[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 61-year-old man was admitted to the department of the gastroenterology with complaints of odynophagia and dysphagia to solid foods for one month. He experienced worsening of dysphagia and he also reported otalgia for the last two days. His oral intake had decreased and he had preferred to consume liquids. As a result, he had lost 10 kg in a month. Fifteen days before the admission, the patient was assessed by several ENT outpatient clinics and was treated for pharyngitis with two different antibiotics. He had no history of smoking, alcohol consumption, or any other systemic diseases. During the questioning of the patient, he pointed out his neck region as the site of obstruction. On physical examination, he was afebrile with normal vital signs. However, the palpation of the neck was painful. The white blood cell count was 6,940/mm³, C-reactive protein was 51 mg/L, and erythrocyte sedimentation rate was 64 mm/hour. The standard barium swallow study was normal. The upper gastrointestinal endoscopy revealed normal findings except for erosive bulbitis. The etiology of dysphagia had not been identified by these tests and a computed tomography (CT) scan of the neck was performed. The CT scan demonstrated a 4 × 2.5 cm sized cystic lesion with minimal irregular border at the base of the tongue (). The patient was referred to the ENT department. On his ENT examination, there was a slight swelling at the base of the tongue. The larynx and the tonsils were normal. There were no signs of airway obstruction. The abscess at the base of the tongue was drained through the oral route by needle aspiration for five consecutive days. On the first day, a 15 cc purulent material was drained and the aspirated material was cultured. Coagulase-negative staphylococci were isolated from the culture media and the empirical treatment with ceftriaxone based on the antibiogram results was not changed. The patient was ordered to complete a 7- to 10-day

[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 second case was a 10-year-old girl who presented with abdominal pain and a weight loss of 2 kg over three months. Laboratory tests performed demonstrated persistently elevated CRP (22 and 24 mg/L), a fecal calprotectin of >300 µg/g. An abdominal ultrasound noted thickening of the terminal ileum with enlarged lymph nodes. A gastroscopy demonstrated thickened gastric folds with evidence for chronic inflammation in biopsies, but no ulcers; Helicobacter pylori was not present. A colonoscopy revealed aphthous ulcers in the transverse colon with linear and aphthous ulcers in the ascending colon, while the terminal ileum was reported as normal. Biopsies demonstrated chronic inflammation consistent with Crohn’s disease. An MRE demonstrated thickening and enhancement of the bowel wall in the distal ileum. Her pediatric Crohn’s disease activity index (PCDAI, remission defined as <10) upon presentation to our clinic was 30, consistent with moderately active disease. She refused medical therapy and was started on the CDED with PEN. After six weeks she was in clinical remission with normal CRP and had regained 1.3 kg. She performed the second phase of the induction diet and then the phase 3 maintenance diet. During the subsequent 12 months remained in clinical remission with normal CRP and fecal calprotectin. An MRE and colonoscopy were repeated between 12–15 months, both were completely normal at this time. She remained in sustained deep remission for three years, maintaining the diet with some difficulty as she struggled with adherence at times. During the ensuing summer she travelled abroad several times and did not adhere to the diet. Though she felt well her calprotectin increased from 16 to 300 µg/g. She regressed to the phase 1 induction diet for four weeks and then returned to the maintenance diet. Her calprotectin normalized and a subsequent ileocolonoscopy was completely normal.
Dr. Arie Levine: These two cases serve as examples of how dietary therapy with the CDED

[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 4-month-old male infant, after an uncomplicated pregnancy and delivery, weighed 3000 g at birth; there were no complications during pregnancy and no family history. The infant had symptoms of mild respiratory distress for 2 months, without fever or cough. He was diagnosed with patent foramen ovale by echocardiography at the primary hospital and received no treatments. Later, the symptoms were aggravated, and his parents sought care, again at the primary hospital, 9 days later. Ultrasonography of the abdomen showed features suggestive of hemangioendothelioma of liver. The hospital suggested that to the infant should be transferred to our hospital for treatment.
Examination revealed an irritable infant with cough, fever, breathlessness and cyanosis; the infant weighed 6.8 kg and was in respiratory distress with a relative ratio of approximately 130/min. The infant had multiple skin hemangiomas of varying sizes on the head, neck, right index finger, and right shank. His physical examination was remarkable for bilateral wheezy phlegm in both lung bases. The physical examination showed enlarged cardiac dullness, but there were no significant heart murmurs. Abdominal distention was noted. The liver was soft and located 8 cm below the costal margin at the right mid-clavicular line.
Echocardiography showed right atrial and right ventricular dilatation with a thickened right ventricular anterior wall and interventricular septum. The normal structure of the cardiac chamber and continuous atrioventricular septum were observed. The infant was diagnosed as having severe pulmonary artery hypertension with mild tricuspid regurgitation and trivial mitral regurgitation. Ultrasonography of the abdomen showed densely hypodense lesions, increased volume of liver lobes, with a clear boundary and a maximum diameter of 4.1 cm. The liver lobes had a heterogeneous internal echo and enhanced peripheral echo. Visible blood vessels were observed in the hypodense lesions. There were only a fe

