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

[User]
RADIOLOGY NOTE:
A 35-year-old woman, gravid 5, para 3, abort 2, was referred to our clinic because of continuous vaginal bleeding from 2 months ago after uncomplicated curettage with missed abortion at the first trimester (GA: 12 w + 4 d). Her obstetric history was notable for two previous low-transverse cesarean section deliveries and two curettages were without any complication. The pathology report after curettage was confirmed to be decidual tissue.
Physical examination was normal. The gynecologic examination of the vulva and vagina was normal, the cervix was closed, the uterus was larger than normal at about 10-12 weeks of gestation, retrovert axis and she had mild bleeding. In the clinical test, her Hb was 12.4, U/A was NL (without hematuria), BHCG was 112 mUI/mL and other coagulation tests, hepatic and renal tests and electrolytes were normal. Transvaginal sonography was performed as requested: UT > NI, retrovert uterus, endometrial thickness = 2.6 mm, hypoechotic mass about 8 cm in the lower uterine segment with necrotic change and increased vascularity with low resistance was seen around it []. Differential diagnosis included invasive mole, chorio carcinoma and uterine tumors, including degenerating myoma. Total abdominal sonography and chest X ray were normal. Surgical intervention was suggested and arranged to confirm the diagnosis and to remove the lower uterine segment mass. Surgery was performed with the patient under general anesthesia and in the 15-degree Trendelenburg position. A Foley catheter was inserted preoperatively to empty the bladder. She received suction and curettage. After removing the debris and much necrotic tissue, vaginal hemorrhage could not be controlled during operation. The decision fell on laparatomy. The lower segment uterine mass appeared as a large, friable, highly vascularized mass that occupied the whole thickness of the uterine. Hysterectomy was performed immediately for treatment of hemorrhage-induced hypotension, fluid replacement and p

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


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

[User]
RADIOLOGY NOTE:
An 84-year-old Japanese male patient with chest pain at rest and syncope 2 months ago who was admitted to the hospital for further evaluation. He had a history of smoking more than 50 years but quit smoking 5 years ago. Rosuvastatin calcium 2.5 mg was administered at a neighbourhood hospital due to dyslipidaemia. His blood pressure was 121/50 mmHg, and his pulse rate was 68/min. There were no abnormal findings regarding auscultation and physical examinations. After routine electrocardiogram and cardiac ultrasonography examinations, we performed computed tomography coronary angiography (CTCAG). After an hour-long administration of 20 mg metoprolol and 5 mg nitroglycerine tape before examination by CTCAG, he complained of typical chest pain and prodrome before syncope. During the attack, bradycardia and inverted T waves in the V5, V6 leads were observed, as shown in . We did not measure the Troponin because his chest pain disappeared within a few minutes. CTCAG revealed severe stenosis (70% <) at the proximal left anterior descending (LAD) artery according to the coronary artery disease reporting and data system (CAD-RADS), as shown in . Hybrid images of CTCAG and thallium-adenosine myocardial scintigraphy revealed no ischaemia in the LAD coronary artery territory, as shown in . We performed coronary angiography. However, LAD artery has a 50% stenosis. We did not measure coronary fractional flow reserve because LAD artery has just 31% stenosis by the analysis of Quantitative Coronary Angiography (, File S1). We administered intracoronary injection of 64 µg ER into the LCA, but no provoked spasm was observed, as shown in . Although we added another 40 µg ER into the LCA, no provoked spasm was recognized ( and Video 1A). After the administration of 80 µg ER into the right coronary artery (RCA), no provoked spasm was found. We administered 20/50/100 µg intracoronary ACh into the LCA without a pacemaker for 30

[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 right-sided complete cleft of primary and secondary palate who had primary surgery in childhood at another hospital was referred to our craniofacial centre for management of his facial skeletal deformities []. The patient was concerned about his lower jaw being ahead of his upper jaw, misaligned teeth, and flattened face.
Examination revealed typical midface deficiency associated with cleft maxilla, which included lack of maxillary projection, flattened malar prominences, depressed nasal supratip and flared ala. Intraorally, the upper arch revealed complete collapse of the two lateral shelves with severe crowding and displacement of the upper dentition, concealing a wide anterior palatal fistula in continuity with an alveolar defect. Overall the maxilla was severely collapsed in all three-dimensional planes []. The discrepancy between the maxilla and mandible was 12 mm in the antero-posterior plane. The clinical and radiographic findings suggested maxillary hypoplasia in transverse and sagittal dimensions resulting in class III malocclusion with double sided cross bite
The objective of the treatment was to achieve an acceptable facial profile and dental occlusion with positive over jet and overbite. Treatment plan included the following, viz., correction of the maxillary retrusion by Le Fort I osteotomy; rigid external distraction; increasing the width of the collapsed maxillary alveolar arch; aligning the maxillary dentition, and closure of the oro-nasal fistula over the hard palate.
The severity of the dental crowding in the maxillary arch was not conducive for the placement of orthodontic brackets, and the short maxillary arch required lengthening, hence pre operative orthodontics was not carried out. ‘Surgery first’ method was adopted in this case for the same reasons. Rapid palatal expansion was not possible in this case since the expander could not be placed due to severe constriction of the upper alveolar arch in addition to the seve

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


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

[User]
RADIOLOGY NOTE:
A 41-year-old man, working in a furniture confection plant, experienced severe “tearing” chest pain upon heavy lifting. On presentation in another health facility, a chest computed tomography (CT) scan, with incomplete imaging of the iliofemoral axis, revealed a type A aortic dissection (DeBakey type I). Following transfer to our center, physical examination showed a pulseless left femoral artery, while no sign of acute limb ischemia was present. The patient underwent a mechanical Bentall procedure with hemiarch replacement under circulatory arrest for a total procedure time of 7 hours, 45 minutes. The immediate postoperative course was uneventful. The femoral pulses were symmetrical and well palpable once the patient rewarmed. Thirty-six hours after surgery, the patient was extubated and complained of severe pain to his left buttock. The lower limb pulses were present and no sensory or strength deficit was found. The left limb was normal, while the buttock was tense and painful especially upon flexion and adduction of the hip. A GCS was suspected. A CT angiography scan of the pelvis showed a dissection flap ending proximal to the iliac bifurcation without direct involvement of the iliac arteries. The false lumen was thrombosed and preferentially oriented toward the common left iliac artery. The opacification of the left internal and external iliac arteries was good. Preoperative CT angiography showed left gluteus muscle swelling (
). This was likely related to a malperfusion following thrombotic or embolic occlusion (
). The patient was diagnosed with GCS, further supported by a peak creatine kinase of 91 865 U/L.
A Kocher-Langenbeck procedure (
) was performed under general anesthesia with the patient placed in a right lateral decubitus position, with his legs bent at a 30° to 40° angle. An incision was made from the posterior superior iliac crest up to 5 cm of the greater trochanter and then to the lateral aspect of the femoral shaft.

[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:
Patient 2, who had a homozygous missense mutation (c.1076C>T [p.359Pro>Leu]) at exon 8, was a 47-yr-old female at the time of her muscle biopsy. At her age of 30, she first noticed difficulty in climbing stairs, which progressed to limitations in daily activities by age 44. At presentation, she had difficulty in rising up from chair and could not stand up by herself from sitting position. Her muscle power was reduced to MRC grade 1 in leg adduction, grade 2 in hip flexion, hip extension, and leg abduction, grade 3 in shoulder elevation, elbow flexion, knee flexion and knee extension, and grade 4 in elbow extension and wrist flexion. Her deep tendon reflexes were lost in limbs except for the ankle jerks. She had no affected family members, and her serum CK level was mildly elevated (496 IU/L). The ECG and chest radiography were normal. Muscle biopsy showed a marked fiber size variation, markedly increased adipose connective tissue, many fibers with internal nuclei, scattered necrotic and regenerating fibers, some fibers undergoing fiber splitting, and type I fiber predominance ().
The patient 3 had been wheelchair-bound for one year when he first presented to us at age 35. He became symptomatic with gait and running difficulty when he was 13 yr old. Since then, his disease was progressively worsened. He started to use canes at age 32 and became wheelchair-bound at age 34. He had a profound muscle weakness on examination. His muscle power was graded as 1 in leg elevation, leg extension, leg adduction, and leg abduction, 2 in distal leg muscles, 3 in upper extremity muscles, and 4 in quadriceps muscles. He also had generalized muscle atrophy, especially in shoulder, pelvic girdle, and intrinsic hand muscles. His deep tendon reflexes were lost except for the knees. He had no affected family members, and serum CK was slightly elevated to 500 IU/L. His ECG

