[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 previously healthy 6-year-old boy visited Samsung Medical Center with complaints of dyspnea and a barking cough lasting for 3 days. Chest radiography revealed a mass-like lesion in the right upper mediastinum. Chest computed tomography demonstrated a well-defined posterior mediastinal mass measuring 4 cm, which was suspected to be a neural foraminal extension to the thoracic spine (T3–T4). Magnetic resonance imaging was conducted for further evaluation; it showed a right upper paravertebral enhancing mass with an adjacent neural foraminal extension to the T2–T5 spine (). A preoperative neurologic examination revealed that the patient had no abnormalities. He underwent mediastinal mass excision by video-assisted thoracic surgery. The mass was in the right posterior mediastinum, was located at the T2–T5 level of the spine, and did not extend to the neural foramen. It was resected by electrocautery. The sympathetic chain at the T2 level was inevitably resected as part of the complete resection of the mediastinal tumor during the operation, because the tumor originated from this sympathetic chain. The intraoperative course was uneventful, with a stable hemodynamic status throughout the surgery. After the patient was sent to the post-anesthesia recovery unit, a sharp midline facial demarcation was observed, and the left face, neck, and chest (contralateral to the operation site) became flushed and warm (). These findings were noted to increase in intensity when the patient cried. In contrast, the right face, neck, and chest (ipsilateral to the operation site) were pale and cool and did not change in color when the patient cried. A neurologic examination including that of the cranial nerves was normal, and miosis and ptosis were absent. The patient’s vital signs and laboratory tests were normal. The symptoms, including the color and the warmness of the face, started to show minimal improvement within an hour and completely resolved without any treatment 3 hours after su

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


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

[User]
RADIOLOGY NOTE:
A 35-year-old man underwent a living donor kidney transplant at our transplantation unit in 2003. His postoperative course was uneventful. The procedure resulted in normalization of his renal function and no signs of rejection were reported in his follow-up records.
The patient was compliant with his immune-suppressive therapy and maintained frequent follow-up visits to his nephrologist during which he had normal renal transplant function.
In 2013, the patient travelled outside the country for work purposes. During his overseas stay, he had gradual deterioration in his kidney function for which he was treated conservatively until his creatinine level ranged between 2.0–3.0 mg/dL. A kidney biopsy of the transplant was performed in March 2014 and he was informed that no obvious pathology could be determined. Conservative management was continued.
In June 2015, the patient returned home and he was admitted for further investigations at our transplant unit. Upon admission, a right iliac fossa pulsatile mildly tender mass was felt and a bruit was clearly audible. His creatinine ranged between 4.0–4.5 mg/dL. Duplex ultrasound revealed a 110 × 90 mm partially thrombosed aneurysm adjacent to the upper half of the transplanted kidney. The exact origin of the aneurysm could not be determined by the ultrasound. A multisliced computed tomography (CT) angiogram showed a 115 × 91 mm false aneurysm extending superiorly to a level above the aortic bifurcation.
A three-dimensional reconstruction of the CT scan demonstrated that the transplanted kidney was supplied by two arteries. The aneurysm was originating from the distal part of the upper renal artery (URA), which was anastomosed to the common iliac artery during the original surgery. Few branches were identified originating from the proximal part of URA and supplying parts of the upper and middle segments of the kidney.
The lower pole of the kidney was supplied by the lower renal artery (LRA) that was anastomosed to the externa

[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 12 year old boy presented to the emergency for the onset of acute anisocoria. Two hours before the boy had started to complain of a blurred vision; his mother, a paediatric nurse, noticed a pupil asymmetry with a clearly dilated right pupil (Figure ). Eyes were normal at wake up and during the early morning; the boy had spent the all morning playing in grandmother's garden. There was no history of trauma, eye drops' instillation, nebulised drugs or local ointments. His past medical history was negative.
On physical examination the boy was well, orientated and collaborative. In room light the right pupil was round, but the reaction to light was sluggish. Left eye's reaction was normal. Anisocoria was more evident in bright light. Ocular motility was normal. On slit lamp the pupil was round and no signs of trauma were detected. Consensual pupillary light reflex of the left eye was elicited. In the anterior chambers no inflammatory changes were detected and both irises and fundi examination were normal.
A third nerve palsy was considered but the performed cerebral MRI was normal.
On further investigation the boy explained that he had spent the morning doing gardening and especially working on a "trumpet plant". A quick internet search helped to find a picture of " Datura suaveolens ", commonly known as trumpet plant, immediately recognized by the child and his mother (Figure ). The boy did not refer a direct contact of leaves or flowers with eyes, however he referred to have handled both leaves and flowers and to have removed new small plants arising at the bottom of the plant. It is very likely that an accidental hands-eye contact after touching the plant had occurred.
The day after anisocoria was much less evident and completely resolved in three days. The patient was diagnosed with pharmacologic mydriasis secondary to unintentional contact with Datura

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


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

[User]
RADIOLOGY NOTE:
A 49-year-old trans man who had been on testosterone therapy for 10 years presented to the emergency department with central chest pain. His high-sensitivity cardiac troponin was 24 ng/L (female reference range <16 ng/L, male reference range <26 ng/L). How should he be managed?
Cardiac troponin is released from damaged cardiomyocytes and is one of the most common biomarkers used in the prediction of myocardial infarction. There is considerable debate regarding the use of sex-specific reference ranges for high-sensitivity cardiac troponin (hs-cTn), as there is uncertainty whether the use of sex-specific reference limits impact upon clinical management or outcome prediction (). However, as upper reference limits based on sex-specific 99th percentiles for hs-cTn are subtly higher for people recorded as males than those recorded females in population studies (), use of sex-specific cutoffs for hs-cTn assays have been endorsed by the International Federation of Clinical Chemistry and Laboratory Medicine (). The difference has been attributed to people presumed male at birth having a larger cardiac mass as well as subclinical coronary artery disease (). No studies have been performed to examine cardiac mass changes that may occur with masculinizing hormone therapy in people presumed female at birth. There are however data in polycystic ovary syndrome in which high testosterone concentrations are a clinical feature (albeit far lower than testosterone concentrations seen in transgender men). Polycystic ovary syndrome has been associated with higher left ventricular mass index and larger left atrial diameter over 5 years of follow-up, even after adjustment for blood pressure, body mass index, glucose, and lipids (). Large population-based studies have also shown that left ventricular mass correlates with body weight, lean body mass, and fat mass (). There is currently insufficient data to draw an inference regarding the appropriate reference range in people using gender-affi

[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 on a 63-year-old female patient who presented in January 2016 with the following symptoms: complaint of cold sensation affecting the upper arms on both sides (left > right), weakness and arm claudication, with an increasing inability to perform work on the computer, and symptoms of a fatigue syndrome. The patient was unable to perform her employment as a hospital secretary. Clinically, pulselessness of the brachial and radial artery on both sides was noted. Bruits were discovered in the left and right subclavian artery. A blood test revealed increased levels of the inflammatory markers C-reactive protein (CRP 47.9 mg/dL) and an increased Erythrocyte Sedimentation Rate (ESR 74 mm/h). The patient had a history of hypertension, hyperlipoproteinemia, and osteoporosis; she was a former smoker and reported moderate daily alcohol consumption.
A neurological examination, an MRI of the cervical spine, and myocardial scintigraphy were without pathological findings. Duplex ultrasound of the carotid artery and upper extremities revealed noticeable intima-media thickening. For suspected large-vessel vasculitis, a diagnostic angiography was carried out, which revealed bilateral stenosis of the axillary artery at the transition to the brachial artery and, on the left side only, an additional stenosis in the proximal segment of the brachial artery. TA was diagnosed based on the American College of Rheumatology criteria, with four out of six criteria met.
The patient was admitted to a rheumatological specialist clinic in March 2016. Treatment with prednisolone 20 mg daily was started, but there was no improvement of the arm claudication. Therefore, the patient received cyclophosphamide 15 mg/kg body weight × 0.75 (=600 mg) plus prednisolone (75 mg/d initially, reduced in stages to 30 mg/d at the time of hospital discharge). Six cycles of cyclophosphamide at 3-week interval were planned, at the end of which treatment with methotrexate 15 mg subcutaneously once a week accomp

