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

[User]
RADIOLOGY NOTE:
A 40-year-old woman presented with a headache and was found to have a sinusitis-related headache pretreated with antibiotics. On admission, she was found to have random venous glucose of 33 mm/L and glycated hemoglobin (HbA1C) of 13.1%. (Table ). She had a significant family history of diabetes, and her father was diagnosed to have diabetes mellitus (DM) before the age of 40. Her weight at baseline was 48 kgs, with a calculated body mass index of 18.5. Detailed history revealed that she did have mild polyuria and polydipsia with the onset of sinusitis-related symptoms. Her vitals were stable, and the initial physical examination was unremarkable. She was started on oral hypoglycaemic agents on admission but soon failed despite adequate doses and was diagnosed with type 1 diabetes mellitus. She was continued on her antibiotics for the treatment of sinusitis and commenced on insulin glargine 16 units at night, glulisine five units three times before meals, and metformin. She was discharged promptly after three days as she recovered from her sinusitis and was competent with the self-administration of insulin.
On Day 4, she was readmitted, as she developed generalized swelling. It started off with lower limb swelling and progressed to develop discomfort over her groin and lower abdominal area due to swelling. This swelling swiftly progressed to involve the upper limbs, abdomen, and torso the following day. She remained ambulant and did her usual activities and was compliant with her medications. She was not taking any other herbs or over-the-counter medicines when she went home. Her vitals were stable and her weight increased to 55 kgs by this time. Physical examination revealed a generalized edematous woman with marked pitting edema extending over all four limbs and face. Her heart sounds were dual and lung sounds were clear. The examination of her abdomen was unremarkable, apart from the soft tissue swelling. The examination did not reveal a shifting

[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 sixty-one-year-old man with a significant two-year past medical history of bilateral lower extremity weakness and a left parasellar meningioma presented with anorexia, intermittent dysphagia, and early satiety with intermittent nausea, vomiting, and diarrhea from which he had been suffering for the past three months. During this time, he experienced a 20-pound unintentional weight loss. He was not taking any medications known to cause peripheral neuropathy; additionally, he reported a 20 pack/year smoking history and denied alcohol or illicit substance use.
Prior to admission, in January 2016, he had undergone extensive workup for similar symptoms of abdominal pain, nausea, vomiting, and dysphagia. The resulting workup included a CT of the chest, abdomen, and pelvis that demonstrated a fatty infiltrative change in the liver and a kidney, ureter, and bladder X-ray that showed a nonobstructive abdominal gas pattern with no dilated bowel loops or masses identified. An esophagogastroduodenoscopy done in March 2016 demonstrated dysphagia likely secondary to underlying neurologic issues, along with a small hiatal hernia, and an MRI that June revealed an unchanged left middle cranial fossa mass consistent with meningioma.
Upon presentation in July 2016, our patient reported bilateral lower extremity pain present over the past six months, which had been attributed to distal axonal motor neuropathy by electromyogram and nerve conduction studies by his outpatient neurologist. He characterized his pain as alternating between throbbing or shooting up his legs, and that he had been started on pregabalin six months prior with some amelioration of his symptoms. Oxcarbazepine had been recently added to his medication, with some results. He also reported weakness in both his feet since receiving radiation therapy for meningioma two years prior, requiring the use of a walker to ambulate.
In the emergency department, his creatinine was elevated to 1.31 mg/dL from a baseline of 0.9 m

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


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

[User]
RADIOLOGY NOTE:
A 45-year-old right-handed male initially presented to the University of Washington Movement Disorders Clinic in March of 2015. Informed written consent was obtained from the patient for the purpose of video-taping and case study publication. He attributed his HT to a fall in 2010, although he also had HIV infections and HIV-related neurological issues such as progressive multifocal leukoencephalopathy and toxoplasmosis. Although the cause of his lesions is unclear, given the location of the lesions, their appearance and the patient’s history of HIV, we surmise that they are the possible result of HIV-related vasculopathy associated with CNS toxoplasmosis. His career was in construction, and the onset of his neurological symptoms was associated with a fall through a roof in 2010. His immediate neurological status post-fall remains unknown; however, he reported the onset of multiple subsequent neurological deficits over the following three to four months, including tremor, seizures, gait impairments, left spastic hemiparesis and dysarthria. Subsequent MRI indicated the presence of bilateral thalamic lesions with the left lesion being substantially larger than the right. He first noted tremors of the left ring-finger, which spread throughout his left arm, then gradually involved his right arm. His right arm tremor represented the most active component of is Holmes tremor and displayed components of resting, postural and kinetic tremors. In addition to arm tremor he demonstrated low frequency tremors of the neck and chin. Consistent with the asymmetry of his thalamic lesions, his tremor was more severe on the right-body compared to his left, whereas rigidity symptoms displayed similar severity in bilateral upper and lower extremities. His tremors were refractory to medications including levodopa, propranolol, gabapentin, topiramate and primidone. Although he found some tremor improvement from baclofen 80 mg per day, this was associated with an exacerbation of his seizu

[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 37-year-old female presented to our clinic with progressive painful swelling and restricted movement of the right thumb for a duration of 4 months. Radiographs revealed an expansile osteolytic lesion involving the entire length of the first metacarpal bone (). The MRI demonstrated irregular expansion of the tumor breaking through the cortex. Extension of the tumor into the surrounding soft tissue and around first carpometacarpal joint was observed (). The pathological findings from the core needle biopsy were consistent with the GCT of bone ().
The en bloc resection was performed. The first metacarpal and the trapezium were excised, and the defect was temporarily bridged with bone cement. Six months later, a repeat MRI revealed no evidence of tumor recurrence. After a discussion with the patient regarding the reconstructive planning, she disallowed any option of using her autogenous bone grafts. A surgical treatment with patient-specific prosthesis was subsequently offered. A computed tomography scan of the patient's left metacarpal was done and used as a mirror image to create the custom mold by an Electron Beam Melting 3D printing technique. This mold was subsequently used to cast the entire titanium prosthesis. Multiple holes were designed in the proximal and distal portions of the prosthesis for the ligament reconstruction and temporary fixation ().
Intraoperatively, an incision was made over the dorsal aspect of the thumb metacarpophalangeal (MCP) joint, coursed along the radial insertion of the thenar muscles, curving ulnarly along the distal wrist crease, and extending longitudinally over the flexor carpi radialis (FCR) and palmaris longus (PL) tendon. The superficial branches of the radial nerve and artery were identified and protected. The biomembrane encapsulating the cement spacer was incised longitudinally. Once exposed, the cement spacer was removed and replaced by the titanium prosthesis. The ligament reconstruction was performed (). The collateral l

[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 anuric 60-year-old woman with diabetic nephropathy had been treated for four months by continuous ambulatory peritoneal dialysis (CAPD) with four daily exchanges and 2.0 L fill volume. She had a history of coronary artery disease with an anterior myocardial infarction seven months prior to the start of CAPD, followed by severe congestive heart failure with an ejection fraction of 23%. Her dry weight, documented one month after the start of CAPD by absence of both edema and hypertension, was 41.2 kg. Her height was 149 cm. She had not been seen by her CAPD providers for three months because of transportation difficulties when she was admitted with grand mal seizures followed by coma. One week prior to this admission, she communicated by telephone call with one provider. At that time, she reported total body swelling, moderate dyspnea and a body weight exceeding 70 kg. She was advised to use exclusively hypertonic dextrose (4.25%) CAPD dialysate and add two exchanges per day with short (1 hour) dwell times. Information obtained from relatives revealed that in the two days prior to this admission she had omitted her insulin dose because of anorexia and greatly decreased food intake.
On admission, she was comatose with a blood pressure of 180/74 mm Hg, regular pulse rhythm with a rate of 110 beats per minute, and temperature of 36.5 degrees Celsius. Her weight was 63.6 kg. Remarkable findings on physical examination included anasarca detected even in her scalp, a ventricular gallop, and crackles in both lung fields. Chest X-ray confirmed the presence of pulmonary edema and electrocardiogram was unchanged from recent tracings, which were consistent with old transmural myocardial infarction. Laboratory tests on admission revealed extreme hyperglycemia, severe hypertonicity, hypokalemia and respiratory acidosis.
Over the next 30 hours, she received insulin boluses and had frequent (every 2-4 hours) determinations of serum glucose and potassium concentrations. Serum gluc

