladder and left ureter. For a safe surgical margin and to avoid bleeding from the internal iliac vessels, en bloc resection of the hypogastric and pelvic nerve plexus was also planned preoperatively.
The patient was placed in the lithotomy position under general and epidural anesthesia. The following ports were placed: a 12 mm port at the umbilicus for a scope, a 12 mm port at the lower right quadrant, and 5 mm ports at the upper right and left abdominal quadrants.
First, the sigmoid colon was mobilized medially-to-laterally and the root of the inferior mesenteric artery was divided. Subsequently, we mobilized the rectum to the bottom of the pelvic floor on the right and posterior sides while completely preserving the right nerve plexus; this point was used as the surgical landmark on the posterior side ().
Second, the external iliac vein was exposed and the obturator nerve and vessels were preserved. The left ureter was mobilized and divided at the oral side of the tumor. The left internal iliac artery was exposed and the umbi

[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:
Here, we present a case of double cancer in a 65-year-old male patient. The patient was diagnosed with 3 cancerous lesions: pancreatic cancer, a cancerous lesion in the liver, and an independent tumor with pneumothorax in the lower lobe of the right lung.
Doctors performed biopsies of the pancreatic and liver tumors. Biopsy of the pancreas revealed that the pancreatic tumor was primary adenocarcinoma (Fig. E–G). The liver lesion was metastatic adenocarcinoma from the pancreatic cancer.
As for the lung tumor, doctors first speculated that it was metastatic pancreatic carcinoma. However, there was no histological evidence on the tumor before surgery.
Additionally, doctors could not control the pneumothorax by conservative treatment without performing surgery. Thus, an emergency surgery with partial resection of the lower lobe of right lung was performed, and the surgical specimen was subjected to histopathological examination. Informed written consent was obtained from the patient for publication of this case report and accompanying images.
The patient died 50 days after the surgery.
The surgical specimen of the right lung was subjected to histopathological examination. The specimen was 105 × 43 × 20 mm in size and had a tumor of 45 × 27 × 15 mm in size.
The main tumor was invasive squamous cell carcinoma of the nonkeratinizing type, and it was diagnosed as primary lung cancer (Fig. A). The primary lung cancer displayed no evidence of pleural dissemination and was classified as pT2b.
The background lung tissue included bronchiolization and fibrotic lesions with mucinous metaplasia and emphysematous changes.
Small adenocarcinomatous lesions were detected in the lung lesion. Metastatic adenocarcinoma lesions were located in the primary lung cancer lesion, outside the pleural elastic fibers (Fig. A–D). We also found metastatic adenocarcinoma in the fibrotic regions associated with pneumothorax and bronchiolization, adjacent to the lung cancer (Fig. E–H).
In addition, ade

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


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

[User]
RADIOLOGY NOTE:
The patient is an 18-year-old boy not known to have any medical illness previously, who was referred to the outpatient department from another hospital after 3 months history of seizures. Seizures started with blurring of vision and proceed to right sided head deviation and tonic posturing of the right upper limp which progress to generalized tonic-clonic seizures. The episodes are followed by loss of consciousness and postictal suboccipital and frontal tension headache. There was no history of fever, loss of weight, trauma, or any sensory/motor neurodificit. Family history was unremarkable, with negative past surgical history. All general and local physical examinations were done and all were within normal range. There were no physical findings or family history in favour of neurofibromatosis. Brain MRI with contrast was done and showed right parieto-occipital cortical and subcortical mass lesion measuring about 1.5 x 1.5 cm that has a low signal intensity on T1 and intermediate signal intensity on T2 and FLAIR with intense enhancement postgadolinium administration mainly peripherally with few small susceptibility artefact on T2 associated with significant vasogenic oedema and mass effect on the adjacent sulci ().
The radiological impression with the above description was most likely representing granulomatous infection (TB) or metastasis. Although a preoperative diagnosis could not be clearly established, the tumor was surgically removed through a right occipital craniotomy. The dura was incised and small area of discoloration was noted. Cortical dissection was done, with multiple pieces for frozen section, which was diagnosed later as suggestive of schwannoma, differential diagnosis meningioma. The tumor was encountered 2mm in subcortical area, which was firm, fibrous in content, yellowish in colour, and resembling meningioma. Postoperatively, the patient did not have any new neurological deficit, and he was discharged 1 day postoperatively in stable condition to

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


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

[User]
RADIOLOGY NOTE:
A 55-year-old female presented complaining of reduced visual acuity in the left eye that had been progressing for 5 months. She had no remarkable medical history and was not receiving any medical treatment. Visual acuity in the Snellen chart was 20/20 in the right eye and 20/40 in the left eye. Pupillary responses were normal in both eyes whereas color vision, tested with the Ishihara charts, was significantly disturbed in the left eye. Slit lamp examination and intraocular pressure were normal in both eyes. Dilated fundus examination disclosed no pathology. Visual fields examination (Humphrey 24-2 SITA standard) was normal in the right eye and revealed a deep central scotoma in the left eye (). The patient refused to undergo the suggested MRI examination, at that time.
Twenty days later, the patient returned with further loss of vision in her left eye. Ocular examination revealed visual acuity in the left eye 20/80 and a relatively afferent pupillary defect (RAPD). Fundus examination disclosed partial atrophy of the left optic nerve.
Emergency MRI and consequent selective digital angiography confirmed the presence of a giant aneurysm of 28 mm of diameter, arising from the supraclinoid part of the left internal carotid and a second smaller aneurysm of 9 mm diameter with a wide base near the origin of the left ophthalmic artery (Figures and ). The patient was referred to the Department of Neurosurgery where successful endovascular embolism of the aneurysms was performed, leaving the left internal carotid blood flow intact. Three months later, the patient presented with worsening of vision in her left eye, which was assessed to 20/400. The new MRA showed late failure of the previous embolization procedure, due to recanalization of the aneurysm. An additional, totally successful, embolization was performed ().
The patient's symptoms gradually recessed, and, at 20 months followup, visual acuity is 20/25 with significant improvement of visual fields findings (). Partial

[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 report presents a case of 58 years old Caucasian male, a case of confirmed prostate carcinoma with GLEASON score 8 diagnosed in August 2014 ruled out through FNAC followed by PET CT. The subject received chemotherapy (Zytiga and Lupron) and hormonal treatment, but represented a refractory pattern after multiple chemo failures, with PSA levels rising above 200 ng/mL. The patient had previously been diagnosed with Renal Cell Carcinoma (RCC) in 1996 and had undergone nephrectomy of the right kidney. With a history of recurrences, he decided to opt for active immunotherapy. PET CT scan prior to the immunotherapy revealed multiple intensely PSMA avid lesions noted in both lobes of the prostate gland with SUVmax −28.3 and the prostate gland measuring 3.2 × 3.2 cm displaying maximum dimensions representing primary mitotic lesions and furthermore showing few mildly avid sub-centrimetric para aortic, aortocaval, and bilateral external iliac lymph nodes. Post-administration of Dendritic Cell Immunotherapy APCEDEN (6 doses between March 2017 and June 2017), remission of the carcinoma was observed as indicated by the significant decline in the PSMA avidity by 50% reduction in SUV max dwindling to 14.0 regaining the normal size and shape of the prostate gland with no obvious focal lesions, consistent with primary disease and likewise no significant PSMA uptake in the iliac and pelvic lymph nodes (Fig. ). Six months post completion of APCEDEN, the patient was administered 6 booster shots of APCEDEN, once monthly from January 2018 until June 2018. PET CT scan in July 2018 revealed the Prostate to be normal in size and no other PSMA expressing lesions were noted elsewhere to suggest a metastatic disease.
The progressive remission of the carcinoma was seen in concordance with the blood PSA and Testosterone levels. The biochemical analysis was done over a period of nine months starting July 2017, indicated a stability and reduction in PSA levels with the lowest of 0.4 ng/mL

