[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 male patient was referred to our hospital because of chronic low back pain for 10 years, acute worsening with radiating pain to left lower extremity over a month. The patient had a chronic low back pain for 10 years. He was diagnosed with LDH and lumbar fasciitis and received conservative treatment in local hospital. The back pain was acute worsening with radiating pain and numbness to the left shank and 1st toe over a month. The patient had experienced Traditional Chinese Medicine (TCM) acupuncture treatment on lower back for five times in the past 1 month before admitting to our hospital. The patient told the longest needles were about 7–8 cm and he could feel the needle hit on the bone during the process of acupuncture. He had a history of hypertension which was controlled well with medication for 10 years without history of any kinds of infection. There was no contact history of cows, goats or raw milk as well. The patient had a 30 years history of smoking, about ten cigarettes per day. There was no history of tuberculosis (TB), alcohol abuse or illicit drug use as well as family history of other diseases for him. On physical examination, the patient had no fever or loss of weight, and his vital signs were stable. However, he had tenderness points on his low back, and had 3/5 dorsiflexor strength in his left 1st toe. Decreased sensation of pin prick over left lateral shank and medial dorsal foot was documented. The straight leg raising test was positive in this patient’s bilateral lower extremities. The Visual Analogue Score (VAS) was 7.
Laboratory examinations indicated a normal white blood cell count of 7.6 K per mm3, erythrocyte sedimentation rate of 69 mm h− 1, and C-reactive protein of 47 mg L− 1. Lumbar X-ray showed degeneration of lumbar spine, hyperplasia of vertebrae, no significant narrowing of inter-vertebral space at L4-L5 level

[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 56-year-old male kidney transplant recipient affected by Lowe's syndrome was admitted to our hospital for a hematoma on his left forearm.
The patient had a history of end-stage renal disease (ESRD) and had undergone hemodialysis for 11 years through a distal AVF on his left forearm. In 2013, the patient received a deceased-donor kidney transplant and has been treated with immunosuppressive therapy with tacrolimus 1 mg + 0.5 mg daily ever since. He also had a recent history of ischemic stroke and accidental fall at home which caused a trauma of his left wrist.
A week before the admission, the patient was evaluated by the surgical team of our department because of a painful and swelling mass on his left forearm where the AVF for hemodialysis was originally created.
The enlarging mass first appeared two months before and was treated in another hospital as a complicated AVF, and thus the vascular access was closed.
During the hospitalization in our Nephrology Department, the patient underwent surgical revision of the hematoma and ligation of the distal radial artery. A left wrist radiogram was also performed which showed an area of diaphyseal osteolysis of the radius surrounded by a voluminous soft-tissue swelling. After a few days, the radial artery required ligation right after its origin from the brachial artery because of enlarging hematoma.
After a short time of apparent stability, the patient was admitted once again to our emergency department because of active bleeding from the surgical site which required urgent evacuation of the hematoma. Although the specific source of the hematoma was undetectable, the hemostasis was achieved using surgical glue devices. A surgical reduction of the brachial artery's diameter was also necessary. The hospitalization was complicated by two events of severe anemia which required blood transfusions.
During the follow-up, because of chronic anemia and worsening of the forearm lesion, the patient was readmitted to our department.

[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 Brazilian male patient was admitted to the hospital with a palpable lump in his right breast, located at the junction of the upper quadrants of the right breast (Fig. ). On physical examination, the lesion appeared firm with irregular margins. Axillary lymphadenopathy was negative and there were no palpable supraclavicular nodes. On breast imaging, ultrasonography showed a hypoechoic mass with partially defined contours measuring 4.0 × 3.0 cm, located at the upper region of the right pectoralis major muscle at the 12 o’clock position with muscle infiltration (Fig. ). Histological examination of core biopsy samples revealed a malignant tumor. Preoperative exams, such as X-rays and chest CT scan, abdominal US did not show any signs of disease. Radical mastectomy was then performed, due to pectoralis major muscle infiltration, consisting in removal of the breast along with the major and minor pectoralis muscles. Biopsy of the sentinel lymph node was performed. Gross examination revealed a solid tumor measuring 3.7 × 3.5 cm with a yellowish-tan cut surface and local foci of hemorrhage. Histopathology showed intravascular papillary proliferation of endothelial cells, spindle cell areas and necrosis, atypia and prominent mitotic figures, consistent with the diagnosis of high-grade angiosarcoma with areas of infiltration of the pectoralis major muscle (HE staining, magnification of 400×) (Fig. ). Histopathology also demonstrated a surgical specimen with clear margins, absence of angiolymphatic and perineural invasion, in addition to sentinel lymph node free of metastasis. Immunohistochemical study revealed a tumor positive for CD31 marker (Fig. ), confirming the vascular nature of the tumor. At the two-week follow-up of the surgical procedure, adequate wound healing was observed, without any evidence of the disease. The patient was transferred to the clinical oncology department, where he presented with severe headache and seizures after the second cycle of a

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


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

[User]
RADIOLOGY NOTE:
We present a 67-year-old female admitted with dyspnea and new onset atrial fibrillation with rapid ventricular rate. She was diagnosed with Graves' disease 3 weeks earlier and had been started on 20 mg of methimazole daily. Thyroid function tests showed suppressed TSH with elevated Free T3 and Free T4. Details of lab results are given in . Pro-BNP was elevated at 1762. Chest X-ray revealed unilateral right pleural effusion which was subsequently drained by thoracentesis and was consistent with transudative effusion. She was managed as a case of congestive heart failure. Her heart rate control was optimized and the dose of methimazole was increased to 30 mg once daily. She was discharged home but readmitted 2 days later with recurrent dyspnea. A repeat chest X-ray showed recurrence of the right pleural effusion. Transthoracic echocardiogram was done showing normal ejection fraction and diastolic function. Her heart rate was controlled. Repeat thyroid function tests showed a normal free T3 and almost normal free T4. Patient was diuresed, and the unilateral right pleural effusion was drained again. The fluid characteristics showed a transformation from transudative to exudative likely in the setting of recent diuretic use.
She was then discharged home after she had improved clinically only to be readmitted again with worsening dyspnea attributed to reaccumulation of the right pleural fluid a few days later. A repeat drainage with pleural catheter was performed, and the fluids revealed an exudative process with elevated LDH. This was further evaluated with a CT scan of the chest with contrast (Figures and ) which showed mediastinal lymphadenopathy and a diffuse ground glass process involving the right lower lobe suggestive of pneumonitis. A bronchoscopy was also performed. The bronchoalveolar lavage showed neutrophil predominant fluid, and cytology and adenosine deaminase were negative. Patient also had an endobronchial ultrasound-guided biopsy of the lymph nodes (EBUS)

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


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

[User]
RADIOLOGY NOTE:
A 43-year-old female patient with localized intrahepatic bile duct dilatation was found by physical examination for 20 years. For recent 3 years, the patient felt repeated right upper abdominal pain and distension, and aggravated for half a year, without fever and jaundice. She was admitted to our hospital for further examination and treatment. The patient's physical examination and hematological tests, including tumor markers Ca-199 were unremarkable. Enhanced CT and magnetic resonance cholangiopancreatography (MRCP) suggested that the intrahepatic bile duct dilatation in segment 4(S4) with an extent of 2.5*3.0 cm (Fig. a, b). Hepatobiliary ultrasound revealed localized dilatation of bile duct with local acoustic enhancement in S4 of the liver (Fig. c). On the basis of these findings, a diagnosis of S4 localized bile duct dilatation with lithiasis was made. Given the recurrent and persistent symptoms, the patient opted for surgical resection of biliary dilatation. Correspondingly, we selected to perform a combined resection of segment 4b and part of 4a with the guidance of subsegmental ICG staining, so as to facilitate the laparoscopic operation more simply and accurately, as well as to retain normal tissues in a certain extent.
Intraoperatively, after mobilization of the liver, relationships of the pathological segment with the hepatic vessels were confirmed by LUS, which was consistent with the preoperative CT imaging (Fig. d). ICG fluorescence positive staining method was performed to define the exact anatomical location of the lesion. Portal vein branch of the target hepatic segment was super-selected and visualized longitudinally, followed by punctured with a 18G needle by LUS guidance, then an injection of 0.05 mg ICG was performed gently (Fig. a, Additional file ). The specific configuration method of dilution was as follows: 25 mg ICG was dissolved in 10 ml sterilized water, and then taken 1 ml of which into 100 ml saline. Significantly, special attention m

