[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 proband was a 34 year-old right-handed man. From the age of 26 years, involuntary movements of the bilateral lower limbs, associated with dysarthria, grinding teeth and drooling, appeared and gradually worsened. At 31, he suffered from epileptic seizures, which were considered to be generalized tonic-clonic seizure, but antiepileptic drugs had never been administered. One year later, involuntary movements spread to his upper limbs and orofacial automatisms including abnormal tic-like facial movements, tongue protrusion and biting his lips appeared. Then he was treated with haloperidol (2 mg three times a day) and baclofen (10 mg three times a day) for 2 years for his choreic and dystonic problems, but he responded poorly to drug treatments. At age of 34, his involuntary movements gradually spread to his whole body and epileptic seizures increased in frequency. Since the disease onset, the patient had never suffer from psychiatric problems. Neurological examination revealed poor muscle tone and absent deep tendon reflexes in all limbs. Additionally, right positive babinski sign was elicited. Laboratory data revealed elevated creatine kinase level in the peripheral blood. Acanthocytes were found in 4% of cells on the peripheral blood smear test. Doppler ultrasound examination revealed splenomegaly. Brain magnetic resonance imaging (MRI) showed progressive, symmetrical, mild atrophy of the caudate heads (Figure ). His 24-h continuous electroencephalography (EEG) showed generalized asynchronous theta and epileptiform activity, which mostly originated from the right temporal lobe. A nerve conduction study showed a polyneuropathy, which revealed the right peroneal nerve, right median nerve and bilateral ulnar nerves were partly damaged. His score of Mini Mental Status Examination (MMSE) was 27. The father of the proband did not show any neurological abnormalities and died from pneumonia at 65 years old (Figure ). The mother of the proband (II-3), a 65-year-old woman,

[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 17-year-old male involved in high school athletics middle-distance running presented with a 3-week history of pain with more training. He was running up to 300 km/week on streets and cross-country in an even distribution. Although he had taken analgesics, the pain during exercise did not improve, and he presented to our emergency department with lower leg pain (Fig. ). There was no clear abnormality on the radiographs of the tibia, but STIR magnetic resonance imaging (MRI) confirmed a high-intensity area of the distal one-third of the tibia, and the diagnosis of stress fracture and shin splint was made. The patient was instructed to suspend training, and the injury was treated conservatively with follow-up on an outpatient basis (Fig. ). Follow-up radiographs were checked at 2 and 3 months. With this treatment, the fracture healed with no complications, and he decided to return to running after 3 months. At 6 months, radiography showed thickening of the bone cortex in the back one-third of the right tibia and in the back of the distal part of the left tibia, so that he was again instructed to stop training (Fig. ). However, he discontinued coming to the outpatient clinic on his own after 6 months.
He was then seen in the emergency department, having sustained an injury to the right lower leg while running a middle-distance race, 1 year after the initial examination. He described how, when he had just started and passed through the first corner, he had felt a ‘‘snap’’ in his right calf, suddenly could not run, and fell and had to abandon the race. He said that his leg was deformed in an impossible direction. It became impossible to run because of the lower leg deformities, and he was brought to our emergency department. He was admitted to hospital, and X-ray examination showed a greatly displaced oblique fracture in the proximal 1/3

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


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

[User]
RADIOLOGY NOTE:
A 10-month-old girl (weight 5.43 kg) suffering from Down syndrome and hypothyroidism was admitted in an emergency setting to the Intensive Care Unit with the symptoms of critical cardiac decompensation. The girl was transferred from another high-reference pediatric cardiology center with the diagnosis of critically narrowed aortic coarctation. In her medical history in the 3rd month of life, weight 3 kg, she underwent an interventional PDA closure in a referring institution.
In the last few months the parents observed increasing symptoms of heart failure – shortness of breath, anxiety, lack of appetite, and fatigability – that began just after the intervention. Although the symptoms were persistently reported to the cardiologists by the parents, echocardiographic controls showed a constantly good effect of interventional PDA closure, without any reasonable suspicion of interrupted aortic blood flow.
Transthoracic echocardiography (TTE) performed on admission showed myocardial injury, with poor contractility and severe valvular incompetence, mild pulmonary hypertension and severe stenosis of the isthmus of the aorta. Further precise TTE showed the critical aortic stenosis of the aorta caused by the aortic disc of the occluder that was used for PDA closure (). Chest X-ray on admission showed a severely enlarged heart silhouette with cardiac index = 0.8 ().
The girl was urgently referred for surgical removal of the occluding device. The procedure with extracorporeal circulation (ECC) and deep hypothermia circulatory arrest (DHCA) technique was performed. Intraoperatively there was significant pericardial effusion, and generally impaired contractility of the heart, with enlarged chambers, observed especially in the left ventricle (LV) wall motion. There was a macroscopic inflammatory-type reaction seen in the soft tissues surrounding the PDA, as well as changes in the arterial wall of both sides of the PDA: pulmonary and aortic. The double-disc occluder was removed with

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


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

[User]
RADIOLOGY NOTE:
The patient is a 61-year-old woman who initially presented to her primary care provider in January 2012 with some hematochezia and diarrhea accompanied by lower abdominal pain. After a change in diet failed to resolve her symptoms, she subsequently underwent a computed tomography (CT) scan, which showed severe proctocolitis. The patient was administered steroids in addition to metronidazole, but her symptoms did not resolve. She underwent a colonoscopy in June 2012, which showed the presence of a mass nearly obstructing the rectum.
On June 21, 2012, she underwent a low anterior resection of a stage IV rectosigmoid adenocarcinoma (approximately 5 × 4 × 1.5 cm). The tumor was moderately differentiated. A wedge resection of a left hepatic lobe was performed at the same time and yielded a diagnosis of adenocarcinoma consistent with the primary rectal tumor. Colostomy formation was also performed at that time. Her pathology review showed clear margins of the rectal primary, positive margin of the liver resection, and five of 15 lymph nodes positive for metastatic carcinoma. The patient tolerated the procedure well, except for bilateral extremity lymphedema starting two to three weeks after surgery, which improved with compression stockings.
A subsequent CT scan showed the presence of a secondary liver lesion as well as a 1.2 cm portacaval lymph node, positive for metastatic carcinoma with positron emission tomography (PET) CT. Otherwise, no lymphadenopathy in the chest, abdomen, or pelvis was found.
Pelvic radiotherapy was started with a total dose between 45 and 54 Gy on September 24, 2012. At about that time (September 2012), the patient was started on XELOX chemotherapy (oxaliplatin 100 mg/m2 over two hours, Day 1, every three weeks; capecitabine 850 mg/m2 orally twice daily, Days 1 to 14, every three weeks) and received approximately three cycles. Although the patient tolerated the first cycle well, the day after chemotherapy she had one isolated episode of complete

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


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

[User]
RADIOLOGY NOTE:
This is an otherwise healthy 25-year-old male who was brought to our emergency department by ambulance after a fall of 8-10 meters; while leaning against the railing of a third-story balcony he lost balance and fell backward over the rail to the ground below. Emergency personnel at the scene found him comatose and pulseless. After several rounds of cardiopulmonary resuscitation (CPR) and rapid sequence intubation, he was stabilized for transport to our hospital. On arrival to the emergency department, he had developed refractory hypotension and lost a carotid pulse for which he again required a round of CPR before return of spontaneous circulation. Once resuscitated and stabilized, head, spine, chest, abdomen, and pelvis CT scans were obtained. He was found to have bilateral temporal bone fractures as well as a transverse clival fracture, as well as diffuse but predominantly right-sided traumatic subarachnoid hemorrhages with scattered locules of pneumocephalus (Figure ). Spinal imaging revealed intradural air at the L3-L4 levels (Figure ). There was no imaging evidence of direct spinal trauma, nor any evidence of pneumothorax or pneumoperitoneum.
Neurological examination on arrival revealed an intubated young male with a GCS of 6T: he did not open his eyes nor display any localizing movements but was able to withdraw all of his extremities from painful stimuli. He had dried blood in both ears but was otherwise without otorrhea or rhinorrhea.
He was admitted to our trauma ICU and an intracranial pressure monitor was placed and monitoring was noted as normal. A follow-up head CT was unchanged. His GCS improved rapidly and he was extubated 11 hours after admission, and his intracranial monitor was removed. Repeat neurological examination noted that he was coherent and oriented, but amnestic to his injury. He had developed a left facial nerve paresis and was prescribed a two-week course of prednisone without significant improvement noted by the time of discharge. He re