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


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

[User]
RADIOLOGY NOTE:
We describe a case of a 78-year-old male who 24 hours after an anterior rectum surgical resection with a terminoterminal anastomosis for a rectal neoplasm,showed sudden pain among the soft tissues of right flank and fever (39°C).
The patient did not have any primary or acquired immunodeficiency; he was under treatment for diabetes and had no other risk factors for necrotizing fasciitis such as immunological disorders or previous administration of chemotherapy.
Clinical examination showed a swollen and hot skin and “crackling snow crepitus” among the right flank. No bullae or other skin signs predicting necrosis were appreciable.
The surgeon, after the clinical examination, requested from our Emergency Department a contrast enhanced CT (CECT) of thorax and abdomen.
We performed a precontrast phase, arterial phase, and an early venous phase.
CT scans showed the outcomes of the surgery and two drainage pipes were present, one in the right pelvis and one in the left flank.
Close to the right drainage access a suspected infection characterized by huge air-densities collections and edema extending along the soft tissues as right subcutaneous fat were observed; parietal abdominal muscles and subcutaneous tissues were also involved ().
Scout of subcutaneous emphysema which extends up to the supraclavicular region was seen (). Solution of continuity, 1,3 cm × 1,5 cm in size, of the rectus abdominis muscles was observed ().
After the contrast medium administration the fascia did not appear enhanced in the arterial phase; in the early portal phase the fascia appeared weakly enhanced; areas of low attenuation within the muscles and the fat tissues structures of the right flank were observed ().
As collateral findings the mesenteric fat tissue appeared hyperdense and small amount of pleural and pericardial effusion was seen; in Sagittal Multiplanar Reconstruction it was clearly appreciable that the infection started from the right drainage pipe ().
CT findings, such as the prese

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


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

[User]
RADIOLOGY NOTE:
An 18-year-old girl was referred to our department with complaints of painless enlargement of the jaw and the loosening of teeth. Family history did not reveal any significant information about the familial origin. She had a history of hypothyroidism for 3 years of age and history of atrial septal defect (ASD) operated at the age of 4 years. The patient had anodontia since childhood, and dental development occurred only after correction of ASD. On clinical examination, there was prominent enlargement in the mandibular region. Some permanent teeth were missing, and wide edentulous interdental spaces were detected on intraoral examination. Few skin lesions were also noted suspicious for café au lait spots. Otherwise, clinical examination was unremarkable. She had attained puberty at the age of 15 years.
The laboratory results of serum cortisol, calcium and phosphorus, alkaline phosphate, Parathyroid hormone, Vitamin D3, complete blood cell count, urine analysis, and liver functional tests were all within the normal range. The orthopantomogram radiograph showed misalignment of teeth with the distorted root of premolar and molar tooth and loss of few incisors and canine teeth [].
Whole-body bone scintigraphy with three-phase imaging of the skull and upper thorax was done by the intravenous administration of 20 mCi of technetium-99 m methylene diphosphonate (99 mTc-MDP). Tc-99 m-MDP first pass images of the skull and upper thorax MDP blood flow images of the skull and upper thorax shows a region of focal hyperperfusion in the right hemimandible [] corresponding to a focal region of tracer pooling in the same region of the right hemi-mandible in the blood pool images shown subsequently. In addition to this focus, the blood pool images show mildly increased tracer pooling in rest of the mandibular and maxillary regions as well []. Delayed phase whole-body and static planar images showed diffuse heterogeneously increased tracer concentration involving the entire mandible an

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


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

[User]
RADIOLOGY NOTE:
A 34-year-old woman with no significant past medical history presented with the chief complaint of left facial numbness, left ear pain and decreased hearing in the left ear of three years duration. The patient had also been experiencing sharp and shooting pain in different areas of her left thigh. The pain was not associated with any weakness, tingling or numbness. Besides mild fatigue she denied having any fevers, night sweats or weight loss. Neurological physical examination was grossly intact except for sensory loss in the V2 (maxillary) and V3 (mandibular) distribution of trigeminal nerve (cranial nerve V). Abdominal exam was without evidence of lymphadenopathy and hepatosplenomegaly. Given deficits in the sensory distribution of trigeminal nerve, she was initially evaluated by ear, nose and throat (ENT) and underwent two sequential minimally invasive surgeries for nasal polyps without significant resolution of her symptoms. She was subsequently referred to a neurologist and had magnetic resonance imaging (MRI) of the brain performed. Brain MRI revealed a soft tissue mass with expansion in the left Meckel’s cave, measuring 22 x 16 x 12 mm (Figure ), raising concerns for a trigeminal schwannoma. She was evaluated by the neurosurgery and underwent an orbital zygomatic craniotomy and left trigeminal schwannoma resection. Pathology revealed deposition of abundant hypocellular eosinophilic material on light microscopy examination (Figure ). Congo red staining demonstrated characteristic 'apple-green birefringence' upon polarization (Figure ), consistent with diagnosis of trigeminal nerve amyloidoma. Unfortunately, no immune fluorescence or electron microscopy was done on the pathology specimen to determine the amyloid subtype. Postoperatively, the patient was referred to oncology to rule out systemic amyloid deposition. Basic workup including complete blood count was unremarkable except for hemoglobin of 12 g/dL with mean corpuscular volume (MCV) of 76 fL per cell. 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 36-year-old man was admitted to our hospital due to severe pain in his left eye. He mentioned that the pain had begun along with redness 2 days prior to his admission.
On admission, he presented with eyelid swelling, conjunctival erosion, and corneal filtrate at 6 o'clock of a size of 3/0 over 3.2 mm. The corneal abscess location was in the midperiphery making any future corneal graft attempt challenging. There were flare and cells in the anterior chamber and the pupil was hardly seen. Ultrasound examination showed a clear vitreous and no involvement of the posterior segment. The right eye was normal with no pathology.
Anamnesis was taken in depth. It turned out that as part of his work, the patient was peeling plaster off of a wet wall that had fungi on it, and that a small piece of plaster had splashed into his left eye.
He was diagnosed as suffering from fungal keratitis, and further laboratory tests using PCR confirmed the infection to be caused by Fusarium solani. He was then treated with voriconazole, however without significant improvement (Fig. ).
A couple of days later, a corneal melting process was observed and as the corneal melting continued, it was decided to try treatment with CXL. The patient underwent a CXL treatment and shortly thereafter, the abscess shrank, with significant improvement in symptoms and vision (Fig. ). The corneal melting stopped after the CXL treatment. The patient was treated for about 3 months with voriconazole.
The following year after the infection, corneal transplantation was done due to severe scarring of the cornea. Today, about 2 years later, best corrected visual acuity in the left eye is 20/80. The corneal graft is clear and shows good indentation with no signs of rejection. The anterior chamber is deep and clear, and other than a mild minimal nuclear cataract. The anterior segment is normal. The optic disc is normal and the C

