[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, previously healthy male was admitted to our intensive care department after suffering a motor vehicle accident. His injuries included: skull base fracture; diffuse axonal brain injuries, bilateral lung contusions with left side diaphragmatic rupture and dissection of descending aorta.
On admission to ICU he was sedated and mechanically ventilated. His blood pressure was 134/54 mmHg and pulse was 69 beats/min. Due to a potentially high risk of rupture and bleeding from the aortic dissection, the patient underwent urgent endovascular stenting. The procedure was completed successfully uneventfully.
For the following two weeks the patient was treated for severe traumatic brain injury. Despite adequate sedation and analgesia the patient had become extremely hypertensive (blood pressure 215/100 mmHg). CT imaging and ICP monitoring did not reveal any signs of elevated intracranial pressure, or signs of herniation.
A detailed clinical workup was performed, and included a repeated abdominal CT, which demonstrated a remarkable subcapsular hematoma of the left kidney (), with no active bleeding. There was no biochemical evidence of kidney dysfunction or reduction in GFR.
The patient was started with and angiotensin converting enzyme inhibitor and an alpha-beta blocker Labetalol. Due to persistent hypertension, despite optimal medical treatment a surgical approach (capsulotomy or nephrectomy) was considered. Due to refusal of the patient's proxy, surgery was not performed. Thus, ultrasound guided hematoma drainage was done with a total of 80 mL of sanguinous fluid withdrawn. Gram stain analysis did not detect any microorganism. Antihypertensive therapy was continued after the procedure. Further workup for primary hypertension which included a cardiac echocardiogram and vascular ultrasound did not reveal abnormalities.
After one month of ICU hospitalization the patient was discharged for rehabilitation for rehabilitation. The patient remained dependent on anti-hy

[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 17-year-old boy reported to the department of oral and maxillofacial surgery with a complaint of painless multiple swelling over the right massetric region since 2 years, which was obvious only after clenching. The patient was healthy without any medical and dental abnormalities. He could not recollect any incidence of trauma to the affected site.
On examination facial asymmetry with swelling at the right mandibular angle region was evident only on clenching []. Palpation revealed superficial well-circumscribed, well-defined, discrete, painless masses of different sizes (2 × 3 mm, 2 × 2 mm, 1 × 2 mm, 1 × 1 mm, approximately). They were not adherent to the underlying structures and freely movable in all directions. Routine blood investigations were within normal range. Serum calcium and phosphorous were also within normal limits. Panoramic radiograph reveals multiple well-defined radio-opaque masses scattered over the lower border of the right mandibular angle region below the mandibular third molar []. Axial view of CT scan examination revealed a multiple hyperdense masses located in the region of the right mandibular angle over the right masseter muscle [].
Myositis ossificans, osseous calcified nodules and osseous choriostoma were considered in the differential diagnosis. Intraoral excision was planned under general anesthesia. The incision was placed in the buccal vestibule opposite to the first molar extending along the anterior border of the ramus toward coronoid notch []. Blunt dissection was carried supraperiostally extending toward the masses till it was identified []. The head was fixed in position with proper retraction throughout the procedure which was important. The assistant fixed the masses from outside while dissecting.
The whole bunch of nodules was excised []. While dissecting intraorally care was taken to prevent injury to the facial artery and vein. During the procedure, bleeding was encountered due to injury to the facial vein, which was manag

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


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

[User]
RADIOLOGY NOTE:
A 54-year-old Caucasian female with a history of lupus presented for elective left total knee arthroplasty following the development of osteoarthritis that had failed conservative measures. The patient had a history of previous left knee ACL reconstruction approximately 25 years ago using the Arthrotek bone mulch screw and WasherLoc system []. She underwent removal of the tibial WasherLoc approximately 10 years later, in the early 2000's ().
The patient was positioned supine; standard incision with a medial parapatellar arthrotomy was performed. A measured resection technique was then performed with an intramedullary guide placed in the femur. The femur was cut in 6 degrees of valgus and 3 degrees of external rotation. A size 4 femoral prosthesis was placed and noted to overhang both medially and laterally on the condyles. At this time, it was decided to downsize the femoral component. The 4 in 1 femoral cutting block was then placed back on the femur and was noted to be in contact with the bone mulch ACL screw. The bone mulch screw was located and identified in the lateral femoral condyle; a curette was used to clear the head of the screw, and it was removed. The proximal tibia was then prepared using an intramedullary guide with 3 degrees of posterior slope. A size 3 tibial component and a 9 mm poly were placed; the knee was noted to be tight in both flexion and extension. An additional 2 mm resection was performed on the proximal tibia. It was noted at this time while trying to trial the prostheses that the lateral femoral condyle was fractured. Conversion to a stemmed femoral component with a cruciate stabilizing prosthesis was attempted. The femoral canal was reamed, and the femoral box cut was made. However, during trialing, the medial femoral condyle was now noted to have a fracture as well. An intraoperative consultation with an adult reconstruction trained orthopaedic surgeon was performed. Immediate surgical correction was not possible due to improper impl

[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 32 years old when he was referred to our center, and he was complaining of infertility. Pregnancy and delivery were normal. He was born at term with standard measurements. On physical examination, his weight was 74 kg, his height was 190 cm, and also body mass index (BMI) was normal at 20.5 (20 < normal values < 25). In clinical examination, Semi-Klinefelter characteristics such as tall stature (190 cm), teeth dysmorphology, history of respiratory disease, low total body hair, long length of fingers and toes, partial deformity of the joints and nails, likewise mental health problems were obvious in this patient. Meanwhile, there was no similar features or history reported within the patient's family members. After consultation, we decided to accomplish karyotype analysis to make sure about chromosome numbers and aberrations that was needed for early diagnosis and then choose appropriate treatment strategies.
The patient's blood samples were cultured, and their chromosomes were analyzed and studied by the G-banding method. A total of 85 cells were counted of which 81 cells had 48 chromosomes, two had 46 and two had 47.
All of the 85 counted cells without exception illustrated three Y sex chromosomes (the cells containing 46 and 47 chromosomes were probably caused by random chromosomal additions or losses from cell breakage). The construction of the cells with 48 chromosomes is thought to be 48, XYYY. The supplementary chromosomes were Y chromosomes because they had the subsequent characteristics in common: The long arms of the chromatids usually remained equal through their length, they never contributed in satellite association, and almost always appeared on or around the border of the metaphase spread, and simultaneously there are no clinical signs attributable to aneuploidy of other G group members.
His karyotype was therefore reported as 48, XYYY (Fig. ). Cytogenetic examination of his wife was normal (46, XX). In order to validate our results, we

[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 9-year-old neutered male Labrador retriever was referred to the medical oncology service for evaluation of a mass on the left rostral maxilla and dorsolateral muzzle. On presentation, the swelling had a diameter of 3.3 cm, round and firm. The mass could be appreciated intraoral at the apex if 204 and extraorally ~1.5 cm caudal to the nasal planum. The patient was placed under general anesthesia for head and thoracic CT as well as incisional biopsy and regional lymph node aspiration. Regional lymph node aspiration showed reactive lymphoid tissue and the thoracic CT showed atelectasis, consistent with general anesthesia, with no evidence of pulmonary metastasis or intrathoracic lymphadenopathy. Head CT revealed a 4.6 cm soft tissue attenuating mass along the left dorsolateral maxilla extending from the mesial aspect of the left maxillary canine tooth to the mesial aspect of the left maxillary second premolar tooth. The dorsal extent of the mass was 1.5 cm from the dorsal midline of the muzzle and ventrally involved the alveolar margin of the left maxillary canine tooth. Results of histological examination revealed a histologically low-grade FSA with mild bony infiltration. Based on the clinicopathologic correlation, the tumor was determined to be a histologically low-grade, biologically high-grade FSA (H/L FSA).
The case was referred to the dentistry and oral surgery service for surgical treatment. A composite resection utilizing a combined intra- and extraoral approach was performed. The soft tissue resection extended from 1 cm rostral to the medial canthus of the left eye and extended into the left lateral nasal planum. From dorsal to ventral, the resection extended from the dorsal midline of the muzzle to approximately 3.5 cm from the mucocutaneous junction. The osseous resection extended from the mesial aspect of the left maxillary second incisor tooth to the furcation of the left maxillary fourth premolar tooth. The palatal extent of the resection was the media