[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 male laborer presented at our institution with complaints of pain, swelling, and stiffness of the knee of a one-year duration and a sinus over the anterior aspect of the proximal leg. The patient was riding a vehicle involved in a road traffic accident about six years ago in which he sustained an injury to the left thigh. The thigh became painful, swollen, and deformed after the accident. The patient was unable to bear weight on the limb. There was no associated wound. He was taken to a hospital in which the attending doctor had diagnosed a fracture of the left femur after radiological investigation. He was treated by open reduction and intramedullary K-nail insertion six years ago. He had visited the same operating surgeon for follow-up care for the past five years for the complaint of pain, pus discharge, and stiffness of the knee. He was treated conservatively for the same.
On examination at presentation to our institute, he was averagely built, walked with a limp, and supported with one axillary crutch. The left knee was moderately swollen, the overlying skin had blackish discoloration, with an active pus-discharging sinus over the anterior aspect of the tibial tuberosity (Figure ). The sinus was discharging turbid purulent fluid. The knee was tender, swollen, but not fluctuant with a reduced range of motion of about 10-20 degrees. There was a healed longitudinal surgical scar on the lateral aspect of the left thigh measuring 10 cm and another healed scar over the superior aspect of the left buttock measuring 4 cm. There was no tenderness or abnormal movement at the fracture site in the left thigh. There was a limb length discrepancy of 6 cm, the left lower limb shorter than the right. No previous radiographs were available for review. Current radiographs were showing distal migration of the K-nail across the knee joint (Figure ).
A 5-cm long anterior midline incision was given over

[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 woman (gravida 2, para 1) was referred to our hospital due to placenta previa at gestational week 31. Her medical history was unremarkable, and her previous pregnancy was an uncomplicated, normal vaginal delivery at gestational week 38. Her current pregnancy was uncomplicated except for the placenta previa. She denied abnormal genital bleeding before the current pregnancy. Cervical cytology performed during early pregnancy was negative for intraepithelial lesions. Vaginal ultrasonography revealed total placenta previa and one lacuna (Fig. a). Magnetic resonance imaging (MRI) at gestational week 31 revealed total placenta previa and loss of the myometrium between the placenta and bladder wall (Fig. b). Other MRI findings of PAS such as uterine bulging, heterogenous placenta, and T2 dark band were not observed. Based on these findings, we suspected PAS, and an emergency cesarean delivery was performed owing to antepartum bleeding (approximately 100 mL) at gestational week 35. An abdominal midline incision was made, and a healthy male infant weighing 2274 g (− 0.42 SD) was delivered with Apgar scores of 8 and 9, at 1 and 5 min, respectively. The placenta was not delivered within 30 min after fetal delivery, thus requiring hysterectomy for PAS. Estimated blood loss was 1000 mL. The postoperative course was uneventful, and the patient and baby were discharged on the 8th postoperative day.
Part of the chorion and placenta were adhered to the uterus (Fig. a). The resected uterus was divided to 7 specimens in order to perform macroscopic and histopathological analyses. The surgical specimen showed a white polyp measuring 2 cm, which parted from the uterine fundus and the lower uterine segment (Fig. b). Histopathological examination of the tumor involving the lower uterine segment revealed endometrioid adenocarcinoma (Grade 1), with < 50% myometrial invasion and positive expression of estrogen and progesterone receptors, in addition to PAS (Fig. a and b). Notab

[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 5-month-old male child presented with recurrent pneumonia. The apex beat was in the right parasternal area, and there was no air entry on the right hemithorax. The skiagram showed an opaque right hemithorax. A contrast-enhanced computed tomography scan revealed a small collapsed right lung being supplied by the pulmonary artery and drained by the pulmonary vein []. The right-sided main bronchus was not identifiable.
A contrast esophagogram showed prompt delineation of the right bronchial subdivisions. A communication of the lung with esophagus was established at the junction of middle and lower one-third of the intrathoracic esophagus [].
The child underwent an exploratory thoracotomy. The preoperative findings were confirmed. The bilobed lung was nonaerated and had a liver-like consistency []. There was a direct communication between the esophagus and the lung across a short bronchial stump [].
The communication was taken down, and the defect in the esophagus was repaired with interrupted 5-0 Polyglactin sutures over a 10 Fr nasogastric tube. The child made an uneventful recovery. The histopathological examination demonstrated the presence of respiratory epithelium and confirmed the diagnosis of EL. The child is currently thriving well and is asymptomatic after 18 months of the operation.
Most of these patients have other associated congenital malformations, mainly esophageal atresia or cardiac anomalies.[] It closely mimics pulmonary sequestration (PS) radiologically; however in PS, blood supply is of systemic origin unlike the pulmonary artery in EL as in our case. Being a rare anomaly, a close index of suspicion is necessary for diagnosis. A history of recurrent pneumonia and relevant radiological studies should clinch the diagnosis in the majority of such cases. The clinical images provided are expected to help understand the abnormal anatomy and surgical repair in EL. Management is excision of the involved lobes along with the abnormally communicating bronch

[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 49-year-old male patient sought treatment due to “repeated cough and sputum for one year and aggravation with chest tightness for one week.” Chest computed tomography (CT) in a local hospital revealed encapsulated effusion in the right thoracic cavity. Chest-enhanced CT after admission revealed a space-occupying lesion in the right chest. The pathological diagnosis according to percutaneous lung biopsy was a solitary fibrous tumor. Preoperative three-dimensional reconstruction showed that the blood supply to the tumor originated from the arteries and veins of the right lower lobe (Fig. ). After complete preoperative preparation, the patient underwent resection of the tumor with single-operation-incision thoracoscopy. Incision selection is one cm for the endoscope port (at the midaxillary line of the seventh intercostal space) and two cm for the operation port (at the preaxillary line of the fifth intercostal space). Intraoperative exploration revealed that the tumor had two tumor pedicles (Fig. ), and both were located in the right lower lobe. The tumor pedicles were intraoperatively separated using a linear stapling device. Because the specimen was large and the surface was smooth, bagging the specimen by the traditional method was difficult; therefore, the specimen was bagged by adjusting the operating table. The detailed procedure was as follows: First, the operating table was arranged with the head at a lower position, and the specimen bag was inserted into the thoracic cavity. Then, the operating table was adjusted such that the head was at a higher position to enable loading of the specimen into the specimen bag by gravity. Due to the large size of the specimen, extracting the specimen by the traditional method was difficult. Therefore, a special method named “pulling carrot” was applied to remove the specimen (Fig. ). The specific procedure was as follows. (1) The operation port was extended to five cm. (2) Several drawstrings were intermittently sewn at 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 51-year-old man presented with recurrent cough following pyrethroids spraying in an enclosed area for eradication of flea. Twenty four hours after the beginning of symptoms he admitted in first medical center and partially treated for 2 days with impression of respiratory poisoning. He discharged seemingly healthy, so that he could walk and breathe normally at the time of discharge. The same night symptoms recurred and he referred to second medical center and admitted for one and a half day and underwent indeterminate treatment. Four days after beginning of symptoms the patient referred to our tertiary university hospital with complaints of ptosis and dyspnea. Within 5-6 days of admission limb weakness, dysphagia, dysarthria, blurred vision, diplopia, tremor and respiratory distress added to previous symptoms. The patient was admitted to the ICU, intubated and mechanical ventilated. There was no history of diarrhea or respiratory infection in preceding 4 weeks.
In first physical examination the Blood pressure was 110/80, Temperature = 37.4, Respiratory rate = 16, Pulse rate = 80. He was conscious aware, obey and oriented. The pupils were of normal size and reactive. There was no evidence of gaze preference and nistagmus. The ophthalmoscopic examination was normal. Cranial nerves were intact and no gaze palsy was detected. In sensory examination, there was no stocking and gloving sensory loss and no sensory level. The position and vibration sensation was intact. In motor exam, there was no hypotonia or spasticity and rigidity, without any evidences of abnormal movements.
Deep tendon reflexes were 2+/and symmetric in upper and lower limbs and a reduced manual muscle force of 4/5 on the Medical Research Council (MRC) grading was detected symmetrically in upper limbs.
Electrocardiogram, chest X-ray and brain MRI were normal. No botulinium neurotoxin was detected in serum or feces. Lumbar puncture revealed normal CSF analysis without cytoalbuminemic dissociation.
In fi

[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 presented with pain on the right side of the neck and odynophagia that occurred at trauma 7 days before presentation. At that time, the patient had experienced a stairway slip and fall, with his philtrum striking against the edge of the stairs and causing a 3.5 cm laceration of the labial mucosa of the upper lip, which was duly sutured. There was no loss of consciousness and no damage to the teeth.
Despite complete healing of the injury site, there was no improvement in cervical pain and odynophagia. When the patient's mouth was opened >3.1 cm, or when a straw was used for the intake of semifluidic formula, the patient experienced pain on the upper part of the hyoid bone and near the mastoid process; this was not accompanied by a cracking sound. The degree of pain was classified as 6 on the visual analog scale (VAS) of 0 to 10, where 0 equals no pain and 10 equals unbearable pain. There was no discomfort on the left side of the neck and no restriction of horizontal head movement.
During physical examination, firm calcified lesions were palpated in both tonsils, as well as between the hyoid bone and submandibular gland on both sides of the neck. Pain was elicited by pressing the lesions on the right side of the neck, but not by pressure stimulation of the lesions on both tonsils or on the left side of the neck.
The patient was diagnosed with diabetes and hypertension, chronic kidney disease, arrhythmia, heart failure, and gout; he was prescribed medications for each of these conditions. The patient had undergone percutaneous coronary intervention and coil embolization of a cerebral aneurysm 4 months and 6 months before presentation, respectively. There was no history of head and neck surgery.
Computed tomography (CT) revealed complete ossification of the bilateral SHC. A fracture line was observed in the ampullary area on the

