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

[User]
RADIOLOGY NOTE:
A 40-year-old male patient discovered a left axillary palpable nodule like a jujube in size when bathing in October 2011, but the patient was not concerned because of busy work. In January 2012, he went to a local hospital for medical checkup. Ultrasonography (US) revealed multiple hypoechoic solid masses with irregular margins in the left axillary cavity; the largest mass was 2.2 cm in diameter and color Doppler US showed that the mass had internal vascularity. He was then referred to the surgical department for further examination and therapy.
Physical examination showed a rigid, nonmobile mass measuring 3.0 cm in diameter in the left axillary; the skin covering the mass was normal and there were no significant enlargement of other superficial lymph nodes. No masses were palpable in either breast or other organs. On imaging examination (Figures and ), computed tomography (CT) scan for ostiomeatal unit, chest, abdominal, and pelvis, and ultrasound for thyroid, breast, genitourinary, and gastrointestinal fail to reveal any malignant or occult primary lesions but the axillary masses with a maximum dimensions of 2.5 × 1.7 cm. The magnetic resonance imaging (MRI) of breast showed that both mammary glands were free of lesions whereas it demonstrated multiple swollen lymph nodes in the left axillary. Positron emission tomography(PET) showed several increased lesions in the left axillary and the metabolic activity of the bone marrow also mildly increased, but did not discover any malignant lesion. Imaging examinations exclude other possible anatomic sites of origin despite hematology system, which was also ruled out by bone marrow puncture.
Detailed pathologic examination of the lymph nodes was recommended, the patient underwent incisional biopsy on February 29, 2012. Upon incision of the left axillary cavity, multiple confluent swollen lymph nodes were seen. Postoperative hematoxylin and eosin staining demonstrated moderately differentiated adenocarcinoma with solid nest

[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 48-year-old female attended the gynecology outpatient department for abnormal uterine bleeding. The patient was a follow up case of right-sided clear cell RCC that had been operated 3 years back by the procedure of radical nephrectomy. She had also been operated for meningioma right sphenoid wing () by the procedure of craniotomy 6 years back following which, the patient developed recurrence. The removal of residual tumor was done by gamma knife therapy. On histopathological examination, the tumor showed features of transitional meningioma (WHO grade I). During follow up, the patient started developing right-sided lumbar pain for 3 months. Ultrasonography revealed a hypoechoic lesion measuring 6.7×6.9 cm in the middle pole of right kidney with displacement of the pelvicalyceal system. CT scan revealed features suggestive of RCC () which was proven on histopathology, when the tumor was removed by the procedure of radical nephrectomy. A Technetium99 MDP bone scan revealed no metastatic foci. Also VHL gene sequencing studies did not show any evidence of mutation.
Patient has been under constant follow up since then, when she started developing abnormal uterine bleeding. On ultrasonography, an echogenic lesion was identified on the right side of pelvis. Intra-operatively, a 5×4×3 cm ovarian mass was identified. The ovarian mass was solid with yellowish-grey and hemorrhagic areas with tiny cystic spaces ().
A frozen section examination was done along with intra operative cytology in the form of imprints and scrape smears. Cytological smears showed cells dispersed singly along with focal clusters of clear cells. There was mild nuclear pleomorphism and presence of prominent nucleoli in some of the cells, however no mitosis or necrosis was identified. Frozen sections showed clear cells arranged in cords, nests as well as tubular pattern with mild nuclear atypia. A diagnosis of malignant epithelial tumor was given. A Total abdominal hysterectomy with bilateral salphingooph

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


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

[User]
RADIOLOGY NOTE:
A 58-year-old female patient presented with a history of persistent pain, redness accompanied by bilateral visual loss since the past one and one half years. Previous significant medical history included surgery for pituitary macroadenoma 26 years ago. Previous investigations included a mantoux test that had been reported as “positive” but the patient had declined to start antitubercular therapy.
Her best corrected visual acuity was counting fingers at 6/12 in the right eye and 6/36 in her left eye. Slit lamp examination of her right eye revealed multiple fresh nongranulomatous keratic precipitates with a severe anterior chamber reaction (cells 2+, flare 2+). The anterior chamber had a normal depth but there were extensive posterior synechiae with a complicated cataract. similar findings were seen in the left eye.
The disc and the retina were normal in either eye. The intraocular pressure was 10 and 12 mmHg.
Systemic evaluation revealed palpable cervical and axillary lymph nodes. A repeat mantoux test showed an induration of 22× ×25 mm. Her total and differential blood counts, tests for serum creatinine, serum calcium, serum angiotensin converting enzyme and serological tests to detect human immunodeficiency virus (HIV) infection were normal.
A 18 FDG-PET scan revealed several metabolically active, bilateral level 5 lymph nodes in the neck, the largest on the left side measuring 1.6 ×1.8 cm with SUV max 5.5 and the largest on the right measuring 1.4 cm with a SUV max 5.2. The lungs and mediastinum were clear. Several metabolically inactive nodes were seen bilaterally in the axilla.
She underwent an ultrasound guided biopsy of a right posterior cervical lymph node suggested by the PET/CT scan. The microscopic examination revealed several medium sized epithelioid granulomas with occasional central necrosis suggestive of tuberculosis.
She was started on standard four drug therapy along with topical and periocular corticosteroids. Two months later there was a marked red

[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 male was diagnosed with central non-small cell lung cancer 12 months earlier. The primary lung cancer was located in the proximal right upper lobar bronchus associated with postobstuctive atelectasis of the right upper lobe. However, at the time of diagnosis, the patient refused all the curative means. He had exhibited cough and increasing blood tinged sputum in the previous 4 months. We performed CT imaging on outpatient clinics, which showed a completely obstructed right upper lobar bronchus by a tumor with postobstructive pneumonia of the right upper lobe. The wall of the right main bronchus and bronchus intermedius was thickened and the lumen of the right main bronchus was almost narrowed by tumor infiltrations. Metastatic lymphadenopathy was observed in the right lower paratracheal and subcarinal area (). Nine days after the CT scan, the patient was hospitalized and underwent bronchoscopy. A bronchoscopic examination demonstrated that orifice of the right main bronchus was nearly completely obstructed by the endoluminal mass and there was diffuse bleeding from the right main bronchus. The patient received urgent external beam radiotherapy to control bleeding from the friable endobronchial tumor and bleeding gradually decreased for several days. However, eleven days after the radiation therapy, a sudden onset of dyspnea developed. Chest radiography showed that the right lung had totally collapsed and bronchoscopic examination revealed complete obstruction of the right main bronchus with diffuse bleeding.
Bronchial artery embolization could not be considered as a treatment option for hemoptysis because bleeding conditions were not because of active arterial bleeding and there was no prominent contrast enhancement of the mass as seen on the CT scan. We decided that bronchial stent insertion in the right main bronchus was necessary to both, re-open the airway and to control the bleeding of tumor through the tamponade effect. After the bronchogram, whi

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


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

[User]
RADIOLOGY NOTE:
The patient, a 55-year-old female, was admitted in the hospital on July 5, 2019, because of the discovery of an abdominal mass that had been present for more than 4 months. Approximately 4 months prior, the patient inadvertently found a hard upper abdomen mass but reported no associated pain. The patient self-reported the tumor to be about the size of an egg but reported no nausea, vomiting, abdominal pain, diarrhea, haematemesis, blood in the stool or other discomfort. A local hospital computed tomography (CT) enhancement scan revealed a solid cystic mass in the upper abdomen, and the initial segment of the jejunum was unclear, suggesting the possibility of a stromal tumor. The patient was physically healthy. The examination upon admission revealed a soft abdomen that allowed the abdominal mass to be palpated. The mass was hard and appeared to contact the upper left abdominal area, and the size was approximately 5 × 6 × 5 cm. The patient's level of activity was good, and there was no tenderness. After admission, the relevant examinations were completed, and no obvious abnormalities were found in the laboratory tests, which included routine blood tests, biochemistry tests, and tumor marker analyses.
The upper abdomen enhanced CT showed the following: an abnormally dense shadow was present across the upper abdomen, but the side was clear, and the tumor size was approximately 6.2 × 5.8 cm. There was an uneven density within the lesion, with obvious visible enhancement present in 1 area and a cystic nonenhanced area. The lesion was closely related to the intestinal tract of the small intestine (beginning approximately at the jejunum), and a small arterial branch was seen inside. There were no obviously enlarged lymph nodes beyond the retroperitoneum (Fig. A–C).
First, the patient underwent ultrasound-guided abdominal biopsy, and the postoperative pathology results showed the following: the cells showed alveolar and trabecular growth and were of a consistent shape, with