[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 woman presented with a 2-month history of mild dyspnea on exertion. A computed tomography (CT) scan showed a low-attenuation defect in the lumen of the right main pulmonary artery (). Pulmonary artery thromboembolism was suspected. Anticoagulation therapy with apixaban was administered; however, the defect in the pulmonary artery did not improve after 4 weeks of anticoagulation treatment. A positron emission tomography (PET) scan revealed the uptake of fluorine-18 fluorodeoxyglucose (FDG) in the intraluminal defect with a maximum standardized uptake value (SUVmax) of 4.35, suggesting a malignant tumor. To confirm the diagnosis and selection of a treatment, we performed endovascular catheter aspiration biopsy of intravascular mass using a 6 Fr Envoy catheter (Codman, Raynham, Massachusetts, USA). Vacuum suction of the mass was performed several times by careful manipulation (). Histological examination revealed pulmonary artery sarcoma. No distant metastasis was identified. A right pneumonectomy with arterioplasty of the pulmonary arterial bifurcation with the use of cardiopulmonary bypass was planned.
Through median sternotomy, the surgery was performed. The tumor completely filled the right main pulmonary artery. No invasion to extravascular tissues was identified. Cardiopulmonary bypass was established with standard techniques using cannulas placed in the ascending aorta and the right atrial appendage. The main pulmonary artery was incised. The solid tumor filled the right main pulmonary artery and extended to the main pulmonary artery trunk. The right pulmonary artery and a part of the main pulmonary artery from the supravalvular to the left main pulmonary artery were resected. Macroscopically, the surgical margin was negative. The main pulmonary artery trunk and left pulmonary artery were reconstructed with bovine pericardium. The patient was successfully weaned from the cardiopulmonary bypass, and a right pneumonectomy was performed. The operation

[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 right-handed female was admitted to our hospital because of a pulsatile mass at the right side of the neck, below the angle of the mandible. The patient reported that she had noticed the mass for the first time 13 years ago and has been followed up regularly. There was no history of any infective lesion, trauma, or any family history of aneurysm disease. There was no palpable lymphadenopathy. Initially, she has treated conservatively and due to the appearance of the symptoms such as enlargement of the size of the mass and dyspnea on exertion. She had been managed with endovascular treatment as parent vessel occlusion 4 years ago []. There was shrinkage of the size of the mass and improvement of the symptoms. Over the past 6 months, the size has again started to enlarge and also the appearance of the symptoms and its pulsatile nature became more evident. Clinical examination showed a pulsatile mass on the right side of the neck. No neurologic symptoms occurred in the patient. Examination of the cranial nerves showed no anomalies. A computed tomography (CT) angiography followed, verifying the presence of a fusiform giant aneurysm of the right ICA, measuring 5 cm in diameter. To further define the right EICA and the remaining cerebral circulation, CT angiography was performed with three-dimensional (3D) reconstruction. The 3D reconstruction confirmed a fusiform aneurysm arising from the proximal right EICA []. Despite the patient had undergone endovascular management 4 years ago in the form of parent vessel occlusion, we could see the minimal flow in the EICA which may be due to recanalization. No intracranial aneurysmal disease was identified. The aneurysm measurements were 25 mm × 30 mm, with a cranial-caudal length of 50 mm and a wide neck. An aneurysm extended from 2 cm after the carotid bifurcation nearly to the base of the skull. The patient elected for surgical correction, as she was finding her symptoms troublesome and was keen for a “definitive”

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


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

[User]
RADIOLOGY NOTE:
A 12-year-old male with a history of a distended abdomen presented to the emergency department (ED) after outpatient imaging studies were significant for an abdominal mass. He initially presented to his gastroenterologist with a 2-week history of intermittent epigastric pain that, worsened after each meal. He also developed early satiety and his parents reported increased distention. Review of systems was otherwise negative. Of note, the patient had a protuberant abdomen starting at 3 years of age. Two ultrasounds were completed at that time and both were reportedly negative for any findings; the images were not available for review. Over the years, his abdomen gradually became more distended.
He underwent an abdominal X-ray, which was significant for an abdominal mass. He was then sent for a CT of the abdomen and pelvis, which again noted an abdominal mass 27 x 33 x 15 cm in size that displaced the majority of his abdominal contents posteriorly and that appeared to be mesenteric in origin (). He was instructed to go to the ED after the CT findings. On physical exam, his vital signs were within normal limits and his abdomen was soft, non-tender to palpation, and distended. There were no palpable masses in the abdomen or palpable lymph nodes. His blood work was also unremarkable.
Hematology/oncology was consulted, and a CT neck and chest were obtained to look for potential metastatic disease, both of which were negative. The patient was admitted and underwent surgical resection of the mass the following day. On exploration, the mass was tan-yellow in color, firm with a rubbery consistency, involved a segment of small bowel, and was connected via a single vascular pedicle (). The vascular pedicle was ligated, and the involved segment of small bowel was resected along with the entire mass. Abdominal exploration revealed no other abnormalities. The patient did well postoperatively, resuming a liquid then regular diet, had return of bowel function, and was discharged

[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 was admitted to the operating theater for aortic valve replacement. During the operation and in the first hours in the intensive care unit (ICU) the patient had to undergo TEE in order to assess postoperative left ventricle performance status. Soon after, in the ICU, the patient presented hematemesis. Gastroscopy revealed a corkscrew esophagus along with a bend before the gastroesophageal junction. A deep 2 × 1.5 cm ulcer covered with blood thrombus was found approximately 2 cm above the gastroesophageal junction. Blood oozing was clearly seen from the ulcer edges. Despite thorough irrigation the thrombus could not be removed. Endoscopic therapy with 10 ml NaCl 0.9% solution successfully stopped bleeding. The rest of the endoscopy was unremarkable. Within the next 48 h, thoracic and abdominal CT scans were ordered twice to rule out esophageal perforation. Only a few blood clots were found in the area between the stomach and the left liver hilum, but no signs of mediastinitis or free intra-abdominal air. The patient remained in the ICU hemodynamically stable and on nil by mouth.
Four days later, as the patient became febrile, a second gastroscopy was performed. A 2 × 1.5 cm perforation was seen at the same site of ulcer with no bleeding (fig. ). Abdominal X-ray confirmed subdiaphragmatic air. Due to the patient's clinical condition and the size of the gap, an endoscopic intervention was decided. A new 12-mm clip (OTSC®; Ovesco Endoscopy, Tübingen, Germany) was engaged. The clip is made of nitinol and approximates large perforation margins like a surgical clamp. It is preloaded over a transparent cap attached to the scope tip. The perforation size was endoscopically assessed with a biopsy forceps. The edges of the perforation were approximated by using a specific endoscopic double grasping forceps and applying suction through the cap. Thus, the tissue was pulled into 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 3-year-old girl was referred to a tertiary metabolic bone disease unit for premature loss of primary teeth with roots intact and low serum ALP activity (123 IU/L; reference range: 230–700 IU/L) []. Routine genetic testing revealed compound heterozygosity (c.350A > G, p.Y117C, c.400_401AC > CA, p.T134H) for different TNSALP missense mutations in exon 5 of the ALPL gene, confirming the diagnosis of HPP. On presentation, radiologic assessment of the left hand and arm showed tongue-like lucencies projecting into the metaphyses consistent with childhood HPP. She did not have any clinical features of skeletal involvement of the lower limbs and no motor developmental delay except for a mild waddling gait as a younger child. The patient had a relatively asymptomatic clinical course until she presented at age 11 years with swelling and tenderness of the left ankle that was nonresponsive to paracetamol or ibuprofen. An MRI scan of the ankle suggested a diagnosis of chronic recurrent multifocal osteomyelitis, which was subsequently confirmed by biopsy. The symptoms of pain and swelling of the lower limb joints showed spontaneous transient improvement at age 13 years. Recurring at age 14 years, the symptoms fluctuated and caused significant pain and disability. These symptoms eventually stabilized when the patient was transitioned to adult care at age 17 years. At age 18 years, she successfully underwent radiofrequency ablation for Wolff-Parkinson-White Syndrome, a cardiac disorder unrelated to HPP. The patient is now 27 years of age and has experienced an episode of metatarsal stress fracture; she also suffers from generalized aches and pain.
Over 22 years, this patient was hospitalized 3 times for a total of 19 days (Table ). Only 1 hospitalization exceeded 3 days, when the patient was admitted for 14 days to receive intravenous antibiotics for suspected osteomyelitis (Table ).
Outpatient specialist visits, outpatient procedures, and day case procedures represent the majori

[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 46-year-old Dominican woman presented to emergency room with complaints of five hours of vomiting and profuse diarrhea in summer 2011. Symptoms started within 3 hours after eating chicken sandwich and salad, which were prepared at home. While frequency of vomiting decreased, she reported diarrhea, which later occurred and was too often to count. Subsequently, her urine output decreased. The patient denied fever or blood in the stool. She had previously been healthy and was not taking any medications. She had no known allergies. Her last travel to Dominican Republic or outside the US was more than 3 years ago. She lived with her husband and son. She consumed alcohol occasionally and did not smoke or use illicit drugs. Her family and friends who had the dinner together had been well. She had no history of similar symptoms in the past. She denied recent use of antibiotics or hospitalization. She had gastric bypass surgery in 2005 and abdominoplasty in 2007. At presentation, she was afebrile with pulse rate of 103 beats/minute. Her blood pressure was 89/52 with orthostatic changes. Her mucous membranes were dry; the remainder of the examination was unremarkable. Laboratory test results were significant for anionic gap metabolic acidosis with acute kidney injury and severe hypokalemia. There was no leucocytosis. Liver enzyme tests showed mildly increased aminotransferases. The laboratory data at presentation are presented in . The patient was admitted to the critical care unit due to acute renal failure with severe electrolyte abnormalities. Human Immunodeficiency Virus test was negative. She had central line placement for close monitoring of central venous pressure. She had a total stool output of 40 liters by the end of 5 days. Later, her stool color changed to green. Stool ova and parasites and Clostridium difficile toxin were negative. Computed tomography scan of abdomen showed normal bowel pattern without any dilated loops of bowel and unremarkable pancreas (). Sh