[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 2-year old girl was referred to the Jos University Teaching Hospital in north central Nigeria, with complains of progressive cough and difficulty in breathing in the preceding six months. She was treated at several health facilities for pneumonia and asthma without resolution of symptoms. Patient had no fever or features suggestive of tuberculosis. Pregnancy, delivery, neonatal and infant periods were uneventful and patient had received all immunization appropriate for her age. Examination at presentation showed a child in severe respiratory difficulty necessitating oxygen administration, with Spo2 89–90% at room air and 96% on oxygen by nasal prongs. There was bulging of the right side of her anterior chest wall and markedly reduced breath sounds on the right hemithorax. No features suggestive of congenital heart disease. Chest X-ray showed homogenous opacity continuous with the cardiac silhouette, involving almost the entire right thoracic cavity with a shift of the mediastinum to the left (Fig. ). Echocardiography confirmed a very large well defined mediastinal cyst compressing the right atrium, left atrium and right ventricle (Fig. ). Contrast-enhanced computed tomography scan of the chest showed a well defined large cyst of the anterior mediastinum compressing the right main bronchus (Fig. ). Blood investigations were all normal. A diagnosis of anterior mediastinal cyst was made and the patient had right posterolateral thoracotomy through the fifth intercostals space. Intraoperatively a large tense cyst measuring 20 × 16 × 3.5 cm was noted adjacent to the pericardium and attached loosely to the thymus compressing but not attached to the bronchus. The cyst was unilocular with a thick wall and contained serous fluid (Figs. & ); the cyst was excised en bloc. There was moderate pericardial fluid which was drained by a pericardiostomy. Histopathological sections showed ectopic pancreatic tissues in the wall of the cyst (Figs. , and ). The post operative course was

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


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

[User]
RADIOLOGY NOTE:
A 42-year-old man with a long history of Ankylosing spondylitis presented with acute urinary retention three months after he was started on a TNF alpha antagonist.
The patient was well until, at the age of 25, he begun to complain of inflammatory back pain due to Ankylosing spondylitis. Initially, he responded well to NSAID medication, at least symptomatically, but the disease progressed over the years, leading to increasing flexion deformity of the neck, thoracic kyphosis, and loss of normal lumbar lordosis. Due to decreasing clinical response coupled with marked elevation of CRP, he was placed on Etanercept (Enbrel), a tumor necrosis factor alpha antagonist (TNFA) [].
Treatment with Etanercept had a dramatically beneficial effect on the quality of life of the patient. Clinically, the back pain waned to nothing, and overall mobility was improved while CRP normalized. However, three months after the treatment was initiated, the patient started having obstructive urinary symptoms: stress incontinence, dysuria, staining to void, nocturia, and increased frequency of passing small quantities of urine. The symptoms culminated in complete distal urinary tract obstruction and required catheterization with evacuation of 1200 mL of residual urine. There was no evidence of urinary tract infection, both by culture and by direct examination; an ultrasonic examination of the urinary tract was normal. There was no evidence of bladder stones.
Alpha blockers were started empirically, and the catheter was removed 72 hours later, with some relief, but the patient continued to have difficulties with micturition and had “two-stage urination” (a normal first stream, followed by a protracted and hesitant stream).
Since there was no evidence of physical bladder neck obstruction, the differential diagnosis at this stage included a side effect of TNFA and possibly cauda equina syndrome, which is a rare complication of Ankylosing spondylitis [].
Consequently, Etanercept was discontinued, and

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


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

[User]
RADIOLOGY NOTE:
A 59-year-old woman was admitted to our hospital 2 days after the onset of a recurrent thunderclap headache and right-side hemiparesis recovered within a day. She was drowsy, and had apparent nuchal rigidity. She had no risk factors for cerebrovascular diseases. She was in normotensive and in sinus rhythm. A computed tomography (CT) scan revealed SAH on left basal cistern (). Magnetic resonance (MR) images showed an acute ischemic lesion in the territory of the left middle cerebral artery with restricted diffusion (). Digital subtraction angiography (DSA) demonstrated an irregularly shaped aneurysm arising from left supraclinoid ICA with moderate stenosis of proximal region (). Moreover, DSA revealed one of the typical findings of pseudoaneurysm. A delayed opacification and stagnation of contrast medium in the aneurysm sac even during the venous phase were observed (). Transthoracic echocardiography with carotid duplex ultrasonography was negative.
Laboratory evaluation revealed a hemoglobin concentration of 18.3 g/dL with an elevated hematocrit of 59.7%, white blood cell count of 11.4×103/µL, and platelet count of 1120×103/µL. There was no evidence of head trauma or any systemic infection signs on admission. We planned to perform surgical clipping with a vessel wall remodeling technique because pseudoaneurysm might be fragile and associated with a high risk of intraoperative rupture. During operation, a pulsatile, thin walled aneurysm adherent to the adjacent tissue was observed in the anterior wall of supraclinoid ICA (). The aneurysmal sac avulsed from the parent vessel due to its friability during dissection of aneurysm. After temporary clipping of the proximal ICA, three curved clips were applied with a facing fashion to close the torn gap in order to prevent rebleeding and maintain patency of the parent vessel (). Postoperative hospital course was uneventful. Pathologic examination showed that most of the lumen mainly consisted of organized blood clot and rece

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


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

[User]
RADIOLOGY NOTE:
An 82-year-old man incidentally presented with a protruded shadow adjacent to the aortic knob in chest radiography during an assessment of the renal dysfunction. Computed tomographic scanning revealed a fusiform-type aneurysm with a diameter of 56 mm in the distal aortic arch. Aneurysmal change extended to the aortic arch around the origin of ARSA and the left subclavian artery. The patient was found to also have a common carotid trunk and an ARSA independently originating from the back of the aortic arch distal to the left subclavian artery. This artery passed behind the esophagus and trachea and connected the axillary artery through the right side of the thoracic vertebra (). Bilateral vertebral arteries ordinarily arose from the superior aspect of the central subclavian arteries. We applied the open repair but not the endovascular repair and decided to perform total arch replacement in combination with frozen elephant trunk and reconstruction of bilateral axillary arteries via the extraanatomical bypass. The occlusion of proximal ARSA was planned just at the right side of the thoracic vertebra in the right pleural approach to avoid troublesome procedures in the deep mediastinum.
Simultaneous preparation for bilateral axillary artery accesses was performed, and a standard median sternotomy was then made. Two pieces of 9 mm vascular grafts (J graft, Lifeline, Tokyo, Japan) were sutured to the bilateral axillary arteries respectively in an end-to-side fashion, and cardiopulmonary bypass was initiated with perfusion via these arteries and atrial drainage with a two-staged cannula. The right pleura was opened during the temporary cessation of mechanical ventilation. The ARSA was easily identified just at the right side of the thoracic vertebra and encircled with a vascular elastic band following the division of the parietal pleura (). After systemic cooling, the systemic circulatory arrest followed by aortic opening was then performed with a rectal temperature of 22.9