[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 an 11-year-old male with a past medical history positive for psoriasis that presented in December 2016 with a complaint of an enlarged lymph node on the right side of the neck of approximately 3 months’ duration. He was born in Vietnam, but adopted at a young age and raised in Michigan. Therefore, family history could not accurately be obtained. There was no history of any precipitating viral upper respiratory infection or any other inciting events. Over 3 months, there were no changes or fluctuation in size of the enlarged lymph node. There was no history of dysphagia, odynophagia, dysphonia, or otalgia. There was no history of weight loss or night sweats. In addition, there was no history of fever.
The patient had previously been evaluated by a primary care physician who trialed a course of antibiotics without any improvement or resolution of the neck mass. In addition, an ultrasound of the neck was obtained which demonstrated multiple large right-sided neck lymph nodes, with the largest measuring 2.7 cm. Multiple lymph nodes in the left neck, which measured approximately 1 cm, were noted as well. Epstein-Barr Virus (EBV) serology was also performed. Epstein-Barr Virus Capsid IgG was positive, EBV Capsid IgM was negative, EBV Early Antigen AB was positive, and EB Early Antigen AB was positive. These results indicated the patient was likely exposed to an EBV infection in the past, with no active or recent infection. A Monospot test was also completed and negative.
On clinical examination, the patient’s neck demonstrated palpable right-sided cervical lymphadenopathy, with a prominent 2-cm lymph node in level 5. It did not appear infectious, as there was no evidence of erythema, edema, or warmth. Other than this palpable lesion, the remainder of his otolaryngologic examination was unremarkable and the patient remained completely asymptomatic. No other infectious serology or workup was pursued.
Given

[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:
Patient 10 (Tables and ), a 76-year-old female, was referred to the department of neurology in July 2012 because of progressing cognitive decline over the last 12 months, loss of weight, nausea, gait disturbance and tremor. She was seen on May 2011 for the first time by a neurologist with a 3-month history of dull holocephalic headache who ordered a cranial magnetic resonance imaging (MRI) and diagnosed a tension-type headache and a depressive disorder. Treatment with an antidepressant (duloxetine) was started. The patient experienced no improvement and a second examination by another neurologist was undertaken 2 months later. Again no focal neurological signs could be detected. Due to the weight loss, an occult neoplasm was suspected but not detected during an extensive inpatient investigation at a medical department during February 2012; however, the MRI showed bilateral white matter lesions (WML) and an old lacunar lesion located at the left striatum, the latter was not seen in the previous MRI from May 2011. Since the patient also suffered from mild hypertension, vascular encephalopathy was thought to be the cause of the progressive cognitive decline. Extensive neurocognitive testing was carried out in a rehabilitation centre in May 2012 and disclosed a severe decline of attention, memory and executive functions corresponding to subcortical dementia (Fig. ). When the patient was seen for a further diagnostic work-up at the SMZ-Ost-Donauspital in July 2012, the weight was 47 kg and a weight loss of 20 kg was reported over the past year. The gait was insecure with postural instability and with a tendency to fall when turning around. Frontal signs were positive, the voice was quiet, the tonus was mildly elevated and showed a slight hesitancy (“Gegenhalten”), tendon reflexes were brisk, paresis and pyramidal signs missing. There were no signs of ataxia, but a mild bradykinesia. Action tremor was more distinct than a mild resting tremor.

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


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

[User]
RADIOLOGY NOTE:
Our case was a 53-year-old man who received a deceased donor kidney transplant 16 years ago, which was presumably due to hypertension. He presented with redness, pain and swelling of his left arm. He reported no trauma but was trimming shrubs and plants one week earlier. He also complained of intermittent fever and chills. There was no significant animal contact or recent travels. He took cyclosporine and mycophenolate for immunosuppression but had no recent use of corticosteroids.
Evaluation showed a temperature of 100.3 °F, heart rate of 99 beats/min, respiration of 20 cycles/min and blood pressure of 109/71 mmHg. Skin examination showed erythema, tenderness and swelling on the medial aspect of his left arm and forearm in a linear fashion (). There was also a wound on his left forearm, which was located distal to the sporotrichoid lesion, which he thought might have been due to an insect bite or an injury related to his recent gardening (). There was an old unused dialysis graft on the forearm, which appeared to be unaffected. There were no significant lymph node enlargement and the examination of the other systems was completely unremarkable.
Ultrasound imaging of the left arm showed hypoechoic, tubular type structures (the largest measuring 8 × 5 mm) in the subcutaneous fat, which is consistent with an abscess. Two views of the chest radiograph was normal.
The patient underwent incision and drainage of a long abscess tract, which measured approximately 35 cm. Frank purulent drainage was expressed from the tract and was sent for bacterial, fungal and mycobacterial cultures. In the meantime, the patient was started on empirical intravenous piperacillin/tazobactam and vancomycin while awaiting culture results. Sporotrichosis was considered as a strong differential but antifungal therapy was deferred until the culture results became available.
Significant laboratory findings include a white blood cell count of 12.2 × 109/L, blood urea nitrogen of 56 mg/

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


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

[User]
RADIOLOGY NOTE:
A16-year-old boy sustained injury to left knee while playing. He had severe pain and swelling in the knee. He was not able to bear weight on affected limb. X-rays revealed displaced tibial spine fracture [, ]. He was treated in cast by orthopedic surgeon. Patient was not comfortable in the cast and came to us. It was a displaced fracture. We did MRI to rule out other injuries []. Patient was treated arthroscopically under spinal anesthesia in supine position.
Anterolateral and anteromedial portals were used. Both the portals should be standard or slightly low as higher portal may put the scope above the fractured fragment and one may not be able to see the fracture clearly. Fractured fragment was clearly defined with the help of a shaver. It also involved significant portion of medial tibial platue [, ]. Fracture was reduced with the help of ACL zig and under C- Arm guidance, provisionally fixed with guide wire from superolateral portal taking care not to cross physis. As it was a large fragment, it did not sit completely from medial side so another wire was used from superomedial portal to fix medial side of fragment perpendicular to lateral wire, again without crossing the physis. Two 3.5 mm partially threaded cannulated screws (Zimmer) were directly used; 45mm from lateral side and 35mm from medial side []. Stability of the fragment was assessed with a probe and was found to be very stable []. Post-operatively, patient was given a knee brace []. Post-op X-rays showed proper position of both screws [, ]. He was allowed to walk full weight bearing with the knee brace and with support. Knee ROM from 0-90 was allowed for 2 weeks then 0-120 for next 2 weeks. After one month, he was allowed to walk without knee brace. At 6 months, patients was allowed to run. Now we have 8 months follow-up.

