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

[User]
RADIOLOGY NOTE:
Here we present a 3-year-old girl, born from non-consanguineous parents after a normal pregnancy and cesarean delivery, hospitalized after 2 days of high fever, productive cough, clear nasal secretions and lack of appetite. One week before, she had suffered a non-febrile respiratory infection treated with azithromycin. She presented incomplete ocular albinism characterized by absence of pigmentation in the peripheral retina but had no history of serious recurrent infections or excessive bleeding. There was no family history of albinism or hypopigmentation, immunological or hematological alterations, or of deaths at an early age.
During her evaluation, pancytopenia and oculocutaneous albinism were identified whilst chest x-rays (CXR) did not show significant alterations. Infectious diseases were ruled out by serological screening and direct observation in blood smears. Analysis for respiratory viruses was positive for adenovirus and respiratory syncytial virus (RSV). She showed normal psychomotor development and her vaccination schedule was up to date. Morphological studies were performed both on peripheral blood (PB) and bone marrow (BM) samples. Results for PB cells were consistent with CHS alterations. Hypercellular BM with increased levels of the granulocytic series and lower erythroid and lymphocytes series was also observed. In PB as in BM, purple inclusions were detected in both lymphocytes and all stages of the granulocytic series. Intense vacuolization, sometimes with a purple inclusion, was also seen in all cell types (). BM’s flow cytometry showed a normal immunophenotype, with an increase of immature myeloid cells (). NK cells showed defective granule exocytosis with low expression of CD107a on stimulated NK cells () and a slightly reduced cytotoxic capacity () evaluated by degranulation assay.
Differential diagnosis by cytogenetic analysis, including conventional karyotype by C-banding and FISH revealed a normal female karyotype (46,XX). Due to the clini

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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 46-year-old lady complained of recurrent paroxysmal tachycardia during physical exercise.
The tachycardia could be seen on an event recorder (Figure ). It was a narrow QRS tachycardia reaching a rate of 194 bpm.
On the base of the tracing, a presumptive diagnosis of typical slow-fast atrioventricular nodal tachycardia was done.
Medical treatment consisted of sertraline and omeprazole.
An electrophysiological study was performed. Para-hissian ventricular pacing at baseline revealed absolutely no retrograde conduction (Figure ). Atrial pacing revealed an anterograde Wenckebach phenomenon at 700 ms atrial pacing cycle length and no anterograde nodal jump. After isoprenaline infusion (1 µg/min), retrograde dissociation persisted but at 2 µg/min one-to-one concentric retrograde conduction could be seen (Figure ). At 3 µg/min isoprenaline infusion, ventricular premature stimulation induced isolated narrow QRS ventricular echoes following progressive prolongation of the retrograde conduction by 65 ms with unchanged pattern of retrograde conduction. This suggested concealed retrograde block in the slow pathway with a slow-fast ventricular echo.
Atrial pacing induced a double ventricular response, one through the fast nodal anterograde pathway and one through the anterograde slow pathway followed by one retrograde fast pathway echo and a second ventricular echo with retrograde block in the fast pathway (Figure ). A typical episode of slow-fast atrioventricular nodal reentrant tachycardia at 152 bpm could then be induced via the double-response mechanism (Figure ).
The atrial activation during tachycardia was identical as the one during ventricular pacing when retrograde conduction was present, and it was not possible to advance the atrial electrogram when a ventricular pacing impulse was delivered during the refractory period of the His confirming the mechanism of the tachycardia. Five cryoablation lesions were delivered on the triangle of Koch on sites with an A/V ratio <

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


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

[User]
RADIOLOGY NOTE:
A 31-year-old man was injured by direct impact with a hockey puck over the left eye and underwent vitrectomy with combined phacofragmentation in our hospital. Two months after the surgery, his left eye exhibited retinal detachment in the form of rigid folds with a large number of proliferative membranes. The patient was young and could not maintain the prone position for long periods because of work obligations, so he refused treatments of SO tamponade and enucleation; he requested FCVB implantation. At that time, his BCVA results were light perception in the left eye and 10/10 in the right eye. His IOP results were 10 mmHg in the left eye and 16 mmHg in the right eye. Anterior segment examination showed large organic membranes on the iris, while the lens was entirely absent. Fundoscopy, fundus photography (), and B-scan ultrasound () examinations all showed extensive retinal detachment in the patient’s left eye. Therefore, the patient provided written informed consent to undergo SO-filled FCVB implantation in the left eye. The specific surgical treatment that the patient underwent is described in .
On the first day postoperatively, BCVA in the patient’s left eye remained light perception, while the IOP was 15 mmHg. Fundoscopy showed that the FCVB was appropriately positioned and the retina was attached. At 3 months postoperatively, the cornea was slightly opaque and exhibited keratic precipitates. The FCVB remained appropriately positioned with respect to the retina and showed a firm connection to the inner scleral wall; the IOP at the time was 10 mmHg. Topical corticosteroids were administered as anti-inflammatory therapy. At 9 months postoperatively, as shown in , persistent corneal opacity was evident with new-onset neovascularization and a thick anterior chamber exudative membrane; no other intraocular structures were visible. IOP in the patient’s left eye was 10 mmHg, while the BCVA remained light perception. B-scan ultrasound showed pseudo expansion of the ey

[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 30-year-old lady presented in the emergency room with swelling and pain of the right shoulder for the previous 4 days. She reported a minor trauma to her right shoulder a week previously, following which she developed swelling and pain, associated with high-grade fever. She was a known diabetic and had been receiving treatment with oral hypoglycaemic agents for the last 5 years.
On clinical examination, the patient was toxic, febrile, tachypnoeic and had tachycardia. On local examination there was a diffuse swelling involving the right shoulder, neck and anterior chest wall, and the overlying skin was inflamed. There was local rise in temperature with tenderness and marked induration. There was gross oedema involving the face and the patient had difficulty in breathing.
Contrast-enhanced computed tomography (CT) scan showed extensive cellulitis and thrombosis of the internal jugular vein and marked necrosis of the underlying muscles (Figs and ). The basic investigations revealed a haemoglobin level of 7.5 g/dl, a random plasma glucose level of 227 mg/dl and the fasting glucose level was 240 mg/dl.
The total count was elevated to 16 370 mm3 and arterial blood gas showed metabolic acidosis.
The patient was started on intravenous piperacillin tazobactam and was subsequently taken for emergency debridement of the wound on the right shoulder. During surgery, as the wound was being debrided, there was practically no bleeding (Fig. ). There was extensive necrosis involving the scapular, neck and facial muscles, although the subcutaneous tissue and the overlying skin looked apparently normal. The tissue was sent for histopathology and, to our surprise, it turned out to be positive for fungal elements. Examination showed acute on chronic inflammatory cell infiltrate, necrosis and splaying of muscle fibres. Many broad aseptate fungal elements morphologically resembling features of the zygomycetes group were seen (Fig. ). Special staining on periodic acid Schiff (PAS) stain

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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 caucasian, 69 y.o., nonsmoker and not consuming alcohol woman referred to our outpatient office seeking for an abdominal profile reshaping procedure. The patient suffered from hypertension and gastroesophageal reflux, both drug-treated. Her BMI was 25,6 and the anesthesiologist assigned her ASA II score.
The patient presented an 18-cm long linear scar on the left lateral side of her abdomen due to open kidney surgery performed 30 years before for renal stones removal and she did not complain any abdominal symptom at the time of the visit. Thus, trunk contour was characterized by both a bulge deformity of the left side and moderate subcutaneous adipose tissue excess with skin laxity of the inferior abdomen (, , ).
At the ultrasound investigation, the bulge revealed a portion of 0,7 cm of relaxed fascia underlying the existing scar with protrusion of fatty tissue through the gap, without any sign of intestinal loops involvement.
The patient was scheduled for flank bulge repair, liposuction and short scar abdominoplasty, which did not include umbilical transposition or recti abdominis muscles plication.
Surgery was performed by a senior consultant specialist of our clinic with the patient under general anesthesia and placed on her right lateral decubitus with a sandbag gel positioner under her right flank. Through a direct skin incision traced along the existing scar we exposed the left bulge: no true adipose tissue hernia was encountered, but only abdominal wall deformity with absence of proper muscle fascia.
A double plication of the left external oblique muscle was performed, after drug-induced muscle relaxation. Turned the patient in supine decubitus we focused on the lower abdomen performing two stab incisions medially to anterior superior iliac spines to infiltrate 800cc of tumescent solution []. Then liposuction was performed using a 4 mm blunt cannula and about 800cc of clear adipose tissue were removed without bleeding.
A short scar abdominoplasty completed