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


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

[User]
RADIOLOGY NOTE:
An 82-year-old, white woman with a history of alcohol abuse, presented to the accident and emergency department with a 4-hour history of an acutely ischaemic right upper limb with motor and sensory deficit. A hard tender, pulsatile mass was palpable in the right subclavian area with significant bruising; there was a palpable right subclavian pulse with no pulses distal to this. X-ray revealed a fracture of the surgical neck of the right humerus with the humeral head abducted and externally rotated, while the humeral shaft was displaced medially (Fig. ).
Ten weeks previously, she had presented with a fracture of the surgical neck of the right humerus following a fall whilst under the influence of alcohol. On that occasion, sensory and motor function of the limb had been recorded to be fully intact by the medical staff in Accident and Emergency and there had been a full complement of pulses. Given she had no neuro-vascular deficit in the affected limb, the vascular surgeons were not involved initially. Under guidance of the orthopaedic surgeons, she had been treated conservatively with a collar and cuff due to her age and history of current alcohol abuse. She was to have been followed up fortnightly in the orthopaedic fracture clinic – but failed to attend after her second visit. She had no neuro-vascular deficit on follow-up. She denied any further falls or trauma to the right upper limb.
The acute nature of the current presentation together with neurological compromise prompted classification as category-II acute limb ischaemia (Society for Vascular Surgery/International Society for Cardiovascular Surgery classification) [] and urgent angiography was performed with a view to revascularisation. This revealed a pseudoaneurysm of the third part of the right axillary artery with complete occlusion of the right brachial artery distal to this (Fig. ).
Operative treatment was undertaken with initial exposure and control of the subclavian artery above the clavicle (Fig. ).

[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 62-year-old male with a past medical history of liver cirrhosis secondary to hepatitis C, tobacco use, and post-stent coronary artery disease, who initially came to the hospital for elective left and right heart catheterization as a pre-transplant evaluation. Physical examination showed abdominal distension and diffuse tenderness with the presence of prominent superficial abdominal veins. A computed tomography (CT) scan of the abdomen with contrast was obtained immediately. The CT showed an occlusive thrombus of the IVC extending from the renal veins to the level of the cavoatrial junction. Thrombus was also observed in the portal vein, and multiple subcutaneous varicosities were found. Initially, a plan was made to start the patient on anticoagulation, but because of the patient’s history of advanced cirrhosis, large esophageal varices on recent endoscopy, and thrombocytopenia, we concluded that the patient was not a candidate for anticoagulation. Given that the patient had significant abdominal distention with pain that did not improve even after therapeutic paracentesis; we inserted a stent in the IVC to relieve the patient’s pain as a palliative procedure to improve his quality of life.
Right internal jugular (IJ) and right femoral vein accesses were obtained for the procedure. A 6F pigtail diagnostic catheter was advanced from the right IJ to the right atrium, and contrast was injected into the right atrium that showed an occluded IVC at the junction of the right atrium. Another pigtail catheter was advanced through the right femoral vein and an inferior venogram was performed that showed the IVC was 100% occluded 2 cm above the renal veins (Figures , ).
A Glidewire advantage was advanced through the right femoral vein but was unable to cross the 100% occluded IVC. Then, a 7-French Swan-Ganz catheter was tried and was successfully advanced through the IVC all the way to the right atrium. A Swan wire was inserted through the Swan-Ganz catheter.

[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 farmer was referred to us 7 hours after he had met with a high-velocity road traffic accident. He was resuscitated as per the ATLS protocol at the hospital where he was initially treated and when he arrived at the casualty department of our hospital, he was conscious and all his vital parameters were within normal limits. He also gave the history that he was under treatment for segmental myoclonus which was characterised by semirhythmic involuntary muscle contractions.
His radiographs showed a left-sided posterior acetabular wall fracture (AO type 6 2 A1). He also had an ipsilateral femoral neck fracture with the femoral head displaced anteriorly (Figures and ) and also an associated middle-third fracture of the shaft of the femur (). He also had an extra-articular distal femur fracture on the opposite side (AO type 3 3 A1). On arrival, his serum lactate level was 1.9 mmol/l indicating that he had been adequately resuscitated.
He was taken for definitive surgery 9 hours after arrival. The patient was positioned in the lateral position and a posterolateral approach was planned to address the acetabular and femoral head fractures. Upon dissection, the femoral head () was found to have buttonholed and displaced anteriorly through the capsule which was found to be torn. The posterior wall of the acetabulum was addressed using two contoured reconstruction plates (). Using the trochanteric flip osteotomy, better access to the femoral neck was achieved and the femoral head was reduced anatomically and secured with K-wires. Then the femoral shaft fracture was reduced by opening the fracture site and held with a clamp. The femoral head fracture and the shaft fracture were fixed with an antegrade femoral nail with two screws securing the femoral head (Figures and ). The flip osteotomy was fixed using a tension band wire and the joint was reduced. The torn capsule was sutured. Closure was done in layers. The operating time was 4

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


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

[User]
RADIOLOGY NOTE:
We present the case of a 71-year-old woman referred to our outpatients department with an actively draining fistula on her right shoulder.
Her present history goes back to nearly 18 months prior to presentation when she underwent an arthroscopic rotator cuff repair with anchor suture of the supraspinatus muscle, at an outside center. In her immediate post-operative course, she explains a wound infection that necessitated an arthroscopic debridement and antibiotic therapy. Upon failure, she had an open articular lavage and debridement, with no avail. And finally, 9 months before her visit, she was submitted to another open revision and anchor suture removal. She failed to provide detailed reports and bacterial cultures for further studies. At the time of her first visit to our clinics, the patient was afebrile, with a preserved general state. Shoulder examination was difficult due to extreme pain, and anteriorly, along the surgical scar, we could observe a 1-cm sinus tract. Analytical workup showed no significant leukocytosis or inflammatory markers, except for an ESR of 53 mm/h. Shoulder X-ray revealed an irregular humeral head, with a bone defect on its greater tuberosity, which could correspond to the previous suture insertion (Fig. ). Also, the deltoid muscle shadow was effaced, in accordance with a generalized local muscular atrophy. A subsequent CT-scan confirmed a marked glenohumeral joint destruction, with a loss of the spherical humeral head morphology, a narrowed articular space, and a flattened articular surface. We could also detect irregular trabecular morphology of the humeral head and some marginal proliferative changes (Fig. ). Magnetic imagery demonstrated an important and generalized synovial inflammatory proliferation as well as contrast-enhancing joint effusion. There was an alteration of the bone signal of the scapula and most importantly, of the proximal humerus, suggestive of chronic and active osteomyelitis. The rotator cuff muscles showed mar

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


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

[User]
RADIOLOGY NOTE:
A 45 year-old woman of Caucasian origin presented to the surgeon with a 6-month history of light pain in the upper third of the abdominal wall. In her medical history, the patient had undergone surgery for tonsillectomy, appendectomy and carpal tunnel syndrome and was suffering from arterial hypertension and thyroid disease, treated with ACE inhibitor and levothyroxine sodium.
Ultrasonography (10 MHz probe), performed in May 2013, showed a 20 mm oval formation localized in the right rectus abdominis muscle with inhomogeneous echogenicity and internal vascular signals.
Computed Tomography (CT) scan with contrast, performed in August 2013, showed inhomogeneous solid nodule with maximum transverse diameter of about 16 mm and a longitudinal extension of 30 mm localized in the right rectus abdominis muscle and characterized by moderate contrast enhancement, without clear demarcation on the profile and light anterior extension in the intra-abdominal adipose tissue.
Contrast magnetic resonance imaging, performed in October 2013, displayed a 20 mm oval formation, localized in the right rectus abdominis muscle, hypointense in sequences T1-T2-weighted, homogeneously hyperdense in the late phase with subcutaneous outer profile and intra-abdominal inner profile, without signs of infiltration of the underlying peritoneum (Fig. ).
Physical examination revealed an oval shaped swelling, motionless on the surface and deep levels, with hard consistency and slightly irregular margins.
At superficial palpation there were no signs of pain; deep palpation evoked moderate soreness at the epigastrium.
In November 2013, the patient underwent to surgical removal of the lesion: surgical access through midline incision of epigastric region showed a not perfectly round hard mass, with adherence zone to the fibers of the right rectus muscle; en block excision was performed with the simultaneous removal of subcutaneous tissue, muscle fascia and parietal peritoneum. No early complication occurred.