[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 Caucasian female presented to the surgical office with a chief complaint of chronic epigastric abdominal pain for seven months duration. The patient was referred to the office after an emergency department visit for her chronic abdominal pain. The workup showed normal laboratory values with a nonspecific, lobulated soft tissue lesion located within the mesentery of the upper abdomen measuring up to 3.2 cm on computed tomography with intravenous and oral contrast. The patient noted her pain had developed and had been persistent since she underwent laparoscopic appendectomy for acute appendicitis roughly one year prior. She described her pain as sharp in nature with intermittent flares. The patient reported that eating exacerbated her symptoms. She endorsed anorexia as well as weight loss. Physical examination at that time was considered unremarkable. The patient’s medical history included gastroesophageal reflux disease, gastritis, depression, and a seizure disorder. The patient’s surgical history included a cholecystectomy for cholelithiasis, hemorrhoidectomy, tonsillectomy, and an appendectomy. Family and social history were non-contributory.
Based on the initial radiographic results and the location of the mesenteric lesion, the patient was referred for endoscopic evaluation and possible biopsy. They were then started on a trial of proton pump inhibitors. The patient had multiple visits to her primary care provider and was eventually transitioned to sucralfate as her symptoms were unresolved. The patient underwent esophagogastroduodenoscopy that revealed LA Grade B gastroesophageal reflux disease, a 2 cm hiatal hernia, and diffuse gastritis. Repeat computed tomography of the abdomen and pelvis with intravenous and oral contrast was performed revealing a lobulated lesion at the level of the kidneys within the anterior mesenteric fat, concerning for an enlarged lymph node or a neoplastic mass as demonstrated by the arrow in Figure . The mass was deemed

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


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

[User]
RADIOLOGY NOTE:
A 50-year-old man was referred to our department with the chief complaint of discomfort on the right side of his neck. He had no medical history. He had initially become aware of pain on the right side of his neck three years before visiting our department. He first consulted with the oral and maxillofacial department of a local hospital. Computed tomography (CT) at that hospital showed styloid process prolongation; however, the patient reported mild discomfort upon follow-up. The discomfort on the right side of his neck worsened, and he was referred to our hospital for the treatment of his neck symptoms.
The patient had no systemic disease at the initial visit. He was aware of the discomfort of the right side of his neck when he turned his head (). A rigid bone-like structure was palpable in the right submandibular region. In addition, panoramic radiography revealed an elongated right styloid process beyond the mandibular plane (). CT showed styloid process prolongation on both sides (). The length of the styloid process was 60 mm on the right side. Calcification of the minor horn of the hyoid bone and the styloid process' tip was also observed. Moreover, prolongation of the right superior cornu of the thyroid cartilage was observed, with a length of 23.2 mm. The cervical symptoms might have been due to the extension of the superior thyroid cartilage angle. Still, the discomfort that occurred during the neck rotation coincided with the tip of the styloid process. The patient was diagnosed with symptoms of styloid prolongation .
Surgical trimming of the elongated styloid process with an extraoral approach was performed under general anesthesia. A skin incision was made in the submandibular region, and detachment was performed to reveal the intermediate tendon of the digastric muscle. A styloid process was observed near the hyoid bone. After the detached surrounding area, the styloid process was resected using an ultrasonic bone scalpel (). The stylohyoid ligament wa

[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 77-year-old female of Sri Lankan origin living in New Zealand for past 21 years presented after an incidental finding of a 23 mm left lingular lesion. The lesion was first identified on a routine plain chest radiograph (following a hospital attendance with headache) and further delineated by computed tomography (CT) scanning. It was described as peripheral lesion with nodular appearance, with contact of the visceral pleura. The lesion appeared to have increased in size in comparative plain radiographs taken eight weeks apart. There was no interval cross-sectional imaging to confirm the subjective enlargement.
There were no respiratory symptoms of note, and no history was obtained of prior significant respiratory illness. Past medical history was notable for type 2 diabetes and treated hypertension. The patient had been a lifelong non-smoker, although her husband had been a heavy smoker and had died of lung cancer 10 year prior. There was no significant occupational exposure.
In view of radiological suspicion of pulmonary malignancy, a CT-guided fine needle aspiration was done. This showed mildly atypical cells and no definite diagnosis was possible on the degree of atypia. A positron emission tomography (PET) CT demonstrated a 17-mm lingular sub-pleural nodule abutting and distorting the major fissure without clear evidence of transgression. The nodule demonstrated minimal PET avidity (maximum standardized uptake value of 2.4) but no signs of nodal involvement or distant disease (Fig. ).
Routine laboratory testing was unremarkable, including a normal full blood count with normal white cell differential (eosinophil count of 0.1 × 109), and a normal C-reactive protein. No serum immunoglobulin E level was done.
The case was discussed at multidisciplinary meeting and it was agreed that possibility of pulmonary malignancy could not be excluded, with a concern of the lesion being very close to the visceral pleura. She was hence put forward for surgical excision of the l

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


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

[User]
RADIOLOGY NOTE:
A 64-year-old female, with chronic kidney disease, hypertension, diabetes mellitus, obesity, and prior right femoral neck fracture treated with dynamic hip screw, presented with a chronic right leg infection. Approximately one year prior to presentation, she sustained a right distal femur fracture treated with retrograde intramedullary nail fixation, which was complicated by early hardware failure requiring revision. She then developed a MSSA infection, requiring removal of hardware and placement of an antibiotic spacer. She completed a course of antibiotics and subsequently underwent total knee arthroplasty, which was complicated by MRSA infection with development of a sinus tract communicating with the distal femur. She underwent three more irrigation and debridement procedures, long-term IV Vancomycin, and replacement of an antibiotic spacer at the most recent debridement. Her sinus tract persisted and she presented for second opinion to discuss alternatives to amputation. On examination, she had a draining sinus tract near the knee, which probed to a depth of 5 cm. Her right lower extremity was 4 cm shorter than the left. ESR was 16 mm/hr and CRP 0.58 mg/l.
Radiographs at presentation are shown (), and she was taken to the operating room where cultures were obtained and all hardware and antibiotic cement were removed. The femur and tibia were then reamed and an 11.5 mm × 700 mm Smith and Nephew intramedullary nail was placed with gentamicin cement packed around the nail. Intraoperative cultures had no growth and she was placed on IV Vancomycin for six weeks given her history of MRSA and MSSA. Postoperative images are shown ().
Her postoperative course was complicated by Vancomycin-resistant Enterococcus (VRE) PICC line infection and E. coli UTI, which were treated at an outside hospital. At follow-up, she was noted to have a draining sinus at the distal femur, which was treated with wet-to-dry dressings. Inflammatory markers were then trended and decreased over

[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 years old lady carried out a complex re-laparotomy for a postoperative small bowel occlusion after a radical cystectomy because of urothelial carcinoma. The procedure lasted 3 h because of thick adhesions that needed to be cleared. At the end of the procedure, total blood loss was 2 litres, and two Units of Packed Red Blood Cells (PRBC) were infused. During the surgical procedure, a central venous catheter was placed in the internal jugular vein by ultrasound-guided puncture of the vessel, but an inadvertent puncture and cannulation of the right subclavian artery occurred before catheter placement. Because of the ultrasound-guided procedure, the anesthesiologist thought to have cannulated the carotid artery and applied local pressure for a few minutes. Two hours later, when the patient was in the Intensive Care Unit (ICU) around midnight, a chest X-ray to check the correct position of the central venous catheter revealed a massive hemothorax (), while the patient was hypotensive and responder to crystalloids and blood infusions. A chest drain was inserted without any substantial output but a small amount of clotted blood. The patient rapidly worsened, despite appropriate resuscitation with 10 U of PRBC, 8 U of Fresh Frozen Plasma (FFP), 3 U of cryoprecipitate and 1 U of platelets from apheresis. A second chest X-Ray to check tube position revealed a tension hemothorax (). The team in charge of the patient, comprising the anesthesiologist that did the general anaesthesia for the surgical procedure, made the diagnosis of suspected subclavian artery perforation and tension hemothorax with both hypovolemic and obstructive shock. The team decided to bring the patient in the hybrid room to control the likely bleeding for the right subclavian artery. While the patient has been positioning on the angiographic table, the ECG monitor showed severe bradycardia, with a heart rate of 30 and an impending cardiac arrest with a systolic blood pressure of 30 mmHg. An emergency

[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 with blurred vision in both eyes of one-month duration was referred to the Nara Medical University Hospital on January 19, 2016. His medical history showed that he had undergone cataract surgery on both eyes 7 years earlier, and he had also been diagnosed with chronic hepatitis C and interstitial pneumonia.
At his initial examination, his BCVA was 20/20 in both eyes, and his intraocular pressure (IOP) was 19 mmHg OD and 17 mmHg OS. He had + 2 inflammation according to SUN Workshop scale in the anterior chamber of the both eyes but not in the vitreous. Funduscopy showed no remarkable inflammatory findings in the retina and choroid. The inflammation of the anterior chamber in both eyes was resolved by 1% topical prednisolone acetate four times/day.
Ten months after his initial visit, + 2 inflammations in the anterior chamber recurred with small white keratic precipitates, and + 1 inflammations vitreous opacities according to SUN Workshop scale were detected in both eyes. Topical prednisolone and sub-Tenon’s injection of triamcinolone acetonide were administrated for both eyes. These treatments were effective for the left eye but not for the right eye and 2 months after, the inflammation in the anterior chamber increased to + 3 and the opacities in the vitreous got worse to + 4 inflammation in the right eye (Fig. ). His visual acuity in the right eye had decreased to 6/20 at this time. The results of laboratory examinations were essentially normal including blood cell counts, hepatic and renal function, serum levels of ACE, calcium, IL-2, and anti-HIV antibody, thus potential cause of immunosuppression was not detected.
A masquerade syndrome was suspected because the steroid therapy was not effective for the ocular inflammation. To confirm the diagnosis, 25-gauge microincision vitrectomy was performed and aqueous humor and undiluted vitreous samples were collected. During the operation, fine vitreous opacities were observed