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


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

[User]
RADIOLOGY NOTE:
A 60 year old man, who was under regular haematological follow-up because of myelofibrosis, presented at a routine clinic visit complaining of increasing shortness of breath, weight loss and lethargy. Clinical examination of the chest was normal but a chest x-ray (CXR) showed multiple lung lesions consistent with metastatic deposits (figure ). A staging computed tomography (CT) scan done shortly afterwards showed marked splenomegaly, causing displacement of the left kidney medially. In the left kidney, there was a 5 cm soft tissue mass arising from the middle of the kidney with characteristics of primary renal cancer (figure ). The staging CT chest showed multiple pulmonary metastases in both lungs.
The patient underwent laparoscopic cytoreductive nephrectomy without complications and agreed to have immunotherapy with alpha-interferon. Histology revealed clear cell renal cell carcinoma. Six weeks following the operation, just prior to commencing immunotherapy, he attended the haematology clinic as routine follow-up. His initial symptoms had completely resolved and a repeat chest radiograph on that day showed clear lungs with no evidence of metastatic deposits (figure ). Although no histological confirmation of the metastatic nature of the lung lesions was obtained, it is highly likely that his pulmonary metastases had regressed spontaneously as the patient had not received any immunotherapy in the meantime. The patient remains well five months after the operation.
Renal cell cancer accounts for 2% of all cancers and its incidence is steadily rising. It usually presents in late adult life and is more common in males than females. Although they are associated with Von Hippel-Lindau disease, adult polycystic kidney disease and multicystic nephroma, most renal cell cancers develop spontaneously [].
The patient may present with urological symptoms such as haematuria or flank pain or with an abdominal mass or alternatively with systemic manifestations, such as anaemia 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 24-year-old male patient had road traffic accident dated January 2018, was taken to a nearby orthopedic surgeon, where he was diagnosed as having intra-articular distal radius fracture of the right side, and was operated 2 days after injury with anatomical distal radius locking plate. He was doing fine for 6 months after the index surgery; thereafter, he noticed a swelling in his lateral aspect of the right forearm for which he consulted his index surgeon, was advised course of oral antibiotics with regular follow-up. However, his swelling did not subside and was slowly increasing in size which made him to visit his index surgeon again where he was advised removal of implant.
One month following removal of implant, he again noticed swelling now on his inner aspect of the right forearm which was also slowly increasing in size; he was advised ultrasonography and fine-needle aspiration cytology (FNAC). Sonographic findings were non-specific, but FNAC report suggested soft-tissue sarcoma and was finally referred to our tertiary care hospital for further management.
Clinically, the patient was afebrile with no history of weight loss. Non-tender, ill-defined, and firm swelling was located on inner aspect of his right forearm; overlying skin was free with normal texture and normal temperature. Swelling was not fixed to underlying structure and regional lymph nodes were not enlarged. Routine laboratory and biochemical parameters were within normal rage except for mild raised erythrocyte sedimentation rate. Radiograph revealed malunited fracture of distal radius with evidence of screw holes of previous implant. Soft-tissue shadow was noticed adjacent to ulna with no evidence of bone erosion and/or periosteal reaction (). Here, the patient was advised contrast magnetic resonance imaging (MRI), which reported calcified soft-tissue mass measuring 8.3 cm × 1.6 cm × 10 cm situated in medial aspect of lower third ulna extending to ventral compartment of the right forearm, appear

[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:
1: A-39-years-old male referred to our General Hospital with sensation of giving away and unable to extend on the right knee after car accident 1.5 years ago. He had history of close fracture of lateral condyle right femur. The patient complain of irreducible patellar dislocation during flexion and extension of the right knee joint. He underwent 4 times surgery of his right knee by other orthopaedic surgeon. The first surgery result still unreduced fragment fracture, and we done open reduction and internal fixation (ORIF) also PCL reconstruction. The right knee became valgus knee after fracture union and instability sensation on the medial knee joint. On physical examination, the right knee had 18° of valgus deformity, moderate instability to valgus stress, complete lateral dislocation of the patellae during extension and flexion, and tenderness at the lateral joint line (). Range of motion was 0–110°.
During radiographic examination, the standing knee radiograph showed mild arthritic changes on the lateral compartment of the right knee that were not observed on the left knee. The long-leg weight-bearing standing radiograph showed 18° valgus on the right knee and 5° valgus on the left knee with depression of the lateral tibia plateau and a mechanical axis passing outside the lateral compartment, and the weight bearing line locates lateral to Fujisawa point. The anatomical lateral distal femoral angles of the right and left knees were 105° and 82° respectively (normal value is 81° and 62°, respectively); the medial proximal tibial angles were 94° and 93° respectively (normal value is 87° and 63°, respectively). This result confirmed valgus deformities of both knees. A skyline view radiograph showed complete lateral dislocation of the patella () [].
2: A-26-years-old obese female came into outpatient clinic with chief complain of left patellar dislocation. She had history of left knee surgery for dislocation at age 5 years old. Her left knee never felt comfortable 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 35-years-old female presented to our outpatient department (OPD) for the assessment of multiple non-healing ulcers present bilaterally on the dorsal aspect of hands, posterolateral aspect of elbows, and inner knees (Figures -). The patient had severe pain at the sites of the ulcer which was present throughout the day. The patient first noticed a hard-elevated lesion on her left elbow two months ago. The lesion first began as a small pustule. It increased in size and became pus-filled to form a blister which later on burst to leave behind a raw area that turned into an ulcer. Several such lesions developed gradually on other parts of her body that progressed similarly. The lesion progressed to her right elbow, advanced further to both knees, and then lastly to the dorsal aspect of both hands. All the lesions turned into painful pus discharging ulcers over time. The patient initially consulted a private practitioner and was prescribed antibiotics along with an analgesic. The patient was unresponsive to this treatment following which she was referred to our tertiary care centre. On initial examination, the lesions were painful that discharged pus. Margins were raised, irregular, and showed bilateral symmetry. A few differentials were suggested like cutaneous tuberculosis, vasculitis, deep fungal infection, and PG. To rule out cutaneous tuberculosis, investigations were done which turned out negative. Further, a skin biopsy from the left elbow ulcer was sent to rule out other differentials.
The biopsy report showed epidermal and dermal ulceration with necrosis, vascular proliferation, granular tissue formation with polymorphs, lymphocytes, plasma cells, and macrophages. The adjacent epidermis showed spongiosis, while there was mild hyperplasia and peri adnexal mixed inflammatory infiltration in the dermis. These histological features were consistent with the clinical diagnosis of pyoderma gangrenosum. Antinuclear antibody (ANA) profile and rheumatoid factor (RF) were