[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 man with recently diagnosed diabetes was involved in a road traffic accident in March 2018. He was the driver of a mini-van which collided with a lorry. He sustained a right hip posterior dislocation and a right acetabular fracture for which he underwent fixation. He also sustained a right foot open lisfranc dislocation with fractures of all 3 cuneiforms and cuboid. He underwent external fixation for his right foot and subsequently midfoot arthrodesis (). Intraoperative cultures were negative and the open wound was eventually covered with an anterolateral thigh flap.
The patient subsequently had 3 readmissions for flap infection. The first admission occurred 4 months after injury. Initial wound swab grew methicillin-resistant Staphylococcus aureus (MRSA). During the wound debridement, there was a sinus over the flap with purulent discharge. The medial cuneiform screws were exposed and the medial cuneiform was unstable. The medial cuneiform was excised with removal of the exposed screws and a cement spacer was inserted. Intraoperative cultures were negative for bacterial growth. An infectious disease consult was made and the patient was started on intravenous vancomycin 1000 mg q12hrly for a total of 6 weeks duration.
The patient was readmitted for the second time 5 months after injury. Seropurulent discharge was noted during wound debridement and intraoperative cultures were again negative for bacterial growth. Decision was made to continue with intravenous vancomycin after consultation with infectious disease specialists.
The patient was readmitted 6 months after injury with new abscesses noted over his foot flap. He underwent debridement and seropurulent discharge was again noted in the wound. Intraoperative cultures grew Mycobacterium fortuitum (sensitivities as shown in ). His antibiotics was switched to IV cefoxitin 2g q6hrly, PO clarithromycin 500 mg OM and PO doxycycline 100 mg BD for 6 weeks.
The patient is still on follow-up at the time of wri

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

[User]
RADIOLOGY NOTE:
The patient was a woman in her 56 years old who had initially consulted our hospital in November 1996, at the onset of leukoplakia. The patient’s major complaint was the appearance of leukoplakic lesions corresponding to left side first and second molar equivalent to palate gingiva. The patient had been previously diagnosed with uterine polyps. Her family history was unremarkable. The patient was examined at our department in late November 1996, following a referral from her local dentist, who detected white lesions on the left palate during dental treatment in mid-November of the same year. The patient was diagnosed with leukoplakia, and the palatal leukoplakia was resected through an excisional biopsy in December of the same year. The patient was subsequently followed up on an outpatient basis. In May 2006, white lesions were observed on the left buccal mucosa and the patient was diagnosed with dysplasia. The condition was treated with another surgical resection, and the patient was followed up as an outpatient. In December 2008, a leukoplakic superficial tumor appeared at left side lower canine, the first premolar equivalency department buccal marginal gingiva.
The patient had moderate physique and was well-nourished, and no swelling of the cervical lymph nodes was observed. Leukoderma and erosion were observed at left side lower canine, the first premolar equivalency department buccal marginal gingiva. (Figure upper).
Panoramic radiography findings did not reveal any resorption of the lower jaw. Computed tomography (CT) findings did not indicate any clear destruction of the lower left jaw or lymph node enlargement, which could be suggestive of metastasis to the neck.
The clinical diagnosis for the patient was tumor of lower left gingiva. In January 2009, the patient underwent an excisional biopsy, with resection of the lower left gingiva tumor. Pathological analysis revealed well-differentiated SCC of more than 20 mm (pT2). No swelling of the cervical lymph node

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

[User]
RADIOLOGY NOTE:
An 88-year-old woman with a history of type II diabetes mellitus, chronic deep venous thrombosis (DVT) of right femoral vein, and atrial fibrillation on coumadin presented to her primary care physician (PCP) with right lower leg extremity swelling, erythema, and pain. A week prior to presentation, there was development of a sore on her right posterior ankle that began to crust over. The patient's leg became increasingly edematous, painful, warm, and erythematous throughout the week. Her primary care physician prescribed cephalexin for 10 days followed by doxycycline for four days. She continued to have progression of her symptoms while on these antibiotics (). She then developed intermittent purulent drainage from the sore behind the ankle concurrently with severe pain radiating down the leg (). She was then hospitalized and assessed for a deep soft tissue infection, abscess, and deep vein thrombosis. Cefazolin was given with subsequent improvement in the degree of erythema, though she continued to endorse significant pain. As the erythema receded to the mid-shin, the patient had persistent scattered papules and macules along the upper calf (). Blood cultures were negative and over the course of her illness, she remained afebrile without night sweats or chills. Laboratory workup revealed an elevated CRP (11.4 mg/L), which was felt to be secondary to an active infection. At presentation, a complete blood count with differential was within normal limits (white blood cell count 6.0 thousand cells/μL). On hospital day 3, she underwent a CT lower extremity with contrast due to continued pain, which was significant for diffuse heterogeneity in the calf muscle, notably a 1.8 × 1.3 × 3.8 cm lesion in the gastrocnemius without evidence of a drainable fluid collection or air within the soft tissue. The leading differential at this time was myositis with phlegmon leading to persistent pain and continued erythema and edema. She proceeded to have a skin biopsy for culture

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

[User]
RADIOLOGY NOTE:
An 18 year old male fell from roof of a moving truck. The truck was moving at low speed and he fell on muddy floor from a height of approximately 12 feet and sustained impact over abdomen. He was admitted in Nepalgunj medical college where contrast enhanced computed tomography of abdomen showed grade III liver injury. He was managed conservatively with bed rest, 12 units of blood transfusion then discharged. He presented 15 days later to Alka Hospital emergency department with complaints of pain abdomen, excessive tiredness and vomiting of blood. His vitals in the emergency were pulse 100/min, blood pressure 90/60 mmHg, respiratory rate 20/min and temperature 99 degree F. Contrast enhanced computed tomography of abdomen was done which showed pseudoaneurysm of right hepatic artery with ruptured hematoma in segments VI, VII and VIII of liver (Figs. and ). Clot was present in the pelvis and lesser sac. Haemoglobin was 8 g/dL.
Patient was immediately transferred to intensive care unit and started on intravenous fluid, antibiotics. Blood transfusion was started but the patient became hemodynamically unstable. Patient was transferred to operation theatre and exploratory laparotomy was done. Intraoperative finding was approximately three litres of clot and blood in lesser sac and pelvis with approximately 5 cm laceration in segments VII and VIII of liver. Bleeding from the liver surface was controlled with gel foam packing, surgicell application. Drains were kept in Morrison’s pouch and pelvis. Five units of packed cell and two units of fresh frozen plasma was transfused intraoperatively. The pseudoaneurysm couldn’t be clipped intraoperatively due to the difficult location and hemodynamic instability of the patient. Postoperatively patient was transferred to intensive care unit. Patient was transfused with two units of blood postoperatively. Patient was transferred to the general ward on third postoperative day. Patient was discharged on eighth postoperative day.
On the 15

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

[User]
RADIOLOGY NOTE:
A 44-year-old Japanese woman underwent a medical examination for health check reasons at her local hospital. An ultrasound scan revealed a uterine myoma-like lesion, 5.9 cm in diameter. The patient revisited the hospital 12-months later for a follow-up examination. In that time, the lesion had increased to approximately twice its size. The patient was referred to our clinic for a detailed examination. At the first internal examination, the body of the uterus was enlarged to the size of a newborn head; cervical and vaginal discharge was unremarkable. The adnexa were not palpable on both sides. The patient’s blood test results were normal. Transvaginal ultrasonography detected an isoechoic solid mass with an ill-defined boundary between the lesion and the uterus (Fig. ). A tumor, 110 × 90 × 80 mm in size, was revealed in the right pelvic cavity by magnetic resonance imaging. The tumor exhibited a slightly lobular pattern with smooth margins. The internal mass had a density similar to that of myometrium on abdominal, T1-weighted magnetic resonance imaging and a low density on T2-weighted magnetic resonance imaging in the horizontal plane (Fig. ). Several flow void regions (a bridging vascular sign) were detected between the lesion and the uterus. These findings suggested a subserous myoma. However, the continuity of the lesion and the uterus was unclear. Since we were unable to identify the right ovary, a fibroma/thecoma of the right ovary was considered as a differential diagnosis (Fig. ). The left ovary did not exhibit any abnormalities. At this point, a preliminary clinical diagnosis of subserous myoma was made and a laparoscopic myomectomy was planned. The laparoscopic findings demonstrated a 10-cm right ovarian mass without intra-abdominal adhesion or rupture of the tumor. The uterus and left appendages were normal in size (Fig. ). A laparoscopic right adnexectomy was subsequently performed. The ascitic fluid was serous, and the