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


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

[User]
RADIOLOGY NOTE:
A 48-year-old, previously healthy male was admitted to the hospital with altered mental status of one day duration. The patient was confused and was not answering questions appropriately. Vital signs were remarkable for low-grade fever of 100.7 ºF and tachycardia. His physical exam was remarkable for a holosystolic murmur at the apex, radiating to the axilla. He was alert and oriented to self, but not to place or time. Cranial nerves were grossly intact with no focal neurological deficits. Laboratory evaluation revealed leukocytosis and mild hyponatremia. A computed tomography scan of the head did not show any acute intracranial hemorrhage. A lumbar puncture was performed and cerebrospinal fluid analysis did not suggest meningitis; however, the patient was started empirically on vancomycin, ceftriaxone, ampicillin, acyclovir, and dexamethasone. Magnetic resonance imaging of the brain showed large area of infarction in the left frontal, left parietal, and left caudate body, suggestive of a cardio-embolic source (Figure ). An echocardiogram revealed a large, mobile, vegetation (1.5 x 1.5 cm) on the mitral valve likely affecting the anterior and posterior leaflets with mild to moderate mitral regurgitation (Figures -). Blood cultures were sent to the lab, which later grew Streptococcus agalactiae. An infectious disease team was consulted and antibiotics were switched to penicillin G and gentamicin.
A cardiothoracic surgery team was consulted and he was not deemed a surgical candidate as it was thought it would be unlikely that the patient will have a meaningful recovery, and the risks outweighed the benefits of surgery. The patient’s mental status remained the same; he remained alert and oriented to self only despite several days of antibiotics. His repeat blood cultures remained negative.
In the third week of his hospitalization, the patient experienced worsening of his altered mental status and he was not responding to questions. An MRI of the brain showed hemorrhagi

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


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

[User]
RADIOLOGY NOTE:
A 41-year-old Japanese man became aware of abdominal swelling in December 2008 but did not seek a medical opinion until he developed marked leg edema, a 30 kg weight gain, and cough. He was hospitalized the same day after a retroperitoneal tumor was detected by computed tomography (CT). After hospitalization, the patient was diagnosed with a liposarcoma by CT-guided needle biopsy. The patient was emergently transferred to our hospital due to worsening respiratory status. On admission his body surface area was 2.18 m2. A CT scan detected a 43 × 37 × 31 cm tumor in the right retroperitoneum, with the right kidney significantly displaced to the left and anterior side (). Whole-body CT scan detected no metastasis. His condition was diagnosed as respiratory failure due to elevation of the diaphragm as a consequence of the rapid growth of the tumor ().
We concluded that surgical resection was the only option for saving the patient's life, so we performed a tumorectomy 3 weeks later through a midline incision. The operation took 3 hours and 20 minutes, and the estimated blood loss was 3990 mL requiring 800 mL blood transfusion. During surgery, the tumor and right kidney were completely resected.
Pathological examination showed that the resected mass weighed 22 kg and was 45 × 40 × 30 cm in size (). Grossly, the tumor was well encapsulated and transverse sectioning revealed a solid multinodular tumor mass. Histopathologic analysis demonstrated many spindle cells with high-grade atypia; some of which were lipoblasts on a myxoid background; there were no split signals on FISH analysis using CHOP DNA probes, thus leading to the diagnosis of dedifferentiated liposarcoma (). Microscopically, no tumor cells were identified in the right kidney and this was an R0 resection. He declined adjuvant therapy. The patient was discharged from our hospital after 18 days. His body surface area at discharge was 1.66 m2. A CT scan performed 12 months after surgery detected no recurrence.

[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 70-year-old Caucasian male with an established diagnosis of DD since his childhood years. He had had innumerable exacerbations in the past and multiple admissions for secondary bacterial infections. He presented to the hospital with worsening of coalescing, firm, greasy, and bright red to skin-colored macules and papules located around his gluteal clefts, back, scalp, and forehead causing severe debilitating pain. The gluteal lesions were the most clinically relevant symptom and they were causing profound distress. He had severe physical deconditioning and had fallen several times prior to his arrival. A few weeks before his hospitalization, he had been diagnosed with intraductal papillary mucinous neoplasm (IPMN) of the pancreas and had undergone a total pancreatectomy and splenectomy with hepaticojejunostomy and Billroth II gastrojejunostomy, which had contributed to his fatigue and weakness. He had no abdominal symptoms and his abdominal exam was initially benign. His vitals were stable, and there was no systemic or laboratory evidence of an infectious process at the time of admission. As the clinical course progressed, his skin lesions and clinical status continued to worsen. He developed bacteremia secondary to Streptococcus dysgalactiae and then Pseudomonas a few days later. A week later, he developed bacterial peritonitis with Enterococcus faecalis, Klebsiella pneumoniae, Candida glabrata, and E. coli. He received multiple courses of broad-spectrum antibiotics and antifungals. The dermatology service was closely following the patient and had started him on acitretin with a dose of up to 50 mg daily. He was also started on systemic steroids. Although he had intermittent days of temporary improvement and relief, his overall progress was mired with worsening skin lesions, sepsis causing hypotension, and functional decline.
Pain management, palliative care, infectious diseases, burn surgery, surgical ICU, social work, cardiology, and endocrinolo

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


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

[User]
RADIOLOGY NOTE:
A 40-year-old woman was referred to the Department of Obstetrics and Gynecology with symptoms of chronic pelvic pain since one month and foul smelling vaginal discharge since 2 years. She had no medical history such as constipation and hematochezia. On physical examination, the patient was afebrile with normal vital signs and mild tenderness was present in her lower abdomen without any palpable mass. Transvaginal examination showed normal appearance of the anus and external genitalia, but vaginal discharge was suspected with fecal material. Transvaginal ultrasonogram revealed a normal uterus and both ovaries. Blood Test demonstrated elevated CRP (37 U/L [normal, <1 U/L]), and other serologic tests were within normal limits. Urine analysis showed pyuria (WBCS, 20–29/high power field; leukocytes, 3+) and proteinuria (1+). CT revealed inflammatory change around the left side of the colon and left ovary with loculated fluid collection in the pelvic cavity (). The initial diagnosis was thought to be an abscess in the left salpinx due to pelvic inflammatory disease, and pelviscopic exploration was planned in the gynecologic department. During the operation, no abscess in the pelvic cavity and 2 appendices were observed with inflammatory adhesion among the sigmoid colon and the left salpinx (). When the patient was referred to our department because of severe adhesion and inflammation, we converted her to open surgery. In operative findings, a near total duplicated colon including a duplicated terminal ileum measuring 3 cm in length was observed. It originated from 5 cm above the native ileocecal valve perpendicularly, was parallel to the native ascending, transverse, and descending colon, and terminated in the native proximal sigmoid colon with adherence to the left salpinx. The diameter of the duplicated colon narrowed distally (). When adhesiolysis was performed, fistula formation was observed between the distal end of the duplicated descending colon and the posterior v