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


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

[User]
RADIOLOGY NOTE:
A 54-year-old man presented with 4-month history of otorrhea and a rapidly growing mass on the external auditory canal and postauricular area after open cavity mastoidectomy at other hospital 5 months ago. He was otherwise healthy, with no significant medical history. He had received no previous radiotherapy. Physical examination revealed polypoid mass totally packed in external auditory canal and exophytic mass about 5×4 cm in postauricular area ().
No cervical lymph nodes were palpitated. No facial paralysis was present. The scalp and the remainder of the findings on otolaryngologic examination were within normal limits. Audiometry demonstrated a mixed hearing loss of 50 dB of bone conduction and 90 dB of air conduction hearing. Routine clinical laboratory data and a chest radiograph were normal. Two biopsies were performed. Histologic evaluation identified the lesion as a leiomyosarcoma with extensive necrosis.
Computed tomography (CT) of the temporal bone demonstrated a mass in the middle ear cavity, with absence of almost the entire temporal bone due to previous operation and with destruction of a part of petrous bone. The inner ear structures were preserved ().
Magnetic resonance imaging (MRI) indicated a mass expending to pterygoid muscles, posterior margin of mandible and middle and posterior cranial fossa dura. The lesion obstructed the external auditory canal and could not be demarcated with granulation tissue ().
For the en bloc excision of the mass, the clear margin was 1.5 cm or more. The auricle was sacrificed for the design of surgical incision with the discolorated skin.
The excisions of the temporal bone was conducted including the external auditory canal, the middle ear, the vestibular organ, middle and posterior fossa dura, and the partial petrous bone. The cochlear, the lateral sinus, and the jugular bulb remain intact (). For the preservation of facial nerve function, the delicate epineural dissection of facial nerve was performed from tympanic

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


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

[User]
RADIOLOGY NOTE:
A 61-year-old male was admitted to our department complaining of pain and paresthesia in the left upper limb associated with massive swelling. He was a heavy smoker and had a past medical history remarkable for hypertension and bilateral polycystic kidney disease. The patient started hemodialysis in 2003 from a distal radiocephalic AVF on the left arm. After spontaneous fistula thrombosis 1 year later, a new radiocephalic AVF for hemodialysis was created on the right arm. In 2005, he received a successful cadaveric kidney transplant in the right iliac fossa and since then had been administered with immunosuppressive drugs (cyclosporine 20 mg and mycophenolate mofetil 2,000 mg daily) and corticosteroids (methylprednisolone 4 mg daily) to avoid renal rejection. The patient lamented a small swelling of the left arm persisting for 2 years, which in the last 4 months went through an important increase in size, associated with mild paresthetic symptoms.
The patient's past medical history was negative for injective drug abuse, upper-limb trauma, and brachial artery access for endovascular procedures.
On physical examination, he had a left arm circumference of 41 cm, compared to the contralateral arm of 26 cm, with a pulsing ovoid swelling on the medial aspect, 3 cm above the medial epicondyle at the level of the armpit (Fig ).
The mass resulted tight, pulsatile and incompressible, and painful on palpation along with mild distal edema. Bilaterally, the supraclavicular and axillary lymph nodes were not palpable. The right and left radial and ulnar pulses were both palpable. An ultrasound duplex scan of the left upper-limb arterial system revealed a giant true aneurysm of the brachial artery in presence of parietal thrombosis with turbulent flow seen along the vessel.
The patient underwent surgical treatment under general anesthesia. He was placed in the supine position with abducted left upper limb. An incision was made over the axilla, and the BAA was isolated with proximal

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


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

[User]
RADIOLOGY NOTE:
This is a case of a 25 years old Malay girl with learning disability and no significant past medical history, who started noticing a sacral mass since August 2015. The mass was painless and gradually increasing in size. The family members of this patient brought her to a traditional healer. They did not seek any medical treatment until late 2017. By this time, the mass over the sacrum was extremely large. Family members claimed the mass was preventing the patient from lying down flat supine. The patient was also unable to ambulate for the past 2 years. Hence, she was bedbound most of the time. It was difficult for her to sit on the wheelchair. She also felt tired to move because the mass was quite heavy. The family members claimed when the patient was lying down flat, she had to flex her hips and knees to achieve a more comfortable position. In addition, she often slept either in prone position or in supine with multiple pillows below her body. The mother also claimed over the last 2 months, the patient’s body had been getting thinner despite her physical weight was increasing due to the increase in size of the sacral mass. The patient had been passing stool and urine in pampers. There was no past medical history and no family history of cancer. Socially, the patient lived with her mother and siblings. The mother was the main care taker. Her father passed away 10 years ago because of heart attack. The patient previously attended a special needs school, but she stopped going to school since 2015 after developing the sacral mass.
This patient was managed in the Southern Region referral centre for Orthopaedic Oncology in Malaysia. On clinical examination in the Orthopaedic Oncology ward, the patient appeared cachexic, she had slightly pale conjunctiva, but she was not dysmorphic. Vital signs were Blood Pressure 142/90, Pulse Rate 98 beats per minute and Temperature 37 degrees Celsius. There was a large mass 40 cm × 30 cm

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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 46-year-old woman (gravida 2, para 2) was referred to our hospital complaining of a lower abdominal mass and pain. Her medical history was unremarkable. She was initially diagnosed with a uterine leiomyoma by transcervical needle biopsy. CT revealed a large heterogeneous tumor occupying the pelvic cavity and an intravascular tumor within the dilated left internal iliac and ovarian veins (Figures and ). Her preoperative cervical cytology results were negative for intraepithelial lesions and malignancy. The endometrial cytology and needle biopsy results were also negative. Thus, the preoperative diagnosis was IVL, with extension of the tumor into the left internal iliac and ovarian veins.
Intraoperatively, multiple myomas were found within the uterine corpus and cervix, and the tumor extended to the parametrium and paracolpium. Detachment of the tumor from the left ureter and vaginal wall was very difficult. Intravenous tumors in the left internal iliac and ovarian veins could be palpated. The left internal iliac vein forming the common iliac vein was transected at the bifurcation region. In addition, TAH and bilateral salpingo-oophorectomy (BSO) were performed, resulting in the complete surgical resection of the tumor (operative time, 11 hours; blood loss, 8462 g). The resected uterus and adnexa weighed 897 g (Figures and ). There was no residual tumor detected in the venous resection stump.
The nodule resected from the uterus and the internal iliac and ovarian veins consisted of a proliferation of spindle cells. There was no nuclear atypia and the mitotic index was low. In addition, vessel endothelium cells and a vascular smooth muscle layer covered the IVL (Figures and ). The tumor cells stained positive for Alcian blue (pH = 2.5) and the staining disappeared after hyaluronidase digestion. However, compared to that in Case 1, the intensity of the staining was weaker and less diffuse (Figures and ). Similar findings for hyaluronan expression were obtained using th

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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 73-year-old Japanese man on PD presented with progressive worsening of abdominal pain and cloudy peritoneal fluid. He had high blood pressure, and he started continuous ambulatory peritoneal dialysis (CAPD) because of hypertensive nephrosclerosis 8 years previously. A PD catheter was primarily inserted at the right abdomen, but it was removed and inserted at the left abdomen because of exit site and tunnel infection 5 years previously. He had no past medical history of diabetes mellitus and major abdominal surgery. In the peritoneal equilibration test, his result was high. Bloody ascites was not evident. One year previously, he had been hospitalized for PD-associated peritonitis caused by touch contamination that was treated with intraperitoneal cephazoline and cephtazidime. Bowel adhesion was not noted 5 years previously; however, local bowel adhesions and agglomeration of the intestine were detected by computed tomography (CT) after the identification of PD-associated peritonitis (Fig. , ). The major findings of EPS, such as peritoneal thickening and calcification, were not noted on CT.
On physical examination, his blood pressure was 134/74 mmHg, pulse rate was 76 beats/min, and temperature was 99.7 ° F. He complained of severe pain in the right upper quadrant of the abdomen, and this area was tender on palpation. The exit site was clear. Laboratory tests revealed mild inflammation, with a white blood cell count of 10,100 /μL and C-reactive protein level of 0.9 mg/dL. The peritoneal fluid cell count was increased at 980 /mL. Based on these findings, PD-associated peritonitis was diagnosed. CT showed localized dilation of the intestine, which suggested adhesive small bowel obstruction (Fig. ). As we suspected that the peritonitis might be associated with bacterial translocation from the dilated intestine, he was advised to stop eating and was switched from CAPD to hemodialysis. Additionally, he was treated with intravenous vancomycin and cephtazidime. The PD cath