[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 40-year-old, right-hand dominant female who had a known history of right breast carcinoma presented to our clinic for evaluation for open biopsy of a lesion at the base of the coracoid. Four months prior to clinic presentation, she underwent right breast lumpectomy and lymph node dissection. Surgical pathology revealed invasive mammary carcinoma, SBR grade 2 with no involvement of the lymph nodes. Resection margins were negative. She was Her-2-neu negative, estrogen receptor negative, and progesterone receptor positive. A bone scan revealed increased uptake at the eighth thoracic vertebra and in the region of the coracoid in the right shoulder. Further CT imaging of both regions indicated a fracture through the transverse process of T8, though the patient was asymptomatic at this level and had a prior history of a fall from a horse that correlated with this finding. There was no history of any shoulder pain resulting from or subsequent to that fall. CT imaging of the scapula showed osteolytic change at the base of the coracoid. Radiographs and relevant CT scan images are shown (Figures and ). She had received the first cycle of adjuvant chemotherapy with FEC-100 but further cycles were discontinued until further information regarding the possible sites of metastases was collected. Instead, she was placed on Tamoxifen and Clodronate. She was otherwise healthy and took no other medications.
On physical exam there was no palpable mass in the region of the right shoulder, no skin discoloration or changes, and her range of motion and strength were normal. She was nontender to palpation over the coracoid process. She had no tenderness to palpation over T8 or elsewhere throughout the spine. Upper and lower extremity neurovascular exam showed no focal deficits.
The patient consented to open biopsy of the coracoid and was taken to the operating room. Through a deltopectoral approach, the coracoid was identified and biopsy specimens from the lesion at the base of the corac

[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 man with a history of peptic ulcer disease was admitted to the Internal Medicine ward for the treatment of septic arthritis. During the hospitalization, he developed hemodynamic instability following acute, massive hematemesis of approximately 750 mL of fresh blood and clot (nadir blood pressure 74/36 mmHg, pulse 110 bpm). Endotracheal intubation was performed along with resuscitation with volume and blood product; a continuous infusion of pantoprazole was initiated and the patient was transferred to the Intensive Care Unit for urgent gastroscopy.
Initial gastroscopy revealed an adherent blood clot occupying the distal esophagus, extending to the gastric cardia and proximal fundus. The clot could not be dislodged despite attempts with a water jet and wire snare, and neither the underlying lesion nor bleeding site could be identified. Five milliliters of a 1:10 000 solution of epinephrine was injected into and surrounding the clot. The remaining mucosa, as far as the third stage of the duodenum, was unremarkable except for pallor. Blood work revealed an initial drop in hemoglobin from 115 g/L to 86 g/L with a normal INR and platelet count. Four units of packed red blood cells (PRBC) were administered and an infusion of norepinephrine was required to maintain adequate mean arterial pressure.
Despite aggressive initial management, the patient required an additional four units of PRBCs, five units of platelets and five units of fresh frozen plasma, along with increasing doses of norepinephrine. Therefore, aggressive gastric lavage with over 3 liters of normal saline was performed, followed by immediate repeat gastroscopy. The actively bleeding site was now identified as arising within severely ulcerated esophageal mucosa just proximal to the gastro-esophageal (GE) junction; no esophageal or gastric varices were present. The area was injected with 10 mL of 1:10 000 epinephrine solution and treated with coaptive electrocoagulation, with apparent hemostasis.

[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 21-year-old male patient, with an uneventful medical history, came to the emergency department of our hospital after an episode in which he lost consciousness. The patient was hemodynamically stable, with blood pressure and heart rate within normal limits; ECG did not present any abnormalities, either. At the time of presentation, he was in a good neurological condition and did not mention any thoracic or abdominal pain. Blood laboratory investigation showed normal values of hemoglobin, hematocrit, glucose and other markers. He was then admitted to the department of internal medicine for further investigation.
Twelve hours later, the patient complained of diffuse abdominal pain, while a decrease of hemoglobin was observed (9.5 mg/dL), and hemodynamic instability presented, with an increase in heart rate to 100 bpm. He was initially treated with intravenous fluids; surgical opinion was then seeked. Clinical examination revealed pronounced rebound tenderness on all of the abdominal quadrants and decreased abdominal sounds. In order to investigate the possibility of intraperitoneal bleeding and considering the stability of the patient, an emergency abdominal CT scan with i.v. contrast was indicated. CT scan revealed the presence of a ruptured proximal splenic artery aneurysm measuring 26 mm × 18 mm, 6 cm from its origin ().
Thanks to the rather stable hemodynamic condition of the patient, and the fact that our institution is equipped to provide an endovascular approach, open surgery was excluded as the first therapeutic option; angiography with coil embolization of the aneurysm and proximal splenic artery was then performed. Under local anesthesia (injection of lidocaine solution 2%, Astra Zeneca, Athens, Greece), a percutaneous puncture of the right common femoral artery, and selective catheterization of the splenic artery was performed, using a 4-F Simmons 1 catheter (Cordis, Tipperary, Ireland). Subsequent angiography revealed the aneurysm, but an attempt to pass

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


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

[User]
RADIOLOGY NOTE:
A 41-year-old Saudi male with situs inversus totalis and peptic ulcer presented to the emergency room with 4-day history of pain in the left upper abdominal quadrant. The pain was colicky in nature, radiating to the back and this condition was aggravated by fatty meals. Physical examination showed positive Murphy's sign in the left hypochondrium Ultrasound showed the location of gallbladder on the left side of the body with a 13 mm stone impacted in its neck and signs of acute cholecystitis. Chest X-ray showed dextrocardia []. Laparoscopic cholecystectomy was performed on the following day. The patient made an uneventful recovery and was discharged home on the consecutive day. CT scan shows the transposition of the major abdominal organs [].
The patient was placed in the supine position with both the surgeon and camera-man on his right side and the assistant on the left side. There was one monitor that was placed near the head of the patient at the left side. A 5 mm laparoscope was introduced through an umbilical incision. A 10 mm trocar was introduced in the subxiphoid area in the mid-line, passing to the left side. Two 5 mm trocars were introduced in the left mid-clavicular and left anterior axillary lines. A grasper was introduced through the anterior axillary cannula to hold the fundus of the gallbladder and it was pushed laterally to the cephalic position. Another grasper was introduced through the medial cannula for the holding Hartmann's pouch and for manipulating it. This was initially held by the right hand of the surgeon. A dissector was introduced through the subxiphoid cannula and was manipulated by the left hand of the surgeon. This procedure proved to be difficult for a right-handed surgeon. The surgeon frequently changed his hands to grasp the dissector with his right hand, while the assistant held the Hartmann's pouch grasper or moved the dissector to the medial cannula and he used

[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 39-year-old female was admitted into our clinic with a complaint of a 3-month history of a slowly growing mass along the neck midline. The physical examination revealed a 3 × 1.5 cm immobile mass along the neck midline over the thyrohyoid membrane, accompanied by a 3 × 2 cm palpable nodule in the left thyroid gland. A neck US revealed a calcified heterogenic-hypoechoic solid lesion of 30 × 18 mm at the level of the hyoid bone in the submental area, which was not related to the thyroid gland. A thyroid gland US revealed several hypoechoic nodules, the largest being 38 × 24 mm, with some having micro calcifications in the left lobe of thyroid gland, while the study identified no right lobe lesions. FNAB was performed on both the midline neck mass and the left lobe nodule. The FNAB results were reported as being consistent with papillary thyroidal carcinoma for the mass along the neck midline and as benign cytology for the nodule in the left thyroid lobe. MRI of the neck showed a 30 × 20 mm midline solid soft tissue mass with hyperintense signal after injection with contrast media. The MRI also demonstrated cystic changes in the mass and evidence of invasion into the infrahyoid muscle group (). After considering all of the clinical and radiological data, despite a histopathologic diagnosis of benign cytology for the left lobe nodule, we performed a Sistrunk procedure with total thyroidectomy and central neck exploration due to suspicion of simultaneous de novo development of papillary carcinoma in the TDC and the thyroid gland. Informed consent was obtained prior to the procedure.
During the Sistrunk procedure, a solid mass invading the infrahyoid muscle group was encountered, and gross total resection of the tumor was performed. A total thyroidectomy operation was also conducted (). During central neck exploration, samples of the suspected lymph nodes were sent for frozen section pathology, the results of which confirmed the diagnosis of papillary carcinoma metastas

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


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

[User]
RADIOLOGY NOTE:
A 13 year old female living in a remote rural area came to our clinic with an 8 year history of deformities in the extremities which had gradually became worse till she was unable to walk. The patient over the years had developed recurrent fractures in her legs and arms after minor falls. The family was poor and lived in a remote area far away from proper medical facilities. She was treated by local healers for her fractures which resulted in bowing of legs and arms. There were no gastrointestinal symptoms of abdominal pain or diarrhea. She was brought to the clinic carried by her father. The patient used her arms to drag herself around the house and developed fractures followed by severe bowing of her arms. She had been diagnosed with rickets and iron deficiency anemia by doctors in community hospitals and had received Vitamin D and iron supplements many times without improvement. She had never had a complete workup to find out the cause of her rickets. The patient also had failure to thrive. On examination the patient was pale, weight was 11 kg and height 97 cm (below the 3rd percentile for her age) (Figure ). She had severe bowing of her arms and legs.
Due to the presence of anemia, failure to thrive and rickets the initial impression was malabsorption probably due to celiac disease and the laboratory work up was done accordingly.
Initial laboratory investigations that were done are mentioned in Additional file : Table S1. X-rays of her upper and lower limbs showed diffuse osteopenia and bowing of both legs and forearms with blurring of the metaphyseal lines. It also showed dense transverse lines in tibia and ulna suggestive of looser’s zones indicative of severe rickets (Figures and ).Anti- endomysial antibodies titer was 80 (normal is negative), anti-tissue transglutaminase IgA was positive 75 U/ml (normal <2.5 U/ml) and anti-tissue trans

