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

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

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


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

[User]
RADIOLOGY NOTE:
An 81-year-old African-American male with past medical history of hypertension and diabetes was briefly lost follow up for 9 months. He presented to our primary care clinic for his routine follow-up examination with complaints of a progressively worsening infected right foot ulcer for over six months. Patient also admitted to having pain and foul smelling drainage from the ulcer. Patient denied any tobacco or alcohol use. Physical exam was unremarkable except for an ulcer on the plantar aspect on his right forefoot measuring 6 × 5 cm with an ulcerated area at the base of fourth and fifth metatarsal involving the interdigital cleft and extending to the forefoot (). The ulcer was necrotic, black with bleeding and minimal purulent drainage. The patient was started on oral antibiotics with local wound care and surgical consultation requested. Outpatient surgical evaluations revealed a black eschar with punctuate areas of bleeding after the removal of the eschar. The patient was admitted to the hospital for surgical debridement of the presumptive diabetic necrotic ulcer. Laboratory studies including C-reactive protein (CRP) were within normal limits. His hemoglobin A1C was 5.6% indicating excellent control of his diabetes. Radiographic studies of the foot did not show air in the soft tissue, bony involvement, or signs of osteomyelitis. In the operating room under careful examination, the edges of the lesion were irregular with hyperpigmentation highly suggestive of a malignancy. An excision biopsy with 2 mm margin was sent for frozen section and pathology evaluation. Pathologic diagnosis was acral lentiginous melanoma. The tumor had an ulcerated surface that permeated the papillary and reticular dermis without permeation of subcutaneous tissue, suggestive of a Clarke level 4 (Figures , , , and ). Maximum tumor thickness was 3.5 mm, and mitotic index was <1/mm2. A positron emission tomography/computed tomography (PET/CT) was negative for metastatic disease. A definitive p

[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 non-smoker female, aged 45 years, reported with a moderately large growth in the mandibular anterior region. Medical history was insignificant. The patient was from low socioeconomic class. History revealed that a small nodule appeared 5 months ago, which was painless and caused spacing in the lower anterior teeth.
On examination, the patient’s lips were incompetent. Lower lip approximation was difficult due to large swelling protruding from the lower gingival region. Oral hygiene was considerably poor, which may be due to poor oral hygiene awareness, since oral hygiene is inversely related to socioeconomic class.
There was a pale pink swelling in the mandibular right central and lateral incisor region. The surface was nodular and irregular, with no ulceration. The growth measured 2.2 × 3.0 cm in size and was extending out from labial gingiva, displacing the central, lateral incisors and canine teeth, and extended lingually. The nodular growth extension in lingual was slightly smaller than that in the labial []. The growth was considerably hard in consistency, sessile and not easily movable.
Intraoral periapical radiograph was taken, which revealed erosion of the crest of bone. The possible reason of crestal bone erosion in the area may be long-standing plaque-induced inflammation and constant pressure of the growth. Clinical appearance and consistency was of a hard fibrous growth, which therefore led to a provisional diagnosis of peripheral calcifying fibroma or peripheral odontogenic fibroma (POdF).
Phase 1 periodontal treatment was carried out. Consent for the surgical procedure was obtained from the patient after proper counseling.
Under local anesthesia, the whole growth was excised and the underlying surface was thoroughly curetted up to deepest possible tissue and crestal osteoplasty was done. After controlling bleeding, periodontal dressing was applied and the patient was discharged with prescription of pain killer and chlorhexidine mouth wash. Follow-up v

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


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

[User]
RADIOLOGY NOTE:
A 15-year-old teenage boy initially presented in a district hospital, with a swelling at the right side of his neck, without any significant clinical symptoms. Although full details of the work-up performed at the time are not available, he was diagnosed with a branchial cleft cyst and was offered surveillance with follow-up imaging. Eight years later, he visited our unit. Physical examination revealed a painless palpable well-defined mass () within the right carotid triangle with positive Fontaine and Kocher I signs []. There was no palpable lymphadenopathy. An ultrasound scan was performed depicting a solid mass of mixed echogenicity in the right carotid triangle echogenicity in the left carotid triangle. This was suspected to be neurogenic in origin because of its location. A digital subtraction angiography (DSA) () followed, which revealed a 60x35mm protruding mass in the right carotid bifurcation, causing local compressive effects and posterior displacement of the vessels. The patient was admitted in our unit in order to be treated surgically. During the operation a large CBP was identified as seen in . The tumor was classified as Shamblin II and was completely excised. Histopathology study showed a 3 cm carotid body paraganglioma with characteristic “zellballen” growth pattern and cell nests surrounded by prominent fibrovascular stroma, with no evidence of malignancy (). The patient had an unremarkable recovery and was discharged home on the second POD.
The surgical technique adopted in both patients consisted of an oblique incision along the sternal head of the left sternocleidomastoid muscle under general anesthesia. Our strategy was to expose, dissect, and isolate the proximal common carotid artery using a vascular tape. The ansa cervicalis was also exposed early in the operation. The carotid bifurcation was exposed in a caudocranial approach. The proximal external and the proximal internal carotid arteries were isolated and controlled with vessel loops. Di

[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 27-year-old Caucasian woman was admitted to the Emergency Department of our Institution because of bloody diarrhoea – up to 10 bowel movements per day – during the last month, 3 weeks after quitting smoking. Physical examination showed no abnormalities but confirmed haematochezia on digital rectal examination. Colonoscopy showed continuous severe colonic inflammation with small ulcers from the anus to the descendent colon, classified as grade 3 in Mayo endoscopic sub-score and 3 points in Ulcerative Colitis Endoscopic Index of Severity (UCEIS); complete examination was not performed because of the risk of perforation. Empirical antibiotic treatment with ciprofloxacin and metronidazole, as well as oral and rectal mesalamine were started and partial symptomatic improvement was achieved. Venous thrombosis prophylaxis with subcutaneous enoxaparin, 40 mg per day, was started. At admittance, haemoglobin, white cell count, platelets, fibrinogen and C reactive protein (CRP) were within the reference range. Stool cultures were negative. Cytomegalovirus (CMV) infection was also ruled out in colonic biopsies (polymerase chain reaction – PCR – and, later, immunohistochemistry). As bloody diarrhoea persisted 48 h later, and histopathological examination of colonic biopsies showed crypt distortion, a mixed inflammatory infiltrate of the lamina propria and crypt abscesses suggesting the diagnosis of UC, intravenous methylprednisolone (1 mg per kg of weight, daily) was started. After 3 days of corticosteroids the patient achieved partial clinical response (6 bowel movements per day, Edinburgh index 2 points, CRP within the normal range); nevertheless, 2 weeks later infliximab therapy (5 mg/kg of weight) was started due to sustained clinical activity, with 10 bloody bowel movements per day and a progressive increase of CRP levels, up to 10 mg/dL. Three days after the first dose of infliximab, the patient presented a massive lower bleeding with haemodynamic instability and severe a

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


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

[User]
RADIOLOGY NOTE:
An 84-year-old female, nursing home resident, with a past medical history of type II diabetes mellitus, hypertension, cerebrovascular accident, anoxic brain injury with permanent percutaneous endoscopic gastrostomy (PEG) tube and tracheostomy to ventilator was noticed to have a high peak pressure on the ventilator on a routine check by the nursing home respiratory therapist. Suctioning was attempted but was unsuccessful. The tracheostomy tube was changed and during the process, increased resistance was felt. Soon thereafter it was noticed that blood was leaking from around the tracheostomy tube. Emergency medical services were called and the patient was brought to the emergency department. On arrival the patient was found to be hypertensive with a blood pressure of 160/74 mmHg, heart rate of 80 beats per minute, respiratory rate of 18 breaths per minute, O2 saturation was 100% on 100% FiO2 fraction of inspired oxygen (FiO2) on assist control-volume control + ventilator mode and a temperature of 37.8°C. On examination, the patient appeared to be generally edematous and was found to have crepitus on palpation starting at the forehead proceeding all the way down to the chest, abdomen, pelvis and upper thighs. In addition, her upper arms bilaterally also appeared swollen with crepitus present on palpation. Examination of the head and neck revealed a tracheostomy with tracheal tube in place with slightly pink secretions and what appeared to be dried blood on gauze surrounding the tube. On auscultation of the chest Hamman’s crunch, a crunching sound, synchronized with the heartbeat was present, as well as slightly decreased breath sounds at the right apex. Stat chest X-ray was performed which revealed extensive PM associated with subcutaneous emphysema in the neck and right chest wall (Figure ).
The patient was emergently assessed by an otolaryngologist and tracheoscopy was performed through the stoma with the tracheal tube in place. It was determined the tracheal tube wa