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

[User]
RADIOLOGY NOTE:
A 13-year-old female of the Marshallese origin presented to the emergency department with complaints of nausea; nonbloody, nonbilious vomiting; and abdominal pain []. The patient denied any recent fevers, and no rash was reported. Review of systems was notable for the left ear drainage. Immunization status was unknown, and she was not reported to have been previously treated for any significant illness, though the history was limited by the patient's custodial circumstances. She lived in a small house in rural North Carolina with 21 other Marshallese immigrants and was cared for by relatives who had assumed care for her at the time of her immigration five years before.
Examination during the initial hospital visit revealed dehydration and acute otitis media with rupture of the tympanic membrane. Laboratory results revealed leukocytosis, prerenal azotemia, elevated liver enzymes, and mildly elevated lipase (). Computed tomography (CT) showed scattered focal pulmonary infiltrates, splenomegaly, and a markedly distended stomach without an obvious focus of mechanical obstruction (). Cytomegalovirus and Epstein–Barr virus serology were requested with results suggesting prior exposure. She was admitted with a presumptive diagnosis of gastroparesis secondary to a nonspecific viral infection and possible mild pancreatitis. An NG tube was placed resulting in high volume output. Her symptoms gradually improved over several days with IV fluid support and bowel rest; her NG was successfully removed, and she was discharged home tolerating a regular diet.
Two days after discharge, the patient returned with recurrence of her prior symptoms. The patient appeared acutely ill with dehydration. On lung exam, scattered crackles were noted. She was also noted to have diffuse small nodular lesions most apparent on her hands, feet, lower legs, and face (). An advocate placed with the family reported her concern for additional symptoms of chronic weight loss and productive cough with postt

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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 2 year old male child with a history of recurrent projectile non-bilious vomiting, since 4 weeks after birth, was referred for a barium meal study to rule out pyloric stenosis or gastro-oesophageal reflux disease. The patient experienced persistent hunger and was always underweight. The results of a full blood count test were within normal limits. A barium examination localised the stomach in the right upper quadrant of the abdomen, on the same side as the liver ().
Subsequent images revealed a distended stomach with indented gastric antrum, narrowed pylorus and delayed emptying suggestive of partial pyloric stenosis ().
Complementary ultrasound examination localised the spleen (which showed no abnormality) and two other structures with the same appearance as the spleen in the right upper quadrant adjacent to the right kidney (). The suspicion of other abnormalities and congenital transpositions of other organs lead to suggestions for other radiological procedures. Although MRI scan is the standard reference for definitive diagnosis of organ transposition, the procedure was, however, not performed owing to breakdown of the MRI equipment at that time. Hence a CT abdominal scan was undertaken with parental consent.
The CT scan confirmed the normal position of the internal viscera of the thorax and the abdomen, except the stomach and the spleen. The CT scan showed a dilated stomach on the right posterior to the liver and partial pyloric stenosis. The pyloric canal appeared elongated, and the whole pylorus was thickened. In addition, the spleen and the other structures with similar appearance as the spleen (suggesting multiple spleens) were found at the right side of the patient adjacent to the right kidney (). A surgical correction of the partial pyloric stenosis further confirmed the anomaly.
A post-operative MRI scan performed 5 months later confirmed the anomaly as described above (–). The procedure was a free-breathing MRI scan as parental consent was without sed

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

[User]
RADIOLOGY NOTE:
A 63-year-old female patient with diabetes mellitus presented to the emergency department with the complaints of a painful swelling over the right lower abdominal pain for 4 days. It was insidious in onset and was associated with fever, nausea and reduced appetite. She did not have jaundice and hematemesis. However, she gave history of intermittent constipation with occasional bleeding per rectum (PR), abdominal discomfort and sense of incomplete evacuation after defecation for past 6 months. She had undergone an open laparoscopic cholecystectomy 1 year ago for symptomatic gall stone disease and her postoperative period was uneventful. She also gave history of significant weight loss for past 4 months.
On her physical examination, she was pale and malnourished. She was afebrile, tachycardia and tachypnea were present, and she was in acute distress due to pain. On examination of the abdomen, there was a tender fluctuant area over the right lower abdomen, predominantly in the subcutaneous and muscular plane. It measured around 6 × 8 cm with the erythema of the skin and surrounding induration (). There was no sinus or discharge from the skin. The rest of the abdomen was soft and nontender. On rectal examination, there was normal tone and finger stained with stool with no palpable mass noted. Laboratory investigation revealed an elevated white blood cell count of 16.5 (normal range 4.0–10.8 × 103 per liter) with neutrophils, hemoglobin was below normal limit of 7 mg/dl (normal range 12–16 g/dl) and albumin 2.6 (normal range 3.4–4.8 g/dl). The level of carcinoembryonic antigen was highly elevated.
After resuscitation with intravenous fluids, administration of broad-spectrum intravenous antibiotics and intravenous analgesics, a contrast-enhanced computed tomography (CECT) scan was done to further characterize the lesion. CECT of abdomen showed large abscess extending from the subcutaneous and intermuscular planes over the right iliac fossa and breaching the peritoneum. It

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

[User]
RADIOLOGY NOTE:
A 47 year-old man was admitted to our emergency department after a motorcycle accident with his right hip in a fixed position of 90° flexion, 90° abduction and externally rotation. The patient had a history of hitting an electric pole with his right thigh with abduction force during collision. The patient complained of severe pain during movement of his right hip joint. His vital signs were stable. There were no neurovascular deficits in the injured limb. An anteroposterior radiograph revealed an inferior, obturator-type dislocation of the right hip joint (). Computed tomography (CT) scan was performed before any manipulation to evaluate any associated injury. There was no additional damage to the femoral head, acetabulum or trochanteric area (). After appropriate consultations, manipulation under anesthesia was taken.
General anesthesia was administered with patient in supine position. The dislocation was reduced as per the recommended techniques. We applied continuous traction in line with femur with gentle flexion and lateral push was given on the inner thigh with the pelvis stabilized by an assistant. However, this was unsuccessful. The hip was then internal rotated and adducted. Forceful resistance was abruptly reduced with audible "clunk" and we checked stability and range of motion of the hip. Reduction of the hip joint was confirmed under fluoroscopy and skin traction was applied for maintenance. Post-reduction CT was taken in order to confirm the congruent reduction. Although the post-reduction X-ray had shown minimal contour change of the greater trochanter (), post-reduction CT scan revealed the fracture of the greater trochanter (). The authors considered the possibility of further displacement of the greater trochanter, because the fracture gap was more than 2 mm on CT image. The fracture of the trochanter was then fixed through the incision under fluoroscopy control with cannulated screws and washers (). The patient was discharged with advice for stric

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

[User]
RADIOLOGY NOTE:
A 75-year-old man presented with progressive left eyelid swelling that started four weeks previously. His medical history included proximal gastrectomy because of a moderately differentiated gastric adenocarcinoma five years previously. The tumor cells expressed cytoplasmic cytokeratin- 7 (CK7) but not cytokeratin-20 (CK20). The eyelid swelling improved with prednisone administration. However, leg weakness and swelling developed one week prior, and the patient was consequently transferred to the oncology department of our hospital with a suspected spinal or vertebral metastasis. Orbital magnetic resonance imaging (MRI) revealed exophthalmos and a T2-weighted high-signal-intensity lesion accompanying fatty stranding on the preseptal and septal areas. The lesion was mostly enhanced and spread to the extraconal area; the inferior rectus muscle was also thickened without any definite mass. There was no specific finding showing an acute infarct on brain MRI. The overall imaging findings were suggestive of preseptal and septal cellulitis. Therefore, teicoplanin and ceftriaxone were administered because of concern about the potential for clinical complications of orbital cellulitis including visual disturbances and central nervous system manifestations.
Upon physical examination at our clinic, the patient presented with localized relatively ill-demarcated erythematous swelling and indurations at the left upper and lower eyelid (). Histopathological examination revealed diffuse infiltration with tumor cells that formed strands or clusters between the collagen bundles throughout the upper dermis (). The infiltrating tumor cells were round and polygonal and of variable size. Cytoplasm was eosinophilic, while the nuclei of the tumor cells were pleomorphic with conspicuous nucleoli with mitotic figures. Signet ring cells with intracytoplasmic mucinous vacuoles that exhibited nuclei laterally were also observed. Immunohistochemical staining showed the tumor cells expressed cytop