[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 male, a seasoned cyclist with no past medical history, presents to the emergency department with complaints of lightheadedness and diaphoresis after a bicycle fall. Patient was participating in a bicycle race when another rider ahead of him fell causing the patient to swerve to avoid him. Patient states that he fell on his left side and hit a tree with his right leg. Patient was wearing a helmet and did not suffer any chest or head trauma. After the fall, he felt lightheaded and diaphoretic and complained of mid back pain. Patient denied any chest pains or shortness of breath. Patient was subsequently brought to the hospital directly following the accident by ambulance.
In the emergency department, patient was noted to be in no acute distress; initial blood pressure was 128/69 mmHg with pulse of 65 beats per minute. He was afebrile, not tachypneic, and well appearing with marked right thigh swelling and tenderness to his medial thigh. Given the dizziness and diaphoresis initially, patient had an ECG performed which showed lateral ST segment elevation () and had a subsequent troponin I that was positive, 0.49ng/mL, with a Creatine Phosphokinase (CPK) of 617 U/L.
There was initial concern for a possible cardiac contusion, although the patient had no chest wall trauma and thus was admitted for further evaluation. As an inpatient, an echocardiogram was performed demonstrating normal right and left ventricular function and trace pericardial effusion while the patients troponin continued to trend upwards towards a maximum of 21ng/mL. He was loaded with Aspirin and Clopidogrel as well as initiation of a heparin infusion, Lisinopril, and a Beta Blocker. Coronary angiography was subsequently performed demonstrating a spontaneous coronary artery dissection of left anterior descending coronary artery. No further diagnostic study was performed at that time. Further history revealed that he took multiple caffeine Jello shots and drank a

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


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

[User]
RADIOLOGY NOTE:
A 42-year-old male came to our hospital with a complaint of defecation pain for 20 days and left lower abdomen pain for 3 days. Abdominal computed tomography showed thickening intestine wall at the recto-sigmoid junction, which leaded to an obvious dilatation of proximal intestine. And the density of intestinal mesentery increased as well as omentum (Fig. ). Through colonoscopy, we found an annular ulcer with irregular bottom and dirty surface near the recto-sigmoid junction, with pathological diagnosis of poorly differentiated adenocarcinoma. Without other obvious anomalies in the preoperative examinations, we performed an exploratory laparotomy on January 25. Massive serous ascites, a recto-sigmoid obstructive lump, and extensive nodules of implantation metastasis in abdomen, especially on the surfaces of intestinal tract and liver, were found during the operation. Considering the advanced stage of the tumor, we decided to perform a palliative Hartmann operation to relieve obstruction and adjuvant chemotherapy was chosen for following treatment. After operation, upper GI obstruction was well-relieved. But on February 10, 16 days after operation, the patient complained of discontinuous abdominal distention and pain again. Digital radiography of upper digestive tract showed a complete obstruction at the horizontal segment of duodenum, while the cavity was so narrow that the contrast agent could not pass through. We presumed that the obstruction was induced by the wide abdominal metastasis of the tumor. Conventional treatments for obstruction were performed, such as fasting, GI decompression, proton pump inhibitor, and parenteral nutrition. However, the intestinal obstruction was not relieved in the following days. Based on his situation, we assessed that the Eastern Cooperative Oncology Group Performance Status of the patient had already reached to 3 which was not suitable for high intensity of chemotherapy. So, targeted therapy was chosen as the further treatment i

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


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

[User]
RADIOLOGY NOTE:
We present a case of a 7.5-year-old boy admitted to our Pediatric and Allergology Clinic due to allergy to BL antibiotics for full diagnostics. The patient was born G1P1 with a birth weight of 3450 g and Apgar score of 9/10 points. His neonatal period was uncomplicated. The patient had a history of frequent respiratory tract infections (average once a month) since the beginning of preschool, usually requiring antibiotics. He was vaccinated according to the schedule. A family history of atopic diseases was negative. The boy was diagnosed with asthma and allergic rhinitis due to house dust allergy, and since 2016, he went under subcutaneous immunotherapy. Previously, he had been hospitalized several times due to pneumonia and asthma exacerbation (at the age of 5 and 6 years) and one time for orchitis (at the age of 2 years). According to the interview collected from his mother, due to infection in May 2017, the child had been given oral cefuroxime. About 15 minutes after the first dose of this antibiotic, a disseminated urticaria appeared, followed by edema of the face tissues. He was seen by a medical doctor and had been given intramuscular corticosteroids and antihistamines, achieving improvement of symptoms; the antibiotic had been changed to clarithromycin. After a course of 5 days of treatment, a similar situation developed—disseminated urticaria and difficulties in breathing. The boy had been hospitalized, and he had been treated with intravenous corticosteroids and antihistamines. Up to the date of first hospitalization for anaphylaxis, the patient had been treated with different BL antibiotics without any adverse reactions. The child was referred to our Allergic Department for drug allergy diagnostics. We performed this diagnostic in 3 months after the adverse event, according to the European Academy of Allergology and Clinical Immunology (EAACI) guidelines. Medical examination and laboratory findings confirmed no current infection. Skin prick tests were perfo

[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 white woman presented to my institution with severe pruritus. She had been diagnosed with stage IV adenocarcinoma of the ovaries with metastasis to the liver 1 year prior. She had undergone three rounds of carboplatin paclitaxel, followed by debulking surgery, followed by an additional six rounds of carboplatin paclitaxel therapy. After her last chemotherapy treatment, her carcinoembryonic antigen normalized. Four months later, she presented with jaundice, dark urine, and pale stools. A computed tomographic scan revealed the cancer had returned to the liver and was now obstructing her biliary duct. A stent was attempted several days later but was not successful. In collaboration with her oncologist, it was decided not to pursue further active treatment, and palliative care was initiated. She was otherwise healthy. The only medication she was taking was pantoprazole 40 mg daily for acid reflux. Her weight was 80 pounds.
One month later, she developed intense pruritus throughout her entire body. It was worse at night, and her sleep was significantly disturbed. She indicated her pruritus was 8/10 on a numerical rating scale (NRS), with a score of 0 reflecting no pruritus and a score of 10 reflecting the worst pruritus. She had no significant skin lesions or excoriations. She first tried over-the-counter moisturizers, with minimal effect. Benadryl was then suggested; it decreased her night waking, but she was too drowsy the following day. Loratadine was also attempted, to no effect. Cholestyramine was suggested, but she declined it due to the gastrointestinal side effects and longer time until onset of action.
The etiology of her pruritus appeared to be centrally induced, as opposed to prurioreceptive, neuropathic, or psychogenic []. My colleagues and I decided to try paroxetine on the basis of its preferable side effect profile, particularly in that it is less sedating. She was started on 5 mg nightly, with the intention to increase 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:
An 18 year old Sri Lankan Muslim female, presented with a 9 month history of colicky right iliac fossa pain and a 5 kg weight loss. She did not have diarrhoea, extra-intestinal manifestations of CD, and contact or past history of tuberculosis (TB). Clinical examination was normal.
Colonoscopy revealed an ulcerated ileocaecal valve and a terminal ileal stricture, while the colon itself was macroscopically normal. Biopsy of these lesions was reported as suggestive of CD. TB polymerase chain reaction (PCR) performed on the specimen was negative. Contrast-enhanced CT abdomen showed a segment of terminal ileum with concentric wall thickening. Mantoux test and Quantiferon gold test for TB were negative and chest X-ray was normal.
She was started on treatment for CD with a short course of oral steroids followed by azathioprine. However, she failed to tolerate azathioprine and subsequently 6-mercaptopurine (6-MP), and therefore was started on intravenous infliximab. Despite 3 dose of infliximab she failed to respond, and a follow up colonoscopy showed persistence of the ileal stricture. Therefore she was referred for surgical resection of the involved ileal segment. During the laparotomy, multiple terminal ileal and cecal strictures were noted and unexpectedly, multiple omental and peritoneal deposits were also seen. A limited right hemicolectomy including resection of the involved terminal ileum was performed.
Histology of the resected specimen showed multiple coalescent caseating granulomata involving full thickness of the bowel wall and extending into the mesentery and pericolic fat, suggesting a diagnosis of ITB (Figs. , ). No evidence of dissemination beyond the intestine was found. She was started on anti-TB treatment (ATT), and 2 months later was free of abdominal pain and has regained 3 kg of weight. Three months after commencing ATT a repeat colonoscopy was performed. There were no macroscopic or microscopic changes in the neo-terminal ileum or residual colon. She