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


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

[User]
RADIOLOGY NOTE:
The patient was a 55-year-old African American male with a significant past medical history of known breast cancer, who presented to an academic teaching hospital in February of 2018 after a surveillance computed tomography (CT) scan of his chest, abdomen, and pelvis showed incidental acute appendicitis. The patient was asymptomatic on his original presentation but subsequently developed nausea and vomiting along with right lower quadrant abdominal pain in the following days resulting in admission to the general surgery service for treatment of appendicitis. The patient did not have any contributory family, drug, or psychosocial history.
On chart review, the patient had an extensive past oncological history dating back to 2014 after resection of an enlarging, exophytic, ulcerating chest mass on the right side just lateral to the midline. Pathology from the wide local excision of this mass demonstrated estrogen receptor (ER) positive, progesterone receptor (PR) positive, and HER2/neu negative metastatic adenocarcinoma with an unknown primary source at the time. He underwent esophagogastroduodenoscopy (EGD) and colonoscopy to rule out a primary gastrointestinal malignancy, however, both were normal. He was followed closely by medical oncology and treated with tamoxifen for hormone therapy. Due to an enlarged anterior mediastinal wall lymph node discovered on routine CT surveillance in May of 2017, the patient underwent CT-guided biopsy and positron emission tomography (PET). The biopsy was negative for malignancy, however, the PET demonstrated abnormal, hypermetabolic activity within a retrosternal nodule, intense activity in a mixed focus in the manubrium, and several hypermetabolic nodes within the mediastinum. It also showed an abnormal hypermetabolic focus in the cecum suspicious for a colon primary (, ). An attempt was made to complete a colonoscopy at the time, but the gastroenterologist could not advance the colonoscope past the transverse colon due to technica

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


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

[User]
RADIOLOGY NOTE:
A 29-year-old female patient had first reported to the ENT Department of the Cantonal Hospital in St. Gallen, Switzerland, in 2001, with severe and progressive nasal blockage. Symptoms had begun 5 years earlier but had been left untreated. She was however known to have an aspirin and histamine intolerance. In addition, she had suffered from symptoms that had been interpreted as hay fever and asthma since her youth and reported a positive family history for nasal polyposis.
Physical findings documented at the time included a normal appearing external nose, complete bilateral obstruction of the nasal cavities by nasal polyps, and anosmia. The anosmia was determined by testing with Sniffin' sticks whereupon the patient was able to identify 3 out of 12 possible odors.
A CT scan showed hypoplastic frontal sinuses and a complete obstruction of all the other paranasal sinuses, with normal bony anatomy of the external nose. After medical treatment with topical and systemic steroids failed, the patient underwent an endoscopic sphenoethmoidectomy and maxillary sinus fenestration in 2002. Upon histologic examination of the polyp tissue respiratory mucosa with severe chronic eosinophilic inflammation was found. Postoperative treatment included topical and systemic corticosteroids. Aspirin desensitisation therapy was repeatedly discussed but declined by the patient. The sense of smell returned and the patient now identified correctly 11 out of 12 possible odors. The patient was free of recurrence during 5 months of follow-up in the hospital before continuing follow-up in the vicinity of her home. During this further follow-up, the sense of smell was not documented.
In March 2014, the 38-year-old patient was again referred to the ENT Department of Cantonal Hospital in St. Gallen, Switzerland, because of complete bilateral nasal obstruction with polyps visible in both nares and a progressive widening of the bony and cartilaginous nose. The patient reported a recurrence of nasal ob

[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-year-old male of Indian origin, who was moderately built and nourished presented for treatment of mobile lower front teeth. However, the patient had also noticed a swelling in the floor of the mouth of five months duration. Initially pea sized, the swelling had constantly and gradually increased in size. The swelling nevertheless did not cause any pain, discomfort, dysphagia nor speech or masticatory difficulties to the patient.
Extra orally there was no clue of the swelling. Clinical intra oral examination revealed periodontally compromised mandibular anteriors. The floor of the mouth revealed a solitary, well circumscribed, distinct, dome shaped sessile midline swelling extending from the lingual aspect of the mucogingival junction of mandibular anterior teeth up to the mandibular molars bilaterally. The mucosa over the swelling appeared normal without any secondary changes. Tongue was slightly raised but the morphology of the swelling did not vary with tongue moment (Figure ). On palpation the swelling was soft to firm, non tender, smooth, fluctuant and was not associated with any discharge. Although submandibular and sublingual gland orifices could not be assessed because they were masked by the swelling, bilateral milking of the glands produced thick, mucous saliva.
Mandibular cross sectional radiograph did not disclose any calcifications. The buccal and lingual cortical plates were normal with no indication of expansion or decortication.
Aspiration from two different sites using an 18 gauge needle yielded scanty white cheesy material. Complete hemogram and ESR were within normal limits.
Ultrasonography showed a well defined submucosal oval mass in floor of mouth in the midline measuring approximately 4.0 × 3.0 cms in diameter with internal echoes. The underlying tongue musculature was normal.
FNAC showed few squamous cells with mild hyperchromatic nuclei visible in the background of sheets of macrophages, few lymphocytes, abundant keratin flakes and anucl

[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 73-year-old Hispanic male with a history of coronary artery disease, hypothyroidism, and arthritis underwent a CT scan of the abdomen and pelvis for an unrelated complaint and was incidentally found to have a hypervascular left renal mass suspicious for malignancy. He was referred to an outpatient percutaneous transcatheter renal artery embolization, in preparation for a subsequent radical left nephrectomy with a view to decrease intraoperative bleeding at surgery. Physical examination prior to the procedure was essentially normal and did not reveal any cardiopulmonary abnormalities. The patient received intravenous conscious sedation over a period of 60 minutes consisting of 100 mcg fentanyl and 1.0 mg midazolam, administered in intermittent doses, while undergoing continuous physiologic monitoring. Per protocol [], the procedure was performed using a total of 40 mL of pure ethanol divided into three doses and administered in slow pushes at 15-minute intervals. This dose was derived based on a weight of roughly 80 kg, using the lower end of the recommended dose of 0.5–1 mL/kg. The result was a significant reduction in tumor vascularity, with approximately 10% residual renal artery tumor perfusion.
After the third ethanol injection, the patient developed cough, agitation, and acute respiratory distress with hypoxemia (SpO2 of 80%; normal >92%). He required sedation and emergent intubation for airway protection. Given the concern for pulmonary embolism, pulmonary angiography was immediately performed and showed patent pulmonary arteries, without central or segmental pulmonary artery embolus or vessel occlusion. The procedure confirmed the presence of PAH with a mean pulmonary artery pressure (mPAP) of 70 mmHg (normal <25 mmHg). Acute pulmonary vasospasm due to venous shunting from the systemic intra-arterial ethanol administration was suspected. A Fogarty balloon was inflated in the renal artery to prevent further dissemination of ethanol into the systemic circulat

[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 obese Hispanic young man presented to the orthopedic surgery service with right-sided ankle pain. His pain began after a sports injury approximately one year prior to presentation but did not respond to immobilization, physical therapy, or prolonged rest. The pain was located at the medial side of the ankle, was worse with activity, and was accompanied by intermittent swelling. He took ibuprofen at night occasionally that provided modest relief.
His past medical history was unremarkable. Family history was negative for autoimmune disease including JIA. His only medication was occasional ibuprofen, and his immunizations were up to date.
On examination, the patient was heavyset, weighing 142.8 kg and standing 173.6 cm tall, with a BMI of 47.4. His vital signs were normal and he was in no distress. Musculoskeletal exam revealed bilateral limited ankle dorsiflexion, worse on the right. He had tenderness to palpation over the medial aspect of his ankle just anterior to the medial malleolus. All other joints were normal.
His initial work-up consisted of radiographs of his right ankle, showing evidence of a healing osteochondritis dissecans (OCD) lesion. He was instructed to continue physical therapy and follow up in three months with the possibility of arthroscopy of the affected joint if there was no improvement.
At follow-up, his pain was unchanged. Radiographs showed the previously seen presumed OCD lesion, now with a sclerotic border. He was scheduled for an MRI of the ankle, which was read as more consistent with a chondroblastoma versus an inflammatory process.
Several months later, he began complaining of left shoulder pain and decreased range of motion of gradual onset. He denied any trauma causing this new complaint. He was again seen by the orthopedic service and found to have significantly decreased range of motion and AC joint tenderness. Radiographs of the shoulder did not show any abnormalities. He was diagnosed with adhesive capsulitis and ins