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

[User]
RADIOLOGY NOTE:
A 70-year-old woman with hypertension, dyslipidemia and morbid obesity (43 kg/m2) status-post gastric bypass surgery over ten years prior to presentation was admitted for evaluation of an upper gastrointestinal bleed. Postoperatively following gastric bypass surgery, the patient became hemodynamically unstable and developed acute kidney injury. Although her renal function improved, the underlying etiology of her postoperative complications remained unknown. An abnormal electrocardiogram noted several years later suggested a prior myocardial infarction, retrospectively hypothesized incurred perioperatively. The abnormal electrocardiogram prompted invasive coronary angiography which showed no evidence of obstructive coronary artery disease. During the current admission for upper gastrointestinal bleeding, an abdominal CT scan with intravenous contrast serendipitously revealed a filling defect in the left ventricular apex. Transthoracic echocardiography confirmed the presence of a large, heterogeneous apical mass and additionally showed midventricular hypertrophy measuring 20 mm in the interventricular septum, resulting in systolic apposition of the midventricular segments ().
Contrast-enhanced continuous wave Doppler revealed paradoxic diastolic flow from the apex toward the base as well as a systolic midcavity gradient of 41 mmHg (). Cardiovascular MRI (CMR) was recommended for further evaluation of left ventricular structure, function and tissue characterization.
CMR revealed a mildly dilated left ventricle (end diastolic volume index 99 mL/m2) with midcavity hypertrophy (maximal wall thickness 20 mm in the interventricular septum), a measured ejection fraction of 65% and an aneurysmal apex ().
Apposition of the midventricular segments in systole effectively resulted in separate apical and basal chambers (). The aneurysmal apical segments contained a large (24 × 20 mm) mass with peripheral enhancement and a hypointense core on late gadolinium enhancement imaging con

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


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

[User]
RADIOLOGY NOTE:
A 20-year-old Danish woman was referred with constant pain in the right proximal thigh that had progressed for 8 years. She had no other known medical conditions. Menarche was at age 13. There was no family history of sclerosing bone diseases. The limb pain was aggravated at night and was moderately relieved during physical activity and by cold baths. She was on daily analgesic medication with nonsteroidal anti-inflammatory drugs, paracetamol, and weak opioid agonists, and she was on sick leave from her university studies at the time of referral due to her symptoms. She was using shoe inserts because of leg length discrepancy.
At age 11 she had consulted a rheumatologist because of hip joint pain. Guided by ultrasound a hip joint puncture was performed due to fluid gathering; serology was negative. After the puncture, the joint pain ceased.
Six months prior to referral to our clinic, she was involved in a traffic accident and hit by a car from the right at knee level. She was discharged from an emergency room (ER) with no suspected fracture and a radiological examination was not performed. She reported that there was significant worsening of the femoral pain after the traffic accident.
A clinical examination revealed no skin lesions, café au lait spots, or redness; there was no increased temperature or swelling in her right thigh. Leg length was unequal but within normality.
She was instructed to fill out a diary with daily registration of pain on an analog scale from zero to 10, where increasing values were equivalent to more intensive pain. Orally administered analgesics were required when the pain exceeded a score of 6 or more, and the score 10 was reserved for symptoms that kept our patient from falling asleep and that did not respond adequately to orally administered analgesics.
Magnetic resonance (MR) and positron emission tomography-computed tomography (PET-CT) scans revealed significant increased cortical thickness in the right femoral diaphysis that partial

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


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

[User]
RADIOLOGY NOTE:
At the end of 2008, a 54-year-old Japanese man was referred to our hospital because a liver mass had been discovered by ultrasonographic examination. Enhanced computed tomography (CT) revealed a large liver tumor 15 cm in diameter extending from the left lobe to the anterior segment of the right lobe, which was enhanced in the arterial phase and washed out in the equilibrium phase, which is typical of HCC (Figure ). The left branch of the portal vein was not identified as being involved in the tumor. Extrahepatic metastasis was not observed. The patient was in good health, and his Eastern Cooperative Oncology Group performance status was 0. He had never smoked cigarettes, drunk alcohol, or been diagnosed as obese or diabetic. Laboratory data demonstrated normal liver function and he had no evidence of past or persistent hepatitis B virus or hepatitis C virus infection. Elevations of alpha-fetoprotein (AFP) and des-gamma-carboxy prothrombin (DCP) levels were observed: AFP level 119 ng/ml (normal range < 10); DCP level 158,000 mAU/ml (normal range < 40). His Child-Pugh score was A 5, and the tumor stage was Barcelona Clinic Liver Cancer stage C. According to the clinical practice guidelines for HCC [], surgical resection was considered because of normal underlying liver, although it was accompanied by vascular invasion. Subsequently, an extended left lobectomy was performed, and complete resection of the tumorous area was achieved. The pathological examination confirmed a moderate differentiated HCC with portal vein invasion of the left branch, and the underlying liver tissues were normal.
Eight months after the resection, recurrence of multiple lung metastases was detected on a follow-up periodical CT scan. Intrahepatic recurrence was not observed. The patient was initially treated with sorafenib at 800 mg per day. Two weeks later, a grade-2, hand-foot skin reaction occurred and a dose reduction of 400 mg per day was made. After two months, follow-up

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


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

[User]
RADIOLOGY NOTE:
A 68-year old lady was referred by her general practitioner to the orthopaedic clinic with complaints of right heel pain for one year. The presenting complaints started about a year back as insidious onset of heel pain which was constant aching in nature and aggravated by periods of prolonged walking and standing. There was no history of trauma. She was a known seropositive rheumatoid arthritis patient on Hydroxychloroquine, Sulphasalazine and Methotrexate for 20 years. She was under the care of a rheumatologist and had steroid injections in the right heel for plantar fasciitis in the past. On examination there was diffuse tenderness around the heel with full range of ankle movements but painful limitation of subtalar joint movements. There was no hind foot malalignment evident on weight-bearing radiographs of foot and ankle (). But that of the ankle revealed a sclerotic line with areas of osteolysis suspicious of a fracture of the calcaneus (). An MRI scan of the ankle with T2 weighted images showed linear high signal intensity in the body of the calcaneus suggestive of an insufficiency fracture of the calcaneus (). The patient was treated with moon walker boot and commenced on oral Alendronic acid 10mg on alternate days for eight weeks with Calcichew and Vitamin D tablets. The patient was advised to use the moon boot while weight bearing and remove at bed time. At the eight weeks follow-up she was completely pain free and able to fully weight bear. The radiographic examination showed the fracture had healed ().
The patient was referred back to our orthopaedic clinic after two years by her general practitioner with complaints of recurrence of right heel pain with no history of trauma. On clinical examination there was tenderness around the talus and painful restriction of ankle and subtalar movements. Radiographic examination revealed a fracture of the talus (). An MRI scan of the foot and ankle showed insufficiency fracture of the head of the talus (). She was tre

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

[User]
RADIOLOGY NOTE:
A 60-year-old male patient from an urban area of Kashmir (Asian) visited the Department of General Medicine of our institute with the chief complaints of severe lower-abdominal pain for the past eight months. The patient also complained of severe constipation, nausea, vomiting, anorexia, loss of appetite, abdominal cramps, incontinence of faeces and weight loss during the past four months. He experienced profuse bleeding from the rectum for the last month. Initial interviews with the patient revealed that the he was a heavy smoker and frequent user of noon-chai (Salt tea), meat and pickles. On examination the patient was found to be anemic. Digital rectal examination revealed an ulcero-infiltrative lesion with restricted mobility about 4 cm from the anal verge on the left lateral wall. A colonoscopy confirmed the rectal examination and biopsies taken at the time of the colonoscopy revealed squamous cell carcinoma (SCC) of basal cell type in the first histopathological examination. The report was re-confirmed by a second independent pathologist. A Contrast-Enhanced Computed Tomography (CECT) of the chest, abdomen and pelvis was also done but no lesions were found in any other site than the rectum. The lesion was without any fat stranding or lymphadenopathy. Furthermore, following the provisional diagnosis, the patient was referred to the Department of General Surgery for radical treatment, where he underwent LAR of the rectum using the standard technique of mesorectal excision (Figure ). The continuity of the gut was restored by a circular stapler for low colorectal anastomosis with formation of a colonic pouch. The colonic pouch takes over the function of rectal reservoir which is lost after excision of the middle and lower rectum. Microscopic examination of the resected lesion demonstrated a 2.5 cm × 3 cm SCC tumor of the rectum infiltrating the serosa. The margins of the excised tissue were found to be free of the tumor. However, four regional lymph nodes were als

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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:
Our case is a 6-year-old boy who sustained direct minor trauma to the left forehead. He was playing at home with his sister and swirling in a circular fashion when he slipped and hit his forehead against the ground. The following day, he reported blurring of vision in the left eye and his parents noticed a white left pupil. Twenty-four hours following the incident, examination of the right eye was normal and the left eye had hand motion vision. Intumescent cataract was evident by slit-lamp examination (). The cornea was clear, the anterior chamber was deep and quiet, the pupil was round and reactive, and the anterior lens capsule was intact. Intraocular pressure measured 14 mmHg in the right eye and 16 mmHg in the left eye. Gonioscopy revealed a normal angle without angle recession. The media opacity precluded exam of the posterior segment. B-scan revealed a flat retina, quiet vitreous, and a breached posterior capsule centrally (). Computerized tomography scan of brain was negative for skull fracture or intracranial bleed. Since the patient was in the amblyogenic age, cataract surgery was performed within hours of presentation.
Surgery was started with trypan blue staining of anterior capsule, anterior circular capsulorhexis, and avoiding hydrodissection to prevent expansion of PCR. Slow aspiration of lens matter with the phacoemulsification probe was performed under low settings of bottle height, irrigation, and aspiration. After aspiration of two-thirds of the lens content, a very large, oval-shaped central posterior capsular rent was exposed (). Anterior vitrectomy was performed, followed by cortex aspiration with the vitrector. Although one-piece foldable intraocular lens implantation in the capsular bag was initially thought feasible, the intraocular lens had a tendency to dislodge into the vitreous cavity, necessitating subsequent fixation in the sulcus without further optic capture (). Intracameral carbachol was applied at the end of the surgery. One week po

