[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 white man presented to our emergency department with a 3-day history of left lower extremity swelling and acute-onset shortness of breath. On evaluation, he was tachycardic with a pulse of 113, hypertensive with a systolic blood pressure of 130-170 mmHg, and demonstrated poor oxygen saturation of 81% on room air. He was supported with continuous positive airway pressure (CPAP) and supplemental oxygen while a computed tomography angiogram (CTA) was obtained, which revealed a saddle PE (Fig. ).
Tissue plasminogen activator (tPA) was administered and he was started on a heparin infusion and admitted to our intensive care unit (ICU) for management. He remained on the heparin infusion for 3 days, during which he continuously improved and was eventually weaned to 3 L oxygen via nasal cannula. On hospital day 2, he was transferred to intermediate level of care. Per hematology recommendations, he would have to be on indefinite anticoagulation due to the massive PE he had sustained, the source of which was a left lower extremity popliteal deep vein thrombosis (DVT). The plan was to transition him from the heparin infusion to enoxaparin twice per day with hematology follow-up in 1 month.
On the day of discharge, however, he had sudden onset of right leg numbness and weakness below the level of his hip. He had previously been working with physical therapy and had been able to walk 200 feet with the assistance of a walker during each session. A physical examination revealed decreased sensation to light touch, 2/5 strength in right hip flexion and right knee extension and flexion, and loss of right patellar reflex. Left leg physical examination was normal at that time.
An emergent head computed tomography (CT) scan was ordered due to concern for a possible stroke, and neurology was consulted. The head CT was negative for infarction or hemorrhage. Neurology was concerned for spinal cord infarction versus hematoma and recommended emergent magnetic resonance imaging (

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


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

[User]
RADIOLOGY NOTE:
A 30-year-old nulliparous pregnant Japanese woman was referred to our institution for prenatal evaluation of a fetal abdominal cyst at 19 weeks of gestation. Fetal ultrasonography showing a distended colon with the presence of bowel calcifications, distal rectal pouch, and undetectable anal mucosa indicated the presence of intermediate- or high-type imperforate anus with rectourethral fistula (Figures and ). No other anomaly or fetal growth restriction was detected (). Fetal ultrasonography at 20 weeks of gestation showed the progression in colon dilation and relatively decreased amniotic fluid but not yet oligohydramnios. Even after informing the parents of possible poor prognosis of the fetus, the parents did not desire termination of pregnancy or amniocentesis. Fetal ultrasonography showed further progression of bowel dilation obviously seen from 26 weeks of gestation, which leads to thoracic compression, and amniotic fluid suddenly decreased after 28 weeks of gestation despite a fluid-filled bladder without hydroureter or hydronephrosis, which implied the presence of fetal urine outflow obstruction but not a decrease in urine production (Figures –, ). Sonographic assessment of fetal well-being, including Doppler velocimetry of the middle cerebral artery, umbilical cord artery, and ductus venous, and biophysical profiling, was normal. MRI was performed at 30 weeks of gestation to assess pulmonary development, which indicated possible pulmonary hypoplasia (). By 32 weeks of gestation, although the fetal bladder was filled, oligohydramnios persisted without any signs of premature rupture of the membranes, placental insufficiency, hydroureter, or hydronephrosis. Taken together with the progression of bowel dilation which distended the fetal abdomen, fetal urethral stenosis or obstruction was expected to have triggered a misdirected urine flow from the bladder to the colon through the fistula. As deterioration of oligohydramnios and bowel dilation which lead to pulmo

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


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

[User]
RADIOLOGY NOTE:
A 16-year-old female patient referred to our outpatient clinic with gradual deterioration of vision for the age of 1 year mostly in the right eye, with episodes of sharp headaches. Ophthalmic examination confirmed reduced visual acuity with only perception of light in the left eye. Neurological examination showed no other neurologic deficit. Brain magnetic resonance imaging (MRI) showed a solid mass lesion involving the hypothalamus and the optic chiasm. The lesion was hypointense on T1-weighted images, hyperintense on T2-WI, and showed marked homogenous enhancement after the administration of contrast material []. The patient was operated by the right pterional craniotomy and transsylvian approach. Bulging of the optic chiasm and the site of lamina terminalis were seen. Incision with knife was done on the right side of optic chiasm through the exophytic part of the tumor and tumor evacuation done from inside the chiasm []. Furthermore, resection of the suprachiasmatic part of the tumor was performed and lamina terminalis was opened. Tumor entry sites were planned to minimize the risk of neural injury. Entry to the optic chiasm was performed from the lateral part of the right optic chiasm where tumor was bulging and exophytic with minimal covering neural tissue. Furthermore, this site is far from the median part of the chiasm in which crossing of optic fibers takes place. In the suprachiasmatic part, we also aimed to the exophytic part of the tumor and planned to enter through the lamina terminalis, which is known for its safety for dissection, to the anterior part of the third ventricle. In general, there was no clear-cut plain of cleavage, and dissection was carried on according the difference of color and consistency between the normal tissue and the friable grayish tumor tissue. Yet, subtotal resection of the tumor was achieved due to the absence of this difference between a part of the tumor and the hypothalamus. Thus, we decided to

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


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

[User]
RADIOLOGY NOTE:
A 67 year old man of Greek origin attended the emergency department with a two hour history of dull central chest pain that radiated into his back. There were no other symptoms and he was normally in good health. Examination and investigations (chest radiography, ECG, full blood count, and biochemistry screen) were thought to be normal. His pain subsided apart from some discomfort on swallowing and he was discharged home. She re-attended the department six days later. He complained that he had been cycling up a hill and had developed severe chest pain radiating into his jaw together with some sweating. Moreover, the discomfort of which he had previously complained had persisted. On examination he had a pulse of 98 per minute, BP 142/72 mm Hg, SaO2 97% on air and temperature 37.5°C. There were no cardiovascular or abdominal signs. There was no surgical emphysema in the supraclavicular fossae. On examination of the chest breath sounds were equal bilaterally for the upper lung fields, but absent for the right lower lung lobe. Chest X-ray confirmed the findings of physical examination and demonstrated right pleural effusion, but no radio-opacity was detected and there was no evidence of pneumomediastinum or subcutaneous emphysema (). At this point, a small amount of free air in the right hemithorax was overlooked and the patient admitted to the hospital with the diagnosis questioned for a basal pulmonary pathology.
Because of an erroneous belief that pulmonary complication was the cause of this specific clinical picture, the diagnosis of esophageal perforation was not suspected. The original diagnosis of esophageal perforation was delayed because of misinterpretation of right pleural effusion as a basal pulmonary pathology. Finally, three days after admission clinical deterioration with increased respiratory distress and discomfort, fever and chest pain did arouse suspicion of an esophageal perforation. At this point with a thoroughly history taken, the patient admitted

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


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

[User]
RADIOLOGY NOTE:
A 71 year old female was referred for investigation of a presacral mass found incidentally during a staging CT (figure ) and MRI (figure ) of a recently diagnosed rectal carcinoma. The mass was located anterior to S4 and S5 in the presacral space. She was completely asymptomatic of this mass. Except for the recently diagnosed rectal carcinoma and hypertension, she had no other medical issues.
Her CT scan revealed a suggestion of an ill-defined presacral mass, reported as possible oedema. The subsequent staging MRI clarified a 3.3 × 1.9 × 2.3 cm presacral mass at the level of S4/S5. Evidence of bony erosion could not be seen.
Initially, differential diagnoses for this mass included chordoma, schwannoma and plasmacytoma. The mass was further investigated with a whole body thallium study and a CT-guided biopsy (figure ). The thallium study revealed no evidence of a thallium avid tumour in the sacrum or elsewhere. The biopsy revealed fat and haematopoietic tissue, consistent with a diagnosis of extramedullary haematopoiesis (figure and ). The occurrence of EH in the presacral area is an extremely rare finding with only 17 reported cases in the literature.
This remarkable diagnosis was further investigated with the help of a haematologist. A full history found no personal or family history of bleeding disorders or anaemia. Full blood examination and liver function tests revealed no abnormality. A bone marrow biopsy was taken which revealed mildly hypercellular marrow, showing a mild increase in trilineage haemopoiesis. This was likely to be reactive. A cytogenetics study was organized to differentiate reactive marrow from early myelodysplasia. No cytogenetic abnormality was detected.
The case was discussed at a multi-disciplinary meeting and a decision was made that this mass was benign in nature. No further investigations or treatment was deemed necessary. The patient subsequently underwent an uncomplicated resection of her rectal carcinoma. This is only the second case