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


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

[User]
RADIOLOGY NOTE:
The patient, a 55-year-old Chinese female, presented with intermittent diarrhea with little bloody mucosanguineous feces, 4 to 6 times a day, and pain in the lower left abdomen. The symptom could relieve for 10 years. An endoscopy showed rough and eroded mucosa of the rectum and sigmoid colon, the vascular network was not clear, there were a few pus secretions, and 3 polypoid protrusions were seen in the sigmoid colon. An endoscopic polypectomy was performed in 2010, and postoperative pathology revealed inflammatory polyps. The patient was diagnosed with UC according to histopathologic criteria. She received intermittent oral sulfasalazine and mesalazine for maintenance treatment, intermittent hormone enemas, and Chinese medicine. This treatment relieved symptoms, but episodes of diarrhea continued.
The patient experienced aggravated symptoms from 2013. Endoscopic examination revealed stenosis of 4 cm at the entrance to the large intestine, mucosa was rough and bleeding easily, and the endoscope could not pass through the colon. Furthermore, the pathologic biopsy revealed rectal adenocarcinoma (Fig. ). On January 5, 2013, a total colectomy and ileostomy were performed with the patient under general anesthesia. The postoperative histology biopsy showed: the ileum 4 cm in length and 4 cm in diameter; the total colorectal anal canal 84 cm in length and 3.5 to 7 cm in diameter; chronic inflammation present in the mucous tissue along the 35 cm ranging from the pectinate line; dilated and congested interstitial blood vessels; erosion ulcers and recess abscesses; focal glands showing atypical hyperplasia; and increased submucous fibrous tissue. The medium and low differentiated adenocarcinomas were found 3 cm from the pectinate line. The volume of the adenocarcinoma was 6 × 3.5 × 0.5 to 0.8 cm, and there was invasion of the fibrous membrane, the recidivist nerve, and the tumor thrombus in the vascular canal. There was no cancer invasion on both sides and metastatic carcino

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


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

[User]
RADIOLOGY NOTE:
A 6-month-old female infant had presented five times to medical services since birth with a history of discharge from the umbilicus. On days 2 and 4, she presented with bleeding from the umbilical stump, which was managed with a pressure dressing. At 2 weeks of age, she attended a general practitioner surgery with discharge of watery liquid from the umbilicus, and it was treated like an umbilical granuloma with silver nitrate application. She came to the paediatric assessment unit of the local district general hospital at 3 weeks of age because of ongoing discharge. The periumbilical skin area appeared raw with features of a chemical dermatitis. An umbilical swab was taken and treatment with oral flucloxacillin commenced. The child presented again with ongoing symptoms. This time, it was diagnosed as excoriated umbilical granuloma with possible tinea corporis infection and she was treated with miconazole and neomycin. The discharge was mainly serous fluid which occasionally turned serosanguinous but did not contain pus.
At 6 months of age, she was rereferred by the general practitioner for persistent umbilical discharge with intermittent blood-stained fluid whilst she had been on her third course of antibiotics. On this occasion a consultant paediatrician reviewed the infant. An ultrasound was requested to investigate for remnants of an omphalomesenteric duct because of the persistence of symptoms. The ultrasound showed a cystic structure of 5 mm diameter with echogenic walls situated deep to the umbilicus (see ).
There was no communication with the bowel. A fistula extended through the anterior abdominal wall to the umbilicus. She was referred to surgeons for further management. She had a surgical excision of the cyst and sinus tract at 7 months. On macroscopic analysis, it was found to be a hard cystic lesion below the umbilicus surrounded by thick chronic inflammatory tissue. A fistula extended through the abdominal wall with no obvious communication or tract to

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

[User]
RADIOLOGY NOTE:
A 38-year-old man was transferred to our emergency room for shortness of breath. Two hours before admission, he began to have sudden onset of dyspnea, and was intubated in another hospital. He reported to be healthy before this episode, and systemic review was negative. He did not have a remarkable past medical history, including surgery, allergy or specific medications. However, he had a family history of ischemic stroke; his father died of complication of ischemic stroke at the age of 65 years and his brother had ischemic stroke at the age of 39 years.
In the emergency department, he had respiratory distress and tachycardia, with an oxygen saturation of 81% even under the intubated state. The blood pressure fell to an unmeasurable level, and the heart rate was 102 beats/min. There were crackles in both lungs on auscultation. Chest X-ray revealed mediastinal widening and cardiomegaly with bilateral infiltrations. Computed tomography (CT) of the chest showed dilated pulmonary trunk, but there was no evidence of pulmonary thrombus, aortic dissection or lymphadenopathy. The patient was admitted to the intensive care unit with a tentative diagnosis of acute respiratory failure due to severe pneumonia.
On hospital day 3, chest X-ray showed decreased infiltration and vital signs were stabilized. However, he developed sudden onset of tachypnea and hypotension on the next day. Arterial blood gas analysis results while breathing ambient air were pH 7.21, PaO2 50.0 mmHg, PaCO2 71.4 mmHg and oxygen saturation 76%. A follow-up chest CT revealed a large thrombus in the right main pulmonary artery and marked dilatation of the pulmonary arteries []. In addition, atrophy of pectoralis and paravertebral muscles was detected []. Transthoracic echocardiogram (TTE) showed pulmonary arterial hypertension (right ventricular systolic pressure 60 mmHg) with D-shaped left ventricle. However, echocardiographic evidence of a thrombus was not identified.
The patient received thrombolytic ther

[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 75-year-old woman presented with a left upper lid mass for a 2-week duration. She was seen in a local clinic, diagnosed as a chalazion, and was treated with neomycin/polymyxin/dexamethasone ointment and hot compresses. She was sent to our department after exacerbation of the symptoms and growth of the mass. On review of symptoms, the patient had no other significant medical history, was not immunocompromised and took no regular medications. On examination, her visual acuity was 20/20 OU; the physical examination was significant for large immobile nonfluctuating supra-tarsal mass with red and erythema surrounding the mass []. There were no orbital signs observed on examination; there was full ocular motility in both eyes, no proptosis and color vision was intact. In addition, the dilated funduscopic examination was normal. Computed tomography (CT) scan of the orbits was performed, revealing a large mass extending from the frontal sinus through the soft tissue of the eyelid [ and ]. There was extensive bony erosion with no inter-cranial extension. Initial laboratory investigations were performed, including a complete blood count, chemistry, and coagulation studies, all within the normal limits. A biopsy was performed with a combined approach; both ears, nose, and throat (ENT) team, and oculoplastic teams were present []. The ENT team approached endoscopically using a navigation system to properly locate the lesion within the area of the frontal sinus. The oculoplastic team approached through a lid crease incision, and the material was sent to biopsy. Biopsy revealed an inflammatory infiltrate with many plasma cells and granulation tissue with a lymphocytic inflammatory infiltrate with plasma cells and neutrophils. There was an abnormal ratio of kappa to lambda and a high level of CD: 138 expression. Polymerase chain reaction was also performed and a monoclonal B-cell proliferation was seen. The histopathological diagnosis was plasmacytoma. The hematology department

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


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

[User]
RADIOLOGY NOTE:
The following is a description of the case of a 25-year-old woman with the initials S.K. in her second pregnancy who came to our antenatal consulting centre.
The first screening for blood count, blood group, biochemistry (ALAT, ASAT, creatine, urea, blood sugar) showed results within the reference range. Hbs Ag, HIV, Wasserman, IgG, IgM (toxoplasmosis), IgG, IgM (rubella), IgG, IgM (CMV) were negative.
At that time the woman was at 6 – 7 weeks gestation. Biochemical screening generally is done at 12 – 13 weeks gestation showed results within the reference range (low risk of development of a baby with an abnormality, low risk of developing preeclampsia in the second half of pregnancy and low risk of premature birth).
The patient came for a second comprehensive biochemical screening at 17 – 18 weeks gestation. The results showed the low genetic risk of congenital anomalies. Fetal morphology of the fetus was normal.
S.K. came again for consultation at 22 weeks gestation in connection with the admittance of her first 3-year-old child to the hospital because of pneumonia. Serological tests of the child had shown elevated CMV titer - specific IgM.
Then we made new serological tests of the patient and the results were as follows: CMV – specific IgG – 98; CMV – specific IgM – 2.1. It was then understood that the patient was most likely infected by CMV primarily in the first trimester of pregnancy. After consulting about the risk of transmission of CMV to the fetus the woman chose monthly ultrasound scans and refused amniocentesis.
The results of all ultrasound scans were normal until that time. At 24 weeks gestation fetal brain ultrasound scan showed thalamic calcifications bilaterally, hyperechogenic foci in the right side of the ventricular wall, asymmetric ventriculomegaly > 10 mm ().
Similar changes were imaged at 28 weeks gestation and also cerebellar developmental