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


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

[User]
RADIOLOGY NOTE:
A 52-year-old man with a complicated past medical history of chronic kidney disease and small bowel transplant status post colonoscopy leading to ischemic bowel presented to the emergency room with homicidal and suicidal ideations. The patient had the small bowel transplant nearly 3 years prior to the emergency room visit. He had been maintained on tacrolimus to prevent bowel rejection, but otherwise was on few medications and in otherwise good health. According to his wife, he had never exhibited such behavior in the past and there were no obvious precipitating factors to this sudden attitude change. His erratic behavior was exhibited by the patient taking ∼24 lorazepam tablets throughout the day prior to admission and firing shots from a gun in their home, leading to police involvement. He had also complained of back pain for several days prior to the emergency room visit. He had no exposure to other drugs and his medications, including his tacrolimus, had not changed.
Owing to this bizarre behavior, a workup was started. Laboratory work in the emergency room revealed a serum creatinine of 1.6 mg/dl, but was otherwise unrevealing. Ultimately, an MRI was performed (Figure ). Imaging revealed several contrast-enhancing lesions within the diploic space of the calvarium, the largest of which was a 3.6 × 3.6 × 1.8 cm plasmacytoma in the right parietal calvarium near the vertex. The mass extended through the inner table leading to displacement of the underlying left parietal cortex, and extension through the outer table contributed to involvement of the overlying soft tissue of the scalp. Multiplanar and multisequence imaging of the cervical and thoracic spine with and without contrast indicated multiple enhancing foci within the left T6 pedicle and T4, T5, T7 and T8–T12 vertebral bodies. Lumbar spinal imaging also revealed areas of altered marrow signal in the L2–L5, S1 and S2 bodies, giving the overall impression of metastatic disease

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


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

[User]
RADIOLOGY NOTE:
A 36-year-old woman with gravida 2 Para 1 Living 1 with previous caesarean section at 29 weeks four days of gestation was referred with diffuse pain abdomen and giddiness. The pain was diffuse and present for the past 20 days which was partially relieved by symptomatic treatment by local doctors, and she also received antibiotics suspecting urinary tract infection. However she presented then with history of giddiness and one episode of vomiting with no history of diarrhoea and was referred. She was married for 10 years. Her first pregnancy was three years back when she underwent caesarean section for placenta previa. She continued to have episodes of pain abdomen in the postnatal and interpregnancy period for which she received symptomatic treatment by local doctor. She was pale on examination. Her vital signs including temperature were normal. There was no guarding or rigidity except mild tenderness on abdominal examination. The uterus was corresponding to 28-week gravid uterus size and was showing occasional contractions but no scar tenderness. Foetus was in breech presentation having regular heart rate. Her investigations showed mild anaemia with haemoglobin of 8.7 g% and neutrophilic leukocytosis (WBC 20900/c mm). Obstetric ultrasound showed single live intrauterine foetus corresponding to 29- to 30-week gestation. Suspecting chorioamnionitis the tocolysis was not administered. She went into spontaneous preterm labour. She was posted for emergency caesarean in view of previous caesarean with breech presentation under spinal anaesthesia with the coverage of antibiotics. On opening the abdomen, multiple pockets of pus were noted in the peritoneal cavity, and the coils of intestine and omentum were found adherent to the fundus and anterior upper surface of the body of the uterus. Lower segment caesarean section was done, and live male baby weighing 1.37 kg was extracted as breech. Then the general anaesthesia was induced, and the exploration was done by extending t

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


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

[User]
RADIOLOGY NOTE:
A 16-year-old female patient presented to the radiotherapy department in July 2008 with complaint of unrelenting hoarseness of voice for the last 1 year. She developed it gradually over a period of time. Initial treatment was directed to common cold but was of no help. There was no associated sore throat, otalgia, localized pain or tenderness over thyroid cartilage, dysphagia or features of airway obstruction. The patient is a nonsmoker and is nonalcoholic and without any history of past or present marijuana smoking. There was no history of prior neck irradiation. An incidence of cancer in the family could not be elicited from a detailed history. An indirect laryngoscopy was performed, which showed both vocal cords to be mobile. There was no visible growth over any of the vocal cords. Contrast-enhanced CT scan of the neck was performed, and it showed a small irregular lesion over the left vocal cord at the junction of anterior one third and posterior two thirds []. Thickening of left true vocal cord with loss of paraglottic fat is seen, suggestive of a neoplastic lesion. The normal paraglottic fat on the right side is seen as black area just deep to the thyroid cartilage (seen as white). The airway is seen as black oval structure. There is no visible neck node. Fiber-optic laryngoscopy confirmed the CT scan finding, which also showed irregular lesions along the medial margin of the left vocal cord []. Both CT scan and fiber-optic laryngoscopy showed an otherwise normal picture. Microlaryngoscopic removal of the mass was performed. Histopathological examination under low-power and high-power fields showed severe dysplasia and full-thickness replacement of epithelium with dysplastic cells and diagnosed it as carcinoma in situ [Figures and ]. However, the risk of a micro-invasive carcinoma could not be ruled out. A second biopsy was advised to obtain deeper tissue, but it was refused by the patient. So from the available documents, we considered it carcinoma in situ 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:
An 88-year-old woman with dementia was brought to our emergency department (ED) due to two rapidly growing painful nodules on her right lower leg. Due to her dementia, the medical history was mostly obtained from her son, and the informed consent for this case report was signed by her son. She had poor performance status and was capable of only limited selfcare (Eastern Cooperative Oncology Group Performance Status Scale grade 3). She was confined to the bed or chair most of the time and was normally cared for at a nursing home. According to her son, the nodule on her right anterior lower leg appeared about 3 weeks previously, and she had begun to complain of right lower leg pain. The other tumor was located at the medial aspect of her right lower leg, and it had appeared only 1 week previously. The two nodules had grown rapidly, with increasing pain. She denied experiencing fever, night sweats or weight loss in recent months. She had been seen at a local clinic prior to her ED presentation. At the clinic, antibiotics had been prescribed and a needle aspiration of the larger skin lesions was attempted. No pus or fluid could be aspirated, and despite antibiotic treatment, the lesions were getting larger. Thus, she was transferred to our ED for further evaluation and treatment.
Physical examination revealed two red and violaceous skin lesions over the right lower leg, ~9 and 3 cm in size, respectively. The lesions were erythematous, had ill-defined borders and were tender on palpation. Local heat and swelling of the skin around the lesions were also noted. Laboratory data, including a complete blood count and biochemical studies, revealed no significant findings. Contrast-enhanced computed tomography of the lower limbs revealed an abnormal space-occupying lesion about 9 cm × 7.5 cm × 3.3 cm in size, at the anterior aspect of the right lower leg. It showed heterogeneous density, heterogeneous contrast enhancement, and involvement of the subcutaneous area, superficial f

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


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

[User]
RADIOLOGY NOTE:
A 55-year-old male with a 20-year history of ulceration over the lateral and medial aspects of his left ankle presented with a two-month history of pain. In 1993, he had developed chronic ulceration on either side of the ankle from friction caused by his shoe. The wounds were originally treated with saline irrigation by a rural doctor. The patient worked in a paddy field and had poor economic circumstances.
Physical examination revealed a 4.5-cm-diameter ulcer over the medial aspect and a 5-cm-diameter ulcer over the lateral aspect of the left ankle. A Marjolin's ulcer with similar histological characteristics occurring in different parts of the body simultaneously is a rarely reported occurrence. The crater-shaped ulcers were dirty, necrotic and malodorous, with surrounding tissue proliferation ( and ).
Radiography showed areas of dense cortical bone and new periosteal bone formation in the middle and distal parts of the left tibia and fibula, and in the calcaneus and talus. There was a small area of bone destruction in the distal part of the tibia, with signs of chronic osteomyelitis and surrounding soft tissue swelling (). Bacterial cultures of the wound surface revealed Proteus penneri.
In September 2012, the patient underwent partial resection of the lesions. Pathological examination showed well-differentiated squamous cell carcinoma in the two lesions (). PET-CT showed abnormal uptake in the lymph nodes of the left popliteal fossa and left inguinal region, but it was unclear whether this represented wound infection or tumor metastasis ().
In September 2012, the patient underwent below-knee amputation of the left leg for these aggressive lesions. Two weeks after surgery, PET-CT still showed increased uptake in the lymph nodes of the left popliteal fossa and inguinal region, indicating possible metastasis. The patient then underwent B-mode ultrasound-guided biopsy of the left popliteal and inguinal lymph nodes. Examination of the biopsy specimens showed metastas