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


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

[User]
RADIOLOGY NOTE:
A 63-year-old right hand dominant gentleman presented to our orthopaedic clinic with a six-month history of an unusual, progressive, painful, and fixed external rotation deformity of his left shoulder (Figures and ).
One year previously, he was diagnosed with oesophageal adenocarcinoma, which was treated with a course of neoadjuvant chemotherapy followed by oesphagectomy. Preoperative staging CT had shown no evidence of distant metastases. Histology revealed a poorly differentiated adenocarcinoma with focal perineural invasion but clear resection margins. He had declined adjuvant chemoradiotherapy.
The patient initially experienced reduced range of movement in his left shoulder six months following his oesphagectomy and began to notice that self-hygiene was becoming troublesome. He was referred to the physiotherapists who noted a progressive permanent external rotation deformity of his left shoulder with a fixed abduction of 30 degrees and a maximum abduction of 90 degrees. He complained of a continuous pain from the shoulder radiating to his elbow, and was slightly tender over the infraspinatus muscle bulk, although no mass was palpable. The awkward position of his arm increasingly interfered with washing and dressing. The external rotation deformity worsened and became fixed at 40 degrees, at which point he was referred to the orthopaedic clinic where he presented a great diagnostic challenge.
As the shoulder pain and deformity progressed, CT and MRI were performed to aid the diagnosis. These showed a discrete mass measuring 4 × 4 × 4 cm in the infraspinatus muscle (Figures and ).
Biopsy subsequently confirmed metastatic oesophageal adenocarcinoma with the histology showing infiltration of the infraspinatus muscle by poorly differentiated adenocarcinomatous cells with calcific deposits. Further imaging revealed local recurrence of the primary. The decision was made in liaison with the patient and oncologist to have palliative radiotherapy to his shoulder to help 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:
The combined surgical and electrochemotherapy technique proposed was adopted to treat a 72-year-old male patient with an RRC developed in a long-standing ulcerative colitis of the rectum. In 1991, the patient underwent surgery for intra-abdominal total colectomy with terminal ileostomy for acute severe UC. In 2018, he noticed the appearance of right ischial-rectal abscess associated with a perianal fistula with evidence of rectal adenomatous villous lesion with high-grade dysplasia. So, the patient went to surgery with proctectomy in November 2018 for adenocarcinoma G2 infiltrating the muscle tunic (pT2 pN0 M0 sec. ajcc 2017). The surgical resection margins were free from neoplastic localization.
After a multidisciplinary consult, an adjuvant chemotherapy and pelvic radiotherapy treatment was proposed to the patient, but he refused and avoided to undergo oncological follow-up until October 2019 when he noticed the appearance of a hard-wooden swelling in the soft tissue of right perineal region (6–7 cm in diameter). After a CT scan () and MRI that confirmed a local recurrence of cancer, following a multidisciplinary discussion between surgeons, radiation oncologists, radiologists and oncologists, a surgical resection indication was given.
However, the CT investigation documented a close relationship between the neoplastic lesion and the root of penis and urethra, with consequent difficulty in obtaining the certainty of disease-free margins without a major demolition procedure that the patient firmly refused.
To increase the chance of best treatment of the margin and perform a local remediation of the tissue adjacent to the neoplasm, it was decided to associate resective surgical treatment to ECT.
Intraoperative time I: the mass infiltrated the perineal muscles and appeared anteriorly tightly close to the prostate plane and root of penis. Removal of the neoformation was made en-bloc with a portion of skin and perineal muscles.
Intraoperative time II: after intravenous

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


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

[User]
RADIOLOGY NOTE:
A 15 years old boy with ESRF due to rapid progressive GN (on peritoneal dialysis) and growth retardation, underwent living related kidney transplantation (from his father), commenced on protocol of triple immunosupression including Tacroluimus, MMF/ Cellcept (750 mg BID) and Prednisolon (to be tapered over three months period to 5 mg) and on bacterial prophylaxis (Bactrim) and CMV prophylaxis (Ganciclovir). On day 22 from the transplant he presented to our emergency department with acute sever colicky right upper abdominal pain and high fever with no similar previous attack. On physical examination he had abdominal distension with generalized tenderness more on the right upper quadrant. His blood work showed leukocytosis (17,000), liver enzyme (including Alkaline phospatase) and renal function were within normal range also CMV antigenemia was negative. Empirically he was started on broad spectrum antibiotics suspecting bacterial peritonitis from the peritoneal dialysis catheter (PDC) and it was connected to gravity drainage (the output fluid was serous). Few hours after admission the abdominal pain start to subside and the PDC drainage became bloody and mixed with bile but the output was decreasing. Then the WBC count went up to 31,000. Repeated ultrasound showed collapsed gallbladder compared to preoperative one with no stones. Further imaging with CT scan confirmed perforated gall bladder (). Under US guidance, a 7F pig tail cholecystostomy catheter and another pig tail tube in the left iliac fossa were inserted. Both tubes were draining biliary fluid (). Patient responded dramatically to this and the pain, fever and leukocytosis subsided gradually over 3 days. One week later the peritoneal pigtail tubes removed after confirming nil output. His Cellcept dose readjusted to 500 mg bid and discharged on the same dose. Three months later the cholecystostomy tube and PDC were removed after confirming no bile leak or collection (). Another follow up imaging after six mo

[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 woman presented with mastalgia and yellowish discharge from her right breast. She reported family history (maternal lineage) positive for cancer. Her mother was diagnosed with BC at 33 and died, and maternal grandmother at 65 years, also from BC. Uncle who had been a smoker died of lung cancer at the age of 70. She has no other live relatives and siblings and has one 3-year-old son. Radiologic imaging found no suspicious lesions in the breast nor enlarged lymph nodes but showed solitary mediastinal mass which was surgically removed. Patohistological examination revealed fibrous tumor with increased mitotic activity, positive for CD34 and STAT6 by immunohistochemistry staining (Fig. ). Both tumors/breast cancer and solitary fibrous tumor have stained negative for p53 protein.
No further treatment was indicated and after 4 years of follow-up, a lesion in the upper left quadrant of the right breast was discovered. Needle biopsy suggested a luminal B-like invasive BC so she underwent mastectomy and axillary dissection. Surgical pathology specimen showed pT1bN1 grade 3 carcinoma (ER 100%, PR 80%, Her2 negative, Ki 67 26.5%, micrometastasis in 1 out of 11 lymph nodes).
Four cycles of adjuvant treatment with doxorubicin and cyclophosphamide was administered followed by radiotherapy and tamoxifen with ovarian function suppression. The testing for BRCA1/2 was carried out and found no mutations.
One year later, during preoperative evaluation for breast reconstruction surgery, 4 pulmonary nodular lesions were discovered on chest computed tomography (CT) scan. A CT-guided biopsy of one of the suspected metastases was performed and pathohistological examination was consistent with metastasis of malignant fibrous tumor. Tamoxifen was switched to exemestane due to its possible proliferative effect on fibrous tumor. Chemotherapy for stage IV sarcoma with temozolomide and bevacizumab was initiated given the prior anthracycline chemotherapy.
In the light of the two know

[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 10-year-old female sustained a twisting injury to her left knee as she was descending a spiral playground slide. She presented to the ED with her leg locked in extension and experiencing severe pain. She was unable to bear weight on her left leg. The patient had no other injuries but did complain of tingling in the lower left leg. She had no muscle weakness and no loss of sensation from the knee distally. On physical examination, the patella was obviously mal-positioned and was rotated 90°, facing perpendicular to its natural plane (). The performed radiograph confirmed a rotation of the patella of 90° about its vertical axis, positioned within the trochlear groove between the femoral condyles (). The Orthopaedic Service was consulted and evaluated the patient in the Emergency Department. Given the patient’s thin body habitus, the patella could be easily palpated and it was determined that the articular surface was facing laterally. A reduction was attempted in the Emergency Department under conscious sedation with etomidate. The patella was successfully reduced via vertical traction to lift the medial side and lateral pressure on the anterolateral edge of the patella to allow it to rotate back to its anatomic position. Reduction was confirmed with radiographic imaging () and restoration of normal motion of the knee passively. After waking from sedation, the patient reported that her pain had markedly improved. A knee immobilizer was placed after reduction and she was discharged from the ED.
Upon follow-up in clinic, an MRI was ordered and revealed medial patella and anterolateral femoral condyle bone contusions, mild femoral trochlear dysplasia, and medial patella femoral ligament sprain. There were no osteochondral defects or loose bodies detected in the MRI. The knee immobilizer was then transitioned to a hinged knee brace and she was able to begin range of motion exercises. She was referred to physical therapy for strengthening and patella stabilization. At fo

[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 female came to our observation due to a limitation in mouth opening range. She also reported crepitus sounds at the left TMJ as well as pain, exacerbated by function (e.g., chewing) and increasing in intensity over the past three months. Clinical assessment showed a limited mouth opening (i.e., 22 mm) and pain with palpation at the left joint and all the main masticatory muscles, more severe on the left side. At the first appointment (T0), mandible manipulation was performed to achieve a forced opening of about 40 mm. A magnetic resonance (MRI) was prescribed to assess the disc-condyle relationship as the possible source of limitation in mouth opening and to gather some pictorial evaluation of the presence of joint effusion (). Despite the clinical suspicion of TMJ arthritis, computerized tomography was not prescribed at this stage due to the expected low impact on treatment planning decisions.
MRI showed a regularly shaped condyle, with an anteriorized disc at closed mouth. At the maximum mouth opening, the condylar translation is reduced and the disc is not recaptured. Joint effusion of severe entity is also present. A conservative approach to provide pain relief and to manage muscle tension was provided, based on counseling, a home program of self-exercise and a stabilization appliance to wear at night. After three months, symptoms improved only partially, with a reduction of pain with muscle palpation but a steady pain at the left joint.
Based on that, a cycle of five arthrocentesis plus viscosupplementation with hyaluronic acid (Sinovial, IBSA) has been performed weekly. Clinical data has been recorded at each time point before each injection and 15 days after the last one ().
After one month from the last arthrocentesis plus viscosupplementation, the patient still showed some pain and, more important, still felt a limitation in the unassisted mouth opening and right laterotrusion. A diagnosis of TMJ intermittent locking on the left side was thus

