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

[User]
RADIOLOGY NOTE:
A 64-year-old Caucasian male was attended at Clinicians Associates in Terrassa (Barcelona); the chief complaint was a fistula on buccal area of tooth 37. At that time the patient was diagnosed with multiple myeloma stage III asymptomatic and only 2 doses of zoledronic acid (4 mg), once per month, have been administrated via IV. After a thorough clinicoradiological examination, a chronic suppurated apical periodontitis of tooth 37 was confirmed (Figures and ). Considering that the analytical parameters were rather good and in order to avoid any active infectious lesion before proceeding to a bone marrow autotransplantation the extraction of this second molar was indicated. A couple of days before performing the conventional tooth extraction, antibiotic prophylaxis with Amoxicillin 500 mg/8 h and Metronidazole 500 mg/8 h was prescribed for 7 more days. The healing process had a complete satisfactory evolution and one week later sutures were removed. Two months later, bisphosphonate treatment was reintroduced with calcium supplementation and six months after the tooth extraction the clinicoradiological control of this localization was normal ().
One and a half year after that tooth extraction the patient came for a routine control visit and he complained of slight pain in the left posterior alveolar ridge, in the lingual area. The patient mentioned that the discomfort started after a traumatic injury during mastication. Although radiologically there was not any relevant findings, clinically only one incipient point of inflamed mucosa was observed, which seemed like a simple foreign body reaction. Chlorhexidine topical gel was indicated and this lesion was monitored every two or three weeks also by the oral and maxillofacial surgeon in the Mútua Terrassa Hospital. The lesion size increased and an osteonecrosis of the jaw was the presumptive diagnosis. According to the clinical features and the presence of a sinus tract (Figures –), antibiotic treatment was initiated, Am

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


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

[User]
RADIOLOGY NOTE:
A 24-year-old otherwise healthy male patient reported with the chief complaint of watery discharge from a swelling on the right side of the face for the past 1 month. Patient had a history of mandibular condylar fracture from a road traffic accident, for which he was treated elsewhere with direct open reduction and internal fixation of the condyle. The surgical scar was observed on the post-ramus swelling, and there was fistula in one end of the scar that was about 0.5 cm in diameter [Figures and ]. The wound was 2 cm deep and had a healthy granulating margin with no obvious clinical signs of infection, but the wound continued to have a drain of a copious amount of clear, watery, and odorless fluid.
On examination of parotid papillae, intraorally, active secretion was present on the left side, but not on the right side. Neurological examination revealed no motor loss due to severance of any branch of facial nerve in the affected side. Location of the fistula and nature of the discharge suggested a laceration of the right parotid gland substance resulting in a sialocele and a right parotid fistula formation. Siaologram confirmed the clinical suspicion [Figures –].
In the present case, trauma in the parotid glandular substance lead to formation of sialocele by accumulation of extravasated saliva into glandular parenchyma. It was decided to create a controlled internal fistula with drainage intraorally under local anesthesia. After standard preparation, intraorally, a 1-cm long incision was placed on external oblique ridge behind the third molar. A small artery forceps was forced through the superficial fascia of masseter reaching the sialocele. With the help of this forceps, approximately 5-cm long, slender, sterile, punched plastic tube of diameter 4 mm was positioned with one end in the glandular substance and the other end in the mouth, seated along the vestibule, ensuring complete convenience. The tube was secured by suturing it to the mucosal surface

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


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

[User]
RADIOLOGY NOTE:
A 24-year-old white man, a middle-distance runner (800 m) competing at national level (seasonal best/personal best of 1 minute 52 seconds), developed severe left heel pain in the pre-season in March 2013. His maximum perceived pain intensity was 10 cm on a visual analog scale (VAS) that ranged from 0 to 10 cm, with 10 cm expressing the worst perceivable pain; the athlete had to interrupt all running activity, and severe pain was perceived even when walking or standing. He continued training with aqua jogging and cycling. He got personalized hand-crafted orthopedic gel peads. Two months later he was attended by an orthopedic surgeon, who additionally prescribed oral intake of nonsteroidal anti-inflammatory drugs (NSAIDs) for 8 weeks. The athlete could continue his training but was not free from pain. When discontinuing medication in July 2013, pain returned immediately, and perceived pain intensity during walking was 10 cm on a VAS (range 0–10 cm). Eight sessions of ESWT were thus added to his treatment plan, and were conducted at a German Olympic center. He did not feel better after the treatment and reported a high level of frustration. An MRI was performed in January 2014 showing a calcaneal spur, signs of inflammation at the calcaneal tubercle, and structural changes of the plantar fascia, surrounded by a large edema (see Fig. ). In February 2014 he underwent an open plantar fasciotomy. Four weeks later he was allowed to perform the first units of regenerative running. Pain returned after approximately 1 week of training. An X-ray revealed no pathology and he was recommended to continue with soft training sessions. He received a peppering injection that reduced pain for 12 hours, and NSAIDs were re-prescribed. His running performance remained at a remarkably low level in comparison to his non-injured state, despite regular personalized training sessions. He presented himself at our out-patient clinic in July

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


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

[User]
RADIOLOGY NOTE:
Our patient was a 32-year-old previously healthy female at the 39th week of gestation who accessed the first aim department of a primary healthcare centre of a peripheral hospital for severe dyspnoea and chest pain. Her past medical history did not present other hospitalizations for the same symptoms. Due to the clinical manifestations, the patient was initially treated as a case of pulmonary embolic disease and subjected to a massive anticoagulant therapy. Considering the clinical diagnosis and the child to term, an emergent caesarean delivery was performed in order to avoid foetal complications. The caesarean section was successfully performed under general anaesthesia using Stark's method due to the urgency related to the patient's clinical condition of increasing dyspnoea. Moreover, although the pAVM was still unknown at time of the caesarean section, the execution of spinal anaesthesia seems to be not indicated because of the risk of pAVM association with other AVMs, such as those located in the spinal cord, especially in case of HHT.
The foetal outcome showed an Apgar index of 3, 6, and 9, respectively, at minutes 1, 3, and 5; these data are in line with the administration of general anaesthesia and the acute maternal condition of severe dyspnoea.
Taking into account the foetal weight at birth, it showed a restriction of the expected value. The child weight was in fact 2590 gr at 39 weeks of gestation. However, ultrasounds performed during the pregnancy reported a reduction of the potential foetal growth from the 33 weeks of gestation without any Doppler alteration. This phenomenon should be the result of the chronical adaptation of the pregnancy to the unknown pAVM.
As far as the macroscopic exam of the placenta is concerned, a percentage of cotyledons infarcts inferior than 10% was reported.
Considering the patient's postoperative course, it showed a subsequently worsening of the clinical conditions, resulting in an acute distress syndrome that required an 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:
An 81-year-old male presented for consideration of vertebral augmentation due to diagnosis of stage IV, metastatic prostate adenocarcinoma, and worsening back pain. Lupron therapy was initiated at diagnosis four months prior. Docetaxel treatment was planned for six cycles but was subsequently stopped after the first cycle secondary to side effects. No radiation therapy was previously given. PSA level was 120.73 at diagnosis and 0.6 before radiofrequency ablation.
At the first appointment, the patient reported mild back pain and required a walker but was able to ambulate without difficulty. He did have pain upon palpation of the thoracolumbar junctional level. He did not have any neurologic deficit at presentation. Computed tomography (CT) scans showed 40% compression deformity of T12. Magnetic resonance imaging (MRI) showed pathologic involvement of T12 and L1 and metastatic involvement of the epidural component, resulting in 40% spinal canal stenosis (Figure ). At this time, vertebral augmentation was recommended although it was believed the epidural component would not be addressed and Radiation Oncology would need to be consulted. In a short period of two months, the patient’s condition deteriorated where he was wheelchair bound due to severe pain, not controlled with NSAIDS or opioids. In addition, repeat studies showed further tumor infiltration involving T11, prompting augmentation of T11, in addition to T12 and L1.
The procedure was performed under monitored anesthesia care (MAC) and fluoroscopic guided imaging. Under this image guidance, 10-gauge introducer needles were advanced into the T11, T12, and L1 vertebral levels using a bilateral transpedicular approach (Figure ). A drill and osteotome were used to create cavities at the anterior aspect of the vertebral bodies. Bilateral 17-gauge bipolar radiofrequency probes were advanced into the vertebral cavities and simultaneous application of radiofrequency energy was performed as part of the protocol for volu