[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 male with history of congenital membranous ventricular septal defect (VSD) developed tricuspid valve endocarditis following a dental procedure in 2007 and subsequently underwent VSD closure and bioprosthetic tricuspid valve replacement. His left ventricular (LV) ejection fraction prior to surgery was normal. In 2009, he presented with heart failure symptoms and was found to have severe LV systolic dysfunction. Since LV dysfunction persisted despite optimal medical therapy, he was referred to electrophysiology for consideration of a primary prevention ICD in 2010.
His 12-lead electrocardiogram at baseline () showed sinus rhythm with a QRS pattern consistent with ventricular pre-excitation over a right free wall accessory pathway (AP). The QRS duration was 193 msec. A transthoracic echocardiogram showed normal LV size with evidence of abnormal septal wall motion and an LV ejection fraction of 35%. The bioprosthetic tricuspid valve showed normal function and there was no evidence of residual VSD. A cardiac CT revealed normal coronary arteries and a cardiac MRI showed no evidence of delayed enhancement. We felt that the ventricular preexcitation pattern mimicking left bundle branch block could potentially contribute to his cardiomyopathy by causing dyssynchrony [,]. Therefore, the patient underwent electrophysiology study with a plan for catheter ablation of the AP.
Baseline rhythm was sinus with a preexcited QRS complex of 193 msec. The HV interval was negative. The antegrade and retrograde AP block cycle length were 270 and 280 msec, respectively. Retrograde atrial activation was entirely eccentric with the earliest local activation in the area of the antero-lateral tricuspid annulus. The antegrade AP effective refractory period (ERP) was 320/600 msec. No significant changes in QRS duration or pattern were noted during atrial programmed stimulation and decremental pacing (). The retrograde AP ERP was ≤ ventricular ERP (240/600 msec). No arrhythmia could

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


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

[User]
RADIOLOGY NOTE:
A 43-year-old man with a history of chronic alcoholism presented with abdominal distension. The previous day, the patient had presented to a local hospital with anal bleeding and abdominal pain after an incidental insertion of barbecue skewer per anus in the drunken state; subsequently, he had undergone sigmoid loop colostomy for rectal perforation. However, after the operation, the patient had become hemodynamically unstable. At presentation, his systolic blood pressure was 90 mmHg and the pulse rate was 135 beats/min. Although there was no gross rectal bleeding, the digital rectal examination revealed a penny-sized anterior rectal wall defect 6 cm from the anal verge (AV). Computed tomography (CT) revealed a hematoma (12 × 10 × 15 cm) with active bleeding in the pelvic cavity and a pseudoaneurysm in the anterior wall of the rectum (). Since the patient was hemodynamically unstable, an emergency operation was performed. During the operation, a massive subperitoneal hematoma in the rectovesical pouch and large amount of blood in the peritoneal cavity were found. After evacuation of the hematoma and blood, oozing continued in the rectovesical pouch (). Thus, compression with gauze was performed for 30 min until the oozing stopped. The Hartmann procedure was performed with the suspected bleeding focus included, but the perforation site was not included.
Although the postoperative course was uneventful and there was no evidence of recurrent bleeding on the follow-up CT on the 7th postoperative day (POD), a focal enhancing lesion in the anterior wall of the rectum indicating a residual pseudoaneurysm was noted (). On the 11th day POD, his hemoglobin decreased from 11.6 g/dL to 7.9 g/dL, and the follow-up CT revealed recurrent hematoma (6.0 × 4.2 cm) in the pelvic cavity and the residual pseudoaneurysm (). Following the diagnosis of recurrent bleeding from the residual pseudoaneurysm, an angiography was performed. However, the angiography failed to localize 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 9-month old boy presented at a hospital in a south western state of Nigeria, with a swollen left upper arm adjoining the chest, low-grade continuous fever (38.1 °C), frequent passage of loose watery stool and persistent cries for more than 3 h. Child had been immunized about 24 h earlier. The mother reported that the symptoms were observed 2 h after the child was vaccinated with the measles vaccine at a private hospital. The child was one of three children reported to have been vaccinated with measles vaccine at a private hospital during the immunization clinic session.
On examination, he was mildly pale, febrile and anicteric. He was moderately dehydrated; mildly dyspnoeic with normal heart sound, heart rate of 148 beats/ min, breath sound was vesicular and respiratory rate of 54 cycles per minute. He was well nourished as the weight was appropriate for age. There was extensive swelling with skin discolouration (hyperemia) involving the entire left upper arm, sparing the distal third of the forearm and hand. There was also swelling of the upper part of the anterior chest wall. The swelling was firm and mildly tender. There was no history of adverse reaction to immunization or any form allergic reaction.
A day after admitting the child, extensive erythema of the left upper arm and anterior area of the chest was observed with extensive scalded skin lesion involving the deltoid area, the upper chest wall and arm (Fig. ). Desquamation of the affected areas was observed presenting like severely burned skin from a hot liquid. There was darkening and hardening of the skin over the affected area on the arm with eventual severe necrosis up to a depth of about 5 mm thereafter (Figs. and ). A diagnosis of severe necrotizing fasciitis was made.
Radical debridement of necrotic tissues was carried out under general anaesthesia. Child was also transfused with blood. Daily dressing of the wound was done and antibiotics administered were intravenous metronidazole (20 mg

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


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

[User]
RADIOLOGY NOTE:
A 65-year-old female presented with a 2 months history of progressive intermittent claudication of the right calf. She had no history of limb trauma but exhibited hypertension, hyperlipidemia, and paroxysmal atrial fibrillation that were well controlled. Her maximum walking distance was approximately 500 meters, but she did not experience rest pain at the time she presented to our hospital. On physical examination, the right posterior tibial or dorsalis pedis arteries were not palpable. The ankle-brachial index on the right leg was 0.70. Her vital signs were stable, with no significant laboratory findings. Enhanced computed tomography showed an occlusion of the right popliteal artery with a 60-mm-long circular cystic arterial lesion but preservation of arterial flow below the knee by collateral circulation (). The left popliteal artery and aortoiliac region showed no signs of arteriosclerosis. She was diagnosed as having ACDPA. Because she was symptomatic, with a 500-m intermittent claudication caused by the occlusive lesion, we decided upon surgical treatment. Under general anesthesia, in the prone position and through a posterior approach, a 60-mm-long intramural cyst of the right popliteal artery was exposed. No popliteal arterial pulse was noted below the knee. The cyst was punctured to reveal tenacious mucoid material, although there was no improvement in arterial flow. We then incised the cyst for drainage and decompression (), but the right popliteal arterial flow remained diminished on intraoperative angiography. Finally, we resected the affected popliteal artery with interposition using a right great saphenous vein graft. The operative time was 3 h 56 min, and blood loss was 170 mL. The ankle-brachial index after revascularization improved to 1.10 in the right leg, and the right posterior tibial and dorsalis pedis pulses became palpable. On the 13th postoperative day, she was discharged from our hospital. Histopathological examination revealed that the muco

[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 forty-five-year-old female patient was admitted to our Clinic for symptomatic gallstones and laparoscopic cholecystectomy was performed without any drainage placement. On the second post- operative day the patient had abdominal pain on the right side; ultrasound showed a small subhepatic fluid collection compatible with laparoscopic surgery. Next day the patient was discharged without any problem.
Because of severe abdominal pain, the seventh postoperative day the patient referred to our Clinic.
On admission laboratory tests were performed and showed slightly elevated values of liver transaminase and alkaline phosphatase. Ultrasound identified minor subhepatic fluid collection. On the third day after admission the patient presented increase in body temperature of 38 degrees. Abdominal computer tomography revealed abundant free fluid in all the recesses, and in particular sub-hepatic, so a biliary fistula was suspected. The same day urgent laparoscopic revision was decided and intraabdominal bile collection with biliary peritonitis was found. After careful washing and drainage placement, an endoscopic retrograde cholangiopancreatography (ERCP) showed contrast spreading from the cystic duct. Sphincterotomy (PST) and 10-French endobiliary stent placement were performed.
In the course of the next few days, the patient was treated with antibiotic therapy and was pain free. After three days she developed fever and the amount of drainage output increased. Computer tomography revealed abdominal free fluid and two subhepatic and perigastric collection, respectively 69x31 mm and 61x27 mm. A laparoscopic peritoneal toilette was performed and four drainages were placed.
During the following days, bile flow through the external drainages did not decreased in spite of fasting; an ERCP allowed visualization of contrast spreading upstream of the stent (). After its removal a contrast spreading from the cystic duct was noticed too (). A nasobiliary tube was placed at the biliary b

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


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

[User]
RADIOLOGY NOTE:
A 63-year-old male complaining about a “wound in the mouth” was referred to Goiás Oral Medicine Center, Federal University of Goiás Dental School, Goiânia, Brasil, for diagnosis and treatment. The patient reported that the lesion had approximately 6 months of evolution and that he was asymptomatic and had not experienced any bleeding. His medical and dental history did not show any significance or any relation to his lesion. The patient had been a smoker for 33 years. Intraoral examination revealed a destructive ulcerative lesion around the upper left first and second molars, which showed mobility and poor dental conditions, including dental caries, gingival recession and bone loss (Fig. a). A panoramic radiograph revealed a radiolucent area in the periapical region of the upper left first molar, suggesting an osteolytic lesion (Fig. b). According to the clinical and radiographic features, the main diagnostic hypotheses were periodontal disease associated with oral squamous cell carcinoma. The patient reported that there was no cancer in his family history. The results of laboratory analyses, including blood and urine studies, were within the normal range. We also performed a biopsy to provide histopathological analysis. At this time, the patient took prescribed antibiotics for 7 days and underwent surgery of the upper left primary molar. Microscopic findings showed an inflammatory infiltrate rich in plasma cells that is commonly present in periodontal disease, without the presence of any atypical cell in this specimen of oral mucosa. Based on these findings, periodontal disease was considered as the diagnosis and the patient underwent periodontal therapy twice without remission of the initial injury. During follow-up, it was observed that the lesion increased considerably.
Since the lesion was increasing in size, a second biopsy was performed on a deeper level of histological plan. It showed a proliferation of cells resembling histiocytes with an occasional pale nu