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


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

[User]
RADIOLOGY NOTE:
A 54-year-old male was struck by a truck while riding a motorcycle and consequently impacted a guardrail. He was reportedly conscious, ambulatory, and unable to bear weight on his left leg at the scene. His pelvis was temporarily stabilized at an outside hospital, and he was transferred to our facility. A pelvic X-ray and a computed tomography (CT) scan of the chest, abdomen, and pelvis from the outside hospital demonstrated diastases of the left pubic symphysis and a fracture involving the left sacral wing extending to the left sacroiliac joint and a ruptured bladder. On arrival, he underwent a retrograde cystogram during Foley catheter placement, which demonstrated extraperitoneal bladder rupture.
The patient underwent an additional CT scan with contrast enhancement of the chest, abdomen, and pelvis with reconstructions of the thoracic and lumbar spine. At the same time, a CT scan of the head and cervical spine was performed. The images demonstrated extensive hyperdensity within the spinal canal subarachnoid space related to extravasation of contrast material, which was not previously observed on the outside hospital imaging [].
The imaging suggested that the contrast material extravasated out of the bladder into the extraperitoneal space []. Because of extensive fracturing of the left sacral pelvic tube with violation of the left sacral nerve roots, the contrast agent entered the subarachnoid space at the left sacral ala predominantly through the left L5 and S1 nerve roots [].
The patient underwent emergent repair of the bladder by the urological surgeon, and the pubic symphysis was secured with plates by the orthopedic team. Two days later, the patient underwent open reduction and internal fixation of the left sacrum and percutaneous pinning of the left sacroiliac joint by the orthopedic surgeons. The dural tear and cerebrospinal fluid leak were treated conservatively.
The patient was discharged home 13 days after presentation with family support, physical thera

[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 eight-year-old female spayed Saint Bernard dog presented to the emergency department of a referral hospital for evaluation of nonproductive retching and lethargy. Abdominal radiographs confirmed the presence of GDV, and emergency surgery was performed to correct the GDV and perform an incisional gastropexy. No history of prior neurologic disease was noted by the owner. The patient recovered uneventfully from anesthesia. The dog was placed in a large kennel with deep bedding, and instructions were to walk or change the dog's position every four hours.
Twelve hours later, significant gait abnormalities involving the right pelvic limb and a small (approximately 1 cm) wound on the dorsum of the right paw were noted. A neurological examination indicated paresis of the right pelvic limb and conscious proprioceptive deficits leading to knuckling and dragging of the right hind foot. The right hind limb had a mild plantigrade stance and notably decreased hopping compared to the left hind limb. The withdrawal reflex was decreased on the right pelvic limb, but the lateral digits elicited a better response than the medial digits. Patellar reflexes were intact bilaterally. The patient's recovery plan was updated to include more frequent leash walks, and a crib mattress was placed in her cage to minimize the potential compression of the sciatic nerve while recumbent. A sports medicine consultation had similar findings to the neurologic examination. The patient was discharged four days after admission with instructions for rehabilitation exercises to perform at home. The patient returned two days later for a recheck of the neuropraxia and for a bandage change on the right hind foot. The paresis of the right hind limb noticed previously was improved, and no knuckling-over was seen. The right tarsus remained dropped compared with the left, but withdrawal reflexes were present in both hind limbs. The owners noted significant improvement with the patient's stability. She was discha

[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 July 2017, a 13-year-old Chinese male experienced intermittent abdominal pain lasting about 10 minutes per stint. The pain could be alleviated without treatment. No fever or diarrhea were observed. The patient subsequently developed vomiting, notably a coffee-like substance, which could not be alleviated by drugs. Gastroscopy results revealed gastric mucosal inflammation, but the patient refused to undergo further systemic examination. On the 30th of July 2017, the patient was diagnosed with an acute intestinal obstruction, with the abdominal CT scan indicating obstruction of the lower intestine and thickening of the splenic flexure (). He underwent an emergency colostomy with a colon tumor resection. No lymph node dissection was performed because of the operation under emergency condition and considering the boy’s young age. Intraoperative findings revealed that an irregular 5cm x 3cm tumor within the intestinal wall near the splenic flexure was the cause of the obstruction. The proximal bowel tube was dilated and multiple lymph nodes were enlarged. The proximal colon was removed 5cm from the edge of the tumor as well as a small mesenteric lymph node. The patient was healthy prior to the surgery with no history of infective diseases, or allergies to food or drugs. His maternal uncle also had colorectal cancer.
From August 2017 to December 2017, the patient underwent six cycles of combined mFOLFOX6 chemotherapy which consisted of oxaliplatin, leucovorin, and 5-fluorouracil. During chemotherapy, the level of CEA and CA199 was stable. An abdominal CT scan evaluation showed that the disease was stable and remained stable after the completion of the mFOLFOX6 chemotherapy regimen (). Oral administration of capecitabine was adopted from January 2018. The disease-free survival (DFS) was 8 months. On April 23 2018, the level of CA199 was significantly higher than before, and the abdominal CT scan suggested the presence of multiple nodules in the greater omentum and perit

[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:
Man, aged 57, farmer, smoker, and previously healthy, referred to the GP in February 2015 due to left upper limb pain, most severe in the elbow, persistent since January. He could not deny the injury (perhaps at work on the farm). Neither swelling nor redness were found. He received Profenidum 2 × 100 mg for 1 week with slight improvement. He was referred to the Department of Neurology with the diagnosis of neuropathy of the ulnar nerve. The clinical picture suggested neuroborreliosis (radicular syndrome), as the patient was the resident of endemic area for tick-borne diseases and was exposed to tick bite. During the following days numbness of fingers of the left upper limb appeared. The straightening of the upper limb at the elbow was not feasible due to the severe pain.
X-ray of elbow joints and bones of the forearm revealed osteolytic lesions. Brain CT presented cyst (28 mm × 40 mm), with inhomogeneous marginal contrast enhancement in the right occipital lobe with the vast area of hypodension in the parietooccipital region of the lobe, the area of similar nature (36 mm × 27 mm) in the right hemisphere of the cerebellum with hypodense zone of edema, metastases. Hyperdense area (11 mm × 7 mm) in the midline at the base of frontal lobes, with heterogeneous contrast enhancement suggested meningioma. Midline brain structures were displaced by 9 mm to the left side, the right lateral ventricle and the fourth ventricle were narrow, and left lateral ventricle was extended. The grooves of the right hemisphere were oppressed and had edematic characteristics. Features of intussusceptions were observed. Chest X-ray showed nodular shade in the upper right lung.
On admission to the Department of Lung Diseases and Tuberculosis patient complained of pain and weakness of left upper limb. Chest CT showed enlarged lymph nodes in the mediastinum. In the top of the right lung heterogeneous mass of irregular lumpy shape with uneven

[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 84-year-old woman with a history of syncope was referred to a general hospital by her primary doctor. Sick sinus syndrome was diagnosed and a ventricular demand pacemaker was implanted via the left axillary vein. The tip of the implanted lead (5076-52 cm, Medtronic, Minneapolis, MN) was a screw type. The lateral chest X-ray film obtained just after pacemaker implantation demonstrated that the tip of the lead was in the correct position () and the pacemaker threshold was normal. Two days after implantation, she complained of the sudden onset of pain in the left precordial region. On the fourth day after implantation, a bulge appeared in the left sixth intercostal space at the site of the pain. A lateral chest radiograph obtained on the same day demonstrated displacement of the pacemaker lead (). Transthoracic echocardiography did not identify a pericardial effusion, but the position of the lead tip could not be seen accurately. Computed tomography (CT) confirmed penetration of the lead though the RV into the subcutaneous tissues of the left thoracic cavity (). There was no pericardial effusion, pneumothorax, or pleural effusion. The patient was sent to our hospital for emergency treatment. Because transvenous removal of the pacing lead was thought to be risky, surgical removal and RV repair were performed. Median sternotomy was chosen as the approach because it would be easy to establish cardiopulmonary bypass if required. There was no pericardial effusion, but the pacing lead was seen protruding through the anterior wall of the RV apex and penetrating the pericardium (). When the left pleural cavity was opened, the pacing lead was found to be embedded in the anterior visceral pleura, but the left lung was not injured in agreement with preoperative CT findings. A purse string suture was placed around the lead in the RV wall and a pledgetted mattress suture was added for reinforcement. Then the part of the lead protruding from the RV was grasped with forceps and cu