[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 18-year-old male patient presented with minimal weakness of the left ankle/toes plantar-flexion, which worsened with gait.
The magnetic resonance imaging (MRI) showed a large sacral mass causing compression of the S1 and S2 roots on the left side. It was hypointense in T1 and hyperintense in T2, originating mainly from the left side of S1, extending into the left side of S2 with extension into the left paravertebral space and through the neural foramen into the extradural intraspinal canal, causing severe compression and displacement of the thecal sac to the right side (Figure ). It exerted a mass effect on the adjacent parts of the sigmoid, but there was no evidence of invasion. An invasion into the left iliac vein was noted. There was a suspected blood fluid level seen at the posterior aspect of the mass. The left sacroiliac joint was involved by the tumor. Informed patient consent was obtained for treatment.
CT scan confirmed a large lytic lesion with a soft tissue mass at the left sacroiliac joint extending to the midline of the sacrum medially and to the sacroiliac joint laterally (Figure ). No metastatic lesions were identified on other imaging.
Image-guided biopsy confirmed the diagnosis of Ewing’s sarcoma. Surgical resection of the tumor with safe margins was planned. Three sessions of chemotherapy were administered preoperatively to shrink the tumor.
A sacrectomy was planned as a two-stage procedure, anterior and posterior. During the anterior approach, the tumor was freed from major vessels and the bowel. Surface cuts were done in the iliac bone anteriorly with a 2 cm margin outside the tumor. These cuts were guided by the navigation system to be precisely outside the tumor (Figure ). It served as markers on the navigation system when the posterior approach was performed as the second stage. During the posterior approach, the surgical procedure included lumbar spine instrumentation with right iliac

[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:
Our patient is a 58-year-old African American woman who initially presented to an outside facility of difficulty swallowing, neck pain, fatigue, and shortness of breath for 3 months. She had bilateral neck swelling, greater on the left side, that started about a year prior to her presentation. This patient also had a 4-day history of productive cough and nasal drainage. She had a 30-pack year history and consumed approximately 12 beers daily for years.
She reported a history of CLL and having been treated with chemotherapy, but she was unsure of the regimen. Examination findings and computed tomography (CT) scan of neck at the outside facility were concerning for impending airway compromise, and she was transferred to our hospital to be evaluated by an otorhinolaryngology or oral and maxillofacial surgery service.
During her evaluation in our emergency department, she was noted to have a muffled voice with mild gurgling of secretions with speech. Large, fixed cervical and submandibular lymph node, and a large left neck mass were present. Enlarged axillary lymph nodes were palpated bilaterally. The uvula and posterior oropharynx were not visible due to her tongue and left neck mass. White blood cell (WBC) count was 83 600/mm3. She was started on dexamethasone to reduce the compression of the neck mass on the airway. The oral and maxillofacial surgery service team evaluated her and determined that a definitive airway was not indicated. She was admitted to the medical intensive care unit for close airway monitoring.
The oncology team became involved at this time. Her CLL was the suspected etiology of the neck mass and lymphadenopathy, and intravenous fluids and allopurinol were started to prevent tumor lysis syndrome. Further laboratory workup showed the predominantly lymphocytic, elevated WBC count as before and a normocytic anemia, hemoglobin 10.6 g/dL. Smudge cells were present on the peripheral blood smear. Iron studies, B12, and folate were normal. Flow cytometry

[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 four year old man presented to the Geisinger clinic emergency department for an evaluation of worsening abdominal pain associated with low grade fever, nausea and vomiting that had started one day prior to admission. The patient denied prior abdominal complaints, recent trauma, or changes in bowel habits. On the physical examination, he appeared to be anxious, mildy tachypneic and pale with heart rate of 132 beats per minute. An abdominal palpation showed moderate distention, diffuse rigidity with guarding, rebound tenderness, and hypoactive bowel sounds. Complete blood count showed a leukocytosis of 22.5 mg/dl, bandemia of 14%, hemoglobin of 9.6 mg/dl (baseline of 15 mg/dl). Liver function tests, pancreatic enzymes, and lactic acid were all within normal limits.
A CT scan showed an abnormally located spleen in the lower pelvis measured 15.7 × 10 × 9.2 cm (Figs. and ). The splenic artery descended inferiorly through the midabdomen and was markedly tortuous, suggesting a pedicular volvulus. The splenic parenchyma failed to enhance following intravenous contrast injection as what typically would have been seen in a normal spleen. The body and tail of the pancreas appeared to be coiled around the splenic vessels (). Significant volume of high density fluid consistent with hemoperitoneum was observed. No free air was identified.
Exploratory laparotomy was promptly performed revealing a large rush of blood upon entering the peritoneal cavity. Once the midline incision was advanced inferiorly, a large mobile spleen was found in the pelvis which was easily brought up into the operative field. There was a volvulus of the splenic pedicle and distal pancreas. Following detortion and inspection, the spleen appeared to be permanently infarcted. A routine splenectomy was performed. Approximately one liter of blood was suctioned and the abdomen was thoroughly irrigated using three liters of normal saline. There was no other obvious pathology found.
Postoperatively, the pa

[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:
In May 2008, 72 year old female was diagnosed of small cell lung cancer incidentally after she was hospitalized for anxiety and dizziness. She was hyponatremic and series of tests which included a CT scan of the chest which showed right hilar lymphadenopathy and mediastinal lymphadenopathy (Figure ). She then had a mediastinoscopy which was consistent with small cell lung cancer. PET/CT scan findings were consistent with CT scan. She was staged as limited stage small cell carcinoma of lung. She was started treatment with etopside and carboplatin. In July2008, after receiving two cycles of chemotherapy, she presented with new onset memory difficulties.
Further work-up included a MRI of brain with and without gadolinium as well as PET scan showed no evidence of metastatic disease to the brain. These symptoms were thought due to underlying anxiety or depression.
Few days later she started with ataxia, vertigo and hearing loss. She was prescribed meclizine which provided no relief. She then went to emergency department. At that time she was found to orthostatic. She was rehydrated and discharged.
Audiogram was done which revealed bilateral sensorineural hearing loss greater on the left side. The paraneoplastic workup was sent to rule out paraneoplastic syndrome. The anti-Hu antibody came positive. The diagnosis of anti-Hu syndrome was entertained. She was started on radiation therapy in addition to her chemotherapy for consolidation. She received 3960 cGy of radiation to the mediastinum in August 2008.
Three weeks later, she began developing loss of smell sensation to the point that she was completely anosmic. Her unsteadiness reached to the point that she needed assistance for walking short distance. MRI of brain showed new area of edema and inflammation in the right medial temporal lobe as well as enhancement in the underlying meningi (Figure ). She was admitted for to the hospital for empiric IV acyclovir therapy for possible herpes encephalitis. The Lumber puncture

[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 79-year-old man came to our gastrointestinal outpatient with complaint of a narrowing in the caliber of the stool without obvious cause for about 1 year. Otherwise, he had no history of asbestos exposure, hematochezia, diarrhea, constipation, abdominal pain and distention. He had a history of prostatectomy due to benign prostatic hyperplasia and he denied recent weight loss. Digital examination of rectum showed the lower boundary of a mass in the rectum was 2 cm from the anal margin, and the upper boundary could not be palpated. Therefore, the patient underwent colonoscopy endoscopic electrocoagulation resection.
A soft tissue shadow was occasionally found by pelvis CT examination in the right pelvic wall. The mass had well-defined boundary and was oval shape with size of 7.3 × 5.3 cm. No calcification was found within the mass. On unenhanced CT images, the mass was heterogeneous with suspected necrotic area (Fig. a). In arterial, venous and delayed phases, CT values were 32–61 Hu, 65–90 Hu, and 46–77 Hu, respectively. The lesion showed mild heterogeneous on delayed enhancement CT images (Fig. b-d). Otherwise, the rectum and prostate were pressed, and no sign of destruction was observed in the adjacent bone. The CT examination suggested that the mass may originate from striated muscles with malignant transformation, and it may belong to neurogenic benign tumor. The source of blood supply to the mass was identified by pelvic computed tomography angiography (CTA), which showed the mass was mainly supplied by the right internal iliac artery (Fig. b). Unfortunately, the local dissection of the right common iliac artery was observed by CTA, and delayed the treatment of pelvic mass. Then, the right common iliac artery dissection was treated in other hospital more than a month later.
Six month after the discovery of the pelvic mass, the mass was slightly larger observed by CT examination (Fig. a). The patient underwent radical excision of pelvic