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


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

[User]
RADIOLOGY NOTE:
A 35-year-old gravida 6, para 5 mother who is 38-week pregnant from last normal menstrual period has presented to Tercha General Hospital (a rural hospital in Southern Ethiopia). The patient is referred from a health center 60 kms far from this hospital for suspected “big baby” in labor. The patient was an illiterate housewife. In terms of past obstetrics history, all previous deliveries occurred at home vaginally with live birth with no major complication. During the index pregnancy, she had antenatal care visits at a nearby health center without ultrasound examination. She reports that the current pregnancy is heavier than previous ones and associated with significant discomfort than her previous pregnancy experiences. Otherwise, she has no self or family history of twinning in the past.
Examination shows a stable gravida with normal vital signs. Abdominal examination shows big for date uterus with two cephalic poles in the lower abdomen and positive fetal heartbeat. Standard ultrasound examination confirmed twin pregnancy with both in cephalic presentation and adequate amniotic fluid; single placenta with no visible dividing membrane; fetal heartbeat is visible at two sites and is in a normal range. Upon pelvic examination, the cervix is 8cm dilated with left occiput-anterior position at a station 0. Fetal membrane is ruptured with clear liquor passing. With diagnosis of twin pregnancy (both cephalic presenting), in active phase of first stage of labor patient is admitted to labor ward and management of labor started in the standard way.
In the next few hours labor progressed well and the first baby is crowning. Duty midwives are attending the delivery. Subsequently, with maternal effort the head and upper extremities of the first baby are delivered and the remaining part of the fetus is delivered by ‘gentle' traction by the midwives. But after delivery of the whole body, baby 1 remained ‘attached' to the mothers' perineum, though the baby is crying vigorously ()

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


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

[User]
RADIOLOGY NOTE:
A 28-week-old premature boy, with a birthweight of 1280 grams, was intubated with a 2.5 mm endotracheal tube via the nose and ventilated for severe hyaline membrane disease (HMD). After receiving two doses of surfactant, the premature neonate was successfully weaned off ventilation and extubated to nasal continuous positive airway pressure (CPAP). On day 9, his clinical course was complicated by a pulmonary hemorrhage, requiring re-intubation. He was given another dose of surfactant and stabilized on high-frequency oscillation ventilation (HFOV). The chest radiograph showed extensive bilateral pulmonary interstitial emphysema, with the left side more extensively involved in comparison to the right. A hemodynamically significant patent ductus arteriosus was treated by intravenous paracetamol. The baby's condition did not improve, and he was selectively intubated into his right main bronchus. The position of the endotracheal tube was radiologically confirmed, allowing the right lung to be oscillated while the left lung was rested. The baby was nursed on his left side for a period of 36 hours, after which the endotracheal tube was retracted into the trachea and secured in that position. The baby's ventilatory status subsequently improved, allowing for extubation on day 7 after the relapse. On day 28 of life, he presented with severe stridor, requiring re-intubation. Difficulty during intubation suggested that subglottic stenosis might be present. One week after this re-intubation a flexible bronchoscopy was performed, which revealed two major findings. The first was a Cotton grade 2 subglottic stenosis, and the other abnormality was near-complete obstruction of the bronchus intermedius. The subglottic stenosis was dilated to 5 mm with the aid of a balloon dilator (Boston scientific Mustang™ balloon dilatation catheter). The bronchus intermedius was extremely narrow, and a 2.2 mm flexible bronchoscope was not able to pass through the area of stenosis.
After 2 weeks, the

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


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

[User]
RADIOLOGY NOTE:
A 45 year old Caucasian woman had a long history of falls due to progressive ataxia since the age of 10. Her birth history and early developmental milestones were unremarkable. She completed secondary school and achieved basic qualification in education but was never good in sport. At age 17, she developed poor night vision and bilateral hearing deficit. She had bilateral cataract surgeries and used hearing aids at age 31. She experienced fatigue but did not complain of overt muscle weakness. She developed moderately heavy proteinuria (Albumin to creatinine ratio 152) but with normal serum albumin level since age 43.
Her mother has glucose intolerance and her father has sensorineural deafness. There was no family history of neurological disorder, eye problem, or cardiomyopathy. All her siblings are fit and well, and as such did not request molecular genetic testing.
Her resting blood lactate level was normal and creatine kinase (CK) level was 276 U/L. There was no glucose intolerance. Her renal function declined gradually and the current urea and creatinine levels were 11 mmol/L and 97 µmol/L, respectively (compared to 5 mmol/L and 88 µmol/L 8 years ago). Renal ultrasound demonstrated loss of cortico-medullary differentiation, increased echogenicity and asymmetrical kidney size (left kidney measured 7.9 cm, right kidney 10.2 cm). Nerve conduction studies were normal at age 28. Her initial CT head and cranial MRI showed bilateral basal ganglia calcification, periventricular white matter changes and cerebral and cerebellar atrophy ().
Clinical examination (at age 43) revealed pigmentary retinopathy, deafness, bilateral pes cavus, areflexia in the lower limbs, mild myopathy with MRC grade 4+/5, cerebellar signs, loss of proprioception sense and vibration sense in the lower limbs and broad-based gait.
She was admitted to hospital with left sided weakness and loss of mobility at age 44. The neurological deficit evolved over 12 hours. There was no associated speech distur

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


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

[User]
RADIOLOGY NOTE:
In August 2015, following a maxilla-facial trauma, a 10-year-old boy patient was admitted at the maxilla-facial department. The patient had no general health problems, was not taking any treatment, had no allergies and was not subjected to passive smoking. The young patient had a significant dental Class II malocclusion (Angle classification) due to skeletal Class II mandibular etiology (Ballard classification). Clinical and radiological examination revealed a complete extrusive luxation of 11 and 21 and intrusive luxation of 12 and 22. Practitioners decided to place a Dautrey arch. Two weeks later, the patient came to the dental emergency due to injuries caused by the Dautrey arch (). Three months later, after removing Dautrey arch, a multi-attach treatment combined with Powerscop was put in place (). Following the beginning of his orthodontic treatment, in December 2015, the patient’s attending dentist performed the endodontic treatment of 11 and 21, after the occurrence of root resorption consecutive to the absence of endodontic treatment immediately after the trauma. The patient was then referred to the endodontic department 3 years after trauma. The first treatment phase is described in and , , , , and .
In February 2020, following the avulsion of the tooth 12, clinical and radiographic examination revealed a bone deficiency in the buccal area. The cephalometric analysis from October 2019 showed that the patient was in his pubertal growth spurt []. Combined with the patient’s young age and his incomplete growth, this contraindicated the placement of conventional diameter implants. Another option for managing this clinical case was to maintain the gap between 13 and 23 by placing a removable prosthesis. However, there is some risk of blocking the jaw’s growth, as well as a lack of acceptance of the device. The patient chose not to have a removable prosthesis. The patient wanted a fixed, comfortable and esthetic solution. Bone capital had to be preserved for impl

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


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

[User]
RADIOLOGY NOTE:
A 58-year-old female presented to the emergency department with intermittent, crampy right-sided abdominal pain, nausea, and vomiting, which began approximately 18 hours previously. Her past medical history was significant for hypertension and her surgical history included a thyroidectomy for treatment of thyroid cancer and a Caesarean section. A contrast enhanced CT abdomen and pelvis was obtained, demonstrating multiple fluid-filled, dilated small bowel loops in the right abdomen, which were predominantly anterolateral to the ascending colon and cecum (). In addition, two transition points were identified in the right lower quadrant, with one transition point at the distal ileum just proximal to the cecum and a second transition point in the proximal ileum. The two transition points were in close proximity to each other, indicative of closed loop obstruction. Decreased wall enhancement of the dilated small bowel loops was concerning for ischemia. Mucosal hyperenhancement of the ileum at the proximal transition point was felt to relate to ischemia or decompressed state (). Given the patient's symptoms and findings of closed loop obstruction on CT, the patient was taken to operating room. In the operating room, an internal hernia with closed loop obstruction was confirmed and resulted from herniation of small bowel through an adhesion of a transverse colon epiploic appendage to the ascending colon mesentery. The herniated small bowel was nonviable and a total of 60 cm of small bowel was resected (). Retrospectively, kinking of the ascending and transverse colon could be seen on the initial abdominal CT and was felt to correspond with the site of adhesion ().
After resection, the patient's small bowel was left in discontinuity and an abdominal wound-vac was placed. The following day, the patient returned to the operating room, at which time the terminal ileum was also found to be nonviable. An ileocecectomy with enterocolonic anastomosis was performed.
The patient ha