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


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

[User]
RADIOLOGY NOTE:
A 71-year-old woman with performance status 2 had right chest and left lumbar pain and was referred to our hospital for treatment. The computed tomography (CT) findings in the previous hospital showed some recurrent masses and metastatic tumors: 144 × 137 × 120 mm3 mass in the left abdomen to the pelvic cavity, a 50 × 43 mm2 mass on the right pelvic wall, a 52 × 47 mm2 mass on the ascending colon, and small metastatic masses on the diaphragm and bilateral lungs (). Serum carbohydrate antigen (CA)19-9 and CA125 levels were 3128 and 96.1 ng/mL, respectively. She had a previous history of 4 years’ treatment with paclitaxel and carboplatin, docetaxel and carboplatin, doxorubicin and cisplatin, medroxyprogesterone acetate, and paclitaxel-alone chemotherapies, as well as immunotherapy for the present recurrent tumors found 5 years after standard surgery for endometrioid adenocarcinoma G1 (Stage IB). Although she and her husband were informed by the former doctor and by us that palliative care would be appropriate, they desired another anti-cancer therapy. They were therefore told about daily oral administration of half-dose etoposide (25 mg/day) that had been reported in the 1990s in Japan. They provided written, informed consent to its administration, and the therapy was then started. Treatment for 4 months reduced serum tumor marker levels and relieved her pain; however, the therapy was discontinued at the end of the fourth month at her request because of mild to moderate stomachache, and serum tumor marker levels increased again. Therefore, the same treatment was quickly restarted. Serum CA19-9 and CA125 levels decreased dramatically to around 110 ng/mL and the normal range, respectively (), and CT showed shrinkage of the recurrent tumors (). She became cheerful with a good appetite and bowel habit, with slight lumbar pain. However, the tumor marker levels gradually increased in the 22nd month of treatment, and she again complained of lumbar pain

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


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

[User]
RADIOLOGY NOTE:
A 60-year-old female with osteoarthritis of the right knee underwent Mako/Stryker robotic-assisted total knee arthroplasty. The patient's past medical history consisted of hypertension. No medical conditions predisposing the patient to a fracture were noted. A midvastus approach was used, and trackers were placed with unicortically inserted pins in the tibial shaft and femoral shaft for the robotic tracking system. The operation was performed without complication, and the tracking pins were removed manually at the conclusion of the case. Postoperative radiology reports noted proper positioning of prosthesis with no acute fracture.
Physical therapy was begun on postoperative day 1 with partial weight bearing with a front wheel walker with PT assistance and was able to walk the entire hospital corridor two times. Patient was discharged on postoperative day 2 with outpatient physical therapy arrangements. Patient had a satisfactory postoperative course.
The patient had an uncomplicated recovery until 6 weeks postoperatively when she was at work and sustained a ground level fall due to acute pain of the right thigh and her leg “giving out.” Patient was unable to bear weight on the extremity. She presented to the emergency department where she was found to have a complete, oblique fracture through the midshaft of the right femur (). On radiography, the femoral tracking pin site is clearly visible at the location of the fracture in the distal segment (). The patient was taken to the OR and underwent intramedullary nailing of the right femur with retention of right knee prosthesis hardware (). CT scan of right lower extremity confirmed evidence of a fracture through the prior surgery pin tracks. Following intramedullary nail placement, the patient had a normal postoperative course. Final films at 6 months showed a healed fracture with stable orthopedic hardware (). At this time, the patient was pain free, ambulating without issue, and elected to proceed with an as needed f

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


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

[User]
RADIOLOGY NOTE:
A 51 year old man presented to the ED for the third time in 2 weeks with complaints of flank pain and hematuria. He had complained of left sided flank pain during the initial 2 visits. During the first visit, the patient was diagnosed to have renal colic. X-ray KUB did not show any renal stone. He was treated symptomatically with analgesia and discharged. During the second visit with complaints of persistent left flank pain despite taking analgesia given at discharge, he was admitted to the emergency observation ward for pain management. Bedside ultrasound done then was noted to have mild left sided hydronephrosis. He was pain free at the end of the observation and was then discharged with analgesia and an outpatient follow-up with the urology department. He was also scheduled to have an outpatient computed tomography scan of the kidneys, ureters, and bladder (CT KUB). However, 2 days before the scheduled CT, he represented to the ED with right sided flank pain since morning on the day of his visit. The pain radiated to the right groin and was associated with hematuria. He was not passing blood clots. He denied any other complaints of fever, weight loss, vomiting, diarrhea, or constipation. He had a past medical history of hypertension, diabetes mellitus, and hyperlipidemia. He had previous surgeries for appendicectomy and cholecystectomy.
His vital signs were stable. There was tenderness over the right flank on physical examination. There was also a palpable tender mass measuring about 5x5cm over the right lumbar region. There was no renal angel tenderness. Bedside ultrasound in the ED showed an appearance of a 6 cm cystic lesion around the inferior pole of the right kidney with internal echogenicity within the cyst. The provisional diagnosis was a bleeding renal cyst versus a tumor. Blood tests done in the ED showed a mildly elevated white cell count 12.64 × 10(9), hemoglobin of 14 gm/dL, and creatinine of 109 Umol/L.