[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 is a 73-year-old man with a history of three previous open right inguinal hernia repairs at other institutions as well as a robotic prostatectomy who presented with a recurrent right and symptomatic left inguinal hernia. Given the patient's history of multiple prior open hernia surgeries, we initially favoured a laparoscopic approach. Given the history of robotic prostatectomy with a post-operative pelvic haematoma and the likelihood of adhesions, we decided on a robotic TAPP approach, which would allow for easier lysis of adhesions, reduction of the hernia sac and sutured closure of the peritoneal pocket.
On insufflation of the abdomen, placement of robotic trocars and docking of the da Vinci Si system, a large right indirect inguinal hernia defect containing small bowel was visualised lateral to the inferior epigastric vessels. The peritoneum was incised and the hernia sac reduced into the peritoneal cavity with subsequent development of a pre-peritoneal pocket. An extra-large Bard 3DMax polypropylene mesh (12.4 cm × 17.3 cm) was tacked into place to the pubic tubercle and onto the anterior pubic ramus at Cooper's ligament. The peritoneal defect was then closed using 2-0 absorbable V-Loc (barbed) suture in a running fashion. The left-sided hernia was repaired in the same manner.
The patient was discharged home on the same day after surgery but returned to the emergency room on the 2nd post-operative day with complaints of significant abdominal pain, nausea, vomiting and obstipation. He was diffusely tender on abdominal examination and a computed tomography (CT) scan [] was performed demonstrating a high grade closed-loop small bowel obstruction with a transition point in the right lower quadrant. The patient was urgently taken to the operating room where he underwent a diagnostic laparoscopy. The peritoneal closure on the right had dehisced, and a loop of small bowel had incarcerated within it [] which upon reduction appeared bruised but viable

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

[User]
RADIOLOGY NOTE:
A 45-year-old male motorcyclist with a history of hypertension, hyperlipidemia, and coronary artery disease was brought to the emergency department after being struck by another car on the highway at speeds of at least 40 miles per hour. Upon presentation, the patient was evaluated using Advanced Trauma Life Support (ATLS) principles. He had a patent airway on arrival and was breathing spontaneously on room air. His initial heart rate was 87 beats per minute, and his blood pressure was 124/63 mmHg without signs of significant hemorrhage. He had an initial Glasgow coma score (GCS) of 15 with equal and reactive pupils. The patient admitted to consuming alcohol and had a serum alcohol of 243 mg/dL. A later CT of the head demonstrated a subcutaneous hematoma without any intracranial abnormalities. His remaining physical examination revealed left lower quadrant abdominal pain without signs of peritonitis, ankle deformities bilaterally, pain with hip range of motion, and blood at the urethral meatus. Given his physical examination findings, subsequent imaging confirmed an unstable pelvic fracture with diastasis of the symphysis pubis of 6 cm, widening of the left sacroiliac joint, a left ischial pubic ramus fracture, and a urethral injury (). He also had a left ankle dislocation and a right compound fracture of the distal tibia and fibula. No intraabdominal injuries were identified on CT imaging of the abdomen. The pelvis was stabilized with a binder by the orthopedic surgeons with subsequent emergency irrigation, debridement, and open reduction and internal fixation (ORIF) of the open ankle fracture as well as reduction of the left ankle dislocation. He was extubated after the procedure and monitored in the ICU while the remaining preoperative medical workup was completed including X-rays and CT scans with 3D reconstructions of the pelvis reconstructions. A hydromorphone patient-controlled analgesia (PCA) pump was utilized for pain control.
On hospital day 2, the patient

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

[User]
RADIOLOGY NOTE:
A 74-year-old Caucasian man with a history of hypertension and stage I clear cell type renal cell cancer underwent right nephrectomy in 2004. In 2009, he was found to have a right upper lobe lung metastasis and underwent video-assisted thoracoscopic surgery with lung node resection. He had since been doing well without recurrence. In March 2016, he presented with a 1-month history of intermittent chest pressure, predominantly occurring at night times.
On physical examination, his blood pressure was elevated at 183/96 mm Hg with a normal heart rate of 78 bpm. The patient's lungs were clear on auscultation with no abnormalities in the cardiac examination. The abdomen was soft and nontender, and no masses were palpable.
Complete blood count, chemistry panel, thyroid function, and cardiac enzymes were normal. An electrocardiogram showed normal sinus rhythm, with T wave inversions in leads II, III, avF, and V4-V6. A transthoracic echocardiogram followed which revealed reduced ejection fraction of 35% with hypokinesis of the apical segments and a suspicious lesion in the left ventricle. In view of the patient's age and risk factors for coronary artery disease and heart failure, he was scheduled for cardiac catheterization. Cardiac catheterization was performed and did not show significant coronary artery obstructions but revealed an abnormal accumulation of contrast in the apex, suggestive of a highly vascular mass (Fig. ). To further characterize the mass, cardiac magnetic resonance imaging (MRI) was performed, which confirmed the findings of a left ventricular mass measuring 4.2 × 3.6 × 3.1 cm with full-thickness involvement of the myocardium, causing moderate dyskinesia of the left ventricular wall (Fig. , Fig. ). Open myocardial biopsy was performed, and pathologic evaluation was consistent with metastatic clear cell RCC.
Given the location of the mass and its involvement of the full thickness of the left ventricle, the patient was not felt to be a surgical candidate,

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

[User]
RADIOLOGY NOTE:
A 72-year-old man was transferred to our emergency department due to the left side weakness. On arrival, he also presented with dyspnea and cough productive of purulent sputum. Three months prior to the current admission, he was hospitalized in a local clinic due to right hemiparesis and was diagnosed with acute left anterior cerebral artery infarction by brain magnetic resonanace imaging (MRI). Chest computed tomography (CT) revealed the mass suspicious of lung cancer in the right lower lobe. The mass was originated from right lower lung field and invaded right pulmonary artery, vein and LA. Biopsy of the lung lesion was recommended for additional diagnostic confirmation but his family rejected the performance of further evaluation.
When he visited our hospital, he had a blood pressure of 100/60 mmHg, a pulse rate of 76/min, a temperature of 36.3℃, and a respiratory rate of 25/min. His general appearance was chronically ill-looking and he was in a drowsy status. His white blood count (12,400/µL) and high sensitive C-reactive protein (6.79 mg/dL) were elevated and chest X-ray showed multifocal pneumonic infiltration in both lung fields as well as a huge mass in the lower zone of the right lung. His brain CT showed the old cerebral infarction in the left medial-frontal area and the acute cerebral infarction in the right fronto-temporal area (). Transthoracic echocardiographic (TTE) examination was performed to investigate the cause of his recurrent cerebroembolic episodes, revealing a very huge, mobile mass in the LA which originated from the right main pulmonary venous trunk accompanied by a small amount of pericardial effusion (). The mass moved in a to-and-fro fashion through the mitral valve with neither significant obstruction of the mitral inflow nor pressure gradient between the LA and left ventricle (LV). LV ejection fraction and LA size were within normal range. In order to figure out the relation of the mass to the surrounding structures,