[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 an 80 year old man admitted to the ER with abdominal pain. At admittance, the patient was unable to walk and described an increased difficulty with movement and coordination of the lower limbs, tendency to fall, extensive fatigue, and pain. Six months earlier, the patient had full movement of his lower limbs and could walk unaided. He described an increased intensity and duration of symptoms during the last three months. He was also confused and was unable to answer correctly on orienting questions. Blood serum samples taken at the ER showed a slight thrombocytopenia and mild kidney insufficiency. An arterial blood gas showed hypercalcemia. His condition was deemed to be a combination of somatic pain and confusion. He was therefore treated as a mild trauma patient. Computer tomography (CT) of the abdomen was performed and a surgical consult ruled out any surgical pathology. A pelvis CT showed deterioration of the right hip and an orthopedic consult diagnosed right-sided hip arthritis. The patient was admitted to the orthopedic trauma ward for one day before being transferred to the geriatric clinic for mobilization and pain optimization. He was placed at the neurogeriatric ward to due to space constraints caused by Covid-19.
At the neurogeriatric ward, clinical examination revealed several neurological abnormalities including apraxia, dysdiadochokinesia, intentional tremor, clonus, and parkinsonism. Both sides of his body were affected although the left side showed more pronounced symptoms than the right. He was paraspastic and there was parkinsonism in his upper extremities with cogwheel rigidity bilaterally. There was hyporeactivity in his triceps, biceps and brachioradialis tendon reflexes. His lower body display mixed neurological symptoms with peripheral rigidity and hyporeactivity in quadriceps tendons reflexes. He admitted no pain sensation in his left lower leg and foot, though both proprioception and sense of vibration were preserved. He had

[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's mother was 36 years old, with a total of 5 pregnancies and 1 live birth. Eleven years ago, she gave birth to a healthy boy via cesarean section. She previously had 2 artificial abortions and 1 spontaneous abortion, with no family history of hereditary diseases. Ultrasound test result was normal at gestational week 6. At gestational week 12, nuchal translucency of 1.3 mm was observed, with no positive findings. Non-invasive DNA analysis showed low trisomy 21 risk, low trisomy 18 risk, and low trisomy 13 risk. At gestational week 24+5, ultrasound examination showed abnormal development of the long bones of the limbs (the length of the long bones was shorter than 1% controlled to the same gestational week of normal fetus), thick metaphysis in the right lower limb, irregular vertebral arrangement, and a narrow and small thorax (Fig. A–D). The patient's parents decided to terminate the pregnancy at 27 weeks of gestation considering this as a lethal skeletal dysplasia.
After the termination of pregnancy at week 27, the gross examination of the fetus showed a flat face and nose bridge, short limbs, asymmetric short lower limbs, and bilateral clubfeet with bilateral ankle joint contracture (Fig. A, B). The autopsy report indicated that the left humerus bone was 2.5 cm long; the right humerus bone, 2.0 cm; the left femur, 3.0 cm; and the right femur, 2.2 cm; all were significantly shorter than 4SD measured at the same gestational age. In addition, the shapes of T3 to L3 were abnormal, the vertebral bodies appeared fused, the thorax was small with a maximum circumference of 16 cm, and the abdominal circumference was 26 cm. The autopsy also found subcutaneous edema in the head and face and thick metaphysis in the lower limbs. X-ray imaging showed short femur and humerus bones, a narrow and small thorax, thick metaphysis with a thick “splashed paint

[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 35-year-old man with a penetrating dorsolateral thoracic injury. The patient was injured by a knife through a street quarrel and brought to the emergency department (ED) by ambulance. The knife had entered the thoracic cavity from lateral to the left mid-clavicle line posteriorly at the level of the third intercostal space with about 4 cm of the blade inside the body (). Hematoma was detected at the site of the injury. Despite an elevated pulse rate (110 bpm), the patient was stable with the arterial blood pressure of 110/70 mmHg, respiratory rate of 18 and oxygen saturation of 96% in room air. We evaluated the patient by extended focused assessment with sonography in trauma (e-FAST)protocol which revealed possible pneumothorax, but no sign of hemothorax was observed. There was no abdominal free fluid and we did not detect any sign of pericardial effusion. The knife at the injury site did not allow performing anterior-posterior Chest X-Ray (CXR), therefore, a hemi-lateral CXR was taken to evaluate the extension of the injury. The radiograph was taken using a portable X-ray machine ().
Considering the patient's stability and the results of imaging which did not show any massive vascular injury, the patient was taken to the operation room for thoracoscopy. We intended to have a better vision of the injury and remove the knife with thoracoscopy, and avoid wide thoracotomy, which is the routine treatment for patients with penetrating thoracic injuries.
At thoracoscopy, we saw 4 cm of the blade in the thoracic cavity between the third and fourth intercostal space (). There was a mild laceration of lung tissue without any active bleeding. Considering the position of the blade and the absence of active bleeding and vascular injury at the trauma site, we successfully removed the blade by the thoracoscope without any complications. After removing the knife, we observed the site of the injury directly via

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


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

[User]
RADIOLOGY NOTE:
A 33-year-old second-gravida was referred to a tertiary care center at 30 weeks of gestation for evaluation of a right lung mass in the fetus. The mother had no significant complication in her previous pregnancy and no other antenatal problem was reported in this pregnancy before 30 weeks of gestation. A 32×31 mm, well-defined calcified hyperechoic mass in the right thorax with hypoechogenic right pleural effusion was detected on antenatal ultrasonography at our hospital, which was initially suspected to be a teratoma (). The fetal thoracic mass increased in size up to 39×32 mm and the amount of right pleural effusion increased during 3 weeks of evaluation (). Fetal hydrops including 7 mm deep ascites and generalized subcutaneous edema developed at 33 weeks of gestation (). No other significant defect in fetal structure was found. Fetal surveillance tests, including biophysical profiling and non-stress test were conducted. Minimal variability was noted on the non-stress test.
A male baby weighing 2,780 g was delivered through an emergency cesarean section owing to non-reassuring fetal heart beat patterns, and admitted to the neonatal intensive care unit with Apgar score 3 at 1 minute and 5 at 5 minutes. No metastatic lesion was found in the placenta and umbilical cord. Initial neonatal hemoglobin from arterial blood was 12.6 g/dL, neonatal hemoglobin dropped to 9.4 g/dL after thoracentesis. Initial neonatal red cell distribution width was slightly increased (18.9%), which suggests fetal anemia was due to the hemorrhage of the tumor. Bone marrow biopsy revealed no metastasis to bone marrow.
Contrast-enhanced computed tomography of the chest revealed a 40×40×30 mm enhanced tumor in the right thorax with bilateral hemothorax causing mediastinal shifting to the left, which was considered a posterior mediastinal teratoma or neurogenic tumor (). Moreover, multiple hepatic metastases were suspected on magnetic resonance imaging () and abdominal ultrasonography. The neuro-s

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


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

[User]
RADIOLOGY NOTE:
The patient was a 10-year-old boy when dental treatment under moderate sedation was first planned. He had a medical history of a sudden cardiac arrest during separation surgery for syndactyly, from which he had been rescued by immediate cardioversion. He had received a diagnosis of long QT syndrome. The QT interval of the patient was prolonged above the normal range in an electrocardiogram (ECG) (). He had been taking beta-blockers (Atenolol) as a routine medication.
At a regular visit, ICDAS 5-6/+ () mesial proximal dental caries at the right mandibular permanent first molar and ICDAS 4/+ caries at the right maxillary permanent first molar were observed. The right mandibular first molar tooth was thought to require endodontic treatment (). Profound local analgesia must be achieved before endodontic treatment because the treatment is often very painful and uncomfortable. Emotional stress can also induce arrhythmia in patients with long QT syndrome, therefore treatment under sedation was planned. On the day of the treatment, we first administered N2O at a concentration of 40 vol % before intravenous cannulation. We attached a bispectral index (BIS) sensor to his forehead. Propofol was infused with a computer-controlled drug delivery system after intravenous cannulation. We adjusted the propofol effect-site concentration to maintain a BIS value in the range of 70-80. The effect-site concentration of propofol was maintained in the range of 0.6-1.2 µg.ml-1 during the treatment period. There was no fatal arrhythmia during propofol sedation. Composite resin restoration of the right maxillary first permanent molar and an endodontic treatment on the right mandibular first permanent molar were successfully performed under propofol sedation. Local anesthesia was achieved with lidocaine without epinephrine.
About 10 months after the first sedation, new dental caries of ICDAS 2-3/+ () were observed on all second permanent molar, all of which required restorative dental treatmen

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


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

[User]
RADIOLOGY NOTE:
The patient is a female in her 40s who underwent a repeat renal transplantation that was complicated by acute tubular necrosis, delayed graft function, and Pseudomonas sepsis with a right upper lobe pneumonia (Figure ). The patient was admitted and treated with an extended course of piperacillin-tazobactam for the Pseudomonas infection. She continued to experience dyspnea following the completion of treatment and had a persistent right upper lobe opacity identified on chest X-ray (Figure ) and the subsequent computed tomography (CT) scan (Figures -). CT scans demonstrated a large opacity (10 cm x 4 cm) with adjacent areas of mixed ground glass opacity, airspace opacity, and thickening of the interlobular septa. The combination of the ground-glass attenuation with superimposed interlobular septal thickening and reticular thickening-specific opacifications was consistent with a “crazy paving” pattern. Given the history of immunosuppression, infectious, inflammatory, and neoplastic lesions were considered in the differential. A follow-up CT scan two months later demonstrated a persistent lesion with little change from the previous imaging. Given the failure of this lesion to resolve, the patient underwent a surgical lung biopsy to exclude an atypical infectious or neoplastic lesion.
A video-assisted thoracoscopic surgery (VATS) was performed and an abnormal right upper lobe with a nodular and cheesy appearance was identified. A representative wedge biopsy was sent for intraoperative consultation. The cryosections showed interstitial pneumonitis with calcification and no evidence of malignancy. Given that this appeared to be a benign process, a lobectomy was not performed, but additional wedge biopsies were sent for permanent sections along with material for culture. As shown in Figures , , , , sections of the lung biopsy were composed of extensive multifocal calcifications, highlighted by a von Kossa stain (Figures , , , ) . The calcifications ranged in size from small