[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 otherwise healthy, non-smoker, obese (his BMI is 35), adult male patient in his late 20s sought medical assistance following agonizing simultaneous pain in both knees with weight bearing. His Visual Analog Score (VAS) pain was 2/10 at rest but increased to 10/10 with weight bearing, rendering him unable to walk. Pain onset was ten days before his first medical consultation, without any history of specific traumatic incident. Prior to pain presentation, the patient had just completed a ten-day training period in order to meet specific criteria to join the police academy. The training consisted of long walks and running sessions on hard tarmac. Before the training period, his lifestyle was rather sedentary. The patient provided a detailed account of his daily training sessions because he was using a specific application on his smart phone (). He had no previous knee injuries or locking-like symptomatology. The patient denies altering his daily diet habits before, during or after training.
On physical examination, no limb malalignment was present. His knees had no apparent effusion/swelling and there were no skin abnormalities. Temperature of both knees was normal. There was significant tenderness over the medial tibial condyle in a wide area including the medial joint line, the pes anserinus and the medial collateral ligament insertion, consistent with the reporting pain site in both knees. Both passive and active range of motion were full and unrestricted and elicited only mild discomfort. Special tests assessing cruciate ligament instability were within normal range. Valgus force test elicited pain, without gross instability. The McMurray test for medial meniscus was positive for both knees, although the examining physician felt that it was non-specific for the patient’s symptomatology. Anteroposterior and lateral plain radiographs of both knees were ordered and were reported back as normal (). Simple painkillers were prescribed and non-weight bearing ambulation

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


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

[User]
RADIOLOGY NOTE:
We report a case of a 68 years old woman presenting to the emergency department with macrohematuria and dysuria. She experienced fever several times, starting two months before medical examination. Fever was treated with NSAID. A history of recent pelvic pain was also reported. Her clinical status was good and no other symptoms or concurrent illnesses were present at the time of hospitalization.
She was admitted to Gynecologic service for further evaluation.
The patient was virgin and in post-menopausal status. Clinical history was unremarkable; negative either for previous medical or surgical procedures. Family history was positive for cancer with one male sibling deceased from a pancreatic malignancy; the remainder two siblings had no positive history for malignancies as well as parents and closest relatives. Social history was negative for use or addiction to drugs, alcohol and exposure to potential risk factors.
A digital rectal examination had to be performed in place of the gynecologic bimanual examination. A gross, firm mass located in the pelvis was found at physical examination.
Pelvic US, abdominal CT scans, descending pielography, cystoscopy and chest RX were performed to both assess local disease and evaluate the presence of local and distant metastases.
Computed tomography imaging confirmed the presence of a complex mass in the pelvis (13 × 14 cm) showing irregular contours and small areas of calcifications. Uterus and adnexa could not be clearly recognized, showing as being part of the mass. Iliac vessels and bladder were displaced. Imaging technique reports stated that no vessels or bladder invasion was present. A hypoplasia of the left kidney was also reported. No other metastasis was reported in the abdomino-pelvic cavity.
Pielography showed a delay in the opacification of the renal pelvis associated to a dilation of the right ureter that was compressed and displaced in its pelvic course till entering the bladder. No opacification of the contra late

[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 47-year-old female patient visited hospital for a national health screening program. Esophagogastroduodenoscopy revealed a 0.8-cm-sized depressed lesion at the posterior wall of the first part of the duodenum (, ). Histologic analysis of the biopsy specimen revealed atypical glands forming cell clusters beneath the intact mucosal layer. The atypical clusters were arranged in tubular structures of columnar epithelium consisting of mucin-producing cells. Dystrophic calcification was scattered within the lesion, and foreign body reaction with giant cell formation was noted around the calcified materials (, ). Immunohistochemistry (IHC) for CD56, chromogranin A and synaptophysin showed negative results, excluding the possibility of a neuroendocrine tumor, which is prevalent in this region. The histologic diagnosis was well-differentiated adenocarcinoma, and the patient underwent routine preoperative work-up. Physical examination, blood tests and abdominal computed tomography (CT) scan showed no abnormal findings. A minute duodenal lesion with submucosal invasion was suspected on endoscopic ultrasonography. Since the calcification was minute, it was not recognized by simple X-ray or by CT scan even upon retrospective review.
Endoscopic resection was not an option because it is usually difficult to remove a lesion by endoscopy at the posterior wall of the duodenum. The possibility of submucosal invasion was also considered; hence, the patient received distal gastrectomy. Since the lesion was located in the duodenal bulb, the duodenal stump was made near the pancreas and the distal resection margin was close to the lesion. D1+ lymph node dissection was performed.
On gross examination, the specimen consisted of 2.7 cm long duodenum and 6.5 cm long stomach. On duodenal mucosa, a 0.8 × 0.8-cm-sized superficial depressed lesion was found (). The lesion was located at the posterior wall of the duodenum, 1.9 cm distal to the pyloric ring and 0.3 cm proximal to the distal resec

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


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

[User]
RADIOLOGY NOTE:
A 31-year-old gravida 4 para 0 African American woman at 22-weeks gestation presented with vaginal bleeding to an outside hospital. Her obstetric history was significant for 2 therapeutic abortions and 1 spontaneous abortion. During prenatal care, the fetus was noted to have a unilateral dysplastic kidney. The patient’s family history was significant for two family members with cervical cancer and two family members with endometrial cancer. She was placed on bedrest with inpatient admission. 48 h after admission she developed pelvic pain and uterine contractions. She expelled a mass vaginally measuring 11 × 9 × 5 cm with no fetal contents. The pathology from the outside facility showed a showed a highly cellular tumor composed of spindle-shaped cells and bizarre multinucleated giant cells with focal myxomatous change with mitotic count is greater than 50 per 10 high power field (Positive for CD10, SMA, ER, PR, EMA) with the differential diagnosis including endometrial stromal sarcoma and undifferentiated uterine sarcoma. The patient underwent examination under anesthesia, demonstrating a 3 × 3 cm defect of the posterior vaginal wall with active bleeding, which was sutured for hemostasis. The cervix was long, closed, and high with no evidence of bleeding and the fetus was intact with normal heart tones. She was discharged in stable condition.
At 27-weeks, the patient was referred to our institution for maternal-fetal medicine, and gynecology oncology consultation. On initial evaluation, she reported no prior abnormal gynecology history and no history of infertility issues. She denied dyspareunia and bulk symptoms prior to or during pregnancy, and her periods before pregnancy were normal. A pap smear at 27-weeks gestation was normal and negative for human papilloma virus. Her intake physical exam at our institution revealed a normal pelvic exam with no evidence of residual vaginal mass, and an ultrasound revealed no intrauterine myomas.
Given the differential diagnosi

[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:
52-year-old man, plumber by profession, presented at the emergency department with one day history of having sudden onset spontaneous pain and functional impairment of left knee while he was walking. The patient had history of hypertension. He had no history of taking medications such as corticosteroids or fluoroquinolones and did not remember having suffered any knee pain previously. On clinical examination effusion was present in knee. It was possible to palpate a gap between the distal patellar tendon and the tibial tuberosity and patient was not able to extend the leg. X-ray of the left knee showed a high patella and presence of calcification in the distal part of the patellar tendon (). Ultrasound later confirmed the diagnosis of distal avulsion of the patellar tendon. Although CT scan and MRI are superior modalities for confirmation of the diagnosis but based on our clinical examination, typical radiographic finding and ultrasound imaging, we considered these expensive investigations unnecessary in this case. On the second day, patient was taken to the operating room. Under tourniquet control, patellar tendon was exposed through anterior approach to the knee. Distal insertion of the tendon was found to be completely avulsed from the tibial tuberosity with some flakes of sclerotic bone (). The torn tendon was found to have degenerative changes at the injury site. The tendon stump was debrided and refashioned. Locking double Krackow stitch was taken with FiberWire number 5, and then it was anchored to tibial tuberosity after drilling four 2.0 mm transverse holes in tuberosity. Full range of motion of the knee was performed to evaluate the repair and we found it satisfactory. Repair of paratenon was performed and wound was closed. Postoperatively, knee was locked in a brace at 0 degrees of extension and the patient was encouraged to do isometric quadriceps strengthening exercises. Patient was allowed weight bearing as tolerated. A range of motion exercises were p

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


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

[User]
RADIOLOGY NOTE:
A 58-year-old woman was admitted to our Department with a sudden inability to extend the second finger of her left hand (). No recent trauma was reported. One year earlier she suffered a displaced fracture of the distal radius - 23 C2 according to the AO/OTA classification. Internal fixation by volar plate was performed, using the flexor carpi radialis–radial artery interval (Henry’s approach). The right positioning of the plate, the screws length, as well as the restoration of the volar tilt were intraoperatively assessed by fluoroscopic images. The 4-week x-ray follow-up showed early signs of fracture healing. However, the screws seemed overlong with respect to the dorsal cortical surface in the lateral view (). No extensor tendons functional deficit was found. 12 months later, the patient came back with a complete functional deficit of the index finger extension. Yet, the metacarpo-phalangeal (MCF) and proximal inter-phalangeal (PIP) joint examination proved no stiffness, and the full passive extension was noticed. The Ultrasound Examination suggested an incomplete rupture of the extensor tendon mechanism of the index finger, confirmed by the MRI examination. A second surgery was recommended, consisting in the plate removal and reconstruction of the extensor tendon mechanism, with end-to-end suture or tendon graft in case of a massive tendon defect. The patient rejected the surgery. However, she came back 6 weeks later due to the unacceptable disability and with the result of a chronic lesion. In agreement with the patient it was decided to proceed to the surgical treatment. It was decided to perform a combined dorsal and volar approach, in order to remove the plate and repair the extensor tendon injury. Starting from the dorsal approach, we confirmed the complete rupture of the extensor tendon mechanism of the second finger, the incomplete rupture of the extensor tendon mechanism of the fourth and fifth fingers, and the presence of a widespread tenosynovitis inv