[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 38-year-old nulliparous woman who suffered from infertility of unknown origin. She had been treated with assisted reproductive technologies including artificial insemination and in vitro fertilization for over four years. During her treatment for infertility, cytological review followed by colposcopic biopsy revealed an invasive nonkeratinizing squamous cell carcinoma (SCC). A 1 cm mass was identified in the uterine cervix, but a pelvic MRI did not describe the cervical mass or parametrial invasion. Additionally, a submucosal leiomyoma of 15 mm in diameter was found in the uterus (). CT scans showed no signs of lymph node swelling or distant metastases. Based on these findings, she was diagnosed with stage IB1 cervical squamous cell carcinoma. We offered radical hysterectomy and pelvic lymphadenectomy as standard treatment although she strongly desired fertility preservation. The submucosal leiomyoma may have been the cause of her infertility, and she was keen to resect the myoma during the same procedure. Submucosal leiomyomas can usually be resected with hysteroscopy but was not advised in this case from the oncological viewpoint. As such, we obtained informed consent and performed an abdominal radical trachelectomy followed by abdominal myomectomy.
During the surgery, we first drained the ascites in the pelvic cavity, resected bilateral pelvic lymph nodes, and sent them for intraoperative pathology. They were reported to be negative. The paravesical and pararectal spaces were then developed. The ureters on either side were resected to their insertion into the bladder. The uterine arteries were ligated and cut at the origin where they branched from the internal iliac arteries. Next, the uterosacral ligaments were divided. A colpotomy was performed circumferentially, and the cervical specimen was excised together with the parametrium at least 2 cm below the internal os. During the surgery, a frozen section procedure was performed for histology. Th

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


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

[User]
RADIOLOGY NOTE:
A 21-year-old gravida 5 para 3 (all alive) abortion 1 mother with a pregnancy of 4 months was presented with severe lower abdominal pain of 2 days duration following a falling accident on her abdomen 5 days ago. She had easy fatigability, vertigo, and light headedness since two days after the accident, but had no vaginal bleeding, fever, headache, chills, and vaginal discharge and she did not feel fetal movement yet. She had no antenatal care follow up. She was referred from a nearby primary hospital to the Jimma university medical center with diagnosis of septic shock secondary to septic abortion where she was admitted and given antibiotics. Medical abortion was tried, but failed at the primary hospital. She had no personal or familial history of hypertension and diabetes. She had no history of chronic pelvic pain. She had no history of ectopic pregnancy, but had one history of spontaneous abortion which occurred at the 4th month. Prior to this accident, she had no history of abdominal pain, bloating, and epigastric pain.
On physical examination, she was acutely sick looking, agitated, and confused in appearance. Her vital signs were as follows: Blood Pressure: 70/30 mmHg, PR: 148 bpm, RR: 24 br/m, T0: 37.5. Her conjunctiva was paper white and had dry tongue and buccal mucosa. Chest was clear and resonant. S3 gallop was heard. On the abdomen there was diffuse lower abdominal tenderness and guarding with positive signs of fluid collection. On pelvic examination cervix was closed with no blood on the examining finger, but, had a right adnexal tenderness.
On ultrasound exam, empty uterus was seen. A collapsed fetus with no cardiac activity having femur length measurement corresponding to 16 weeks and placenta measuring 4 cm × 5 cm looks attached to the left cornual part of the uterus was seen. There was significant free fluid in cul-de-sac and paracolic gut

[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 16-year-old single girl, with 10 years of formal education, from rural background presented to surgery outpatient with complaints of pain in abdomen and vomiting for the last 6 months. She would have frequent bouts of vomiting, frequency of which increased in the last few days prior to presentation. On physical examination, she was found to have a mobile mass of 14 × 16 cm size in the upper abdomen, which was tender, with smooth surface and irregular margins. Ultrasound abdomen revealed a bizarre lesion in the right upper and middle abdomen suggestive of gastric bezoars. Upper gastrointestinal endoscopy did not reveal any abnormality in the esophagus and a large mobile mass made of hairs was seen in the stomach. Based on the findings of ultrasound and upper gastrointestinal endoscopy, a diagnosis of trichobezoar was considered and psychiatry consultation was sought. Psychiatric evaluation revealed that the girl was eating hairs and clay since early childhood. She would eat the hairs thrown here and there by her mother, other family members and neighbors. The patient would like the taste of hairs and had a strong and persistent desire to eat hairs. She would often go out searching for the same. Additionally, at times she would also eat clay. The description of the patient was corroborated by the mother too; who described that despite persistence reprimands, the patient persisted to eat hairs and occasionally would eat clay. However, the patient denied pulling out her own hairs. Physical examination of scalp and other body parts did not reveal any evidence of alopecia or pulling of hair/short hair. Past history did not reveal any evidence of depressive disorders, obsessive compulsive disorder, other anxiety disorders, eating disorders, emotional disturbances, mental sub-normality and other impulse control disorders. Also, there was no family history of any mental illness. Investigations in the form hemoglobin level, complete blood counts, serum electrolytes, liver 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:
RC is a 62-year-old male who initially presented with a T3N2M0 midrectal cancer and underwent neoadjuvant chemoradiation four weeks prior to a laparoscopic low anterior resection with diverting loop ileostomy. He completed adjuvant chemotherapy and returned for an elective reversal of his ileostomy nine months postoperative. His preoperative workup included a colonoscopy which revealed exclusion colitis for which he was treated. He also underwent a gastrografin enema and computed tomography (CT) imaging of his abdomen and pelvis with no evidence of recurrence, obstruction, or distant metastases. On CT imaging, the proximal ileum appeared normal, but the distal ileum was not imaged. After his reversal, his postoperative course was complicated by persistent small bowel obstruction, for which he was managed conservatively for two weeks. He subsequently underwent a CT abdomen and pelvis, which was highly suspicious for anastomotic stricture.
On postoperative day 14, the patient underwent a diagnostic laparoscopy showing multiple adhesions around the previous reversal site with normal-appearing dilated proximal and collapsed distal small bowel. There was no localized stricture in the defunctionalized distal ileum. He underwent a resection of the prior reversal site and creation of a new side-to-side primary anastomosis. Despite creation of new anastomosis, his small bowel obstruction continued for additional two weeks. CT imaging and small bowel series were obtained, both modalities showing a narrowing of the ileum distal to the previous anastomosis (Figures and ). On hospital day 27, the patient underwent a final exploratory laparotomy with intraoperative findings of persistent collapsed bowel loops distal to the new anastomosis. The collapsed distal segment was resected, and an ileocolic anastomosis was created. On gross examination, the entire distal ileum was thickened without stricture (Figures and ). The pathology of the distal ileum showed submucosal fibrosis with

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


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

[User]
RADIOLOGY NOTE:
A 62 years old male presented with recurrent SCC of the left nasal bulbar conjunctiva. The patient's previous medical history detailed multiple interventions at this site. Initially, the diagnosis of a left nasal pterygium (a wing-shaped growth that starts on the conjunctiva and can spread across the limbus to the cornea affecting visual function) was made 3 years prior to the reported presentation, and was surgically removed with local excision. The lesion recurred 1-year post-surgery, and was subsequently managed surgically with a wide local excision. At this time, pathology revealed positive margins for SCC. A further recurrence 6 months later was treated with Plaque Therapy to a dose of 50 Gy in 5 fractions. Subsequently, the lesion was re-excised with adjuvant cryotherapy 7 months later.
On presentation 3 months post-cryotherapy, a recurrent lesion (10 × 5 × 2 mm) was detected on the nasal bulbar conjunctiva (Fig. ). The patient declined enucleation following this SCC recurrence. Subsequently, multidisciplinary consultation offered SXRT as an alternative treatment option (Fig. ).
The patient also presented with a history of Crohns Colitis (treated with immunotherapy) and a previous excision of a non-melanoma skin cancer from the right temple, and a subsequent skin graft of the area. The patient was on no other medications and had no allergies.
The patient was prescribed a dose of 48.4 Gy in 22 fractions, to a depth of 3 mm. This resulted in a skin surface dose of 54.4 Gy. A 2.0 cm diameter direct applicator was used with a 3 mm margin on the treatment region (Fig. ). To allow for an acceptable treatment margin that encompases the target volume and accounts for set up variability, the left inner canthus and tear duct were included in the treatment field. A single en-face beam of 2.0 mm Aluminium energy (2 mm Al) was used to meet the previously articulated dose

[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 55-year-old, Turkish female patient experienced generalized tonic clonic seizures which started 2 years previously and had become persistent during the last 3 months, despite antiepileptic treatment. In addition, the patient had complained of speech defects, forgetfulness, perception deficit for 2 months, cognitive disorders and a weakness in the right side of the body for the 2 days prior to admission. The patient had history of an operation in her left maxillary area due to basal cell carcinoma 7 years previously and then history of radiotherapy due to relapse 2 years later the operation. She had treated with a total dose of 56 Gy radiation, administered in 15 fractions to her left maxillary region, and she had no chemotherapy history.
During neurological examination it was found that the patient experienced confusion and disorientation. However bilateral papilledema was detected on neurological examination. In addition, the patient had right hemiparesis. Her muscle strength grade was 3 (active movement against gravity) in the right side of her body. A cranial CT scan showed hypodense lesions in the left frontal lobe (3 × 4 cm) and in the left temporal lobe (6 × 4 cm). No significant edema was observed around the lesions, which compressed the left lateral ventricle and did not show contrast enhancement (). Cranial MR imaging showed in the left frontal region 3 × 4 cm and in the left temporal region 6 × 4 cm lesions, which were hypointense in T1 (), hyperintense in T2-weighted images. These lesions observed with mild peripheral contrasting. They made us think about cystic masses. An EEG showed reduced bioelectrical activity in the left frontal and left temporal regions. A course of antiepileptic treatment was organized for the patient. The patient, who was using 2 × 500 mg Sodium valproate, was given dual antiepileptic therapy, starting with 3 × 100 mg Phenytoin. In addition, steroid treatment was begun. However, despite this treatment, the patient experienced