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


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

[User]
RADIOLOGY NOTE:
A 52-year-old woman experienced a blunt neck trauma due to a bicycle accident. After a car collision car the impact with the windscreen wipers caused the injury. At the time, the patient was suffering from Graves’ disease, positive for anti-thyroid-stimulating hormone receptor antibodies, with a multinodular goiter and was receiving long-term medical therapy with carbimazole 5 mg per day. Two hours after the accident, the patient presented to the emergency department with painful swelling of the neck, inspiratory stridor and increasing hoarseness. The clinical examination revealed a palpable mass on the right anterior part of the neck. Emergency tracheal intubation was performed due to progressive breathlessness and dyspnea. Subsequently, a contrast-enhanced computed tomography revealed a laceration of the right thyroid lobe with surrounding hematoma and tracheal deviation to the contralateral side (Fig. ). Therefore, the patient underwent emergency neck exploration with a 4-cm Kocher incision followed by a right hemithyroidectomy. Intraoperatively, the dorsal aspect of the right lobe of the thyroid gland was found to be ruptured with active arterial bleeding from branches of the inferior thyroid artery. The recurrent laryngeal nerve was macroscopically identified and preserved. Because of the bleeding into the surrounding tissue, it was particularly difficult to definitely identify the parathyroid glands due to anatomical complexity in this case. Even the location of the upper parathyroid gland, normally identified on the posterior surface of the upper pole of the thyroid gland, was not obvious, due to disturbed surrounding tissue caused by the bleeding. Postoperatively, the patient was monitored in the intensive care unit for 32 h. The patient was extubated after a further six hours, and the subsequent postoperative course was uneventful. Hoarseness disappeared spontaneously after two days. The histopathological analysis confirmed a multinodular goiter. Laryngosco

[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 woman without known comorbidities was transferred to our hospital due to fever and abnormal laboratory test findings. She had not taken any medications prior to the emergence of symptoms. She had climbed a mountain about two weeks prior to our hospital admission and had no memory of insect or tick bite. The patient was admitted to another hospital due to fever after 7 days of climbing. She had a fever with a maximum temperature of 39 °C, aggravating nausea, and vomiting. Abdominal CT revealed hepatosplenomegaly. Therefore, she was referred to our hospital seven days after the onset of symptoms. The patient was alert with a blood pressure of 90/60 mmHg, pulse of 84 beats/min, and body temperature of 37.6 °C on admission. Physical examination revealed no palpable lymph nodes, and there were mild macular rashes on the trunk and both thighs but no eschar. The patient stated that the skin lesions tended to improve 1–2 days before admission. Mild tenderness of the right upper quadrant of the abdomen was noted. She complained of febrile sensation, vomiting, and nausea. The initial complete blood count revealed leukopenia and thrombocytopenia. She had increased aspartate aminotransferase (AST), alanine transaminase, and lactate dehydrogenase (LDH) levels. The blood test findings are shown in .
Based on the patient’s outdoor activity history and laboratory findings, an SFTSV infection or other tick-borne diseases were suspected. Since SFTSV infection and other tick-borne diseases cannot be differentiated based on clinical characteristics alone, and the relevant serological test results take time, ciprofloxacin (400 mg intravenously twice a day) and doxycycline (100 mg twice a day) were administered empirically while waiting for the test results (). The patient’s fever and vomiting gradually improved, and the white blood cell and platelet counts approached normal levels. Since the patient’s LDH remained elevated, she underwent 18F-FDG PET/CT on the eighth hospit

[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 2007, a 46-year-old woman was referred to the Department of Otorhinolaryngology, Seoul National University Hospital for evaluation and further treatment of bilateral huge cheek masses. The masses had grown intra-orally and filled the whole oral cavity, disturbing normal mastication so that the patient had lived on soft or fluid diet (). Although her dentist had recommended surgery 5 years earlier, she was reluctant of undergoing operation and had repeatedly delayed the surgery. Over the 5 years, the disease was aggravated and the size of the mass increased progressively with intra-oral bleeding occurring intermittently.
Imaging work-up including neck computed tomography (CT) scan and magnetic resonance imaging (MRI) was performed. Large bilateral masses showed strongly enhanced solid tumors originating from the mandible which resulted in expansile destruction and erosion of both sides of the mandilble (). These lesions extended from the body to the condyle of the mandible. Intra-oral mucosal deep tissue biopsy from the left side mass was conducted and it was reported as an inflamed granulation tissue with necrosis. Therefore, the initial diagnosis was presumed to be central giant cell granuloma. Incidentally detected thyroid nodules on the CT scan were studied with ultra-sonography guided fine needle aspiration (FNA) cytology and the results were simple benign nodules (). Though the cheek masses had locally destructive features, there was no evidence of malignancy. Due to the patient's hesitancy about having an operation, we initially tried intra-lesional triamcinolone injection rather than surgical resection. Intra-lesional steroid injection is the alternative treatment of central giant cell granuloma, especially in large lesions, which may compromise vital structures []. The patient was treated once a week with an injection of 40 mg of triamcinolone into both mandibular tumors. The triamcinolone injections were not effective except transient size reductio

[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-month-old female infant weighing 3050 g with Apgar score of 9 and 8 at 1 min and 5 min was referred to our centre to enter Home Parenteral Nutrition Program (HPN). The girl was born to a non-consanguineous Polish couple and delivered by spontaneous labour at 35 weeks of pregnancy. There were no records of genetic diseases in the family tree. During the ultrasound scan at 22 weeks, megacystis has been noticed in the fetal pelvis with bilateral pelvicalyceal dilatation. At 24 weeks gestation, fetal magnetic resonance imaging (MRI) was performed which revealed a large cystic mass with a maximum diameter of 8 cm and moderate bilateral hydronephrosis. Because of lower urinary tract obstruction, fetal vesico-amniotic shunt (VAS) was implanted at 31 weeks. At birth, there was abdomen distension and absence of intestinal sounds. A few hours after birth, the patient presented food intolerance and gradually developed respiratory distress. The infant has not passed stool for the first 24 hours. Because of these symptoms, intestinal obstruction was suspected. The nasogastric tube for decompression of gastrointestinal tract was inserted, and the central line was implanted to apply total parental nutrition (TPN). Abdominal radiography showed gastric distention and multiple dilated loops of small bowel (). Contrast study of upper gastrointestinal tract excluded the mechanical bowel obstruction. Microcolon was detected in the barium enema (). The infant underwent exploratory laparotomy on 2nd day of life, in which markedly enlarged intestinal loops extending to 20 cm from Bauhin's valve were discovered. A full-thickness biopsy was taken and ileostomy was performed.
The histological findings were nonspecific (smooth muscle cell vacuolization and insignificant disorders of cytoskeletal architecture). Alpha-smooth muscle actin (alpha-SMA) immunoreactivity was maintained. After surgery, the patient still presented oral feeding intolerance. Stoma has not passed intestinal content, a

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


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

[User]
RADIOLOGY NOTE:
A 58-year-old, male, from the urban environment, heavy smoker – 1 pack of cigarettes per day for 25 years, alcohol consumer, referred to Coltea Clinical Hospital, E.N.T. Department for dysphagia, odynophagia, left ear pain and the presence of a tumor mass of the neck, which he stated that appeared about 6 months prior to the examination, with a slow and progressive evolution. The patient is known to have high blood pressure, maximum value of 210 mmHg, under treatment, and without any other significant pathology.
When performing the clinical exam we found an ulcerated tumor mass in the hypopharynx, referring to the left lateral wall of the pharynx and to the root of the tongue. The tumor process extended to the lateral region of the neck involving the submandibular gland, the levels II-V lymph nodes, large vessels of the neck and skin. Imaging studies confirmed the extension of the tumor process. The Doppler ultrasound examination showed a near to 0 blood flow through the external carotid artery and its branches. After performing a biopsy from the tumor under local anesthesia – invasive squamous cell carcinoma, we informed the patient about the choices of therapy and obtained his informed consent to perform the surgical intervention.
We performed a tracheostomy in order to ensure a maximum access to the oro and hypopharynx, radical neck dissection with the resection of the internal jugular vein, accessory spinal nerve, sternocleidomastoid muscle, entire fatty tissue from the clavicle to the base of the skull. In order to get the access to the entire tumor mass we needed to perform a lateral mandibulotomy (). The resection piece included the root of the tongue, lateral wall of the pharynx, the submandibular gland, lymph nodes levels II to Va and skin.
The pharynx was primarily closed with silk sutures and the continuity of the mandible was made by plates and screws osteosynthesis. The remaining defect was then closed with a pectoral musculocutaneous pedicle flap