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


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

[User]
RADIOLOGY NOTE:
A 59-year-old man with hypertension and diabetes presented with progressively worsening back pain radiating down the right leg, right flank pain, nausea, and vomiting. He denied hematuria, dysuria, or any problems with urination. He also had an unintentional weight loss of 5 kg during the past 6 months.
Based on systemic symptoms, CT scan was ordered to rule out malignancy. Radiographic findings were remarkable for hypodense liver lesions, pulmonary nodules, retroperitoneal lymphadenopathy, and increased bone density in L1 and L3 vertebral bodies as well as the right iliac bone. The patient also had moderate right hydroureteronephrosis of both renal moieties with delayed nephrogram and transition point within the proximal common right ureter ( and ). Lumbosacral MRI revealed right L5 nerve root impingement by a lumbar mass. Brain MRI showed abnormal signaling within right temporal lobe concerning for metastasis.
To further characterize the ureteral mass as well as to confirm the extent of collecting system duplication, the patient underwent a right ureteroscopy. Cystoscopy revealed bilateral orthotopic ureteral orifices with no ectopic orifice. Right retrograde pyelogram showed a filling defect at the proximal ureter with reduced amount of contrast moving in two levels more proximally, corresponding to a partially duplicated system (). A wire was placed into the upper pole of the kidney. A flexible ureteroscope was advanced alongside the wire confirming a bifurcation of a bifid collecting system at the level of the filling defect. The ureteroscope was advanced into the lower pole ureter, with multiple papillary tumors noted in this segment distally by the bifurcation. Selective barbotage cytology and tissue samples using a Piranha™ grasper (Boston Scientific, Marlborough, MA) were obtained. Narrowing of the proximal right lower pole ureter precluded advancement to the lower pole kidney. Attention was then turned to the upper pole ureter where multiple papillary tumo

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


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

[User]
RADIOLOGY NOTE:
A 25-year-old Mexican female with family history of ovarian cancer at her maternal side and personal history of a mass on her right breast clinically and radiologically diagnosed as fibroadenoma 2 years ago. The same mass had a growth of 2 cm so an incisional biopsy was performed at another institution. This was positive for mucinous carcinoma, and the patient was referred to our institution for treatment and follow up.
At our institution in the biopsy slides revision, we found a tumor composed of mucinous lakes with numerous tumor cells of medium to large size with a moderate amount of eosinophilic cytoplasm confirming the presence of pure mucinous carcinoma. We could not identify the tumor size and surgical margins by no prior radiological and pathological report. []. The tumor was classified as a Low grade tumor (G1) based on the Scarff Bloom Richardson scale. We did not observe perineural or vascular invasion. On immunohistochemistry the results were 100% and 90% positive for estrogen and progesterone receptors respectively with high intensity, and HER2 receptors negative.
On physical examination a surgical injury was seen. Upon palpation, this zone felt indurated, edematous and presented as a rough irregular texture. No other lesions were found. An ultrasound was performed, showing avascular distortion and a heterogeneous mass with microcysts (white arrows) []. MRI showed a hypointense irregular mass that indicates a mild enhancement in contrast sequences and a hyperintense sequence in SPAIR. The evaluation of the lymph nodes was not suspicious for metastasis.
With the radiological suspicious of residual tumor and pathological findings accomplished at our institution a partial mastectomy and a sentinel lymph node biopsy was performed. Pathological findings showed a residual mass of 25 mm of pure mucinous carcinoma with negative surgical margins. Sentinel lymph node was negative for metastasis.
Molecular screening with EndoPredict clinic showed a score of 2.7 cl

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


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

[User]
RADIOLOGY NOTE:
A 69-year-old female was referred to our clinic for an incidental finding of a large Morgagni hernia found on a recent CT chest scan for lung cancer screening. Patient reported occasional shortness of breath after prolonged ambulation but denied chest pain. She did have remote history of acid reflux symptoms but nothing recently. She denied issues with prematurity or issues with development as an infant, chest trauma, or MVA history. She did complain of occasional right shoulder pain but attributed this to arthritis. Denied history of heart attack, stroke, DVT, or PE. She had a 30-pack-year smoking history but quit a year prior. She was up-to-date on her colonoscopy, current within the past year. She denied hematochezia and melena, bowel habit changes or major body weight changes as well as any current abdominal pain. On examination her vitals were within normal parameters. Heart and lungs were unremarkable. Abdominal examination was soft with normal bowel sounds and nontender. Remainder of examination was unremarkable. Laboratory values included a normal CBC and BMP. A CT chest scan had demonstrated a large retroxyphoid hernia of Morgagni involving several loops of small bowel and transverse colon located in the right inferior hemithorax (Figs and ). No evidence of acute incarceration or strangulation were noted. A detailed discussion was undertaken with the patient regarding her hernia and she was consented for a laparoscopic repair with mesh.
Patient underwent a laparoscopic approach in lithotomy positioning with the primary surgeon working between the legs. Three working ports were used, a 12 mm port at the umbilicus and two 5 mm ports; one in the LUQ and one in the RUQ. Upon initial laparoscopy multiple loops of small bowel were progressively reduced out of the hernia sac which also included the ascending colon and part of the transverse colon (Figs and ). All the small bowel and the colon

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


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

[User]
RADIOLOGY NOTE:
A 5-year-old girl was referred to our hospital for the investigation of urinary incontinence. The patient had continuous low volume urine leakage requiring 4–5 daily pads. The parents could not specify whether there was any connection with standing, coughing, or effort and she had no urge to void.
She was constantly wet but had normal voiding habits. On initial physical examination the external genitalia appeared normal with no vaginal pooling of urine or ectopic ureteral orifice. However, a long-term external genitalia examination revealed normal urethral and vaginal openings, with an intermittent urine leakage through the vaginal orifice, which slightly increased in abdominal pressure.
In her past history she had recurrent febrile urinary tract infections (UTIs) since her infancy. At the age of 3 she underwent an abdominal ultrasound that suspected a double left kidney. A voiding cystourethrogram (VCUG) was performed and a vesicoureteral reflux (VUR) grade III on the right kidney was found. She was given chronic chemoprophylaxis without any UTI recurrence. She had a good toilet training and gave up daytime diapers around the age of 3. At this moment parents noticed the urinary incontinence, but this didn't bother them. At the age of 4 parents asked a urologist for help, who considered the symptoms to be the result of an overactive bladder and anticholinergic treatment was recommended. No improvement was noticed, and for this reason the little girl was sent to our department for further investigation.
Complete blood count, biochemical tests, and urinalysis were all normal and the urine culture was negative.
An abdominal ultrasound was performed and both kidneys had normal parenchyma and size, with a duplex-system suspicion on left side; the bladder was normal in appearance. The VCUG was repeated but no VUR was visualized. As we had a high suspicion of an ectopic ureter a contrast-enhanced computed tomography (CT) of the abdomen and pelvis was performed to visualize

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


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

[User]
RADIOLOGY NOTE:
A 66-year-old woman presented at a hospital with chest pain. Her history included diabetes, hypertension, and hyperlipidemia. On examination, the patient had a pulse of 100 beats/minute and blood pressure of 150/80 mmHg. Her electrocardiogram, echocardiogram, and blood test results were normal. Multislice computed tomography (CT) showed a saccular LMCA aneurysm and significant stenosis in the LAD artery (Fig. ). Coronary angiography revealed a saccular LMCA aneurysm measuring 9.8 × 7.5 mm with 75% stenosis in the proximal portion of the LAD artery. The operation was performed under general anesthesia. A median sternotomy was performed, and after a longitudinal pericardial opening was made, the heart was inspected. The LITA was removed from the inner chest wall in a skeletonized fashion using electric cautery. A distal segment of 1.5–2 cm was procured and reserved for use as a patch repair. Before aortic cannulation, the ascending aorta was dissected from the pulmonary artery. Under cardiopulmonary bypass, coronary artery bypasses of the left internal thoracic artery to the LAD artery were constructed in the beating heart. After aortic cross-clamping, the LMCA saccular aneurysm was exposed without main pulmonary artery transection. The saccular LMCA aneurysm was carefully dissected and completely excised. There was no thrombus in the lumen. Then, the LITA was longitudinally divided and trimmed to fit the incised LMCA. The small internal thoracic artery patch was sutured to the normal and firm lateral coronary arterial wall with a continuous 7–0 Polypropylene suture. Resection of the saccular aneurysm and closure using a small internal thoracic artery patch was then complete. The aortic cross-clamp time was 120 min, and the CPB time was 147 min. The patient had an uneventful hospitalization and was discharged on aspirin therapy. Follow-up multislice CT 10 days after the operation revealed the complete disappearance of the aneurysm and a successful repair with no lumin