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


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

[User]
RADIOLOGY NOTE:
A 52 year old male smoker undergoing coronary artery bypass grafting for three vessel coronary artery disease and moderately impaired left ventricular function was felt to have a mass arising from the under surface of right costal margin adjacent to right lower sternal margin while sternopericardial ligament was being broken off by finger dissection prior to sternotomy. Preoperative chest X-ray suggested a soft, globular paracardiac shadow in relation to the right pericardiophrenic angle, appreciated better retrospectively (Figure ) Sternotomy was made, the right pleura was opened to facilitate delineation of the mass. The mass measured 8 × 6 × 3 cms and was arising from the right costal margin and the adjacent surfaces of 7th, 8th, 9th and 10th ribs (Figure ). The mass was of firm to hard and variable consistency and was filled with cartilaginous material and there was no definite demarcation between the mass and the chest wall. The chest wall mass was excised in its entirety along with the intercostal muscle and the periosteum (Figure , Figure and Figure ). The frozen section revealed it to be either a chondrosarcoma or teratoma. Quadruple coronary artery bypass grafting to left anterior descending artery and its diagonal branch, obtuse marginal branch of circumflex artery and left ventricular branch of right coronary artery was performed using left internal mammary artery and long saphenous vein for conduits, employing cardiopulmonary bypass with antegrade cold blood cardioplegic arrest. Patient made uncomplicated postoperative recovery.
Histopathology revealed the overall appearances of grade 1 chondrosarcoma with a tumour composed of lobules of cartilage of varying size separated by fibrous tissue (Figure ). The chondrocytes showed cytological atypia, binucleate cells, focal hypercellular areas with areas of calcification and necrosis (Figure ). The tumour was seen to focally infiltrate into surrounding skeletal muscle.
The patient was discussed at the Regional

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


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

[User]
RADIOLOGY NOTE:
A 63-year-old male with a past medical history of non-ischemic cardiomyopathy (ejection fraction 10%-15%), hypertension, chronic kidney disease stage G3A, and severe mitral valve regurgitation status post valve repair initially presented for an upgradation of his biventricular pacemaker to biventricular implantable cardioverter defibrillator (BIV-ICD) and replacement of non-functional right atrial lead. The pacemaker pocket was exposed and identified and the atrial and ventricular leads were pulled back under fluoroscopic guidance. A new left coronary sinus lead was placed. Next, right atrial (RA) and right ventricular (RV) leads were placed and access was obtained via the left coronary sinus as the left subclavian vein was found to be occluded with formation of collaterals. The leads were sutured in fascial planes via silk suture. The pacing and sensing parameters were confirmed. BIV-ICD was placed in the pocket, and the pouch was closed via vicryl sutures. The patient had electrocardiogram (EKG) (Figure ) and chest X-ray (Figure ) performed after the procedure. He had developed small pneumothorax from the procedure, which resolved on its own.
The patient was asymptomatic for the next seven months and then he developed increasing shortness of breath. At that point, the EKG (Figure ) revealed loss of appropriate pacing function. It was discovered that the patient kept massaging his pacemaker pocket site in the last seven months but he denied manipulating the device itself. He had also been moving his arm up and down frequently, which would have led all his device leads to be pulled up towards the device in a ratchet-like fashion. The patient was scheduled again for revision of BIV-ICD and on incision of the generator pocket, the left ventricular lead was found coiled up in the pocket beside the generator (Figure ). A new left ventricular lead was placed in the coronary sinus and then access was obtained via the right subclavian vein for right

[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 male presented to emergency department with tender mass on lower back and posterior aspect of neck. Apparently, he had noticed it on his lower back 6 months ago and had grown in size with another similar swelling appearing on his neck, also they were increasingly painful and sore to touch. He had a history of ongoing sore throat for 3 years for which he was extensively investigated by ENT services. His CT neck and mediastinum did not show any abnormalities at that time. This was followed by laryngoscopy which showed a white patch on the right vocal cord, biopsy of which showed non-specific chronic inflammatory changes and cultures grew candida. Background history included COPD; he was heavy current smoker and smoked about 60 cigarettes per day. His medications included salmeterol/fluticasone propionate and ipratropium bromide inhalers. Vitals were within normal range. On examination, 4 cm nodular, firm, tender, immobile mass on lower back and 3 cm mass on posterior aspect of lower cervical spine were noted.
His laboratory investigation including renal and liver function, full blood count and coagulation profile were normal. A CT of thorax, abdomen and pelvis was arranged which showed 2 × 2 cm mass in right lung lower lobe likely malignant with no hilar or mediastinal lymphadenopathy, also 3 × 3 cm soft tissue mass at C6-C7 level posteriorly and 4 × 2 cm mass was noted on lumbar region with multiple prominent inguinal lymph nodes ().
A referral for bronchoscopy was sent and biopsy of the nodule was planned. While awaiting bronchoscopy appointment, biopsy was taken from mass in lower back and send for histopathology. Histology showed poorly differentiated tumour cells in cohesive groups and sheets with moderate pleomorphism and eosinophilic cytoplasm; immunohistochemistry was positive for AE1/3, cytokeratin 7 and carcinoembryonic antigen antibody stain and periodic-acid schiff. Weak nuclear positivity for TTF-1 was also seen. Overall features were consis

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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:
Diabetic male, 57 year old presented to us with history of pain in left ear for the last 8 days. 48–72 hrs after the onset of otalgia, patient developed facial weakness on left side along with vesicular eruptions on left conchae and in left external auditory meatus. After another 24–48 hrs patient had similar episode on right side. On the day of reporting to us patient was having bilateral facial weakness, impaired taste sensation, dryness of eyes along with decreased hearing on both sides but there was no history of vertigo or any ear discharge. There was history of stressful life events in past 6 months before the onset of rash.
On examination, there was bilateral lower motor neuron facial palsy which was complete. Bell's phenomenon was present on both sides Fig-. There were adherent crusts and scabs in left conchae and external auditory meatus. While vesicular eruptions were present in right external auditory meatus. Tuning fork tests were showing bilateral sensorineural hearing loss.
The patient was admitted and investigated. His postprandial blood sugar was 339 mg%, HbAIc was 7%. Pure tone audiometery was showing mild to moderate bilateral sensorineural hearing loss, stapedial reflexes were absent on both sides on tympanometery. There was impaired taste sensation from anterior two third of tongue. ELISA and Western Blot tests for HIV infection were negative. Liver function tests, tumor markers, thyroid hormones; serum ACE levels were all with in normal limits. Lumbar puncture revealed normal pressure. Glucose, protein and white blood cell count were all with in normal limits in CSF. Plain X-ray views of mastoid, internal auditory meatus and chest were normal. Computerized tomography of brain stem, cerebellopontine angle, temporal bone and skull base were normal. A smear from floor of vesicle stained with Giemsa stain showed degenerating cells with multiple nuclei. This favoured the clinical diagnosis of herpes zoster oticus. This diagnosis

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


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

[User]
RADIOLOGY NOTE:
An 80-year-old Caucasian man was referred to the Stomatology Department, because he presented with a swelling on the right side of his face, which he first noticed 2 months earlier. His medical history included chronic renal failure.
The extraoral examination revealed a swelling of the right parotid gland and the submandibular gland, as well as an extensive ipsilateral cervical lymphadenopathy. On intraoral examination, two masses were observed: one on the left side of the palate and the other on the floor of the mouth (). Tongue mobility was normal and there was no evidence of paresthesia of the lingual nerve.
Examination of the right parotid gland by MRI revealed a solid and expansive mass in the superficial lobe, which was characterized by a hyposignal and a hypersignal on a T1-weighted image (T1W) and a T2-weighted image (T2W), respectively. Another two nodular masses were observed in the inferior pole of the parotid gland. MRI also examined the contralateral parotid gland, and three small nodular masses were observed in the superficial lobe, which presented signal features similar to those on the right side. Moreover, a mass involving the left side of the palate showed continuity, with an ipsilateral narrowing of the pharyngeal airspace ( and ). The posterior two-thirds of the tongue (left side) and both lingual tonsils showed expansive lesions. The epiglottis was posteriorly displaced and the vallecula was obliterated, leading to narrowing of the pharyngeal airspace (). Evidence of expansive masses was also noted on the floor of the mouth and in both sublingual and submandibular areas, without affecting the salivary glands. Bilateral lymphadenopathy was also observed, in contrast with the clinical examination findings (). Considering the clinical and imaging findings, the working diagnosis pointed to a malignant disease.
An incisional biopsy was performed on the floor of the mouth, and the histopathological examination showed a monotonous proliferation of smal