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


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

[User]
RADIOLOGY NOTE:
A 40 year old lady with malignant metastatic paraganglioma was admitted electively to a medical ward for management of severe and incapacitating orthostatic hypotension.
She had been diagnosed at the age of 10 following unsuccessful treatment of suspected migraines. She had had symptoms of severe headaches and visual disturbances associated with sweating and vomiting, and had been treated with clonidine therapy. During a visit to her general practitioner, her blood pressure was noted to be unreadably high, and she was therefore immediately sent to hospital. In hospital, chest x-ray demonstrated a right-sided paravertebral opacity, and 24 hour urine collection revealed increased catecholamine levels. She underwent thoracotomy and tumour excision, and a diagnosis of extra-adrenal phaeochromocytoma was made. She was discharged from follow-up 3 years later.
At the age of 23, she became pregnant and had debilitating morning sickness and regular urinary tract infections. At 32 weeks' gestation, a 24 hour urine collection was performed and revealed increased catecholamines once again, at which point she was admitted to hospital. Investigations, including MIBG scanning, revealed recurrence of the paravertebral mass in her chest, and a deposit in the left scapula was also noted. She was started on oral labetalol at this point. She remained in hospital until the onset of labour at 38 weeks, at which point she underwent elective Caesarean section under general anaesthesia. 3 months post-partum, she commenced the first of five cycles of intravenous MIBG therapy, the duration of treatment lasting 2 ½ years in total.
Following this treatment she remained well for the next 8 years, during which time she underwent premature menopause at age 25. At age 29, with the assistance of in-vitro fertilization, she gave birth to twins, this pregnancy being eventful only by the need for Caesarean section due to breech position and hysterectomy being necessary intra-operatively due to intra-pa

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


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

[User]
RADIOLOGY NOTE:
The patient is a 67-year-old woman with relevant medical history of colon cancer treated with hemicolectomy, radiation, and chemotherapy 14 years ago without recurrence during the follow-up. The patient had several visits to the emergency room for immediate postprandial abdominal pain (especially epigastric and on upper quadrants) as well as nausea, vomiting, and significant weight loss during the last 18 months. Ultrasound demonstrated thrombosis of the inferior vena cava at epigastric level with an 80 × 30 mm thrombus. Computed tomography (CT scan) revealed a retroperitoneal heterogeneous soft tissue density mass that involved the infrarenal IVC without affecting the iliac veins of 8 × 4.6 cm in size and no evidence of metastatic disease (Figures and ). Celiac and mesenteric arteries were patent without stenosis. A biopsy of the tumor wall was conducted through a median laparotomy, because of technical difficulties by laparoscopic approach due to previous abdominal surgery and pericava localization of the tumor. As there was no definitive intraoperative diagnosis and the patient was not informed about the therapeutical procedure, tumor extirpation was postponed until pathology results were available and so the patient can be fully informed, as well. Pathologic study demonstrated a fusocellular stromal tumor, showing fascicles which intersect at 90°, histochemically and immunohistochemically concordant with IVC leiomyosarcoma (LMS).
Surgical approach by transverse abdominal incision is done, and the retroperitoneal mass arising from segment I IVC was exposed through a Kocher maneuver and right colon mobilization from the renal to the iliac veins. Inflammatory tissue and fibrosis were found and dissected carefully to preserve the surrounding structures, especially both ureters and renal veins. Tumorectomy, resection and ligation of the infrarenal IVC, was made leaving the iliac veins patent (Figure ).
The specimen was composed of nine pieces, the principal of 7.5 ×

[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 30-year-old male of asthenic build presented with the complaint that fecal matter was coming out through an opening in the right iliac fossa region of his abdomen for the past 6 months. Initially, he had developed a swelling in the skin of the right iliac fossa over the scar of an appendectomy done 14 years back. The swelling had ruptured after 7-8 days, to discharge fecal matter mixed with pus. Within a week, the opening healed, but the swelling reappeared 7-8 days later, only to rupture again after a few days. This cycle of swelling followed by rupture was associated with evening rise of temperature. The fever was of moderate degree and was associated with the swelling stage only. His appetite was adequate and he was passing stools and urine normally.
On examination, the patient was moderately nourished and there were no features of anemia, hypoproteinemia, dehydration, or electrolyte disturbances. A 0.5 cm × 0.5 cm fistulous opening with fecal soiling was seen over the scar of a previous surgery in the right iliac fossa []. No mass could be palpated in the abdomen. The patient had no history of any other surgery or hospitalization. There was no history suggestive of any chronic disease such as TB, diabetes mellitus, or ischemic heart disease. Biopsy of the inflamed appendix and of an enlarged lymph node, taken at the time of the surgery done 14 years back, had not shown caseating granuloma but only nonspecific inflammatory reaction.
We took X-rays of the chest and abdomen, both of which were normal. Abdominal sonography revealed bowel-wall thickening in the ileocecal region and enlarged mesenteric lymph nodes, as well as a fistulous tract between the terminal ileum and the skin. A percutaneous fistulogram was obtained, which revealed a narrowing involving the ileocaecal junction and the terminal ileum, and a fistulous tract connecting the terminal ileum to the opening in the skin in the right iliac fossa []. Colonoscopy was performed and

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


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

[User]
RADIOLOGY NOTE:
A 32-year-old G4P2212 mother was referred to our institution for a fetal echocardiogram after a routine ultrasound raised concern for multiple congenital anomalies, including cardiac defects. The fetal ultrasound demonstrated the presence of an abnormal nuchal cord, left renal agenesis, rocker bottom feet, and possible omphalocele. Fetal echocardiography demonstrated a large atrial communication with right to left shunting, dilated right atrium, tricuspid atresia with a hypoplastic right ventricle, and pulmonary atresia with a hypoplastic pulmonary trunk. Branch pulmonary arteries appeared confluent and there was a moderate sized patent ductus arteriosus with left to right flow and subsequent flow reversal in the ductus venosus. Free fetal deoxyribonucleic acid (DNA) for trisomy 13, 18, and 21 was negative and amniocentesis demonstrated a normal 46XY karyotype and normal microarray. Maternal history was unremarkable with all negative serologies during pregnancy. Family history was significant for a first cousin with tricuspid atresia who had undergone Fontan palliation.
The male infant was born at 36 6/7 weeks gestational age at another institution with a birth weight of 2,150 grams. Apgar scores were 7 and 8 at 1 and 5 minutes, respectively. Umbilical lines were placed and E type Prostaglandin was started before transport to our institution. The infant also required intubation due to respiratory distress before transport. Upon arrival to our institution, the infant underwent an echocardiogram, which demonstrated cardiac anatomy consistent with that noted on the fetal echocardiogram [Figures -]. Of note is the absence of the right atrioventricular connection, which is the essential feature of tricuspid atresia. The pulmonary trunk was thread-like, thus, leading to an effective absence of the ventriculo-arterial connection as well. Left ventricular function was normal and the coronary arteries had normal origin and distal course. Renal ultrasound demonstrated left re

[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 presented as a 53 years old white male with anemia and fatigue. Previous history included no medications, distal left lower extremity venous thrombophlebitis 2 months prior, status post laparoscopic gastric Roux-en-Y bypass (for obesity and diabetes mellitus which had been untreated and resolved postoperatively) three years prior to presentation and a left ulnar nerve decompression nine years prior. Physical examination revealed no palpable lymphadenopathy, a fullness in the left upper quadrant and fecal occult blood positive stool. Laboratory studies showed a serum hemoglobin of 6 mg/dl. Computed tomography (CT) scan of the abdomen showed a 24 cm left upper quadrant mass with multiple liver lesions, splenomegaly and a 1 cm mass in the spleen (Fig. ). A laparoscopic liver biopsy was performed and histopathology was initially reported as hepatocellular carcinoma versus hepatoid carcinoma. One month later, serum hemoglobin was 4.4 mg/dl and gross melena was seen. Blood transfusions did not resolve the anemia. Serum albumin was decreased to 1.7 g/dl.
The patient underwent gastrectomy, splenectomy, distal pancreatectomy and resection of small bowel and a portion of colon that were adherent to the tumor mass. At the end of surgery, there was no gross tumor remaining except for the previously identified liver metastases. Pathology showed a tumor that originated in the pancreas with direct extension to the small bowel, colon, and stomach. The resected specimen weighed 3500 g and the spleen measured 14x7x10cm (Fig. ). On cut section, the spleen contained a 1.0 cm lesion consistent with a metastasis, which was then confirmed to be a metastatic lesion on histopathologic evaluation (Fig. ).
The final pathology report showed a pNET, well differentiated, stage T4N0M1 with 0/13 lymph nodes containing tumor. The lesion in the spleen was located near the edge of the spleen, but there was no direct invasion by the tumor mass (Figs. and ) grossly or histologically. Examin

[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 first case involved a 60-year-old woman with intracranial hemorrhage, hospitalized in our hospital in a stable neurological state. She had a history of a total arthroplasty of her right ischium 25 days ago and mild thrombocytopenia after the administration of low molecular weight heparin, which had been replaced by aspirin. On day 5, she developed acute respiratory failure with clinical signs of right heart failure, due to massive pulmonary embolism and deep venous thrombosis at the level of right iliac, femoral and popliteal veins. At that time, the platelet count was determined at 50.000/μL, disseminated intravascular coagulation was not present and all routine laboratory tests were within normal limits.
In view of thrombocytopenia after the administration of low molecular weight heparin and the thromboembolic events, HIT was clinically suspected. The diagnosis was confirmed three days later, by the positive enzyme immunoassay for antibodies to heparin-platelet factor 4 (Asserachrom HPIA, Diagnostica Stago). Antibody titers were determined on citrated plasma and results were expressed as percent of the absorbance measured at 450 nm with a positive control (1.900 optical density units), representing the value 100%. Antibody titers were estimated to be 87% (cut off for positive value 23%).
Despite the increased risk of a recurrent intracranial hemorrhage, the presence of severe deep venous thrombosis on the ground of HIT immediated the administration of an alternative anticoagulant and fondaparinux sodium (Arixtra®, GlaxoSmithKline) was started subcutaneously in the dose of 7,5 mg daily. Given the severity of the patient's condition and her stabilized neurological status, we decided the administration of the highest recommended dose. Furthermore, the insertion of vena cava filter (Gunther, Tulip™, Cook USA) was decided for the prevention of new embolic events. The clinical status of the patients gradually improved and platelet count normalized 5 days after the 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.