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


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

[User]
RADIOLOGY NOTE:
We present a case of a 60-year-old female who presented to the hospital with complaints of dull substernal chest pain. She had chronic atrial fibrillation, chronic obstructive pulmonary disease with home oxygen, osteoarthritis, and anxiety disorder as her comorbid conditions. On examination, she did have chronic dyspnea and was on home oxygen. She did not have any cyanosis, palpitations, paroxysmal nocturnal dyspnea, or orthopnea.
She was initially evaluated with a nuclear stress test that did not show any reversible ischemia but dilation of the right ventricle (RV); ejection fraction was identified to be 54%. The patient was further evaluated by a transthoracic echocardiogram (TTE) in order to evaluate the RV dilatation. TTE identified a complete absence of IAS and a CA (). The findings were confirmed with a positive bubble study (). Transesophageal echocardiogram (TEE) was performed that confirmed the absence of IAS, demonstrated free mixing of color flow, moderate to severe tricuspid regurgitation, normal mitral valve structure, normal left ventricular ejection fraction, and enlarged right atrium (RA) and RV.
The patient was evaluated with cardiac computed tomography angiogram (CCTA) that demonstrated the right coronary artery to be the dominant artery, all coronary arteries to be ectatic/aneurysmal and measuring up to 8-10 mm, a complete absence of IAS, marked dilation of CA and both ventricles, a coronary arteriovenous fistula (CAF) between the distal left anterior descending and coronary sinus, massive dilation of pulmonary arteries, and no mitral or aortic valvular abnormalities; left ventricular ejection fraction was measured to be 59% (Figures –).
The patient underwent an invasive angiography (IA) which demonstrated many abnormal findings. It showed that the patient had coronary artery aneurysms measuring 0.7 cm to 1 cm (). IA was instrumental in taking measurements regarding oxygen saturation and pressure at multiple levels identifying a large interatrial

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


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

[User]
RADIOLOGY NOTE:
A 57-year-old right-handed woman presented with involuntary compulsive grasping with her right hand and intermanual conflict with her left hand. The typical symptom of involuntary compulsive grasping and grabbing with her right hand, which was associated with a frontal variant of AHS, manifested in this patient as an inability to release a comb or the hand of the examiner during the muscle strength examination (). In addition, the typical intermanual conflict associated with the callosal variant of AHS occurred while she combed her hair or ate food with her right hand; her left hand counteracted the purposeful movements of her right hand (). However, her hand movements were perfectly coordinated and smooth when she used her left hand for purposeful movement. She said that these symptoms, which were not under her control, affected her daily life. She presented to our hospital because she could not control her left hand. She had not received any medical treatment for this condition until she was admitted to our hospital. She had a history of hypertension. A history of epileptic seizures, cranial demyelinating pathologies, and other neurodegenerative diseases was not elicited. In addition to antihypertensive drugs (calcium channel blocker), there was no other medication history and no relevant family history. The general examination showed no obvious abnormalities, and her vital signs were normal. Neurologic examination revealed positive Babinski and Chaddock signs in her right lower extremity, and the muscle power of the right limbs was 4/5 grade. The grasp reflex was positive. The rest of the physical examination disclosed no abnormalities. Her National Institutes of Health Stroke Scale score was 3 points. Routine laboratory test results were normal.
Magnetic resonance imaging (MRI) revealed that she had developed ischemic strokes in the corpus callosum and the left frontal lobe due to stenosis of the A4 segment of the anterior cerebral artery. MRI revealed cytotoxic

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


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

[User]
RADIOLOGY NOTE:
A 78-year-old man was admitted to the pulmonary hypertension service at Stanford Hospital in December, 2010 with elevated pulmonary arterial pressures and progressive right-sided heart failure. He reported progressive shortness of breath over a period of two months, culminating in dyspnea at rest. This was associated with a 20-pound weight gain, abdominal bloating, and leg edema.
He was first evaluated for dyspnea several years prior to admission, where he was diagnosed with bilateral pleural effusions and extensive pericardial calcification on chest computed tomography (CT). Echocardiography and cardiac catheterization were consistent with constrictive pericarditis. He subsequently underwent uneventful complete pericardiectomy in 2008. The pericardium was stripped from phrenic nerve to phrenic nerve and the diaphragmatic and posterior pericardium was removed as well.
The patient enjoyed symptomatic improvement for approximately one year but then developed recurrent dyspnea. An echocardiogram demonstrated right ventricular (RV) pressure overload and a right ventricular systolic pressure of 66 mmHg. A trial of sildenafil was initiated but was discontinued after the patient developed a marked worsening of his dyspnea.
His medical history was remarkable for pericarditis diagnosed in 1978, which was presumed to be viral in origin. He had permanent atrial fibrillation/atrial flutter which did not respond to an attempted atrial flutter ablation in 2003. He had a history of chronic hypertension and gradually progressing stage 3-4 chronic renal impairment.
On admission, his jugular veins were distended to angle of his jaw when upright. Pitting edema was noted up to the mid thighs bilaterally. Crepitations were heard on auscultation of his lungs. N-terminal pro-brain natriuretic peptide was measured to be greater than 30,000 pg/mL. Chest x-ray showed blunting of the costophrenic sulci with coarse reticular linear basilar parenchymal opacities ().
Prior to admission, ventilat

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


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

[User]
RADIOLOGY NOTE:
A 24-year-old man was brought by ambulance to our facility after having been involved in an unhelmeted motorcycle collision. He presented with sinus tachycardia up to 123 beats per minute, a Glasgow Coma Score of 15, and had an obvious deformity of the right lower extremity. His tachycardia improved with 2 L of crystalloid fluid bolus. He was stabilized in a cervical collar and a Sager traction splint on his right lower extremity and taken for CT scans of his head, cervical spine, chest, abdomen and pelvis as well as plain films of his extremities. According to our institutional protocol, he underwent CT angiogram of his neck given his skull base fracture. He was found to have a right kidney laceration with active extravasation, two large hepatic lacerations without active extravasation, a right midshaft femur fracture, bilateral distal radius fractures, a left occipital condyle fracture, a dissection of the left internal carotid artery, and pooling of IV contrast near the bifurcation of his inferior vena cava (IVC). This was concerning for a vena cava or iliac vein injury (Fig. ). Given his hemodynamic stability, we consulted the vascular and interventional radiology teams regarding management. We decided to proceed with visceral arteriogram to control bleeding from the right kidney as well as a venogram to further delineate the suspected venous injury (Fig. ).
The visceral arteriogram demonstrated extravasation from the right adrenal artery and superior pole of the kidney, both of which were embolized with microcoils. Post-embolization angiography demonstrated no further evidence of active extravasation. There was no injury to the aortic bifurcation. A venogram was then performed, which demonstrated a 2.8 cm pseudoaneurysm arising from the proximal portion of the left common iliac vein with involvement of the base of the IVC without active extravasation. There was no involvement of the right common iliac vein. The patient continued to be hemodynamically stable so

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


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

[User]
RADIOLOGY NOTE:
A 30-year-old man referred for evaluation to our center with epigastric pain from three days prior to his evaluation. The pain was nonspecific and colicky distributed in periumblical region, did not radiate to any site and was unrelated to bowel movements. He had experienced also nausea, anorexia and intermittent vomiting.
There was a history of marijuana and alcohol usage from several years ago. Upon physical examination, he was ill with restlessness. There was mild periumblical tenderness without rebound tenderness. There was no other positive finding in physical examinations.
The patient’s laboratory results upon admission showed mild leukocytosis. Other laboratory values such as hemoglobin, platelets, serum amylase, erythrocyte sedimentation rate, aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase, and electrolytes were normal.
His workup on admission including; chest x-ray, abdominal x-ray, and abdominal ultrasonography were reported normal. An upper gastrointestinal endoscopy was performed after four days of admission that was normal.
Within second week after admission, because of continuing pain, colonoscopy was performed. The left and right colon appeared normal. The terminal ileum was also examined and appeared normal. The appendiceal orifice was discovered in the floor of cecum which was draining pus into the lumen ().
Result of the biopsies of the mucosa at the base of the appendix showed mild nonspecific inflammation with some necrotic materials and staphylococcus organism. The biopsies of the mucosa at terminal ileum, left and right colon demonstrated mild nonspecific inflammation.
A second abdominal ultrasonography was performed that showed a fluid collection (about 70× 40 mm) in favor of appendiceal abscess in right lower quadrant (). The patient was scheduled for spiral abdomen-pelvic computed tomographic scan which showed a hypodense well defined collection with air fluid level (about 70× 40× 30 mm) in right lower quadrant. T