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


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

[User]
RADIOLOGY NOTE:
A 20-year-old female presented complaining of recurrent right forearm pain for the preceding three months. The pain was felt predominantly in the volar aspect of the forearm running from the wrist to the elbow and was associated with parasthesia of the entire hand. Onset of the pain was always after exertion—she was a competitive rower and typically would experience the pain after intense rowing. She also noted slight swelling and a flexion contracture with ulnar deviation of the wrist. Following cessation of activity, the pain would subside over approximately 15 minutes and sensation return to normal. She had no medical history of note and no prior trauma to the upper limb.
On examination, the upper limb appeared of normal bulk compared to the contralateral side. Assessment of tone, power, and sensation of the right upper limb was normal. Radial and ulnar pulses were palpable at the wrist. There was no objective evidence of Thoracic Outlet Syndrome and cervical spine movements were normal. After using an indoor rowing machine, the symptoms were reproduced, the volar aspect of the right forearm tense and the wrist held in a flexed and ulnar deviated disposition ()—attempts to manually extend the wrist and digits was painful. Symptoms subsided gradually on cessation of rowing disappeared completely by 15 minutes.
Plain radiographs of the elbow to the wrist were normal. Nerve conduction studies showed a borderline carpal tunnel lesion but ulnar nerve function was normal both before and after provocation with exercise. Electromyography of the forearm musculature did not show any underlying myotonic or myopathic disorder. Compartment pressure testing of the volar compartments confirmed a raised resting pressure of 20 mmHg. A diagnosis of chronic exertional compartment syndrome of the flexor aspect of the forearm was made and surgical decompression offered.
A flexor compartment release was performed of the volar compartments via an incision ulnar to the midline on the vo

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


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

[User]
RADIOLOGY NOTE:
A 25-year-old young woman presented to the outpatient medicine department with the complaints of dry cough which was relentless for 1 month provisionally diagnosed as upper respiratory tract infection. On enquiry, the patient revealed that she had shortness of breath during cold seasons suggestive of bronchial asthma. She had no childhood illness indicating rheumatic heart disease. There was no significant past medical or surgical illness. She was married for two years but did not conceive yet. Her immunization history cannot be elicited as she could not remember them all. Her family members were in good health, and there was no worth mentioning illness that runs in the family. The patients' menstrual cycle was regular with an average menstrual flow. She was of a lower middle class socioeconomic status family. No family member had been suffering from any significant illness.
General examination revealed she was ill looking with mild tachypnea. Her heart rate was 90 beats per minute which was regular in rhythm; blood pressure was 80/60 mmHg; JVP was not raised. There was no anemia or edema. Her nasal mucosa was congested indicating upper airway infection.
Precordial examination showed normal apex beat in the left 5th intercostal space with little bit lateral displacement. There was palpable p2 with left parasternal heave but no palpable thrill. Intensity of the 1st heart sound was normal. The second heart sound was loud over the pulmonary area but not definitely splitted. There was an ejection systolic murmur over the pulmonary area with no radiation or respiratory variation.
Respiratory system examination revealed a respiratory rate of 22 breaths per minute. There was no crepitation or rhonchi.
As our patient was being investigated for her illness, her chest X-ray revealed cardiomegaly with RV type apex, pulmonary conus was full and bulged, and right pulmonary artery was dilated (). ECG showed right bundle branch block with right axis deviation.
Subsequently, her ec

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


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

[User]
RADIOLOGY NOTE:
A 58-year-old female walked into our clinic with intractable dizziness and nausea for 3 days. She was undergoing dialysis for her chronic renal failure caused by familial polycystic kidney disease. She had a history of neck clipping of unruptured left middle cerebral artery aneurysm some 13 years ago at another institution. Her GCS was E4V5M6 so WFNS grade was I. Head CT scan demonstrated small amount of SAH in the interhemispheric fissure []. CT angiography revealed 6 mm ACoA aneurysm, as well as complete clipping of left middle cerebral artery aneurysm []. Endovascular surgeons were reluctant from coiling because of wide neck of the aneurysm.
Operation was performed via anterior interhemispheric approach. Dissection of interhemispheric fissure between rectus gyrus and genu of corpus callosum provided sufficient exposure of the ACoA aneurysm. During dissection, left olfactory nerve was missing and A1 segment of left ACA adhered to surrounding brain tissue, suggesting ACoA had been explored in the previous operation. The adhesion was more prominent around the aneurysm, and hypothalamic artery was encased in the aneurysmal wall with glue material []. Gentle and meticulous dissection was performed, but minor leak of blood occurred from the neck of the aneurysm adjacent to right A2. Any attempts for neck clipping only enlarged laceration of aneurysmal neck. Trapping of the aneurysm including the neck laceration was unavoidable to secure the aneurysm, with simultaneous revascularization of right A2 because right A1 was aplastic on initial CT angiography []. Temporary hemostasis of lacerated neck was obtained by compression with cottonoid under flow control for a few minutes. Back to A3 segment of ACA, A3-A3 side-to-side anastomosis was performed with bilateral A3 cross-clamping time 37 min []. The aneurysm, together with hypothalamic artery, was trapped with two aneurysmal clips []. Complete elimination of the aneurysm and reconstruction of right A2 segment of ACA was c

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


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

[User]
RADIOLOGY NOTE:
A previously healthy 14 year-old boy presented to the Emergency Department (ED) for evaluation of right eye injury that was sustained one to two hours prior to arrival. According to the patient, he was standing on a street corner on his way to school when he was struck in the right eye with a rock thrown from a passing car. He reported no loss of consciousness and no other injury. He denied nausea or vomiting. His past medical history and family history were not significant. The patient did not have any prior ocular injuries, history of ocular disease, or prior ocular surgeries. The patient reported that he does not wear glasses.
In the ED, he was alert, awake, answering questions, and following commands with a GCS of 15. His only complaint was pain to the right eye. His vital signs were as follows: temperature 98°F, heart rate 79 beats/minute, respiratory rate 18 breaths/minute, blood pressure 151/73 mmHg, and oxygen saturation 99% on room air. On examination, blood was oozing and pooling in his right eye with eye lid swelling and surrounding abrasions ().
The patient expressed severe photophobia in his right eye and was unable to open it. Detailed examination of the right eye could not be performed due to the possibility of right ocular globe rupture. A metal eye shield was placed on the patient's right eye for protection. His left eye refractory status was normal with a visual acuity of 20/20. The patient had a negative battle sign, no hemotympanum, no rhinorrhea, and no cervical spine tenderness. The remainder of his examination was noncontributory.
A non-enhanced CT scan of the orbits was obtained and revealed rupture of the right globe with associated orbital and periorbital swelling with intraconal hematoma ().
An ophthalmology consultation was obtained. He was then taken to the operating room where a 20 mm linear laceration was noted crossing 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:
44-year-old man had a history of trauma and splenectomy dating back to 2008 due to a high fall accident injury. The patient came to our hospital for routine follow-up health check for trauma. During the interview with the doctor, the patient had complaints of fatigue, flu-like symptoms and occasionally had the sense of thoracalgia for about a week. During the physical examination, a well healed laparotomy scar measuring about 10 cm in the upper left abdomen was identified. No spleen was palpable when palpation of left costal region was conducted by the doctor. No other significant findings were identified. All laboratory findings were within normal range. Hematology and biochemistry tests were within normal range. All other laboratory findings were within normal range too. Pulmonary function tests and cardiovascular examination showed the normal state. Plain chest computed tomography (CT) with an attenuation value 52HU was performed. There were multiple nodules under the left upper lobe tongue segment, lower lobe basal segment subpleural and right diaphragmatic, partial fusion showed wavy changes with uniform density. There were clear boundary and enhanced scanning lesions, measuring up to 18 mm, suggesting suspicious for primary lung cancer. There were old fractures of the left side 9th and 10th ribs, and no right sided pulmonary lesions or mediastinal lymphadenopathy were seen on CT. Contrast-enhanced CT scans showed obvious enhancement in soft tissue masses (Fig. ).
Based on CT imaging, the surgery of left thoracic exploration and lumpectomy of the chest wall was planned to relief symptom, remove masses. After discussed with patient. Via video-assisted thoracic surgery (VATS) was performed to remove the masses. During the operation, we found mass on the surface of the upper lobe of the left lung, and a large number of nodules that scattered on the surface of left lung surface, diaphragm and mediastinal pleura. The largest nodule was tough in texture, regular in 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 72-year-old woman with a medical history of coronary artery disease, ischemic cardiomyopathy, carotid artery stenosis, renal artery stenosis, chronic kidney disease, hypertension, and hyperlipidemia presented to the ED with two months of right lower extremity pain and swelling. She stated that both symptoms had worsened to the point where she was having difficulty ambulating. The patient also related new symptoms of tingling in her right foot that had started today. She revealed that she had a lower extremity ultrasound done 11 days ago with the onset of these symptoms.
Her initial vital signs were within normal limits. Her physical exam was remarkable for an enlarged, cold, discolored right lower extremity with calf tenderness and non-palpable or Dopplerable pulses in the foot. The vascular surgeon was consulted and recommended the patient be given a heparin bolus and placed on a heparin drip with a lower extremity venogram ordered for the morning. Meanwhile, a bilateral lower extremity ultrasound was done showing right-sided DVTs (Figure -). CT of the abdomen and pelvis was done without contrast due to the patient's chronic kidney disease. A ventilation perfusion scan (V/Q) was ordered and care was transferred to the inpatient team.
After the patient was admitted to the medical ward with a heparin drip in place, she underwent a ventilation-perfusion (V/Q) scan which showed a high probability of a PE (Figure ). CT abdomen without contrast on admission showed only bilateral hydronephrosis secondary to enlarged para-aortic lymph nodes.
During her hospitalization, she was maintained on the heparin drip for the management of her right-sided DVT. However, despite the heparin drip and maintenance of an appropriate partial thromboplastin time, her right leg pain and swelling did not improve. Vascular surgery took her to undergo a catheter-directed thrombolysis and angioplasty of right leg, after which her symptoms improved.
She underwent a left para-aortic lymph node bi