[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 female patient was presented with swelling in front of the neck since 12 yrs, initially small in size started in thyroid region and gradually increased to present size (25 × 15 cm) with watery discharge form swelling of 6 months duration ().
On examination there were multiple cystic swellings extending from thyroid cartilage to mid sternum. There were about 12–15 cysts with features of intercommunication. The whole swelling moved with deglutition and there was no independent mobility of cysts. A sinus was present on right side of neck with active serous discharge (). Cervical lymph nodes were not enlarged. On indirect laryngoscopy, no abnormality was detected. Thyroid profile was within normal limits. Neck and chest X-ray showed increased soft tissue density seen in neck region extending up to upper sternal region and indenting trachea. Fine Needle Aspiration Cytology of the swelling showed features suggestive of nodular goitre. Ultrasound of the neck showed multiple anechoic areas with areas of calcification and internal septae in the neck extending from carotid level to midsternal level. Lesion seemed to be arising from thyroid tissue showing minimal vascularity suggestive of multicystic goitre or lymphangioma. On computer tomography there were multiple fluid attenuation coalescent cystic lesions in subcutaneous plane of neck and proximal thorax. There were no inhomogenous enhancing areas within the cyst. Thyroid gland could not be visualized seperately from cysts. There was no infiltration of surrounding structures or lymphadenopathy. The cystic lesions seem to be arising from thyroid gland and only part of left lobe of thyroid was visible (). Patient was subjected for surgery. Under general anesthesia Kocher's horizontal incision taken over the swelling and in middle incision extended vertically downwards over right breast as T incision and flaps raised. Fluid in cyst was clear light brown color. Some cysts were intercommunicated and cysts were fou

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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 23-year-old healthy male presented with midthoracic spinal pain with radiation to anterior chest wall since 6 months. Plain radiography revealed mild collapse of D6 vertebra (). Magnetic resonance imaging (MRI) revealed an expansile lytic lesion with multiple fluid levels. Computed topography (CT) revealed thinned out sclerotic margins in anterior aspect of the lesion (). As a first stage procedure, we performed posterior instrumented stabilization from D4 to D9 and biopsy. Histopathological examination was suggestive of aneurysmal bone cyst ().
The second stage tumor excision and anterior reconstruction was done after preoperative embolization. Patient was positioned on right lateral decubitus position and standard left transthoracic approach was employed under general anesthesia. A double lumen endotracheal tube was used for allowing single lung ventilation. Fourth rib was excised, parietal pleura was opened up and lungs were hypo-ventilated to expose D6 vertebra adequately. Corpectomy was performed followed by anterior reconstruction. Ventral surface of dura was visualized and completely decompressed. No CSF leak was noticed during the procedure. Inter costal chest drain tube of size 32F was applied and thoracotomy wound was closed in a water tight fashion.
The chest drain collections were 350, 600, and 850 mL, respectively on the first, second, and third day following surgery. The patient had 3 episodes of vomiting on the third postoperative night .The next day patient started experiencing headache, giddiness and nausea. On auscultation of chest, breath sounds were diminished on left side. Chest radiograph revealed diffuse haziness of left chest cavity suggesting pleural effusion. The volume of fluid drained, started rapidly progressing. The diagnosis of SPF was made after identifying beta 2 transferrin protein in the fluid which is specific to CSF and the patient was started on noninvasive positive pressure ventilation (NPPV). The patient has given a written

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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 15-year-old boy presented to Fujian Medical University with giant scrotal elephantiasis and swelling of both lower extremities. The penoscrotal edema began fifteen years earlier, soon after his birth, and it resulted in bilateral lower extremity edema with the penis becoming buried by the scrotum. His scrotal size was massive, and for the past 5 years, the glans penis was not visible nor palpable (Fig. a–c). He had undergone circumcision 13 year earlier and had no history of travel in filariasis-endemic areas. There was also no family history of scrotal elephantiasis or known genetic disorders.
Upon examination, the patient had a massively enlarged scrotum, with a volume of approximately 16 cm × 13 cm × 7 cm. The anatomical structures and urethral orifice were visible as a deep depression on the scrotum. Both lower extremities exhibited generalized swelling, which was especially noticeable on his ankles. His thigh circumference was 52 cm on the left and 56 cm on the right.
Tissue biopsy of the lower extremities was performed 13 years earlier and revealed lymphangioma and connective tissue hyperplasia. A urinary system ultrasound examination was performed 14 months prior to presentation at our hospital, which confirmed diseased subcutaneous scrotal soft tissues with no abnormalities in the bilateral testicular morphology and blood supply. The results of lower limb lymphoscintigraphy demonstrated that the lymphatic drainage of the lower extremities was obviously tardy. The development of bilateral inguinal and iliac lymph nodes was obviously tardy (Fig. ). The lower limbs and anterior pelvic position was imaged after injecting with the tracer (99mTc-SC) subcutaneously between the first and second toes. The images demonstrated that the lymphatic drainage in both lower extremities were unclear. In the early stage, the images showed that the bilateral inguinal and iliac lymph nodes were blurred, which was obvious on the left side. The concentration of imaging agent (99

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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 92-year-old man with osteoarthritis and a remote history of right total hip replacement and bilateral total knee replacements presented with a two-day history of severe right hip pain accompanied by nausea, chills, and fatigue. He was unable to bear weight due to pain, and range of motion in his right hip was severely limited. He denied recent trauma or pain in other joints but had undergone routine dental cleaning one week prior to presentation. He had received 2 gm of amoxicillin immediately prior to his dental procedure. He presented afebrile, mildly hypotensive, and was noted to have exquisite tenderness with passive movement of the right leg and reduced range of motion secondary to pain. He had full range of motion and strength distally. He had a leukocytosis of 15,600 WBC per milliliter. Aspiration of right hip joint revealed cloudy fluid with WBC 68,000 cells per milliliter. The patient was resuscitated with IV fluids and started on vancomycin and piperacillin-tazobactam. On the third hospital day, he underwent prosthetic joint drainage and washout with retention of liners. Joint aspirate culture grew Gram-positive cocci in chains, which we subsequently identified by matrix-assisted desorption ionization time-of-flight mass spectrometry (MALDI-TOF MS) as S. salivarius. We narrowed antibiotic therapy to ceftriaxone to complete six total weeks of intravenous therapy, after which he was treated with amoxicillin for additional six weeks. At this point, the patient discontinued his oral antibiotics rather than complete a full three months of oral therapy or remain on long-term suppression.
Five months after completion of the above therapy, the patient presented to the ED with hip and back pain following a mechanical fall at home. He was found to have a fracture of L4 and was admitted. On hospital day 5, he was found to have an occult superior dislocation of the R femoral head on CT and an ESR of 71 and CRP of 12.3. He was

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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 26-year-old lady presented with her husband and mother with the complaints of recurrent and intractable vomiting since past 2 years. The vomiting was regular, occurring throughout the day, and it used to increase after meals. For the past 6 months, she was not able to hold even the liquid diet to the extent that few sips of water were sufficient to induce vomiting. Along with vomiting, she also complained of episodic loss of consciousness, which she used to regain after 1-2 h. These episodes of unconsciousness specifically occurred when she was under some stress. Besides this, she was not having any other complaint, e.g., abdomen pain, fullness in the stomach after having meals, diarrhea or constipation, or swallowing difficulties. Her history did not suggest any cardiac problem, focal neurological deficits, or convulsions. At the time of presentation, she was pregnant (second trimester) with normal fetal growth. Her family history was unremarkable except that she had strained relations with her parents-in-law. Though her husband was very supportive but for almost 1 year she was staying at her mother's house due to this illness.
Since the onset of illness, she was taken to many physicians, gastroenterologists, neurologists, and psychiatrists. She underwent extensive laboratory investigations including upper gastro-intestinal endoscopy, barium meal, and MRI brain but any of the tests did not reveal any finding that could explain the symptoms. Results of her liver and kidney function tests were within normal limits since the onset of illness.
In the past, she was treated with a number of drugs including antidepressants, antipsychotics, promethazine, proton-pump inhibitors, and prokinetics for optimal periods without any relief. Her husband also took her for a vacation when suggested by a physician, but it also did not improve the situation.
Looking at such a long history, multiple consultations, and extensive laboratory work-up, she was interviewed in the presence o