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


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

[User]
RADIOLOGY NOTE:
A 51-year-old woman was referred to the Department of Oral and Maxillofacial Surgery at Tokyo Medical University Hospital for a closer evaluation and treatment of an asymptomatic firm mass in the left posterior maxillary site. Intraoral examination revealed a palpable mass located in the posterior lateral region of the left maxilla (Fig. a). The overlying mucosa was intact and normal in color. The firm mass was not movable. Laboratory data were within the normal limits. Computed tomography (CT) scan of her head and neck showed a clear circumscribed solid mass measuring 28 × 23 mm in size between the lateral aspect of the posterior maxilla and the anterior region of the masseter muscle with no evidence of maxillary bone involvement (Fig. b). There was no lymphadenopathy in the cervical region. Magnetic resonance imaging scans revealed homogeneously enhanced signal intensity on T1-weighted images after gadolinium administration (Fig. a) and high signal intensity on Short T1 Inversion Recovery images (Fig. b). Incisional biopsy demonstrated benign lymphoid tissue. CT examination was conducted in the chest and abdominal region taking into consideration Castleman’s disease as a differential diagnosis. However, systemic lymphadenopathy was not recognized. The submucosal mass was completely excised under general anesthesia. In the course of the surgical resection, the mass was observed to be adjacent to the buccal fat pad.
Gross examination showed a solid mass measuring 38 × 23 × 17 mm in size, which was encapsulated with fibrous tissue (Fig. ). Microscopic examination revealed lymphocytic tissue composed of scattered lymphoid follicles with germinal centers and predominant small well-differentiated lymphocytes in the parafollicular area (Fig. a). The follicles showed various sizes of the germinal centers surrounded by well-defined mantle zones consisting of small lymphocytes (Fig. b). The germinal center contained a mixture of centrocytes and centroblasts with occasional

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


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

[User]
RADIOLOGY NOTE:
On November 2009 a 33-year old woman with no significant previous medical history was referred to her gynecologist due to complaints of pelvic pain. A right ovarian cyst was diagnosed upon examination. However, due to persistent pain, a CT scan was performed that revealed a right pelvic mass. On 12 November 2009 the patient’s gynecologist performed laparoscopic surgery during which a sub peritoneal lesion likely to start from the bladder was found. The mass was removed but ruptured during surgery, with intraoperative spillage of mucinous material. A cystoscopy was performed postoperatively, which showed a reddish lesion of the dome of the bladder. The intraoperative histological diagnosis was mucinous adenocarcinoma. This was then confirmed by the final histological examination.
The patient was referred to our hospital, Istituto Nazionale Tumori (National Tumors Institute), Milan, Italy, a referral center for the treatment of oncological disease in Italy, and a histological review was performed by our genitourinary pathology expert. The immunohistochemical analysis was positive for CDX-2 and CK20 and negative for CK 7, suggesting a diagnosis of mucinous adenocarcinoma originating from the urachal ligament. We then performed a whole body CT scan that showed two metastases in the right lung, one at the lower lobe and one in the middle lobe, with a diameter of 15.6 and 8.5 mm, respectively, and one lesion anterior to the bladder wall and the dome that extended through the bladder wall, protruding into the lumen. Serum CEA was 15.39 ng/mL (normal <5), CA 19.9 was 70.1 U/mL (normal <37), CA 125 negative, CA 15.3 negative.
We discussed the case of the patient with the urological surgeon and, given the extension of the disease, we decided to treat the patient with systemic chemotherapy rather than performing surgery.
The histological type, the strong mucinous component and the phenotypic similarities with a cancer of gastroenteric origin, rather than urothelial, prompted u

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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:
We present the case of a 74-year-old male who was admitted to the hospital after presenting to the emergency department (ED) with the chief complaint of right arm weakness and difficulty in speaking. His past medical history included diabetes mellitus, hypertension, persistent atrial fibrillation on long-term anticoagulation with rivaroxaban, heart failure with reduced ejection fraction of 30% and aortic stenosis with two previous bioprosthetic surgical aortic valve replacements in 2004 and 2014. Two months prior to admission, he was diagnosed with IE caused by Group B Streptococcus involving the aortic bioprosthetic valve. Initially, he presented with complaints of intermittent febrile episodes and night diaphoresis for approximately 8 weeks. At that time, the decision was made to treat him conservatively with oral antibiotics and close clinical monitoring. Blood cultures were negative in two different occasions, and the patient was discharged on stable conditions. However, a day prior to his second hospital admission, the patient noted sudden onset right upper extremity weakness (MRC power grade 3) and dysarthria. Upon further evaluation in the ED, a magnetic resonance imaging (MRI) of the brain revealed multiple embolic strokes ().
Transthoracic echocardiography and computed tomography angiography (CTA) of the chest revealed nonspecific structural changes with images compatible with a possible aortic perivalvular abscess/pseudoaneurysm (). Transesophageal echocardiography (TEE) confirmed a perivalvular cavity around the aortic root, and this cavity was communicating with the aorta. Furthermore, the cavity was also in communication with the left ventricle (LV), creating a dynamic of retrograde flow, with blood passing from the aorta to the LV through the fistulous tract (). As a result, the patient developed an ACF due to perivalvular endocarditis, which resulted in symptomatic severe aortic valve regurgitation.
The patient was transferred to a tertiary care cente

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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 45-year-old man presented to our otorhinolaryngology outpatient department with the symptoms of persistent odynophagia and hoarseness for 1 week after ingesting a fish bone. There was neither dysphagia nor dyspnoea. At first, he sought medical consultation in a local clinic and cervical X-ray was done. However, it was not conclusive, and there was no sign of presence of foreign body in the pharynx. Due to the worsening of his symptoms, he presented to our clinic on 25 August 2016. Flexible pharyngolaryngoscopy was done, and it was noted that there was left vocal cord immobility, oedematous left aryepiglottic fold, and left pyriform fossa with secretions in it. We could not find any foreign body in his pharynx nor in larynx. However, based on his history, the presence of fish bone impaction in the larynx was suspected. The patient was then admitted to the hospital, and urgent computed tomography (CT) scan of the neck was done and revealed a 3 cm linear foreign body embedded in the soft tissue medial to the left thyroid cartilage with surrounding hypodense soft tissue swelling causing mild indentation of the left vocal cord extending into the supraglottic region up to the left pyriform sinus and downwards minimally extending to the infraglottic region causing mild asymmetric narrowing of the involved laryngeal segments and causing mass effect on the glottis and supraglottic airway causing mild asymmetric narrowing ().
The diagnosis of inflammation of the paraglottic region and vocal cord immobility secondary to fish bone impaction in the paraglottic space was made. The patient was then shifted to the operation theatre (OT), and rigid direct laryngoscopy was performed under general anaesthesia. It revealed oedema in the left pyriform fossa and left supraglottic region, and no foreign body was visualized. Also, rigid oesophagoscopy was performed, and it showed the same findings as the laryngoscopy. Therefore, foreign body retrieval endoscopically has failed

[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 woman arrived in the emergency department complaining of acute right lower quadrant abdominal pain and vomiting. She did not report any weight loss or diarrhea. She had no history of abdominal surgery or any other allergic disease. She denied taking any drugs or herbal medicines. A physical examination of the abdomen revealed tenderness with rebound tenderness in the right lower quadrant of her abdomen. Initial laboratory investigations showed a white cell count of 14,400/mm3 with 75% neutrophils, 16% lymphocytes, 3.3% monocytes, and 4.3% eosinophils (an absolute eosinophil count of 619/mm3). Other laboratory tests and stool examination for ova and parasites were within normal limits. Based on her physical examination, a laparoscopic appendectomy was performed for a presumed diagnosis of an acute appendicitis; however, it revealed bowel edema and a moderate amount of ascites in the abdominal cavity without gross evidence of appendicitis. The appendectomy specimen showed eosinophilics were infiltrating the muscular and subserosal layers of the appendix wall (). Ascitic fluid analysis showed exudative ascites with predominant eosinophils (a white cell count of 3,150 cells/µL with 75% eosinophils) and no evidence of malignant cells. Postoperatively, the degree of peripheral eosinophilia progressed to 1,729/mm3. Tests for antinuclear factor, rheumatoid factor, antineutrophilic cytoplasmic autoantibody, and skin prick test were all negative.
A gastroscopy showed marked edema of the gastric antrum and narrowing of the pyloric ring. The duodenum also showed mucosal edema with erythema. Biopsies of the gastric antrum and proximal duodenum revealed inflammation with eosinophilic infiltration (). A colonoscopy showed normal mucosa without eosinophilic infiltration. Although an abnormal skin lesion was not observed, a punch biopsy of the central abdominal skin revealed diffuse perivascular and interstitial inflammation with marked eosinophilic infiltration (). Th