[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 71-year-old Caucasian male patient sought medical care complaining of a 4-month history of exertion dyspnea and edema of the lower limbs. His past medical history included hypertension and congestive heart failure, and although he had been abstinent for 1 year, he had previously smoked 75 packs/year. On physical examination he was hypotensive and cyanotic; his pulse was arrhythmic; he had edema of the lower limbs; he had bulging jugular veins when in the supine position; there were rales in the lower two-thirds of both lungs; and tender hepatomegaly was present. The electrocardiogram showed atrial fibrillation, and the echodopplercardiogram estimated the left ventricle ejection fraction of 63% (Teicholz), eccentric left ventricular hypertrophy, marked mitral insufficiency, and a left atrium of 85 mm. Pulmonary systolic pressure was estimated at 62 mmHg with marked tricuspid valve insufficiency. There were no valvular morphological abnormalities. He was hospitalized with the diagnosis of hypertensive cardiomyopathy and cor pulmonale.
He also complained of vision loss for 2 months accompanied by protrusion of the right eye globe. The ophthalmologic examination in the right eye revealed marked corneal deepithelization and edema, ocular protrusion, the absence of photomotor and consensual reflexes, and low visual acuity. The left eye was normal. Brain computed tomography and cranial magnetic resonance imaging (MRI) confirmed the presence of a neoplastic lesion infiltrating the paranasal sinuses and the frontal encephalic lobe (). A tumoral biopsy was scheduled, but the patient died before the procedure could be done because of a refractory cardiogenic shock.
Autopsy findings included marked cardiomegaly with four-chamber dilation; the interventricular septum measured 18 mm, and the ventricular wall (posterior, anterior, and lateral) measured 15 mm. Radiological findings were confirmed at autopsy as a metastatic lesion most probably from an epithelial neoplasm of the e

[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 20-year-old male who presented at the medical service complaining of moderate to high intensity pain in the left flank. He described the pain as “stabbing” and stated that he had suffered from these pains since he was 6 years of age. They had initially been triggered by physical effort and had a frequency of one painful episode per week, but had become more recurrent, with sudden onset and without trigger factors (at rest) during the year preceding the consultation. He also reported an episode of macroscopic hematuria associated with pain one 1 week previously. He reported no other signs and no other complaints. He had no family history of nephropathy or hematuria. During physical examination he was lucid, well-oriented in space and time, with clear speech, good oxygenation, acyanotic, a heart rate of 84 bpm, blood pressure of 120 x 60 mmHg, and weight of 70 kg. Laboratory tests and initial clinical investigation were inconclusive. A computed tomography examination of the whole abdomen () revealed compression of the LRV between the aorta and spinal column and a dilated and tortuous LGV, with no pelvic varicose veins, confirming a diagnosis of posterior nutcracker syndrome. It was decided to manage the patient with clinical follow-up and he was medicated with diosmin-hesperidin and analgesics.
After a succession of return visits for further evaluations, the patient reported that the pain had not improved and there had been further episodes of macroscopic hematuria. Abdominal angiotomography () was ordered, to provide a better view of the compression and the decision was taken to conduct a surgical intervention for venous revascularization, without using a stent. The procedure chosen was transposition of the LGV, which was transected distally and reimplanted at the inferior vena cava (IVC), with a left paramedian incision and extraperitoneal access. The postoperative period was uneventful, the patient reported improvement of the painful complaints an

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


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

[User]
RADIOLOGY NOTE:
An 82-year-old male patient presented in the Oral and Maxillofacial Surgery Service of the Federal University of Rio Grande do Norte for evaluation of a swelling on the alveolar ridge of the anterior mandible, which had been previously identified in routine radiographic examination with prosthesis purposes. During anamnesis, the patient reported to be hypertensive and diabetic, as well as having chronic heart disease. At the clinical examination, no volume could be observed in the anterior region of the mandible, and the patient reported no painful symptomatology.
Radiographical examination revealed an unilocular and irregular radiolucent lesion, measuring approximately 3 cm in diameter (). Preoperative laboratory tests (hemogram, coagulogram, and blood glucose testing) were performed, as well as surgical risk and preanesthetic evaluation. Under the diagnostic hypothesis of residual cyst or another odontogenic lesion, the patient underwent surgery under general anesthesia in order to enucleate the lesion. In the transoperative period, in addition to surgical enucleation, a peripheral osteotomy and interposition of synthetic material for guided bone regeneration (Bio-OSS and Bio-Gide) were performed, considering the need for prosthetic rehabilitation of the patient. After the procedure, the specimen was sent to histopathological examination. Gross examination of the specimen revealed a firm and oval mass with cystic aspect, containing liquid in the interior (Figures and ). Microscopically, the hematoxylin and eosin (H and E) stained section showed a defined cystic lesion with a fibrous capsule and a lining of odontogenic epithelium (Figures –). The basal cells of the epithelial lining were mainly columnar and similar to ameloblasts and the overlying layers were loosely arranged, resembling the stellate reticulum of the enamel organ. Several amounts of ghost cells were found within the epithelial component and also in the capsule (). Extensive areas of eosinophilic ma

[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 83-year-old African American male patient presented with chronic cough for many years. He reported mild progressive dyspnea on exertion improving with rest. He denied hemoptysis or sputum production. He has been a resident of an assisted living facility for the past 17 years. He smoked 1/2 pack per day for 14 years and quit 40 years ago. He worked in the construction business, mainly demolishing buildings for more than 20 years, which led to significant exposure to construction dust and asbestos. He did not wear a mask as the use of protective gear was not mandatory at the time. The rest of the exposure history was negative for tuberculosis, pets, recent travel, or sick contacts. His past medical history was significant for right middle lobe and right lower lobe pneumonia 3 years ago successfully treated with antibiotics.
A chest X-ray showed bilateral calcified pleural plaques and the presence of right middle lobe band like atelectasis. This prompted further workup with computed tomography (CT) of the chest showing calcified aorta, coronaries, mediastinal lymph nodes, calcified right upper lobe nodule suggestive of old granulomatous disease, right middle lobe ovoid opacity 3 × 2 cm, right upper lobe anterior segment bronchocele and stricture, right lower lobe and left lower lobe mild fibrosis (Figures and ). The above changes were stable for 3 years except for the new right middle lobe opacity. A positron emission tomography (PET) scan failed to demonstrate metabolic activity within the lesion. Pulmonary function tests showed forced expiratory volume for 1 second to slow vital capacity (FEV1/SVC) ratio of 69 (normal range 63–84), normal FEV1 and forced vital capacity (FVC), normal lung volumes, and moderate reduction in diffusing capacity for carbon monoxide (DLCO). His echocardiography showed normal right ventricular size and function with no tricuspid valve regurgitation.
Bronchoscopy was performed to further assess the new right middle lobe opacity and showed

[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:
Emergency medical services (EMS) were called to the home of a four-year-old female with a history of intermittent asthma and recent outpatient diagnosis of pneumonia after found to be cyanotic, surrounded by emesis, and without apparent respirations. Cardiopulmonary resuscitation was initiated by EMS upon arrival for pulseless electrical activity, and after eight minutes the patient achieved return of spontaneous circulation. She was subsequently intubated without the need for induction medications and transported to the emergency department (ED). Upon arrival to the ED, an initial physical exam revealed an intubated, unresponsive child with markedly diminished lung sounds bilaterally without wheezing, and an oxygen saturation of 60% on 100% fraction of inspired oxygen (FiO2). Additionally, respiratory therapy reported extreme difficulty with ventilation. Initial bedside chest radiographs (CXR) () were obtained and showed evidence suggestive of bilateral pneumothoraces, which in conjunction with the patient’s clinical picture prompted bilateral chest tube placement. Both returned large volumes of serous fluid, although no blood or air.
Continuation of the primary survey revealed tachycardia at 132 beats per minute with strong and regular peripheral pulses in all extremities. There was no jugular venous distention. The abdomen was soft without masses. A limited neurologic exam revealed bilateral sluggish pupils, with the right pupil at 6 millimeters (mm) and the left pupil at 3 mm. There were no obvious signs of trauma, and no dermatologic findings.
After initial stabilization, collateral history was obtained from the mother who stated the patient had been feeling tired with intermittent fevers over the prior few days, which led to a diagnosis of mild viral pneumonia by her outpatient pediatrician. Per her electronic health record, this was based on the patient’s age, gradual onset of symptoms with non-toxic appearance, and non-focal pulmonary findings on auscultatio