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


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

[User]
RADIOLOGY NOTE:
A 41-year-old man presented to our Neurology Department with pain at the level of the right shoulder and right interscapular–vertebral region, with onset for about 6 months. In the last 30 days, the pain exacerbated and radiated in the anteromedial part of the arm and clavicular area. The patient also reported pain in the joints of the distal part of upper and lower limbs, especially in the small joints, which afterward became swollen.
The patient presented with a medical history of arterial hypertension for the last 10 years, treated with beta-blockers and sartans, and he was a heavy smoker (in the last period he used only electronic cigarettes).
The neurologic examination was normal, except for slightly diminished deep tendon reflexes of the lower limbs. The patient reported pain that did not correspond to any radicular or nerve territory, which was exacerbated by pressure on the distal third of radius and ulna, but was not related to active or passive movements of the cervical spine. The general examination showed clubbing of the fingers and toes (not mentioned initially by the patient, but present for about 1 year) with an increase of the shoe size of more than 1.5 sizes, enlargement of the large joints, swollen extremities with a tubular appearance (Figs. and ), a right lateral cervical mobile, painless adenopathy of 1 cm diameter, and pachydermia with thickening of the skin of the scalp, forehead, and fingers, with cranial skin folds.
Cervical magnetic resonance imaging performed in another clinic before the admission to our department showed the presence of disc protrusions from C2 to C7, with concomitant C2, C4, and C5 root compressions. The electrophysiological study revealed an active denervation in the territory of the right C5, C6, and C7 roots.
The radiographic examinations of the upper and lower limbs depicted symmetric osseous abnormalities, typical for periostosis, and linear halving of the diaphysis

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


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

[User]
RADIOLOGY NOTE:
A 55-year-old female reported for replacement of missing teeth. On intraoral examination, there were only two natural teeth present in the oral cavity #13, 23 in the maxilla. Mandibular arch was completely edentulous []. Clinical and radiographic examination revealed that maxillary canines were periodontally sound with no mobility and periapical pathology. Various prosthetic treatment modalities were explained to the patient. The patient was not willing to extract #13 and #23, and due to severe gag reflex and presence of sufficient interarch space for the placement of metal bar, copings, denture base, and teeth arrangement, it was decided to fabricate maxillary palateless bar-supported overdenture. For mandible, treatment option decided was implant-fixed prosthesis as retention and stability are compromised in the mandible to greater extent than maxilla.
Proper case history was recorded for the patient including medical history which was noncontributory, with routine blood investigations and dental and oral examination. Diagnostic impressions and casts were prepared. DentaScan was carried out to evaluate the dimensions of available bone and appropriate-sized implants were selected []. Template in the form of conventional complete denture was prepared for mandible, and the positions of implants were decided before the surgery. Radiographic template was fabricated with the help of gutta-percha cylinders inserted in the expected location of implants and an orthopantomogram (OPG) 2D image was taken []. It helped in determining height of the available bone at the site of implant placement. At the time of surgery, radiographic template was converted to surgical template.
Flapless surgical protocol was planned as there was adequate amount of bone, 1 mm bone buccolingually, and sufficient attached mucosa was present at the surgical site such that at least 2 mm of attached gingiva would remain around the implant site. Preoperative antibiotics and analgesics were given to the

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


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

[User]
RADIOLOGY NOTE:
A 46-year-old female was referred from an outside hospital for squamous cell carcinoma of the right ala. The mass measured 2 × 1.5 cm and had an ulcerated portion from a previous punch biopsy site (). A single-stage operation was offered, to which the patient consented. The tumor was excised through all three layers with a 5 mm margin, and the resultant defect measured 2.5 × 2.0 cm. Intraoperative frozen biopsy report was consistent with squamous cell carcinoma. The lining mucosal defect measured 2.0 × 1.5 cm, and the graft for this inner layer was prepared using a septal mucosal hinge flap based on the septal branch of the superior labial artery. The typical incisional boundaries of a mucosal flap are located superiorly, about 1 cm from the nasal dorsum, inferiorly along the maxillary crest, and posteriorly as far as the extent of the defect. The mucosal flap was elevated from the septum in a posterior-to-anterior direction and turned laterally toward the defect, such that the mucoperichondrium was external and the mucosa faced internally () []. A right conchal cartilage graft was harvested, fashioned into a suitable shape, and placed over the mucosal hinge flap to provide structural support. The outermost surface was restored using a nasolabial island flap with a subcutaneous pedicle that was based on a perforator vessel from the angular artery. This flap was designed using a 3 × 2 cm mirror-image template from the contralateral ala, and was elevated in an inferior-to-superior direction. Once rotated over the septal mucosa-conchal graft construct, the flap was sutured into place (). The nasolabial fold was re-established with primary closure of the cheek skin, under which a capillary drain was left for three days and then removed.
The postoperative course was uneventful, without any vascular complications. By 6 months, however, scar contraction along the reconstructed rim had resulted in a

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


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

[User]
RADIOLOGY NOTE:
A 57-year-old man with known Marfan syndrome was admitted to the emergency department with sudden onset of right arm and leg weakness and slurred speech 50 min before presentation. His past medical history included a metallic aortic valve replacement 12 years ago, which was infected with MRSA and so this was replaced with tissue valve a month later. Other history included mild congestive heart failure (New York Heart Association class II) and a transient ischemic attack 2 years ago. Echocardiography (ECHO) 1 year prior to this admission had shown an ejection fraction of 41% but stable prosthetic valves. He was fit and independent in activities of daily living. His medications on admission were frusemide, bisoprolol, amlodipine, losartan, spironolactone, and fluoxetine. He was no longer taking aspirin and dipyridamole at the time of admission.
On examination, he had a partial left anterior circulation syndrome with right hemiparesis (Medical Research Council grade power of 3/5 in the arm and 4/5 in the leg), a right upper motor neuron facial palsy, expressive dysphasia, and right sided visual neglect. His National Institute of Health Stroke Scale (NIHSS) score was 12. His blood pressure was low at 100/80 mm Hg. Apart from the thoracotomy scar, and the tall features of Marfan syndrome his physical examination was normal. Routine blood tests, electrocardiogram and chest X-ray were normal. A computed tomogram (CT) of the head, performed 2 h after symptom onset, did not show evidence of infarction or haemorrhage (Figure ). Intravenous thrombolysis with alteplase at a dose of 0.9 mg/kg bodyweight was started 2 hours and 30 min after the onset of symptoms. There were no immediate complications, and he remained haemodynamically stable. Twenty hours later he became drowsy. His NIHSS score worsened to 18 with more pronounced right hemiparesis. A repeat CT head scan (Figure ) showed an established left middle cerebral artery territory infarct

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


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

[User]
RADIOLOGY NOTE:
A 37-year old homeless male, with a past medical history of peripheral vascular disease, type 1 diabetes mellitus, hypertension, and depression, presented to the emergency department with intermittent chest pain and progressive shortness of breath for a few weeks. The patient denied intravenous drug use, although admitted to the use of recreational marijuana. The patient’s vitals on admission were stable except for low saturation on a pulse oximetry of 86% on room air. On physical examination, the patient was tachypnic and had fine crackles in the bilateral lung fields on auscultation. Laboratory results on admission showed a normal complete blood count and basic metabolic panel, but a urine drug screen test was positive for opioids. Because of persistent hypoxia, a D-Dimer was checked and came back highly elevated. The patient underwent a computed tomography angiography (CTA) of the chest to rule out pulmonary embolism. The CTA was negative for pulmonary embolism, however, it displayed extensive miliary densities throughout the bilateral lung fields (). The patient was admitted to the floor with a differential diagnosis of military tuberculosis versus fungal infection. Human immunodeficiency virus (HIV), fungal, and Quantiferron testing were negative. The cardiac work up and autoimmune serology were also unremarkable. The patient was then started on intravenous steroids and inhaled albuterol, although no improvement was seen. The patient remained hypoxemic despite therapy, and, therefore, underwent a bronchoscopy with a lung biopsy to find out the etiology of the disease process. The lung biopsy showed alveolated lung tissue with a miliary pattern of perivascular foreign body histiocytes containing refractory material suggestive of microcrystalline cellulose material (). There was no evidence of malignancy and there were no fungal or acid fast bacilli organisms identified on special stains. The histological features suggested intravenous injection of foreign materi

[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 22-year-old woman presented with intense pain in the shoulders that began 2 weeks after injury during a CrossFit competition, especially on the right side, without edema or reduced range of motion. She started the CrossFit practice routine 2 months before the injury. The patient trained CrossFit three times a week without any other sport activity on the remaining week days. Olympic weightlifting (overhead movement) was described as the last activity before the acute pain started. The initial overhead load was 55 pounds and was part of a “novice” training routine with reported adequate technique. One week prior to the CrossFit competition the patient was oriented to increase the Olympic weightlifting load to 75 pounds as a requirement for competition. Repetitions were set to her own limitation. After the injury, she stopped her exercises and applied ice to the shoulders and upper arms. During the following days, she experienced continuous pain and sought medical attention. Physical examination did not show any reduction of passive and active arcs of movements. Also, Jobe and Bear Hug tests were negative. There was only a mild ligamentous laxity and 10 degrees of elbow hyperextension. Her medical history did not include medications, prior fractures, neoplastic disease or prior surgery on the upper extremities. Also, she did not have history of anabolic or glucocorticoid steroid use. The patient’s height was 1.53 m and weighted 54 Kg, with a BMI of 22.9 and was physically active for more than 3 years. She has never had CrossFit lessons or prior training. Before she started CrossFit practice, the patient used to swim three times a week in college, but did not participate in competitions. The patient had an episode of amenorrhea 3 years ago, considered to be due to weight loss, probably due to intense training and reduced caloric intake. Laboratory tests and densitometry were performed in the same period of the imaging