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


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

[User]
RADIOLOGY NOTE:
A 63-year-old man was admitted at the emergency department of a general hospital after experiencing painless hematuria which was his only symptom; he had a history of smoking and hypertension. Laboratory tests showed results within normal limits: creatinine levels were 0.9 mg/dL and he had a glomerular filtration rate (GFR) greater than 60 mL/min. Urological ultrasonography revealed a 4 cm tumor on the right posterolateral wall of the bladder which appeared to be invasive.
Computed tomography (CT) of the abdominal and pelvic area showed a mass in the urinary bladder corresponding to stage 3 (cT3b) with apparent infiltration into the fat but without lymph node involvement. Cystoscopy and transurethral resection (TUR) of the tumor was carried out but residual tumor remained. Pathological examination confirmed a urothelial carcinoma with evidence of invasion into the muscular layer.
The patient did not receive neoadjuvant chemotherapy but surgical treatment was planned which consisted of radical cystectomy and Bricker-Wallace reconstruction. Histological examination of the resected specimen described a grade 3 urothelial carcinoma with infiltrations into the adjacent fat tissue. Twenty-two tumor-free lymph nodes were also removed, and the tumor was staged as a pT3bN0. The tumor margins as well as the urethers were microscopically negative and there was no in situ carcinoma. After surgery creatinine blood levels were 1.2 mg/mL and the GFR was higher than 60 mL/min.
The patient remained disease-free for 18 months until a single, newly-formed 1.6 cm lung nodule was discovered which was not accessible for biopsy using standard techniques. No mediastinal lymphadenopathies were found and there was no evidence of disease in any other location. At this point, the patient underwent resection of the mass and the histo-pathological examination revealed a 1.2 cm metastatic lesion from a urothelial carcinoma with tumor-free edges. No chemotherapy was administered after surgery.
Twe

[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 thirty eight year old lady was admitted with complaints of worsening breathlessness and low grade fever of one month duration. This was associated with pleuritic type of chest pain on inspiration and orthopnea for past three days. She had developed multiple skin ulcers on her lower back over one month duration. Two of these were discharging serous fluid over past two weeks. She had undergone right knee surgery seven years ago and incisional hernia repair three years ago. There was no history suggestive of tuberculosis in the past. She had been treated unsuccessfully with antibiotics for suspected folliculitis with abscesses on the back, at another centre for one week prior to admission in our hospital. On examination, BCG vaccine scar was seen on the left deltoid. There were multiple, nontender skin ulcers on bilateral lumbar areas, some oozing serosanguinous discharge and few others with scarring []. Respiratory system examination revealed restricted right sided respiratory movements, stony dull percussion note in right hemithorax and absent breath sounds on right side in all lung fields. Other system examinations were normal.
Chest X-ray was suggestive of right sided pleural effusion []. Pleural fluid aspiration and analysis was done. Results are detailed in . Pleural fluid was exudative in nature with 99% lymphocytes and adenosine deaminase level of 108 IU/L, suggestive of tuberculous etiology. Other blood investigation results are given in . Echocardiography was normal. Intradermal Mantoux (1 TU PPD with RT 23 Tween 80) was positive (12 mm) at the end of 48 hours. Skin biopsy was taken from the edge of the ulcer and histopathological examination was done. It was reported as granulomatous inflammation suggestive of tuberculosis. The biopsy specimen contained multiple granulomas composed of epithelial cells and langhan’s giant cells; areas of necrosis and dense lymphocytic infiltrate []. It did not stain for acid fast bacilli. Diagnosis of pulmonary tuberculosis

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


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

[User]
RADIOLOGY NOTE:
A 35-year-old G4P2012 presented to labor and delivery at full term in early labor with spontaneous rupture of membranes. She had undergone living donor kidney transplant 8 years prior for ESRD suspected secondary to IgA nephropathy versus post-streptococcal glomerulonephritis. She was maintained on Prograf and prednisone throughout her pregnancy with a stable baseline serum creatinine 1.2 mg/dL. Obstetrical history was significant for two prior uncomplicated Cesarean deliveries, both prior to her kidney transplantation. It was unclear from her records whether she had undergone counseling regarding pregnancy post-transplant. She declined a of trial of labor after Cesarean section despite counseling on the risk of injury to the transplanted kidney given its location in the operative field, which was confirmed on transabdominal ultrasound prior to the case.
The patient was taken to the operating room for and indicated repeat Cesarean section. Routine dissection was performed down to the level of the fascia through a Pfannenstiel incision and the fascia was carefully transected horizontally in the usual fashion. When the superior fascial edge was lifted for traction to allow for dissection from the underlying rectus muscle, brisk pulsatile bleeding was noted. The transplanted kidney was noted to be densely adherent to the overlying anterior abdominal wall, and avulsion of a portion of the transplanted kidney was confirmed (Fig. ). Direct pressure was applied to the organ while the Trauma Surgery team was consulted. The avulsion was repaired using 3–0 pledgetted Prolene sutures in interrupted horizontal mattress fashion and using Evarrest compound. At this time, the decision was made to extend the skin incision in the vertical midline for improved access to the uterus given the concern for further shearing forces to the exposed transplanted kidney in the process of delivering the baby. The rest of the case was uneventful. No blood product transfusion was necessary. After

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


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

[User]
RADIOLOGY NOTE:
A 33-year-old female motorcyclist presented to our emergency department with a 3-h history of severe abdominal pain following blunt abdominal trauma after bumping by a car. She denied any medical or surgical history. We evaluated this patient according to the advanced trauma life support algorithm. The airway was patent, and bilateral breath sounds were clear. The heart rate was mildly elevated to 100 bpm without low blood pressure. She was conscious and clear without any neurologic deficits. No obvious open wounds were observed, except for an erythematous bruise on the right middle abdomen, measuring 3 × 3 cm in size. Contrast-enhanced computed tomography (CT) revealed pneumoperitoneum with mild ascites and a retroperitoneal hematoma in zone 1 (Figs. and ). We performed an emergency exploratory laparotomy suspecting hollow organ perforation and retroperitoneal hematoma. On midline laparotomy, we noted that a considerable amount undigested food had spilled out of the distended stomach onto the gastrohepatic ligament and lesser sac. A transverse full-thickness laceration on the lesser curvature of the stomach was observed, measuring approximately 10 cm in length (Fig. ). On retroperitoneal exploration, we used the Kocher maneuver to examine the first and second portions of the duodenum and observed them to be intact. We then opened the lesser sac to examine the pancreas and fourth portion of the duodenum, which were intact as well. No bilious ascites or active bleeding was noted during retroperitoneal exploration. Therefore, we performed a primary repair of the perforated stomach and sent the patient to the intensive care unit for further resuscitation. However, on the second postoperative day, peritonitis presented again, and the drainage tube showed bilious content. Hence, a second laparotomy was performed. This time, however, we observed bilious ascites in the lower abdomen. The repaired perforated stomach was intact. We then performed a complete right medial visc

[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 Syrian boy presented to the dermatology clinic with complaints of a widespread yellowish-white subcutaneous nodule on his right thigh. During 2 years of follow-up, other lesions had appeared gradually on the forearm, elbow and brachium (). Then the lesions showed chalky discharge (A) and no similar lesions were observed elsewhere in the body. There had been no increase in the number of lesions since the last visit. Clinical examination revealed palpable firm nodules below the skin. There were no signs of inflammation, joint pain or photosensitivity. His past medical history did not reveal any underlying diseases, including metabolic, autoimmune, malignant or traumatic events. There was no family history of similar complaints.
We did full blood count for the patient and all values were within normal ranges (). serum calcium and phosphate levels as well as parathormone, vitamin D hormone levels (vitamin D was checked to exclude high levels and hypercalcemia); alkaline phosphatase levels were within normal limits. Also, a 24-hour urine collection test showed normal calcium and phosphate levels. Erythrocyte sedimentation rate and Rheumatoid Factor tests were done at first to investigate inflammatory and immunological causes and the results came negative (). Then we did more specific tests to screen the most common conditions associated with the disease, Anti-Jo1 for dermatomyositis and it was negative (4.3), serological tests for systemic lupus erythematosus (SLE) and scleroderma, including antinuclear antibody (ANA) and anti-dsDNA were negative.
The possibility of familial hyperphosphatemia is unlikely because we checked-up parent’s calcium and phosphate blood levels and the results were normal. Plain x-ray revealing calcification around the elbow and brachium separate from the adjacent bone (B).
Surgical excision was performed and histological examination of one of the nodules revealed thick, chalky discharge at the time of the procedure and microscopic