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

[User]
RADIOLOGY NOTE:
A 32-year-old man with a history of progressive increase in dyspnea saturation for 1 month presented to a peripheral hospital. On examination he was tachypneic (room air –84%) with decreased air entry on the right side and with normal hemodynamics values. Cardiac auscultation revealed normal heart sounds and no cardiac murmur. A chest X-ray was done which showed a massive right-sided pleural effusion, and a right intercostal tube drainage was done at an outside hospital which drained 1 L of blood immediately and 1 L subsequently.
The patient was referred to our institute with the diagnosis of massive right hemothorax. An ultrasound of the chest was done which showed gross right pleural effusion with collapse of underlying lung. A well-defined retrocrural collection of size 7 × 6 cm was noted. The liver was normal in echotexture. Emergency computed tomography angiography (CTA) was suggestive of massive right hemothorax, with an aortic rent at the T7 level communicating with the right pleura and multiple aortic rents at the T10–11 level with a surrounding 8 × 4 cm hematoma (
).
On detailed history taking, the patient informed us that 6 years ago he had laparoscopic cholecystectomy during which his common bile duct was inadvertently injured and eventually a Roux-en-Y hepaticojejunostomy was done.
With a provisional diagnosis of a leaking pseudoaneurysm, the patient was taken for surgical exploration to repair the aortic rent as well as the communication with right pleura through a left thoracoabdominal approach. After taking proper proximal and distal aortic control, the descending thoracic aorta was opened above the renal arteries, but the aortic wall was found to be normal with no rents. The aorta was closed. Surgical exploration could not be extended on the right side because of dense adhesions due to the past surgery.
The patient was then repositioned and right thoracotomy done, which showed a 2 × 2 cm laceration on right lower lobe 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:
We report the case of a 42-year-old woman who presented in our clinic due to recent diagnosis of early left breast cancer. The computer tomography performed revealed no other organs compromised or distant metastatic extension. The patient did not have relevant medical history of interest, except for a Darier's disease known for many years.
The patient underwent a lumpectomy with axillary lymph node dissection. The pathological diagnosis was moderately differentiated invasive ductal carcinoma (IDC) of the right breast of 2.3 cm in size with metastasis detected in 1/18 lymph nodes removed (pT2 pN1 M0). Immunohistochemical study of the tumor cells showed positive staining for both estrogen receptors (ER) and progesterone receptors (PR) in 95% and 95%, respectively, and showed positive membrane staining of HER-2 marker. With this diagnosis, the patient received postoperative adjuvant chemotherapy consisting of 6 cycles of FEC followed by maintaining treatment with trastuzumab for 1 year and adjuvant hormone therapy with tamoxifen 20 mg daily during the following 5 years. Then, the patient was referred to our radiation oncology department where she received adjuvant radiotherapy (50 Gy) on left-breast residual tissue.
She was primarily diagnosed of DD in 1991 with pruritic eruption on the trunk. There was no family history of a similar skin summer. A biopsy specimen revealed acantholytic dyskeratotic cells in the upper epidermis, suprabasal clefts with focal hyperkeratosis, and parakeratosis which were consistent with the clinical diagnosis of Darier's disease. Various therapeutic options had been applied: lotions containing cortisone, estrogens, or testosterone and several homeopathic options. Due to progression disease, the patient was treated with oral retinoids (acitretin: initial 10 mg) plus cyclosporine, obtaining an initial good response with disappearance of the skin lesions. After nine months using systemic retinoid and cyclosporine, the papules have reappeared

[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 21-years-old man who was diagnosed with β-thalassemia major at the age of 8 months. He underwent splenectomy at the age of 10 years and has been receiving monthly blood transfusions ever since. Three months prior to admission, he presented to a peripheral emergency department with a sudden episode of dyspnea and central cyanosis and was suspected to be infected with COVID-19. Chest CT scan was made and ruled out any interstitial lung involvement and revealed the presence of bilateral pulmonary emboli. Anticoagulation therapy with warfarin was started, but on follow-up the patient developed progressive exertional dyspnea, deteriorating to NYHA functional class III.
The patient was referred to our institution because of worsening symptoms. Physical examination showed clinical evidence of right heart failure and pulmonary hypertension, with a mild drop in arterial oxygen saturation (93%). Echocardiography revealed a dilated right atrium (RA) which contained a large 47 × 35 × 16 mm hyperechogenic mobile mass attached to the RA free wall near the orifice of the inferior vena cava. The right ventricle (RV) was severely dilated and dysfunctional, with tricuspid annular plane systolic excursion (TAPSE) of 13 mm and severe tricuspid regurgitation. Estimated systolic pulmonary arterial pressure (PAP) was 85 mm Hg. Lung perfusion scintigraphy was not available at our center. Chest CT angiography showed bilateral defects in the pulmonary arteries consistent with bilateral chronic pulmonary thromboemboli (Figure ).
On the basis of this evaluation, the diagnosis of CTEPH was established and PTE was performed, the technique of which was reported previously. Total circulatory arrest time was 45 minutes, and total cardiopulmonary bypass perfusion time was 94 minutes. A large organized clot was removed from the RA, in addition to removing the thickened intima and organized thrombi from lobar and segmental pulmonary arteries of the left middle and lower lobes, as

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


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

[User]
RADIOLOGY NOTE:
A 64-year-old man visited the emergency room for abrupt-onset chest pain. He had undergone a closed thoracostomy for left hemothorax in another local clinic. Whole body computed tomography imaging indicated a possible ruptured thoracic aortic aneurysm; the maximal diameter of the thoracic aorta was 65 mm (). The patient underwent an urgent thoracic endovascular aortic repair procedure the next day. Since the proximal landing zone of the stent graft was estimated to be between the innominate artery and the left common carotid artery (zone I), he concomitantly underwent the debranching of the arch vessels. All procedures were performed in the operating room. The extrathoracic exposure of the arch vessels was performed via two small supraclavicular incisions. The debranching of the arch vessels was done by bypassing the left common carotid artery and the left subclavian artery to the right common carotid artery using a single 8 mm vascular graft (InterGard Woven; InterVascular, La Ciotat, France). The course of the graft crossed above the trachea and above the left internal jugular vein. The thoracic endovascular aortic repair procedure was carried out using a SEAL thoracic aortic stent (SEAL Thoracic 38/34×180 mm; S&G Biotech Inc., Seongnam, Korea) via both femoral arteries. All procedures were uneventful. The patient underwent perioperative cerebrospinal fluid drainage to prevent paraplegia.
Postoperatively, the patient twice failed to be weaned off the ventilator because of intractable stridor and desaturation immediately after extubation. He underwent reoperation on postoperative day four due to suspected airway edema caused by the obstruction of venous return. When neck ultrasonography was performed in the operating room, a large amount of thrombi was found in the left internal jugular vein and no flow was found through the left internal jugular vein. In the operative theater, the left internal jugular vein was found to be totally obstructed by thrombosis (), whic

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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 here report a 25-month-old male child born by full-term vaginal delivery presented to us with sudden onset of left-sided hemiparesis lasting 2 hours, not preceded by constitutional symptoms or seizure activity. He had similar episodes of transient hemiparesis on either side in past which relieved spontaneously without any neurological deficit. First episode of right-sided focal seizures occurred at age of 4 months. Frequency of seizures increased and child was started on antiepileptic drugs. Since age of 11 months, child had recurrent episodes of transient hemiparesis on either side with or without associated seizures, lasting 2-3 days and relieved by itself. There was history of developmental delay noticed after the age of 4 months and presently he could only walk with support corresponding to developmental age of 11 months. On examination he was afebrile with normal vitals. There was port-wine stain of 4 × 1 cm in an atypical site involving midline of forehead extending over nose []. His modified GCS was 13/15, had UMN type left facial nerve palsy with left-sided hemiparesis. Rest neurological and systemic examination was unremarkable. Contrast CT scan of brain showed linear hyperdense area in right high parietal lobe with gyriform enhancement along with enlargement of right choroid plexus and left frontal atrophy [Figures and ].
EEG done urgently revealed no ictal activity, excluding postictal hemiparesis. PET scan revealed hypoperfusion and decreased metabolism in cortex surrounding the leptomeningeal angioma. Therefore the hemiparesis was presumed to be of vascular in origin. Child was started on aspirin to prevent further recurrences of these thrombotic events. On 3rd day of admission, child developed right-sided tonic clonic seizures with facial twitching lasting 15 minutes, and loss of consciousness followed by right-sided hemiparesis. Meanwhile his hemiparesis on left side improved. A concurrent EEG revealed epileptic activity with focus on left side, su