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


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

[User]
RADIOLOGY NOTE:
We report the case of a 24-year-old male who sustained a gunshot wound to his left shoulder. He presented to the emergency department with a primary complaint of shoulder pain and difficulty in swallowing. On primary survey, the airway was patent and he was hemodynamically stable. A single bullet wound was visualized above the left scapula. On chest radiograph, the bullet was located in the left pulmonary hilum near the mainstem bronchus []. No pneumothorax or hemothorax were apparent; this was confirmed with the radiologist. At this point, the patient complained of increasing difficulty in swallowing and was intubated for airway protection. An orogastric tube was passed erroneously into the airway precipitating vigorous coughing and eventual vomiting of gastric contents. Once this was properly replaced, the patient underwent CT angiography (CTA) of the chest and flexible bronchoscopy. CTA revealed no vascular injury; however, air was present throughout the mediastinum and the subcutaneous tissues of the anterior neck []. The bullet was again seen near the left mainstem bronchus []. There was no pneumothorax or hemothorax. After discussion with our radiologist, we believed that the bullet had likely caused a small airway injury which had quickly sealed, leading to the pneumomediastinum without evidence of pneumothorax or bronchopleural fistula. Flexible bronchoscopy revealed no blood or bullet fragments, but only a small abrasion in the left posterolateral trachea which was thought, at the time, to be due to trauma from the initial orogastric tube placement.
As no significant injuries were noted on initial bronchoscopy, the patient continued to be managed nonoperatively. In light of there being no pneumo- or hemothorax, the presumed trajectory of the bullet was from above the left scapula directly to the left pulmonary hilum. Based on this, it was felt that he was at low risk for esophageal injury, and gastrointestinal endoscopy was deferred. He remained intubated,

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


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

[User]
RADIOLOGY NOTE:
A 44-year-old female office worker sustained a right anterior glenohumeral dislocation with an associated avulsion of the greater tuberosity, as described by Mutch et al. []. Open reduction and internal fixation of the fracture were performed with a tension band technique, using an anchor screw and nonabsorbable sutures []. The functional outcome was poor. The patient was painful and had marked weakness in external rotation and abduction. Active forward flexion and abduction were 40° with full passive motion, and active external rotation was 30°. Her single assessment numeric evaluation score [] was of 40 %. Past medical history was significant for noninsulin-dependent diabetes mellitus and obesity (BMI 42). Radiographic evaluation demonstrated a complete osteonecrosis and resorption of the greater tuberosity (Fig. ) with a suspicion of massive rotator cuff tear involving both supraspinatus and infraspinatus tendons, without retraction. There was a state 1 Goutalier fatty infiltration of the supraspinatus and infraspinatus muscles. The electromyographic evaluation of the axillary nerve was normal. It was decided to reconstruct the defects with a fresh-frozen Achilles allograft tendon with attached calcaneal bone. Written informed consent was obtained from the patient for publication of this case report and accompanying images.
Under general anaesthesia and interscalene nerve block, the patient was placed in the beach chair position, with the operative arm draped free. An open anterosuperior incision with a deltoid split was performed in order to expose the greater tuberosity defect. The long head of the biceps was already resected. The remaining posterosuperior rotator cuff was carefully dissected, and the proximal humeral head was debrided. The quality of the cuff tissue was poor. The Achilles tendon allograft with attached calcaneus was then prepared (Fig. a). The calcaneus was shaped to fill proximal humeral head defect. The Achilles tendon was then split longitu

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


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

[User]
RADIOLOGY NOTE:
A 40-year-old man presented with gastrointestinal bleeding due to esophageal varices and liver cirrhosis. Review of his records revealed that he had been diagnosed with GSD at the age of two years following a liver biopsy, when he had a distended abdomen due to hepatomegaly. He had problem with weakness from early childhood. In his childhood, he had frequent nose bleeding and easy fatigability. His growth was very slow. He was on no specific therapy and never suffered from symptomatic hypoglycemia. He went into a late puberty at about 17–18 years, but grew very rapidly and became much taller than his parents. During that period, his muscle weakness worsened and he had been in a wheelchair since he became 24 years old. His weakness in his arms also dated back to his puberty. At the time of presentation, he was unable to brush his hair and had to lean forward to eat. He had not had any heart problem. He had not had any sleep problems or chest infections. He suffered from low back pain after sleeping. His diet was high in protein with lots of meat, nuts, eggs, and yoghurt. He had never tried uncooked corn starch. GSD IIIa, for the first time, was confirmed at the age of 28 in the National Hospital for Neurology and Neurosurgery, Queen Square in London, on April 7, 2004. His parents were unrelated, alive and doing well. There was no family history of other muscle disorders. He had no other medical problems. He had normal schooling and studied engineering at university but had to stop in his 3rd year because of the weakness. He was on no regular medication. He was unable to sitting in wheelchair and needed assistance to be transferred. On physical exam, he appeared dysmorphic, thin, disable but intelligent. His vital signs, chest and heart were normal without any evidence of cardiomyopathy. Abdominal examination revealed a firm and enlarged liver, splenomegaly, and ascites

[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 39-year-old female patient was admitted to hospital with epigastric pain which was lasting for two months. She had no remarkable history except for her mother having DM. Moreover, a physical examination revealed epigastric tenderness on palpation, and laboratory examinations revealed no important findings. Endoscopy revealed edematous and fragile papilla of Vater, and a polyp was seen on the 2nd part of duodenum. A biopsy yielded a hyperplastic polyp, and a biopsy from the papilla was performed due to the imaging findings on endoscopy with suspicion of an ampulla tumor; however, biopsy specimens yielded no malignant cell.
Ultrasonography (US) of the patient showed a diffusely enlarged hypoechoic pancreas with punctate hyperechogenities representing calcifications (). There was no altered vascularization of pancreatic parenchyma on Doppler US. Computed tomography (CT) revealed a huge pancreas, which was enlarged diffusely with multiple calcifications and punctate hyperdensities. The pancreatic duct and peripancreatic fat tissue were normal. There was no inflammation sign (). CT of the thorax did not yield an important feature in the mediastinum and lung parenchyma. On magnetic resonance imaging (MRI), a diffusely enlarged pancreas was seen as hypointense on both T1- and T2-weighted images (). There were hyperintense cystic nodules in pancreas parenchyma on T2-weighted images (). After gadolinium administration, enhancement of the pancreas began in the early phase, and became more prominent at delayed images. Punctate nodular unenhanced areas in pancreas parenchyma were seen on delayed images. Since the patient's history revealed no sign for chronic pancreatitis and amylase levels were normal, a trucut biopsy with an 18 G needle (Bard Biopsy Systems, Tempe, AZ) was performed. According to the histopathological results, the diagnosis was islet cell primary amyloidosis of the pancreas. Only islet cells in the islands of Langerhans were stained red with congo red ink.

[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 39-year-old Thai male patient presented with progressive pain and swelling of seven-month duration over the antecubital fossa of the right elbow. Initially, there was only slight swelling. Three months later, he complained of dull pain. The patient went to a private clinic where the diagnosis was distal biceps tendinitis. The first doctor gave a local steroid injection, but the symptoms recurred about one month later. Four months later, the patient complained of pain at night and weakness on supination of the forearm and flexion of the elbow. He had no underlying disease, chest symptoms, fever, weight loss, or history of contact with patients suffering from pulmonary tuberculosis.
Physical examination of the right elbow when patient visited the hospital in Thailand demonstrated swelling at the antecubital fossa, mild tenderness at the distal biceps, and muscle weakness or pain when attempting to supinate the forearm and flex the elbow. All other systemic examinations were normal. There was a high white blood cell count (12,710 cells/mcL); neutrophil count was 72% and lymphocyte count 17%. Erythrocyte sedimentation rate was 17 mm/hr, and C-reactive protein was 6.69 mg/L. Radiography of the right elbow showed swelling at the antecubital fossa, and chest radiographs showed infiltration of the left upper lung. Magnetic resonance images showed disruption of the distal biceps tendon with an associated ill-defined soft tissue mass (about 2 × 2 cm). A less enhanced area was observed at the inferior part, which was likely to be necrotic or cystic. An abnormal marrow signal was detected at the proximal radius with focal cortical erosion at the radial tuberosity ().
In this case, we suspected that the patient had disseminated tuberculosis because preoperative chest radiographs demonstrated left upper lung infiltration, which was likely pulmonary tuberculosis, and there was a soft tissue mass at the distal biceps tendon. We performed an open excisional biopsy and debridement