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


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

[User]
RADIOLOGY NOTE:
A 69-year-old Caucasian male presented to his outpatient gastroenterology office with complaints of copious rectal discharge and for discussion of treatment options. His medical history was significant for trauma leading to a T7 spinal cord injury resulting in a thoracic arteriovenous malformation requiring surgical intervention. His postoperative course was complicated by paraplegia leading to him being constricted to a wheelchair. Twenty-five years after his initial surgery, the patient developed a left ischial ulcer and a sacral decubitus ulcer with concomitant methicillin-sensitive Staphylococcus aureus (MSSA) bacteremia, which was treated surgically with multiple debridements and prolonged courses of broad-spectrum antibiotics. During this time, the patient also underwent sigmoid end-colostomy placement due to chronic constipation. After another three years without complications, he presented with a new ischial wound and fevers, with wound cultures positive for MSSA, Streptococcus agalactiae, and Morganella morganii. He was treated with incision and drainage along with another eight-week course of ceftriaxone and metronidazole. In the following months, he began to have new onset of copious, purulent rectal discharge, leading to poor healing and further debridement procedures for his wounds.
When inquiring further, the patient previously reported minor mucus drainage from the anus, occurring about once every three weeks. However, in the months leading to his presentation, his purulent fluid drainage increased in both volume and odor, with up to estimated 1 L daily of purulent rectal discharge. He was referred to a colorectal surgeon due to above-mentioned complaints. On presentation, his physical examination was notable for paraplegia, flexion contracture of bilateral knees, and a well-pouched colostomy in the left lower quadrant of the abdomen. No parastomal hernia was noted. His rectal examination was notable for a normal-appearing anus with some minor residua

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


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

[User]
RADIOLOGY NOTE:
The patient was a 55-year-old woman hospitalized in the Department of Oncology, the 309 Hospital of the Chinese PLA on December 23, 2009 for 4 years of chest pain which was further aggravated for 8 months. Previously, she had paroxysmal dull pain in the chest for 4 years without obvious incentives; unfortunately, no attention was paid to it. The chest pain aggravated since April, 2009, accompanied by cough, white phlegm, hoarse voice, and cough after drinking water. No fever, night sweats, or weight loss was observed. Chest computed tomography (CT) done in another hospital in April, 2009 showed a mass localized in the superior mediastinum with a maximum diameter of 4.3 cm. Routine blood test, erythrocyte sedimentation rate, biochemical test, and tumor marker test were normal, as was abdominal ultrasonography. Thoracic operation was conducted, during which no clear boundary between the mass and surrounding blood vessels was found. As a result, the mass could not be excised and only an incisional biopsy was performed. Postoperative pathologic examination showed reactive hyperplasia of lymph nodes accompanied by charcoal particle deposit. The patient was clinically suspected to have mediastinal tuberculosis lymphadenitis and was given an anti-tuberculosis treatment for almost half a year. No obvious relief occurred and the patient suffered from somasthenia with a weight loss of about 10 kg in 6 months. A chest CT performed in November, 2009 found no obvious change in the superior mediastinal mass ().
The patient came to the 309 Hospital of the Chinese PLA for further treatment. Results of the tuberculin (PPD) test and MycoDot TM test were both negative. As a result, the Department of Tuberculosis excluded the possibility of tuberculosis and discontinued anti-tuberculosis treatment. The pathologic specimen of the thoracic mass incised in April 2009 was consulted by Departments of Pathology from several hospitals including the Peking Union Medical College Hospital. In th

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


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

[User]
RADIOLOGY NOTE:
A 67-year-old Japanese man presented with dysphagia. He had a medical history of exploratory laparotomy for ileus but no history of anticoagulant medication. Upper gastrointestinal (GI) endoscopy revealed type III esophageal cancer in the middle thoracic esophagus (Fig. a). An upper GI series revealed an irregular stricture in the middle thoracic esophagus. Computed tomography (CT) revealed a primary tumor and swollen cervical and mediastinal lymph nodes (Fig. b, c). Fluorodeoxyglucose-positron emission tomography (FDG-PET) also revealed a primary tumor in the esophagus (Fig. d) and swollen lymph nodes in the mediastinum with abnormal uptake.
As a result, he was diagnosed with middle thoracic esophageal cancer (squamous cell carcinoma) and T3N3M0 in clinical stage III according to the criteria of the Japan Esophageal Society. He was treated with combination chemotherapy of docetaxel, cisplatin, and fluorouracil as neoadjuvant therapy. Chemotherapy for 2 months resulted in shrinkage of the primary tumor of the esophagus and lymph nodes in the mediastinum (Fig. e–g). FDG-PET revealed decreased uptake in the primary tumor and lymph nodes in the mediastinum (Fig. h).
After chemotherapy, he underwent subtotal esophagectomy with three-field lymphadenectomy and gastric conduit reconstruction through the retrosternal route by thoracoscopy and laparotomy. Postoperative care was performed under mechanical ventilation in the intensive care unit (ICU). On postoperative day (POD) 1, mechanical ventilation was terminated because of a good respiratory condition. However, he suffered from dyspnea and severe acidosis and chest X-ray examination revealed right pneumothorax, which was observed 5 h after extubation. Furthermore, air leakage was observed from the water seal chamber of the chest drain system. We thought that the respiratory disorder was caused by the right pneumothorax. Therefore, mechanical ventilation was started again. After that, it became clear that the cause of 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:
The present case is about a 27-year-old woman who referred to the private dental clinic in June 2009. Her complaints were slight pain, gum swelling and bleeding on tooth brushing from the upper incisor teeth. She was also dissatisfied with the color of the anterior gingiva. Medical history of the patient was not remarkable. As learnt from her dental history, dental filling, root-canal treatment, apical resection and metal-ceramic crown restoration procedures had been carried out for the upper central incisors from 2006 to 2009. Periodontal evaluation revealed findings of gingival hyperemia, edema, bleeding on probing (BOP), slightly increased pocket depths and first degree mobility at teeth #11 and #21 []. Tenderness to percussion and fistula were also identified at her same teeth. Remaining teeth were healthy and few amount of supragingival deposit existed in lingual aspect of lower anterior teeth. Only an asymptomatic, extensive dental filling was located at tooth #24. In her orthodontic examination, Class I occlusion in the posterior region with slight mandibular anterior crowding was present and there were no occlusal contacts between the maxillary and mandibular anterior teeth in the intercuspal position. The maxillary central incisors were slightly proclined and minimal deep-bite was also present; however, the lips were competent, lower border of the upper lip generated a normal smile-line and there was no speech impediment. Radiographic examination revealed no alveolar bone loss in the anterior maxilla associated with the maxillary incisors and remaining part of the dentition was intact except endodontically treated tooth #24 with no pathological view [].
A multidisciplinary treatment was planned following clinical and radiographic examinations. It was decided to perform forced eruption before extraction of two incisor teeth to augment the future implant site. The patient was also informed about other treatment options. Before orthodontic phase of treatment,

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


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

[User]
RADIOLOGY NOTE:
An 87-year-old Caucasian male with a past medical history of benign prostatic hyperplasia and irritable bowel syndrome presented to the hospital with urinary incontinence, diarrhea, abdominal pain, hypotension and altered mental status. A diagnosis of septic shock secondary to urinary tract infection was made on arrival based on symptomology and initial investigation. The patient had a history of lower abdominal pain for last two weeks. He visited his primary care physician and underwent a computed tomography (CT) scan of the abdomen and pelvis which showed hypertrophy of the prostate and bilateral hydronephrosis. The patient had progression of symptoms leading to hospitalization. On arrival to the hospital, the patient was hemodynamically stable but quickly decompensated. Vitals showed a blood pressure of 88/55 mmHg, heart rate of 143 beats per minute, respiratory rate of 20 breaths per minute, and temperature of 96.3°F. Initial pertinent laboratory findings included acute kidney injury with serum creatinine of 12 mg/dL (from a baseline of 1.2 mg/dL) and blood urea nitrogen (BUN) of 161 mg/dL. Labs demonstrated an anion gap metabolic acidosis secondary to lactic acidosis. Urinalysis showed evidence of infection, and blood and urine samples sent for cultures. Physical exam at arrival was significant for a minor distress, diaphoresis, enlarged and tender prostate, abdominal distension without tenderness to palpation, guarding, rebound tenderness, or abnormal dermatological findings. The white blood cell values from the day of surgery until discharge are detailed in Table .
The patient received empiric intravenous antibiotics and fluid resuscitation in the emergency department along with placement of a urinary catheter to relieve urinary obstruction. Urinary catheter placement revealed gross hematuria, but hematuria resolved by the next day. Blood and urine cultures were positive for E. coli and initial antibiotics were deescalated to ceftriaxone, to which the organis