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


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

[User]
RADIOLOGY NOTE:
An 81-year-old female with a 24 h history of acute, worsening abdominal pain with associated abdominal distension and bilious vomiting was referred by her GP to the general surgical admissions unit. The patient reported no other gastrointestinal symptoms and there was no prelude to the presentation.
The patient had an extensive surgical history. She had undergone a Billroth I gastrectomy in 1977 for peptic ulcer disease, a splenectomy following blunt trauma in 1989 and further gastric surgery for a cancer in 1999. During a therapeutic endoscopy for a benign stricture 4 months previously, the patient had suffered an iatrogenic perforation. This was treated endoscopically with the deployment of a Hanaro-antireflux covered stent, covering the defect that was identified at 35 cm. The stent was deployed at 32–41 cm. These margins were chosen in order to give a ±3 cm cover of the perforation. The extra 2 cm distal cover was because the stent was the only suitable stent available that would be both wide enough to remain in situ and long enough to give adequate cover of the perforation. There were no concerns regarding the apposition of the stent, and the stent was not sutured in place. Routine follow-up was arranged for 4–6 weeks; however, for an unconfirmed reason, this follow-up never took place.
On presentation, her physiological observations were stable and she was apyrexial. The abdomen was very distended, tympanic and tender on palpation. Bowel sounds were not present.
Blood results on admission, including liver function, urea and electrolytes, CRP, amylase, lactate and full blood count, were within normal limits.
Abdominal X ray showed multiple distended loops of small bowel with a migrated stent inside small bowel Fig. .
Following the diagnosis of mechanical small bowel obstruction due to oesphageal stent migration, the patient was booked and consented for a laparotomy. At laparotomy, distended small bowel was found, with the cause of the obstruction being

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


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

[User]
RADIOLOGY NOTE:
A 72-year-old man was referred to our cardiovascular center with previous history of hypertension for 5 years and a 2-month history of worsening dyspnea on exertion that motivated him to seek medical attention. Atrial fibrillation was detected during a recent medical check up at a local clinic, and the patient was referred to our hospital and admitted for closer examination. The laboratory data was unremarkable. His electrocardiogram revealed new-onset atrial fibrillation compared with previous data. A chest X-ray film revealed no particular anomalies. Two-dimensional transthoracic echocardiography (2D TTE) showed 1.04×0.87 cm nodular mass attached to the aortic valve. The echogenic mass originated from the ventricular side of the non-coronary cusp of the aortic valve (). Based on these findings, a papillary fibroelastoma of the aortic valve was suspected. Because of his old age and atrial fibrillation, scheduled surgery was performed to avoid systemic embolization. After aortic cross clamp, the aorta was opened. Inspection of the aortic root revealed a normal structure. A mass was found on the ventriclular side of the non-coronary cusp. The mass was successfully excised from the aortic valve (). The tumor measured 1.5 cm and had a smooth surface with a spherical shape. The aortic valve was repaired rather than replaced after tumor resection. Intra-operatory transesophageal echocardiography showed normal left ventricular outflow without regurgitation and no residual mass.
Histopathological examination of the tumor revealed a benign soft tissue tumor mass. The margin of the mass was irregular but was easily distinguishable from the normal valve tissue. The tumor consisted of plump gray purplish myxoid stroma and slender and long spindle stromal cells. The stromal cells had eosinophilic scanty cytoplasms and dark small nuclei. Fibrocollagenous bands of aortic valve tissue were also noted in the myxoid stroma (Hematoxylin and eosin; ×200) (). The final pathologic diagn

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


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

[User]
RADIOLOGY NOTE:
A 50-year-old Hispanic man with known history of obesity and hypertension presented with a 3-month history of abrupt episodes of weakness and altered mental status. He referred severe psychomotor symptoms as well as anxiety, aggressiveness, agitation, weakness, diaphoresis, and decreased visual acuity occurring at any time of the day and improved by eating. Upon further questioning, our patient, who worked as a truck driver and whose symptoms had reflected poorly in his workplace, also expressed overall discomfort with life and wishes of death due to the intensity of his symptoms. He had no history of tobacco smoking or excessive alcohol consumption. Medications taken prior to admission included candesartan 16 mg and hydrochlorothiazide (HCTZ) 12.5 mg once a day for hypertension.
During the following weeks, the symptoms increased in severity and frequency, with continued unremitting anxiety and weakness accompanied by loss of consciousness and extreme burning sensation in his entire body. After this acute episode, he was evaluated by a primary care physician in a local hospital and hospitalized for 4 days, where he continued to present recurrent episodes of irritability and aggression to self and others. He was discharged and referred for psychologic evaluation by mental health services at another institution. No specific diagnoses were given.
Upon release from mental evaluation, he was evaluated by a third physician, who performed a 3-hour postprandial blood glucose test which revealed a blood glucose level of 58 mg/dL. Suspecting an insulinoma, our patient was admitted to a third-level hospital, and upon arrival his vital signs were: afebrile (37 °C), heart rate of 93 beats per minute, blood pressure of 161/84 mmHg, respiratory rate of 19 breaths per minute, and oxygen saturation of 98% on room air. A physical examination revealed an oriented, well-nourished, and hydrated patient, without any stigmata on skin, a normocephalic and atraumatic head, and no masses or

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


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

[User]
RADIOLOGY NOTE:
A 61-year-old woman with a heavy medical history of arterial hypertension, sarcoidosis, hypothyroidism, and bilateral optic nerve atrophy was referred to the Emergency Department for severe headache, vomiting, and alteration of consciousness. Her Glasgow Coma Score on admission was 15/15 but the patient had a slurry speech and exhibited choreic movements of the upper limbs. The admission brain computed tomography (CT scanner) revealed a Fisher grade 4 SAH with initially mild intraventricular bleeding uncomplicated by hydrocephalus. Angiographic examination confirmed the presence of a saccular aneurysm at the junction of the left pericallosal and callosomarginal arteries, which was successfully treated by coiling. The neurological status worsened a few hours after the procedure and an early follow-up brain CT scanner was performed with increased hydrocephalus and the de novo constitution of a subpial hematoma collected at the upper border of the corpus callosum (). Extubation was possible soon after surgery for intraventricular drainage. The neurological examination showed spontaneous eye opening and some spontaneous movements of the upper and lower limbs with a mild left hemiparesia. When stimulated, the patient remained completely mutic but demonstrated some orientating reactions toward the source of intense verbal and/or auditory stimulation. A brain magnetic resonance imaging (MRI) performed on day 6 failed to reveal vasospasm or ischaemic injury in both ACA territories (Figures -). In contrast, there was a significant impingement by the mass effect of the subpial hematoma on the superior border of the corpus callosum. Expectedly, major haemorrhagic contamination of the whole ventricular system was still present.
Event-related evoked potentials were recorded on days 13 and 28, using an auditory oddball paradigm (at least two independent acquisitions of 100 stimuli, consisting of an 85 dBHL binaural tone burst at 500 Hz for the frequent stimulus and 750 Hz for 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:
We present the case of a 56-year-old female with history of syncope due to third degree atrioventricular heart block presenting initially with onset of stroke symptoms six days after pacemaker placement and two days after hospital discharge. At 5 PM she developed abrupt onset of left facial droop along with left upper and lower extremity weakness. The patient was initially treated at an outlying hospital and received alteplase at 6:35 PM for treatment of acute ischemic stroke.
A chest radiograph performed at the outlying hospital prior to alteplase administration demonstrated an enlarged cardiac silhouette when compared to prior radiographs showing only borderline cardiomegaly. Upon administration, the patient reported mild chest pain and was given nitroglycerine and morphine. Her chest pain resolved and she was transferred to our comprehensive stroke center for admission. The patient presented to our emergency department at 10:10 PM with a heart rate of 122 beats per minute (bpm) and a blood pressure of 109/41 millimeters of mercury (mmHg).
At 11:20 PM the patient went for a computed tomography angiogram (CTA) after an initial assessment by the emergency physician in consultation with the stroke-team attending physician. After CTA at 10:28 PM, she was documented to have a blood pressure of 49/25 mmHg and heart rate of 109 bpm. She was returned to the resuscitation bay for re-evaluation. Cardiac tamponade was suspected due to the extreme hypotension in the setting of thrombolytic administration after recent pacemaker placement.
On reassessment, the patient had become confused with a Glasgow Coma Scale of 14. The emergency physician performed a POCUS, which demonstrated a pericardial effusion with features of cardiac tamponade including diastolic collapse of the right ventricle (). At that point the diagnosis of cardiac tamponade was made. The patient was alert and responsive, so an intravenous bolus of normal saline was given while a stat surgical consult was obtain