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


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

[User]
RADIOLOGY NOTE:
An 80 year old female came to the emergency department of our hospital complaining of abdominal pain of recent onset. She related a history of frequent episodes of non-bloody diarrhea of approximately one month's duration, unresponsive to loperamide. Her past medical history included surgical correction of rectal prolapse six months previously, implantation of a pacemaker, anticoagulation, osteoporosis, and hypothyroidism treated with levothyroxine.
Her temperature was normal. Physical examination revealed lower abdominal tenderness but was otherwise unremarkable. The white blood cell count was 8.1 ×109/L (normal: 4.5-10.8 ×109/L). The patient was admitted to hospital.
Due to chronic renal failure unenhanced abdominal CT scanning was performed (Fig. ). This showed a 15 cm length of colon at the splenic flexure with significant parietal thickening and fat stranding, as well as pneumatosis and free air in the surrounding mesocolon. Ischemic colitis was diagnosed based on location in a watershed area and signs of necrosis and perforation.
The following day the white blood cell count was 20.4 ×109/L. In light of this and the CT scan findings, an exploratory laparotomy was performed which revealed a small amount of ascites. A 16 cm segment of thickened bowel from the splenic flexure was resected.
The postoperative course was uneventful. The patient was discharged on the eighth post-operative day. However, the next day she was readmitted to hospital with abdominal pain accompanied by at least ten episodes of non-bloody diarrhea occurring that day. An abdominal CT scan with rectal contrast showed no evidence of anastomotic leak or other abnormality. Stool culture and testing for Clostridium difficile toxin were negative. The patient improved with conservative management. Given the diagnosis of collagenous colitis (see pathologic findings below), treatment with oral budesonide was started and she was discharged on the eleventh day of her hospital stay. One month later she r

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


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

[User]
RADIOLOGY NOTE:
A 29-year-old man presented with left renal colic as a complication of nephrolithiasis. The patient was brought in by an ambulance with complaints of acute left flank pain with radiation to the scrotum, nausea, and macroscopic hematuria. This was the first episode of renal colic in his life. At birth, he was diagnosed with a Klinefelter syndrome and was receiving testosterone substitution therapy for the five years before admission.
Habitus: The patient was tall, slim, narrow shouldered, broad hipped, and with dense and small testes. Slight rebound tenderness to the left lower quadrant suspicious for peritoneal irritation was disclosed on examination; body temperature was 38°C.
Laboratory investigation showed leukocytosis and pyuria. Admission ultrasound disclosed mild hydronephrosis on the left and raised a suspicion for fluid presence in the perirenal fat.
Almost immediately after admission, before the pain was controlled with intravenous analgesics, there was a spontaneous decrease in pain. Computed tomography (CT) with contrast enhancement was performed 2 hours later and showed distribution of the contrast around the left kidney ().
Also lower third ureter scanning was performed showing a 4-millimeter obstructive stone at the left ureterovesical junction ().
A double-J ureteric stent was placed immediately after tomography without technical problems. On the next day, the patient did not have any discomfort and was discharged from the hospital with the prescriptions for peroral tamsulosin and diclofenac.
Three weeks later, he had no complaints as well. Discharge of stone has not been observed during this period. The red blood cell count, serum creatinine, and urea were normal, and ultrasound of the upper urinary tract was unremarkable.
Control CT showed a partial distal migration of the ureteric stent (), which was removed with following CT urography showing no extravasation of the contrast out of the upper urinary tract (). On the CT images, there was no evidenc

[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 42-year-old female who presented with complaints of palpitations accompanied by nausea and vomiting four years back. Her past medical history revealed that she had high blood pressure since four years. At that time she was investigated with radiological studies, serum markers and eventually diagnosed as a case of TA in accordance with the 1990 American College of Rheumatology criteria for TA []. An ophthalmological examination was non-contributory. The cardiovascular assessment showed normal carotid upstrokes with bilateral carotid bruits and soft right and left subclavian bruits with weak peripheral pulses. A computed tomography (CT) aortogram of the chest showed severe stenosis of bilateral subclavian arteries and mild stenosis of the right and left common carotid arteries at the origin (Figure ).
A CT aortogram of the abdomen showed an occluded left renal artery, a very small left kidney, and mild narrowing of the abdominal aorta below the level of renal arteries (Figure ).
She was started on a combination regimen of glucocorticoids with azathioprine. Initially, her symptoms improved for six months, but later there was a clinical decline in her condition. She was switched to cyclophosphamide. During this period, her serum erythrocyte sedimentation rate (ESR) and C- reactive protein (CRP) were regularly followed, but as it can be seen in the graphical presentation, except the initial down bulging in 2012 on glucocorticoid and azathioprine regime, it didn’t show remissive response to any regime after 2012 (Figures -).
After six months of follow-up, she was put on etanercept (TNF inhibitor). During her follow-up, her routine radiological imaging and other workup for systemic review was done, but in spite of aggressive biologic therapy, she continued to have active disease. Later in her disease process, she was also put on tocilizumab (humanized monoclonal antibody against the interleukin-6 receptor) and rituximab (chimeric monoclonal antibody a

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


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

[User]
RADIOLOGY NOTE:
A 13 year old female patient is referred to an emergency service with a mostly bilateral retroocular headache after 2 years of evolution. the pain increased in frequency and intensity for two months which caused the patient to woke up in the mornings. Due to this, in the remission site, a cranial computed tomography (CT) scan was performed. It showed an infratentorial lesion, so the initial emergency service physician sends us the clinical record and the patient for integral management. When the patient came, a cranial nuclear magnetic resonance imaging (MRI) was performed [Figures –].
A large infratentorial mass with robust enhancement, heterogeneous dilation of the lateral ventricles, and other signs of hydrocephalus such as horizontalization of the temporal horns was found. Taking into account the patient's findings and symptoms, it was considered necessary to perform a tumor resection through occipital craniectomy. During the procedure, we did not have any complications []. Furthermore, considering the high risk of hydrocephalus, we performed a system of the fifth ventricle. The patient was sent to the pediatric intensive care unit.
The outcome of the 1st day became torpid, with a high rate of production of xanthochromic cerebrospinal fluid (CSF), for which it was considered necessary to perform a ventriculoperitoneal shunt.
After several days of satisfactory evolution, the patient became drowsy again, for that reason it was considered necessary to perform a new cranial CT scan [], in which significant ventricular dilatation was evidenced. With a diagnosis of hydrocephalus due to shunt failure, the patient was taken back to surgery.
In the surgery, it was found a high quantity of detritus in the porosities of the proximal catheter shunt, so a review of its functionality and a cleaning was performed. Two hours after the procedure, the patient was awake without neurological deficit. A control CT scan was performed on the 3rd day [].
Fifteen days postoperatively, t

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


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

[User]
RADIOLOGY NOTE:
We present a case of a 76-year-old man with severe symptomatic aortic valve stenosis requiring replacement of the valve. He had a preoperative examinations including trans-thoracic echocardiography (TTE), chest X-ray but not computed tomography (CT) of the thorax. His aortic valve area was 0.7 cm2 with mean and peak pressure gradient (PG) 95 and 47 mmHg, respectively. His EuroSCORE was 11; noncandidate for TAVI. After a full median sternotomy and the pericardial opening, we found an unexpected heavily calcified (porcelain) ascending aorta. We did not perform an epiaortic ultrasound to quantify the calcification and to discover an area less calcified for cannulation because we do not dispose. With the palpation, it has been found only a restricted safe area in proximity of the aortic arch. In this, we were able to cannulate the aorta and put a cross-clamp. We discussed the option of TAVI, but we had not a hybrid room for this procedure. The only solution was the surgical AVR. Then we had difficulties in aortic cross clamp; we used two clamps to occlude the aorta due to calcification with the risk of embolism. This was a really very risky action for cracking atherosclerotic plaques and induces a multifocal and severe stroke. We perform the aortotomy very high to avoid the ascending aorta. The aortic annulus was extremely calcified and small (21 mm) with an aneurysmatic dilatation of the ascending aorta (40 mm) extremely calcified. This dilatation was known from the preoperative TTE examination. In the preoperative chest X-ray, we could see also this dilatation, but all these indications of aortic dilatation and the suspicions of porcelain aorta where underestimated. The valve of choice was a sutureless Perceval S valve to manipulate as less as possible the aorta and perform a “rapid” intervention. We were able to implant this valve of the size: Medium. Closure of the aortotomy with the use of