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

[User]
RADIOLOGY NOTE:
An 11-year-old male presented with a painless mass over the superior aspect of the globe for the last three months which was progressively increasing in size. The child had progressive, painless loss of vision in the same eye for the last three years. On ocular examination, visual acuity was no perception of light in the same eye and 6/6 in the other. Firm, non-tender mass measuring 4cm x 3cm was noted in the superior aspect of the globe (). It was covered by conjunctiva in the posterior half, while conjunctiva was adherent on the anterior half. Its surface was irregular with some vascularization. The cornea was hazy due to scarring, and inner details could not be evaluated. The examination of the left eye was within the normal limit. Systemic examination was normal with no palpable lymph nodes. B-scan ultrasound showed homogenous opacity in the anterior part of the eye with moderate reflectivity persisting up to 70dB. CT-Scan of the orbit revealed hyperdense focus attached to the anterior surface of the eyeball with surrounding thickening, likely foreign body with an irregular wall of the globe with areas of internal hyperdensity likely a hemorrhage or infection ().
After consent, enucleation was performed with minimal manipulation under general anesthesia with the orbital implant and conformer. The specimen was sent for histopathological examination.
Gross examination of a cross-section of the enucleated globe revealed a solid grey lesion with exophytic and endophytic components (Figure 2.a and b). Histopathological examination revealed thick bands of polarized epithelium resembling medullary epithelium along with thinner cellular strands of acellular myxoid stroma (Figure 3.a). The tumor cells aggregated radially along the central space forming Flexner Wintersteiner rosette (Figure 3.b). It also involved the anterior chamber and vitreous cavity, but the optic nerve stump was free of tumor. This was highly suggestive of medulloepithelioma grade II. The origin of m

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

[User]
RADIOLOGY NOTE:
A 35-year-old female was transferred to the department of hematology with a primary central nervous system posttransplant EBV-associated lymphoproliferative disorder. Biopsy from the tumor showed a highly necrotic polymorphous infiltrate of variably sized lymphocytes. The large cells displayed pleomorphic nuclei, with prominent nucleoli, some of which had immunoblastic appearance (). Immunohistochemical studies showed the large atypical cells to be positive for CD20 (). The histological diagnosis of the tumor was diffuse large B-cell lymphoma, and EBV was detected in the tumor cells by immunohistochemistry for latent membrane protein-1 (LMP-1) (). The patient had been diagnosed with diabetes mellitus type 1 at age 7; a renal transplantation was performed 3 years earlier because of diabetic nephropathy. After the transplantation, the patient was initially treated with cyclosporine, and, after 6 months, the immunosuppressive therapy was changed to tacrolimus (4 mg twice a day). Prior to the admission, the patient had suffered from headaches, nausea, and dizziness for several weeks. A magnetic resonance imaging (MRI) of the CNS showed a 3.8 × 7.8 cm tumor infiltrating the right parietooccipital region; there was surrounding edema and compression of the right lateral ventricle and right side of the mesencephalon (). A complete resection was not possible, and treatment with prednisolone, 100 mg per day, was started. A bone marrow examination and computer tomography (CT) of the neck, chest, and abdomen did not show lymphoma outside the CNS. HIV testing was negative. An MRI 3 days after the operation showed a 3 × 6 cm resection cavity with contrast in the remaining tumor and nonresolved compression of the ventricle system. Obviously, intrathecal therapy was not possible, and, due to considerable comorbidity, intensive chemotherapy and/or radiation therapy was not feasible. Instead, the patient was treated with the monoclonal antibody rituximab, ganciclovir, and continuous

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

[User]
RADIOLOGY NOTE:
A 22-year-old male patient was referred to the Oral and Maxillo-Facial Surgery Service at Federal University of Paraná after occasional finding on a routine panoramic radiograph. The patient experienced no symptoms. A computed tomographic (CT) was requested and showed a well-defined hyperdense mass showing a hypodense center inside the left maxillary sinus measuring approximately 15 mm × 10 mm situated in a posterior position of this anatomical space (). It was observed that this calcified mass was associated with the roots of the impacted third molar. Treatment proposed was the complete excision of the lesion through an intraoral approach and Caldwell-Luc access to reach the maxillary sinus.
Under general anesthesia, an incision from the superior left first molar extending to retromolar area, with anterior and posterior relaxant incisions, was conducted to provide a sufficient access to the region of interest without causing gingival tissue tension. Osteotomy of the lateral maxillary sinus wall was conducted in order to expose its membrane. Once the sinus membrane was exposed, it was carefully detached from the bone without it disrupting until the calcified mass was reached (). The third molar with calcified mass associated with the roots was removed.
The chosen postoperative drug therapy was cefazoline-oral (500 mg) each 8 hours during 7 days, nimesulide (100 mg) each 12 hours during 5 days, and dipyrone (1 g) for each 6 hours during 3 days. Patient experienced no infection symptoms and drug therapy showed to effective in swelling and pain control.
Pathological mass removed was stored in 10% formalin and sent as excision biopsy for further histopathological investigation. It was fixed in 10% neutral formalin, subjected to decalcification in formic acid, bisected in a mesiodistal direction, and then processed for light microscopic examination. Histopathology showed that the calcified tumor mass was composed of sheets of cementum-like tissue with lack of interstitia

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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:
Patient 4 (PA-4) experienced premature loss of deciduous teeth since he was one and half years old. The physical examination was unremarkable, other than the absence of the upper and lower anterior incisor and canine teeth (Fig. m). Serum ALP activity was 42 U/L at diagnosis when he was 4 years old. Panoramic X-ray showed a reduced alveolar bone of whole dentition (Fig. n). His wrist and knee X-ray revealed normal growth plates without any evidence of defective bones (Fig. o and p). Patient 4 was diagnosed as odonto HPP at 4 years old (Table ).
In order to confirm the diagnosis of HPP and correlate the phenotype with specific genotype, mutational analyses of the ALPL gene were performed in all four patients and their parents except the mother of patient 1 was not involved in this study. The ALPL variants in patient 1 and patient 3 were identified using next generation sequencing and confirmed with Sanger sequencing, whereas the variants in patient 2 and patient 4 were identified and confirmed by direct Sanger sequencing. A 3D structural modeling of the TNSALP constructed based on its sequence homology to the placental isozyme (PDB ID: 1EW2), was used to locate the missense mutation [].
Six different variants were identified in the ALPL gene in our four patients, including five missense variants and one small insertion variant (Table ). All variants were inherited from their unaffected parents except patient 1 (Fig. ). As the most severe and lethal infantile HPP in the present study, patient 1 carried a novel homozygous variant of c.359G > C (p.G120A) at exon 5 of the ALPL gene, which was predicted to be disease-causing by in-silico analysis of bioinformatics software. His father demonstrated a heterozygous status, while his mother was not involved in this study. To further investigate the effect of the novel missense mutation of c.359

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

[User]
RADIOLOGY NOTE:
A 25-year-old man was admitted to the emergency department of our university hospital with sudden onset of nausea, vomiting, slight mental disability, and abdominal pain. Cardiovascular, respiration, and gastrointestinal system examination findings were normal. The neurological examinations of the cranial nerves and limbs were normal. He was clinically dehydrated. On the first day of his admission, laboratory studies revealed a BUN level of 35 mg/dL, creatinine level of 3.17 mg/dL, calcium level of 8.6 mg/dL, and moderate metabolic acidosis with a pH of 7.30. The urinalysis showed hematuria [++++], leukocyturia [++], and proteinuria [+]. A lot of red blood cell casts and white blood cell casts with a few granular casts and epithelial cell casts were observed in urine sediment. Renal ultrasound showed normal sized kidneys with no hydronephrosis. The fractional excretion of sodium (FeNa) was 4%, and he was diagnosed with acute kidney failure. He was admitted to the nephrology department, and intravenous fluid therapy was started immediately due to his dehydration status. Kidney function tests and blood gases were monitored daily. His condition was stable until the 3rd day. On the 3rd day, anuria was developed, and his creatinine level increased to a level of 13,5 mg/dL and revealed a blood gas pH of 7.19 with high anion gap metabolic acidosis. He was admitted for urgent venovenous hemodialysis intervention for two hours via a jugular hemodialysis catheter. On the 4th day, a kidney biopsy was performed. On the 5th day, unilateral right peripheral nerve palsy developed abruptly (). His temporal computerized tomography scan was normal, and electromyography showed a lesion on the right facial nerve. There was no history of cold exposure, and diabetes mellitus, vasculitis, and neuropathic disorders were ruled out by the negative autoantibody screen, normal serum electrophoresis, and negative HIV test. On the 7th, day pathological examination of the kidney specimen revealed