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


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

[User]
RADIOLOGY NOTE:
A 53-year-old man was admitted to the local hospital with left upper abdominal pain lasting 2 weeks. A gastroscopy showed a bulging gastric lesion in the antrum. However, the pathology was benign. The patient did not receive any treatment, and still had abdominal pain. Then, he was referred to the Second Affiliated Hospital of Xi’an Jiaotong University. Physical examination revealed no mucocutaneous pigmentation, no palpable masses in the abdomen, but left upper abdominal tenderness. The patient had no family history of polyps or tumors in the gastrointestinal tract. Laboratory tests were normal, and the tumor markers were within normal limits. Abdominal computed tomography revealed that the gastric wall in the antrum was thickened (Fig. ). A gastroscopy showed a giant and extensive bulging gastric lesion located on the greater curvature and posterior and anterior walls of the gastric antrum, involving three-quarters of the gastric wall. The mucosal surface of the lesion was smooth without erosion or ulcer. Magnifying endoscopy with narrow-band imaging showed the almost normal microvascular morphology of the lesion (Fig. ). Endoscopic ultrasonography was performed, showing a low-echo area in the muscularis mucosae and no invasion into the submucosal layer, without enlarged celiac lymph nodes (Fig. ). An endoscopic mucosal resection was performed, and a bigger specimen was sent for histopathological examination to confirm the diagnosis. The final pathology report indicated a hamartomatous polyp (Fig. ). After excluding PJS, a solitary Peutz–Jeghers-type hamartomatous polyp was diagnosed. Then, the patient underwent an ESD. The resected specimen was measured in 110 × 80 × 4 mm3 (Fig. ). We treated patients with acid suppression. The patient recovered quickly, without any complications. A gastroscopy on the fourth day after endoscopic surgery showed a large postoperative artificial ulcer (Fig. ). A gastroscopy on the 40th day after endoscopic surgery showed a narrow lu

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


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

[User]
RADIOLOGY NOTE:
Our 23-year-old female patient with no significant past medical history presented to the hospital complaining of acute shortness of breath, abdominal pain, and severe left lower extremity pain. The patient was in her usual state of health until the evening of her symptoms, when she suddenly turned in her bed and began to experience numbness, tingling, and purplish discoloration of her left lower extremity. On arrival to the emergency department, the patient was in respiratory distress and had bilateral swelling of her lower extremities, the left side larger than the right. A bilateral lower extremity duplex ultrasound revealed a deep vein thrombosis (DVT) in the left lower extremity, the popliteal, and the femoral veins. In addition a CT of the chest utilizing our pulmonary embolism protocol delineated two pulmonary emboli in the first order pulmonary arteries and multiple segmental emboli located in the right upper and right lower lobes. She was subsequently started on a heparin drip.
The patient denied any tobacco use, recent immobilization, or travel. She reported the use of an estrogen vaginal delivery device (ethinyl estradiol vaginal ring) for the previous 6 months. Her hypercoagulable workup was revealing for heterozygosity at C677T for factor V Leiden. It should be noted that heterozygous carriers of FVL have been shown to have an overall 3- to 7-fold increased risk of venous thrombosis, while homozygotes to C677T have a 50- to 100-fold increased risk. []
Due to the acute presentation of her venous thromboembolism, a left pelvic and lower extremity venous thrombectomy was performed. This was followed by stenting of a popliteal venous occlusion, and subsequent thrombolysis with tissue plasminogen activator. Surprisingly, a left lower extremity venogram revealed bilateral inferior vena cavas.
In our patient, the left-sided duplicated IVC and iliac veins were found to be thrombosed. This was marked by the stippled appearance of the duplicated left IVC vessel se

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


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

[User]
RADIOLOGY NOTE:
A 47-year-old female with background history of heavy consumption of alcohol at younger age initially presented to us with an acute back pain at the lower thoracic and upper lumbar spines, which was associated with an acute onset of paraparesis with Medical Research Council (MRC) power of 1, paraesthesia and discomfort at voiding following a traumatic event during travelling on a speed boat to an island at a time of heavy waves season. The urgent magnetic resonance imaging (MRI) of the thoracolumbar spine disclosed an abnormal sizeable mixed hypo- and hyperintensed lesions on T1 and T2 [Figure –] at multiple spinal levels. Eccentrically, the lesions did not seem to cause compressive effect onto the spinal cord. The conservative management was opted after noting the harmless looking lesions on the MRI. Two weeks of regular analgesia and physiotherapy in neurointensive care were given, but the lower limbs weakness recovered partially to grade 3 with more intense pain at the back. She remained bed bound and was unable to urinate and therefore was catheterized. At the same time she started to complain of right subcostal and lower pelvic pain, which were tender; further investigation revealed two cystic lesions in the liver and her ovaries. Our initial provisional diagnosis was either a traumatic or vascular malformation-induced spinal hematoma, or spinal metastases. Nonetheless, history did not favor the second provisional diagnosis. Since the recovery was partial and the diagnosis was doubtful, we decided to proceed with laminectomy at lesional site of T9-T11.
Laminectomy was completed from T9 to T11 and the intraoperative finding is shown in . The histopathological diagnosis was arachnoiditis. The surgery was uneventful and she was discharged home with regular follow-ups. One month after the spinal surgery, the abdominal and pelvic pain became more frequent and tenderness was noted mainly at pelvic area. She was operated endoscopically by the gynecologist and biopsy w