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


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

[User]
RADIOLOGY NOTE:
A 42-year-old female patient was admitted because of a cystic mass on her left kidney. The cystic mass was incidentally identified during a routine health evaluation. There was no relevant past history. Results of the physical examination were unremarkable. Laboratory data, such as blood chemistry and urine analysis that included urine cytology, showed normal levels.
The computed tomography (CT) demonstrated a homogeneous cystic mass at the upper pole of the left kidney (). An irregularly shaped solid mass of 5 × 3cm was adjacent to the cystic mass on the renal hilar area. The solid mass showed irregular enhancement in the arterial phase (). To determine whether the solid mass was intrarenal or extrarenal, we used a retrograde pyelography that revealed a bifid left renal pelvis. We used radiological contrast media to visualize the pelvis and calices of the lower moiety. However, we did not visualize the upper moiety calyx (). Selective urine cytology of the upper moiety calyx was negative for malignancy. The patient underwent nephrectomy in order to remove the renal mass. A 5 × 3-cm protruding mass in the left renal hilum was found intraoperatively. En-bloc resection of the left kidney with the masses was performed.
According to the pathologic examination, the kidney was 15.0 × 8.7 × 6.0cm and weighed 174g. The cystic lesion at the upper pole of the left kidney was a simple cyst. The renal pelvis of the upper moiety was blind-ended and was filled with a gray-white solid mass. The mass was 5 × 3cm and well-marginated. Moreover, portions of the mass showed a grayish mucoid appearance emerging (). Tumor necrosis was not identified in the solid mass. In the low power microscopic field, the mass arose from the smooth muscle layer of the renal pelvis (). Furthermore, the mass showed a few atypias of the nucleus, a few mitotic figures, and positive staining for smooth muscle-specific actin and for desmin

[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 case was a 13-month-old baby with 9.7 kg, which was 3.5 kg at birth, and second male child of a family habitant in a village in Ardabil, Iran. He was referred to the hospital because of undescended testis (UDT) with a testis in the abdomen and one inguinal canal that was detected by ultrasound. Because the case was infant, the family history was asked to examine the problem in more detail. Accordingly, there was UDT history in the family, where the baby’s old brother also underwent orchiopexy surgery 4 years ago for UDT. During the pregnancy, the progesterone was injected to the mother for Hemorrhage every day for a week. The pregnancy was healthy and the baby is born by cesarean section.
Because of complete similar appearance to testis as the images show, we did not perform biopsy fearing of primary testicular delicate perfusion impairment. The baby referred to our centre because of bilateral UDT and nonpalpable testicle on the right side. However, sonography revealed both testicles in the proximal inguinal canal. The scrotum was not grown, HCG therapy had been started by pediatrician, and Other clinical signs were typical.
Surgical intervention was considered for the patient. Before surgery, four HCG 1200u injections were administered to the patient in four times at 1 month (one for per week) for testicular descent. However, the intervention did not completely resolve the problem, and there were no more diagnostic challenges. The patient underwent surgical procedure with general anaesthesia to diagnosis and as a final treatment stage. It was diagnosed that the testicles were on the left in the proximal inguinal canal and the sac hernia was ligated parallel to the inner ring. The left testis was a small component in the proximal without the epididymis. Two testes were closely connected in the lower part by a common epididymis, which all of them were situated in the left scrotum (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:
We report a case of a 33-year-old gravida 2 para 1 that was referred to our department after the first trimester ultrasound scan (performed in another institution) had revealed a huge ovarian mass. The patient was asymptomatic, denying weight loss and abdominal pain or distention. A more detailed medical record was obtained and there was a positive family history of borderline ovarian tumors (BOTs). The physical examination showed a palpable abdominal mass that reached the umbilicus. The ultrasound performed in our institution showed a 12-week singleton pregnancy and an adnexal mass, measuring approximately 17 × 11.5 cm, with a heterogeneous and highly vascular solid component, arising from the right ovary (). An abdominal magnetic resonance imaging (MRI) was performed afterwards revealing a pelvic mass, measuring 18 cm, arising from the right ovary, with a liquid component but with a major solid area (Figures and ). All laboratory data was within the normal range. CA 125 was 11.5 U/mL. Due to the high suspicion of malignancy, a laparotomy was carried out at 15 weeks of gestation (vertical midline incision). Intraoperative findings revealed a large cystic tumor of the right ovary with a solid component. Peritoneal washing was performed afterwards. The abdomen and the appendix were thoroughly examined and no signs of implants, adhesions, or metastasis were found. Right salpingo-oophorectomy was performed and the frozen section revealed a borderline mucinous ovarian tumor. Definite histology confirmed this diagnosis. The remaining pregnancy was uneventful and a cesarean section was performed at 39 weeks of gestation due to obstetrical reasons. Once again the abdomen and the appendix were systematically examined and no macroscopic changes were observed.
After discussion with the patient secondary staging surgery (peritoneal washing, total abdominal hysterectomy, unilateral salpingo-oophorectomy, omentectomy, appendectomy, and peritoneal biopsies) was performed and no e

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


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

[User]
RADIOLOGY NOTE:
A 65-year-old man was admitted to our hospital complaining of exertional dyspnea for 10 days. He had been medicated with oral antihypertensive drugs for 4 years. He discontinued his medications by himself due to the dropping of systolic blood pressure to 90 mm Hg 7 days ago. On the admission, his blood pressure was 130/90 mm Hg and his pulse was regular at 66 beats per minute. The transthoracic echocardiogram (TTE) showed a dilated right ventricle (RV) with marked RV systolic dysfunction (), D-shaped left ventricle (), and showed a large mass, about 50 × 30 mm sized, considered to be a thrombus between the right ventricular outflow tract (RVOT) and the main pulmonary artery (MPA) (). The systolic RV pressure measured by maximal tricuspid regurgitation velocity (TR Vmax of 5.2 m/sec) was about 110 mm Hg. TTE also revealed mass lesion mimicking thrombus in the MPA with severe stenotic component (measured maximal MPA velocity of 4.6 m/sec) (). Spiral computed tomography (CT) of the chest demonstrated an intraluminal filling defect, about 55 × 31 mm sized, occupying the lumen of the MPA () and multiple filling defects of the peripheral pulmonary arteries. Although the patient had normal blood pressure, he was initially treated with intravenous recombinant tissue plasminogen activator (rt-PA, 100 mg for 2 hours) to improve his severely decreased RV systolic function.
Despite receiving two days of treatment with thrombolytic and anticoagulation therapy, the patients showed little improvement. The follow-up TTE still demonstrated similar features of the previous echocardiographic examination. Dyspnea of the patient aggravated from New York Heart Association functional class II to III. After a thoughtful review of the follow-up TTE, we found several differences that differentiated from the usual echocardiograms of PTE. The mass filled the proximal portion of the MPA with involvement of the pulmonary valves. The mass was also attached to the anterior portion of the RV

[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 23 year old woman presented at our trauma resuscitation room after a fall from 8 meters. During physical examination (ATLS® protocol) there were no clinical signs of life-threatening injuries. Neurological examination did not reveal any abnormalities either. She did however have a large amount of subcutaneous emphysema of the chest and neck and complained of low back pain. Plain X-rays of the chest confirmed the subcutaneous emphysema of the chest and revealed a pneumomediastinum without signs of pneumothoraces (Figure ). Due to the massive amount of subcutaneous emphysema the normal X-rays were considered inevaluable and subsequent contrast enhanced Computed Tomography (CT) scanning of the neck and chest was performed. This showed an unstable fracture of the first lumbar vertebra, a fracture of the right inferior pubic ramus, a small right-sided pneumothorax and confirmed the pneumomediastinum. CT also raised suspicion of an esophageal injury, in the absence of large pulmonary or tracheal injuries. After administering oral contrast no contrast leakage could be detected on a second CT scan the same day. Bronchoscopy was also performed and showed no abnormalities. Intravenous antibiotics (Amoxicillin and Metronidazol) were administered for 4 days based on clinical and radiological suspicion of esophageal rupture.
An emergency operation was indicated for stabilization of the unstable lumbar vertebral fracture and the patient was observed postoperatively at the Intensive Care Unit (ICU). In this phase the Ear/Nose/Throat specialist (ENT) was consulted and during examination the patient only complained of dysphagia and painful coughing. Subsequently, a flexible laryngoscopy was performed which revealed a lesion in the upper esophagus just under the level of the upper esophageal sphincter. A contrast-swallow examination showed contained leaking of contrast from the posterior wall of the cervical esophagus into the retropharyngeal area next to the esophagus (Figure ).
B