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


[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 details a 54 year old woman who was referred to our clinic by her general practitioner for investigation of bilateral breast pain that she had for 6 months.
Her past medical history included hypertension for which she took a single anti-hypertensive. She had no familial history of breast or gynaecological malignancy. On clinical examination pathological nodes were palpated bilaterally in the axillae. There was left sided nipple inversion with a palpable mass in the upper outer quadrant of approximately 3 cm diameter.
On examination of the right breast there was skin tethering of the nipple and 3 masses were palpated, the largest being in the upper inner quadrant at 5 cm diameter.
Ultrasound and mammography of bilateral breasts demonstrated advanced bilateral breast cancer with axillary node metastases.
The right breast had a large lesion consistent with primary breast cancer at 12 o’clock measuring 44.3 mm in diameter. An additional 7 smaller lesions were distributed through the right breast consistent with satellite lesions. The largest pathological node in the right axilla measured 42 × 30 mm.
In the left breast at the 2 o’clock position there was a lesion consistent with breast carcinoma measuring 31.2 mm. The largest node in the left axilla measured 13.1 × 10.2 mm.
There was skin thickening of both breasts consistent with oedema, the right side was most pronounced. Core biopsies from lesion on right breast at 12 o’clock and the left breast at 2 o’clock demonstrated invasive carcinoma. , : (H&E x10) Left/right core biopsy show invasive carcinoma, no special type
The hormone receptor status was identified with right breast lesion being ER negative whilst the left breast lesion was ER positive.
, , : (x10) Positive staining for ER and PR. HER2 Immunohistochemistry score 3 + .
, , : (x10) Negative staining for ER and PR. HER2 Immunohistochemistry score 3 + .
The patient was

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


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

[User]
RADIOLOGY NOTE:
We describe the case of a 50 year old Caucasian female patient who was born with tricuspid atresia and transposition of the great arteries. At the age of 4, she underwent a modified Glenn procedure followed by a classical left Blalock-Taussig shunt at the age of 16. Since then, she has had two major cardiac operations. In 1990, at the age of 25, she had a fenestrated modified atrial pulmonary Fontan. Following a very difficult pregnancy 18 years later, she underwent conversion to a total cavopulmonary anastomosis Fontan circulation, modified MAZE procedure and implantation of an epicardial defibrillator with biventricular pacemaker system. Cardiac catheterisation at that time showed a ventricular end diastolic pressure of 16 mmHg and a Fontan chamber pressure of 18 mmHg, giving a transpulmonary gradient of 2 mmHg. Her cardiac medical history was further complicated with arrhythmias requiring ablation in 1998 and episodes of non-sustained ventricular tachycardia in 2014.
This lady has been under regular follow-up by our team since 2008. Various medications have been trialled over the last 8 years due to her progressive reduction in exercise capacity and exertional dyspnoea. She had initially taken part in a trial to test the safety of bosentan in 2010 [] and at the time had shown good response to the drug with improvement in 6-min walk test. Bosentan was discontinued at the end of the study.
Unfortunately, over the course of the next few years, she continued to deteriorate with worsening breathlessness (NYHA III), four-pillow orthopnoea and paroxysmal nocturnal dyspnoea, ventricular function was preserved. She noticed a significant limitation in everyday activities, requiring social care input and a mobility scooter for outdoor travel. Sildenafil was commenced however this was discontinued shortly after due to symptomatic hypotension.
Cardiac CT scan confirmed non-restrictive Fontan pathway, and normal ventricular function.
In early 2016, bosentan was re-commenced wi

[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 male has experienced hot flashes for the past five to six years; this is associated with obvious erythema of the face and is accompanied by hypertensive episodes as high as 226/128 mmHg with no palpitations. In the past year, these spells had become more frequent with headaches in both temples. He also reports decreased peripheral vision during these episodes. Lying down seems to reduce the severity and duration of these spells. He often feels light-headed in the upright position and experiences vertigo while lying on his side, at times; this is always relieved by changing his position on the bed. His symptoms are relieved by sublingual medication, such as nifedipine, but the patient states that his episodes are brought on by excitement such as watching a football game, walking barefoot on hard surfaces, having a bumpy car ride, or making sudden head movements. He also reports heat intolerance and excessive sweating. The patient's past medical history was positive for SCI, after which he developed pain in the neck and lower back, with numbness and tingling in his upper extremities and pain radiating down his hip. Table lists the common signs and symptoms of AD generally experienced by patients with SCI.
Laboratory results revealed an increased excretion of epinephrine and dopamine but a normal output of norepinephrine. His epinephrine levels were increased by injections of intravenous glucagon, a response highly suggestive of the presence of pheochromocytoma. He also had prolonged spells of tachycardia induced by exercise despite taking propranolol, which was further suggestive of the production of large amounts of epinephrine, overriding the effects of propranolol.
He underwent an evaluation for pheochromocytoma. An octreotide scan, a metaiodobenzylguanidine (MIBG) scan, and a magnetic resonance imaging (MRI) scan of the adrenal glands were all negative. After some time, the patient reported episodic anxiety and hypertension with a full bladder and im

[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 Indian girl, 12 years old, was referred to Department of Pedodontics and Preventive Dentistry of Dental College, for inspection of a painless swelling in the mandibular left primary molar region since 6 months. Past dental history revealed that she had undergone incomplete endodontic treatment with the same tooth a year ago. Her oral hygiene was good and was overall in good health. Extraoral examination revealed, a diffuse, bony nontender swelling on left side of jaw extending from corner of mouth to angle of mandible. While, intraoral examination revealed a grossly carious and mobile left primary second molar tooth (). Panaromic radiograph showed a round unilocular radiolucent lesion, 1.8 × 2 cm in diameter, below the left second primary molar (), displacing the successive permanent second premolar apically. A closer examination of the radiograph revealed that the border of the lesion appeared corticated and was smooth and well-defined. Occlusal radiograph revealed buccal cortical plate expansion extending from distal aspect of permanent mandibular left lateral incisor to mesial aspect of permanent mandibular left second molar and revealed an interesting finding that the successive premolar was displaced and aligned buccolingually in the cystic cavity ().
From history and clinical examination a provisional diagnosis of radicular cyst associated with them andibular left primary second molar was made which could be due to either secondary caries or the medicament used duri ng endodontic treatment. Differential diagnosis included periapical granuloma or dentigerous cyst.
Primary left second molar was extracted under local anesthesia and cystic cavity was exposed. Cystic lining was removed as much as was accessible and sent for histopathological examination (). The successive permanent second premolar was also extracted because of its improper alignment. After thorough curettage of cystic lining, the premolar was placed back into the cystic bony cavity with proper a