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


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

[User]
RADIOLOGY NOTE:
A 64 years old male diabetic patient with coronary artery disease and a history of myocardial infarction had recently experienced two episodes of transient ischemic attacks. The presumed diagnosis was cerebral embolism since an intracranial hemorrhage was excluded and there was no detected ipsilateral carotid stenosis. The patient was in NYHA class III, with no angina. Thallium-201 myocardial scintigraphy showed a combination of scar and viable myocardium in the territory of the occluded left anterior descending.
On coronary angiography he was found to have triple vessel disease, with total occlusion of the left anterior descending branch and of the right coronary artery. Left ventriculography revealed left ventricular dysfunction with a LVEF of 35%, akinesia of the anterior-apical wall and hypokinesia of the inferior wall. He was referred to our department for coronary artery bypass grafting.
The operation was performed with the aid of cardiopulmonary bypass, moderate hypothermia and intermittent combined (retro and antegrade) cold blood cardioplegia. Intraoperatively the apical walls were found to be thin and scared and collapsed with ventricular venting.
We performed a triple coronary artery bypass with a left internal mammary artery to the intermediate artery (since it was the best target vessel) and two saphenous vein grafts to the obtuse marginal and the left anterior descending. The latter was endarterectomised due to chronic occlusion. Despite the fact that the patient had no absolute indication for a ventricular restoration (SVR) procedure, the extent of the damaged apical wall found intraoperatively and the history of the Transient Ischemic Attacks made us perform a ventriculotomy and an "anti-remodeling" procedure. After the ventriculotomy, inspection of the left ventricular cavity revealed a "round – shaped" calcification of the peripheral interventricular septum (diameter of 5 cm) with a central crater filled with clot (Figure ).
We performed a resectio

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


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

[User]
RADIOLOGY NOTE:
We present the case of a 30-year-old male patient who was admitted to our emergency department with a 24 h history of severe abdominal pain, diarrhea and vomiting. During clinical examination, the patient reported mentioned an episode with identical symptoms three months before that was treated conservatively at another institution. The patient’s past medical history included posttraumatic stress disorder and chronic consumption of cannabis via inhalation (10–15 joints a day). The pain intensity was so strong that the patient was observed by his girl-friend to sluice boiling water on his body. In the hospital at admission the patient was aggressive and endangered himself and others. The blood test demonstrated an increased leucocyte count with 16.88 G/l, but a normal C-reactive protein level with 0.1 mg/dl. At first, the patient was treated with lorazepame and olanzapine under clinical suspicion of acute psychosis related to his cannabis consumption. Due to further exacerbation of the pain, a CT scan was performed showing several small bowel intussusceptions in the left abdominal region (Fig. A and B). Because of the acute abdominal symptoms and the findings in the CT scan a diagnostic laparoscopy was performed. Intraoperatively numerous, at least ten, regions of jejuno-jejunal intussusceptions were found (Fig. A, ). The intussuscepted jejunal segments were repositions by careful stretching of the small bowel. During examination of the affected bowel segments there was no evidence of a tumorous lesions or any other pathology (Fig. B). Only the intestinal content appeared thickened and pasty. Most interestingly severe atony of the whole small bowel was observed (Fig. A, ). Because no ischemic leasions or other pathology was found, no intestinal resections deemed necessary and the operation was terminated. The patient developed no surgical complications, and had bowel movements after gastrografin application. Due to a good recovery, he was discharged on postoperative

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


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

[User]
RADIOLOGY NOTE:
A healthy 51-year-old woman underwent a neurologic checkup because of persistent, severe headache. An intrasellar, multilobular, and cystic lesion extending to the suprasellar region was detected by brain magnetic resonance imaging (MRI) []. The lesion compressed the optic chiasma upwards. Her endocrinological function was normal, based on the results of several hormone loading tests. She underwent surgical treatment by endoscopic transsphenoidal approach, and the tumor was completely removed. During surgery, the dura on the sellar floor was sutured with a PVDF suture to avoid postoperative CSF rhinorrhea, though intraoperative CSF leakage was not detected. Subsequently, reconstruction of the sellar floor with an autogenous bone graft from the anterior wall of the sphenoid sinus was performed. The pathological diagnosis was null cell adenoma. She took 5 mg oral hydrocortisone daily for 2 weeks after surgery for the prevention of temporary central adrenal failure. She had an uncomplicated postoperative course without recurrence of the tumor. She did not require hormone replacement because her postoperative endocrine function was normal.
Five years after the TSS, she complained about abnormal odor and visited an otolaryngologist at a local clinic. On rhinoscopy, a white mass was detected in the sphenoidal sinus. A diagnosis of bacterial sphenoiditis was made, and daily intake of oral antibiotic drugs for 2 weeks improved her symptoms. However, after 3 months, the unusual odor recurred. Brain MRI showed a thickened sphenoid sinus mucosa, well-enhanced on T1-weighted images []. During the second rhinoscopy, a fungal ball was suspected, and a second surgery was performed. In the second operation, while the sphenoid sinus mucosa was intact, the end of a dural suture was focused to be the focus of the fungal ball []. The suture protruded into the sphenoid sinus though the gap in the reconstructed sellar floor. We removed the lesion as well as the suture completely. Postope

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


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

[User]
RADIOLOGY NOTE:
A 51-year-old woman presented to her general practitioner with a 2-week history of a painful left breast lump. She denied any history of trauma. Her past medical history included ischemic heart disease, myocardial infarction, type 2 diabetes, dyslipidemia, hypertension, anxiety, depression, and asthma. Examination demonstrated a firm 30-mm breast lesion at 10 o’clock position in her left breast, 7 cm from the nipple. No axillary lymphadenopathy was appreciated. She was subsequently referred to a general surgical outpatient clinic and underwent further investigations.
Mammography revealed a poorly circumscribed mass, measuring 40 × 24 mm, in the lateral aspect of the left breast at the level of the nipple. There were irregular and stranded contours without suspicious calcifications (). The right breast appeared normal. Ultrasound (US) revealed a lobulated, heterogeneous, hypoechoic mass lesion at the region of palpable abnormality (). The mass measured 31 × 17 × 21 mm with accompanying distortion of the surrounding structures in combination with edema and skin thickening. Given the nature of these imaging findings, the lesion was considered suspicious for malignancy.
Five days following mammogram and US the patient represented to her general practitioner with increasing left breast erythema and swelling. Pus had also begun to be discharged from the upper inner quadrant of the left breast. She was commenced on oral clindamycin for cellulitis and was referred for a US-guided biopsy. US revealed that the lesion had significantly increased in size with marked skin thickening and erythema. This was thought to represent an inflammatory lesion; however concerns remained that this may have occurred secondary to an underlying malignancy. Aspiration of the main lesion was attempted under US guidance with a 19-G needle; however, the highly viscous nature of the pus precluded aspiration. The patient was advised to continue taking oral antibiotics.
The patient presented to the em

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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 38-year-old Chinese female presented with pain at the right upper side of the chest and adjacent soft tissue swelling for 3 months. A week before admission to our hospital, she was suffering from a gradually severe pain at the chest and fever. As a result, the patient was referred to our hospital for examination and treatment. Physical examination showed the patient had a mild soft tissues edema at her right upper lateral chest wall and severe pain was elicited upon chest pressure. The patient had a low grade fever of 37.4°C. There was no weight loss and no palpable lymphadenopathy or organomegaly. The laboratory results, including blood count, differential, liver and renal function, were within the normal range. A computed tomography (CT) scan of the chest revealed a single osteolytic lesion in the right second rib with associated soft tissue mass, measuring 6.0 × 5.0 × 5.0 cm in size. The most of rib was observed to be destroyed and the involvement of adjacent pleura and right upper lobe of lung were also noted (Figure ). The lesion showed moderate enhancement after gadolinium injection. There was no enlarged lymph node found in mediastinum and thoracic cavity. A CT scan of neck and abdomen showed no pathologic findings, particularly no lymphadenopathy could be observed. A CT guided needle biopsy was performed initially, but histopathological examination showed pieces of fibrosis with infiltration of inflammatory cells. Therefore, a surgical biopsy followed by a microscopic examination was performed. After diagnosis, the patient underwent polychemotherapy according to a modified COPP protocol (bleomycin, etoposide, adriamycin, cyclophosphamide, vincristine, oncovin, procarbazine, prednisone) for five cycles before initiation of involved field radiotherapy. The lesion was regressed, and the patient was on regular follow-up for 24 months after radiotherapy. The bone marrow examination was performed at 6 months after radiotherapy, there was no abnormality found. Du