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

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

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

[User]
RADIOLOGY NOTE:
A 27-year-old male patient presented at our hospital in September 2008. He was suffering from a sudden onset of headache that had awoken him from sleep and increased with eye movements. He also had vision loss in his left eye. A neurological examination identified only bilateral papilledema, and a visual field examination demonstrated bilateral (more prominent on the right side) peripheral narrowing. He had no known systemic disease and no drug use, except for amoxicillin one week prior to his presentation.
All tests performed to determine the symptom etiology were negative. His cranial magnetic resonance imaging (MRI) was within normal limits. Cranial MRI venography demonstrated that the left transverse sinus and sigmoid sinus were hypoplastic, and the right side was dominant (MRI venography) (). The patient did not benefit from medical treatment. He underwent daily lumbar punctures for one week. The opening cerebrospinal fluid (CSF) pressure was above 40 cm H2O. The patient's headaches improved, but his vision loss remained constant.
The patient was diagnosed with PTC. We took him into surgery and implanted a lumbo-peritoneal shunt in January 2009. The operation was carried out under general anesthesia in the left lateral decubitus position, with bilateral lower limbs in the bent position. The L2-3 intervertebral space was selected as the point of puncture, through which a 1-cm opening was made with a sharp knife. A modified spinal puncture needle was inserted 5-7 cm along the midline. When an obvious breakthrough feeling was noted, this indicated that the needle was penetrating the spinal dura mater, at which point the needle core was withdrawn until the needle had been inserted through the subarachnoid cavity, with CSF flowing. Meanwhile, the shunt tube was inserted 7-9 cm into the subarachnoid cavity through the spinal puncture needle, and when CSF flowed through the shunt tube, the spinal puncture needle was pulled out. The shunt tube was tunneled to 2 cm late

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

[User]
RADIOLOGY NOTE:
A 62-year-old Caucasian man, service engineer presented to accident and emergency with sudden onset of low back pain whilst lifting a washing machine at work. Pain radiated to groins and was associated with progressive bilateral weakness with numbness in the legs, with more marked symptoms on the left side. There were no cardiovascular symptoms, and the patient had normal observations. He was previously fit and well. He had no medications. He was a smoker for around 40 years and smoked twenty cigarettes a day. He was referred to the orthopedic team as a possible case of cauda equina syndrome secondary to a prolapsed intervertebral disc.
Neurological examination revealed profound motor deficit in the legs with Medical Research Council (MRC) grade 2/5 muscle power in the hip flexors and complete paralysis in all other groups distally. All reflexes including the plantar reflexes were absent, and sensation was altered throughout both legs. Sensory and motor functions at level T12 were preserved. Perianal tone and sensation were both markedly reduced and he was unable to feel the passage of a bladder catheter. His vital signs were stable with normal pulse and blood pressure. Complete cardiorespiratory examination was normal and all peripheral pulses were palpable. However, abdominal examination revealed a nontender pulsatile mass.
Baseline laboratory investigations including Erythrocyte Sedimentation Rate were normal with the exception of a white cell count of 14.4 × 109/Lt. Lumbar puncture was unremarkable. His other blood parameters including LFT, Renal functions and bone profile were normal apart from slight raised cholesterol 6.2(5.3 mmol/lt). Plain radiographs revealed mild degenerative changes in the spine. An urgent MRI scan was requested to rule out caudaequina due to disc prolapse. An MRI revealed () multiple disc protrusions in the lumbar spine, in particular at the L5/S1 level, but there was no evidence of acute cord or caudal compression. The scan also reveal

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


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

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

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


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

[User]
RADIOLOGY NOTE:
A 10-year old boy with OI presented at the Stomatology service of the Federal University of Ceará (Sobral). The OI type was not identified, the genetic test was inconclusive, and the patient had no family history of OI. Physical findings included short stature, blue sclerae, and locomotion difficulties due to deformed and arched limbs (). The medical history included reports of 16 bone fractures and intravenous administration of pamidronate disodium infused over a period of 3 days and repeated every 4 months. Anterior and posterior cross-bites, Angle class III malocclusion, and mild mandibular prognathism were observed on oroscopy. The anterior teeth were brownish, especially the lower incisors. Hypomineralization was observed on the vestibular surface of the upper left lateral incisor and a gray band was seen on the posterior teeth, especially the molars, suggesting DI (). The remaining deciduous teeth (the upper right maxillary canine and the right mandibular molars) were more brownish than the permanent teeth and were undergoing exfoliation, requiring extraction. Periapical radiography revealed enlarged pulp chambers, with insidious early obliteration of the coronary pulp chambers of the lower incisors and a thin layer of dentin deposited along all the teeth producing a taurodontic appearance. The teeth had ample crowns and cervical constrictions, with molars taking on a bell-like shape resembling a crown (). Panoramic radiography confirmed large pulp chambers in all teeth, but no agenesis, impaction, or supernumerary roots (). The primary mandibular molar teeth (first and second left mandibular teeth) presented physiologic mobility for some time, but were retained in spite of the underlying erupting premolars, which generated dental plaque accumulation, pain, and gingival bleeding during mastication and tooth brushing. Thus, these teeth were extracted to prevent further discomfort and to allow proper dental eruption. The child's mother requested the extraction o

[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 super-super-morbidly obese female (BMI 90 kg/m²) with a past medical history of chronic obstructive pulmonary disease and cor pulmonale presented to the emergency department with altered mental status and difficulty ambulating secondary to lower extremity edema. Vitals revealed an elevated heart rate of 100 beats per minute and decreased respiratory rate of 10 breaths per minute. Physical exam was significant for lethargic mentation and denuded abdominal wounds under her pannus. Bi-level positive airway pressure and intravenous clindamycin were started due to hypercapnic respiratory failure and concerns for infection. Chest X-ray showed hyperinflated lung volumes without obvious signs of pneumonia (Figure ). Arterial blood gases demonstrated elevated serum bicarbonate, consistent with chronic carbon dioxide retention. The patient was admitted to the intensive care unit and emergently intubated due to worsening respiratory status. General surgery recommended discontinuation of clindamycin in favor of local wound care.
On hospitalization day seven, palliative care was consulted around goals of care and tracheostomy tube placement. Percutaneous endoscopic gastrostomy (PEG) tube or gastrostomy tube placement were discussed for nutrition; however, the ICU and surgical teams presented concerns of abdominal wall thickness and potential displacement into the peritoneal and abdominal cavity. The family was counseled regarding the risks and benefits and elected to proceed with a tracheostomy tube and PEG placement with full code status. Standard approaches for tracheostomy and PEG tube placement were performed. Directly post-procedure, however, the patient developed atrial fibrillation with a rapid ventricular response. Advanced cardiac life support (ACLS) protocols with phenylephrine, midazolam, cardioversion, and amiodarone were successively given in addition to a heparin drip, which stabilized the patient. Two hours after direct current cardioversion, the pat

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


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

[User]
RADIOLOGY NOTE:
A 45 year-old right hand dominant gentleman sustained a fall on his left shoulder in a skiing accident in Colorado. He was in significant pain and shortness of breath and therefore referred to a local hospital for evaluation. A chest radiograph was unremarkable and particularly revealed no evidence of a pneumothorax, hemothorax, or widened mediastinum (Figure ). Due to significant tenderness over the left sternoclavicular joint, a CT scan was obtained which demonstrated a locked posterior sternoclavicular dislocation (Figure ). The patient was transferred to our academic Level 1 trauma center for definitive care. On arrival in our emergency department, the patient complained of significant pain in his chest and left shoulder, as well as left-sided neck pain. The upper airway was patent, and the patient was hemodynamically stable and fully awake, alert, and oriented, with a Glasgow Coma Scale (GCS) score of 15. A CT-angiogram of the neck revealed no sign of an acute cervical spine injury or associated vascular injury (not shown). Due to the locked position of the clavicle behind the manubrium (Figure ), no attempt for a closed reduction maneuver was made, and the patient was consented for surgical open reduction and internal fixation. As part of the pre-operative planning, we ensured immediate availability of a vascular surgeon, and the presence of a sternal saw and vascular set in the operating room, for immediate access in case of an accidental intraoperative vascular laceration. The patient was placed in supine position with a bump placed under the left shoulder. The left upper extremity freely draped. The surgical approach consisted of an incision of 10 cm length along the superior border of the medial clavicle, with a slight curve just medial to the sternoclavicular joint, across the midline of the manubrium. A full-thickness soft tissue dissection was performed down to the left sternoclavicular joint utilizing a meticulous dissection technique to avoid accident