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


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

[User]
RADIOLOGY NOTE:
A 42-year-old male presented to our outpatient department with an incidentally detected renal mass on ultrasonography of the abdomen done for a routine health check-up. The patient had no history of loin pain or hematuria. He never had any complaint of bone pain, loss of weight, or hemoptysis. There was no family history of malignancies. He was neither a smoker nor an alcoholic. There was no history of exposure to thorostat or vinyl chloride and he was a farmer by occupation.
On evaluation of his hemogram, renal parameters and liver function tests were within normal limits. Contrast-enhanced computed tomography (CT) was done which revealed a 10 cm x 8 cm heterogeneous enhancing mass involving the upper pole and interpolar region of right kidney (Figure ). The inferior vena cava and renal vein were free of thrombus and there was no regional lymphadenopathy. There was no evidence of distant metastases in the liver or bones. CT of the chest was also normal (Figure ). The patient underwent right-sided open radical nephrectomy. On the cut section, the tumor was seen to be composed of focal fleshy and necrotic areas intermingled with vascular spaces (Figure ). Histopathological examination revealed areas of extensive necrosis and anastomosing vascular spaces lined by pleomorphic cells (Figure ). The tumor had a high mitotic index of 25 to 30 per ten high power fields and a ki-67 index of 40%. Immunohistochemistry was done which showed strong positivity for cluster of differentiation (CD) 34; whereas, it was negative for epithelial membrane antigen (EMA), CD 10, and human melanoma black (HMB) 45 consistent with angiosarcoma. The surgical margins were free of tumor and the pathological staging was pT2bN0M0.
In view of the histological diagnosis of angiosarcoma, the patient was treated with adjuvant chemotherapy. He received three cycles of paclitaxel-based chemotherapy. The patient is doing well on one year of follow-up. Several reports of primary

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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:
Eleven years ago, a 46-year-old white man presented with painless jaundice. He showed no other symptoms and had no risk factors such as high alcohol consumption or tobacco smoking. With a bodyweight of 73 kg and a height of 175 cm his body mass index (BMI) was 24.49 kg/m2 at the time of presentation. His mother had colorectal cancer otherwise there was no family history.
An endosonography showed an intraluminal polypoid tumor with disintegration of all wall layers at the bifurcation of his bile duct system. The finding was confirmed by endoscopic retrograde cholangiopancreatography (ERCP). Biopsies were taken with the pathologic results coming back inconclusive.
Computed tomography showed an intrahepatic cholestasis and two hypodense lesions in segment VIII of his liver. It showed no signs of metastasis or other unknown pathologies. The analysis of serum tumor marker carcinoembryonic antigen (CEA) was negative and cancer antigen (CA) 19-9 was found to be elevated at 75 kU/l (<37 kU/l).
He was treated with right liver lobectomy with resection of the bile duct directly distal of his pancreatic head, resection of the bile duct of his left liver lobe up to the first intersection, and with a regional lymphadenectomy. The reconstruction was performed by biliodigestive anastomosis with Roux-en-Y hepaticojejunostomy. A bile duct drain was inserted in the dorsal bile duct of his left lobe and closed on day 10 after contrast imaging of the anastomosis. Postoperatively, he recovered well. On the planned day of discharge he developed an aphasia leading to further diagnostics, which showed a transitoric ischemic attack of his left-brain hemisphere. He was transferred to neurology and fully recovered.
A gross examination showed a right hemihepatectomy with a 4×2×2 cm polypoid tumor in his right hepatic bile duct extending into the bile duct junction (mainly intraductal growth type). The liver parenchyma was non-cirrhotic and prominent portal tracts were seen

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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 72-year-old female presented 14 months after a two-part left proximal humerus diaphyseal fracture (OTA11 B2). Her past medical history was significant for osteoporosis. Physical examination revealed gross deformity, tenderness and motion at the fracture site. No neurologic deficit was found. Radiographic evaluation revealed an oblique fracture of the left proximal humerus diaphysis with lateral and anterior angulation of the distal fracture fragment []. There was minimal osseus bridging between the proximal and distal fracture fragments with associated callus formation. She was indicated for operative intervention.
The patient was administered regional anesthesia and positioned in a sloppy lateral position. An extended anterolateral approach was utilized as described by Gardner et al.[–] The skin incision began at the anterolateral tip of the acromion and was extended to approximately 5 cm proximal to the lateral epicondyle. Proximally, the subcutaneous tissue was divided to expose the raphe between the anterior and the middle heads of the deltoid. The raphe was carefully divided in the “safe zone” above the location of the axillary nerve, 6 cm below the anterolateral border of the acromion.[–] The muscle was separated using blunt dissection proximally. The axillary nerve was then palpated and found to be scarred to the humeral head. Neurolysis was performed and the nerve and surrounding soft tissues were protected with a vessel loop. The deltoid was further divided proximal and distal to the nerve and the insertion site was tunneled under for future plate placement. The lateral border of the biceps was then identified and the muscle retracted medially to expose the brachioradialis and brachialis muscles. The faschia between the muscles was then incised in line with the intermuscular plane and the radial nerve was identified. The radial nerve was found to be scarred down to the inferior aspect of the fracture, and was mobilized. The fracture site was then exposed

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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 78 year-old man was admitted to the outpatient clinic of our department of otolaryngology with complaints of sudden pain of left auricle and ear canal. The patient also showed facial paralysis on left side (House-Brackmann grade III). He didn't have any underlying disease and showed a social history of smoking with 60 packs years and no history of alcohol intake. According to the physical examination, there was found no dermatological lesion such as rash, vesicle or crust near the ear drum, external auditory canal and near the external ear. The patient showed a sensorineural hearing loss of high frequency in both ears on pure tone audiometry. The hearing ability showed no worsening pattern as the symptoms were developed. The pain that was shown in this patient was of great severity compared to that generally shown in Bell's palsy, and he complained of a stronger, deep pain in the external auditory canal rather than in the areas near the auricles. Accordingly, beside to Bell's palsy, we considered an atypical type of Ramsay-Hunt syndrome that doesn't show dermatological lesions, as our possible differential diagnosis. We started with high doses of steroid (prednisolone, 60 mg/day) and antiviral drug (Acylovir 1800 mg/day) after the patient was hospitalized. Even though it's rare to present severe otalgia from primary or metastatic tumors of the skull base, we performed a CT scan of the temporal bone to rule out these possibilities. The findings from the CT scan showed a bony destruction of the temporal bone of the left, anterior attic and sphenoid bone (). Consequently, we could assume that the facial paralysis occurred due to damages of the first geniculate ganglion of facial nerve. We performed a MRI of the temporal bone in order to find out the etiology of the bony destruction of temporal bone and we observed a neoplastic lesion that is invading the base of the skull and left sphenoid bone. It was observed that the neoplastic lesion inv

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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 14-year-old boy presented with asymptomatic swelling of the chin that had been occurring over 18 months. The lesion gradually increased to involve the left side of the lower lip. There was no history of similar lesions elsewhere in the patient or his family members. There was no history of pain, alteration in speech or difficulty in speaking.
On examination, there was a skin colored, non-tender, firm and irregular swelling over the left mentolabial groove extending onto the lower lip (). There was bulging of the left part of the lower lip with distortion of the lip architecture even on occlusion of the lips. The mass produced an irregular, smooth protrusion on the mucosal surface of the lower lip without any discoloration. There was no local depigmentation or hypertrichosis. There was no evidence of freckles or café au lait macules and no bruit over the lesion. Clinically a diagnosis of neurofibroma was made and excisional biopsy under local anesthesia and aseptic conditions was performed. The specimen was sent for histopathological examination.
Gross observation showed that the tumor consisted of a skin covered nodule measuring 1×0.5×0.5 cm. The cut surface was solid grey white. Histopathology sections showed an unremarkable superficial skin and a sub-epithelial tumor. The tumor was ill defined and consisted of fascicles of mature nerve tissue arranged in a multinodular pattern separated by fibrocollagenous septa. The cells were seen surrounding the pilosebaceous unit. The nerve fascicles showed an intricate admixture, with mature striated skeletal muscle bundles of varying sizes ranging from 15 to 20 µm with some being up to 50 µm (, ). Few muscle fibers were seen to be contained within the perineural sheath (). Areas of myxoid change were noted as were many capillary sized blood vessels. Mild chronic inflammation was seen. A histopathology diagnosis of BTT involving the mental branch of the trigeminal nerve was made. There