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


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

[User]
RADIOLOGY NOTE:
The patient is a 20-year-old female who presented to the emergency department (ED) with the complaint of a diffuse whole-body rash. Her past history was notable for depression as she was recently prescribed lamotrigine two weeks prior to ED presentation. She was recently discharged from another hospital two days ago where she was hospitalized for three days due to complaints of blistering of her lips, sore throat, and mild rash on the extremities. She was given the diagnosis of hand-foot-mouth disease and was treated with 1 gram of ceftriaxone. She reported a decrease in the severity of sore throat upon discharge from ED but the rash continued to progress and had spread throughout most of her body parts. The lamotrigine was subsequently discontinued by the primary care physician. She decided to present to the emergency department (ED) for further evaluation.
In the ED, she had a temperature of 102.4 F, blood pressure of 152/67 mmHg, heart rate of 120, and a respiratory rate of 22 per minute with an oxygen saturation of 98%. Physical examination was notable for a young female appearing uncomfortable with a diffuse maculopapular erythematous rash with scattered bullae lesions covering approximately 36% of her body surface area (Figure , ). Her lips were blistered with erythematous mucus membranes as well as erythema with erosions of the eyes (Figure ). The Nikolsky's sign was not appreciated. The rest of the physical examination was unremarkable. The laboratory data were unremarkable for signs of active infection given no leukocytosis and sterile blood cultures. Acetaminophen 1 gram was administered orally for fever and she was resuscitated with intravenous fluids. The patient was admitted to the progressive care unit for closer hemodynamics monitoring and supportive care. She was then transferred to a tertiary level burn care center within the next few hours for the continuation of care. She was diagnosed with toxic epidermal necrosis. She was monitored closely and r

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


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

[User]
RADIOLOGY NOTE:
A 62-year-old postmenopausal woman presented to the emergency room after a fall that resulted in acute exacerbation of right shoulder pain. She first noticed this pain three weeks prior, but could not identify any inciting factors. In the emergency room, an X-ray was obtained that showed a proximal humeral facture with lytic lesions in the surrounding bone (). She was placed in a sling and discharged with outpatient follow-up. As part of her workup, a computed tomography (CT) scan of the chest, abdomen, and pelvis was obtained and revealed multiple pulmonary nodules, necrotic-appearing mediastinal and hilar lymph nodes, a left adrenal nodule, a mass within the T10 vertebral body with epidural extension and spinal cord compression, and multiple bony lytic lesions. Bony lesions were noted throughout the T1 and T10 vertebral bodies, left ileum, right ileum, left femoral head, and left acetabulum. The pelvis was notable for a fibroid uterus, but was otherwise unremarkable. There was no pelvic lymphadenopathy or ascites.
One week later, she presented to the emergency room with rapid onset of lower extremity weakness. She was admitted with a diagnosis of spinal compression and initiated on dexamethasone to prevent further neurologic compromise. Magnetic resonance imaging (MRI) demonstrated a large T11 lesion with extensive epidural extension, a T2 lesion expanding into the prevertebral and ventral epidural space, and numerous other lesions throughout her spinal column (). Neurosurgery took her to the operating room for decompression and performed a T10–T12 laminectomy, tumor resection with T11 vertebrectomy, T9–L1 fusion and reconstruction with titanium cage and bone matrix allograft.
The pathology specimen showed a poorly differentiated adenocarcinoma. It was strongly positive for estrogen receptors, progesterone receptors, and Pax 8, suggesting an endometrial or breast cancer. On further interview, the patient reported five months of intermittent vaginal bleeding and a

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


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

[User]
RADIOLOGY NOTE:
A 21-year-old previously healthy woman, a college student, was on a waterslide at an amusement park, when her left arm became caught between the side of the waterslide and adjacent rocks. She sustained a forceful twisting and loading injury to her left upper extremity which resulted in a severe pain and deformity to her left arm, forearm, and wrist. She was brought by ambulance to our emergency department. On physical exam, her injuries were closed, her arm and forearm compartments were soft, and she was neurovascularly intact. Radiographs of the humerus, forearm, and wrist demonstrated a left distal third humeral shaft fracture () as well as a left Galeazzi fracture, with a midshaft radius fracture and disruption of the distal radioulnar joint (Figures and ). She was placed in a well-padded long arm posterior plaster splint extending from the posterior shoulder to the fingers, with an additional coaptation component to the splint to stabilize the humerus fracture.
Within 24 hours of admission, the patient underwent open reduction and internal fixation of both her humeral shaft and radial shaft fractures. The decision was made to reduce and fix the humeral shaft first. The humeral shaft fracture was amenable to reduction and fixation with an extraarticular locking plate through a posterior approach with the patient in the lateral decubitus position. Because of the manipulation of the forearm, which may be required during reduction and plating of the humerus, we chose to avoid fixation of the radius and the possible transfixion of the distal radioulnar joint until after the operation on the humeral shaft was completed.
The surgery was performed under general anesthesia. The patient was positioned on a radiolucent table in the lateral decubitus position with the left arm which was supported over a foam roller. The left upper extremity was then prepped and draped, and 2 grams of cefazolin was administered prior to incision

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


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

[User]
RADIOLOGY NOTE:
A 60-year-old man with hypertension and type II diabetes mellitus was admitted to the local community hospital for a six-week history of low grade fever and recent development of chills and shortness of breath on October, 2005. Prior to this admission, the patient had been treated as an outpatient by his primary care physician for possible sinusitis and pneumonia with three different kinds of oral antibiotics including levofloxacin. On admission, the patient had a fever of 37 degrees centigrade and elevated white cell count of 17 × 109/L. Physical examination was significant for a hyperdynamic precordium, 2+ parasternal lift, grade 2–3 out of 6 continuous murmur best heard at the left sternal boarder, and gallop at the apex. The chest x-ray showed right pleural effusion and features consistent with congestive heart failure. An echocardiogram showed a markedly dilated sinus of Valsalva, measuring at least 6.4 cm, with turbulent blood flow in a RVOT. This was felt to possibly represent a left-to-right shunt and the possibility of a ruptured sinus of Valsalva was raised. The echocardiogram also showed a vegetation on one of the pulmonary valve leaflets (figure ). The patient was subsequently treated empirically for infective endocarditis with vancomycin and gentamycin for 28 days. During cardiac catheterization, oximetry studies showed there was no step-up in saturation in the pulmonary valve. This made the presence of a significant left-to-right shunt less likely. Aortic injection revealed significant dilation of all of the coronary sinuses. There was no jet noted from the coronary sinus to the right side of the chamber. Minimal aortic regurgitation was present. Pulmonary artery injection showed mild pulmonary insufficiency. Blood cultures did not grow any organisms.
On May 2006, the patient underwent resection of a large aortic root aneurysm, replacement of the aortic valve using a 23 mm St. Jude medical valve conduit, re-implantation of left coronary artery, coronar

[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 special needs 16-month-old Saudi boy. The chief complaint was a large ulcer on his tongue that caused pain, bleeding overnight, lack of sleep, and feeding difficulties. The mother reported that she noticed the ulcer 2 months ago and clinically examined by eight separate dentists. One of them thought that the lesion was a fungal infection and prescribing Daktarin oral gel 40 mg but in spite 1 month of treatment, the ulcer got bigger with more feeding and sleeping difficulties.
The mother also reported that the child was having a repetitive forward and backward movement of the tongue. The parents were very anxious as some dentists informed them that this lesion could be cancer.
Regarding familial history, the parents are first cousins and the mother has hypothyroidism. This boy was her only child after two abortions; one born with anencephaly (absent brain). The medical history revealed that he was born preterm (36 weeks) with microcephaly. After delivery, he was hypoactive, hypotonic and had respiratory distress, neonatal convulsion, and poor sucking reflexes. Before their visit to me, they had visited 12 local, national, and international medical centers for clinical examinations and laboratory investigations [].
On the first visit, he was not responding, and no eye contact. It was difficult to open his mouth as he had a strong bite and uncontrolled tongue thrust. The intraoral examination revealed an ulcer approximately measuring about 3 cm × 2.5 cm on the dorsal surface of the tongue extended from the tip to the middle of the tongue []. Smoothing the sharp edges by removing mamelons of the lower primary incisors using a diamond bur in a high-speed dental handpiece was completed. A month later, the RFD ulcer had healed successfully []. After 1 year, a follow-up visit disclosed that the boy had stopped the habit of repetitive tongue thrust and no signs of ulcer reoccurrence. A written informed consent had been obtained from the child’s parents

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


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

[User]
RADIOLOGY NOTE:
The patient was a 65-year-old man with a prior history of repeated plastic surgery for scar contracture of the hands and fingers, ablation surgery for idiopathic ventricular tachycardia, and diabetes. There was no family history of no consanguineous marriage or EB.
He had experienced recurrent blistering of the skin that was readily caused by an external force since the time shortly after birth, which had been treated symptomatically. He was diagnosed with EB during a genetic consultation that he had received before getting married at the age of 28 years. Subsequently, he was diagnosed with RDEB at the age of 38 years. Application of a strong external force to the skin results in blister formation as early as 15 min. In June 2012, he presented to a nearby hospital with epigastric pain, where he was diagnosed with cholelithiasis and cancer in the transverse colon and was referred to our hospital. In September 2012, transverse colectomy and cholecystectomy were performed via laparotomy, followed by an uneventful postoperative course. In April 2013, a liver metastasis (S2) was detected. The lesion was a solitary tumor measuring ≤2 cm and was treated by radiofrequency ablation (RFA) in June 2013, again followed by an uneventful postoperative course. In September 2015, a recurrent tumor was detected at the site of RFA, with suspected invasion into the diaphragm. He was then admitted to our hospital for curative open surgery. On admission, although no active blistering was noted, pigmentation and scars due to recurrent blistering were noted especially in the extremities and back. Most fingers in both hands were club-shaped, with a few intact fingers. Blood test showed a mild increase in glucose to 123 mg/dl and increases in tumor markers, including mean levels of CEA and CA19-9 of 25.0 (0–5) ng/ml and 62.1 (0–37) U/ml, respectively.
Abdominal CT/MRI revealed a 3.5 cm metastatic liver carcinoma with diaphragmatic invasion in the lateral segment