[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 from a Middle Eastern country presented to the Jefferson Pancreas, Biliary and Related Cancer Center for evaluation of a recurrent pancreatic mass. She complained of right upper quadrant fullness, and physical examination revealed a remote right subcostal incision. At the age of 12 years, she had first developed decreased appetite, weight loss, fatigue, pruritus, and subsequently became jaundiced. Medical records from that episode revealed that an endoscopic biliary stent was placed with surgical exploration through a right subcostal incision and partial resection/enucleation of a pancreatic mass. In the intervening 12 years, the mass had persisted and enlarged, although the patient was asymptomatic, having neither anorexia, pruritus, nor jaundice.
Routine hematology and basic chemistry panels were normal. The tumor marker cancer antigen 19-9 was mildly elevated at 89 U/mL (<35 U/mL). An abdominal computed tomography (CT) scan with contrast revealed an 8.2 × 7.6 cm heterogeneous-enhancing lesion, prominently involving the uncinate process of the pancreas (). The pancreatic head and neck were displaced and splayed around the anterior aspect of the tumor. The mass abutted the superior mesenteric vein (SMV) as well as the superior mesenteric artery (SMA). There was no evidence of main pancreatic ductal dilatation and the pancreatic neck, body, and tail were normal. Imaging showed no evidence of metastatic disease to the liver or regional lymph nodes. The mass was believed to be an SPT, based on the previous partial resection and the accompanying pathology report.
The patient underwent an open cholecystectomy and a difficult classic pancreaticoduodenectomy. The operative time was 12 h and the estimated intraoperative blood loss was 1500 mL. There was no evidence of metastasis, but the tumor had adhered extensively to the SMV and portal vein and surrounded the SMA. We were able to accomplish the separation of the tumor from the venous structures witho

[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 73-year-old female presented with a new 3 cm mass in the pancreatic head that was found on an annual surveillance computerized tomography (CT) scan eight years after a radical left nephrectomy for renal cell carcinoma (RCC). Her initial nephrectomy was for an 8 cm clear cell RCC that had one positive periaortic lymph node (LN). The patient had no further treatment and denied abdominal pain but reported progressive weight loss (>60 lbs) over the last several months. She was not jaundiced and there was no evidence of duodenal or biliary duct obstruction on the CT scan. Other diagnostic modalities (endoscopic retrograde cholangiopancreatography (ERCP) and magnetic resonance imaging (MRI)) confirmed the pancreatic head mass. A bone scan and a chest X-ray were negative for metastatic disease. The patient underwent a diagnostic laparoscopy with pelvic washing and biopsies from peripancreatic tissue, celiac, splenic and periportal lymph nodes. There was no evidence of peritoneal, omental or hepatic spread and all biopsies were negative for malignancy. A pancreaticoduodenectomy (Whipple procedure) was performed for presumptive pancreatic cancer. Section through the specimen showed multiple solid yellowish necrotic and hemorrhagic areas (0.5 - 2.2 cm). The histologic exam was consistent with metastatic clear RCC (Figure ), two of nine peripancreatic LN were positive for metastases. There was no neoplastic thrombus in the pancreatic duct and the margins were free from disease. Immunohistochemical stain showed tumor focally positive for cytokeratin 7 and keratin AE1/AE3 but negative for cytokeratin 20 and carcinoembryonic antigen. The tumor stained strongly positive with vimentin; all consistent with RCC. The pathology was identical to the slides from initial nephrectomy. Four months later, a gradually enlarging right lobe thyroid nodule was noticed associated with dysphagia. The nodule was cold on radionuclide scanning and solid on ultrasound, measuring 2.9 x 2.6 x 2 cm. Do

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


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

[User]
RADIOLOGY NOTE:
A 64-year-old woman with a history of hypertension and arrhythmia presented to the emergency room with severe pain and immobility in her left elbow, which resulted from a previous traffic accident. The patient complained of severe, painful limitation of motion on straightening or bending of the elbows, and her left hand was heavily bruised and swollen. Physical examination using palpation revealed burning and local tenderness. X-ray revealed a displaced fracture of the left olecranon with soft tissue swelling. The fracture was defined as a type IIA olecranon fracture according to the Mayo classification system.[ The orthopedic specialist suggested surgical open reduction with internal fixation, but the patient hesitated under the consideration of increased surgical risk due to her history of hypertension and arrhythmia. Therefore, the orthopedic surgeon fixed her left elbow with protective clothing only. Later that day, she visited our outpatient clinic to seek help from TCM.
In the first visit, we used the TCM methods for manipulative reduction of the fracture after physical examination. The physician held the patient's left palm in one hand and held the left elbow of the patient in the other hand. Next, the doctor pushed the proximal end of the patient's elbow with his finger to move closer to the distal end, and at the same time, straightened the patient's elbow slowly. Finally, the patient slowly buckled the elbow to 60°. It was then braced securely. We also asked the patient to avoid flexion and extension activities of the elbow and to fix the elbow with protective clothing for about 1 month, until her fracture had healed. That duration depended on X-ray interpretation to ensure complete union of the fracture. The protective clothing, similar to a triangular scarf, was for fixation and immobilization of the displaced olecranon fracture. The patient removed the protective clothing after about 1 month and then started rehabilitation. At the same time, we prescrib

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


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

[User]
RADIOLOGY NOTE:
A 60-year-old male with a past medical history of asthma, spastic paraplegia, hypertension, hyperlipidemia, peptic ulcer disease, and tibial osteomyelitis post-infected hardware removal was admitted for altered mental status. He was admitted to the orthopedic service for infected hardware removal one month prior to the current admission. He was subsequently started on IV cefepime 2g every eight hours for tibial osteomyelitis and then discharged to a skilled nursing facility for six weeks. Approximately 17 days later, the staff at the nursing facility reported that the patient was delirious, slurring his speech, and pulling out his peripherally inserted central catheter (PICC) line in the night. He was then hospitalized at an outside facility for four days where he had an extensive workup, including a CT head, MRI head, and EEG without any conclusive etiology for his altered mental status. The EEG showed generalized slowing and evidence of metabolic encephalopathy and he was discharged. He returned to an outside emergency department three days later for persistent neurological symptoms, where he was found to have acute kidney injury. Following administration of IV fluids, he was discharged to his skilled nursing facility. His mental status did not improve. After consultation with the infectious disease team, the patient was admitted to our hospital for further workup. Upon admission, his vitals were unremarkable and physical examination showed confusion and disorientation without any other focal neurological deficits. Laboratory results were unremarkable except for an elevated creatinine of 1.8mg/dL (baseline 1-1.2mg/dL) indicative of unresolved acute kidney injury. Cefepime was discontinued, and the patient’s mental status and speech improved over the next 72 hours. Nephrology was consulted. After extensive workup, acute kidney injury was presumed to be secondary to cefepime toxicity with a component of acute tubular necrosis given the hyaline and granular casts see

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


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

[User]
RADIOLOGY NOTE:
A 74-year-old female presented to the emergency department (ED) with upper abdominal pain and melanotic stools. She had an elective open juxtarenal abdominal aortic aneurysm repair a month before her index presentation. She was hemodynamically stable. Her pertinent initial labs showed a hemoglobin of 6.7 g/dl (baseline 9.6 g/dl) with a hematocrit of 23%. Patient did not have any fever or leukocytosis. A CT abdomen with contrast done in the ED for abdominal pain showed nonspecific findings, i.e, irregularity of the “aneurysmal sac” with a small amount of fluid around the sac (see ) which was read by the radiologist as early postsurgical changes. She was admitted and was started on proton pump inhibitors. An esophagogastroduodenoscopy (EGD) was performed that revealed mild duodenitis. Her hemoglobin remained stable the next couple of days, and she was discharged home with a 6-8-week course of proton pump inhibitors. Two months later, she presented again with similar complaints with a drop of hemoglobin. A repeat EGD was performed that did not reveal any obvious source of bleeding, and she was discharged home after stabilization.
A month later, she came for the third time into the ED with abdominal pain, hematochezia, and profound hypotension. Her pertinent laboratory findings include leukocytosis, low hemoglobin and hematocrit, thrombocytopenia, and transaminitis. She was resuscitated with IV fluids and blood transfusions. She was started on broad spectrum antibiotics after blood cultures were drawn. A CT abdomen and pelvis was performed which showed tiny foci of air at the anterior aspect of the native aneurysm wrap just inferior to the location where duodenum crosses (see ). At that time, a decision was made to perform push enteroscopy instead of simple EGD to evaluate second and third portion of duodenum which showed an aortoduodenal fistula with infected graft adherent to the bowel wall and extruding purulent exudate (see ). She underwent emergent

[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.