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


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

[User]
RADIOLOGY NOTE:
A 17-year-old female was admitted to the hospital due to severe suicidality. At the time of admission she complained about an irritating feeling in her nose, which made her constantly grimace in the area around the nose. She was excessively worried about having a serious illness of her nose (secondary hypochondriacal delusions) and was suicidal as a consequence. Her belief persisted even after any underlying medical condition of the nose has been ruled out by extensive medical examinations. She also presented with disorganized behavior, stereotypical movements, emotional instability and lability, and a below average level of intelligence during hospitalization. On the PANSS, her symptoms scored 29/23/70 (for the Psychotic, Negative and General Psychopathology Scale, respectively). Brief neurological examination revealed no abnormal neurological signs. As ascertained by the history taken from the patient and her mother, she had a history of school phobia that began at the age of 12 years, emotional disorders, normal cognitive and physical development, and a three-year history of chronic headache. She managed to complete primary and secondary education with the help of school counseling services given to her on account of school phobia. She had not received any psychiatric care before the described admission. A diagnostic evaluation for chronic headache at the University Children’s Hospital was undertaken a year before admission.
Calcium, phosphate and parathyroid hormone blood levels were normal. Vitamin D levels were decreased with decreased calcium levels in the urine. No signs of calcium depositions in organs other than the described brain regions were determined by ultrasound. Ophthalmological, ear-nose-and-throat examination and electroencephalography were also normal.
Detailed neurological examination revealed dysfunction of pursuit eye movement, dystonic positioning of both arms when stretched ahead, discrete ataxia of the arms and legs, and a pathological ext

[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 woman with hepatitis C was being seen by the gastroenterology service to monitor a liver nodule. Abdominal ultrasonography identified a visceral artery aneurysm as an incidental finding. Angiotomography revealed that it was a saccular aneurysm of the pancreaticoduodenal artery, with a diameter of 40 mm, and showed subocclusive stenosis of the celiac trunk compatible with extrinsic compression ( ).
The patient underwent laparoscopic relief of celiac trunk compression ( ), thereby averting the possibility of mesenteric ischemia, as the pancreaticoduodenal artery is an important collateral route between the celiac trunk and the superior mesenteric artery and an undiscovered occlusion of this artery can cause visceral ischemia. The laparoscopic procedure was performed using a 10 mm trocar for the camera, in an umbilical position, and a further four trocars; in the right and left hypochondrium, the left flank, and a subxiphoid position. The gastrohepatic ligament, phrenoesophageal membrane, esophagus, and crura of the diaphragmatic were dissected, with inferior sectioning of the crura to enable the arcuate ligament to be viewed. Relief of celiac trunk compression was achieved by sectioning the arcuate ligament by electrocautery and the crura were drawn back together to prevent gastroesophageal reflux. Doppler ultrasonography conducted before hospital discharge showed that there was no longer compression of the celiac trunk and revealed some residual stenosis and post-stenotic dilation (the pre-stenotic celiac trunk diameter was 10 mm and at the stenosis it was 3.5 mm) ( ).
The patient returned 2 months later for pancreaticoduodenal artery aneurysm repair, which was performed under local anesthesia and sedation, via a left brachial access with selective catheterization of the superior mesenteric artery and selective embolization of the aneurysm sac with microcoils, with no intercurrent conditions ( ). Four 20 mm to 25 mm x 50 cm Axium 3D microcoils and two A

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


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

[User]
RADIOLOGY NOTE:
We are presenting a case of a 15-year-old male from a rural area living on a farm and raising livestock. He presented with six months history of easy fatigability, shortness of breath, and dull right upper abdominal pain. Physical examination revealed that the patient had tachycardia at rest and hepatomegaly and no other significant findings. Chest X-ray (CXR) showed clear lung fields and mildly enlarged heart. Ultrasound examination of the abdomen revealed few cysts in the liver without any associated lymphadenopathy in the coeliac group of lymph nodes. As part of the workup, the patient had a CT scan of the abdomen, chest, and brain. The CT showed one cyst in the heart, four cysts in the liver, but no cysts in the lungs or the brain (Figures -).
The cystic nature of the lesions and their locations in multiple organs made us think of the HC as the pathology. The serology test for HC using the ELISA test came positive, which helped to confirm the diagnosis. The patient was scheduled for urgent open-heart surgery, fearing the risk of potential rupture of the cyst and the grave consequences which come with that. The patient underwent conventional median sternotomy and aortocaval cannulation with aortic cross-clamp and cardioplegic heart arrest. CT images helped to locate the cardia cyst and its relation to the cardiac chambers. The location of the cyst was confirmed by direct examination of the heart when it was arrested. The cyst was totally located intramurally in the interventricular septum and expanding down mostly to the left side of the diaphragmatic surface of the heart and partly crossing intramurally to the diaphragmatic surface of the right ventricle making a visible and palpable soft cystic bulge. The myocardium overlying the cyst on the left side of the posterior descending coronary artery on the diaphragmatic surface of the heart was fibrosed, making part of the ectocyst wall. This was the most epicardially prominent part of the cyst and was chosen as 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 63-year old male presented with a history of lumbar laminectomy and fusion seven months prior to his initial presentation. He recalls that two days following his prone lumbar operation he began experiencing severe bilateral pain along the respective anterolateral thigh. Lumbar magnetic resonance imaging (MRI) ruled out spinal nerve root-related pathology as causative and a definitive diagnosis of bilateral MP, secondary to LFCN compression during the prone spinal surgery, was rendered. Conservative measures with oral analgesics were initially recommended given the typically self-limited course of this pathology. Despite an increasing regimen, including NSAIDs, narcotics, and anti-neuropathic pain medications, the pain persisted over the course of several months. Additionally, traditional anatomically-guided local anesthetic injections were attempted without improvement in his symptoms. Thus, the patient elected to proceed with operative decompression after eight months of failed conservative therapy and worsening quality of life.
The history of failed local anesthesia to even temporarily alleviate symptoms suggested a possible non-classic nerve location and prompted preoperative ultrasound to outline the superficial course of the LFCN. The ultrasound technique utilized has been previously described in the setting of percutaneous injection guidance (Figure ) [].
Skin markings in the inguinal region and upper thigh indicating the course of the LFCNs were made by the ultrasound technician prior to operative site preparation for surgery. Indeed, anatomically variant LFCNs were identified bilaterally on the preoperative ultrasound with neither nerve passing in a classic location medial to the anterior superior iliac spine (ASIS) (Figure ). On the right, the ultrasound identified the LFCN passing directly over the ASIS, while on the left, the nerve was localized lateral to the ASIS. Oblique incisions were made centered over the marked LFCN locations identified by ultras

[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 abnormal shadow with anterior mediastinal calcification and an elevated left hemidiaphragm was incidentally observed in a 57-year-old man who underwent chest radiography during a periodic health examination (Fig ). Chest computed tomography (CT) revealed an anterior mediastinal mass with multiple ring calcifications (Fig ). He denied a relevant medical history and symptoms such as muscle weakness or red blood cell hyperplasia. Physical examination revealed no abnormal findings and no lymphadenopathy. Routine laboratory parameters were within reference ranges. He reported no history of other operations.
Based on a high index of clinical suspicion for a non-invasive thymoma or teratoma, we decided to perform surgery for accurate diagnosis and treatment. After induction of general anesthesia, an extended total thymectomy and concomitant pericardial resection were performed via a median sternotomy. Using blunt and sharp dissection, the gland was freed from the pericardium and the adjacent mediastinal pleura. Although the tumor was observed to have invaded the pericardium and the left phrenic nerve, the extent of tumor invasion was unclear. A cardiovascular surgeon was consulted, and the invaded pericardium and the left phrenic nerve were carefully resected. The tumor had not invaded the heart, and the remaining thymic tissue was removed.
The resected tumor measured 8.0 × 7.0 × 3.0 cm in size (Fig a) and was observed to invade the pericardium directly. In gross sections, the tumor appeared to be a solid mass separated by multiple rings of calcification, and the surgical stage was identified as Masaoka–Koga stage III.
Histopathological examination revealed that the tumor was encapsulated by a calcified and ossified layer with invasion of the pericardium and pericardial fat tissue (Fig a,b). A high-power view showed epithelioid cells intermingled with lymphocytes and perivascular lymphocytic infiltration (Fig c,d). Based on World Health Organization histopathological cl