[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 60-year-old Sinhalese man from a rural area of central Sri Lanka who presented to a teaching hospital with on-and-off fever of 4 months’ duration and pain in the lateral aspect of the right upper thigh of 2 months’ duration. He had been admitted to a local hospital 3 weeks prior to admission to our hospital with a history of nearly 3 months of on-and-off fever and a painful lump at the lateral aspect of the thigh. He had been treated for multilobar pneumonia at the local health facility with intravenous meropenem and teicoplanin for 14 days, and he required intensive care unit management during the course of his illness. Although his pain and the size of the lump at the lateral aspect of the thigh decreased with treatment, the lump and pain over the area persisted even after he was discharged from the local hospital. Further, he experienced on-and-off fever again, though he was afebrile upon discharge from the local hospital. With time, he experienced difficulty in walking with increasing severity of pain in the lateral aspect of the right upper thigh, for which he sought medical advice. On admission to our hospital, he had high-grade fever, and he denied any respiratory or urinary symptoms. His bowel motions were normal with normal color and contour. He was a farmer and had a history of exposure to surface water. He was a nonsmoker and never used alcohol. He was diagnosed for the past 8 years with type 2 diabetes mellitus, which was treated with oral hypoglycemic drugs. He was not receiving any medication other than oral hypoglycemic drugs, and he denied recent use of steroids. He did not have any high-risk behaviors.
On examination, he was febrile (102 °F) and mildly pale but not icteric. He did not have enlarged peripheral lymph nodes or skin rashes. He had a small induration over the lateral aspect of

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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 81-year-old man was admitted to our institution with a five-month history of a painful enlarging mass at the right popliteal fossa and calf. There was no history of trauma. His past medical history was unremarkable. He had undergone a primary total knee arthroplasty of his right knee seven years previously for degenerative knee osteoarthritis.
Clinical examination showed painful restriction of the range of motion of the right knee, and a palpable mass at the posterior-medial aspect of the knee (Figure ). The calf was slightly painful during palpation and passive stretching.
Plain radiographs of the right knee showed narrowing of the medial compartment, varus deformity of the arthroplasty, and features of loosening including radiolucent lines next to the femoral and tibial components. Some degree of polyethylene wear, especially in the medial compartment, was suspected (Figure ). Magnetic resonance imaging of the right knee showed a cystic lesion located at the postero-medial aspect of the knee joint mimicking a popliteal cyst or soft tissue sarcoma (Figure ). Plain radiographs of the chest were normal. A routine laboratory examination including complete blood cell count, serum chemistries, erythrocyte sedimentation rate and C-reactive protein reported values within normal ranges. Triplex ultrasonography showed no evidence of deep venous thrombosis.
Fine needle aspiration biopsy was carried out, but it was non-diagnostic. A core-needle biopsy revealed a black fluid containing thick, amorphous metallic debris and fragments of broken polyethylene. Histological sections showed necrobiotic tissue, wear debris and metallic particles, fibroblasts, osteoblasts, histiocytes and multinucleated giant cells. Nucleous atypia and mitotic features were not observed. Gram stain and cultures were negative for infection.
Revision knee surgery showed massive metallosis, osteolysis of the distal femur and the proximal tibia and extensive polyethylene wear and deformation distributed

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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 42-year-old Caucasian female was diagnosed with acetylcholine receptor antibody positive oculo-bulbar myasthenia gravis nine months ago. Her initial presenting symptoms were drooping eyelids, double vision and difficulty swallowing with diurnal variation and characteristic fluctuation of symptoms. She initially failed her bedside swallow evaluation with notable aspiration to thin liquids on modified barium swallow (MBS). She underwent plasmapheresis with complete resolution of symptoms following IVIG as her swallowing functions didn’t improve with the latter. Eventually patient’s repetitive nerve stimulation study and antibody titers confirmed the diagnosis of postsynaptic neuromuscular junction disorder. Prior to discharge patient was started on pyridostigmine 60 mg 4 times daily, gradually up-titrated dose of prednisone 30 mg daily and mycophenolate 1000 milligrams twice daily. Her past medical history included generalized anxiety disorder and allergic rhinitis for which she continued to follow with her primary physician at discharge.
During her routine neurology clinic follow-up patient was noted to have recurrence of drooping eyelids and change in voice with concerns of impending myasthenia exacerbation. As she responded very well to plasmapheresis compared to IVIG, she was started on regular plasma exchange, 3 exchanges every 4 weeks. She continued to take rest of her medications including prednisone 30 mg daily and mycophenolate 1000 milligrams twice daily. Patient’s CT chest showed 6.7 cm lobulated soft tissue mass in anterior mediastinum with no local invasion, consistent with thymoma or thymic carcinoma. She was referred to cardiothoracic surgery for possible thymectomy (which had been put on hold due to patient request).
Four weeks ago, patient presented to emergency department (ED) with fever, chills, cough with minimal clear sputum production, exertional shortness of breath, decreased sense of taste and smell, decreased appetite going on for the past 5

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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 previously healthy 14-year-old female presented to the office with sharp, generalized abdominal pain and dark brown urine since the previous night. Additionally, the patient noticed that her whole body ached after running for two hours that same day. She was afebrile and had a cough and runny nose for the past three days. All of these symptoms were not preceded by trauma or Streptococcus infection within the past month. Her last menstrual period was 20 days earlier.
On observation, the patient looked well. All vital signs were normal. Physical examination findings were unremarkable (non-tender abdomen, no edema noted on extremities). Urine sampling demonstrated light yellow clear urine. A urine dipstick was not performed because it was unavailable in the office. Consequently, the patient was advised to call the office or go to the emergency room should she have the reemergence of abdominal pain or brown urine. Shockingly, the office was notified that the patient had been admitted to a hospital with acute renal failure the following day. She was in the hospital for three days before finally being discharged home to be followed up by the renal clinic.
Four months later, the patient presented to the office with diffuse back pain of one day's duration. The pain did not radiate anywhere. She also presented with chest pain that had been going on for five months. The pain occurred mainly in the left lower breast area, and it typically increased with inspiration. It occurred roughly one to three times per week and, along with a cough, was associated with recreational sports. The patient stated that the last time she had any chest pain was the previous week. An electrocardiogram (EKG) taken four months earlier was unremarkable. She denied any palpitations, nausea, vomiting, and any dizziness during exercise or rest. Upon further questioning, it was discovered that her throat had felt ‘tight’ for the past year when running, and she often tried

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

[User]
RADIOLOGY NOTE:
The patient was a 60-year-old man who was the husband of the patient described above. He experienced lumbago on the same morning his wife was hospitalized. Fever and disturbance of consciousness occurred in the evening, and he visited the emergency room at another hospital. He had completed the course of neoadjuvant and adjuvant chemotherapy and radiation for glioblastoma 6 years ago, and was able to carry out his daily activities independently. He had no medical history of pneumonia or a history of pneumococcal vaccination. Although right lumbar pain was observed, the origin of fever was unknown; antimicrobial treatment was initiated with 4.5 g piperazine/tazobactam every 8 h. The results of the blood test taken at hospitalization are shown in Table . Pneumococcus was detected in his blood culture as well, and the regimen was changed to 2 g ABPC every 6 h. There were abnormal findings in the lumbar MRI scan taken on hospital day 2. Nonetheless, the results of the spinal fluid test, head MRI, thoracoabdominal contrast CT, transesophageal echocardiography, did not reveal presence of infection at other sites. Because lumbago persisted, MRI was performed again on hospital day 9; the consequent MRI results revealed purulent spondylitis (Fig. ). The patient was transferred to our hospital on hospital day 9. To normalize white blood cell count, CRP level, and blood sedimentation rate and to improve CT findings, antimicrobial drug treatment was carried out for a total of 9 weeks.
Both patients tolerated the antimicrobial treatment well, and recovered completely. A 13-valent pneumococcal conjugate vaccine was administered initially, and a 23-valent pneumococcal polysaccharide vaccine was administered 1 year later in both patients. More than 1 year has elapsed since the completion of treatment, and there has been no recurrence.
In the bacterial strain analysis (Table ) performed on the samples from both patients, the capsule serotype was 12F identified by the capsule quellin