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


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

[User]
RADIOLOGY NOTE:
This is the case of a 29-year-old female patient, G2P1001, at 12 weeks + 4 days, referred to us for management of giant splenic artery aneurysm. History goes back to 11 months prior to presentation when the patient had severe left upper quadrant pain during the 8th month of her first pregnancy. Her pain was then attributed to uterine contractions and thus she was delivered by Caesarean section with no further investigations carried out at that time.
During her subsequent pregnancy and few days before presentation, she developed the same left upper quadrant pain. Ultrasound was performed showing: enlarged spleen 15.5 cm, well-defined rounded heterogeneous lesion of 7.6 × 6.8 cm in favor of a splenic artery aneurysm. MRI was performed for better evaluation (Figs and ), revealing a single aneurysm 7.5 × 7 × 6.5 cm in the distal portion of the splenic artery with an intramural thrombus, abutting the splenic hilum.
Laboratory studies performed were normal.
At this point, open aneurysmectomy was decided for the following reasons: the large size of the aneurysm, its location in the distal third of the splenic artery, the extensive involvement of the splenic hilum, the potential need for a formal splenectomy, the fact that our patient was pregnant, and the potential risk of rupture in endovascular repair.
A left subcostal incision performed, entering the lesser sac by division of the gastrocolic ligament and liberation of the splenic flexure. The aneurysm could be palpated over the distal pancreas and splenic hilum, dissection and control of the splenic artery proximally. Dissection of the gastrosplenic ligament and ligation of the short gastric vessels. The aneurysm was adherent to the pancreatic tail, and exhibiting a severe desmoplastic reaction. Thus, a distal pancreatectomy was warranted. Ligation and division of the splenic artery proximally and distal pancreatectomy was thus performed. Ligation and division of the splenic vein, liberation of spleen

[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 6-day-old Pakistani boy was admitted to hospital in June 2005 for bleeding from the left nipple. His parents are first cousins. He has two siblings aged 8 and 6 years. There was no family history of bleeding diathesis. The mother had a normal pregnancy with full antenatal care. Mode of delivery at term was an elective Caesarean section due to previous Caesarean sections. His birth weight was 2.7 kg. 1 mg of Vitamin K was given intramuscularly at delivery. His first neonatal check was normal. He had a small amount of self-limiting bleeding from the umbilical cord on day 3 of life. He went home on day 4.
On day 6 of life he had mild spontaneous left sided nipple bleeding, which presented as spots of blood stains on the left side of his baby dress.
Over the next 7 days he had two further episodes of a similar nature. Baseline biochemistry and full blood count were normal but a coagulation screen showed a prolonged prothrombin time of 41 s (control 14 s), a prolonged partial thromboplastin time of 132 s (control 33 s) and normal thrombin time of 15 s (control 14 s). In view of the mild nature of bleeding, the child was only treated with 1 mg of i.v. vitamin K. Subsequent coagulation assays revealed a plasma factor V activity of less than 0.01 IU/ml (normal range 0.50–1.50 IU/ml) determined by factor V clotting assay with all other coagulation factors in the normal range. Hence the diagnosis of congenital factor V deficiency was made. A cerebral ultrasound done at this stage was within normal limits. Oral transexamic acid at a dose of 15 mg/kg/dose 3 times daily was started.
Mother was found to have a plasma factor V activity of 0.44 IU/ml (normal range 0.5–1.50 IU/ml) and the father of 0.52 IU/ml by factor V clotting

[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 59-year-old man with a past medical history of nonischemic cardiomyopathy who initially underwent OHT in 1994 (biatrial anastomosis) was referred for pacemaker lead revision. His posttransplant course had been complicated by transplant vasculopathy, and he ultimately required a second heart transplant in 2002 (bicaval anastomosis). He also developed ESRD and underwent deceased donor kidney transplantation in 2004. He developed ehrlichiosis in 2011 in addition to cryptococcal pneumonia and histoplasmosis requiring chronic treatment with antifungals. In 2013, he had syncope leading to a subarachnoid hemorrhage and was diagnosed with sinus node dysfunction in the setting of intermittent sinus bradycardia to less than 20 beats per minute. He underwent dual chamber pacemaker placement in 2013 (Medtronic ADDRL1) with a Medtronic 5076 lead in the ventricular position and a Medtronic 5592 lead placed in the right atrial appendage after an active fixation lead was deemed to be unstable.
He was admitted for volume overload three years later, and pacemaker interrogation revealed undersensing on the atrial channel due to a gradual P wave amplitude decrease from 4.7 mV at implant to ~0.4 mV, leading to asynchronous ventricular pacing and failure to recognize atrial arrhythmias. No change in lead position was detectable on chest X-ray. An atrial lead addition was planned. However, the left subclavian vein was occluded. He underwent extraction of the atrial lead to obtain venous access. A 12 French Spectranetics SLS II laser sheath was advanced over the lead, and minimal application of laser energy was used to free adhesions. Countertraction using a snare was also employed from the femoral vein. The lead was removed, and subclavian access was retained. A Medtronic 3830 lead was implanted in the right atrium. The patient tolerated the procedure well, and he had no complications within the next 30 days. However, he was admitted with cryptogenic encephalopathy two months later whic

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


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

[User]
RADIOLOGY NOTE:
A 15-year-old female patient (bodyweight 50 kg, height 160 cm) presented with syncope. Severe arterial hypertension was diagnosed (178/147 mmHg left arm, 102/83 mmHg left leg). She reported previous episodes of exercise independent headaches and nose bleeds. Auscultation revealed no cardiac murmurs, but an accentuated second heart sound and reduced pulses in the lower limbs. There were no clinical signs to suggest Alagille or William’s syndrome or clinical evidence of neurofibromatosis. Blood tests showed normal inflammatory markers and normal creatinine. The urine dip showed no markers for blood or protein. No regular medication was taken at the time she presented. The electrocardiogram showed normal sinus rhythm, no significant signs of left ventricular (LV) hypertrophy or abnormal repolarization. Echocardiography detected a severe concentric LV hypertrophy (14 mm diastolic septal diameter, 15 mm diastolic diameter of the LV posterior wall) and a long hypoplastic segment in the abdominal aorta with massive arterial collateralization. Cardiac catheterization confirmed the diagnosis of a midaortic syndrome with a minimum diameter of <1.5 mm and a gradient of 50 mmHg between the aortic arch and the femoral arteries (Figure ). The narrow part began directly under the diaphragm above the truncus coeliacus and continued down to the bifurcation of the arteriae iliacae including the renal arteries, with reversed flow in the caudal aorta up to the renal arteries. Because of the extraordinary length of the hypoplastic segment of 23 cm, we decided for a stepwise interventional therapy with a paclitaxel covered balloon. No additional computed tomography scan or magnetic resonance imaging (MRI) was performed. Consultation with our surgeon, supported the interventional approach. The proposed procedure was reviewed and approved by our institutional review board, extensively discussed with the patient’s family, and informed consent was obtained before proceeding.
After balloon in

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


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

[User]
RADIOLOGY NOTE:
A 35-year-old male was hospitalized for a 4 months complaint of worsening difficulty in swallowing, predominantly to solids, accompanied by mild loss of weight. Hematology and biochemistry laboratory tests were within normal limits, and standard chest radiography did not reveal any lung or mediastinal lesions.
Contrast-enhanced computed tomography of the chest showed a well-defined 3 × 3.5 × 4 cm homogeneous mass on the right side of the distal esophagus, proximal to the gastro-esophageal junction (Figure ). Transesophageal ultrasound was not available, but upper gastrointestinal endoscopy showed a smooth submucosal bulge in the distal segment of the esophagus, resulting in evident localized narrowing of the esophageal lumen. The overlying mucosa was intact.
Decision was made to perform elective excision of this mass lesion and, since the distal esophagus is usually more accessible from the left, this was carried out employing a left-sided video-assisted thoracoscopic surgical (VATS) approach. Using three 5-mm ports, the lower esophagus was dissected and the mass was identified (Figure ). Attempts to enucleate the mass were unsuccessful and, upon incising the mass to perform a frozen section procedure, thick creamy fluid leaked out confirming its cystic nature (Figure ). Consequently, layers of the decompressed cyst were dissected off the esophageal musculature with ease, the cyst was excised, and the specimen was retrieved through a limited thoracotomy incision. The continuity of the esophageal mucosa was confirmed by infusing methylene blue solution into the esophageal lumen while occluding the esophagus at the gastro-esophageal junction (Figure ). The muscular edges of the esophagus were reapproximated, and the resection site was buttressed with the mediastinal pleura.
There were no postoperative complications. The patient returned gradually to full oral intake and was discharged home on the fourth postoperative day in an excellent general condition. He remains s