[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 30-year-old Middle Eastern male with a history of multiple surgical interventions in the gastro-intestinal tract following carcinoma was chosen to be the subject of this preliminary report. The patient initially underwent colonic transposition as a reconstruction followed by a delayed jejunal transposition due to the development of a 12 cm upper oesophageal corrosive stricture.
History and clinical examination revealed no history of further carcinoma; upper endoscopy and radiological examination revealed residual 8 cm upper oesophageal stricture and right recurrent laryngeal palsy.
The surgical access was through a previous pharyngectomy scar in the line of the right sternomastoid muscle with the raising of sub-platysmal flaps. Dissection continued to reveal the thyrocervical trunk and inferior thyroid artery with the excision of the previously fibrosed jejunal graft and the preparation of good vascular supply to the proximal jejunum. During which a generous cuff of muscosa was preserved with good exposure of the right piriform fossa and the remaining 8 cm gap from the pirifom fossa to the oesophagus.
An upper midline laparotomy was performed with local adhesionolysis. The second loop of the jejunum was identified and harvested on good arcade. The pedicle was ligated and remaining jejunal continiuity established and abdomen closed.
The free flap was transposed to the neck with posterior serosal layers to the proximal and distal ends in an iso-peristaltic fashion. A micro-vascular technique was used to create an end to end arterial anastomosis to the transverse cervical artery and an end to side venous anastomosis to the internal jugular vein.
Once good flow was confirmed (by microendoscopy) with satisfactory peristalsis and mucosal reaction the flap was further inset with proximal and distal fish mouthing techniques
An operating room Storz Hopkins II Forward oblique 30° microendoscope (4 mm diameter and 18 cm long) attached via a stroz fibre optic cable was connec

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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 40-year-old man with a swelling in the right palatal region was referred to the department of oral pathology for evaluation and diagnosis. The painless mass was noticed 4 months ago by the patient.
Intraoral examination exhibited a firm, exophytic, oval mass with an intact overlying mucosa in the region of the right hard palate measuring 3 × 4.5 cm in size []. There were no signs of ulceration, bleeding, discharge, or numbness in the area. The patient did not have the habit of chewing tobacco or betel nut. On general examination, he was found to be afebrile, with no palpable lymph nodes in the head and neck region. He did not mention any sudden weight loss in the recent past and the medical history was noncontributory.
CT scan revealed a mass on the right side of the hard palate, with no involvement of the maxillary sinus []. A provisional diagnosis of benign tumor of salivary glands was given.
An excisional biopsy [] was performed under local anesthesia. and a bony crater-like defect was seen on the palatal bone after soft tissue removal. Histopathological examination of sections of the resected specimen revealed an intact stratified squamous epithelium with underlying vaguely follicular and diffuse proliferation of lymphoid cells [Figure and ]. The follicle-like structures were composed of central large cells (giving a ‘washed-out’ appearance) surrounded by a thin rim of small, round lymphocytes. The central large cells had abundant pinkish cytoplasm and convoluted nuclei with inconspicuous nucleoli []. Epimyoepithelial islands were also observed. On microscopic examination of hematoxylin and eosin (H and E)–stained sections, there was a conflict of opinion over the distinction between benign (reactive) lymphoid hyperplasia (pseudolymphoma) and non-Hodgkin lymphoma. Immunohistochemical investigations were performed to resolve the issue. The large lymphoid cells showed immunoreactivity for CD20 and the rim of small lymphocytes were positive for CD5 [

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


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

[User]
RADIOLOGY NOTE:
An 80-year-old man presented with a 4-day history of swelling and pain behind the left knee with reduced mobility with very short distance intermittent claudication affecting the left calf and reduced range of knee movement. This patient in the preceding week was admitted under the care of medical specialty where a diagnosis of a spontaneous haematoma behind the thigh was made. Haematoma was thought to be a result of the patient being on oral anticoagulation (warfarin) for atrial fibrillation. The patient did not report history of trauma. He looked frail on the current admission on the vascular ward requiring support for some activities at home and had been on treatment for prostate cancer. He had previously also had coccygectomy for metastasis as well as a recent history of permanent pacemaker insertion for syncopal episodes and bradycardia. He also suffered from hypertension and was on a number of medications including warfarin. He was a lifelong nonsmoker and lived in a retirement home. There was no family history of aneurysms.
Examination revealed extensive bruising at the back of the left thigh and knee with palpable femoral and pedal pulses. The popliteal pulse was difficult to feel due to a large haematoma. The left foot was viable with fully intact sensory and motor function. There was no clinical evidence of calf compartment syndrome on the left leg. The right foot was warm with all palpable pulses in the leg.
An initial ultrasound scan revealed PAA with no evidence of popliteal or femoral vein DVT. A CT angiogram performed on the same day showed generalized arteriomegaly and the ruptured 9.4 cm PAA involving only the above-knee popliteal artery () and relatively disease-free 3-vessel runoff to the ankle and foot. Options to treat this patient were either a surgical exclusion bypass with evacuation of haematoma or an endovascular treatment. For a number of reasons including patient frailty, associated comorbidities, and potential feasibility of successfully

[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 69-year-old woman whose abnormality was initially identified by chest radiography at a local hospital in 2008. At that time, transthoracic echocardiography revealed a calcified and immobile mass on the posterior mitral valve leaflet. She was referred to our hospital for evaluation of the mass. Her past history was significant with pulmonary tuberculosis at the age of 6 years and systemic hypertension. However, there was no history of infectious endocarditis or chest trauma. Any thrombus formation due to a hypercoagulable state was not recognized. Differential diagnoses included calcified cardiac fibroelastoma and myxoma. We offered her a surgical treatment option because of the potential risk of a thromboembolic event. However, she refused the surgical intervention. She was managed on an outpatient basis and periodically underwent transthoracic echocardiographic evaluations every 6 months.
The patient claimed to have chest discomfort in March 2011 and was admitted to our hospital in October 2011. A transthoracic echocardiogram showed that the calcified mass measuring 19 × 8 mm was located between the P2 and P3 areas of the posterior mitral valve leaflet. There was no mitral regurgitation, and her ejection fraction was 67%. There were no findings suggestive of infectious endocarditis (Figure ). On cardiac catheterization, the coronary arteries were intact without an obvious thrombo-occlusive lesion. Computed tomograms (CT) confirmed the severe calcified mass on the posterior mitral valve leaflet (Figure ). Laboratory examinations were unremarkable.
Because there was potential risk of thromboembolism, surgical intervention was indicated for the calcified mass or tumor on the mitral valve. Definitive diagnosis was also expected after surgical excision of the mass.
The patient underwent surgical removal of the mass with the aid of cardiopulmonary bypass. The mitral valve was inspected through a right-sided left atrial incision. A round mass was origina

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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 20-year-old female patient reported with a chief complaint of pain and bleeding gums while brushing in left upper posterior region and for replacement of a poorly constructed bridge in the upper anterior region. She was unable to follow proper oral hygiene because of recurrent bleeding from the swelling in the left upper posterior region.
Patient's history revealed that the lesion started 3 years back and slowly attained the present stage. She was free of any epileptic symptoms and there was no sign of mental retardation. The patient was communicative but apprehensive. The family history revealed no relevant findings.
Extraoral examination revealed the presence of portwine stains on the left-hand side of the face, extending along the second division of the trigeminal nerve unilaterally []. Facial asymmetry and macrochelia was noted with enlargement on the left side.
Intraoral examination revealed prominent reddish purple gingival enlargement posteriorly on the left side [Figures and ]. Blanching on pressure was noted in the enlarged gingiva, suggesting angiomatous enlargement. Upper anterior teeth had a broken fixed partial denture. Teeth on the lower arch were malpositioned. Oral hygiene was poor with extensive amounts of plaque and calculus.
Chest X-ray and PA view of the skull showed no abnormality. Blood picture was normal. Ultrasound Doppler flowmetric study [Figures and ] was done to determine the blood flow in the growth. Treatment plan consisted of oral prophylaxis, surgical excision of the lesion under general anesthesia (GA), and replacement of the worn out bridge in the upper anterior region.
The scope of the treatment and the goals were explained and informed consent was obtained from the patient. A thorough plaque control regimen was started from day 1 to minimize the inflammatory component of the gingival enlargement. It included oral prophylaxis, use of chlorhexidine mouth rinse, oral hygiene instructions, and motivating the patient at each visit.
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.