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

[User]
RADIOLOGY NOTE:
An 86-year-old white English man was referred to the surgical clinic in September 2007 for melaena and weight loss. He was anaemic on physical examination with no other clinical findings. He had a history of a left pneumonectomy in 1985 for a squamous cell carcinoma of the lung, Chronic Obstructive Airway Disease, Benign Prostatic Hypertrophy and diverticulosis. His Haemoglobin was 6.0 gm/L.
Abdominal CT () showed an apple-core stenosing tumour in the proximal transverse colon and a 2 cm intra-luminal lesion in the mid-ascending colon. He underwent a radical right hemicolectomy in November 2007. Macroscopic examination of the specimen revealed a 50 mm × 45 mm circumferential tumour in the large bowel, and invading the full thickness of the wall. The tumour was present at the serosal surface, and was situated 40 mm from the distal resection margin and 160 mm from the proximal resection margin. Other findings included full thickness (probably incisional) defect, 30 mm in maximum diameter that lied 80 mm proximal to the tumour and adjacent to a 24 mm sessile polyp (). The background mucosa showed six polyps in total, measuring between 4 mm and 25 mm, and the largest lied 60 mm from the proximal resection margin. The terminal ileum was sliced through the wall at approximately 40 mm from the proximal end and was attached to the rest of the ileum by a strand of ileal tissue only. Microscopy showed moderately differentiated adenocarcinoma (,). The tumour had an infiltrating growth pattern with minimal lymphocytic infiltration at the advancing edge. The tumour was present at the serosa (pT4). An area suspicious of extramural lymphovascular invasion was also seen. The largest polyp was a severely dysplastic tubulovillous adenoma. The rest of the polyps were moderately dysplastic tubulovillous and tubular adenomas. One other hyperplastic polyp was also identified. Thirteen lymph nodes were identified and none of them showed metastatic deposits. All those findings confirmed

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


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

[User]
RADIOLOGY NOTE:
The patient was a 2-year-old boy from Russian republic of Ingushetia. Both parents and younger sibling (female) were asymptomatic. Family history is not burdened. Parents may be related, as the mother of the child and the grandmother (father's line) are from neighboring villages of Malgobek region of Ingushetia.
The patient is the first child of healthy parents. Pregnancy proceeded against the background of gestosis in the first and second trimester, threats of interruption for a period of 12 weeks, anemia, and lack of hydration. The child was born as a result of fast unassisted childbirth. His birth weight was 3570 g and height was 55 cm. Apgar scores were 6/7. Early motor development slightly delays: He attained head holding at 3 months, sitting without support at 6 months, by the year the boy got up and walked with support. From the age of 8 months, the baby had a weight loss of 2 kg for 2 months with episodes of repeated vomiting. At the age of 1 year 2 months against a background of acute respiratory viral infection, there was a regress in development—the boy stopped walking. Subsequently, rachitic skeletal changes, an increase in the volume of the abdomen appeared, and a loss of motor skills progressed. Magnetic resonance imaging (MRI) of brain revealed a mildly expressed leukopathy in white matter of parietal lobes. Proteinuria and glucosuria appeared at the age of 1 year 8 months.
At the age of 2 years 2 months, he was admitted to Russian children's clinical hospital with psychomotor retardation and treatment resistance. On physical examination, he was observed to have a pronounced delay in psychomotor development (he did not get up, walk, crawl; he could only keep his head and turn over). Neurological examination revealed muscular hypotrophy, tendency to hypotension in axial musculature, and uniform decrease in tendon reflexes from hands and feet. MRI of brain revealed subat

[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 74-year-old Japanese woman noticed a tender lump in her right breast. She immediately went to a breast clinic to get a breast cancer screening. She had no family history of breast and ovarian cancer. After a month, she was referred to our institution with suspicion of metaplastic breast carcinoma with a core needle biopsy at the breast clinic. Physical examination revealed a hard, tender, and 25-mm mass in the upper outer quadrant of her right breast and a palpable lymph node in her right axilla. Mammography indicated an indistinct mass on the mediolateral oblique view and the craniocaudal view. Ultrasound (US) showed an 18 × 16-mm, irregular-shaped, and hypoechoic mass with a suspicion of a spread to the nipple inside the duct (Fig. a) and several swollen lymph nodes in levels I to II (Fig. b). Magnetic resonance imaging (MRI) detected enhancement of a 17 × 17-mm indistinct mass surrounded with a non-mass enhanced segmental lesion toward the nipple side spreading a maximum of 74-mm range, which had no interaction with the chest bone, muscles, and breast skin, in the right breast tissue (Fig. ). Invasive carcinoma with multiple axillary lymph node metastases was strongly suspected on clinical examination and imaging. Histological evaluation of the biopsy for the mass revealed a tumor with the growth of oval and spindle-shaped cells and multinucleated giant cells, the infiltrating lymphocyte into the breast tissue, and hyalinization in the stroma. The multinucleated giant cells stained positively for CD68. A part of the oval and spindle mononuclear cells stained weakly positive for CD68. These tumor cells stained negatively for estrogen receptor (ER), progesterone receptor (PgR), and human epidermal growth factor receptor 2 (HER2). There was a focal hemorrhage without necrosis. Few non-epithelial atypical cells were observed in the breast duct, but no atypical epithelial cells consistent with breast cancer were detected. GCT 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 healthy 11-year-old girl was presented to the National University of Malaysia (UKM) Paediatric Dental Clinic with a referral for further management of pulp necrosis of an immature lower right second premolar (tooth 45), secondary to the fractured tubercle of dens evaginatus. Two weeks earlier, she had treatment at a general dental clinic for pain related to tooth 45. Tooth 45 had spontaneous and lingering pain following cold and thermal stimuli. The tooth was diagnosed to have symptomatic irreversible pulpitis, and root canal therapy was initiated. The canal was accessed, and pulp extirpation performed before the placement of intracanal nonsetting calcium hydroxide by the general dental practitioner (GDP).
At the time of current assessment, her tooth-related symptoms had completely resolved. General oral examination showed the presence of generalised mild gingivitis with a basic periodontal examination (BPE) score of 1 in all sextants. The patient's oral hygiene was fair with a plaque score of 30%. The patient is still in her mixed dentition with the presence of the primary maxillary canines. Her upper dental arch was well aligned, and mild crowding of anterior teeth was noted in the lower arch. Tooth 45 has an occlusal glass ionomer dressing of the access cavity made for the pulp extirpation earlier by the GDP (). Cold and electric pulp sensibility testings showed positive responses to all fully erupted premolars indicative of tooth vitality expect for tooth 45. Tooth 45 also has slight tenderness to percussion. Periapical radiograph of tooth 45 showed an immature root with convergent open apex and small periapical radiolucency. The pulp space of tooth 45 is of an even width from the coronal to the apical portion (). Based on the assessments, tooth 45 was diagnosed with pulp necrosis secondary to fractured dens evaginatus and symptomatic apical periodontitis.
On the day of initial assessment, tooth 45 was isolated with rubber dam after infiltration of local anaes

[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 white female patient was admitted to the emergency department of our hospital with symptoms of acute intestinal obstruction, first noted 48 hours before (colicky abdominal pain, vomiting, and abdominal distention). The patient was tetraplegic due to Friedreich's disease diagnosed 25 years ago and was hospitalized permanently in a center for chronic disorders.
Upon physical examination, a prominent abdominal mass distorting her trunk shape was noted. In palpation, the abdomen had considerable distension with diffuse tenderness and moderate rebound tenderness. Despite the distension in the upper abdomen, a huge tumor could easily be palpated occupying mainly the lower abdomen.
The neurological examination revealed good responsiveness of the patient, quadriplegia, loss of tendon reflexes, and positive Babinski sign bilaterally. She was then referred for cardiac evaluation, where mitral insufficiency and left ventricular hypertrophy were found.
The white blood cell count was 18,100/μL with 79.1% neutrophils, which was further elevated the second day; urea was found 51 mg/dL and γGT 54 mU/mL. The rest of the blood tests were normal.
The most possible diagnosis was intestinal obstruction probably due to the tumor. An abdominal computed tomography was performed, which revealed a huge intra-abdominal mass originating most possibly from the right cornu of the uterus (Figures , , ).
An emergency exploratory laparotomy followed with a midline incision.
After the peritoneal cavity was opened an enormous circumscribed mass measuring 29.5 × 22 × 12 cm was revealed displacing the bowel to the abdominal periphery. The mass originated from the right cornu of the uterus. After lysis of the adhesions between the tumor and the greater omentum, the tumor was excised () and the right uterine cornu was ligated with a nonabsorbable suture. Inspection of the small intestine revealed a stenotic area in its central portion due to an adhesion with the omentum. The adhesion was ta