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

[User]
RADIOLOGY NOTE:
A 23-year-old female was seen in the emergency department regarding bilateral knee pain after a motor vehicle collision. As she was restrained, she likely experienced a sudden flexion force across the knees. Plain film radiography demonstrated no abnormalities and she was discharged home. On follow-up, she complained of mild swelling with clicking of her knees which caused her pain. She denied any locking sensation of her knees. Prior to the accident, she had no complaints of knee pain.
Plain film radiography was repeated in office and demonstrated no pathology.
The patient's physical exam revealed no visual deformity. She ambulated with a slightly antalgic gait. There were mild effusions present bilaterally. Passive range of motion was limited secondary to pain. There was a five-degree extension lag present on the right knee while the left knee achieved full extension. Flexion was symmetric to 135 degrees with pain at the extreme. She complained of pain with medial joint line compression and McMurray's testing was positive medially (both audible clicking and pain) bilaterally. Lachman test was stable and symmetric bilaterally. There was no posterior lag. Valgus and varus stressing was normal. Further clinical knee testing was negative. She admitted that her right knee was more symptomatic than the left one.
MRI revealed findings consistent with bilateral medial meniscus bucket handle type tears. There was no evidence of abnormal meniscal shape. All ligaments, including her ACLs, were intact bilaterally. No further pathology was noted.
Attention was paid to the right knee first, as the patient had limited passive range of motion and was where she reported the most pain. Traditional anteromedial and anterolateral portals were utilized. On initial visualization, no tear was noted of the medial meniscus. When the probe was introduced, however, there was a clear medial meniscus bucket handle type tear. The tear appeared in the red-white zone of the meniscus as the poste

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

[User]
RADIOLOGY NOTE:
An 18-year-old male presented after a motor vehicle rollover accident. He was taken to the emergency where standard X-ray revealed odontoid fracture. He was transferred to the tertiary care center for further management in a rigid cervical collar. Physical examination revealed significant tenderness in the upper cervical spine. He had restricted neck flexion up to 30 degrees and extended to neutral. He had minimal lateral bending motion and refused to turn head from side to side because of pain. His neurological examination was normal. Anteroposterior (AP), lateral and open mouth odontoid films were obtained followed by computed tomography (CT) scan. CT scan confirmed the diagnosis of Type II odontoid fracture with a gap of 2.5 mm and anterior displacement of the dens by 4 mm. The fracture angulation was 27 degrees with an associated anterior and posterior arch of atlas fracture leading to unstable left lateral mass of C1 (). Magnetic resonance imaging (MRI) showed intact transverse ligament. Possible treatment options were nonsurgical management in a halo vest as well as surgical management. Both were discussed with the patient. The patient denied a conservative treatment with halo vest because of the long duration of treatment and high incidence of associated complications.
Since the fracture had angulation of 27 degrees, the surgeon felt that it would be difficult to get appropriate trajectory for screw fixation and in turn adequate reduction. Hence, anterior odontoid screw fixation was not considered. Considering the patient's young age and the limitations of C1-C2 fusion including significant loss of cervical rotation, temporary internal fixation with a lateral mass fixation of C1 and pedicle fixation of C2 without fusion was planned. The intention was to remove the internal fixation after radiological healing of odontoid fracture to maintain the rotational motion of the cervical spine. As a part of the preoperative work-up, CT angiogram was done which showed t

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

[User]
RADIOLOGY NOTE:
The patient was a 59-year-old man with an unremarkable medical history who worked as a civil engineer. During an accident at work, he got buried deeply under a large amount of sand, collapsed, and then transported to the emergency department of our medical center (day 1). Computed tomography (CT) revealed bilateral pubic and sciatic fractures, anterior partial separation of the right sacroiliac joint, and left sacral fracture (Denis zone II, a) accompanied by a 15-mm vertical dislocation (b). Additionally, a giant bone fragment (25 × 5 mm2) was present in the spinal canal at the S1 level (c, d). He had numbness at the left S2 region but no complaints related to motor impairments or bladder and rectal dysfunctions. He was, therefore, diagnosed with S2 nerve root compression caused by the bone fragment in the spinal canal and thus patient required immediate removal of the bone fragment and decompression to improve the numbness of S2 root maximally. He underwent surgery on day 2.
First, a robust minimally invasive anterior fixation was performed by INFIX in the supine position in a time-effective approach to prevent further deterioration of the S2 nerve root compression when changing position. After INFIX, he was moved to a prone position. Then, decompression was performed by laminectomy to release the S2 nerve root, and the large bone fragment was removed (a). Finally, sacral vertical reduction and strong posterior fixation were performed by the CSF method (b).
The operative time was 90 min on INFIX and 237 min on laminectomy and CSF. The estimated blood loss was 400 mL. Postoperative CT proved that vertical dislocation of the sacral fracture had reduced to 7.5 mm (c). Sensory numbness was alleviated; however, the patient experienced discomfort and pain due to protrusion of the anterior screw and rod, so the anterior implant was removed 3 months post-surgery. The posterior implant was removed within

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

[User]
RADIOLOGY NOTE:
A 41-year-old man was assigned in our department with a 2 months history of stereotypic vertigo attacks. The symptoms appeared immediately after a head concussion. The initial CT scan of the head at the emergency department was without pathological findings. Due to persistent symptoms, a cranial MRI scan of the head was performed, also with normal findings. The attacks were triggered by a specific change in head position, namely when lying down into a supine position, or when looking upwards by reclining his head in sitting or standing position. He reported having a spinning sensation and a severely blurred vision during the attacks and an increasing feeling of nausea with repeated attacks. The patient was otherwise in full health and worked in a bakery. Due to vertigo, his general practitioner put him on permanent sick leave after the accident.
Apart from positioning maneuvers, the clinical neurotological, extended neurological, and ENT examination showed normal findings throughout. The video head impulse tests for all 6 semicircular canals showed normal gain values (>0.8 for horizontal and >0.7 for LARP and RALP planes) and no suspicious catch-up saccade patterns. The dynamic visual acuity test was also normal to both sides. Cervical vestibular evoked myogenic potentials showed a normal, symmetric reflex threshold of 90 dB SPL bilaterally. Ocular cervical vestibular evoked myogenic potential showed normal reflexes bilaterally with a 27% asymmetry ratio to the left side, which was interpreted as normal (cutoff 35%). Normal cyclorotation of the eyes was found in fundus photography. Video nystagmography showed normal ocular motion in smooth pursuit and saccade testing, absent head-shaking nystagmus, and a strong reaction to caloric ear irrigation on both sides without pathological asymmetry. The testing of the subjective visual vertical showed a slight tilt (2.2°) toward the left side (normal range <1.9°). Pure tone audiometry was normal and did not suggest any damag