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


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

[User]
RADIOLOGY NOTE:
Our patient is a 48-year-old female who has a history of localized early stage right renal cell carcinoma and had undergone an open right radical nephrectomy in 2002 via a right flank incision. She is in remission currently.
During her surveillance, an MRI done in August 2010 detected an incidental lesion in her spleen measuring 3.9 cm. A follow up MRI done 3 months later showed the lesion to have increased in size to 4.5 cm. Interventional radiology performed a CT guided biopsy and the pathology showed it to be a possible spindle cell tumor or an inflammatory myofibroblastic tumor. A PET CT done showed low level activity in the splenic lesion. She denied any other local or constitutional symptoms.
She had previously undergone a left oophorectomy and salphingectomy for an ectopic pregnancy, both via a Pfannenstiel incision. She has 3 children, all vaginal delivery.
Due to her menorrhagia for the past couple of months, an ultrasound of her pelvis was done which showed large uterine fibroids. She was scheduled for a laparoscopic hysterectomy in 3 weeks.
Physical examination was unremarkable except for her previous Pfannenstiel and right flank incisions.
Due to the indeterminate nature of her splenic lesion with concerns for malignancy, patient was agreeable to undergoing a splenectomy. Discussion with her gynecologist then yielded the possibility doing both surgeries on the same day, possibly doing the laparoscopic splenectomy first, then the laparoscopic hysterectomy. After a careful review of the literature, we also pursued the idea of transvaginally extracting the spleen after the hysterectomy was performed. Pneumococcal and Hib vaccines were given 2 weeks prior to surgery.
She underwent surgery in February 2011. Pre-operatively, the left ureter was stented to protect the left ureter in view of her single remaining kidney. The laparoscopic splenectomy was conducted with the patient in the supine position. One 12 mm port and 3 other 5 mm ports were placed in a

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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:
53-year-old woman was admitted to the hospital with a 1-month history of abdominal and flank pain and 10 kilograms of weight loss in three months. She had no remarkable medical history except a 10 pack-year history of smoking. On her physical examination, blood pressure was 120/70 mmHg and her pulse was 72/min. There were no signs and symptoms of adrenal hormonal hypersecretion. Abdominal computed tomography (CT) scan showed 10.5 × 6.5 × 9.5 cm cystic mass with irregular borders located in left adrenal and 6.5 × 3.5 × 4.5 cm lobulated cystic mass with irregular borders and multiple septations in the right adrenal gland. There was also an 8.3 × 6.5 cm cystic mass with irregular borders in liver segment six and the lower margin of this mass could not be clearly differentiated from the borders of the mass described in right adrenal on CT scan ().
Serum cortisol, serum androgens, urine catecholamines and their metabolites, and the aldosterone to renin ratio were normal. Her liver function tests including ALT and AST were four times higher than normal and renal function tests were normal. Mammography, upper gastrointestinal system endoscopy, and thorax CT were performed to exclude metastasis to adrenals, which gave normal results. Bilateral adrenalectomy, simple nephrectomy, distal pancreatectomy, splenectomy, right hepatectomy, and cholecystectomy were performed. The surgery was completed uneventfully. On gross examination specimen removed from right adrenal was brown and nodular measuring 9 × 6.5 × 4.0 cm and weighed 80 g. Its cut surface showed that the tumor was variegated with whitish-grey firm solid areas and extensive necrosis. The specimen removed from left adrenal measured 8.5 × 6.0 × 3.5 cm and was composed of cystic mass. On microscopic examination the tumor of right and left adrenal showed pleomorphic tumor cells with epithelial and spindle cell morphology with evidence of foci of necrosis. Giant cell formation and high mitotic rates were observed in

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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:
We present a case of a 50-year-old Caucasian male who presented to the emergency department with complaints of lower abdominal pain, fever and sweating. On examination, the patient had tenderness to palpation in the right iliac fossa, with significant rebound tenderness and guarding. Body temperature was recorded at 38.5°C.
The patient's past medical history was significant for an incident of similar pain six months prior to presentation. He was diagnosed with sigmoid diverticular disease confirmed by computed tomography (CT) scan and managed conservatively. A subsequent colonoscopy confirmed the diagnosis, and did not reveal any other colonic pathology.
Further investigations revealed a raised white blood cell count of 16,000 per microliter. CT scan of the abdomen and pelvis disclosed evidence of extensive free gas under the right dome of the diaphragm confirming suspicion of a perforation. Fluid-filled prominent loops of small bowel were noted. However, none of them were dilated to suggest obstruction. Mild bowel thickening was also noted around the cecum. Pneumatosis coli suggestive of ischemic bowel, extending from the cecum to the proximal ascending colon was seen. A blind ending structure with calcifications was also seen (Figure ). Other significant findings on the scan included a liver cyst, consistent with the patient’s previous CT scan, and consolidation at the base of the right lung.
Subsequently, the patient underwent an emergency laparotomy and a diffuse four-quadrant peritonitis was seen. A giant perforated MD, 80 cm proximal of the ileocecal valve was identified as the cause of the peritonitis. The giant MD measured approximately 10 cm in length and 2.5 cm in width (Figure ). A small perforation at the tip of the MD was observed. No other intraabdominal pathology was identified, in particular, there was no evidence of colonic ishchaemia. Resection of the segment of small bowel bearing the MD was performed with a side-to-side stapled anastomosis.
Patho

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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 77-year-old male with a past medical history significant only for gout, and hypertension presented as a stroke alert. His last known normal time was 12 hours prior, before going to sleep. His wife noted an episode of right facial droop and speech slurring, which prompted her to call emergency medical services. His wife also described an episode of thrashing in the bed and urination. She mentioned that the day before presentation the patient was “not feeling well” and took aspirin. He did not mention experiencing any specific symptoms.
Upon presentation to the emergency department, the patient could localize to pain but had a decreased level of consciousness. Vital signs were unremarkable, but frequent premature ventricular complexes were seen on the electrocardiogram. The patient’s wife did not know of any prior history of this. Physical examination was remarkable for 5-mm dilated pupils bilaterally, crackles bilaterally at the lung bases, and decreased level of consciousness. The National Institutes of Health Stroke Score (NIHSS) was 18: 2 for level of consciousness, 3 for visual fields, 2 for the left arm, 2 for the right arm, 2 for the left leg, 2 for the right leg, 3 for best language, and 2 for dysarthria. Laboratory evaluation revealed no leukocytosis, a normal glucose of 115 mg/dL, and lactic acid of 1.4 mmol/L. Urine drug screen was negative, as was the urinalysis. The patient had normal vital signs and thus did not meet the criteria for sepsis. Initial computed tomography (CT) of the brain did not reveal an infarct or hemorrhage (Figure ).
CT angiography (CTA) of the head and neck did not show any sign of aneurysm but revealed scattered carotid calcifications, a left parotid mass of 2 cm, and a right apical cavitary lesion with peripheral calcifications confirmed by chest radiography (CXR). CXR also revealed several small pulmonary nodules scattered in both lungs as

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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 attending the dermatology unit of our university hospital was referred to our gastroenterology outpatient clinic in 2002 due to symptoms of epigastric pain, postprandial fullness, and bloating. She reported no other upper or lower gastrointestinal symptoms.
The patient had a history of hoarseness since the first months of life. When she was one year old she presented with recurrent blisters, superinfected skin, and mucous membrane lesions that progressed to affect the whole body. Histological analysis of skin biopsies taken at the age of three showed deposition of eosinophilic hyaline PAS-positive material in the dermis and around small blood vessels, confirming the clinical diagnosis of LP. Her parents were nonconsanguineous and no other family members were affected.
The hoarseness progressed over the years, and she experienced recurrent superinfected blisters. The skin lesions healed after several treatments with different drugs, including etretinate and chloroquine, but visible scars developed in the areas where the lesions have been present. There was no history of seizures or neuropsychiatric abnormalities.
Previous laryngoscopy revealed thickening of the vocal cords and nodules on the base of the tongue and supraglottic portion. Magnetic resonance (MR) imaging showed symmetrical calcifications on the amygdaloid nucleus and uncus.
On admission the patient had a hoarse voice, and multiple scars were visible on the face and body. Upper endoscopy showed multiple yellowish nodules throughout the esophagus (), body of the stomach (), and duodenum. There was no evidence of esophagitis or gastritis. Histological examination revealed deposition of eosinophilic hyaline material in the lamina propria and submucosa and around blood vessels (). The material was positive on periodic acid-Schiff (PAS) staining and negative on Congo red staining, confirming the diagnosis of LP. Esophageal manometry was normal.
Colonoscopy also revealed multiple ye