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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 50-year-old female patient who had no specific medical history visited the hospital with facial asymmetry (chin deviation to the right side), limitation of mouth opening, and jaw pain that had persisted for two years. The clinical examination showed limitation of mouth opening (approximately 20 mm) along with TMJ pain on the left side and deviation of chin top to the right side. The radiography and computed tomography showed signs of considerable osseous proliferation extended to the cranial base and multiple radiopaque lesions suspected as phlebolith.() The initial diagnosis was osteochondroma on the left condyle. She underwent condylectomy, and her chin top--which deviated to the right side--was also reduced to the midsagittal plane. Active physical therapy was conducted, and clinical favorable mouth opening (approximately 32 mm) was finally achieved in four months.() Two years after surgery, however, she complained of limitation of mouth opening and discomfort of mastication. The X-ray revealed trauma from occlusion (TFO) in the maxillary molar area on the ipsilateral side as well as progressive osteoarthritis on the previous resection area. Total TMJ replacement using stock prosthesis on the ipsilateral joint was finally planned.
Stock TMJ prosthesis consists of fossa and condylar components, each of which requiring preauricular and retromandibular approaches. After condylectomy was performed to secure spaces for prosthesis via the preauricular approach, retromandibular incision was conducted. Bone trimming of uneven surface on articular eminence was followed by the installation of fossa component, and subsequent positioning of the condylar component was accomplished. After the optimal occlusion of the patient was maintained, fixation of the mandibular component was done with titanium screw.() Since the TMJ replacement, the patient had not suffered from remarkable postoperative complications including ipsilateral facial nerve weakness, paresthesia, pain, and d

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


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

[User]
RADIOLOGY NOTE:
A Caucasian, 27-year-old female was being followed up during her second pregnancy. Her past medical and obstetric history was unremarkable. This was her second pregnancy; her older child from the first pregnancy was well. There was no family history of renal diseases or congenital abnormalities. She was not on treatment with any medications. A dating ultrasound scan was performed at 15 weeks of gestation showing a single live foetus.
The pregnancy advanced uneventfully. The anomaly ultrasound scan at 20+2 weeks of gestation showed evidence of duplex right kidney with dilatation of the upper moiety. The ultrasound scan was repeated at 23+6 weeks of gestation with the same findings. The dilatation of the upper moiety was measured at 10.8 mm. The right kidney was in normal position and there was satisfactory parenchymal differentiation. The left kidney, the ureters, and the bladder appeared normal. The amniotic fluid index was normal throughout the pregnancy. A follow-up scan at 32+1 weeks of gestation showed the right duplex kidney with resolution of the dilatation previously seen. The foetal growth was optimal. No other abnormalities were detected in the antenatal scans.
She delivered a male infant via normal vaginal delivery at 39+2 weeks of gestation. The infant was born in good condition without any perinatal complications. An ultrasound scan () was performed at 12 days of age. This scan showed features consistent with an uncomplicated right duplex kidney measuring 6.1 cm. The left kidney had a single collecting system and was measuring 5.2 cm. Both kidneys were visualised within the renal fossae and had normal parenchymal differentiation. There was no pelvic dilatation and the ureters were not visible in either of the kidneys. The bladder looked normal. Clinically, the infant was asymptomatic with normal blood pressure and renal function. There were no other evident congenital abnormalities.
The infant had a follow-up ultrasound scan at 3.5 months of age. During

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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 31-year-old female with a past history of endocarditis status post mitral prosthetic valve repair an year ago and continued intravenous drug use presented to the emergency department with altered mental status. On initial arrival, the patient was found to be hypotensive with systolic blood pressures of 50 mmHg and 60 mmHg, a heart rate of 110 beats per minute, a temperature of 38.1 degree Celsius with mild respiratory distress, and an oxygen saturation of 95% on room air. There was difficulty in establishing vascular access due to severe vasoconstriction (increased peripheral vascular resistance from shock); however, ultrasound-guided vascular access was ultimately established. The 12-lead electrocardiogram showed ST-segment elevations in high lateral leads, and cardiac catheterization lab was activated immediately after loading aspirin, clopidogrel, and statin therapeutic heparin drip. On left heart catheterization (LHC), she was found to have an embolus lodged in her left main coronary artery which was removed. When flow was restored, an intra-aortic balloon pump (IABP) was placed due to severe refractory hypotension despite inotrope and vasopressor support with dobutamine and norepinephrine, respectively. However, the patient continued to experience ventricular arrhythmias on the monitor and on electrocardiogram (Figure ).
A tentative diagnosis of severe mixed shock (cardiogenic and septic) was made with the source suspected to be a probable prosthetic valve endocarditis (PVE) due to continued drug use. The patient was started on broad-spectrum antibiotics in addition to hemodynamic support. Due to worsening hypoxia and respiratory distress, she was intubated and mechanically ventilated. Her chest x-ray showed worsening bilateral pulmonary infiltrates (Figure ).
A transthoracic echocardiogram revealed severely depressed right and left ventricular function with mitral and aortic stenosis but with no obvious vegetations on the valves including the prosthetic mitr

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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 48-year-old man was admitted to our department with the diagnosis of an adenocarcinoma of the gastroesophageal junction. Preoperative staging was negative for distant metastases. Endoscopic ultrasound findings confirmed the presence of a locally advanced tumor (type I – Siewert classification). It was an adenocarcinoma of the distal esophagus arising from an area with intestinal metaplasia and infiltrating the esophagogastric junction from above. As a consequence preoperative synchronous chemoradiotherapy was proposed. The scheme was consisted of fluorouracil (15 mg/kg of body weight) daily for five days and cisplatin (75 mg/m2 of body surface area) on day 7 and a course of radiotherapy (40 Gy administered in 15 fractions, anterior-posterior mediastinal fields) over a a three week period, beginning concurrently with the first course of chemotherapy. After the completion of chemoradiotherapy, the stage of the disease was reevaluated (CT scans of the abdomen, chest, pelvis, upper gastrointestinal endoscopy and ultrasound). Restaging was completed with no evidence of distant disease and surgical removal of the primary tumor and lymphadenectomy was proposed. The patient was eligible for an Ivor Lewis esophagogastrectomy.
He was intubated with a left-sided 37-F double-lumen endotracheal tube by a specialist anesthesiologist experienced in cardiothoracic surgery anesthesia. The technique includes the following points. The tube was held with the bronchial curve concave anteriorly. As the tip was passed through the larynx, the tube was rotated 90 degrees to direct the endobronchial part to the intended side. The tube was then connected to the breathing circuit via a double catheter mount.
The abdominal part of the operation was uneventful. During the second phase and while the intrathoracic esophagus was being mobilized a hissing noise was heard and a careful inspection revealed part of the double-lumen tube and the inflated tracheal cuff protruding through the ruptured m

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

[User]
RADIOLOGY NOTE:
An 81-year old female with a history of coronary artery disease, hypertension, and thrombocytosis suffered a witnessed trip and fall onto a nightstand. The patient took 75 mg of clopidogrel daily in addition to an 81 mg aspirin tablet. She reported a mild headache however had no change from her baseline mentation per family members with no evidence of obvious injury aside from a small area of ecchymosis near a small forehead laceration. She remained up and ambulatory with no further complaints. Ten hours after her injury the patient presented to the Emergency Department with stridorous and agonal respirations with a profoundly decreased level of consciousness. She was noted to have developed extensive ecchymosis on the anterior portion of her neck and chest. Her symptoms had begun rapidly shortly prior to arrival while lying in bed. Family reported that she had been in the constant company of her husband with no further falls or injuries that had occurred since her fall. The patient was intubated upon hospital arrival due to respiratory extremis with obvious swelling and crepitus noted on neck examination. A noncontrast CT scan of head was unremarkable while there was demonstration of a large retropharyngeal hematoma measuring 3.6 cm by 5.3 cm by 20 cm on a CT of the cervical spine with no evidence of fracture. Her hemoglobin was 9.5 gm/dL and platelets were 1234 per deciliter, with an INR of 3 and a slightly below normal and activated partial thromboplastin time of 23.9 seconds (reference range 25-35 seconds). A CT angiogram of the neck was subsequently obtained demonstrating active bleeding from the anterior ligaments of the vertebral column that was not felt to be amenable to embolization (). Given the extent of the hematoma intraoral surgical evacuation was performed with bleeding from the anterior vertebral spine controlled with Bovie cauterization, placement of topical thrombin, and drain placement. No reaccumulation of hematoma was noted during her hospital c