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


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

[User]
RADIOLOGY NOTE:
A 41-year-old Japanese woman presented to our clinic with a 4 month history of bilateral groin pain and right buttock pain. Her right hip was more painful than her left hip. There was no history of trauma, alcohol abuse, or steroid use. Her medical history included iron-deficiency anemia diagnosed 2 years earlier, after which she had been on iron supplements. She had no fracture episodes, including fragility fractures.
Her height, body weight, and body mass index were 155 cm, 42 kg, and 18.7 kg/m2, respectively. She was able to walk for approximately 10 minutes without a stick, albeit at a slow speed. Limitations in the passive motion of her bilateral hip joint were observed thus: flexion, 100°, internal rotation 5°, external rotation 15°, and abduction 20°, on both sides. She was able to perform a straight-leg raise of the right limb with substantial pain. The neurovascular status of both lower extremities was intact. The Japanese Orthopaedic Association scoring system for the evaluation of hip-joint function (JOA hip score) was 46 points for her right hip and 56 points for her left hip. The score was based on a total of 100 points, comprising 40 for pain, 20 for range of motion, 20 for the ability to walk, and 20 for activities of daily living [].
Standard radiographs of both hips (Fig. a–c) demonstrated no characteristic findings such as the crescent sign, sclerotic band pattern, and collapse of the femoral head, and no joint space narrowing was seen in either femoral head. MRI of both hips (Fig. d, e) presented a low signal line in the subchondral region of the femoral head in the T1 weighted image and high signal region in almost all of the femoral head in the short tau inversion recovery (STIR). The oblique axial views of the proton density-weighted image showed a low-signal sinuous line in the anteromedial region

[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 9-year-old girl presented to our orthopaedic clinic, with main complaint of a mass which was getting bigger on her upper back. Her parents noticed that she has already had the mass since six years. The initial mass size was around 1 cm in diameter (like a marble) located just below the tip of both scapulae. Subsequently, more masses appeared on the left lateral side of vertebrae. It was accompanied by difficulty in moving both shoulders and neck since 4 years. Because of these complains, her family tried various traditional medicines without improvement.
Six months prior to admission, she fell down on her back, and since then the masses grew progressively. She also felt pain around the masses. Meanwhile her neck and shoulder movement were becoming more limited than usual. She was brought to a district hospital in other province and then referred to our hospital to get more appropriate treatment. There was no history of similar disease in her family.
On physical examination, general condition was good and no abnormality was found in other organ. We found multiple bony prominences measuring about 2 cm in diameter at paravertebral region from cervical to lumbar and posterior thoracic wall. They made bone bridges starting from inferior occipital bone to cervical spine and extending to paravertebral lumbar region. We also found multiple masses at both axilla. Cervical lordosis and thoracic kyphosis were diminished. All the masses were hard in consistency. There was no tenderness, and the masses were fixed to the bone. The shoulder, cervical, and thoracal spine ranges of movement were limited ().
Radiograph of the cervical spine showed new bone formation starting from occipital bone, cervical, until upper thoracal spine. Chest and shoulder radiographs also showed new bone formation at both humerus bridging to the tip of scapulae, with subluxation of both humeral head superiorly. The radiologist saw it as mustiple exostoses (osteochondroma lesion) with the differential d

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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 27-year old female that denied any past medical and surgical history. Her family and drug history were also unremarkable. The patient presented with a 7-month history of progressively enlarging mass on her left ring finger. The patient mentioned that the mass appeared suddenly with no history of trauma and that she was concerned about the potential malignant nature of the mass. The patient also mentioned that she underwent incision and drainage of that mass 2 months after its appearance with no improvement and provided no detailed surgical or pathological reports, which was the reason for her delayed presentation. Upon her assessment, the mass was located over the ulnar side of the proximal phalanx of left ring finger with extensive involvement of the 4th web space. The overlying skin coverage was ulcerative with no active signs of infection. Range of motion of the involved digit was limited, however neurovascular examination was normal. ().
Radiological evaluation of the involved hand showed a soft tissue swelling with no evidence of bone involvement (). Further magnetic resonant (MRI) evaluation showed a mass on the volar aspect of the ring finger encasing about 50% of the flexor tendons of that digit with low signal intensity on T1 and high signal intensity on T2 evaluation with strong enhancement in post contrast evaluation. Assessment of neurovascular structures showed partial abutment of the radial sided bundle together with complete encirclement of the ulnar sided neurovascular bundle. The surrounding bone was free of any masses and associated mass effect.
The patient was taken to the OR for exploration and mass excision by the senior author. Possible risks associated with such intervention were explained. Intra-operatively, bruner type incision was designed together with island of skin involved in the mass. Exploration revealed extensive subcutaneous mass with fibro-fatty consistency with extensive fascia like extension to the surrounding so

[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 describe the case of a 56-year-old female who complained of swelling over the right side of forehead for 15 days. Magnetic resonance imaging (MRI) brain showed lytic lesion involving left frontal bone with erosion of inner and outer tables suggestive of plasmacytoma. Laboratory work-up revealed an elevated β2-microglobulin level of 3018 ng/ml, raised kappa-lambda ratio- 29.640 and presence of multiple myeloma band. Bone marrow examination confirmed the diagnosis of plasma cell neoplasm with 42% plasma cells. Under the suspicion of MM, the diagnosis was proved histopathologically by specimen from tumour attached to the dura that revealed hypercellular marrow with increased plasma cells. Diagnosis of MM, stage III (International Staging System) was made. Further work-up with FDG PET/CT imaging demonstrated multiple hypermetabolic lytic osseous lesions suggestive of mitotic osseous involvement.
Six cycles of Inj. Bortezomib 2 mg weekly along with Inj. Dexamethasone 40 mg weekly, and T. Thalidomide 100 mg (VTD regimen) were administered. She came to our hospital 1 year after the first treatment with relapse of MM. At this time, she was treated with 4 cycles of VTD regimen and achieved complete marrow remission. Further plan was to proceed with the HSCT.
However, just before her planned transplant date, she developed weakness of both lower limbs, low backache which progressed to difficulty in walking over a couple of days. MRI Brain showed two lobulated extra-axial dural based soft tissue lesions in left frontal and parietal regions measuring 47 x 15 mm and 10 x 8 mm, respectively with perilesional edema. Whole spine screening showed diffuse altered signal intensity of all visualized vertebrae with ill-defined focal lesions and a soft- tissue component at the S3 – S5 level in the presacral region, extending into the left S3 and S4 neural foramina. There was similar soft tissue component in the left paraspinal region on left side at S

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


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

[User]
RADIOLOGY NOTE:
This is a case of a 54-year-old divorced Caucasian male who has no prior psychiatric history or hospitalization. He was the lead singer of a local rock band. The patient has a 20-year history of cocaine abuse. He routinely uses cocaine prior to his stage performances. He reportedly binged on cocaine following a concert performance in a downtown bar. He snorted more cocaine than usual and immediately developed a severe headache and lower extremity numbness. He was rushed to the local emergency room, and an MRI of the brain without contrast was done. The MRI of the brain without contrast showed two small foci of increased signal intensity within the subcortical white matter of the left frontal lobe (Figure ).
It also showed the finding of bilateral foci of infarct involving the right side of the pons (Figure ). Both figures are consistent with an embolic phenomenon.
The patient has not complained of any somatic issues related to his cocaine use. The patient reported some depressive and anxiety symptoms as a result of the stroke but he remained optimistic about his recovery. He denied any vegetative depressive symptoms or suicidal ideations. He was initially seen by a nurse practitioner at the emergency room who diagnosed him with an adjustment disorder. After stabilization in the medical floor and a two-week stay at a rehabilitation program, the patient was sent home with good family support. Over the course of two weeks, the patient noted significant crying spells most of the day, nearly every day. He consistently denied that he was depressed and suicidal. His family became concerned and sent him to his primary care physician. The physician believed that he was suffering from depression because of his dramatic clinical presentation. The patient was eventually referred to the local mental health center by his primary care physician because of uncontrollable crying spells. He was not subjectively depressed but objectively tearful with a flat affect. He also complained

[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 66-year-old male (height 5'2”, weight 50.9 kg) with a history of severe idiopathic pulmonary fibrosis with two spontaneous pneumothoraces and a persistent bronchopleural fistula underwent a successful leak repair via pleurodesis. Following the procedure, the patient developed acute respiratory failure with persistent hypoxia requiring intubation and mechanical ventilation. An echocardiogram showed right ventricular strain with an EF of 78%, right ventricular systolic pressure of 115 mmHg, and enlarged pulmonary arteries, suggestive of obstructive shock from a pulmonary embolism or pulmonary hypertension. Limited improvement prompted the need for monitoring beyond that provided with transesophageal echocardiogram. Initiation of a right heart catheterization with a pulmonary artery catheter allowed continuous real-time monitoring of hemodynamics and assessment of pulmonary capillary wedge pressure, to further guide therapy towards a potential lung transplant.
A critical care fellow, under the supervision of an attending physician, used an ultrasound-guided technique to successfully place a 9 Fr introducer sheath [Arrow International, PA, USA] in the right internal jugular vein, through which the pulmonary artery catheter [Edwards Lifesciences, CA, USA] was inserted. During the initial attempt to float the catheter, right atrial, and ventricular wave forms were confirmed with the catheter advanced 20-30 cm, and a pulmonary artery wave form was confirmed at about 40-50 cm. Pulmonary artery pressures were measured varying between 100/30 mmHg, but wedging of the catheter was unsuccessful. Subsequent attempts confirmed appropriate right atrial and ventricular wave forms but failed to advance through the pulmonary artery. During the final attempt, the catheter was advanced to about 40-50 cm without acquiring a pulmonary artery wave form, but upon attempted removal, it stopped at approximately 30 cm, without any possible further retraction. The inability to remove the cath