[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 twenty-two-year-old male with extensive limb deformities reported to the department of Oral Medicine, Diagnosis, and Radiology with a chief complaint of unclear speech and difficulty in tongue movements.
The patient's medical history was insignificant. He was the fourth child of normal and unrelated parents. He had four siblings: one brother and three sisters all of whom were normal.
His prenatal history revealed that his mother had four episodes of fever during her first trimester and was medicated for the same. She was unable to remember the names of the medications. She had spontaneous vaginal delivery after thirty-nine weeks of gestation to give birth to a male baby with multiple limb deformities. Patient's family history for congenital abnormalities was negative.
On general examination, a healthy, moderately built male of normal intelligence presented to the clinic with an altered gait. He had anomalies affecting all the four limbs. His right hand showed brachydactyly (short digits) of second to fourth fingers with hypoplastic thumb and little fingers. Finger nails appeared normal (). In the left hand, hemimelia (missing half the limb) was observed below the elbow with five nubbins attached to its distal part. Radiograph of the right hand showed hypoplastic second and third metacarpals with deficient second to fourth phalanges. Absence of distal part of the radius and ulna was noted in the left hand radiograph with subluxation of the superior radioulnar joint. Lower limbs were also severely deformed. Right limb showed hypoplastic foot with adactyly (missing digits). Left limb had apodia (missing foot) with adactyly (). Radiographically, right limb revealed hypoplasia of the phalanges and first metatarsal bone; left limb revealed absence of tibia, fibula, and both the malleoli. Detailed systemic clinical examinations with appropriate investigations were also performed. Though patient was clinically normal, his chest radiograph showed prominent pulmonary bay. 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 34-year-old man presented to the emergency department with a 2-hour history of sudden acute severe back pain at the thoracic level. He described that the pain was initially dull and then became sharp. There was no history of trauma, drug use or any physical exertion. The past medical history was unremarkable. On arrival, he was conscious and alert, with no respiratory distress and normal vital signs. The rest of the physical examination was normal. Initial laboratory tests including complete blood count, chemistry panel and coagulation evaluation revealed no remarkable contributions.
During observation, at 3 hours from the beginning of the pain, the patient complained of weakness and numbness over the lower limbs. A physical examination revealed paraparesis (muscle power scores of 2/5 for thigh flexion muscles and 2/5 for foot flexion on the bilateral lower limbs) with flaccid lower extremities and bilateral extensor plantar responses, decreased sensation below the T10 dermatome with anesthesia in the perineal region, and urine retention. Neurological and neurosurgical consultants were contacted and emergency magnetic resonance imaging (MRI) was ordered.
MRI of the thoracic spine demonstrated an anterior epidural mass extending from T3-T4 to T8-T9, causing spinal cord compression, especially at T5-T6. The mass had isointensity to the spinal cord on T1-weighted images and hyperintensity on T2-weighted images (Figure ). Diffusion-weighted imaging revealed no alterations in the spinal cord. Based on the clinical presentation and imaging findings, an epidural hematoma of the thoracic spine was suspected. The patient was administered 1 g of methylprednisolone intravenously and was taken to the operating room for an emergency decompression laminectomy at approximately 130 minutes after the initial onset of the spinal cord compression symptoms. A bilateral laminectomy from T5 to T7 was performed. During the operation, an epidural hematoma was discovered and evacuated. 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:
A 31-year-old female patient with a height of 164 cm and weight of 60 kg was admitted to undergo ethanol sclerotherapy for a large painful vascular malformation in her left leg. Magnetic resonance imaging revealed an AVM measuring 28 × 7 × 4 cm in her left calf (). All preoperative examinations, including laboratory tests, electrocardiography, and chest X-ray, were normal. Vital signs before general anesthesia were stable: her blood pressure was 130/80 mmHg and her heart rate was 82 beats/min. Following the application of routine hemodynamic monitoring (3-lead electrocardiogram, noninvasive blood pressure, and pulse oximetry), anesthesia was induced using a bolus intravenous injection of 120 mg propofol and 40 mg rocuronium. A 20-gauge catheter was inserted into the radial artery to monitor her arterial blood pressure continuously. The target controlled infusion of 2% propofol and remifentanil (2-3 µg/ml and 2-5 ng/ml of the effect-site concentrations, respectively) was applied to maintain anesthesia. Immediately following the injection of ethanol, the patient's blood pressure and heart rate rose slightly to 160/100 mmHg and 100 beats/min, respectively. Thereafter, the patient's blood pressure and heart rate were stable throughout the procedure while she was in the prone position. A total dose of 50 ml of 99% ethanol was injected into the lesion over a period of 30 minutes without the use of a tourniquet. As soon as the patient was turned from prone to supine after finishing the procedure, an abrupt drop in her arterial blood pressure occurred, 40-50 mmHg systolic and 10-15 mmHg diastolic blood pressure with a simultaneous increase in her heart rate to 100-110 beats/min. To restore blood pressure, 20 mg of ephedrine was immediately injected, but the patient's heart rate rather decreased abruptly to < 30 beats/min. Chest compressions were performed along with the simultaneous injection of 50 µg of epinephrine. A few minutes later, the patient's blood pressure and hea

[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 43-year-old female had attempted suicide in the morning by burning charcoal and was found unconscious in the evening by her son. She had been diagnosed as having depression for 8 years while her son had mild intellectual disability. She was taken to the emergency room of our university hospital. It was estimated that it took about 27 hours from the time of the suicide attempt to the time of admission. The level of carboxyhemoglobin was within normal range at that time. HBOT (2.5 ATA for 120 min) started immediately after admission, and her unconsciousness gradually resolved and returned to the normal level. However, after the thirteenth session of HBO, it was interrupted to treat her wound because there was a second-degree burn mainly in her upper left limb. Her disorientation and abnormal behaviors appeared about twenty days later after interruption of HBOT. She could not open the door and try to eat hand cream. The EEG at that time showed predominant slow waves (3~7 Hz theta and delta) with poor alpha (8 Hz) waves, and MRI at that time showed diffuse hyperintensity of the bilateral hemispheric white matters consistent with changes of delayed leukoencephalopathy as a result of prior CO injury with hyperintense change of the bilateral globus pallidi (). Three sessions of HBOT were thus performed immediately. Eleven days later, she was transferred to our department for the purpose of detailed examinations and treatment of CO intoxication. Since HBOT and burn treatment could not be performed at the same time, the policy was to give priority to burn treatment. Thirty-two days later, burn treatment was finished and HBOT was thus restarted. During 136 sessions of HBOT, her neuropsychiatric symptoms gradually ameliorated. Her clinical improvement went side by side with the improvement in scores of FAB as observed in case 1. 326 days after her suicide attempt, she was discharged from our university hospital. At that time, the score of FAB was 18/18 and

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


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

[User]
RADIOLOGY NOTE:
A 68-year-old man complained of a neck mass with laryngeal invasion and underwent a wide excision of the thyroid bed and a complete laryngectomy in October 2010. The patient was initially diagnosed with a sarcomatoid carcinoma of the neck with unusual histology. The tumor showed epithelioid-tubular structures containing mucin pools, with a fibrous or sarcomatous background, which is not consistent with the typical morphological features of ATC ( and ). The patient received adjuvant radiotherapy (42 Gy) and chemotherapy. However, the size of the residual neck mass and lung nodules increased, and the patient died 9 months after their last operation.
The patient had a history of total thyroidectomy for a PTC 6 years previously. In addition, the patient underwent a dissection of neck lymph nodes for PTC recurrence and a total of 200 mCi of radioactive iodine (131I) therapy 3 years previously.
The patient's tissue samples were reviewed retrospectively, and additional immunohistochemistry (IHC) staining and direct sequencing of the BRAF gene were performed. The primary PTC samples could not be included due to their poor quality. High expression levels of thyroid transcription factor-1 (TTF-1), thyroglobulin (Tg), paired box gene 8 (PAX8), and human bone marrow endothelial cell-1 (HBME-1) were observed in the recurrent node, but not in the laryngeal mass (). Other data obtained through IHC testing showed identical results for both the recurrent neck node and the laryngeal tumor: positivity for vimentin, p53, cytokeratin (CK) 7 (), and galectin-3; focal positivity for CK19; and negativity for CK20. Although the histopathological findings, as well as the IHC results, of the undifferentiated larynx tumor did not suggest that it originated from the thyroid, the positive result for the BRAF V600E mutation, by direct sequencing, indicated a possible PTC origin for the ATC (). Thus, we performed a BRAF mutation analysis using IHC on metastatic PTC samples in the patient's neck ly