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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 41-year-old male presented to a Level 1 Emergency Department as a transfer after a traumatic injury to the right eye. The patient reported that he was repairing farming equipment when a pair of pliers slipped and hit him in the right eye. He reported experiencing complete vision loss in the right eye for several minutes. At time of ophthalmic examination, 8 h from time of injury, patient reported that although his vision had slowly returned and was back to normal in the upper portion of his visual field, the lower portion remained “darker and hazy.”
External examination was significant for pronounced periorbital ecchymosis and edema on the right. Ocular examination revealed a VA of 20/40 on the right and 20/25 on the left on Snellen chart. 10/11 plates were identified in the right eye and 11/11 in the left via Ishihara subjective color testing. Confrontational visual field revealed depression in the inferior quadrants in the right eye. Intraocular pressure was 16 mm Hg in the right eye and 11 mm Hg in the left. Pupil examination was significant for a 2+ rAPD in the right eye. Motility examination in the right eye revealed 30% restriction of ocular movements in all fields of gaze. Slit lamp and dilated fundus examination of both eyes revealed scattered subconjunctival hemorrhage of the right eye but otherwise was unremarkable with no retinal or disc edema on fundoscopic exam. The patient did not have macular or retinal nerve fiber OCT or fundus photography at presentation.
An initial noncontrast CT scan at an outside hospital showed retrobulbar hemorrhage with mild proptosis (shown in Fig. ). A repeat CT scan performed 7 h later revealed a stable hematoma surrounding the optic nerve within the optic nerve sheath with surrounding fat stranding and a superior orbital rim fracture with a fragment displaced into the orbit. Based on clinical and imaging findings, a diagnosis of ONSH secondary

[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:
The patient was a 53-year-old female with no significant past medical history who presented back to the hospital with similar complaints of chest pain. The family and social history were noncontributory. Electrocardiography (EKG) showed normal sinus rhythm with no ischemic changes (). On previous admission, the patient had presented with new-onset chest pain that was sudden, constant, and severe, with fever and leukocytosis. The patient was deemed at that time to have a viral illness in addition to costochondritis and was discharged on cyclobenzaprine as well as a nonsteroidal anti-inflammatory (ibuprofen).
The patient’s chest pain did not improve, and she returned after the initial admission to the hospital. The blood cultures from the previous admission came back positive for Staphylococcus aureus. The patient had, at the previous admission, originally presented with leukocytosis at 19,000 white blood cells per mL and with fever as high as 102°F (39°C) that had both immediately trended down. Low-grade fever was also present on this admission without leukocytosis. The patient did have some days on which her heart rate was above 90 beats per minute and respirations were occasionally over 20, thus septic by criteria.
The Infectious Disease service was contacted for management of infection and recommended to repeat blood cultures to confirm no further growth of the organism after administration of antibiotics for 48 hours. The patient was also switched to intravenous (IV) ceftriaxone 2 g daily from IV vancomycin 1,250 mg twice daily, as the Staphylococcus bacteria were sensitive to ceftriaxone and resistant to penicillins. With the presentation of chest pain in addition to mild murmur, fever, and bacteremia, it was thought the patient may have some suggestion of endocarditis, and a transthoracic echocardiogram was performed. The patient had normal ejection fraction and only trivial regurgitation of valves, except for the mitral valve, which showed mild regurgitation.

[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 male with chronic pulmonary and cardiac conditions developed blood per rectum and a change in stool caliber which lead to workup with colonoscopy. This demonstrated a 4 cm proximal anal canal lesion with biopsy identifying invasive poorly differentiated squamous cell carcinoma. Staging CT of the brain, chest, abdomen, and pelvis demonstrated an isolated hepatic metastasis as the only distant site of disease (). The patient was treated with chemoradiotherapy including 5-FU, Cisplatin, and 50.4 Gy radiation followed by further Cisplatin-based systemic therapy. Twelve weeks after completion of chemoradiotherapy, anoscopy demonstrated complete resolution of the anal canal lesion with a remaining scar that was biopsied and was negative for carcinoma. Additionally, imaging of the liver revealed reduction in the size of the hepatic metastasis. However, 6 months later, surveillance anoscopy and imaging revealed recurrence of the anal canal primary and enlargement of the hepatic metastasis with biopsies of both demonstrating SCC. The anal lesion was increasingly symptomatic causing pain, tenesmus, and bleeding. Repeated imaging of the brain, chest, abdomen, and pelvis confirmed that the disease was still isolated to the liver and anal canal; therefore, synchronous abdominoperineal and liver resection were undertaken. Pathologic analysis revealed that the primary was 5.7 cm and was associated with negative lymph nodes, proximal, distal, and radial margins, and the hepatic metastasis was 6.1 cm and also had negative resection margins ().
Despite having an uneventful postoperative course, three months after surgery, the patient presented with blurry vision and right eyelid ptosis. CT of the head and MRI of the brain demonstrated a 4 cm intracranial mass eroding the sphenoid and temporal bones, and an involvement of the left orbit, optic nerve, and rectus muscle (). Biopsy demonstrated metastatic SCC identical to the anal and hepatic lesions (). At this point stere

[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:
An 18-year-old man was referred to our hospital in 2019 with a complaint of a painless mass in the left palate. The patient was aware of the swelling in his right palate for approximately 2 years. However, he noticed a recent and rapid increase in the swelling. Hence, the patient initially consulted a general dental practitioner, where a diagnosis of a tumor of the palate was established. The patient was subsequently referred to our department. His medical history revealed febrile seizures at the age of 1 year, and his family history was unremarkable. On initial assessment, no systemic symptoms were observed. An extra-oral examination revealed facial symmetry. No swollen cervical lymph nodes were palpable bilaterally. Intraoral examination revealed a dome-shaped mass measuring 4.0 × 3.0 cm on the left side of the hard palate, extending anteriorly to the distal first premolar area and posteriorly to the soft palate. The mucosal surface of the mass was smooth, but partially ulcerated (Figure ). On palpation, the mass was elastic hard in consistency. Panoramic radiography revealed opacity of the left maxillary sinus with an impacted tooth and the level of the left maxillary sinus floor was lower than that on the right side (Figure ). Computed tomography (CT) revealed a well-demarcated multilocular-appearing expansile radiolucent lesion in the left maxillary sinus with an impacted tooth in the posterior wall (Figure ). Magnetic resonance imaging revealed a nonhomogeneous, mildly enhancing lesion in the left hard palate and alveolar process, along with a highly enhancing homogeneous lesion in the left maxillary sinus (Figure ). CT of the neck revealed no enlarged bilateral lymph nodes, and CT of the abdominal and thoracic regions revealed no other specific findings.
Incisional biopsy of the palate revealed the epithelium comprising primarily squamous epithelial cells and the focal presence of clear cells and ghost cells along with the presence of calcifications, which su

[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 69-year-old man was admitted to the Department of Gastroenterology for evaluation of an incidental hepatic mass in August 2013. In 2005, he had been admitted to the Department of Endocrinology because of cold sweating, facial flushing, and uncontrolled blood pressure. A ~7 cm right adrenal mass had been observed on computed tomography (CT) and there had been no distant metastasis on an MIBG scan. The patient had undergone laparoscopic right adrenalectomy due to PCC. After surgery, he had been followed up in the outpatient clinic until 2007. During that period, there was no evidence of metastasis in abdominal CT. The patient had also been treated for hypertension and type 2 diabetes mellitus for 3 years and had a history of coronary stent insertion for non-ST-elevation myocardial infarction in March 2012. At admission to the Department of Gastroenterology, he experienced dizziness, diaphoresis, general weakness, and poor oral intake; his blood pressure was 130/80 mm Hg and his heart rate was 78 bpm. Contrast-enhanced abdominal CT and magnetic resonance imaging (MRI) were performed. They revealed a ~10 cm hepatic mass in the right lobe of the liver that had a high signal intensity on T2-weighted images and early arterial enhancement and delayed washout on dynamic contrast-enhanced images. Also, it had a low signal intensity on the hepatobiliary phase and high cellularity on the diffusion phase (). The hepatic mass was considered to be hepatocellular carcinoma rather than malignant PCC. For these reasons, liver biopsy was performed to evaluate the incidental hepatic mass. The patient was given the α-adrenergic antagonist phenoxybenzamine to prevent a hypertensive crisis before biopsy because we could not completely rule out the possibility of metastatic PCC. However, during and after the liver biopsy, his vital signs were stable. PCC was finally confirmed on the basis of morphological and immunohistochemical findings, with the specimens staining positive for chromogr