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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 69-year-old man presented with severe chest pain and was subsequently diagnosed with extensive anterior wall myocardial infarction. Echocardiography showed akinesia of the anterior septum and anterior wall, and left ventricular ejection fraction was 35%. During admission to the coronary care unit, his blood pressure and urine output were noted to be decreased. Despite inotropic administration, the patient's condition did not improve. Bedside portable echocardiography showed low mitral E velocity and reversed E/A ratio, suggesting volume depletion or dehydration (). Based on Doppler echocardiographic findings, fluid was administered rather than diuretics or volume restriction. After hydration, the patient's condition improved and blood pressure and urine output increased.
Volume expansion is the first therapeutic measure when a patient presents with hemodynamic instability. However, when the preload of the heart is already high, volume expansion can be hazardous, especially in elderly patients with decreased left ventricular compliance. Because of this concern, despite the need for adequate fluid balance, dehydration in elderly critically ill patients who are admitted to the ICU is not uncommon but usually unrecognized. It is important to avoid hypovolemia in these patients because it can lead to subsequent unexpected complications, such as hypotension and renal failure. Close monitoring is needed in patients being treated with volume expansion because of the delicate balance between excessive pulmonary congestion and reduced preload. Although diuretics are appropriate for the relief of congestion and edema, they are most effective in patients with evidence of fluid retention. In addition, caution should be taken to avoid overdiuresis, which may result in intravascular volume depletion and resultant hypotension or prerenal azotemia. Unlike in patients with grade 2 or 3 diastolic dysfunction (with elevated filling pressures) in whom the addition of diuretics should

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

[User]
RADIOLOGY NOTE:
An 85-year-old female patient visited our hospital, complaining chiefly of scalp swelling. Two weeks earlier, the patient had fallen backward. Upon physical examination, we detected a subcutaneous mass in the patient's left posterior parietal area. The 3.5 cm mass was covered by normal skin. She also complained of a little pain on palpation. No tactile pulsation was detected. It was believed to be a posttraumatic subcutaneous hematoma, so we decided to continue observation, and wait for any spontaneous disappearance. The swelling in the patient's scalp decreased in size after one week. She attended no follow-up sessions thereafter.
Two months after her first visit, the patient was admitted to the emergency room due to scalp bleeding. The swelling in the patient's scalp had, at that time, increased to 4 cm in diameter with an overlying scalp defect which was oozing blood. Tactile pulsation was detected. The defect was sutured, and the bleeding was controlled via manual compression.
The patient was admitted for further evaluation of the pulsatile scalp mass. Brain CT revealed a slight increase in the attenuation of the hematoma in the left parietal scalp, with dense contrast filling (). Upon routine laboratory examination, the level of creatinine in the patient's blood was higher than normal (22 mg/l, normal range 7-14).
Angiography of the external carotid artery revealed a pseudoaneurysm, which was fed by the left occipital artery (). An aortogram revealed complete occlusion of the right renal artery, as well as severe proximal stenosis in the left renal artery. The radiologist (Y.H.C.) attempted to occlude the pseudoaneurysm via transarterial embolization. However, this attempt failed, due to the complex geometry of the proximal artery. A two-hour attempt was made to occlude the pseudoaneurysm via US-guided manual compression. Thereafter, the pulsation of the scalp swelling became negligible.
Doppler US, taken five days after the procedure, revealed thrombus formati

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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 24-year-old previously asymptomatic male presented to his primary care physician with a complaint of focal penile irritation related to sexual intercourse. The irritation originates from a lesion along the midline on the dorsum of his penile glans. He was referred to a urologist for further evaluation.
The patient reported noticing a small dimple along the midline on the dorsum of his glans for as long as he could remember. The lesion had not previously caused him any discomfort, nor did he report a history of discharge, including urine, semen, blood or pus from the orifice. In recent months, the patient has become more sexually active and he has become aware that during and after intercourse the site is painful and inflamed for a short period of time. The patient wants to make sure there is not something wrong with his anatomy and seeks a solution.
The patient had no significant past medical history. There is no family medical history of relevance, specifically no one has reported any genital malformation. Physical examination by a urologist demonstrated a well-developed adult male. A small midline opening was present on the dorsum of the penile glans. There was no focal erythema or discharge present at the time of examination. Manipulation of the opening demonstrated a thin lumen that appeared to continue proximally along the dorsum of the penile shaft. The most likely aetiology was determined to be urethral duplication. Imaging was necessary for confirmation and to delineate the particular anatomic presentation in order to plan treatment. Demonstration of communication with the urethra or bladder would require more extensive surgical intervention to eliminate the sequelae of discharge accumulation in the lumen causing infection, cyst formation or recanalisation of the accessory orifice. The patient was referred to radiology for urethrography.
Since no urine, semen or other discharge had ever been noted to exude from the accessory urethra, a retrograde urethrogr

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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:
In May 2014, a 30-year-old Caucasian woman presented to our department (Fig. a). For the past 4 years, the patient had suffered from severe PPR (principally on the forehead, cheeks, and chin) with signs of rosacea fulminans, as well as severe background erythema in the central facial and forehead regions. She had previously been treated with metronidazole 7.5 mg/g cream and permethrin 50 mg/g cream, which had not provided a reduction in the number of inflammatory lesions. She had also been prescribed doxycycline modified-release 40 mg for 18 months, which had also proved unsuccessful in reducing the inflammation.
At presentation, the patient reported feelings of hopelessness, indicating a profound impact of the disease on her quality of life. Following diagnosis of PPR with severe background erythema, different treatment options were evaluated. In such a severe case, a specific strategy tailored to the patient was essential, particularly given the lack of success with prior regimens, which seemed to indicate that a more potent treatment regimen was needed in this patient to combat the inflammation upfront. Isotretinoin was initially considered; however, because the patient was not taking hormonal contraception at the time of her visit to our department, this therapy was contraindicated. The patient was offered a gynecology appointment to start hormonal contraception, so that isotretinoin could be an option in the future. The patient was initially prescribed an 8-week regimen of azithromycin 500 mg three times weekly (taken in the morning) in combination with prednisolone 30 mg once daily (reduced to 10 mg once daily after 1 week). The choice of this regimen was based on results from the literature showing that a rapid response can be obtained with a multimodal, tailored approach with a short course of macrolide antibacterials []. Furthermore, the use of corticosteroids over the short term is not strictly contraindicated in the treatment of rosacea and can be conside

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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 28-year-old married housewife presented in the orthopedics outpatient department of tertiary care hospital in Central India with the chief complaints of pain in both thighs, more on the right side and difficulty in walking for the past 2 years. Pain had started spontaneously, was insidious in onset, and localized initially to both thighs. It increased with weight bearing, walking and household chores and partially got relieved on rest and medication. There was pain in elbow, wrist, and both hands for a few months initially. There was no history of fever, loss of appetite, loss of weight, or any change in menstrual cycle. Her joints’ pain and left thigh pain got completely relieved with drugs, but pain in the right thigh and hip area did not improve. She noticed progressively increasing difficulty in walking, squatting, and sitting cross-legged during the past 6 months. She started feeling rest pain in the right thigh and started taking stick support for the past 2 months. She had undergone repeated consultations, investigations, and treatment, but was not relieved of her symptoms.
Examination revealed painful gait with minimal weight bearing on the right lower limb. The patient was thin built with mild pallor and without any systemic abnormality. Her pulse was 84/minute and blood pressure 130/70 mmHg. Tenderness was present on upper one-third of right thigh and both pubic rami with adductor muscle spasm. Right hip rotations and abduction adduction were grossly restricted with flexion possible up to 70°. Left hip movements were normal except terminal restriction of flexion. There was no neurovascular deficit. Examination of other bones and spine did not reveal any abnormality.
A clinical diagnosis of Osteomalacia with Looser’s zone in pubic rami and incomplete fracture in right femur was considered. Metastatic lesions, multiple myeloma, or hyperparathyroidism with brown tumors were considered as differential diagnoses. The patient underwent X-rays of relevant areas

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

[User]
RADIOLOGY NOTE:
A 63-year-old female with a chief complaint of a progressive headache has been admitted to the Department of Neurosurgery. The headache first has been presented 4 months ago. Before that time, the patient had always been symptom-free, following a normal active life. The pain was pulsating, with a concentration in frontal and periorbital area with no particular radiation. When severe, it has been followed by eye irritation and involuntary tearing. Headache was progressive along the day, and most severe at night. The severity of the pain has also been intensified within the recent weeks comparing to time it started. The patient had no history of seizure or convulsion, aphasia, and diplopia. Otherwise, she gave a history of occasional vomiting, nausea, amnesia, and sphincter dysfunction in form of stress incontinency and equilibrium problems. Cerebellar tests were abnormal, and she could not walk on her own. She had a history of left kidney tumor, for which she had undergone partial nephrectomy for about three years ago. Furthermore, she gave a history of controlled diabetes, hypertension, and hyperlipidemia. No history of ischemic heart disease or cerebrovascular attack was mentioned. She had a drug regimen of insulin, losartan, memantine, atorvastatin, zinc plus, magnesium, propranolol, and venlafaxine. In her physical examination, cranial nerves were intact, with a Glasgow Coma Scale of 15/15. Cerebellar tests were abnormal with obvious equilibrium dysfunction and inability to self-manage walk. Both pupils were normal sized, symmetric and reactive to light. Visual acuity was at level of finger count out of three meters distance. Sensory and motor function of the four extremities were normal; and no sensory level was detected. The patient suffered from sphincter dysfunction in the form of stress incontinency.
Magnetic resonance imaging (MRI) was performed for better evaluation. In T1 view a well-defined hypo-signal mass was detected in middle gyrus of each frontal lo