[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:
On January 4th, 2018, a 57-year-old woman was hospitalized in the department of Psychiatry, Sir Run Run Shaw Hospital because of pain and acid bilge in multiple sites of her upper body for more than 1 year. Over a year ago, the patient started feeling pain and discomfort in the upper left abdomen, and the pain got worse when coughing but with no other discomfort. Two months later, the upper left abdomen pain and acid bilge extended to the front chest, back, abdomen, and upper limbs. The symptoms persisted for months, and aggravated when changing body posture. Test results including cervical MRI, chest CT, abdominal B ultrasound of upper abdomen in a local hospital showed no abnormalities. Treated with Chinese medicine for more than 3 months, there was no significant improvement. About 6 months ago, the patient came to our hospital, expressing the symptoms above and worries about them, with weight loss of about 1–1.5 kg, but denying continuous depression, anxiety, and other symptoms (the score of 24 items of Hamilton Rating Scale for Depression was 12, and Hamilton Anxiety Rating Scale score was 11), and was diagnosed as “somatic symptom disorder.” After 4 months of treatment with 60 mg of duloxetine enteric-coated capsules twice daily and hypnotic drugs, the symptoms were obviously alleviated but not completely relieved and there was a significant weight loss of about 5 kg. Therefore, medication was adjusted to escitalopram tablets 20 mg once daily. Two months later, the patient felt no further improvement.
With hypertension history of more than 10 years, the patient claimed that it's not necessary for her to take any antihypertensive drugs to control blood pressure in recent 1 year. She had bronchitis for 12 years but no medicine was needed. She denied any history of diabetes, heart disease and other diseases and claimed there was no history of surgery and trauma. Also, the patient denied long-term chemical substances, drug or poison

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


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

[User]
RADIOLOGY NOTE:
A 25-year-old male who is medically free presented to the ED after a motor vehicle collision (MVC) with a speed of 50 m/h, frontal impaction and there was no roll over, or ejection from the car with minimal epistaxis and a small superficial wound over the nose. A nasal X-ray was done to rule out facial bone fractures, which shows no abnormality. Analgesia was given and he was referred to the otolaryngology department for follow-up. However, at that time CT scan was not done. He presented three weeks later to the primary healthcare in which the first impression was migraine and was given analgesia. However, as the headache persisted, he went to the ED and he was given analgesia and discharged. The patient returned to the ED two days later, because the headache was not gone. He described it as a throbbing headache, on and off, which increased with laying down, stress, and at night and relieved by analgesia. He scored the pain severity as nine out of 10 and described it as a pain he cannot tolerate. There was no loss of consciousness, seizures, blurred or double vision, weight loss, fever, weakness, or any neurological deficits. He was vitally stable, and the Glasgow Coma Scale (GCS) score was 15, oriented to time, place and person, intact memory, pupils reactive to light equally, all limbs power were five out of five, no pronator drift, intact sensation, and normal gait. At this time, the CT scan was done and showed bilateral frontoparietal SASDH with midline shift with mass effect upon the adjacent brain parenchyma (Figure ). A cerebral angiogram with embolization was done for him. The patient improved after the intervention and was discharged. He followed up with neurosurgery and another CT which showed that the hematoma regressed in size. After this regression, conversion to chronic SDH was observed in CT (Figure ).

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


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

[User]
RADIOLOGY NOTE:
A 46-year-old male was referred for surgery from the peripheral center with diagnosis of spine tumor. The patient presented with complaint of sudden onset of asymmetrical weakness on both lower extremities over a period of 3 days. He has associated mild back pain around dorsolumbar region for more than 3 months duration. There was no history of trauma or any injury over the back. Treatment in the previous facility was mainly in the form of diagnostic in the form of MRI and symptomatic in the form of oral gabapentin and nonsteroidal anti-inflammatory medications. He had history of hypertension for 2 years and was on antihypertensive medications in the form of combination of losartan and hydrochlorothiazide. There was no family history with similar weakness. There was no significant history with similar illness. Physical examination revealed heart rate of 102 beats/min, blood pressure of 150/102 mmHg, oxygen saturation (SpO2) of 96%, temperature of 98 degree F, and respiratory rate of 26/min. There were no pallor, icterus, lymphadenopathy, cyanosis, clubbing, edema, and dehydration noted. No jugular venous distension or swelling around neck (goiter) was appreciated. Cardiac examination revealed regular rhythm with normal heart sounds. Respiratory examination revealed tachypnea with decreased breath sounds in bilateral basal areas. Abdominal examination was normal. On neurological examination, cranial nerve functions were grossly intact, however, power in all muscle groups in the right lower extremity was 2/5 and in left lower extremity was 3/5. The sensations of all four limbs were normal; however, the deep tendon reflexes were absent with bilateral flexor plantar response. There was no tenderness or swelling over back noticed. The patient did not have any problem with bowel and bladder movement.
MRI of dorsolumbar spine showed evidence of intradural extramedullary lesion at L1 level (right-sided prominent) measuring 9.9 × 9.4 × 11 mm in size (). MRI of brain with cer

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


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

[User]
RADIOLOGY NOTE:
A 21-year-old man presented to our institution with sudden onset pain in the left trapezius and shoulder.
At the time of symptom onset he was engaged at work driving heavy machinery, but denied any recent history of injury or trauma. He had not been recently unwell and denied any constitutional symptoms such as weight loss or fever. Over the following five hours his pain began to also affect his right shoulder and there was associated generalised abdominal pain of increasing severity, most marked in the left and right upper quadrants.
The patient had no significant past medical history, specifically never having had an episode of pancreatitis before. He was not taking any regular prescription medications but upon closer questioning admitted to occasional recreational cocaine use, the most recent ingestion of which was within 24 h of hospital admission.
The patient had no significant family history of medical illness.
Clinical examination revealed a well-looking man in no obvious distress. Although he was mildly tachypnoeic (20 breaths/min) his other vital signs were normal (heart rate 78 beats/min, blood pressure 129/84 mmHg, temperature 36.9 ºC and oxygen saturations 99% on room air). His abdomen was not distended but there was generalised percussion tenderness most profound in the left and right upper quadrants. Examination of his shoulders revealed no focal tenderness and full active and passive ranges of motion with preserved motor and sensory function.
Initial biochemical findings included a haemoglobin of 138 g/L, leucocyte count 4.74 × 109/L, platelets 197 × 109/L and international normalised ratio of 1.1. Plain chest X-ray was unremarkable. Repeat blood tests were performed after five hours due to the increasing severity of his symptoms which revealed a haemoglobin of 99 g/L, indicating a significant decrease from the initial value.
The combination of worsening abdominal pain and a falling haemoglobin prompted a computed tomography (CT) scan of

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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 54-year-old female patient with a past medical history significant for diabetes presented to the emergency department with worsening abdominal pain. The day before she underwent a diagnostic colonoscopy for complaints of chronic diarrhea (2 months) where a transverse colon adenomatous polyp was resected, and several mucosal biopsies were obtained.
The patient reported that the abdominal pain started suddenly about 4–5 h after the colonoscopy. She described the pain as being colicky and intermittent, occurring every hour, lasting for about 15 min, and then resolving on its own. She reported that overnight the pain worsened to the point that she sought medical care the next morning when we (the gastrointestinal team) were consulted by the emergency department. Additionally, she noticed that she had some red mucus in her stools on the morning of presentation.
Her vital signs in the emergency department were stable with a blood pressure of 128/72 mm Hg, a pulse of 83 bpm, and a respiratory rate of 16/min with normal oxygen saturation. Physical examination showed a nondistended abdomen, with mild tenderness over the right upper quadrant without any palpable masses. Her blood work was significant for a white cell count of 13, lactate of 1.2, and a normal metabolic profile.
In the emergency department, the patient had an abdominal X-ray, and a CT of the abdomen with intravenous contrast which showed a transverse colo-colonic intussusception (Fig. , , ) with partial obstruction.
The patient was seen by the surgical team who deemed her not to be obstructed and opted for conservative management with intravenous fluids and nil per os. On the following day, the patient reported that her symptoms had rapidly improved and subsequently had an abdominal X-ray that showed spontaneous resolution of her intussusception (Fig. ). She was started on a liquid diet which was advanced without any complications. She was discharged on the third day of stay after she had had a normal bowel m

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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 19-year-old male who had been in a motorcycle accident. The patient was admitted to our department as an open tibial plateau fracture 3 h post-injury. The emergency medical staff at the scene of the injury provided simple dressing and stabilization. The main complaint of the patient was pain and bleeding with limited movement of the knee.
On physical examination, after an advanced trauma life support protocol was performed in the emergency department, the patient’s blood pressure and pulse were within normal limits. There was a 5-cm-long wound without active bleeding on the anterior aspect of the knee joint (Fig. ). The femoral condyle was exposed, the suprapatellar pouch was empty, and the injury endpoint was visible at the quadriceps tendon. Internal and external stress tests of the knee joint were negative, and anterior/posterior drawer tests were not able to be performed, as the patient could not tolerate them. The patient had a normal dorsalis pedis pulse without neurovascular injuries or any other accompanying injuries. Plain radiographs showed complete intra-osseous dislocation that locked into a tibial plateau fracture. Computed tomography showed a partial avulsion fracture of the patella and intercondylar eminence (Fig. ).
The patient was taken to the operating room for emergency surgery. Intraoperatively, the patella was found to have rotated 360° and was completely locked into the tibial plateau fracture. The dislocated patella was found inside the tibia, approximately 10 cm below the tibia plateau. There were avulsion fractures of the anterior/posterior cruciate ligament insertions on the tibia and a partial patellar avulsion fracture with a “hat-off” type rupture of the quadriceps tendon at the attachment point on the patella; these operative findings confirmed our preoperative diagnosis. After thorough surgical debridement, the patella was pulled out. The tibial plateau fracture was restored and stabilized using an anatomical steel pl

[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.