[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, referred to the orthopaedic outpatients department in July 1997, presented with a painful right hip of several months' duration. Examination revealed a grossly reduced range of movement in the right hip. His previous medical history included gout, controlled by 300 mg allopurinol. Radiographs of the pelvis revealed severe osteoarthritic changes of the right hip and a normal left hip.
He was kept under review for one year, during which his pain increased and in August 1998 he underwent a right Exeter cemented total hip replacement via a posterior approach. Immediate postoperative recovery until hospital discharge was uneventful, with radiographs of the hip showing no problems. At a routine 6-week follow-up it was noted that although pain free he was making slow progress. There was no leg length discrepancy and the range of movement of the right hip was good, with 100° of flexion, 30° of abduction, 15° of internal rotation and 20° of external rotation. However, the muscular strength was reduced in comparison with his left hip and he had an unsteady gait. He was referred to a physiotherapist and made good progress with improvement in hip strength. Follow-up at one year revealed him to be making excellent progress, and at two years post-operatively he was discharged, entirely symptom free and very happy with his surgical result.
The patient did not see his general practitioner about hip pain until he next presented in November 2006 complaining of pain in the left groin. An anterioposterior radiograph of the pelvis revealed degenerative changes in the left hip and a dislocated right total hip replacement (Figure ). The dislocated femoral component had formed a neoacetabulum within the ilium, in which it was freely articulating (Figures and ). He remained pain free on this side, had 5 cm of true leg length shortening, with a good range of movement, and was very pleased with his hip replacement. He was later placed on the waiting list for

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


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

[User]
RADIOLOGY NOTE:
This was a case report of a 20-year-old male patient, with weighing 56 kg, was admitted to our hospital with a painless huge, tense swelling of around 12 cm × 10 cm size in the floor of the mouth. The mass was gradually increasing in size and extending to the submental and submandibular region occupying the upper anterior part of the neck []. He had a history of discomfort while eating and difficulty in deglutition, speech and sleep for 6 months. The intraoral part of the mass was extending more toward the left, deviating the tongue toward right and making the uvula and soft palate invisible thus graded as Mallampati IV [].
The general and systemic examinations revealed no abnormality. On evaluation of airway, the mouth opening was three fingers, thyromental distance could not be assessed due to the position of the swelling, Mallampati was graded IV[] and there was slight restriction of neck movement. Nasal patency was checked using cotton wisp.[]
Routine investigations were within normal limit including bleeding time and coagulation time. Indirect laryngoscopy, done by ear, nose and throat surgeon, was found to be normal. Lateral X-ray neck showed soft-tissue shadow at upper part of the neck and computed tomography scan of the neck showed a cystic lesion with septae not involving any part of trachea or larynx []. Excision of ranula was planned under general anesthesia after awake nasal intubation as the first line of airway management and retrograde intubation was thought as the second line of management, keeping tracheostomy as back up.
Patient was explained and reassured about the technique of anesthesia. He was kept fasting for overnight. Premedication was given with glycopyrrolate, ranitidine and ondansetron after intravenous cannulation in the operating room.
Patient was supine in sniffing position and standard American Society of Anesthesiologists monitors were attached. Transmucosal topical anesthesia of nasal passages was performed by gentle insertion

[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 male presented with sudden visual disturbance that started one month prior to presentation. The patient had been having problems with blurred vision, loss of peripheral vision, and floaters in his left eye only. He was specific in that his symptoms were only occurring out of his left eye. He stated that his symptoms started with his central vision loss and then he could not see out of the peripheral part of his vision. He did have a history of ocular migraines, but these symptoms were different than his usual migraines. These new symptoms were persistent and not intermittent. In addition, he had just had a full eye examination by a neuro-ophthalmologist the week before and no eye abnormalities were found. The patient denied any events that provoked or alleviated the complaint. There was no significant medical and social history related to his chief complaint. He worked as a construction worker and reported a significant amount of stress in his life. Magnetic resonance imaging (MRI) of the brain and carotid ultrasound were recently done and were reported as normal.
Past medical history included a history of lumbar back pain, gastroesophageal reflux, allergic rhinitis, and depression. He had a minor surgery as a child for his knees and a broken ankle. He was married, non-smoker, and worked full time as a construction worker. Family history was otherwise unremarkable. He had no recent foreign travel history. Review of systems was otherwise normal.
On physical examination, his vitals were normal. He was awake, alert, and oriented, and his mental status was normal. He had a normal eye examination except that he had a monocular left-sided inferior visual field defect (confirmed by formal visual field testing). Right eye examination was normal including visual eye fields. The remainder of the neurological and physical examination was normal.
Initially, as the eye examination was normal and the symptoms were monocular, an assumption was made that the symptoms

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


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

[User]
RADIOLOGY NOTE:
A 61-year-old male was admitted to the clinic with numb upper limbs, feelings of weakness and an unstable gait that had been apparent for more than one month. The patient complained of a sense of strapping in his chest and an inability to grip with his hands or hold objects without dropping them. Furthermore, the patient had weak fine finger movements, such as writing, and felt his walking was like walking on cotton. Physical examination revealed normal neck and bilateral shrug activities, Grade IV flexion and extension strength of the elbow muscle, numbness in the bilateral forearms and hands and weak fist-clenching abilities. The bilateral Hoffmann sign was (+), the lower extremity muscle strength was of Grade IV, the muscle tension was high and the tendon hyperreflexia was (++++). The cervical MRI revealed high signal changes at the C3–4 level in the spinal cord and slipped discs were observed at C3–4 and C4–5 ().
The MRI examination indicated that the compression at the C3–4 level of the patient’s spinal cord was of Level 2, according to the Nagata grading, and T2W MRI revealed high signal changes within the same level of the spinal cord. In addition, the patient exhibited symptoms typical of motor neuron injury in CSM. Laboratory tests measured that the level of serum VB12 was 182 pg/l, which was below the normal range (211–946 pg/l). Although the spinal cord compression was not serious, there were high signal changes in the intramedullary spinal cord that were apparent with T2W MRI, and the clinical manifestations were typical of spinal cord injury. The VB12 deficiency of the patient may have been the factor leading to the spinal cord damage.
Similar to the patient in case one, the patient in the present case underwent anterior decompression-fusion and internal fixation and, following three months of VB12 replacement therapy, the balance of the patient when walking

[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 man with 1-year history of a retractable mass in the right groin arrived at our emergency department with a 5-day history of progressively aggravated right inguinal pain associated with the appearance of an incarcerated right femoral hernia. He denied abdominal pain and distension, nausea and vomiting, fever, and any other signs of bowel obstruction. He had no other relevant medical history. His vital signs were normal, and his body mass index was 18.0 kg/m2. Physical examination revealed a non-reducible tender lump in the right groin below the level of the right inguinal ligament. The lump was approximately 6 × 4 cm in size, warm, and erythematous. Routine blood examination revealed a white cell count of 8.62 × 109/L and neutrophilic granulocyte percentage of 75.7%. A computed tomography scan revealed a quasi-circular hypodense lesion of approximately 6.0 × 4.0 × 4.0 cm located medial to the right femoral vessels and connected to the abdominal intestines (–). There were no signs of intestinal obstruction.
The patient was preoperatively diagnosed with a right incarcerated inguinal hernia and taken to the operating room for surgery under general anesthesia after providing written consent for treatment. Preoperative prophylactic antibiotics were administered. An oblique incision was made above the inguinal ligament in the right groin, and an anterior approach was performed. Dissection in layers revealed an incarcerated right femoral hernia under the inguinal ligament, and the hernia could not be reduced from below. The peritoneum was dissected through Hesselbach’s triangle, revealing a non-reducible appendix in the femoral canal without signs of peritonitis. The tip of the appendix was purulent and swollen. After yellow-white purulent fluid was extracted by fine needle puncture from the hernia sac, the tip of the appendix was still unable to be reduced because the femoral ring was narrow and the tip of the appendix was purulent and swollen. We cut off th

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


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

[User]
RADIOLOGY NOTE:
The patient was a 32-year old woman with a one-year history episodes of cholecystitis treated conservatively. She did not have any other disease history. After an abdominal magnetic resonance imaging that confirmed multiple gallbladder stones (Fig. a), an elective LC was performed without intra-operative complications. The recovery was uneventful and the patient was discharged two days after operation. On the second day after discharge, the patient developed severe right upper abdominal pain and she was sent to our emergency department at 8:30 pm. At arrival, her heart rate was 110 bpm and the blood pressure was 80/55 mmHg. The hemoglobin dropped to 86 g/l from 127 g/l. The CT scan showed a 10.9 × 12.5 × 6.6 cm ISH in the right liver without obvious free fluid in abdominal cavity (Fig. b). Two hours after fluid resuscitation including 2 U red blood cell, the hemoglobin further declined to 78 g/l and the hemodynamics remained unstable. The abdominal pain was not relieved, after intravenous analgesics. A Doppler ultrasound was performed, two hours later and it found the hematoma had increased in size. Active intrahepatic bleeding was suspected. We called radiologist for consultation, however, the interventional angiography and embolization was not available at mid night. We explained the potential risk of sudden rupture of hematoma during conservative methods which may cause sudden death, to the patient and her relatives. After careful consideration of the continuous decline of hemoglobin, unstable hemodynamics after fluid resuscitation, we explained our surgical plan to the patient and her relative. We planned to perform laparoscopic exploration at first, if the hematoma continued to expand, we would evacuate or drain it, if not, we would put a drainage tube under liver which could serve as an early warning of rupture. The patient requested surgical method to reduce the risk of sudden death. Therefore, an emergency laparoscopic exploration was performed under general