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


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

[User]
RADIOLOGY NOTE:
A 50-year-old man with no previous history of illness was diagnosed with stage I papillary thyroid cancer, tall-cell variant and underwent total thyroidectomy. Two years later, he developed lymph-node and multiple lung metastases and underwent additional neck dissection and radioactive iodine treatment, thyroid-stimulating hormone-suppressive therapy and sorafenib and lenvatinib therapies; unfortunately, he developed resistance to these therapies. Seven years later, the cervical tumour was observed during regular follow-up to have gradually increased in size and additional neck dissection was scheduled. However, the lesion was judged to be inoperable because of its rapid growth just before surgery and radiation therapy began 1 week later. At the first visit to our department, the patient’s left cervical lymph-node metastasis had markedly increased to 13 cm maximum diameter and the tumour had grown circumferentially around the common carotid artery (CA). The patient was referred to our department for palliative EBRT to reduce exudates and bleeding.
CT scan showed lymph-node metastases not only in the left neck but also in the axilla and mediastinum, which squeezed the superior vena cava (). Many small lung metastases were also observed. The patient had good performance status, had no dysphagia that could lead to aspiration pneumonia, had no complications that increased the risk of adverse event from high-dose irradiation and had no other life-threatening distant metastatic lesions; therefore, we presented high-dose IMRT as an alternative to standard palliative irradiation. Although this case presented with a huge cervical mass, fiber–optic investigation of the pharynx showed no airway narrowing and no symptoms of facial oedema, suggesting that emergency irradiation was not indicated. That is, 1 week of IMRT treatment was considered acceptable. The purpose of this treatment was to prevent fatal airway obstruction and to prolong patient survival by maintaining tumour s

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


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

[User]
RADIOLOGY NOTE:
A 26-year-old, a male who is an auto driver by profession presented with a relapse of alcohol dependence. The patient was treated for alcohol dependence in a private hospital, and he was abstinent for last 4 years till 2 months before. He also a complaint of hearing voices for the 4 months but it did not disturb him much. Patient complaint of excessive anxiety and restlessness 2 months ago following the demise of his relative. He started consuming alcohol and within 4 days he developed tremor, insomnia, craving for alcohol which qualified him for a relapsed episode. He was admitted to hospital and detoxified. During the stay, complaint of hearing of voices getting more prominent following deaddiction treatment. After the admission, he complaint of hearing multiple people talking among themselves about him. He used to talk back to them but could never control it. He also used to get irritated on silly matters and cry like a helpless boy with an expression of suicidal ideation to get relief from the agony of hearing derogatory voices. He continued to be abstinent from alcohol after 2 weeks of discharge, but the hearing of voices got worsened which was quite unexpected even in the presence of olanzapine 20 mg and quetiapine 25 mg. His cognition was well preserved with Mini-Mental State Examination score of 27. Due to the atypical course of illness, we sought a neurological consultation, who suggested for magnetic resonance imaging (MRI) brain and electroencephalogram (EEG). Out of our surprise, MRI report revealed the presence of an arachnoid cyst in right middle cranial fossa compressing temporal lobe. EEG did not reveal any paroxysmal discharge. Other investigations such as total and differential count, blood sugar, thyroid function, urine routine, liver and renal function tests were within normal range. Hence, neurosurgical consultation was asked for. They suggested mannitol to reduce intracranial pressure and phenytoin to prevent focal seizure. Surgical interventio

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


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

[User]
RADIOLOGY NOTE:
A 45-year-old gentleman, the clerk by occupation, presented to us in the OPD with pain in the lower half of posterolateral aspect of left thigh travelling down the lateral aspect of leg till ankle since 3 months. The pain was insidious in onset and gradually progressive, worse since a month. He had worsening of pain on taking a few steps and needed to sit after walking 50 m. He did not have any pain when sitting or lying down. He complained of mild paresthesias in left lateral aspect of leg on walking. He did not complain of numbness. There were no symptoms in the right lower limb. He did not have any back pain. There was no history of recent more than usual physical activity or trauma. For the last 1-month he was being treated by a local doctor as L5 radiculopathy. He was on oral non-steroidal anti-inflammatory drugs and pregabalin, with temporary and partial relief. Magnetic resonance imaging (MRI) (Figs. and ) ordered by the same local doctor, due to resistant symptoms, showed diffuse disc bulge at L4-5 and lateral recess stenosis. He was later given transforaminal nerve root block at his local center with no relief. He had taken a course of injectable vitamin D3 without prior estimation of its serum levels. He was finally referred to our center for surgical L4-5 root decompression. On clinical examination at our center, the patient had tenderness at the lateral aspect of proximal left leg. There was a pain on compression, bringing the fibula closer to tibia. The left knee had a varus deformity (). Knee joint examination revealed medial joint line tenderness and crepitus on a range of motion testing. There was no joint laxity and the knee range of motion was full. The patient had an antalgic gait. The spine and neurological examination was within normal limits. There was no thickening of the common peroneal nerve at the

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


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

[User]
RADIOLOGY NOTE:
We present the case of a three-year-old Caucasian girl with ASD, focusing on her PEH (Table ). She was born after 41-weeks gestation via caesarean section and had an Apgar score of 9/10. A birth weight of 3.85 kg, head circumference of 37 cm and length at birth of 50 cm were recorded. No dyschromias or malformations were found. Our patient's growth and karyotype were otherwise normal. She was breastfed until the age of nine weeks. By five months, she was able to hold her head steady and erect, and was able to walk on her own at 15 months of age. Our patient currently walks on her tiptoes and began this when she first started walking. On examination, our patient had normal growth and anthropometric data. Her muscle tone was moderately decreased, widespread and symmetric, with normal osteotendinous nerve reflexes. Acquisition and delayed maturation of language was observed. Sensory perception and attention were thought to be normal until 12 months of age. Subsequently, her parents noticed that our patient did not respond to their calls and seemed isolated with introverted behavior. Our patient was not communicative and was consistently unresponsive to the calling of her name. In addition, she did not interact with other children and presented with restricted interest and repetitive stereotypical behavior. Our patient did not show imitative or projective play. In terms of education, starting at two years of age she was schooled with additional support from an early learning program. Brain magnetic resonance imaging (MRI) scans appeared normal. Our patient was diagnosed with pervasive developmental disorder of the autistic spectrum and moderate mental retardation.
The 32-year-old mother and 36-year-old father lived on the second floor of a 14-year-old building in Puente Tocinos, Murcia. The mother had given birth to a healthy boy six years earlier. In the current case, the pregnancy was not planned. During the

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


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

[User]
RADIOLOGY NOTE:
A 67-year-old male chronic smoker with medical history significant for chronic obstructive pulmonary disease was admitted for imaging guided biopsy of a 1.2 cm left lower lobe lung nodule found recently on a computed tomography (CT) scan of the chest. The nodule was highly suspicious for primary lung malignancy. The patient was placed in a prone position and lung parenchyma in the posterior lateral left chest was visualized. Under CT guidance, a 19-gauge guide was advanced into the left lower lobe and two separate 20-gauge core biopsy specimens were obtained from the mass. There was no hemorrhage or immediate post procedure complication. However, towards the end of the procedure, the patient started complaining of sudden onset of chest pain and became unconscious. No palpable pulses were identified. A code blue was called and cardiopulmonary resuscitation was begun according to Advanced Cardiovascular Life Support guidelines. The patient subsequently demonstrated ventricular fibrillation which responded to defibrillation shock and epinephrine. The patient had three cycles of chest compressions, one dose of epinephrine, and a shock of 200 J. He was successfully resuscitated and intubated for mechanical ventilation. A CT scan of the chest was obtained immediately after the resuscitation and it demonstrated development of a small anechoic area in the left cardiac ventricle consistent with air embolus (Figure ).
The vital signs recorded at the time were as follows: blood pressure of 130/80 mmHg, pulse rate of 90 beats per minute, respiratory rate of 18 breaths per minute, and normal oxygen saturation of 92% on room air. The patient was admitted to the intensive care unit. Bedside transthoracic echocardiogram (TTE) did not reveal evidence of an air embolus. Additionally, no cardiac wall motion abnormalities were noted. The patient remained hemodynamically stable for 24 hours, and he was successfully weaned off from the mechanical ventilator next day and discharged home i

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