[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 59-year-old female patient presented to a plastic surgery clinic with a lump on her right medial thigh. She noticed the lump eight months ago and it was gradually increasing in size. It was painless initially; however, the lump gradually became tender. The patient was otherwise fit and well with no co-existing morbidities. Closer examination of the right thigh revealed a high consistency mass, with reduced mobility. There was no right inguinal lymphadenopathy or lymph nodes enlargement.
Laboratory blood tests were unremarkable. An MRI scan was requested to further assess the mass, which was irregular but well-defined in the medial compartment of the thigh, measuring 8.2 x 6.6 x 4.3 cm in size. The mass showed an intermediate signal on both T1 and T2-weighted imaging, appearing hyperintense compared to the adjacent muscular tissue, which also persisted on fat-suppressed imaging. The mass invaded the intramuscular fat planes and caused compression and displacement of the adductor muscles. There was no evidence of intra-muscular invasion. Normal cortical outline and medullary signal intensity of the femur were seen in the right thigh. There was no evidence of bone contusion, marrow oedema, fracture line, or cortical discontinuity. Other muscles of the thigh had a normal outline and signal intensity with no evidence of focal or diffuse oedema. Neurovascular structures were unremarkable. Overall, MRI findings were suggestive of soft tissue neoplasm, with a possibility of a neurogenic tumour. A wide excisional biopsy was then performed to further assess the tissue histologically by the pathologist and confirm the diagnosis. The removed mass measuring 8.5 x 6.5 x 5.4 cm and is shown in Figure . The mass had a smooth outer surface and a soft consistency. The cut surface showed a homogenous tan-white appearance with some slit-like spaces and occasional haemorrhagic spots. Multiple sections were processed for histopathological examination from different planes.
Histopatholo

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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 83 year old female, who had been hospitalized for years due to schizophrenia, complained of vomiting and diarrhea for 2 days. She had no history of diabetes mellitus, neurogenic bladder, or previous antimicrobiotic therapy, but had a urinary catheter in place for a considerable period since she was bedridden for many years. The diagnosis was acute enterocolitis and intravenous fluid was administered. After she developed a chill and lower abdominal pain with muscular defense, she was diagnosed as surgical acute abdomen and transferred to our emergency department.
On arrival, her body temperature was 38.2°C, blood pressure was 150/70 mmHg with a regular heart rhythm of 110 beats/min, and her respiratory rate was 22 breaths/min. Physical examination revealed tenderness over the lower abdomen with muscular defense, rebound tenderness, and loss of bowel sounds. Laboratory examination revealed a normal white blood cell count with elevated C-reactive protein (24.9 mg/dL). Urinalysis was unremarkable. An X-ray of the abdomen showed gas collection in the pelvic cavity, and CT scans of the abdomen revealed intraperitoneal fluid collection and abnormal gas accumulation in the pelvic space. The distribution of this abnormal gas was between the abdominal wall and retroperitoneal cavity including the urinary bladder wall, and its association with the intraperitoneal cavity was unclear ().
In accordance with the history, physical examinations, and radiological findings, the patient was diagnosed as acute peritonitis with possible perforation or penetration of the lower intestine, and exploratory laparotomy was performed. At laparotomy, severe inflammatory changes were observed in the peritoneum from just below the umbilicus to the lower abdomen (). Ascites in the peritoneal cavity was slightly turbid, but without a stool smell and there was almost no intraperitoneal inflammation. Other abdominal structures were intact, however, the bladder was swollen. When the bladder wall was

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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 29-year-old military male basic trainee (71 inches, 200 pounds, BMI 27.89) presented with a one-month history of atraumatic bilateral leg pain. He reported pain within the first week of initiating running at basic training. He was diagnosed with bilateral proximal tibia stress fractures at three weeks with instructions to stop impact activities. After failure of his symptoms to improve, he was referred to our facility. On presentation, he had tenderness about the medial aspect of each proximal tibia. Radiographs obtained at that time demonstrated bilateral proximal tibia stress fractures with varus alignment about each knee and articular collapse of the left tibial plateau. Metabolic labs were obtained and significant for a low vitamin D (15), but the remainders of labs including calcium, thyroid-stimulating hormone (TSH), and testosterone were unremarkable. MRI of the left knee demonstrated a medial tibial plateau fracture with two millimeters of articular depression and extension of the fracture to the tibial spine (). MRI of the right knee demonstrated a hypointense linear T2 signal surrounded by diffuse hyperintense signal suggesting a medial tibial plateau stress fracture with surrounding bone edema, without articular collapse or extension (). These fractures were at the level of the physis, and there was surrounding sclerosis on plain radiographs. Given the collapse of the articular surface in his left knee, the patient was indicated for open reduction internal fixation with allograft bone. The patient underwent the aforementioned procedure without complication, and the patient remained nonweight bearing to his bilateral lower extremities (). At the time of surgery, the bone at the fracture distal to the articular surface was softer and more friable in composition than expected for the stress fracture. It was easily debrided back to stable, healthy bone edges, and we were interested in analyzing its composition, so a biopsy was obtained and sent to the lab f

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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:
46-year-old woman with 8 years of primary infertility was admitted to Clinart International Hospital for bilateral multicystic complex adnexal masses diagnosed 4 years ago as bilateral endometriomas. She had 7 IVF attempts and only in 3 cycles; embryo could be transferred with no clinical outcomes. She had a history of laparoscopic endometrioma surgery 8 years ago and endometriomas on both ovaries were aspirated and their capsules were excised together with the laparoscopic excision of a subserous myoma. Ca 12-5 and Ca 19-9 values had been high before the laparoscopic surgery. She had no other medical or surgical history and all biochemical serological and hormonal parameters were normal other than high Ca 12-5 and Ca 19-9 which supported the diagnosis of endometrioma.
MRI investigation was carried out 2 years ago and bilateral endometriomas were reported without any radiological signs of malignancy. Patient was informed about the possible risks of malignant transformation of the adnexal masses at all times; she was admitted for fertility reasons but surgical intervention was rejected. All attempts for fertility were failed due to either the absence or diminished ovarian response to ovarian hyperstimulation by gonadotropins. Some cycles were monitored naturally with no collected oocytes. It was not easy to differentiate the follicular response by ultrasound and all oocytes retrieved from the follicles were aspirated through the endometriomas and endometriotic fluid was seen in the aspiration tubes. Oocyte retrieval (OR) by bypassing the endometriomas was not possible technically because the masses on both sides were huge and multilobulated and ovaries could not be discriminated easily. In two cycles the endometriomas were aspirated to reduce the size of the mass and to obtain oocytes easily under the suppressive antibiotherapy.
She decided to have the surgical operation and admitted for surgery at 31.03.2015. Pelvic MRI (), Ca 12-5, Ca 19-9, and all preoperative tes

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

[User]
RADIOLOGY NOTE:
A 44-year-old Japanese woman, gravida 3 para 3, who had undergone cesarean section 2 years previously, presented to our emergency room with a 2-day history of intermittent right flank pain. She had no fever, nausea, vomiting, diarrhea, or cough. She had no history of abdominal trauma, and her past medical history and family history were not significant. She did not have hypertension or cardiovascular disease, and had not taken any anticoagulants. Her bowel and urinary habits were normal, and her menstrual periods were regular. Her last menstrual period had begun 2 days before the onset of right flank pain. On admission, her blood pressure was 115/78 mmHg, pulse 70 beats per minute, body temperature 36°C, and blood oxygen saturation 100%. She was found to be somewhat anemic, with a hemoglobin concentration of 9.8 g/dL and hematocrit of 28.2%. Her white blood cell count was elevated (13,900/mm3), and a urine pregnancy test was negative.
On physical examination, her abdomen was diffusely tender without muscle guarding. A pelvic examination revealed a small amount of menstrual discharge and a normal uterus and bilateral adnexae. Abdominal ultrasonography demonstrated a large retroperitoneal hematoma surrounding her right kidney (Figure A). Emergent abdominal and pelvic computed tomography (CT) was performed. Contrast-enhanced dynamic CT revealed a large retroperitoneal hematoma surrounding her right kidney with an enhancing round structure in the center of the hematoma in the arterial phase (Figure B). Although extravasation in the venous phase was not clear, findings on three-dimensional CT angiography were suggestive of a retroperitoneal hematoma due to rupture of an aneurysm of her right ovarian artery (Figure C), and no other responsible lesion was seen. A transfemoral angiography was performed for arterial embolization under a clinical diagnosis of bleeding from a right ovarian artery aneurysm. A selective angiogram of her right ovarian artery revealed a tortuous a