[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:
We present the case of a 60 year-old male smoker with a history of chronic obstructive pulmonary disease (COPD) who presented with a two-week history of increasing shortness of breath and occasional wheezing. Review of systems was otherwise negative. Past medical history was remarkable for mild COPD, but the patient had otherwise been free of health problems. Physical examination of the chest revealed clear lung sounds bilaterally, and no other abnormal physical findings were evident. Chest x-ray demonstrated a right pneumothorax, and a subsequent CT scan confirmed a right pneumothorax (less than 10% of lung volume), a small right pleural effusion, and two large blebs in the right lung. No mass lesions were apparent. A nuclear medicine lung perfusion and ventilation scan showed retention of radiotracer consistent with COPD and heterogeneous patchy areas of perfusion, most likely related to air-trapping. It was decided to procede with surgical exploration and possible excision of the patient's emphysematous blebs. A right mini-thoracotomy was performed, and a large bleb was readily identified within the anterior chest, which was resected. A separate aarea of possible abscess was noted in the right apex, which on dissection by the surgeon contained yellow viscous fluid. Otherwise, no mass lesions or findings suspicious for carcinoma were encountered.
Histologic examination of the patient's bullous resection revealed emphysematous changes and mild subpleural fibrosis. Additionally, multiple glandular structures were noted within the pleural tissue (Figure ). These structures were composed of plump epithelioid cells with mild nuclear enlargement, fine chromatin, and inconspicuous nucleoli. No mitotic activity was evident. The glands were surrounded by fibrovascular tissue and showed no evidence of vascular or lymphatic invasion. The majority consisted of irregular small acinar structures, and there was no evidence of cribriforming or formation of solid structures. Immun

[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 nonverbal female presented to the emergency department (ED) from home with her daughter who had noted that the patient has been acutely grimacing in pain from even the lightest palpation over her right flank. She had decreased urine output for the prior two days and her family had noticed an enlargement on the right side of her back one day prior to her ED visit. Of note, the patient presented with poor functional status, was totally bedridden, and was on no antibiotics. She also had a renal flow scan several months prior to her presentation, which revealed the absence of blood flow to the left kidney. A nephrectomy was ultimately rejected based on her medical history and current health status. The patient's medical history was significant for CVA with left hemiparesis, sacral stage 4 pressure ulcers, DM, HLD, failure to thrive, and asthma. Her past surgical history included a left double J-stent placement, an appendectomy, and a tracheostomy that was reversed.
On physical examination, the patient appeared to be in mild distress with a blood pressure of 93/50, heart rate of 116, and otherwise normal vital signs. Abdominal examination was remarkable for tenderness to palpation over the right flank with visible erythematous skin seen in the same area. Results of the initial laboratory tests were significant for a lactate of 2.9, white blood cell count of 18.4, hemoglobin of 7.1, platelet count of 933, albumin of 2.3, and potassium of 5.8, yet with a creatinine of 0.62. She underwent an IV contrast computed tomography (CT) scan of the abdomen and pelvis, which revealed a right hydronephrotic kidney that contained numerous large calcifications (Figures and ). The right previously placed ureteral stent was in satisfactory position. There was an extremely large fluid collection in the right retroperitoneum extending into the right flank consistent with leakage of urine from the obstructed right kidney ().
While, in the ED, urolog

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


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

[User]
RADIOLOGY NOTE:
A 36-year-old woman (G4,P2), at the 15th gestational week of twin-pregnancy following IVF-embryo transfer, was found to have a solid adrenal mass on a regular checkup. MRI revealed a 11×7.5 cm right suprarenal hypervascular mass with mixed signal intensity in T2-weighted images (). The diagnosis of PC was confirmed by laboratory analysis (). The patient had no genetic testing and her family history was not indicative of any hereditary disease. She had two previous vaginal deliveries (14 and 11 years ago) and a history of one abortus at 10-week gestation two years earlier. The patient confirmed that she had no symptoms relating to PC in her previous deliveries. She had no genetic testing and her family history was not indicative of hereditary disease. She was asymptomatic and normotensive and had no hemodynamic instability during pregnancy. She was asymptomatic and normotensive and had no hemodynamic instability during pregnancy. Perinatological ultrasonography revealed normal morphology of dichorionic and diamniotic male and female fetuses.
A multidisciplinary team consisting of urologists, anesthesiologists, endocrinologist, and obstetricians focused on the therapeutic approach. The patient did not receive any medical treatment for alpha or beta blockade preoperatively. She underwent laparotomy with a subcostal incision and transperitoneal tumor resection at 17 weeks of gestation (). During surgery blood pressure (BP) was stabilized with phentolamine and esmolol, with occasional bouts of brief hypertensive periods up to 240 mm Hg systolic pressure. A hypervascular mass with fragile large veins was dissected free of the upper pole of the right kidney, between the vena cava and the lower border of the liver. The estimated blood loss was 1100 ml. The patient was transfused with 3 units of erythrocyte suspensions. The postoperative period was uneventful and she remained hemodynamically stable. Histopathological examinations were in accordance with a PC.
She had a norma

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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 clinical case of a 29-year-old male patient treated at the Instituto Nacional de Cancerología of Colombia with a diagnosis of chronic myelogenous leukemia (CML) in high-risk chronic phase since February 2010. He started treatment with imatinib at a dose of 400 mg, obtaining a hematological response in the second month but not achieving a cytogenetic response in the 18th month. At that time, the patient continued treatment in another institution. It was possible to elucidate that the patient had a change of his treatment to dasatinib in March 2013 with the previous verification of the lack of cytogenetic response documenting a level of BCR-ABL transcription of 6.3%, period after which the patient, unfortunately, lasted eight months without treatment due to assurance problems. In September 2016, a BCR-ABL transcription level of 58% was documented, without a real knowledge about how much time he had taken dasatinib continuously at the moment of BCR/ABL evaluation; then, nilotinib treatment was begun.
The patient was readmitted to our institution in March 2017 and we diagnosed a progression to blast crisis of myeloid origin with a bone marrow study that documented 72% of blasts with karyotype without the growth of metaphases, being also very striking, the concomitant infiltrative cutaneous involvement, bone lesions of lytic type and hypercalcemia that required the use of zoledronic acid as an oncological emergency (Figure ).
At the end of the induction with 7 + 3 (seven days of cytarabine and three days of idarubicin) chemotherapy associated with bosutinib for 14 days and after several infectious complications, including invasive fungal infection and bacteremia due to Enterococcus faecium, as well as symptomatic hypocalcemia because of bisphosphonates, it was documented a percentage of blasts by flow cytometry of 29% in bone marrow and the existence of 46% of cells with basophilic versus mast cell characteristics on day 28 at the end of induction (Figures

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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 12-year-old boy sprained his left ankle by forced inversion while playing soccer. He and his mother were referred to our clinic 2 days after the injury. No issues were noted in his family history, developmental history, or psychological conditions. He was a right-handed active Japanese boy with normal physical development, 140 cm tall, weighing 31 kg. He suffered from the same left ankle sprain 3 months before the present injury, although he recovered completely within a few days at that time.
At the first visit, he could walk using his left foot, reporting pain in the lateral aspect of the ankle during motion at an intensity of 85 mm on a 100 mm VAS. X-ray images showed no abnormal changes in the ankle joint or surrounding bones. An analgesic poultice was prescribed and he was allowed to walk with the diagnosis of a grade-1 ankle sprain. Running, sports, and physical activity were prohibited and the patient was requested to revisit 1 week later. Two days after the first examination the patient visited again, reporting increasing pain with a 94 mm VAS score. The painful area had expanded to the entire foot. He could not bear weight on his left foot with allodynia and hyperpathia in the sole. These were obviously unusual signs for a grade-1 ankle sprain. A supporting band was worn and non-weight-bearing ambulation using a pair of crutches was instructed by a physical therapist. Oral acetaminophen (400 mg/day) was prescribed, but was ineffective. On the fifth day, VAS score increased to 100 mm both in motion and at rest. Intense allodynia and mild edema were observed in the entire foot. The patient reported difficulty standing on his left foot because of fear of evoking pain induced by touching his foot on the floor. Subcutaneous bleeding suggestive of underlying ligamentous ruptures was not seen anywhere in the foot. CT performed to detect deep injuries, such as bone contusions, revealed normal

[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 Caucasian man suffered from a distortion of his right ankle seven months prior to presentation. The incident happened when he was at work. Due to persisting pain in his joint he first saw a general practitioner. An X-ray image of the patient's right ankle showed no pathological findings. The joint was immobilized for six weeks in a plaster cast, which was then followed by physical therapy. Six months after the therapy, however, the patient still suffered pain in his ankle with no sign of any improvement. A magnetic resonance imaging (MRI) scan revealed an unknown but well-circumscribed localized tumor at the ventral part of the ankle, coupled with focal bulging and erosion of the tibia and talus (Figure ). The MRI detected no damage to the fibular collateral ligaments. On examination, about thirteen months after trauma of the ankle, tenderness to pressure was found at the ventral aspect of the right ankle next to the medial malleolus. A dorsal extension of the ankle was very painful. The collateral ligaments showed no insufficiency and a new X-ray still did not show any conspicuous findings. An ultrasound investigation showed a solid, homogeneous hypoechoic mass measuring 3.5 × 2.5 × 2 cm. It was not clear whether the tumor was directly connected to the joint. An impingement syndrome of the right ankle caused by a synovial hypertrophy was diagnosed preoperatively.
The tumor was resected through a ventral access. A brownish yellow tumor that was mainly solid was found during surgery. The tumor showed adhesions to the capsular of the patient's ankle and the complete tumor was treated with marginal resection (Figure ). A small hypertrophy of the cartilage below the tumor was also removed. However, the complete cartilage of the joint was not damaged.
Microscopically, the tumor was partially encapsulated and composed of round to polygonal cells. Some were spindle cells and some were multinucleated giant cells (Figure ). The diagnosis of localized tenosynovi