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


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

[User]
RADIOLOGY NOTE:
A 38-year-old japanese man with no previous cardiovascular disease was admitted to our hospital because of paroxysmal nocturnal dyspnea and low grade fever of four weeks duration. He had the history of the resection of subcutaneous abscess in the neck, several days before the onset of symptom. On admission, blood pressure was 104/40mmHg with a regular pulse of 102/min. His body temperature was 37.4C. An early systolic murmur and a diastolic blowing murmur with thrill were detected at the left parasternal border. Increased pulmonary vascular marking was observed in his chest X-ray and the cardio-thoracic ratio was 50%. Electrocardiogram revealed a prolonged P-Q interval of 0.28 second, left ventricular hypertrophy and ST depression in the left precordial leads. After admission, first-degree of atrioventricular block normalized in 0.18 second of P-Q interval. Echocardiography was performed with a Tohshiba 65A after normalization of P-Q interval, which revealed the dilated and hyperkinetic left ventricle and the slightly dilated left atrium. M-mode echocardiography showed premeature mitral valve closure (), and the left ventricular end diastolic dimension was 6.4 cm and the end systolic dimension was 4.4 cm. The right coronary cusp and left coronary cusp of the aortic valve were extremely elongated and the left Valsalva sinus was dilated. Both aortic cusps were prolapsing and no coaptation was seen. Severe aortic regurgitation was observed on color Doppler flow imaging. In late diastole, mitral regurgitation which ran just behind the posterior mitral leaflet and extended to the posterior wall of the left atrium was detected (). The diastolic mitral regurgitation began with the atrial systole and disappeared with the ventricular systole ().
Although several blood cultures were all negative, the diagnosis of acute aortic regurgitation due to infective endocarditis was made from the clinical history and destructive changes of the aortic valve. After intensive antibiotic t

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


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

[User]
RADIOLOGY NOTE:
A 46-year-old male with a history of severe developmental delay, hydrocephalus, and seizure disorder presented to the hospital with blunt head trauma after a ground level fall. Work-up revealed bilateral acute subdural hematomas for which an external ventricular drain was placed. Despite intensive care management, the patient deteriorated to brain death. He was subsequently evaluated for organ donation. Abdominal computerized tomography (CT) scan () revealed an “elongated structure with metallic components in the upper portion of the IVC that extends into the right atrium.” There was no medical history of a prior procedure, or symptoms, to explain the incidental finding. The radiologist's interpretation and presumptive diagnosis were a retained atrial pacing wire.
He subsequently underwent procurement for organ donation after brain death. At the time of cross-clamp, the previously identified foreign body was transected when the right atrium was incised for exsanguination. During the back-table dissection, it was apparent that the foreign body had eroded into the posterior wall of the IVC, extending down the retrohepatic IVC (Figures and ). It also created a calcified reaction at the junction of the suprahepatic IVC and right atrium, adjacent to the left hepatic vein (LHV) and middle hepatic vein (MHV). We removed the foreign body () and performed a venoplasty () of the posterior wall of the IVC and of the common wall of the LHV and MVH, so that the outflow of the LHV and MHV was not compromised after transplant. We discovered that the foreign body was, most likely, a fractured CVC due to the overall appearance and interval markings.
The liver recipient was a 65-year-old woman with cirrhosis due to alcohol abuse; her Na-MELD score was 40 at the time of transplant. She underwent caval-sparing total hepatectomy and deceased donor liver transplantation via piggyback technique: the donor suprahepatic IVC was anastomosed to a common orifice of the recipient's right

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


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

[User]
RADIOLOGY NOTE:
A 38-year-old North African man, with no past medical history, consulted our out-patient clinic for a painless left scrotal mass. There was no history of previous orchitis or scrotal contusion. He noted the mass a month ago. A physical examination found a 2 cm palpable mass in the upper pole of his left testis. There were no signs of scrotal inflammation. The mass had a firm consistency and regular margins. Palpation of his right testis and the lower pole of his left testis were normal. Routine blood tests were normal. As a testicular tumor was strongly suspected, a bioassay of testicular tumor markers was ordered. Alpha-fetoprotein, human chorionic gonadotropin (hCG), and lactate dehydrogenase (LDH) were in the normal ranges. There was no bacterial growth in urine analysis, including Mycobacterium tuberculosis screening. A scrotal ultrasound showed a homogeneous testicular parenchyma, with a conserved vascularization on Doppler. An extratesticular mass was observed, attached to the upper pole of his testis. The mass was isoechoic to the testis parenchyma, and poorly vascularized Doppler (Fig. ).
He underwent a radical inguinal orchiectomy. We first performed a high ligation of the spermatic cord. The operative specimen included the testis and the tunica vaginalis in one piece (Fig. ). The macroscopic aspect of the supratesticular mass looks similar to splenic tissue (Fig. ). There were no macroscopic lesions of the testis and the spermatic cord. His postoperative course was uneventful. He was discharged on the second postoperative day.
Histological examination of the operative specimen confirmed the presence of regular splenic tissue in the suspect mass, without any signs of malignancy. The splenic proliferation had its proper and regular capsule, demarcating it from the testis. Testicular pulp, the albuginea and the tunica vaginalis had a preserved microscopic architecture (Fig. ). He was examined 3 weeks after orchiectomy and he was examined again 2 months after

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


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

[User]
RADIOLOGY NOTE:
Our patient was a 47-year-old male with past medical history including aorto-occlusive disease status post femoral-popliteal bypass, with peripheral artery disease, coronary artery disease, and tobacco dependence. He initially presented with right groin and lower-extremity numbness with an otherwise unremarkable review of systems. The patient was diagnosed with right limb occlusion with critical limb ischemia of the right lower extremity due to an aorto-femoral bypass graft occlusion. Initial workup included a computed tomography (CT) angiogram of the chest, prior to treatment of the occlusion with a femoral-femoral bypass.
Computed tomography angiography (CTA) of the chest revealed a 1.4 cm nodule at the left lung apex, slightly cavitary in nature together with a left paratracheal soft tissue density that was suspected to be adenopathy related to pneumonia that was being treated. The lesion was considered to be incidental with the recommendation of short-term follow-up with another chest CT in three months. There was no prior imaging for comparison.
Two months later, the patient presented to the emergency room with bilateral chest pain and associated shortness of breath and dyspnea. He was admitted to the intensive care unit (ICU) for respiratory instability and treated for multiple bilateral pulmonary embolisms. The diagnosing CTA of the chest showed an increase in the left upper lobe mass density with 2.5 cm x 2.4 cm dimensions including marked interval increase in diffuse mediastinal and bilateral hilar adenopathy involving levels T5, T10, and T11, suggesting a primary neoplasm with metastatic disease. The primary lesion was pleural based and thought to be invading the pleura. Once the patient stabilized, a CT-guided left upper lobe biopsy was obtained.
Biopsy revealed a poorly differentiated non-small cell carcinoma consistent with squamous cell carcinoma. Sections showed nests and individual large cells with brisk mitotic activity with medium to large nuclei.

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


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

[User]
RADIOLOGY NOTE:
A 35-year-old healthy pregnant lady with a history of 3 previous cesarean sections was scheduled for her 4th cesarean delivery. The operation was performed under spinal anesthesia. Severe adhesion of the urinary bladder to the lower uterine segment was encountered but there was no apparent lower urinary tract injury. Her postoperative period was uneventful and she was discharged home the next day. On the 11th postoperative day she was readmitted to the emergency unit at 11 pm with considerable abdominal distension, shortness of breath and difficulty of micturition with straining to void. Further questioning revealed sudden inability to void 5 days earlier followed by mild hematuria and passing a small amount of urine. On examination she was dyspneic, the abdomen was distended, pulse rate was 100 BPM, blood pressure was 100/60 mm/Hg and afebrile. Immediate resuscitation was started and Foley catheter was inserted which drained 100 ml concentrated urine. Serum creatinine (6.8 mg/dl), blood urea (123 mg/dl) and serum potassium (5.6 meq/l) were high. Abdominal and pelvic ultrasound showed marked ascites (), normal both kidneys with no hydronephrosis. A trial of diagnostic and therapeutic ascitic fluid drainage was performed by putting a percutaneous 12 French pigtail catheter in the right lower abdomen under ultrasonic guidance (). Six and a half liters of clear fluid was drained. Biochemical investigation of the drained fluid showed high urea (145 mg/dl) and creatinine (20 mg/dl). Diagnosis of urinary ascites was confirmed. Later on, there was a dramatic improvement in the general condition of the patient. Next day blood chemistry was repeated and showed normal blood urea and serum creatinine. Through cystoscopy, we detected a perforation at the posterior wall of the bladder (), while both ureters were normal. Then a Foley catheter was fixed to completely drain the urine in addition to the peritoneal drain to allow the perforation to heal. The patient was put on intrav