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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 22-year-old man, weighing 65 kg, was admitted to our hospital to evaluate a murmur in the routine examination. He had complained of mild shortness of breath on physical exertion for one month. Physical examination on admission revealed a systolic murmur in the left para-sternum, trans-thoracic echocardiography showed a subarterial VSD with a diameter of 8 mm, left to right shunting, pressure gradient via the defect was 70 mmHg. The left ventricle dilated mildly with left ventricle end-diastolic diameter was 57 mm and left ventricular ejection fraction was normal range. Pulmonary artery systolic pressure was 33 mmHg at rest. Mild aortic regurgitation was present.
The patient was conducted under general anesthesia with a single-lumen endotracheal tube and placed in supine position as for standard median sternotomy with two arms along the body. Defibrillation pads were placed on the right and left chest before sterile draping. The femoral artery and vein were dissected in preparation for cannulation with a 2–3 cm oblique right groin incision. A 4 cm left parasternal thoracotomy was used to enter the thorax via the third intercostal space (ICS). The left internal thoracic artery was preserved carefully. The third costal cartilage was divided close to the sternum, without resection, to increase exposure. The ribs were slowly spread with a mini-thoracic retractor. The pericardium was opened longitudinally and suspended with stay sutures. The femoral artery cannula was inserted directly into the common femoral artery. A multi-stage venous cannula was inserted using the Seldinger technique with the tip of cannula advanced to the superior vein cava under transesophageal echocardiography guidance. After femoral arterial and venous cannulation, cannulas were secured, and cardiopulmonary bypass (CPB) initiated. CPB was initiated with vacuum-assisted venous drainage and body temperature maintained at approximately 34 °C A long cardioplegia needle (Livanova, London United Kingd

[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 87-year-old woman with left femoral nonunion following periprosthetic fracture after bipolar hip arthroplasty was referred to our department. She had undergone bipolar arthroplasty for left femoral neck fracture (Figures and ) and had been treated for osteoporosis with alendronate for 27 months after the bipolar arthroplasty. Her medical history included rheumatoid arthritis since the age of 60 years and diabetes mellitus diagnosed at the age of 83 years that was being treated using voglibose. She noticed thigh pain 36 months after the operation, which worsened 2 months later without any episode of injury. According to her, she felt pain at first and then fell because of the pain. A periprosthetic simple transverse fracture at the level of the distal end of the stem was found (). Internal fixation with a locking plate was performed at the hospital (). The remaining gap between the fragments was evident. To promote fracture healing, low-intensity pulsed ultrasound and teriparatide administration were started six days and two months after the surgery, respectively. Despite these treatments, the fracture did not heal in nine months; she was therefore referred to our department. The retrospective radiographic analysis revealed that a periosteal thickening of the lateral cortex at the stem tip level had existed at least two months before the fracture ().
On admission to our hospital, she could hardly walk due to the left thigh pain. Radiographs showed a nonunion fracture with osteosclerotic changes in the left femoral shaft at the level of the stem tip (). Radiographs of her contralateral femur showed lateral bowing but no features of AFF ().
The implant was replaced with a longer stem (Exeter; Stryker, Tokyo, Japan) using the cemented technique. The implant of bipolar arthroplasty was not loosened. Osteosynthesis was performed with a locking plate for the distal femur (NCB Periprosthetic Femur Plate; Zimmer Biomet, Tokyo, Japan) and a cable system ().
She regained th

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


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

[User]
RADIOLOGY NOTE:
A 23-year-old man with abdominal pain and diarrhea was admitted to the in-patient service at a Department of Gastroenterology in September 2014. The symptoms had reportedly been present for 2 months. The frequency of defecation was 3 or 4 times a day, and there was no mucus or blood in the stool. No family history of inflammatory bowel disease was reported by the patient. His body mass index (BMI) was 15.8 at the time of admission. Follow-up workup included computed tomography (CT) enterography (CTE), colonoscopy, and regular blood tests. The erythrocyte sedimentation rate (ESR) was 42.4 mm/h, serum C-reactive protein (CRP) was 65.2 mg/L, the leukocyte count was 11.64 × 109/L, and hemoglobin was 111 g/L. In CTE the ascending colon was thickened, and there was effusion and enlarged lymph nodes around the colon. Segmental lesions were detected via colonoscopy. Polypoid proliferation was found 45 to 48 cm from the anus and was more severe at 60 cm. Bowel stenosis was found approximately 70 cm from the anus. Chronic inflammation was evident in multiple biopsies. No erosions or ulcers were detected via peroral small bowel endoscopy. A diagnosis of CD was made, with a Clinical Disease Activity Index (CDAI) score of 240. The patient refused to take corticosteroids or biological agents reportedly based on consideration of potential side effects. Mesalazine was then administered at a dose of 1 g 4 times a day for 2 years. His abdominal pain was relieved, but his defecation pattern was similar to that on initial admission.
The patient was readmitted to the in-patient service in September 2016 due to severe abdominal pain and ongoing fever that he reported he had been experiencing for 1 week. His temperature was >39 °C. Masses could be felt via palpation at the right groin area and right posterior superior iliac crest. ESR and CRP were substantially

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


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

[User]
RADIOLOGY NOTE:
A 28-yr-old addict man was referred to our institution with an 8 month history of chronic pain in both groins aggravated by weight bearing sometimes keeping him awake at night. He had previously normal activities without specific sport or job program. By disease onset, His activities were restricted because of the pain and decreased range of motion. About 4 months before operation, the patient was visited by a physician who took a plain pelvic radiograph which revealed displaced left and non-displaced right femoral neck stress fracture (Fig-).
After 8-month, because of low socio-economic state and not appropriate follow-up by him, finally, the patient was referred to us with displaced bilateral hip fractures (Fig-).
On examination, his weight was 65 kilograms and both active and passive motions were painful and restricted. Active straight leg raise was not possible on either side. No limb-length discrepancy was observed because of symmetrical nature of the deformity.
There was no evidence of any underlying metabolic or endocrine disease affecting the bone strength in physical examination or family history.
In laboratory tests, CBC, ESR, alkaline phosphatase, serum calcium, phosphorus and serum total protein levels were normal. Normal Parathyroid, thyroid, renal, gonadal and liver function tests were detected. 24-hour urinary excretion for calcium and phosphorus was also within normal ranges.
Because of long period of immobilization and lesser activities, which decreased bone density, we did not consider bone densitometry for him.
Skeletal bone scan with TC-99m showed no other abnormal findings except bilateral femoral head osteonecrosis and bilateral femoral neck fracture (Fig-).
Surgery was performed using general anesthesia with the patient lateral on a conventional operating table for both right and left hips at one section choosing posterolateral minimal incision approach. The cartilage of the acetabulum was intact and heads of the femurs were decided to be repl

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


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

[User]
RADIOLOGY NOTE:
A 49-year old asymptomatic male was admitted to our institution after referral from his cardiologist in an outpatient care clinic, where he was monitored because of a dilated aortic root (46 mm). This was an incidental finding by transthoracic echocardiography (TTE) 6 months earlier at presentation due to non-specific chest pain. Except for hypertension, the patient had no other history of disease. Now 6 months later, the most recent TTE did not only show an increase in the aortic root diameter (50 mm), but also a hypo-echogenic structure in the right ventricular cavity (). The latter was interpreted as a right ventricular thrombus, position-wise possibly related to the tricuspid valve. Moreover, because of the rapid increase of the aortic diameter (4 mm in 6 months), the patient was referred to our hospital where a regular non-gated computed tomography angiography (CTA) scan was performed for acute aortic pathology. At the initial evaluation of the scan there was no suspicion of acute aortic pathology besides the dilation. After this CTA, the patient was discharged home with the intention to perform magnetic resonance imaging (MRI) a week later to determine the nature of the right ventricular structure. However, upon review of the CTA the next morning there was a suspicion of aortic dissection, based upon a possible tear in the aortic root. The patient was readmitted urgently for a new and dedicated electrocardiogram-gated (ECG-gated) cardiac computed tomography angiography (CCTA) scan () on which a structure of hypodense tissue was observed to derive from the sinus of Valsalva of the NCC bulging into the right ventricular cavity with involvement of the perimembranous septum. This suggested it to be a SVA filled with thrombus. As there was no continuation of contrast from the aortic root to the right ventricular cavity, a rupture was highly unlikely. However, given the potential risk for rupture with the rapid increase in aortic diameter and the thrombus suggesting

[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.