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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 72-year-old male presented with a complaint of swelling on both sides of the groin for the past 40 years and left groin pain for 1 month. The pain reduced when the patient was in the supine position. The patient had undergone bilateral inguinal hernia suture repair 50 years ago. He had no sexual dysfunction and was fertile; he was married with three sons. On physical examination, a swelling of approximately 10 cm in diameter was found in the left groin extending into the left scrotum and a swelling of approximately 3 cm in diameter was found in the right groin. The swelling was reducible on both sides. Laboratory data were normal. Computed tomography showed a herniation in the left groin, but not in the right. The hernia contents seemed to be the intestinal tract and solid tissue considered the omentum (Fig. ).
After confirming the patient's fitness to undergo anesthesia, surgery was planned. TAPP was performed. There was a fibrous structure linking the left and right hernia orifice and a muscular structure in the hernia sac on the left (Fig. A). It was difficult to separate the peritoneal cavity and the structure of the fiber and muscle. The muscular structure was continuous in the pelvic cavity and adherent (Fig. B). We consulted a pediatric urologist and noticed that the muscular structure was a vagina and fibrous structure was a salpinx, and we diagnosed the patient with PMDS (Fig. C). We explained it to patient family and it was decided to resect a vagina and a salpinx for hernia repair. After dissection of the uterus, right salpinx, and the upper part of the vagina, supravaginal hysterectomy and right salpingectomy were performed. We divided the vagina with a linear stapler after dissecting the vagina as much as possible. Following which a preperitoneal mesh repair was performed for bilateral inguinal hernia. The mass comprised of Müllerian duct derivatives with a rudimentary uterus and right salpinx (Fig. D).

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


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

[User]
RADIOLOGY NOTE:
A 49-year-old man was referred to our department with persistent serous fluid discharge via a Penrose drain that had been intraoperatively placed into the operation site and had remained until postoperative day 10 after orthopedic internal fixation with metal screws for multiple pelvic bone fractures. The creatinine and blood urea nitrogen values of the discharged fluid were 25.56 mg/mL and 86 mg/mL, respectively. Subsequently, intravenous urography was performed, which showed urinary extravasation arising from the right distal ureter suspicious of a right distal ureteric injury (). Renal ultrasonography was also performed, which confirmed grade I hydronephrosis of the right kidney. Following this, a percutaneous nephrostomy (PCN) tube was successfully inserted to divert the urine output into an external drainage bag. To further specify the location and severity of the right distal ureteric injury, an antegrade nephrostogram was performed via the PCN tube, which clearly demonstrated extravasation of contrast material around the right distal ureter (). However, an antegrade attempt to internalize the right ureter by placement of a double J ureteric stent failed. After detailed discussion with the patient, it was decided to proceed with an emergent reconstructive operation to repair the right distal ureteric injury. A midline laparotomy was performed to obtain adequate surgical exposure of the injured right ureter. After careful dissection, the right ureter was found to be displaced medially by a well-formed urinoma secondary to urinary leakage along the right pelvic side wall. In addition, reactive inflammatory changes adjacent to the injured ureter had resulted in adhesions that made ureteric dissection difficult. Two penetrating holes leaking urine at the same level of the right distal ureter were intraoperatively identified. After complete evacuation of the urinoma, approximately 2 cm of the injured ureteral segment was excised and an additional ureteral dissectio

[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-yr-old Asian man who presented with intermittent melena and significant weight loss was diagnosed with small bowel GIST with multiple liver metastases and peritoneal seeding on May 25, 2010. He underwent jejunal resection and anastomosis with palliative intent. The excised jejunal GIST measured 7 × 5 × 5 cm and had a c-KIT exon 9 mutation (1,510-1,515 duplication). After surgery, the patient was treated with 400 mg/day imatinib. He had no concomitant medications or co-morbid diseases.
Two months later, the patient developed grade 3 edema, grade 3 ascites, and grade 2 vomiting, with chest radiography revealing layering of a moderate amount of pleural fluid. Because the patient had peritoneal seeding, it was hard to determine whether his ascites and pleural effusion were due to imatinib toxicity or the progression of GIST. Although the follow-up abdomino-pelvic computed tomography (CT) scan showed that the patient's liver metastases had not changed significantly, disease progression was suspected, which prompted a cessation in imatinib treatment and a commencement of sunitinib treatment. The patient was transferred to our hospital for a second opinion after he had been taking sunitinib for approximately 2 months. A thorough review of his previous serial CT scans showed no definitive evidence of disease progression whilst he was on imatinib treatment. We therefore decided to resume 400 mg/day imatinib and use 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET)/CT for accurate assessment of response to imatinib treatment.
One month after the patient restarted imatinib, a PET/CT scan revealed a significant decrease in maximum standardized uptake value from 4.2 to 2.9 in one of his liver metastases (), suggesting the tumor was responding to imatinib. However, the patient required paracentesis once weekly to control his ascites, and he complained of peripheral edema and dyspnea. Because imatinib blood level testing revealed that the patient had very high i

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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 79-year-old man who was a current smoker was admitted to our hospital for hemoptysis in July 2011 (day 0). Before admission, pulmonary emphysema and multiple pulmonary bullae were detected on a chest computed tomography (CT) scan, and we also discovered that the patient had hypertension. He had a history of lobectomy of the left lower lobe for lung cancer in 1993, with no recurrence; two episodes of bacterial pneumonia; gastrectomy for gastric cancer in August 2010; right spontaneous pneumothorax that required tube drainage in November 2010; and hospitalization for dyspnea in February 2011, at which time chest radiographs showed left lung opacity and a chest CT scan showed consolidation with pleural effusion in the left lung. Several bacterial antibiotics failed to improve the opacity on chest radiographs. A sputum culture was negative for Aspergillus. The lack of efficacy of bacterial antibiotics and the presence of multiple bullae and precipitating antibody to Aspergillus in the serum (day -163) led to a presumptive diagnosis of chronic necrotizing pulmonary aspergillosis. Voriconazole with a loading dose of 800 mg a day followed by a maintenance dose of 400 mg a day was started on day -155. A switch from intravenous to oral administration of voriconazole at a dose of 400 mg a day was made on day -106. With administration of voriconazole, the opacity on chest radiographs had significantly improved by June 2011. The patient underwent transurethral resection of bladder cancer in March 2011. Oral voriconazole was continued at our outpatient clinic until his admission for hemoptysis. He had no hematologic neoplasm.
On admission, a chest radiograph (a) showed consolidation in the upper field of the left lung and an infiltration shadow in the middle and lower fields of the left lung. A chest CT scan (b) showed consolidation in the pulmonary bullae adjacent to the aortic arch. These shadows were considered to be due to hemorrhage. Bronchoscopy revealed slight bleeding

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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 16-year-old female patient was first administrated to our hospital because her right leg was 18 cm shorter than contralateral side (Fig. ). When she was 4-year-old, she contracted right tibia pyogenic osteomyelitis, leading to a 6-cm tibial absorption involving the distal epiphysis. The patient had no other past medical history. When she was 5, the tibia defect was reconstructed by her ipsilateral vascularized fibular graft. However, progressive leg length discrepancy developed with limited range of joint motion (ROM) (Table ). When she was 16, lengthening of FVFG with a unilateral external fixator was performed to correct the LLD (Fig. ). We executed an open osteotomy at the level of the middle metaphysis of the matured fibular graft. The patient received preventive intravenous antibiotic (Cefuroxime) for 72 h. The latency period was 7 days after the operation and distraction was performed at a rate of 1.0 mm per 36 h in four increments of 0.25 mm, and when the length of bone regeneration had reached approximately 6.0 cm, the distraction rate was reduced to 1.0 mm every 48 h []. Clinical and radiological examination was carried out every 15 days to assess new bone formation and the pin sites []. The rate was adjusted according to the discomfort and swelling of the limb and the quality of the regenerate bone like our previous study []. Partial weight-bearing was allowed as soon as union of the vascularized fibula graft on either junction was observed on radiographs. We achieved equalization with a unilateral external fixator in 26.5 months. The mean external fixation index was 44.2 day/cm. She had a pin-track infection and local inflammation, which were managed with pin care and oral antibiotics. The unilateral external fixator was removed when at least three of the four cortices were observed to be united on anteroposterior and lateral radiographs. She was able to walk without walking aids or braces,

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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.