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


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

[User]
RADIOLOGY NOTE:
A 60-year-old female housewife was admitted to the Urology Clinic of Sina Hospital, Tehran (capital of Iran) eight months before admission (winter of 2013) with pain in the suprapubic area (). The patient had been treated by antibiotic therapy since eight months ago following intense suprapubic pains accompanied by dysuria and frequency symptoms and had been diagnosed as simple cystitis. In spite of partial recovery and continuation of long-term treatment with antibiotics, non-steroid anti-inflammatory drugs, sedative drugs and alpha-blocker, the symptoms were recurred with severe and mild periods. The pain was persistent and spread towards the perineal area. Along with the pain, the patient had frequency, nocturia and dysuria, which resulted in inability to pass urine completely. The pain intensified when the bladder was full and the patient also had occasional flank pain on both sides. In abdominal physical examination, slight tenderness in the suprapubic area was found, but the rest of examination had normal findings. In paraclinical tests, urine culture test had normal results, and urine analysis showed normal findings regarding the values of white blood cell, red blood cells, sugar and protein. Urine cytology had negative results regarding malignancy. Abdomen and pelvic sonography and the liver and kidney function test had normal results.
In cystoscopy report, the size of bladder was slightly decreased and there was a mild inflammation of the epithelial lining of the bladder. No tumoral lesion or glomerulation was observed. Bladder biopsy and hydro distention were performed. Bladder biopsy had negative results for malignancy, but chronic inflammation was reported. The results of the examination of the genitalia system in physical examination and dilation and curettage (D&C) had normal findings.
The patient reported diabetes mellitus type 2 for three years and used metformin daily. FBS was 120 mg/mL. The digestive problems of the patient were a persistent bloat

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


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

[User]
RADIOLOGY NOTE:
A 42-year-old man presented with a 3-months history of right neck pain that worsened on turning to the left. He did not complain of any other symptoms such as globus sensation or odynophagia. Physical examination was negative. Palpation of the tonsils did not worsen the pain. 3D-CT reconstructed images showed a longer left process than the right. Quantitative measurements showed the left styloid process was abnormally long (44 mm), while the right was normal (25 mm, Figure
). In view of the neck pain, the patient was diagnosed with Eagle's syndrome. The condition was explained to the patient and operative treatment was recommended. Surgical correction was made via the transoral approach. On the first postoperative visit, rotation of the head did not elicit any pain.
The operation was performed under general anesthesia while the patient was in supine position with neck extension. An endoscope was inserted through the mouth, and the magnified surgical field allowed identification of the small vessels and nerves and allowed the surgeon to avoid injuries. Unilateral tonsillectomy was performed first, the tonsillar bed was palpated and the tip of the styloid process was identified. The mucosa was separated longitudinally at the point of palpation of the process in the tonsillar fossa. The tissue of the parapharyngeal space was carefully separated by q-tips to avoid vascular injury. Palpation was occasionally used during surgery to confirm the location of the styloid process. After exposure of the styloid process, the periosteum was incised at the tip of the process, then stripped from the tip to the base. The styloid process was excised with a bone nibbling rongeur. The styloid process must be penetrated before its removal. If the styloid process fractures accidentally before it is completely dissected, the fractured piece(s) can be pulled down through the tonsillar bed after diverging the muscles attached to it, a step that

[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 59-year-old male presented to hospital complaining of severe nausea and generalized abdominal pain requiring admission. The patient had an episode of gastroenteritis 6 month prior, and since then experienced multiple episodes of colicky abdominal pain with intermittent vomiting. The patient had no other medical history of significance. On physical examination, he was hemodynamically stable, although generally tender with a distended abdomen. His laboratory results and chest X-ray were unremarkable. A computed tomography scan was suggestive of a subacute small bowel obstruction with a high
suspicion of an internal hernia through an omental defect. Given the patient’s clinical status correlated with these radiological findings, he was counselled for surgery and underwent an exploratory laparotomy.
Intraoperatively, thick fibrous tissue involving the visceral and parietal peritoneum was found enveloping grossly dilated loops of small bowel (). There was no evidence of a transition point contributing to this patient’s obstruction. As any manipulation or mobilization of the bowel was thought to be high-risk of causing enterotomy, a decision was made to close the abdomen after collecting peritoneal washings and biopsies for histopathology and microbiology.
The patient was monitored on the ward post-operatively during which he made a good recovery with broad-spectrum antibiotics and supportive management. He was discharged home 9 days following his operation, after demonstrating significant improvement in gastrointestinal function, with reduced pain and able to tolerate oral intake.
Intraoperative peritoneal swabs tested negative for acid-fast bacilli and no organisms were cultured from peritoneal fluid. Haematoxylin and eosin stained sections of peritoneal biopsy showed markedly thickened collagenous fibrous tissue with adherent loose fibrovascular connective tissue and intervening myofibroblast-like cell, the latter supported by smooth muscle actin immunohistochemist

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


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

[User]
RADIOLOGY NOTE:
We present the case of a 63-year-old man who was admitted to our hospital with significant upper-body burns. The previous night he had been cooking when his clothing ignited. He did not call for help until the following morning.
Initial assessment revealed approximately 60% total body surface area burn, most of which was full thickness involving his torso and upper extremities. In addition, there was some minor involvement of his lower extremities. The patient complained of pain and inability to pass urine. Limited history was obtained in the emergency department. The patient denied any allergies and was not taking any medications.
Intubation for airway protection was performed early in the trauma room, and the patient was transferred to the burn unit where extensive fasciotomies to bilateral arms, hands, chest, and abdomen were performed at the bedside. Initial laboratory reports revealed acute renal failure with a creatinine level of 2.2, which marked the beginning of an undulating course. The next day, the patient was taken to the operating room for his first of several procedures. Fascial excision of both arms and left flank, with allograft, was performed. Skin biopsy was taken per protocol, with a view to obtaining cultured epidermal autograft.
His hospital course was complicated by pneumonia and polymicrobial sepsis. Organisms isolated from blood and wound-bed cultures included Pseudomonas, Aspergillus, vancomycin-resistant Enterococcus, and Klebsiella. Broad-spectrum antibiotic coverage was instituted.
By the sixth week of hospitalization, a decline in platelet function was noted from more than 150 × 10 to less than 15 × 10. This was paralleled by a generalized coagulopathy with a rise in international normalized ratio to more than 1.52. At this time, the patient had been taken to the operating room for fascial excision of the lower back with limited autografting. Although the procedure was uneventful, by the end of the operative procedure, bleeding was noted