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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 35-year-old man suffered from immunoglobulin-A nephropathy 2 years before admission and was treated with steroid therapy. He complained of epigastric pain about 9 months before. A mass on the greater curvature of his stomach was found by gastroscopy and gastric cancer (signet cells) was diagnosed by biopsy. The abdominal CT scan showed that there were tumours in the abdominal cavity with enlarged para-aortic lymph nodes. His body surface area was approximately 1.57 m2 as determined from the DuBois formula. He started taking S-1 50 mg, twice daily for 3 consecutive weeks, followed by a 2-week rest period 8 months ago. He also started intravenous cisplatin every 5 weeks and took dipyridamole, lansoprazole, granisetron hydrochloride and naproxen orally every day. He received six cycles of chemotherapy and showed a partial clinical remission.
He received 60 mg cisplatin for the last time about 1 month before his admission, and his serum creatinine increased slightly (from 95.47 to 114.92 μmol/l) 1 week after receiving cisplatin. He continued to report appetite loss and went to hospital 1 week before his admission. He also took a blood examination after the consultation and his serum creatinine had increased to 683.33 μmol/l. However, his doctor did not know the result until after his admission. He continued to take S-1 and the other drugs for about 1 week from the start of the renal insufficiency. His appetite loss and general fatigue were aggravated and he consulted the emergency room in our hospital.
He was drowsy and on the Glasgow Coma Scale his score was 13 of 15. His blood pressure was 133/82 mmHg and his heart rate 87 beats/min. He complained of a slight stomachache, and slight tenderness was found on physical examination. There was no free air or niveau on the abdominal X-ray. The serum creatinine and blood urea nitrogen were elevated to 1919.16 μmol/l and 32.49

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


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

[User]
RADIOLOGY NOTE:
A 15 years old girl presented with complaints of pain and swelling over the left wrist for 3 months. She associated the onset of pain to a direct injury to wrist while playing. The pain was mild to begin with and responded to Ibuprofen. The pain later became severe and did not respond to anti-inflammatory drugs. The patient also noted a swelling on the radial aspect of the wrist. The swelling had been gradually increasing in size []. The range of movement at the wrist joint at presentation was dorsiflexion of 45° and palmarflexion of 20°. The grip strength of the left hand was 4 kg as compared to 18 kg at the right dominant hand. Her past medical and family history was unremarkable. Serologic workup performed showed a negative rheumatoid factor, a white blood cell count of 6000 cells/mm, a C-reactive protein of 0.6 mg/L, and a sedimentation rate of 15 mm in the first hour. The radiographs showed a well circumscribed lytic lesion in the distal pole of the scaphoid []. Computed tomography (CT) scan of the wrist showed a lytic lesion with a nidus in the center, with cortical perforations []. Magnetic resonance image (MRI) scan of the wrist showed a well defined eccentric lesion with sclerotic margins and central calcification involving the scaphoid, measuring 5 × 5 mm with inflammatory edema and synovitis of the periscaphoid region and articulations [].
Dorsal approach was selected for the excision of the tumor and synovectomy as there was maximum swelling over the dorsoradial aspect of the wrist. On exploration, there was synovitis of the whole wrist joint, which resembled on naked eye as tubercular synovitis [Figure ,]. There was inflammatory granulation tissue at the scapho-trapezio-trapezoidal joints. Thorough synovectomy was done. The perforation of the osteoid osteoma at the scaphoid was seen as a break in continuity of the surface of the scaph

[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 three-year-old male presented to the emergency department (ED) with the chief complaint of one episode of hemoptysis that occurred just prior to arrival. His adopted mother stated that he had cold-like symptoms for the past few days prior to arrival, and on the day of arrival, he began to cough up blood. She brought the blood-tinged rag with her to the ED. He had vomited the night prior, as well as on the morning prior to arrival, and had diarrhea during that same time frame. His adopted mother said that the diarrhea and vomit were not blood-tinged. There had been no change to his urine output. She stated that he had a fever the night prior, as well as on the morning of presentation, with a maximum temperature of 101º F. His adopted mother said that he attends daycare, and that multiple children in his daycare had recently come down with respiratory syncytial virus (RSV).
His adopted mother stated that he was born full term with no complications. She also said that he had multiple bronchitis infections since his adoption, which she stated was at a few months of age. According to her, he is up to date on all vaccinations. Due to his adoption status, his family history was unknown.
His temperature on arrival to the ED was 98.7º F. He had a pulse rate of 131 beats per minute, a respiratory rate of 22 breaths per minute, and a blood pressure of 89/60. Physical exam revealed the presence of clear rhinorrhea as well as diffuse crackles and expiratory wheezing in all lung quadrants.
A complete blood count and comprehensive metabolic panel were all within normal limits. Chest radiographs in two views were performed, and it was determined that no acute lung abnormalities or pulmonary infiltrates were present (Figures -). A hemoccult test was done on the blood-tinged rag which confirmed that the substance was blood. It was

[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 British Caucasian female patient aged 10 years and 11 months presented to our institution with a thoracic and lumbar scoliosis. She was noted to have the phenotypic features indicative of Smith-Magenis syndrome at the age of three years and the diagnosis was confirmed with chromosomal studies. There was no family history of syndromic conditions or scoliosis.
The development of a scoliosis was first noted at the age of 4 years and the patient was treated with an underarm spinal brace in another spinal centre. The deformity remained stable up to the age of 10 years when the curvature progressed rapidly as the patient started going through her pubertal growth spurt. During that stage, the brace was discontinued as the patient's compliance was very poor and any brace effectiveness was limited due to the fact that the patient was significantly overweight. At presentation to our clinic, she remained premenarchal with a body weight of 63 kg which was above the 95th percentile for sex- and age-matched normal population. Her arm span was 142 cm which was between the 25th and 50th percentiles for stature and her BMI was calculated to be 31.2.
On clinical examination, the patient was found to be very hyperactive. Overall, she had a balanced spine with level shoulders and pelvis despite a mild thoracic translocation to the right and no leg length discrepancy. However, she had a severe thoracic and lumbar deformity with a significant rib hump adjacent to the convexity of the thoracic scoliosis, as well as a marked waist line asymmetry with prominence of the pelvis on the concavity of the lumbar curve. There were no skin or soft tissue abnormalities overlying the spine. The patient was a community ambulator and had no neurological abnormality. Neurological examination showed normal tone, muscle power, sensation and tendon reflexes in the upper and lower limbs, as well as symmetrically elicited abdominal reflexes. There were no upper motor neurone signs.
Radiographs of the spine

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


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

[User]
RADIOLOGY NOTE:
A 58-year-old male with no particular background who, after falling from a 5m height, reported pain and restriction of movement on both shoulders and loss of sensibility and movement in his right arm.
The patient showed functional impotence, not being able to perform adduction and internal rotation with both upper limbs, evident ecchymosis in both of his shoulders and absence of humeral, radial, and cubital pulse in his right arm, with signs of acute ischemia (coldness, paleness, diminished sensibility, and motor function of the elbow and the hand), with no capillary filling in the right hand. Oxygen saturation, measured with a pulse oximeter, couldnot be measured in the right index finger in comparison with 99% in the left one ().
Radiographies and computed tomography showed a fracture-dislocation of the proximal front humerus in both of the shoulders (). A Doppler could not find distal pulse in the right upper limb, so the patient was immediately remitted to surgery.
In the surgical room and under general anesthesia, an emergency arteriography was carried out through transfemoral access, and a tear in the intima of the right axillary artery was found, being that the reason why an emergency intervention was indicated.
Then, through deltopectoral path, we proceeded to perform an open reduction and internal fixation using a pre-molded plaque of the proximal humerus (). After that, an auto-expandable stent was implanted and a bypass graft with interposition of the great saphenous was performed by the service of angiology and vascular surgery (). Finally, a distal embolectomy with a Fogarty catheter was performed to eliminate any thrombus. The control arteriography proved vascular permeability.
Four days after the emergency surgery, the left shoulder was operated again through deltopectoral path, performing an open reduction and internal fixation with a pre-molded plaque of the proximal humerus.
The patient was discharged several days after the humeral,