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


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

[User]
RADIOLOGY NOTE:
A 2-year-old girl weighing 9.5 kg was referred to department of palliative care in the month of September ‘08 with the diagnosis of neuroblastoma stage IV and disseminated systemic disease. The child presented with proptosis of right eye with periorbital ecchymosis and secondary deposits over scalp. She had developed paraparesis [secondary to lumbar mass]. There was no role for oncological intervention at the time of reference to palliative care. On presentation to palliative care department, child was crying incessantly, had no relief with ibuprofen syrup and was started on oral morphine solution 1 mg 8 hourly with nimesulide syrup 5 ml BD. After 24 hrs she had taken 4 prn doses besides three regular doses. The parents had to carry the child on the shoulders and walk around the ward round the clock. She could not be made to sleep on the bed. By 36 hrs she was titrated to receive 2 mg 4th hrly along with nimesulide syrup. Constipation was managed with lactulose syrup 5 ml on alternate days. She had no other side effects. She was comfortable, sedated but arousable. Parents were counseled and had accepted the prognosis well. They wanted pain relief and comfort for the child. They were taught eye care and dressing for the scalp metastases. She was discharged after 72 hrs and was on regular follow up every fortnight till death in the second week of December.
The morphine requirement escalated as follows. On discharge 2 mg 4th hrly with prn doses. On first visit it was increased to 5 mg 4th hrly. At second follow up it was increased to 7.5 mg 4th hrly. At the subsequent visit, it was increased to 10 mg 4th hrly with prn doses till death. Parents returned the remaining oral morphine solution to the department after the death of the child and reported that child was comfortable, feeding, and sleeping well until death

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


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

[User]
RADIOLOGY NOTE:
A 65-year-old male patient came to the hospital with multiple traumatic brain injuries caused by a motorcycle accident. He had a history of diabetes and asthma, for which he had been pharmacologically treated for several years. He also had a history of open surgery to treat peritonitis 3 years before. Upon arrival at the hospital, he was in a lethargic state (Glasgow coma scale; E3V5M5), with a loss of direct and indirect light reflexes due to damage to the right optic nerve. Skull X-ray and cranial computed tomography (CT) showed comminuted fractures of the skull and multiple areas around the skull base, a Le Fort type II fracture of the facial bones, multiple comminuted fractures of the nose and around the orbit, and a small amount of pneumocephalus in the anterior recess (). Plastic surgeons decided to delay operating on the facial fractures because of severe edema of the face and orbit, and the patient was treated conservatively at the bedside. On day 8 following the trauma, the patient complained of severe headache and nausea, and CT performed on day 8 revealed a large tension pneumocephalus with a tented configuration and noticeably enlarged shadows of air compressing both sides of the frontal lobe (). As an emergency treatment, a rupture of the dura mater in the area of the right anterior cranial fossa was sutured using a subfrontal approach, and fixation surgery was performed on fragments of the comminuted fractures. Four days later, open reduction and fixation surgery were performed on the multiple facial fractures in the department of plastic surgery. On cranial CT performed 2 weeks postsurgery, pneumocephalus was no longer observed (). Subsequently, the patient did not have any specific abnormal symptoms and was discharged in a favorable condition. Two months after surgery for tension pneumocephalus, however, the patient returned to the hospital with primary complaints of memory loss, problems in walking, and urinary tract dysfunction. On cranial CT taken

[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 21-year-old male with a history of Tetralogy of Fallot (TOF) repair (with Dacron Patch over a large ventricular septal defect (VSD)) was admitted with complaints of fever and weight loss for 2 months and left sided abdominal pain since 1 week. He was recently admitted with similar complaints to another hospital where he was found to have a right sided pneumonia and was being treated with intravenous ceftriaxone. Later, suspecting infective endocarditis, gentamicin was added but as the patient was still having persistent fevers of 40°C, he was referred to our hospital. On examination, the patient was of lean built with grade IV clubbing without cyanosis, and there were no peripheral stigmata of infective endocarditis. He had a loud pansystolic murmur on the left sternal edge and had tenderness on palpation of the left upper abdomen. His initial investigations showed a high white blood cell count and C-reactive protein (CRP) (). A chest X-ray showed left mid and right lower lung zone infiltrates, and an ultrasound of the upper abdomen showed an ill-defined splenic lesion without internal vascularity suggesting either an abscess or infarct. Three sets of blood cultures were subsequently negative. Echocardiogram showed vegetation on the VSD patch along with dehiscence, a large VSD, and moderate right ventricular outflow obstruction. A CT abdomen with contrast was done which showed multiple liver, splenic, and lung abscesses with infarcted left kidney and thrombus at the bifurcation of the aorta secondary to the septic embolic phenomenon. Cardiothoracic surgery consultation was sought, and the patient underwent a redo-sternotomy and removal of vegetations from right ventricular outflow tract site, removal of Dacron Patch, and complete repair of TOF. Postoperative echocardiogram did not show any residual VSD or vegetation, only mild left ventricular dysfunction and moderately reduced right ventricle function was seen. The vegetation removed from right outflow tract 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:
This 15-year-old male had experienced symptoms for 3 weeks prior to admission, which were initially limited to persistent bilateral frontal headaches. Two weeks before presentation, he began to complain of peripheral vision loss in his left eye, which at one point became bilateral then returned again to just left-sided visual field deficits. His symptoms again worsened in the 4 days leading up to admission, when he began to complain of increased headache severity, along with new ataxia, left-sided hemiparesthesias, and worsening vision loss. His speech became rambling and incoherent, and he was generally sleepy. On the day he was admitted, all of his symptoms were at their peak severity.
Upon admission, the patient was sleepy but alert and oriented. His eye examination revealed decreased peripheral vision bilaterally and a lack of convergence. He reported left-sided facial numbness, and he demonstrated difficulty with finger-nose pointing and heel-to-shin on his left side. Strength was decreased in the left upper and lower extremities. Magnetic resonance imaging (MRI) revealed multiple areas of ischemic infarction throughout the posterior circulation of the brain. The lesions were seen in the left lobe of the cerebellum, the right and left occipital lobes, and thalamus bilaterally. They appeared to be of various ages, which suggested a stepwise and stuttering course of infarction. Selected MRI images are presented in . The MRI also revealed an abnormal bony process off the left occipital condyle that appeared to be in contact with a small left vertebral artery. It was felt that the bony spicule was likely traumatizing the left vertebral artery resulting in emboli showering to areas of the brain in the posterior circulation and leading to infarctions. The MRI findings prompted magnetic resonance vascular studies with 3-dimensional reconstruction. These images showing the left vertebral artery and the occipital bony spicule are presented as . Echocardiogram and coagul

[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 eighteen-year-old male patient was brought to our emergency department five hours after an alleged history of suicidal attempt with gunshot under the chin. He was presented with a burst open face and no recognizable structures on the face, except for the eyes. He was uncooperative and drowsy. His arterial blood pressure was 80/60 mm Hg and pulse rate was 124/min. His respiratory rate was 26/min and was slightly distressed. He was unable to lie supine as the shredded structures tended to fall back; causing airway obstruction and blood trickled into the oropharynx causing him considerable distress.
After initial resuscitation in emergency department with intravenous fluids (colloid and crystalloids) and blood transfusion patient was stabilized and suctioning of the blood from the upper airway, a closer examination of the face was done. There was comminuted fracture of mandible, maxilla, and nasal bones. Tongue, hard palate, and nasal structures were not recognizable []. Three loose teeth were seen embedded in the lower half of the face. The eyes were spared and his vision was unimpaired. Cerebrospinal fluid leak could not be made out because of the presence of blood. The expired gases had an exit near the root of nasal structure, which could be made out by the movement of cotton strands and no foreign body was present. The neck was not injured. Nervous system examination, as far as could be elicited, was normal with no cranial nerve damage or sensory and motor weakness. On auscultation, the breath sounds were normal with no added sounds, suggesting no aspiration of blood into trachea. Rest of the systemic examination was also normal. Chest radiograph was normal and no foreign body was present. He was scheduled to undergo emergency tracheostomy for airway management, debridement, and closure of facial laceration under general anaesthesia.[]
The patient was shifted to the operating room in the sitting position. We planned for tracheal intubation under sedation using