[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 Japanese man was admitted to our hospital. He had sustained a right femoral neck fracture at the age of 19 years. At that time, he underwent osteosynthesis for the femoral neck fracture. The details of his operation were unclear, but he had developed an infection of the operative wound. There was no record of bacteriological examination performed at that time. One year later, when the patient was 20 years of age, the infection had resolved, and he underwent hemiarthroplasty of the hip joint with a bipolar cup. There was no record of that operation or the amount of damage to the acetabular cartilage. He had no particular problems following the procedure and was still able to surf as a hobby. He noticed a leg-length discrepancy, but he did not seek medical attention because there was no pain.Twenty years later, at age forty, the patient was injured while surfing. He felt a strong pain in the right femoral region and had difficulty walking. He was transported by ambulance to a nearby hospital. The diagnosis was Vancouver type B2 peri-prosthetic fracture of the femur. However, because the prosthesis had migrated, there was a massive bone defect of the acetabular roof on the pelvic side (Figure
) that had resulted in the leg-length discrepancy.The plan was to treat only the peri-prosthetic fracture because the hospital had no bone bank. The implant was removed using a posterolateral approach and an extended trochanteric osteotomy. He underwent a new hemiarthroplasty of the hip joint with a modular neck and long stem. He also underwent osteosynthesis of the femur using a plate and hook for trochanteric fixation (Figure
). The femoral shaft fracture achieved bone union, and his walking ability recovered to his previous level.He was later admitted to our hospital for reconstruction of the acetabular roof. He did not complain of coxalgia; however, his physical examination showed that the leg-length discrepancy was approximately

[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:
Case 1. A 14-year-old female patient was admitted to our emergency department with the complaints of hip pain and the inability to walk, which occurred after a minor fall, based on the patient history. There was no previous fracture in her medical history. However, family history of the patient showed a similar bone disease. Physical examination revealed pain with palpation as well as loss of hip range of motion. Ocular and neurological examination demonstrated bilateral loss of vision. Other systemic examinations showed normal vital findings. Laboratory test results were within normal limits, except mild anemia. Plain X-ray showed a mildly displaced fracture of the right femoral neck with a dense sclerotic line. Based on the patient history, physical examination findings, and laboratory and imaging test results, along with consultation remarks, the patient was diagnosed with osteopetrosis tarda and osteopetrotic femoral proximal fracture. Following closed reduction, a lateral straight mini-incision was performed under fluoroscopic visualization. Drilling was highly difficult and time-consuming, and one of the drill tips was bent. However, osteosynthesis was performed using two 4.5 mm spongious screws without any other complications. Fluoroscopic assessment revealed an adequate reduction and fixation. Based on the intraoperative examination, the range of motion of the hip was within normal limits. Bone specimens which were obtained by drilling and the intraoperative biopsy were sent for pathological examination. No perioperative complications were observed. In the postoperative period, there was no scar-related complication, either. The patient was referred to the rehabilitation program on the third postoperative day and sutures were removed at 12 days. She was mobilized without loading on the healing fracture, using a crutch at two weeks and with partial loading at six weeks. The histopathological examination confirmed the diagnosis of osteopetrosis. No complicatio

[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 six year old girl presented to the Orthopaedic department with a five day history of right hip pain, fevers and difficulty weight bearing. There was no history of trauma or any recent illness. The patient was of Somail origin but there was no recent history of travel or infectious contacts and no significant past medical history.
On examination she had a temperature of 39.5 degrees Celsius and the right hip was held in flexion, with localised anterior joint line tenderness. Both passive and active movements of her hip were painful and restricted. Examination of her left hip, knees and ankles was normal. Examination of her abdomen revealed mild tenderness in the right iliac fossa.
Blood tests showed a neutrophilia with left shift and a raised C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR). Sickle cell screen was negative and initial pelvic x-rays were normal. She was diagnosed with hip septic arthritis and an open washout of the hip joint was performed. Two millilitres of blood stained fluid was aspirated and the patient was commenced on intravenous (IV) antibiotics. The following day the patient remained pyrexial and the CRP and ESR continued to be raised. A second open washout of the right hip was performed but no pus or fluid was aspirated.
Blood and joint fluid cultures were subsequently positive for staphylococcus aureus. A magnetic resonance imaging (MRI) scan of the right hip was performed which showed collections of the right iliacus and distal iliopsoas, with abnormal marrow signal in the right iliac wing consistent with osteomyelitis ().
The patient was diagnosed with iliac osteomyelitis and transferred to Manchester Children’s Hospital were she underwent exploration of the right iliopsoas abscess. This revealed a large collection of pus and some necrotic muscle, which was thoroughly washed out and debrided.
She gradually made a recovery and was eventually discharged home after a total of 30 days. Oral antibiotics were

[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 68-year-old male with a past medical history of a neuroendocrine tumor (NET) of the left femur presented with progressive dyspnea, orthopnea, and lower extremity edema. Three years ago, the patient was found to have a mass on the left femur. Biopsy revealed poorly differentiated neuroendocrine carcinoma of unknown primary. He had undergone surgical resection of the left femoral tumor and above-knee amputation with adjuvant chemotherapy (cisplatin and etoposide) and radiation therapy. Routine surveillance imaging showed no evidence of malignancy. Chest computed tomographic (CT) and magnetic resonance imaging of the abdomen/pelvis with contrast were performed at three-month intervals for the first year followed by six-month intervals. The patient was in clinical remission for the last two years.
On physical exam, his blood pressure was 119/76 mmHg, heart rate was 104 beats per minute, respiratory rate was 22 breaths per minute, and jugular venous pressure was elevated. Grade III/VI systolic ejection murmur was present at the left sternal border and rales at the lung bases. Chest X-ray revealed cardiomegaly and bilateral pleural effusions. A transthoracic echocardiogram revealed a large mass measuring 8.10 X 6.54 cm within the right ventricle causing right ventricular outflow obstruction, and the left ventricular ejection fraction was 60-65% (Figure ). Cardiac magnetic resonance imaging confirmed the mass extending from the right ventricular free wall with compression of the left ventricle and dilated right atrium (Figure ). A positron emission tomographic/computed tomographic scan showed increased standardized uptake value activity of 9.3 in the right ventricular mass (Figure ). Cardiac biopsy of the right ventricular mass was consistent with metastatic neuroendocrine tumor (Figure ). The tumor cells were negative for synaptophysin and chromogranin A but positive for CDX2, a marker for neuroendocrine tumor of unknown primary []. In view of the tumor that caused impa