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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 8-year-old boy presented to our hospital with severe hydronephrosis in his right kidney. A day before admission, the patient experienced right lower back pain accompanied by nausea, vomiting, fever, polyuria, dysuria and haematuria. Ultrasound examination of the right kidney showed severe hydronephrosis and magnetic resonance imaging (MRI) showed severe hydrops. There were no obvious abnormalities in the patient’s left kidney (). Before this event, the patient had been physically healthy and had no prior history of high blood pressure, diabetes, immunodeficiency or recent foreign travel
Initially, the patient was thought to have ureteropelvic junction stenosis and so transperitoneal pyeloplasty using the Anderson-Hynes technique was performed. During the laparoscopy it was confirmed that there was right ureteropelvic junction obstruction. Post-surgery, the patient was prescribed a daily intravenous infusion of ceftazidime 2.0 g for two weeks. At the end of this period, a computed tomography (CT) scan of the lower abdomen and pelvis showed that the hydronephrosis of the right kidney had significantly reduced and the ureteral stent was in a good position. However, the previous healthy left kidney showed some high-density shadows in both the ureter and kidney, and hydronephrosis had developed ( and ).
A retrograde double J ureteral stent was inserted on the left side and intravenous ceftazidime was terminated. The patient’s liquid intake was increased and he was given potassium sodium hydrogen citrate granules to alkalise his urine. Six days later, a CT scan showed that the left ureteral stones had decreased in size and had returned to the renal pelvis and the hydronephrosis had reduced significantly ().
Twenty-five days after the left kidney catheterization, a subsequent CT scan showed that the kidney stones and hydronephrosis had disappeared completely and so the stent was removed (). Six months after the operation, a CT scan showed no signs of kidney stones or hy

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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 six-year-old girl was brought to the emergency room after falling from the second floor when playing at home. She is not known to have any chronic medical illness. She could not stand or bear her body weight when standing and complained of left hip pain. The Advanced Trauma Life Support (ATLS) protocol was completed. She was conscious and alert with normal and stable vital signs. A full head-to-toe examination showed superficial bruising over the dorsal aspect of the left foot. Locally, there was tenderness over the left hip on deep palpation associated with lateral and posterior bruises, but there were no open wounds or visible swelling. Her range of motion of the left hip was restricted due to pain. Radiographs of the pelvis showed a type I transphyseal fracture without epiphyseal dislocation and a type III cervicotrochanteric ipsilateral femoral neck fracture (Figure ). An ankle x-ray showed a displaced talus fracture (Figure ).
After studying the x-rays and CT scans for the pelvis, treatment options were discussed with the patient's family (Figure ). The patient underwent a clinical assessment by an anesthesiologist for an urgent operative intervention to fix the fracture. The patient was taken to the operative room and placed in the supine position under general anesthesia with a full aseptic technique. An image intensifier was used as an intraoperative assessment of the fracture reduction and implant placement. A trial of closed reduction failed, thus the surgical team moved to an open reduction technique. Between the sartorius and tensor fasciae latae, the anterior hip approach was performed to reach the capsule of the hip joint and the dissection was made throughout the layers. The hip joint was opened in a T-shape, the fracture lines and three parts were identified as follows: (1) femoral head, (2) slippage physical injury, and (3) neck of femur fracture. Then, the team reduced the fracture using five k-wires

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


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

[User]
RADIOLOGY NOTE:
A 63-year-old man presented with a lesion on the right upper eyelid that had been present for 7 years. The lesion was nodular, measuring 5.0 cm × 7.0 cm, ulcerated, indurated, and erythematous. It involved the lower eyelid (). The patient had no light perception with the right eye and had a visual acuity of 20/20 on the left. Due to the presence of the tumor over the right eye, his intraocular pressure could not be measured, and it was found to be 18 mmHg on the left.
The left orbital examination did not reveal any abnormalities. A full examination of his local lymph nodes and lacrimal duct did not reveal any abnormalities. He explained that he did not have any previous therapy for this lesion. He was otherwise systemically well with no relevant family history. He did not have any history of trauma and informed us that he was a farmer by occupation.
A computed tomography (CT) scan of the orbit revealed right anterior orbital invasion with no bony or lacrimal gland involvement (). A subsequent incisional biopsy revealed squamous cell invaginations extending from the epidermis into the dermis. The invaginations and papillary projections were lined with a bilayer epithelium: the luminal layer was composed of columnar cells with decapitation secretion and the outer layer was composed of small cuboidal cells. These cells had significant nuclear pleomorphism, prominent nucleoli, and increased mitotic activity (). Immunohistochemical staining demonstrated positivity for epithelial membrane antigen (EMA), Cytokeratin 8/18, and a Cytokeratin cocktail of high and low density (). It was negative for GCDFP-15 (protein 15 of the fibrocystic disease of the breast), which excluded a lesion of breast origin and carcinoembryonic antigen (CEA). The diagnosis of SCACP was therefore confirmed. A positron emission tomography (PET) scan did not reveal any metastatic spread.
The patient was treated with exenteration of the right orbit to remove the tumor. After 11

[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 70-year-old male was admitted to the Department of Surgical Oncology (The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China) in November, 2011 with suspected PTMC and lateral cervical lymph node metastasis identified by careful digital palpation and ultrasonography (US) during a routine health examination. The patient had a >2-year medical history of hypertension, which was controlled with antihypertensive agents (indapamide and amlodipine besylate) and a 10-year history of smoking half a pack of cigarettes per day. There was no remarkable family history and the patient was in good general health with no significant weight loss. The thyroid gland appeared normal upon physical examination and no abnormalities were identified on the chest X-ray, electrocardiogram or pulmonary function examination. Furthermore, laboratory examinations, including thyroid hormone and tumor marker analysis, were unremarkable. Enlarged lymph nodes on the left neck were painless, solid and immobile, and could be identified by palpation; the largest lymph node measured 2.0 cm in diameter. Ultrasonographic examination identified one hyperechoic nodular lesion ~0.4 cm in diameter in the lower pole of left lobe, and three well-circumscribed, heterogeneous hypoechoic nodular lesions with a diameter of ~0.9 cm in the lower pole of the right lobe, ~1.0 cm in the superior pole and ~0.4 cm in the lower pole of left lobe. No obvious indicators of metastasis were identified. In consideration of the abovementioned data, the patient was diagnosed with thyroid carcinoma and consequently underwent a right lobectomy, a partial left lobectomy and a lymph node biopsy. Analysis of the intraoperative frozen pathological sample revealed a diagnosis of bilateral PTMC with metastatic lymph node SCC from a different primary location. Furthermore, all of the thyroid tumors were surrounded by an intact capsule and demonstrated no definitive evidence of capsular extension or invasion, however,

[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 white man arrived by ambulance to our emergency department with chief complaints of lower abdominal pain and profuse diarrhea. On examination, general signs of poor health were observed. His blood pressure was 150/60 mmHg and pulse rate 90 beats per minute (bpm). His temperature was 37.3 °C and he did not appear to be in distress. A physical examination did not reveal any bowel obstruction. His laboratory findings were within normal range except for an elevated white blood cell count (14.5 × 109/L), slightly low red blood cell count (3.12 × 1012/L), and slightly raised level of creatinine (124 μmol/L). His medical history included recent completion of radiotherapy treatment for a Gleason score 9 prostate adenocarcinoma, previous cerebrovascular event, asbestosis, atrial fibrillation, and chronic lymphoid leukemia. His abdominal surgical history included only an open appendectomy 40 years prior. He is a retired marine engineer and lives with his wife. He reported that he did not drink alcohol and had quit tobacco smoking 30 years ago. His family history is noncontributory.
Computed tomography (CT) of his abdomen and pelvis was performed and demonstrated a peritoneal recess containing multiple small bowel loops over the anterior side of the intraperitoneum lying between peritoneal lining and the transverse abdominis fascia consistent with a pseudoherniation of a preperitoneal subtype (Fig. ). There was no mass or dilatation of bowel loops and no mass to his upper abdominal organs or retroperitoneum.
In view of CT abdomen findings, a surgical opinion was sought. As there was no evidence of bowel compromise, he was managed non-operatively. Fecal polymerase chain reaction (PCR) tested positive for Salmonella and our patient improved on antibiotics with resolution of abdominal pain. He was discharged and followed up 2 weeks later at out-patient clinic and had no abdominal discomfort; therefore, no elective hernia repair was planned and further follow-up was

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


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

[User]
RADIOLOGY NOTE:
A 62-year-old Caucasian woman presented to the emergency department with a history of progressive muscular weakness associated with nausea, vomiting, and diarrhea. At baseline, the patient was independently ambulating with a walker. However, she started to have a gradual bilateral upper and lower extremities weakness for two weeks before her presentation. As a result, she became dependent on her roommate to perform daily living activities (i.e., bathing, dressing, toileting, transferring, and feeding). She also reports an associated history of diarrhea three to four times a day since the onset of her symptoms. She reports a history of weight loss, poor appetite, polyuria, polydipsia, memory impairment, decreased visual acuity, and hearing loss on review of systems. She denied any history of shortness of breath or chest pain. The patient stated that she has been drinking 8-10 cans of 16 oz of Pepsi cola every day. The past medical history is remarkable for chronic obstructive pulmonary disease (COPD), history of abdominal trauma with subsequent splenectomy, gastroesophageal reflux with esophagitis and hiatal hernia status post failed Nissan fundoplication, alcohol abuse, and longstanding multiple psychiatric disorders treated with different antipsychotics and antidepressants. The patient stated that she had not taken any of her home medications for more than two weeks before the presentation. In addition, she reports a 20 pack-years history of cigarette smoking and lived with a roommate who has been busy lately and did not provide sufficient support to the patient.
On physical examination, vital signs were normal; the patient looked cachexic and dehydrated with dry skin and mucous membranes. She was also confused with impaired remote memory and appeared in poor hygiene as she could not shower or sanitize her excreta for three to four days due to weakness. Neurological examination showed normal cranial nerves, a decreased strength in the upper and lower extremities (3