[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 April 2018 a 23-year-old Caucasian man presented to the general practitioner for the appearance of a rapidly increasing palpable mass in the proximal part of the left thigh in the last month. His clinal history was negative, as well as his oncological family history. He worked as a plumber and did not report any traumatism. He was a light smoker (less than 5 cigarettes per day for 3 years) and denied the consumption of alcohol or drugs. The clinical examination revealed only a solid lesion of 6 cm of the upper third of the left thigh which was hard, fixed on the deep plane and not painful. A magnetic resonance imaging (MRI) scan was performed, showing an enhancing solid lesion of 50 × 45 × 60 mm localized between the rectus femoris and the tensor fasciae latae muscles, associated with enlargement of homolateral inguinal lymph nodes, radiologically suspected for reactive lymphadenopathies, but not clinically palpable for the presence of the main lesion in the proximal part of the thigh.
In May 2018 a biopsy of the mass was performed, revealing an initial diagnosis of nodular fasciitis, and consequently the patient was addressed to follow up. In consideration of the clinical dimensional increase of the mass, a new MRI was performed in July 2018 confirming the increase of the left thigh lesion (54 × 64 × 75 mm). A surgical approach was, therefore, planned but the pre-operative blood tests reported an important elevation of serum transaminases values (GOT = 145 U/L, GPT = 440 U/L, GOT/GPT = 0.32). According to the suspicion of liver metastases, a staging Total Body (TB) computed tomography (CT) scan was performed in November 2018, but no secondary lesions were shown. According to the hepatological consultation, the transaminase elevation was not amenable to a viral or autoimmune disease, but a paraneoplastic syndrome.
The radical surgery was, therefore, planned in February 2019 but the pre-operative 18F-FDG

[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 73-year-old man, with a weight of 105 kg, admitted to our hospital with chest pain symptom. After the diagnosis of myocardial infarction, he underwent coroner angiography emergently and he was treated by percutaneous transluminal coroner angioplasty. When he was admitted to the hospital, the platelet count was 391 × 109/L. The prothrombin time was 11 s (reference range: 11–13 s). LMWH (enoxaparin sodium 6000 Anti-XA IU/0.6 ml) twice a day was administered subcutaneously by the cardiologists as anticoagulation. On the 5th day of LMWH therapy, the patient complained of prolonged pain at the both upper and lower extremities and the control platelet count was 154 × 109/L. There were no significant changes in the other parameters of the complete blood count at the time of admission to the hospital and at the 5th day of LMWH treatment. The control prothrombin time was 13 s. There was no history of thrombophilia, protein C and S deficiency. The fingers were swollen with tenderness and warmness. Doppler ultrasonography assessment of both upper and lower extremities showed arterial and venous thrombosis at the radial and ulnar arteries and veins of both upper extremities, and tibialis posterior and dorsalis pedis arteries and veins of both lower extremities. HITS was diagnosed by significant decrease in platelet count, physical examination, enzyme-linked immunoassay (ELISA) test against the PF4/heparin complex, and Doppler ultrasonography. The optical density of the ELISA test was >1.0. No confirmation test was performed as it indeed requires a specialized laboratory for platelet aggregation tests. As a result, the diagnosis of HITS was only based on high clinical probability and the positive screening ELISA test. The 4-T test which scores four parameters such as platelet fall, timing of platelet fall, thrombosis, and other causes for the thrombocytopenia is high correlation with HITS with the scores between 6 and 8 []. In our patient, this score was 6. After 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:
An 18-year-old female who was previously diagnosed with Glanzmann’s thrombasthenia had undergone laparoscopic aspiration of the ovarian cyst three weeks back at another center. She was on synthetic progesterone and tranexamic acid which is an antifibrinolytic agent for menorrhagia. She presented to us with lower abdominal pain, fever, loose stools, and intermittent rectal bleeding. Her blood picture revealed low hemoglobin of 8 gm/dl, increased white cell count of 14000 cells per cubic millimeter, normal platelet count, and normal prothrombin time and partial thromboplastin time. Contrast-enhanced computed tomography (CECT) of the abdomen showed pelvic collection with an air pocket and thickened sigmoid colon (Figure ). Colonoscopy was performed as she had persistent bleeding per rectum with low hemoglobin and it showed multiple colonic mucosal hemorrhages and a fistulous opening in the sigmoid colon, probably an iatrogenic perforation which happened during prior laparoscopic cyst aspiration. She was planned for computed tomography (CT) guided drainage of the pelvic collection under platelet cover as she was hemodynamically stable and the CT showed only localised collection. Since source control with radiology-guided drainage was inadequate and the patient had persistent fever with loose stools, she was taken up for laparotomy and pelvic abscess drainage. A sigmoid colectomy with proximal end colostomy was also performed as there was a sigmoid perforation which resulted in pelvic abscess and dense adhesions. She received single donor platelets and irradiated packed red blood cells during surgery. In the postoperative period, she had a surgical site hematoma and her hemoglobin dropped to 5.6 gm/dl. Irradiated packed red cells and human leukocyte antigen (HLA) matched single donor platelets were transfused. Thromboelastography (TEG) was performed pre- and post-platelet transfusion to assess the response as she had previously received platelet transfusions and the risk

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


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

[User]
RADIOLOGY NOTE:
A 57-year-old asymptomatic man was found to have multiple intestinal masses by computed tomography (CT) done as part of his routine medical examination in December 2011. Surgical resection (R0) was performed in December 2011. The resected specimen consisted of a mass measuring 10.0 ×10.0 cm in maximal diameter. Final pathologic diagnosis revealed a high-risk GIST according to the Armed Forces Institute of Pathology (AFIP) criteria (). The patient was not treated with adjuvant treatment after surgery in the local hospital because he had difficulty paying for adjuvant imatinib therapy. On routine follow-up visit in May 2012, local recurrence and metastasis were confirmed by imaging. He was then referred to West China Hospital in May 2012.
Beginning in May 2012, this patient received first-line imatinib orally with a dose of 400 mg/day resulting in a partial response. Disease progression occurred after the continuation of imatinib for 54 months. The patient was then treated with cytoreductive surgery combined with imatinib and showed a PFS of 7 months. New biopsy of an abdominal metastasis yielded a KIT mutation in exon 11 as well as in KIT exon 13 (V654A), confirming the clinical observation of secondary imatinib resistance (). In May 2017, this patient received second-line sunitinib. After 11 months of treatment, sunitinib was discontinued due to disease progression. The patient refused biopsy for additional mutational analysis for personal reasons.
Although regorafenib had been approved for the third-line treatment of patients with advanced GISTs by China Food and Drug Administration at that time, the patient refused the agent due to the cost and budget constraints. In the meantime, there was a medical-product-donating project for apatinib that patients could get support since they were enrolled in a clinical trial. After signing informed consent, the patient was treated with apatinib 500 mg daily beginning in April 2018. Abdominal CT scans before apatinib therapy s

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


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

[User]
RADIOLOGY NOTE:
A 62-year-old woman was referred to the authors' hospital for evaluation of a corneal ulcer in her left eye. With the patient's consent, a review of the clinic record was conducted. Ten years previously she received an allogeneic hematopoetic stem cell transplant for treatment of myelodysplasia syndrome. Her course was complicated by the development of cGVHD affecting the liver, skin, esophagus, mouth, and eyes. Severe keratoconjunctivitis sicca had been treated with a PROSE lens for more than 2 years prior to developing this corneal ulcer. Her medical status was compromised by systemic steroid dependence and by steroid induced diabetes mellitus.
After presenting with a corneal ulcer in her left eye, the patient was empirically treated with topical 0.5% moxifloxacin (Vigamox, Alcon) that was applied 6 times a day (once before the PROSE lens was inserted in the morning, 4 times during the day inside of the PROSE lens reservoir, and once again at night after the PROSE lens was removed). After failure to improve on 4 days of this treatment, she was referred to Massachusetts Eye and Ear Infirmary for additional corneal ulcer evaluation, culture and modification of treatment. Upon presentation, the central cornea was opaque and neovascularized with tissue loss of approximately 60% of the corneal thickness. There was an epithelial defect that measured 2.5 mm by 1 mm, with an underlying 2 mm by 1 mm infiltrate. Microbiological smears and cultures were performed with the specimen from corneal scraping. No bacteria or fungi were evident with Gram stain or Calcofluor white stain. At the time, frequency of application of topical moxifloxacin was increased to every 2 hours while awake (approximately 8 times per day), delivered as one drop added to the PROSE reservoir after removal and cleaning reinsertion of the device and replenishment of the reservoir with preservative free saline (B).
Four days after culture and modification of antibiotic

[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.