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


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

[User]
RADIOLOGY NOTE:
In November 2009, a 52-year-old Korean woman who had never smoked presented with a history of isolated coughing. Chest computed tomography (CT) scan revealed a 4×3 cm sized mass on the upper lobe of the left lung (). Percutaneous needle biopsy of the lesion revealed adenocarcinoma. There was no evidence of metastases in bone scan, brain magnetic resonance imaging, or positron emission tomography (PET)-CT scan. Finally her disease was clinically staged as T2aN0M0. Polymerase chain reaction-based DNA sequencing of the EGFR gene revealed an activating mutation (Leu858Arg) in exon 21 of the EGFR gene. She underwent lobectomy of the upper lobe of the right lung. Tumor was a 4.0×4.0×3.5 cm in size and directly extended to visceral pleura on pathologic examination. She subsequently received three cycles of adjuvant chemotherapy with paclitaxel and cisplatin from December 2009. Following adjuvant chemotherapy, evaluation with chest CT scan, PET-CT scan and bone scan every three months revealed no evidence of recurrence until March 2011 when multiple small nodules were developed on both lung fields. Wedge resection of the upper lobe of the left lung was performed and metastatic adenocarcinoma was pathologically confirmed in the specimen. The DNA sequencing of the EGFR gene of resected specimen did not revealed any activating mutations of the EGFR gene. She received four cycles of chemotherapy with irinotecan and cisplatin and her disease was shown to be stable. In December 2011, pulmonary nodules were newly noted in the upper lobe of the left lung (). Then treatment was switched to the erlotinib monotherapy, 150 mg once daily. Her disease was shown to be partial response to the treatment by criteria of Response Evaluation Criteria In Solid Tumors version 1.1 in February 2012 and has been stable until June 2012. During the treatment, she experienced skin rashes on her face, chest, and scalp, which were adequately controlled with topical therapy. In addition she was complained

[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 66-year-old single man, who worked for a cleaning company, and had hearing impairment; however, there was no evident medical history of psychiatric disorders. He was found lying in front of his apartment and was sent to the emergency room. A physical examination revealed fracture of the left patella and calcaneus, which appeared to be related to trauma. He kept his eyes closed for most of the day and demonstrated no spontaneous speech or reaction. Although his blood tests showed inflammatory reaction, his vital signs were normal, and computed tomography and electroencephalography of his brain showed no significant findings. He had no relatives and there was no life history information of him. According to the information of the neighboring residents, he had exhibited strange behaviors since about 2 months before admission and often annoyed the neighbors. Before his arrival to the emergency department, a neighbor called the police because the patient had stood in front of his apartment for a long time. While in detention, he did not respond to the police interrogations at all; he was found lying in front of his apartment a few hours after police released him. After admission to the emergency department, he was consulted with our department for the assessment of psychotic symptoms by his physician. Including the process leading to hospitalization, he was diagnosed with catatonia based on the presence of stupor, mutism, and negativism which was detected from the information by the police about the patients’ uncooperative behavior during detention. He was started on intravenous administration of 5 mg/day midazolam, which was switched to lorazepam, administered through a feeding tube. He then gradually opened his eyes and started speaking. He stated that “someone was trying to kill me, so I jumped to escape. I don’t want to talk about anything because I am being seen and heard by someone.” He was, therefore, suspected to have hallucinations and del

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


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

[User]
RADIOLOGY NOTE:
A 70-year-old obese male presented to the emergency room (ER) with fatigue and shortness of breath. He reported that during the past few weeks, he had developed progressive breathing difficulties and weakness. He had no fever and only mild right upper quadrant and right chest discomfort. On physical examination, diminished breath sounds in the right lower lung were found. The patient was anaemic (haemoglobin 8 mg/dl), and leukocyte count was normal. The CT scan showed a large Morgagni-type hernia with the entire right hemicolon, parts of the transverse colon and terminal ileum, and ample omentum trapped in the chest (), causing atelectasis of the right lower lobe. After stabilization in the ER, he was admitted to the hospital, and workup for the blood loss anaemia was initiated. He had a positive stool guaiac test and underwent a colonoscopy showing a large mass in the right colon (). During colonoscopy, the endoscope was maneuvered with extra care to avoid any injuries; the colonoscope entered the right chest but could ultimately be advance to the ileocecal valve. Biopsies of the mass in the proximal ascending colon revealed an adenocarcinoma.
He consented for laparoscopic repair of the diaphragmatic hernia and resection of the right colon. Surgery was done in the supine position and was initiated by insertion of a 5 mm 1st entry port in the left upper quadrant. An additional 5 mm port was inserted in the left lower quadrant and a 10-12 mm port above the umbilicus. A large right-sided diaphragmatic defect (7 cm diameter) was encountered anteriorly to the liver with the entire right hemicolon and terminal ileum and omentum trapped inside. The hernia contents were gently reduced from the mediastinum (). The peritoneum at the anterior aspect of the defect was incised using an Enseal, and the entire hernia sac was carefully mobilized out of the mediastinum, avoiding injury to the pleura or phrenic nerve. The Valsalva maneuver was applied to

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


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

[User]
RADIOLOGY NOTE:
A 55-year-old Caucasian female presented with productive cough, dyspnea, chest pain and weight loss. The patient's medical history was significant for hypertension, hypercholesterolemia, dyslipidemia, chronic renal failure, gastroesophageal reflux disease and chronic anemia. She was a 30 pack-year smoker and her mother was diagnosed with lung cancer. Her physical examination was unremarkable. An initial chest X-ray showed a large subcarinal mass. On computed tomography (CT), a 6.2 × 5 cm tumor was detected in the subcarinal area (Figs and ). A bronchoscopy with transbronchial biopsy was performed, and the resulting pathological analysis was suspicious for malignant cells; however, no specific tumor type was identified. A positron emission tomography scan showed a large hypermetabolic subcarinal lesion with a standard uptake value of 14.3, consistent with malignancy. The differential diagnosis at the time included an infected bronchogenic cyst, esophageal duplication cyst or a malignant subcarinal lymph node. Thoracoscopic surgical resection was planned for diagnostic and therapeutic purposes.
Prior to surgical resection, esophagoscopy and bronchoscopy documented the absence of any communication of this mass to the esophagus and airway. The resection was completed thoracoscopically, with a five-port approach. One port was made at the mid-axillary line of the eighth intercostal space for the camera, in addition to two anterior and two posterior ports. The dissection of the tumor began at the level of the inferior pulmonary ligament and posterior mediastinum, all the way to the azygous vein. The esophagus was found completely adherent to the tumor, necessitating an esophageal myotomy for en bloc resection. The esophageal mucosa was not violated at any point throughout the procedure. The anterior dissection proceeded at the level of the posterior atrial wall, the inferior and superior pulmonary veins, the main trunk of the pulmonary artery, and the membranous areas of 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 25-year-old patient presented with an 8×7-cm posterior wall fibroid diagnosed for the first time during pregnancy at 12 weeks. The course of the pregnancy was smooth, with mild enlargement of the fibroid to the size of 10×9 cm.
The patient delivered by Caesarean section at a private clinic due to malpresentation (breech presentation). In the first week postpartum, the patient experienced malodorous vaginal discharge. The patient sought medical advice and antibiotics were given for 14 days, but the discharge did not resolve and the patient felt a mass inside the vagina.
The patient presented to Tanta University Hospitals where she was admitted, and under general anesthesia, an examination revealed a solid mass extending from the cervix into the vagina. A biopsy was taken from the mass for histopathological examination, and it was identified as a degenerated cellular fibroid polyp.
Antibiotics also were given for 14 days after a culture and sensitivity test, but the discharge still did not resolve. At this point, the patient became frustrated and sought medical advice from more senior practitioners, who advised her to receive gonadotropin-releasing hormone analogues for 2 months. Nonetheless, the discharge was not cured; it became more malodorous as well as greenish and stool-like in character.
The patient developed abdominal pain, distension, vomiting, and absolute constipation 1 week later and was readmitted to Tanta Emergency Hospitals where thorough investigations were performed, including a pelvic ultrasound and a computed tomography scan with gastrointestinal tract contrast.
An examination revealed cachexia and toxicity facies, The patient's vital signs were a blood pressure of 100/60 mm Hg, a pulse of 110 beats per minute and a temperature of 38.1℃. An abdominal examination revealed distension, tenderness with guard and rigidity, and resonance over all quadrants of the abdomen. No peristalsis was heard over any region of the abdomen.
A pelvic examination demo