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


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

[User]
RADIOLOGY NOTE:
A 55-year-old male presented with insidious onset diplopia while looking to the right and to distant objects of 3 months duration. There was no history of visual blurring, jaw deviation, facial asymmetry, hearing loss or tinnitus. There was no associated headache, vomiting, seizures or loss of consciousness, limb weakness, gait, and bowel or bladder disturbances. On examination, patient was conscious with stable vital signs. Higher mental functions were normal. There was right side sixth nerve palsy and nystagmus on looking to the right. Visual acuity and visual field examination were normal. There were no other cranial nerve, motor or sensory deficits. Other system examinations were within normal limits. Magnetic resonance imaging of the brain showed an expansile mass lesion involving entire clivus that was T1- and T2-isointense and showed contrast enhancement. There was erosion of posterior wall of the sphenoid sinus with lesion bulging into the sinus. Pituitary was normal []. With a preoperative diagnosis of clival chordoma infiltrating into the sphenoid sinus, the lesion was decompressed by subfrontal trans basal approach.
Microscopy showed respiratory epithelium with an underlying neoplasm composed of sheets of plasma cells with a moderate amount of cytoplasm and eccentric round nuclei []. Cells were positive for CD 138, CD 38 and CD 56, while negative for CD 20, cytokeratin and synaptophysin. Ki 67 (MIB) labeling index was < 5%. Cells were kappa light chain positive and negative for lambda light chains thus establishing monoclonality. A diagnosis of plasmacytoma of clivus was given, and workup for myeloma was suggested.
Patient underwent whole-body X-ray studies, serum and urine electrophoresis, complete blood counts, serum calcium levels and a bone marrow biopsy, as part of myeloma investigations, which were negative.
Patient received radiotherapy (50 gray given in 25 fractions) and is now 8 months postoperative and doing well. The right side lateral rectus p

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


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

[User]
RADIOLOGY NOTE:
A 23-year-old male was sent to our institution. The patient had a 3 years history of shoulder pain and sense of posterior instability with recurrent episodes of posterior subluxation events. He experienced had many of these episodes during normal activity of daily living.
Nonsurgical approach did not lead to any benefit. During the first consultation, the patient had a full range of motion, demonstrable generalized ligamentous laxity, hyperextension at the elbows and wrists. All impingement tests were negative, and all strength tests equally. There was a 1.8 cm sulcus sign on the left shoulder, as well as a positive apprehension sign. He demonstrated loss of external rotation of approximately 12° on his left extremity, as compared to his right extremity.
In the light of the imaging and clinical presentation, we diagnosed a recurrent posterior instability. We suggested to perform an arthroscopic posterior capsulo-labral repair and surgery was scheduled.
While waiting for surgery the patient had a car accident and sustained a traumatic anterior dislocation of the left shoulder. The dislocation was reduced in the emergency room, and physical treatment started after 1 week []. A new visit was scheduled 4 weeks after the car accident and the patient reported a worsening of instability with extreme apprehension and several new episodes of dislocation which he to be both anterior and posterior and that he was able to reduce by himself.
At physical examination his range of motion was 110° of flexion, extrarotation 15°, intrarotation arrived to L-5. Tests for rotator cuff were negative, but the patient had a loss of strength. Tests for instability were all positive (sulcus, Rowe and load and shift test). No vascular or nervous impairment were present.
For further evaluation we performed a computed tomography scan that revealed a Hill-Sachs lesion at the posterior aspect of the humeral head, 10-15% (of the total glenoid surface) bone loss at the anterior glenoid rim and about

[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 47-year-old woman in good general health, with no other co-morbidities presented with a long history of chronic right fifth toe pain for 30 years. She reported a history of injuring her right foot when playing sport for 30 years. She when landing recalled that she had twisted her right foot; moreover, the foot was not well treated at that time of the injury. The only treatment for the fifth toe was with the temporary bandage to reduce the deformity. Then, the PIP joint of the fifth toe was redislocated for several times in 6 months after the first injury and the same treatment was attempted each time. After that, the fifth toe gradually became permanently swollen and painful on movement. When the patient presented in the out patient clinic with chronic right fifth toe pain and swelling, (Figure ), the toe was displaced in the dorsolateral plane. The plain radiograph showed a simple dislocation of PIP joint in the dorsolateral direction. The articular cartilage of middle phalanx impinged on the lateral condyle of proximal phalanx. There was no indication of definite joint destruction, erosion or unhealed fracture (Figure ). The distal segment of the toes was unstable because of the chronic and persistent joint subluxation.
The decision was made to attempt the correction of the chronic dislocation by open reduction, as the problem had been present for many years and all previous attempts at closed reduction had been non-successful. The dislocated PIP joint was exposed via a dorsal incision, revealing that the joint capsule and attenuated lateral collateral ligament were interposed within the PIP joint space, and the articular cartilage at lateral condyle of proximal phalanx of the fifth toe became eroded (Figure ). The joint capsule and the lateral collateral ligament were dissected away from the joint space. The tight plantar plate was released from plantar lateral aspect of the joint and the corrected position of the PIP joint was maintained by inserting a longitu

[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 76-year-old man with severe chronic obstructive pulmonary disease (COPD) presented with a feeling of fatigue, weight loss, and reduced physical activities. He was diagnosed with COPD at the age of 69 years and had retired from work the following year. His smoking history included 40 cigarettes per day between the age of 14 and 69 years; his airflow limitation was classified as severe by the Global initiative for Chronic Obstructive Lung Disease; and a chest computed tomography (CT) scan showed severe emphysema. He had started long-term oxygen therapy at the age of 72 years and is currently inhaling 3 L/min of oxygen. Medical and family histories were otherwise unremarkable. Cardiac ultrasound excluded comorbid congestive heart failure or pulmonary hypertension, and CT pulmonary arteriography also excluded chronic pulmonary thromboembolism. As the patient had a history of acute exacerbations of COPD more than twice a year with extreme respiratory symptoms, he was prescribed a combination of inhaled long-acting antimuscarinic antagonist, long-acting beta2-agonist, corticosteroid, and oral carbocysteine, ambroxol, and theophylline. He reported symptoms of dyspnea on exertion, depression and anxiety, and a decrease in physical activity. He also experienced anorexia with a weight loss of more than 5 kg in a year, and no other possible causes of weight loss, such as tuberculosis and malignant tumor, were observed. Therefore, in addition to respiratory pharmacotherapy, we prescribed an antianxiety drug and provided nutritional supplement therapy, patient education, and pulmonary rehabilitation. However, the patient's mental and physical symptoms did not improve after 4 months. Furthermore, he exhibited deterioration in activities of daily living as well as physical and mental weakness; hospital visits were difficult and therefore, he considered home care. Persistent weight loss, poor endurance and energy, and low physical activity levels led to the diagnosis of physical

[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 19-year-old male presented with gross total painless hematuria of a 5 days duration. There was no past family history of cancer. General physical examination and systemic examination were normal. Blood workup showed anemia. Renal function and liver functions were within normal limits. An ultrasound showed a polypoidal mass attached to the anterior wall of the bladder of 7 × 5 cm in size, which was further confirmed by a contrast enhanced CT scan (CECT) of abdomen. There was no evidence of lymph node or visceral metastasis. Transurethral resection of the bladder mass was performed. The upper gastrointestinal tract (GI) and lower GI endoscopy was within normal limits. A bone scan did not show any skeletal metastasis. Thereafter, the patient underwent robot assisted partial cystectomy and bilateral lymph node dissection till aortic bifurcation. The histopathology was suggestive of a high-grade urothelial carcinoma with six out of seven nodes showing metastasis. Post operatively, the patient developed fever and intestinal obstruction, initially managed conservatively, however, the patient did not show improvement. A repeat CECT abdomen was done which showed soft tissue lesions in both lungs, with pleural effusion, multiple liver lesions and ascites, suggestive of disseminated metastasis. The patient's general condition deteriorated, and he subsequently succumbed to his disease. An overview of the medical disease history is illustrated in a timeline (). Photomicrographs of the tumor from the urinary bladder showed a high-grade urothelial carcinoma with plenty of large pleomorphic cells and infiltrating the detrusor muscle ().
Whole-exome sequencing (WES) analysis of the paired tumor-normal sample from the patient was performed. A detailed description of the sequencing methods is provided in the . WES data analysis revealed 558 exonic somatic mutations, of which 360 missense, 26 nonsense, 30 frameshift deletions/ insertions and, also 10 splice site mutations were annota

[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.