[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 African American man with a past medical history of herpes simplex virus (HSV) infection presented to the emergency department with a chief complaint of right knee pain and swelling of a couple of weeks. The symptoms began shortly after the patient returned from his trip to Minnesota where he was diagnosed with gonococcal urethritis by urine polymerase chain reaction (PCR) at a local emergency department. He had initially presented with a thick white urethral discharge and had been treated with one dose of cefixime 400 mg and doxycycline 100 mg twice a day for seven days. The patient returned to Connecticut and presumably finished his antibiotics treatment.
Over the next two weeks, the patient developed right knee pain and swelling and sought care in an outside emergency room. He was noted to have bilateral conjunctival injection in addition to right knee synovitis. He was given ibuprofen as well as erythromycin ophthalmic ointment. The patient returned the following day to the same emergency room due to minimal relief of his knee pain and this time was given prednisone taper for five days starting with 50 mg daily. Six days later, he presented to our emergency department with ongoing right knee pain.
Upon presentation, the patient also endorsed complaints of right ankle pain and swelling as well as left lateral hip pain. He had also complained of open sores on his penis, which per patient felt very similar to his prior HSV outbreaks. On further questioning, he noted feeling febrile but denied fatigue, weight loss, eye pain or redness, vision changes, rhinitis, ear discharge, chest pain, shortness of breath, abdominal discomfort, nausea, vomiting, diarrhea, dysuria or urethral discharge. Patient admitted to smoking about two to three cigarettes a day and drinking alcohol occasionally but denied use of illicit drugs. He has had multiple sexual partners over the past six months and did not use protection.
On physical examination, he was febrile (102.9°F)

[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 27-year-old Thai female presented with a rapidly growing mass over her right thigh for 3 months. She had no underlying or previous surgery. She had pain when she walked. She had slightly limited her right hip function on flexion and abduction. Physical examination revealed a firm nonpulsatile mass over the right thigh measuring ~8 × 6 cm. in diameter (). No notable grossly skin involvement and the mass appears not fixed to bony structure. No sensory deficit was identified. Inguinal lymph node cannot be palpated.
The magnetic resonance imaging (MRI) scan demonstrated a 7.8 × 5.8 × 5.7 cm, in vertical × transverse × AP diameter of well-defined, thin rim, enhancing simple cyst with vascularity at the right anterior intermuscular fascia of the upper thigh, just inferior to the right inguinal region. The cyst was located between the pectineus muscle and sartorius muscle, accompanied with anterior bulging to subcutaneous fat. The right common femoral artery and vein and superficial artery and vein were displaced posteriorly ().
Percutaneous aspiration of cyst revealed clear yellowish fluid about 60 ml., and the cytological examination showed hypocellularity consisting of few small lymphocytes and foamy macrophages in background of few erythrocytes and concluded cystic fluid. The cyst disappeared for a few days and presented in the same size within one week.
The operation was performed on supine position under general anesthesia. Vertical incision was performed; the cyst was identified and found dense adherance to femoral artery. Carefully, dissection was done. Complete cystic removal with femoral artery preservation was successful with minimal leakage of cyst wall (). Cystic content had shown the clear, yellow fluid ().
Microscopic examination was demonstrated as . Hematoxylin-eosin staining (H&E staining) indicated that the wall of the cyst consisted of a single flattened cell lining. The cell lining was histologically supposed to be derived from endothelium or mesothe

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


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

[User]
RADIOLOGY NOTE:
A 15-year-old woman with no medical history was admitted to our intensive care unit (ICU) a few hours after a longboard fall without initial loss of consciousness or head trauma. The patient was not able to walk and she had to be transported to find help. When the medical team arrived, she was conscious, Glasgow coma scale (GCS) of 15, without hemodynamic or respiratory instability and with a left femur fracture. During the medical transport, she received analgesics medications and immobilization after the reduction of the fracture. The initial body CT scanner, performed 3 hours after the trauma, found a left femur fracture and an anterior left pneumothorax, without cerebral lesions.
She presented secondarily a neurologic status impairment with a GCS of 11, initially attributed to an excess of analgesic therapy. Anyway, she was operated with a left femoral nailing during which a prolongated hypotension without hypovolemia or other obvious causes occurred. At the end of the surgery, 7 hours after the initial injury a new brain scan was performed. It showed the appearance of a cerebral swelling ().
Postoperatively, she was admitted to the ICU because of consciousness disorders requiring a drug induced coma to permit a mechanical ventilation. A cerebral fat embolism was rapidly suspected. Despite a hemodynamic stability and a normality of the PaCO2, the transcranial Doppler ultrasound found a bilateral high pulsatility index at 2.2 and low end-diastolic flow velocity below 20 cm/s. These Doppler profiles led us to suspect an intracranial hypertension. A new brain CT scan, performed 16 hours after the trauma, confirmed a diffuse major cerebral edema. No other organ dysfunctions, rash, or petechiae were noticed.
The patient was managed as a severe brain injury. An intracranial pressure catheter was inserted and found a very high intracranial pressure (ICP) of 75 mmHg. Despite a maximal medical treatment including osmotherapy, hypothermia, barbiturate sedation, and use of

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


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

[User]
RADIOLOGY NOTE:
A 57-year-old female patient presented with a painful right breast in a previously implant based right breast reconstruction for correction of Poland syndrome [].
Clinical examination revealed hypoplasia of the right breast, absence of the right pectoralis major muscle, ipsilateral upper limb anomalies and pectus excavatum chest wall deformity without cardiac or respiratory impairment []. A Baker III capsular contracture was observed in the right reconstructed breast and a volume deficit over the inner and lower poles, compared with the left side, was also noted.
The patient was seeking treatment of the painful breast and aesthetic improvement of both the breast symmetry and the sternal depression. CT angiography imaging of the chest and abdomen showed a 2A1 pectus excavatum chest wall deformity according to Park's classification [], as well as a hypoplastic appearance and a substernal displacement of the internal mammary vessels. A free DIEP flap was considered for reconstruction.
After the implant and capsule removal, a new subglandular pocket was prepared, extending from the mid-axillary line to the left border of the sternum and from the manubrium to the xiphoid process. Thoracodorsal artery and vein were prepared to accommodate the flap. At the same time a pre-shaped DIEP flap based on the size of the contralateral breast was raised and anastomosed to the thoracodorsal vessels []. Almost the whole flap was de-epithelialised, sutures were placed to maintain the pre-shaped breast mound and buried into the prepared skin pocket to reconstruct the breast, providing both breast projection and pendulous appearance, and also forming the anterior axillary line in the area of the pectoralis major tendon and filling the depressed chest and sternum area. A small 2 cm × 1 cm skin island was left intact and placed at the inframammary fold for flap monitoring. Nylon bolster sutures were placed through the skin to the adipose tissue of the flap and remained for 2 weeks to secu

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


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

[User]
RADIOLOGY NOTE:
A 67-year-old man visited the emergency department of our hospital due to sudden paraplegia of both lower extremities caused immediately after slip down. On presentation to the department, both his lower limbs were observed to be almost paralyzed, with a motor grade of 2 or lower in both limbs. This paralysis showed a gradual aggravation. The patient had a history of renal cell carcinoma diagnosed 7 years prior, and achieved remission without any recurrence after total nephrectomy and adjuvant chemotherapy. He was also diagnosed with papillary thyroid carcinoma 5 years ago, and yet again achieved remission after surgical treatment. The patient signed an informed consent statement, and the study was approved by the Institutional Review Board of the Yeungnam University Medical Center.
The plain radiograph revealed the collapse of the T12 vertebral body. CT showed an acute burst fracture at the T12 vertebral body with an osteolytic mass-like lesion within the vertebral body and pedicle, causing severe encroachment of the spinal canal (Fig. ). Magnetic resonance imaging (MRI) revealed a bulging posterior cortex, with an acute fracture of the vertebral body and severe compression of the spinal cord (Fig. ). Considering his medical history and the MRI findings, a pathologic fracture with a tumorous condition was suspected. Therefore, the evaluation of the malignant potential and metastasis in the remote area was necessary. Hence, 18FDG PET/CT was performed, and 18FDG uptake at the T12 level was measured. A maximum standardized uptake value (maxSUV) of 1.7 was noted, with a central FDG defect on the vertebral body (Fig. ); this was interpreted as a benign fracture by a senior radiologist. Additionally, there was no positive uptake in the other body parts on PET/CT. Although there was a discrepancy between the interpretation of the spine fracture lesion on MRI and PET/CT, the patient required emergent surgical treatment owing to acute paraplegia caused by spinal cord compre