[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 male patient reported to the outpatient department with a chief complaint of swelling on the right side of the palate for the past 5 years. The patient had undergone surgical treatment for a bony swelling at lower border of the mandible about 30 years back. After that, he was apparently normal until 5 years back when he noticed a small swelling on the palate which was very slowly increasing in size. The past medical history revealed chronic bowel upset in the form of abdominal cramps and diarrhea. Family history revealed that both sons of the patient had bony swellings of the jaw and both of them were reluctant to get their screening done for Gardner's syndrome.
On examination, multiple small nodular swellings were seen on the forehead. The nasolabial folds were obliterated bilaterally []. The overlying skin appeared normal. On palpation, all the swellings were bony hard in consistency, nontender and were fixed to the underlying bone.
Intraoral examination revealed swellings on the right and left sides of the palate. On the right side, buccal vestibule was obliterated in 14 and 15 region and palatal swelling was extended from the mesial aspect of 16 to the distal aspect of tooth 17 anteroposteriorly. On the left side, the palatal swelling extended from mesial aspect of tooth 25 to the mesial aspect of 28 anteroposteriorly []. A diffuse swelling was seen on mandible on the left side, causing buccal vestibular obliteration in 34 and 35 region. The overlying mucosa was intact, with no ulceration or sinus discharge. On palpation, all the swellings were bony hard in consistency and nontender. There were clinically missing teeth 11, 15, 23, 34, 35, and 45.
To see the exact extent of the lesion, a panoramic radiograph was obtained which revealed impacted teeth w.r.t. 11, 15, 23, 34, 35, and 45. Diffuse radiopaque areas were seen in the

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


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

[User]
RADIOLOGY NOTE:
A 67-year-old female presented with three months of hoarseness and dysphagia following an upper respiratory infection. Her past medical history included invasive ductal carcinoma of the breast (ER positive, PR negative, and HER2 negative) treated by mastectomy two years prior to presentation. On clinical examination, she was found to have paralysis of the right vocal cord, and a follow-up CT scan of the neck revealed an enlarged thyroid gland with multiple bilateral thyroid nodules. FNA of a right-sided 3.5 cm thyroid nodule was diagnosed as atypia of undetermined significance (Bethesda category III). A repeat FNA three months later yielded a diagnosis of benign follicular nodule (Bethesda category II). Persistent hoarseness and compressive symptoms, combined with atypical findings on the initial FNA, necessitated right thyroid lobectomy and right vocal cord injection. Intraoperatively, the right thyroid lobe was noted to be moderately enlarged with multiple nodules but no evidence of extrathyroidal extension.
The right lobectomy specimen measured 4.6 cm in greatest dimension and weighed 16 grams. The cut surfaces of the thyroid parenchyma showed multiple variably sized brown gelatinous nodules, with focal areas of hemorrhage and cystic change.
Histologic examination revealed evidence of nodular thyroid hyperplasia, along with multiple scattered subcentimeter foci of metastatic breast carcinoma, which were present in 7 out of the 16 submitted tissue sections. Most of the smaller metastatic foci, measuring around 1 millimeter each, consisted of a few irregularly shaped nests of epithelioid tumor cells interspersed between thyroid follicles (). The largest metastatic focus measured 0.6 cm and was comprised of tumor cell nests arranged along the periphery of a sclerotic stroma containing cords of tumor cells showing retraction artifact (Figures –). These areas resembled the dense amyloid-type stroma often seen in medullary thyroid carcinoma (MTC). Additionally, there 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:
This is a case of a 54-year-old divorced Caucasian male who has no prior psychiatric history or hospitalization. He was the lead singer of a local rock band. The patient has a 20-year history of cocaine abuse. He routinely uses cocaine prior to his stage performances. He reportedly binged on cocaine following a concert performance in a downtown bar. He snorted more cocaine than usual and immediately developed a severe headache and lower extremity numbness. He was rushed to the local emergency room, and an MRI of the brain without contrast was done. The MRI of the brain without contrast showed two small foci of increased signal intensity within the subcortical white matter of the left frontal lobe (Figure ).
It also showed the finding of bilateral foci of infarct involving the right side of the pons (Figure ). Both figures are consistent with an embolic phenomenon.
The patient has not complained of any somatic issues related to his cocaine use. The patient reported some depressive and anxiety symptoms as a result of the stroke but he remained optimistic about his recovery. He denied any vegetative depressive symptoms or suicidal ideations. He was initially seen by a nurse practitioner at the emergency room who diagnosed him with an adjustment disorder. After stabilization in the medical floor and a two-week stay at a rehabilitation program, the patient was sent home with good family support. Over the course of two weeks, the patient noted significant crying spells most of the day, nearly every day. He consistently denied that he was depressed and suicidal. His family became concerned and sent him to his primary care physician. The physician believed that he was suffering from depression because of his dramatic clinical presentation. The patient was eventually referred to the local mental health center by his primary care physician because of uncontrollable crying spells. He was not subjectively depressed but objectively tearful with a flat affect. He also complained

[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 female with a past medical history of migraines and benign paroxysmal positional vertigo (BPPV) presented to the ED with the complaint of new onset numbness and tingling of her right face that eventually progressed to the left side. She also developed significant nausea which resolved with meclizine. A noncontrast CT scan of the brain was performed in the ED to rule out stroke and found no acute abnormalities. The patient’s neurologist was consulted and suggested that her symptoms might be caused by complex migraines and she was discharged. The patient then noticed that her right eye was beginning to have diminished vision over the week after she was discharged from the ED. She went to see her primary care physician who ordered an MRI study with and without contrast of the brain and a magnetic resonance angiogram (MRA). These images revealed an aneurysm at the left PICA origin (Figure ).
She was then referred for a digital subtraction angiogram (DSA) of the brain, commonly referred to as a cerebral angiogram. The cerebral angiogram was scheduled and took place a month later. The cerebral angiogram showed clearly an irregular aneurysm at the origin of the left PICA, 5.7 mm in size, with a wide neck (greater than 3.75 mm) (Figure -D). The neurointerventionist who performed the diagnostic cerebral angiogram then scheduled her for treatment. A neurvas pipeline flex stent 4 mm x 14 mm was placed in the PICA to divert flow from the left PICA aneurysm. The patient took aspirin (81 mg) and clopidogrel (75 mg) prior to and following the procedure. In the evening following the stent placement, the patient experienced mild right homonymous hemianopsia that improved throughout the hospital course. She was discharged with complaints of seeing dark shadows in her right visual field in both eyes on post procedure day two and was referred for follow up with ophthalmology

[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.