[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 37-year-old female visited with a complaint of gradually decreased visual acuity. At the first ophthalmological examination, the corrected best visual acuities in the right eye and the left eye were 1.0 and 0.4 respectively. Slit lamp examination revealed that there was no specific finding in the anterior segment, and the funduscopic finding of both eyes showed that cotton wool spots, macular edema and vascular tortuosity were present around the optic disc in the left eye (), but the right eyes was unremarkable except the suspected cotton wool spots near superotemporal arcade (). Fluorescein angiography revealed microaneurysms and macular edema in the left eye (), and right eye showed minimal microaneurysms without macular edema (). We found that the thickness of macula was increased when measured by optical coherent tomography (). Past medical history included modified radical mastectomy for right breast cancer 5 years ago. She had no medical history of diabetes, hypertension and systemic vascular disease and no evidence of abnormalities in laboratory finding.
One year before this visit, she was confirmed to have metastatic tumor on her right frontal lobe shown on MRI () which was taken after a sudden convulsion. And she had received radiation therapy of fractionated external irradiation to the whole brain (3,000 cGy/10fraction) for 2 weeks and local boost irradiation (1,200 cGy) After that, she was transferred to another hospital for gamma knife surgery on that lesion. Total dose of gamma knife surgery on the tumor bed was 40 Gy and the amount of irradiation for each eye was 0.2 Gy.
Immediate intravitreal TA injection was performed for macular edema and two weeks later, the visual acuity was improved to 0.6. But the visual acuity was decreased to 0.3 again 3 months later, so we performed intravitreal TA injection again. Three months after the second injection, the fundus examination and optical coherent tomography revealed that retinal thickness was improved and

[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 male presented with left-sided headache after inadvertently colliding with a door and hitting the left side of his face. The patient's past medical history was significant for mechanical mitral valve on anticoagulation, HLA-B27 associated uveitis, and bilateral retinal detachments. Four years ago, he underwent prosthetic replacement of the right eye and silicone oil (SO) endotamponade on the left, however this maneuver was ultimately unsuccessful, and he had no vision in either eye at baseline. Physical exam was notable for an irregular and non-reactive left pupil with no light perception; clean prosthetic within the right orbit; and a small abrasion on the left forehead and nose with minimal ecchymosis. His neurological exam was otherwise unremarkable.
The patient's initial CT head was misinterpreted as favoring intracranial metastasis which led to further work up with MRI head, CT chest, abdomen and pelvis. He was found to have a 13 mm spiculated nodule in the right lower lobe of the lung with low uptake on a positron emission tomography scan that also revealed other nonspecific findings in the gastrointestinal tract.
The patient was admitted to the intensive care unit where his anticoagulation, warfarin with therapeutic level at the time of admission, was held for concern of intracranial hemorrhage. He underwent an esophagogastroduodenoscopy and colonoscopy given the abnormal positron emission tomography scan findings.
He was seen by multiple services. While there were initial plans to obtain a surgical biopsy of his lung nodule, image review with radiology led to a prone CT head which confirmed the mobile debris in the ventricular system was in fact SO. Supine CT head revealed new (compared to a prior imaging two years earlier performed when he was presented to an outside emergency room with dizziness) hyperdense nodules in the anti-dependent portions of the lateral ventricles. MRI head with and without contrast showed the hyperdense lesions in the

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


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

[User]
RADIOLOGY NOTE:
A 61-year-old man presented at our hospital with pain and swelling on the outside of his right foot. Right foot was injured falling into the groove of 50 cm during the work. He did not remember how his foot was twisted. The lateral column of his right foot was shortened by approximately 6.5 mm on X-ray (). A computed tomography (CT) scan showed displacement of the joint surface between the cuboid and the fourth metatarsal, with a 3.5 mm depression observed in the range of the articular surface 3/4 (). There are no other fractures except the cuboid. We took MRI to find other injuries. MRI showed only cuboid fracture. And there were no injuries of other bones and ligaments. There were no tenderness points except the cuboid. Based on these findings, we diagnosed the patient with an isolated nutcracker fracture of the cuboid and planned to perform an open reduction and bone grafting.
A lateral incision was made along the axis from the tip of the fibula to the tip of the fifth metatarsal. Next, we identified the Lisfranc joint using fluoroscopic guidance and made an incision in the joint capsule. Using a 1.9 mm arthroscope, we examined the Lisfranc joint () and noted that the cuboid articular surface between the cuboid and the fourth metatarsal was crushed (). Articular surface of metatarsal was kept with a little fibrillation. The articular capsule was opened widely, and the fracture site was identified using fluoroscopic guidance. A hole was created at the fracture site, and the depressed fragments were elevated using surgical instruments, until the regular joint line was restored. A bone biopsy needle was then used to fill in the large defect with artificial bone (). We used granular type OSferion® produced by OLYMPUS in Japan. We used about 2.0 g in the fracture site (). Finally, the articular capsule was resutured.
The patient's right leg