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


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

[User]
RADIOLOGY NOTE:
A previously healthy 14 year-old boy presented to the Emergency Department (ED) for evaluation of right eye injury that was sustained one to two hours prior to arrival. According to the patient, he was standing on a street corner on his way to school when he was struck in the right eye with a rock thrown from a passing car. He reported no loss of consciousness and no other injury. He denied nausea or vomiting. His past medical history and family history were not significant. The patient did not have any prior ocular injuries, history of ocular disease, or prior ocular surgeries. The patient reported that he does not wear glasses.
In the ED, he was alert, awake, answering questions, and following commands with a GCS of 15. His only complaint was pain to the right eye. His vital signs were as follows: temperature 98°F, heart rate 79 beats/minute, respiratory rate 18 breaths/minute, blood pressure 151/73 mmHg, and oxygen saturation 99% on room air. On examination, blood was oozing and pooling in his right eye with eye lid swelling and surrounding abrasions ().
The patient expressed severe photophobia in his right eye and was unable to open it. Detailed examination of the right eye could not be performed due to the possibility of right ocular globe rupture. A metal eye shield was placed on the patient's right eye for protection. His left eye refractory status was normal with a visual acuity of 20/20. The patient had a negative battle sign, no hemotympanum, no rhinorrhea, and no cervical spine tenderness. The remainder of his examination was noncontributory.
A non-enhanced CT scan of the orbits was obtained and revealed rupture of the right globe with associated orbital and periorbital swelling with intraconal hematoma ().
An ophthalmology consultation was obtained. He was then taken to the operating room where a 20 mm linear laceration was noted crossing 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 64-year-old caucasian male with an unknown past medical history presented to the Bayfront Hospital ED in St. Petersburg, Florida, in early November. The average outside temperature that night was in the mid to upper 60s. The patient was initially found by local police officers lying unconscious in a ditch next to his bicycle. When EMS arrived on scene the patient was cold, unresponsive, GCS 3, covered in ants and without any other obvious signs of skeletal or traumatic injury. The patient was fully immobilized in a cervical collar and on a backboard prior to transport to the ED and was intubated secondary to his low GCS. The patient's vitals at the time showed sinus bradycardia at a rate of 30-40s, palpable pulse but an unobtainable blood pressure on multiple attempts.
At 08:22 the patient arrived at the ED and upon transfer to the trauma bed was noted to be in ventricular fibrillation. At that time AED pads were attached and advanced cardiac life support (ACLS) protocol was initiated. Trauma protocol labs were sent which consisted of CBC, CMP, serum cortisol, serum ETOH, amylase, TSH, cardiac enzymes, and a coagulation profile.
During the resuscitation the emergency room physician and trauma surgeon noted that the patient was very cold to the touch. A rectal temperature was performed but the temperature did not register. Per trauma protocol, the patient was being given warm IV fluids as well as warm humidified air via mechanical ventilation. It was not until 09:06 that the patient's temperature was accurately recorded to be 24.9°C (76.9°F). At approximately 09:22 the patient had been undergoing ACLS protocol for one hour and had been defibrillated 13 times and given five rounds of epinephrine, two rounds of atropine, and two rounds of amiodarone. With the patient still in ventricular fibrillation, it was decided to continue cardiopulmonary resuscitation with chest compressions

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


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

[User]
RADIOLOGY NOTE:
A 28-year-old female, G1P1, was hospitalized in The First Affiliated Hospital of Guangxi Chinese Medicine University with a perianal mass found more than 4 years ago. The patient denied contraceptive use, injury, obvious pain, chills, or fever, and change in urine or stool. At the local hospital in 2013, a perianal incision and drainage procedure was performed on the diagnosed perianal abscess (the specific process was unknown). The postoperative incision had healed and the mass had decreased in size. The mass increased during a 2015 pregnancy. Postpartum the patient used no contraceptives, had no injury, pain or other symptoms; the untreated mass was smaller after childbirth. With the mass now larger than that in 2015, the patient presented to our hospital in 2017 for treatment. The patient had a history of broad bean disease and a past caesarean section. The patient had no family history of genetic atypical leiomyoma. The diagnosis was a perianal subcutaneous mass (nature to be investigated). The patient was signed share her perspective or experience consent for treatment and surgery, and since this article belongs to the clinical retrospective study, an ethical approval was not required.
The 5 cm × 4 cm × 4 cm sized mass was located on the left side of the anus and vagina; it was firm upon palpation, had distinct boundaries, was approximately 1.5 cm from the edge of the anus and vagina, was fixed and nontender. On rectal examination, the rectal mucosa was smooth and, similar to the mass in the intestinal wall, was extremely difficult to palpate the pole.
The magnetic resonance imaging (MRI) scan revealed: (1) an occupying lesion in the left perineum; the specific process was unknown. A 4.1 cm × 5.2 cm × 4.9 cm sized round mass was observed on the left side of the circumference (unclear if this was a fibrous tumor, tendon sheath giant cell tumor,

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


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

[User]
RADIOLOGY NOTE:
A 12-year-old female with a known history of GT presented to the Emergency Department (ED) with a chief complaint of HMB. She was diagnosed with GT in infancy in setting of extensive bruising, recurrent mucosal bleeding, and persistent gastrointestinal bleeding. Prior to menarche, she had recurrent episodes of epistaxis and an episode of deep tissue hematoma that was managed outpatient with aminocaproic acid. She had two hospital admissions secondary to gingival and dental bleeding requiring treatment with intravenous recombinant rFVIIa and a tooth extraction. She had no need for major surgical procedures to date. She was followed by a Pediatric Hematologist for her condition but had not yet been evaluated by a Pediatric Gynecologist prior to menarche due to limited access.
Prior to presentation to the ED, she had experienced menarche followed by 24 days of HMB refractory to high-dose oral contraceptive taper (norgestimate-ethinyl estradiol 0.25 mg-25 mcg three times daily for three days, twice daily for two days, and daily thereafter). As bleeding continued, she was brought to the ED for further evaluation and admitted for management of acute blood loss anemia with a team of Pediatric Hematologists and Gynecologists.
Evaluation included a transabdominal pelvic ultrasound that revealed a thin endometrial stripe of 5 millimeters. She was started on intravenous estrogen therapy (intravenous conjugated estrogen 25 mg every four hours) and transitioned to oral estrogen (conjugated estrogen 2.5 mg every 4 hours) for a total of 48 hours. During this initial phase, the patient required 5 units of packed red blood cells due to acute blood loss anemia. Upon improvement of her vaginal bleeding similar to a light menses, she was transitioned to daily oral progesterone (norethindrone acetate 10 mg twice daily). Unfortunately, her HMB soon returned. Due to persistent bleeding refractory to the aforementioned hormonal therapy, she received leuprolide acetate (intramuscular 11.25

[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 21-year-old woman presented with acute onset of abdominal pain with recent hematochezia and constipation. The pain was initially described as being most severe in the suprapubic area, followed by diffuse involvement of the entire abdomen, and ultimately localizing to the right lower quadrant. The clinical differential diagnosis at this point included acute appendicitis, ovarian cyst with possible rupture, urinary tract infection, internal hemorrhoids, inflammatory bowel disease, and pancreatitis. An abdominal computed tomography (CT) scan demonstrated an irregular, right adnexal mass measuring 8.8 × 7.8 cm (). A pelvic ultrasound also demonstrated a large right adnexal mass measuring 9.1 × 8.4 × 7.7 cm with internal vascularity. The mass was radiographically concerning for an adnexal tumor with possible ovarian torsion. The decision was made to perform a diagnostic laparoscopy and remove the adnexal mass. During the operation, the mass was noted to be an extrinsic sigmoid colon mass with active bleeding and hemoperitoneum (approximately 400 milliliters of blood) without involvement of the adnexa. The uterus, bilateral fallopian tubes, ovaries, and liver were grossly normal intraoperatively. The procedure was changed to an open laparotomy and the mass was resected along with the sigmoid colon and a low pelvic anastomosis was performed. The patient recuperated well after surgery. A CT scan was performed after six months to assess for residual or metastatic disease. The scan demonstrated multiple new ill-defined, low attenuating lesions in the liver, the largest measuring 6 cm in greatest dimension. A follow-up magnetic resonance imaging (MRI) scan showed several subtle, ill-defined areas of restricted diffusion that were not consistent with metastatic disease. Four years after surgery, the patient remains free of disease.
Grossly, the mass was fragmented and 16 × 11 × 9 cm in size (aggregate measurement). The mass was well-circumscribed but unencapsulated and 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.