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


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

[User]
RADIOLOGY NOTE:
A 50-year-old Caucasian female presented initially with a spontaneously occurring, non-tender, right anterior chest wall soft tissue cystic-like mass in late 2014 (). Her past medical history included Waardenburg syndrome (a genetic condition associated with hearing loss and changes to hair skin and eye pigmentation), well-controlled non-insulin-dependent diabetes, learning difficulties and she had 15 surgeries performed on her deformed feet. She also suffered from sideroblastic syndrome since 2002 for which she was receiving blood transfusions three times a week with well-controlled iron overload. A month after developing the right anterior chest wall mass, she developed a non-tender swelling in her left elbow which got progressively larger and uncomfortable (). She was seen by both orthopaedic and rheumatology teams, who after reviewing the images suspected that the swelling could be due to an inflammatory reaction rather than infection. She was therefore started on a reducing dose of 30 mg oral prednisolone which she took intermittently for a year. During this time her swelling remained non-tender, however towards the beginning of January 2016 she presented with pain in her elbow joint. Repeat imaging showed worsening of the left elbow joint mass and an enlarging right sternoclavicular mass. She was referred to a specialist centre for biopsy of the right sternoclavicular joint mass for suspected lymphoma. In April 2016, multiple biopsies of her right sternoclaicular joint showed necrotic material and inflammatory cells along with granulation tissue suggestive of osteomyelitis. As no evidence of granulomas was seen, tissue samples were not sent for any mycobacterial cultures. She was started on oral flucloxacillin 1 g QDS to be taken for 4 weeks. At the beginning of May 2016, while on flucloxacillin, she became unwell with signs of sepsis and her left elbow swelling had started to ulcerate. Chest X-ray on admission showed infective changes to the bases of both lun

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


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

[User]
RADIOLOGY NOTE:
A 64-year-old Asian female was presented to our hospital with a recurrence of liver nodular lesions after multiple surgical resections.
The patient had received lung lobectomy due to lung cancer in the right upper lobe 11 years ago (). Postoperative pathology showed a 4.0×3.9 × 3.0 cm moderately differentiated adenocarcinoma, with one positive mediastinal lymph node among all the 10 dissected lymph nodes (). She quit adjuvant chemotherapy after one cycle due to intolerance. No elevation of tumor markers had been reported perioperatively.
Seven years ago, the patient developed jaundice. CT assessment showed a pancreatic head mass with involvement of the distal common bile duct (). Results of tumor markers including CA19-9 were negative. She was then treated with radical pancreaticoduodenectomy, where a 2.5×2.0 × 2.0 cm moderately differentiated adenocarcinoma with negative lymph node metastasis was removed (). Afterward, she received adjuvant S-1 chemotherapy (consisting of tegafur 40 mg, gimeracil 11.6 mg, and oteracil 39.2 mg, administered orally twice a day) for 3 cycles (2 weeks per cycle followed by a one-week rest period), which was also discontinued due to adverse events.
The patient was then put on surveillance with an annual imaging assessment. Four years after the Whipple procedure, a follow-up examination showed a solitary liver lesion in segment VII (). She refused interventional treatment or chemotherapy and chose cytoreductive surgery to resect the segment VII lesion. Postoperative pathology demonstrated a 3.0 cm segment VII adenocarcinoma and suggested the diagnosis of liver metastasis ().
Recently, the patient was admitted for the recurrence of a liver lesion, along with multiple lung nodules (). Recurrence of the previous adenocarcinoma in the liver and lungs was the first impression. The tumor board reviewed her past medical history and proposed the possibility of metastases of the lung adenocarcinoma to the pancreas, liver, and lungs. Liver biopsy

[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 woman patient visited our outpatient clinic after experiencing headache and blurred vision for 1 month. Her neurological examination was within the normal limits, except that bilateral congested papillae were identified. Her family history was unavailable because she was adopted. MRI revealed a solid tumor with a maximum diameter of 3.5 cm accompanying an internal cyst in the left cerebellar hemisphere. In addition, extensive cerebral edema and ventricular dilation were noted. On presurgical brain MRI, the solid region showed uniform contrast enhancement. On cerebral angiography, feeding arteries were noted to arise from the left anterior inferior cerebellar artery (AICA) and left posterior inferior cerebellar artery (PICA), and both the draining veins to the petrosal vein and the inferior vermian vein were identified [].
We performed 200 ml of 10% glycerol (twice a day) with dexamethasone (8 mg/day) for 6 days before the operation. Because the symptoms improved, we did not perform external ventricular drainage prior to the operation. Surgery was performed via the midline suboccipital approach with the patient in the prone position. The dura mater was dissected and ICG fluorescence angiography was performed. We observed the feeding artery coming off the PICA arose from the cerebellar hemisphere and drained via the horizontal fissure, additionally feeding vessels from the AICA were confirmed on the outside. The lesional veins drained into the inferior vermian vein []. Intraoperatively, the feeding artery from the PICA was coagulated first and then cut. Because there was a clear cleavage plane from the surrounding tissue, which was not swollen, detachment was performed, leaving the thick draining veins intact. The most significant draining veins, which converged onto the petrosal vein, were positioned anteriorly on the outside. Finally, these veins were coagulated and cut, and the tumor was removed en bloc. The estimated blood loss was 500 ml. Pathologic

[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 one-year-old Thai boy was referred to Phramongkutklao Hospital due to subacute fever, abdominal distension, mucous diarrhea, and failure to thrive. He was born at term with uneventful pregnancy, and he is the first child of nonconsanguineous parents. There was no history of autoimmune or primary immunodeficiency disorders in the family. Intradermal BCG vaccination was inoculated at the left buttock without any reaction within 3 months of life, and intramuscular vitamin K was routinely given after birth. He was exclusively breastfed. At 3 months of age, he developed frequent vomiting and irritability. Physical examination revealed enlarged and tense anterior fontanelle. CT brain showed hyperdensity lesion size of 1.5 × 1.8 cm at left temporal lobe with perilesional edema () which was confirmed to be intracerebral hemorrhage. All hematologic, coagulation studies and biochemical laboratory tests () were consistent with deficiency of vitamin K dependent clotting factors. The cause of vitamin K deficiency in this patient was presumed to be caused by malabsorption mechanism. Therefore, intravenous vitamin K was given for 3 days at initial presentation, and the coagulogram data was corrected within 24 hours. One week later, the patient developed steatorrhea. Fat malabsorption was suspected as the levels of fat-soluble vitamins were evaluated (). Cystic fibrosis was excluded by the negative sweat chloride test. At 4 months of age, perianal abscess was detected and treated with amoxicillin/clavulanic acid for 7 days without surgical drainage. However, subsequent pus culture was not performed. At the age of 6 months, lymphadenopathy of 3 cm in size at the left groin was detected. Fine needle aspiration was accordingly performed, and pus culture was found to be positive for BCG and the tuberculin skin test was positive at 15 × 20 mm. Chest X-ray revealed no pulmonary infiltration. The patient was diagnosed with BCG lymphadenitis and was treated with isoniazid and rifampicin.

[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 78-year-old man with a history of emphysema, hypertension, and hypothyroidism presented to his primary care physician for routine followup. During the review of systems, he was found to have dyspnea on exertion reported as unchanged from his baseline as well as progressive dysphagia of solid foods over an unspecified period of time. Physical exam was significant only for central obesity and decreased breath sounds with prolonged expiration bilaterally. A modified barium swallow one week afterward showed mild esophageal dysmotility and small caliber of the esophagus throughout. During the exam, the technician made note of hoarseness, which the patient stated had been ongoing for three weeks.
Esophagogastroduodenoscopy was performed approximately six weeks following initial presentation. Note was made of difficultly passing the endoscope into the esophagus secondary to hypopharyngeal edema. Endoscopy was terminated prematurely due to respiratory distress and decreasing oxygen saturation.
Emergent intubation was performed and the patient was transferred to the intensive care unit. Approximately three hours postintubation, the patient was awake and communicative, and wished to be extubated. As he had been otherwise stable, the decision was made to extubate. Within minutes, he began having inspiratory stridor. He was able to explain that this “shortness of breath” had been increasingly experienced over the past few weeks, to the point when it was present at rest to varying degrees. The otolaryngology service was called to assist in evaluation of the airway and emergent intubation; examination was normal, including appearance and movement of the vocal cords, and the patient was reintubated successfully.
Palpation of the neck by the intensivist team as well as the surgical oncology service was significant for mild adiposity and loosened neck folds, but despite easy identification of anatomical landmarks, including the cricoid and apparent movement of the isthmus with swa

[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.