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


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

[User]
RADIOLOGY NOTE:
A 29-year-old female patient was referred to our department with acute onset postpartum paraplegia with bowel bladder involvement after delivery of her third child by normal vaginal delivery. Her antenatal course had no significant history with any history of antepartum low-back pain, trauma, drug use, or any physical exertion. On examination, she was conscious, well oriented, and afebrile. Neurological examination showed complete paraplegia (power 0/5 with decreased tone), associated bowel bladder involvement, and absent deep tendon reflexes at knee and ankle joint with complete sensory deficit below the level of L1. All necessary blood investigations including coagulation profile came out to be normal. Patient was planned for magnetic resonance imaging (MRI) of dorsolumbar spine with screening whole spine, which revealed extradural broad based ellipsoid lesion, measuring 50 × 9 mm along T12 to L2 vertebra displacing the dura anteriorly and T1 hyperintensity (
), T2 hypointensity with minimal postcontrast enhancement suggestive of early subacute bleed causing mass effect on adjacent cord with areas of altered signal intensity at the level of lesion.
On the basis of clinical evaluation and MRI report, the patient was planned for urgent decompression in emergency operation theater. After preoperative marking of D12–L2 vertebral levels under fluoroscopic guidance, midline exposure done and paraspinal muscles elevated upto medial edge of transverse processes on both sides with the help of cobb's and broad osteotome. Intraoperatively, bilateral complete laminectomy of L1 vertebrae was done with removal of ligamentum flavum, a well-defined firm organized hematoma dark reddish black in color (5 × 1 cm) was seen over the dura which was removed (
) and checked for adequate decompression utilizing infant feeding tube. Sample removed was sent for histopathological examination reported as organized hematoma. Postoperatively, patient recovered rapidly in terms of neurological d

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


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

[User]
RADIOLOGY NOTE:
A 55-year-old male patient, farmer by occupation presented to our STD clinic with a large polypoidal growth on the penis, scrotum and right upper thigh since last 10 years. 10 years back he developed progressive itching on the tip of the penis and subsequently within a few days he developed small skin colored lesion with clear fluid oozing from them on scratching. Later the lesions progressively increased in size and circumferentially over the skin of prepuce. Similar polypoidal growth developed over the scrotum and right upper thigh that subsequently increased in size. All these lesions were progressively enlarging became hard, not associated with pain but with a mild itch. There was no history of similar lesions elsewhere in the body. Patient was also able to have sexual intercourse during the initial 2 years.
On examination of the patient [], there was the polypoidal growth involving the skin over the prepuce, scrotum and right upper thigh. There was circumferential growth involving the skin of the prepuce, scrotal growth involving its tip and growth over right upper thigh measuring an average size of 3 cm × 2 cm. The perianal area, gluteal region and rest of the body surface were free of similar lesions. The patient was able to urinate without any difficulty. His sexual activity was compromised during the last 8 years. The wife did not complain of any such lesions on her sexual organs and was found normal on examination.
The initial diagnosis of giant condyloma acuminata, verrucous carcinoma over genitalia, giant acrochordons (skin tags) was kept in mind, and the patient was investigated. The complete hemogram, liver, and renal function tests and immune status were found to be normal. The patient was taken up for shave excision of the lesions under general anesthesia. The preputial skin with the lesion was excised along with shave excision of similar lesions over the scrotum and right upper thigh

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


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

[User]
RADIOLOGY NOTE:
This case report is of a 34-year old man who was married, Catholic, and a construction worker. He had primary school education with no history of previous hospitalizations, surgeries, transfusions, allergies, or known pathologies. He referred only to head trauma suffered 8 months ago by way of physical assault. The assault caused a nose-bone fracture with a nasal septum deviation to the right, but with neither purulent material nor a rinusinusal infectious process. He had only mild, intermittent, and sporadic obstructive dyspnea after the incident. The patient smoked 20 cigarettes a day for 21 years, from 13 to 34 years of age. Up to 5 months prior to his admission, he also suffered from alcoholism for 11 years, drinking 1000 ml of alcohol every week.
He was admitted to the hospital with an occipital headache which he had endured for 2 months. For over 1 and a half months, he had also experienced behavioral disorders and a disruption of higher mental functions. He had retrograde and anterograde amnesia with both echolalia and the presence of visual hallucinations. A private physician initially treated him with diazepam, pentoxifylline, diclofenac, and phenytoin, all with standard doses but with no improvement. Three weeks prior to admission, the patient experienced acalculia and multiple apraxia that did not allow the patient to perform ordinary work and other daily activities such as bathing, and dressing. At this point, the patient required the support of a family member. The individual was evaluated by a second physician who prescribed amitriptyline, bromazepam, B complex, and additional phenytoin. Five days later, the patient developed ataxic gait and was evaluated at a regional hospital where he was given treatment for poisoning (benzodiazepines with flumazenil and a gastric lavage with activated carbon). One week prior to admission, the man quickly and progressively lost the ability to hold himself up. He suffered from psychomotor agitation and myoclonic movem

[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 patient was referred to a private genetic counseling service because, besides an extensive family history of cancer, she had a 2.0 cm lump detected in her right breast, as assessed by Magnetic Resonance Imaging, of Breast Imaging Reporting and Data System (BIRADS) category 4. The biopsy by fine needle aspiration showed a ductal proliferative breast lesion. The patient had a high risk for breast cancer and family history of cancer, with kindred diagnosed before the age of 50 years. The analysis of her pedigree showed an autosomal dominant disorder from her paternal side () with early onset cases of colon adenocarcinoma, gastric, lung, prostate and pancreas cancer.
According to the ANS guideline, the patient did not meet the criteria to be tested for germline mutations because (i) she had no current or previous cancer diagnosis, (ii) she was not of Ashkenazi jewish origin, and (iii) there were no known mutations in her family. It is important to highlight that the patient was informed she was not the perfect index patient for family genetic counseling since she was not diagnosed with cancer; thus, her result was limited to individual genetic counseling, i.e., a negative result for presence of mutation would not mean the absence of mutation in her family.
Since Brazil lacks a specific guideline to screen hereditary cancer, the worldwide applied United States National Comprehensive Cancer Network (NCCN) is routinely used. It comprises recommendations on the prevention, diagnosis, and management of malignancies across the continuum of care. The NCCN Guidelines incorporate real-time updates in keeping with the rapid advancements in the field of cancer research and management. For hereditary nonpolyposis colorectal cancer (HNPCC), or Lynch syndrome (LS), the patient should meet revised Amsterdam criteria or revised Bethesda criteria.
Genetic counseling consultation is a health service that provides information and support to people who have or may be at risk

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


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

[User]
RADIOLOGY NOTE:
A 34-year-old Caucasian woman, gravida 1 para 0, presented to our hospital with repeated attacks of mild vaginal bleeding. Our patient, according to her sure reliable dates, was 16 weeks and three days pregnant. She had a history of primary infertility for seven years preceding this pregnancy, and she had sought medical advice for delayed conception one year after marriage. Male factor infertility was excluded by a single semen analysis and she was informed that her hysterosalpingography was quite normal; she was given medical treatment that she could not recall to improve her cycles (these were infrequent and irregular over the last five years). She used these medications for about four months after which she reported some improvement in her cycles but conception did not occur. A hormonal profile was ordered and our patient was examined transvaginally by ultrasound. Subsequently, she was informed she had bilateral polycystic ovarian syndrome. Her physician prescribed clomiphene citrate (Clomid, Global Napi, Egypt) 100 mg for five days beginning on the second day of her cycle. Our patient continued taking the drug without ovulation monitoring and the regimen was repeated with an increasing dose up to 200 mg daily for six successive months. Laparoscopic ovarian drilling was performed and our patient resumed using clomiphene citrate three months after the operation without prescription. Two months prior to admission, she took 250 mg of clomiphene citrate (five tablets per day) beginning from the second day onwards until the 13th day of the cycle.
Our patient had a missed period immediately after this haphazard regimen. Pregnancy was confirmed by a urine pregnancy test then by a trans-vaginal ultrasonographic examination that was carried out six weeks and three days after her last menstrual period. According to this ultrasound report, the gestational sac corresponded to seven weeks of gestation. However, there was no comment regarding the presence of theca lutein ovari

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


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

[User]
RADIOLOGY NOTE:
A 32-month-old Middle Eastern boy was born full term at a community hospital in Michigan with birth weight of 3135 g (15.0 percentile). He had normal prenatal ultrasounds. He passed meconium at birth and had no other complications including prolong neonatal jaundice or dehydration. His CF NBS showed serum IRT 139 ng/ml and was negative for the 40 gene mutations panel. At 1 month of age, he developed a wet cough without any other symptoms. He was followed by his primary care provider (PCP), and no treatment was given at the time. His symptoms continued on and off until 1 year of age. At 1 year, the mother noticed increased frequency of productive cough, lack of appetite, and poor weight gain. His weight-for-age percentile ranged from 0.3 to 5.0. His stools were reportedly normal. He had no excessive sweating. He was referred to an outside asthma/allergy specialist for evaluation of asthma. He was prescribed budesonide without any improvement. He had frequent pharyngitis and otitis media that were treated with oral antibiotics that reportedly helped treat acute infection, but the cough persisted. He was also prescribed a H2 blocker for possible gastroesophageal reflux disease, but no improvement in symptoms was noted. Family history was negative for CF.
At 30 months of age, he was seen by his PCP for one week of cough and fever. He was treated with amoxicillin. His symptoms continued to worsen despite oral antibiotics, and he had two episodes of small-volume hemoptysis. He was subsequently admitted for community-acquired pneumonia and influenza B. Chest X-ray showed diffuse ill-defined opacities in the perihilar area and diffuse bronchiectasis. During the hospitalization, pediatric pulmonary consult was obtained. Given the negative NBS, it was stated that CF was unlikely and no sweat chloride test was recommended. He had a normal videofluoroscopic swallow study. Immunodeficiency workup revealed elevated immunoglobulin levels, protective vaccine titers