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


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

[User]
RADIOLOGY NOTE:
A healthy 35-year-old woman with a history of 2 elective cesarean sections and one miscarriage (G4 P2 A1) was accepted as a referred case to our hospital. The patient was admitted for the elective cesarean section at 37 weeks of gestation. She was referred from the rural primary care hospital where routine ultrasonography revealed low-lying placentation. A Doppler ultrasound at 35 weeks showed complete covering of the cervical os which was attached to the scar with incessant hemorrhagic lesions in the inner anterior myometrium, indicative signs of PA (Figure ). She had diagnosed placentation in the lower uterine segment and had given a history of irregular, painless bleeding of the vagina during the fifth and seventh months of gestation. Further, magnetic resonance imaging (MRI) was performed, images still revealed that the placenta was completely covering the cervical os and suspected implantation of placental villi penetrating the full thickness of the myometrium, which further extending posteriorly up to the bladder wall and anteriorly displayed vascular engorgement (Figure ). On the day of surgery, an expert urologic surgeon had been involved along with the interventional cardiology team. During the cesarean, the uterus was opened along the midline in upper segment of uterus, and a baby of the 3 kg was delivered with a good Apgar score. Due to invasive placentation and bleeding, cesarean hysterectomy was proceeded immediately after the birth of the baby. The lower uterine segment was noted to be relatively thin but was covered by a plexus of deep vessels which spread over the bladder near the broad ligament which was covered by peritoneum. The bladder was opened and repaired due to continuous bleeding as the placenta extended to the bladder. Left-sided salpingo-oophorectomy was also performed due to constant bleeding from the left tubo-ovarian ligament. The estimated blood loss was approximately 3500 mL during the procedure. Afterward, three units of whole blood

[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 share the case of a 34-year-old gentleman, office executive in a tertiary care hospital, who presented with weakness of all four limbs of acute onset over a few hours duration. He gave history of low grade fever, dry cough, myalgia, chest tightness and sore throat for 2 days prior to the onset of weakness. His past history was remarkable for acute episodes of muscle weakness dating back from 17 years of age, the last occurrence five years back. His mother also had similar complaints. He admitted inhalation of salbutamol via metered dose inhaler (2 puffs on four occasions) on the previous day at the advice of a general practitioner for chest tightness. Evaluation revealed a comfortable gentleman with respiratory rate of 20/minute and peripheral blood O2 saturation of 97% on room air. Auscultation of chest revealed fine crackles at both lung bases. Neurological examination identified grade 2-3 power of multiple muscle groups of all four limbs with hyporeflexia. Cranial nerve examination was normal and no signs of meningeal irritation were elicited. Considering the present pandemic situation, nasal and throat swab was sent for COVID-19 RT-PCR which returned positive. He was admitted in isolation room and symptomatic medications were started. His blood counts, renal and liver functions, serum electrolytes and thyroid functions were requested. Chest radiograph revealed a few peripheral infiltrates in lower zones []. Serum potassium levels returned as 1.9 meq/l. A possibility of hypokalemic periodic paralysis was entertained considering the low serum potassium levels, episodic paralysis and family history. Potassium supplementation was done via oral and intravenous route. Neurology opinion was taken and alternate differentials like CVA, spinal cord lesions, thyroid disease and myopathies were ruled out with appropriate tests. His muscle strength rapidly improved to grade 5 power in next 6-8 hours with return of potassium level to 4.1 meq/l. The rapid return of potassiu

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


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

[User]
RADIOLOGY NOTE:
A 66-year-old man presented acutely to hospital with a week's history of abdominal pain, ‘coffee ground’ vomiting and progressively worsening malaise with signs of dehydration. His symptoms commenced with a sudden onset of severe abdominal pain followed by the inability to pass urine. There was no history of abdominal trauma. He was a smoker with a previous history of alcoholism, however, had been abstinent now for several years. He had no Urological history.
On examination, he was significantly dehydrated with a moderately distended generally tender abdomen with a moderate degree of peritonism. No other specific signs were elicited.
The patient was resuscitated with crystalloid fluid and bloods were sent for analysis. Noted abnormalities of his blood results included a C-reactive protein of 107, a creatinine of 812 mmol/l and potassium of 5.9 mmol/l. Amylase and hemoglobin were within normal range.
A non-contrast CT (NCCT) scan was arranged in view of the patient's significant renal impairment; images revealed a moderate amount of ascites, a thickened but collapsed bladder, and a small cirrhotic liver with no evidence of hydronephrosis or pneumoperitoneum []. He was admitted under the general medical team for further investigations including upper gastrointestinal endoscopy which demonstrated signs of esophagitis, gastritis and a chronic duodenal ulcer in the first part of the duodenum.
His serum creatinine normalized over the course of a few days and a subsequent ultrasound scan that had been arranged to exclude portal venous hypertension, appeared to show that the ascites had resolved. A week after admission, the patient failed his trial without catheter, with a painful 200 mls clear urine residual on re-catheterization and a subsequent rise in creatinine to 200 mmol/l. On direct questioning, the patient admitted that he had suffered from urinary frequency and nocturia with progressively poor flow for the last year. Digital rectal examination revealed an enlarged

[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 presented to the emergency department (ED) complaining of progressively worsening swelling over the angle of his left jaw associated with difficulty speaking, described as hoarseness and pain with phonation, as well as difficulty swallowing. It began spontaneously one day previously, right after he felt a snap or pop. There were no triggering incidents, although he was unclear if he was talking or swallowing at the time. It was associated with a non-radiating, moderate intensity pain, just below the angle of the mandible on his left side that increased in severity when he moved his jaw to speak, turn, or swallow. Over the course of 12 hours he developed worsening anterior cervical neck swelling and progressive odynophagia, dysphagia, and hoarseness. His medical history was significant for hypertension and left-sided Bell’s palsy since 2014, which was associated with ipsilateral tinnitus.
On examination, he was hypertensive with a blood pressure of 187/105 millimeters of mercury, heart rate 91 beats per minute, temperature 98.4° Fahrenheit, and oxygen saturation 100% on room air. The patient’s physical exam was unremarkable with the exception of palpable and visible swelling to the soft tissues below the left side of the mandible and clear discomfort on swallowing. Concern for a vascular abnormality such as aneurysm or thrombosis prompted immediate CT of the neck with IV contrast. This imaging revealed a fracture though an elongated, calcified left styloid process () with hematoma formation causing mass effect on the left lateral hypopharyngeal wall ().
The patient was preliminarily diagnosed with a spontaneous fracture of an elongated calcified styloid ligament with hematoma formation and was admitted to observation with otolaryngology (ENT) consultation for airway monitoring and the potential for surgical intervention if worsening airway impingement. He did well with no further progression of symptoms and was discharged after 24 hours. At follow-u

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


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

[User]
RADIOLOGY NOTE:
A 58-year-old woman without significant medical history visited an outpatient clinic because of radicular compression at L4 level due to scoliosis. The patient underwent posterior pedicle screw fixation with Universal Spinal System (USS) Synthes, which provided segmental stabilization and decompression from D12 to L5. In the first postoperative day, the patient developed mild dyspnea, which prompted the attending clinician to perform an anteroposterior chest radiograph (Figure ). The radiograph revealed bilateral pleural effusion, which was more pronounced on the left side. At the same time, the blood sampling revealed a decrease in hemoglobin levels. Thus, we decided to insert a chest tube to drain blood. In the second PO day, after the blood volume stabilized, the patient underwent a contrast-enhanced CT scan of the chest and abdomen. The CT scan revealed the resolution of the hemothorax (Figure ) and showed the presence of tissue in the thorax with a radiological density similar to that of fat tissue. This finding was associated with the displacement of one pedicle screw that breached the anterior limit of the vertebral body, thereby penetrating into the peritoneal cavity (Figure ). There was no evidence of other thoracoabdominal lesions.
Diaphragmatic injury and subsequent herniation of the omentum into the thorax were discussed with the general surgeon, neurosurgeon, and anesthetist, and we decided to perform double-access surgery to both remove the pedicle screw in the prone position and to confirm and repair the diaphragmatic injury in the supine position.
In the third PO day, after the pedicle screw was removed, we performed explorative laparoscopy with three trocars. We observed a partial axial torsion of the gastric fundus and herniation of the omentum. We checked for the absence of visceral and parenchymal injuries and found a diaphragmatic tear near the left aortic pillar. Then, we reduced the omentum into the abdomen. Primary suture was not a suitable t

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