[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 53-year-old woman presented to our department with signs and symptoms of multinodular goiter (MNG). Bulky hypertrophy of the thyroid gland at the anterior neck was determined by inspection. Larger nodules with regular margins were palpated in both lobes by physical examination. Serum thyroid-stimulating hormone and free thyroxine levels were normal by biochemical analysis. Thyroid ultrasound revealed multiple nodules in both lobes. Bigger nodules were a 50 x 36 x 40 mm hypoechoic solid nodule in the right lobe and a 33 x 25 x 37 mm isoechoic solid nodule in the left lobe. Fine needle aspiration from dominant nodules revealed benign cytology. The diagnosis was MNG. Total thyroidectomy under the guidance of IONM was planned as the surgical treatment. Informed consent was obtained from the patient.
The right thyroid lobe was partially mobilized after ligation of the middle thyroid vein. The carotid sheath was incised, and the right vagus nerve (VN) was located behind the carotid artery and the jugular vein. Direct stimulation of the VN with the stimulator probe at a standard distal point did not create a sound signal. The absence of a distal V1 (d-V1) signal revealed the early proximal separation of the inferior laryngeal nerve and eventual presence of the non-RLN. The carotid sheath incision was extended toward the cephalic direction. The right VN was proximally followed under the guidance of IONM with serial electrophysiological stimulation to identify the separation point of the inferior laryngeal nerve. A positive signal from a proximal point of stimulation (p-V1 = 648 µV) helped us to locate the separation point of the right inferior laryngeal nerve. Stimulation of the inferior nerve when first identified at the separation point posterior to the carotid artery created a positive sound signal and wave amplitude (R1 = 661 µV). Both lower and upper poles of the right lobe were carefully dissected, and the lobe was mobilized medially. The right non-RLN arising

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


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

[User]
RADIOLOGY NOTE:
A 73-year-old Caucasian male with past medical history of Pott's disease as a child, osteoarthritis of the right knee, and a right Baker's cyst presented to the Emergency department with complaints of worsening leg pain for two days and confusion for one day. At presentation, the patient was tachycardic. All other vital signs were within normal limits. His review of systems was remarkable for chronic knee pain for the last two years and right leg pain for the last three months and decreased appetite and weight loss over the course of four months. On physical examination, the patient was in moderate distress. He was alert and oriented to time, place, and person but had poor concentration. On musculoskeletal exam there was a diffuse area of swelling on the right lower extremity which was extremely tender to touch with minimal warmth and erythema. This was located posteromedially involving the calf and medial aspect of the leg. Knee joint was nonswollen, nontender, and without any erythema or warmth (). Laboratory data revealed leucocyte count 14.6 k/cumm, Hemoglobin 10.2 mg/dL, and hematocrit 30.4%. HIV testing was negative. His metabolic panel showed hyponatremia, 124 mEq, but was otherwise unremarkable. Leg MRI was performed. This showed a large heterogeneous fluid collection involving the subcutaneous soft tissues of the posterior medial right lower extremity measuring approximately 21.1 × 7.2 × 8.5 cm with marked mass effect on the gastrocnemius muscle. Heterogeneity of the distal femur including the femoral condyles, tibial plateau, and proximal fibular head was also visualized suggesting possible osteomyelitis as well (). The patient underwent surgical resection of the left Baker's cyst. Intraoperative findings included a thick, boggy synovium with dull and dusky appearing cartilage. Tissue and fluid stain revealed acid fast bacillus (AFB) in one of two samples which was later identified as MTB. On pathologic section, a granulomatous reaction with giant

[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 61-year-old woman with a past medical history of treated stage III ovarian cancer presented with an asymptomatic new solitary left renal mass detected on surveillance imaging. Computed tomography (CT) of the abdomen and pelvis showed a 3.3 cm endophytic mass (RENAL nephrometry score 9P) [] in the upper pole of the left kidney suggestive of a cT1a primary RCC. There was no evidence of other synchronous lesions or metastases. Given the patient's prior history of ovarian cancer, we opted for a CT-guided renal mass biopsy. Under CT guidance, a three-core biopsy was performed using an 18-gauge needle over a coaxial sheath. Pathologic examination of the mass was consistent with RCC.
Given that the patient was asymptomatic and the uneventful nature of the renal mass biopsy, the lesion was not reimaged and we proceeded with transperitoneal RPN. After dissecting the renal hilum and overlying renal fat, a 12 mm laparoscopic drop-in ultrasound probe was used to evaluate the renal mass prior to resection. The mass was well visualized and there was no obvious perinephric hematoma noted. During sharp tumor resection, however, we encountered an intrarenal hematoma that was clearly outside of the tumor margin (). The hematoma had several small areas of pale yellow coloration that appeared to be organizing hematoma. Since this was consistent with recent biopsy, we completely suctioned the hematoma and performed a wide margin resection to completely remove the tumor and hematoma. The tumor pseudocapsule was not violated during the resection. The specimen was extracted via an EndoCatch bag, and was grossly confirmed to be an intact specimen on the back table. Final pathology confirmed a 4.5 cm Fuhrman Grade 3 Papillary RCC with negative margins and an adjacent organizing hematoma.
Five months after the initial surgery, surveillance CT revealed a new 2.4 cm left renal mass, enlarged para-aortic lymph nodes, and several nodules present in the oment