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


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

[User]
RADIOLOGY NOTE:
We report a case of 1-year-old male child presented to the ophthalmology OPD with abnormal appearance of both eyes since birth. He was born by an uneventful, full term delivery of a nonconsanguineous couple. At the time of birth, he had slight protrusion of both the eyes with abnormal lids, and bleeding off and on. The eyes continued to protrude until 3 months of age; the condition remains static ever since. He also developed tonic-clonic seizures after 3 months of age which still continued but decreased in frequency, and the last episode was 2 days before the presentation. He also reported having increased head circumference at birth that has not progressed since then. At the time of presentation, the child has abnormally protruded eyes with coloboma of middle 1/3 of right upper lid, and medial 1/2 of left upper lid; an abnormal skin fold present below the malformed left lid. A skin tag was present at the outer canthus of right eye [ and ]. The conjunctiva on the right side appears slightly cystic, both the conjunctiva and cornea were keratinized because of exposure. No other ocular abnormality in the form of orbital cyst or microphthalmia was present. He had frontal bossing with depressed nasal bridge [] and also slight protrusion of tongue. There were focal patches of alopecia with dermal hypoplasia of scalp [Figure and ]. Hyperpigmented patches were seen on the right side of the chest, abdomen and back with a slight extension onto the nape and right arm []. Developmental milestones were evidently delayed. A thorough general and systemic examination did not reveal any abnormality except for decreased muscle strength. Baseline investigations were unremarkable, and an abdominal ultrasound showed a complex splenic cyst of 6 mm.
Magnetic resonance imaging of the head showed aplasia of cerebellar vermis with enlarged superior vermian cistern. There was subependymal grey matter heterotopia of the postero-inferior aspect of the atrium 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 60-year-old man was admitted with acute onset of confusion, personality change, and intermittent headache. His symptoms worsened over three days prior to admission. There was no history of nausea, vomiting, fever, or seizures. His past medical history was significant for hypertension, but he was not using any medications. He was a non-smoker and never consumed alcohol. In the emergency department, vital signs including blood pressure and temperature were normal. He was confused, disoriented to time and place with no neck rigidity or stiffness. Neurological examination showed a normal tone and power (muscle strength by medical research council scale) with normal symmetrical deep tendon reflexes. His gait was normal, but the examination of coordination and fundi was difficult to perform. Unenhanced computerized tomography (CT) scan of the brain was normal. The patient was taken to the magnetic resonance imaging (MRI) suite, but he was moving and irritable, which made this imaging modality difficult to perform. Routine investigations revealed normal biochemical tests and inflammatory markers. His white blood cells (WBC) count revealed a leukocytosis (20,000) with normal platelets and hemoglobin. Blood and urine cultures and chest radiographs were unremarkable. Examination of cerebrospinal fluid revealed no WBCs or red blood cells, normal glucose and protein with negative gram stain and culture. Polymerase chain reaction tests were negative for common viral pathogens. Electroencephalogram recordings showed a slow background in the theta range with no epileptiform activity or evidence of encephalitis. Two days after admission, his condition deteriorated, and he became more agitated and combative with a drop in his blood pressure to 80/40 mmHg and tachycardia (120 bpm). He was intubated and mechanically ventilated, but unfortunately, his Glasgow coma scale dropped. His pupils became fixed and dilated. Repeat work-up of septic shock was again unremarkable, and he require

[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 dead body of a 34-year-old male was found from a gutter line in Thatta district, Sindh. Upon external examination, the dead body was found to have widespread blisters and swollen face and abdomen. The macerated foul-smelling body with a half-opened mouth was missing nose, upper lip, and left eyelid as a result of being eaten by fish/insects dwelling in the gutter. The clothes, hair, nails, and nail scrapings of the dead body were sent for DNA and serological analyses. Upon serological analyses, blood was detected on the clothes of the victim. The DNA profile obtained from the hair and nail of the victim was consistent with a single source of male origin. The DNA profile obtained from nail scrapings was a mixture of at least two individuals with a major and minor component. The major component matched the DNA profile of the hair and nail of the deceased, but the minor component did not match, which further adds weight to the possibility of a homicide. The dead body was then buried without forensic intervention due to a lack of forensic expertise in the rural area of Thatta.
After almost six months post burial, exhumation of the dead body was requested by the investigating officer to ascertain the cause of death, whereafter, it was performed. Upon unearthing, the body was found in an advanced stage of decomposition, with soft tissues decomposed and the underlying skeleton intact (Figure ). Greater cornu of right upper 1/3rd of hyoid bone was found fractured, and both maxilla and mandible were dislocated (Figure ). The rest of the skeleton was unremarkable in appearance. The left clavicle and right femur were reserved for chemical analysis to detect the presence of diatoms and traces of poison (Figure ). Water from the death site (gutter) was taken to compare and detect diatoms. The right clavicle bone

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


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

[User]
RADIOLOGY NOTE:
A 10-year-old male fell while riding a bicycle on the road. On the day of the fall, he had no definite symptoms; however, he complained of a mild, intermittent headache and nausea five days after the incident and visited the hospital. His neurological state was normal and there were no blood stains in the ear, nose, or throat. The brain computed tomography (CT) revealed a linear fracture, small amounts of epidural hematomas and pneumocephalus in the right occipital area. When compared to the left side, a higher density lesion within the right sigmoid sinus was found (). The brain magnetic resonance image (MRI) showed the effusion and hemorrhage in the right mastoid air cell and a signal intensity, which was suspected to be thrombus, in the right sigmoid sinus (). The brain magnetic resonance venography (MRV) revealed an absence of a flow signal between the right sigmoid sinus and the jugular bulb, which was confirmed to be sigmoid sinus thrombosis (). During the physical examination, he showed no papilledema, intracranial hypertension, or otogenic infections such as otitis media. His blood tests, including complete blood count, prothrombin time, partial thromboplastin time, antithrombin III, protein C activity, and protein S activity, were in the normal ranges. The patient was treated conservatively because the patient's symptoms were mild and gradually improved. He was discharged with a full recovery on the 4th day in the hospital. On the 10th day after discharge, the patient complained of vomiting and visited the department of pediatrics. The laboratory tests, including a prothrombotic evaluation and a physical examination, were performed. The results of the laboratory tests were normal. Due to concern regarding the progression of the previous sinus thrombosis, the brain MRV was re-checked, and it showed the recovery of the flow signal in the right sigmoid sinus (). The spontaneous recanalization of sigmoid sinus thrombosis occurred within about three weeks of 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 46-year old female patient, who had been suffering from autoimmune thyroid disease for eight years, presented at our clinic with an acute exacerbation of GO. Clinical examination revealed a convergent strabismus fixus with severe hypotropia of both eyes (Fig. ). The patient complained of increasing loss of eyesight and heavy retrobulbar pain. Visual acuity had deteriorated significantly from 0.6/0.5 to 0.1/0.1 within 3 months. A contrast enhanced orbital MRI scan showed distinct swelling of all extraocular muscles with bilateral compression of the optic nerve (Fig. ). There was no history of comorbidities except nicotine abuse. Laboratory tests showed a euthyroid biochemical status with TSH within the normal range, but elevated levels of Anti-Thyroid Peroxidase Antibody, Anti-Thyroglobulin Antibody and Thyroid Receptor Antibody. The patient’s daily medication comprised of 200 μg L-Thyroxin and 200 μg Selenium. Over many years, the patient had shown only mild to moderate symptoms of GO, but following a thyroidectomy, the symptoms had recently worsened dramatically. Since the disease could not be controlled by high-dose systemic glucocorticoid therapy, bilateral three wall orbital decompression had been performed twice previously. In the first step, the medial orbital wall had been resected via an endonasal approach. Due to ongoing findings as before, two months later partial resection of the orbital floor and fenestration of the lateral orbital wall via a combined transconjunctival/transcaruncular approach with piezosurgery had been performed. In addition, high-dose systemic glucocorticoid therapy was conducted prior to surgery and for the first two months after surgery. Glucocorticoid medication had to be gradually reduced until zero because the patient suffered from an upcoming depression and Cushing syndrome. Orbital radiotherapy for the treatment of thyroid eye disease had been considered as a therapeutic option, but the rapid progress of the disease with the g

[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.