[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 male patient aged 60 years was hospitalized due to sudden dizziness for 3 h combined with slurred speech on May, 16, 2017. The patient had nausea, but he did not have vomiting, incontinence and unconsciousness. The patient was immediately referred to China-Japan Union Hospital of Jilin University. Head CT performed within 3 h of onset of symptoms (Fig. a) showed hemorrhage in the left temporal lobe, and the patient was admitted in our department with a clinically confirmed diagnosis of ��hemorrhage in the left temporal lobe”. The patient had a previous history of hypertension for more than 10 years, and was under medication to control and maintain the blood pressure to be around 130/80 mmHg. The patient denied the history of diabetes and had no bad habits, such as smoking and drinking alcohol. Physical examination at admission revealed that his body temperature was 36.2 °C and blood pressure was 196/119 mmHg. The patient was conscious and suffered from incomplete aphemia. Bilateral pupils were of the size and round, the diameter of pupils was 3 mm, and pupils were sensitive to light reflexes. Muscular strength of the limbs was about grade 4. Bilateral pathological signs were negative, and there was no significant abnormality noticed during nervous system examination. Head MRI conducted the next day after admission indicated no significant vascular malformations (Fig. b). General consultation evaluated that bleeding sites of the patient were slightly different from hypertensive intracerebral hemorrhage. The hematoma sites were close to the middle cerebral artery and the walking areas of its branches, mainly in the temporal lobes. Therefore, cerebral vascular hemorrhage and other causes could not be excluded, and head CTA was further suggested. Head CTA performed on 17th May 2017 showed that the patient suffered from intracerebral hematoma caused by aneurysm rupture at the M1 bifurcation of the left middle cerebral artery, without any significant subarachnoid hemo

[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 46-year-old male with a history of severe developmental delay, hydrocephalus, and seizure disorder presented to the hospital with blunt head trauma after a ground level fall. Work-up revealed bilateral acute subdural hematomas for which an external ventricular drain was placed. Despite intensive care management, the patient deteriorated to brain death. He was subsequently evaluated for organ donation. Abdominal computerized tomography (CT) scan () revealed an “elongated structure with metallic components in the upper portion of the IVC that extends into the right atrium.” There was no medical history of a prior procedure, or symptoms, to explain the incidental finding. The radiologist's interpretation and presumptive diagnosis were a retained atrial pacing wire.
He subsequently underwent procurement for organ donation after brain death. At the time of cross-clamp, the previously identified foreign body was transected when the right atrium was incised for exsanguination. During the back-table dissection, it was apparent that the foreign body had eroded into the posterior wall of the IVC, extending down the retrohepatic IVC (Figures and ). It also created a calcified reaction at the junction of the suprahepatic IVC and right atrium, adjacent to the left hepatic vein (LHV) and middle hepatic vein (MHV). We removed the foreign body () and performed a venoplasty () of the posterior wall of the IVC and of the common wall of the LHV and MVH, so that the outflow of the LHV and MHV was not compromised after transplant. We discovered that the foreign body was, most likely, a fractured CVC due to the overall appearance and interval markings.
The liver recipient was a 65-year-old woman with cirrhosis due to alcohol abuse; her Na-MELD score was 40 at the time of transplant. She underwent caval-sparing total hepatectomy and deceased donor liver transplantation via piggyback technique: the donor suprahepatic IVC was anastomosed to a common orifice of the recipient's right

[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 14-year-old female patient presented to the emergency department with a sudden onset of left leg pain and oedema. She had a fever of 38 °C once a few days before. Physical evaluation revealed a swollen and painful left leg with reduced range of motion of the left hip and bumps palpated on the right tibia proximal metaphysis. No signs of arthritis, possible intestinal inflammation or skin changes were seen during physical evaluation. The patient’s blood pressure and urinary output were normal. After the emergency ultrasound exam revealed a diagnosis of femoral and pelvic deep vein thrombosis, she was admitted to the hospital. According to her parents, the patient had had no chronic diseases to date. They indicated that she had a foot fracture at the age of 8 years. There were no autoimmune or auto-inflammatory disorders in the patient’s family history.
Initial investigations revealed high levels of inflammatory markers (CRP and ESR), and a severe microcytic anaemia as well as thrombocytosis, hypoalbuminemia and elevated fibrinogen concentration and D-dimer values (Table ). Suspecting an infectious cause, a urinalysis was performed, and haematuria and proteinuria were detected. Both blood and urine cultures were sterile. X-rays of the legs were done (Fig. ), showing sites of hyperostosis and sclerosis in the metaphysis of the right tibia along with a periosteal reaction, suggesting a possible osteomyelitis or oncological processes in the bones. As the diagnosis of acute osteomyelitis could not be disproved, broad-spectrum antibiotics were prescribed. However, the CRP level did not change significantly over the first few days, so other causes of acute thrombosis and inflammation were investigated. An abdominal ultrasound showed a giant, homogenous pelvic mass and hydronephrosis of the left kidney. Kidney function was quite abnormal as the creatinine level was 185 μmol/L and urinary protein excretion of 7 g over 24 h was detected. Within the next few days the patient’

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


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

[User]
RADIOLOGY NOTE:
Our patient is a 47-year-old female who has been diagnosed with undifferentiated mucinous cervical adenocarcinoma a year and a half ago and had hysterectomy with salpingo-oophorectomy along with chemoradiation. She presented to the hospital with complaints of fatigue, nausea and reduced appetite for a week. Her examination revealed icterus and mild right upper quadrant tenderness but no ascites. She had no petechial rash and had no features of encephalopathy. Her initial workup revealed elevated liver enzymes with alanine transaminase (ALT) of 1891, aspartate transaminase (AST) of 600 and alkaline phosphatase (ALP) of 178. She had a total bilirubin level of 2.1 with the direct bilirubin of 1.9. Her electrolyte panel, renal parameters, and hemogram were normal.
At this point, we revisited history to inquire about the possibility of toxin or drug-induced hepatitis and viral hepatitis. She did not mention any recent addition of new medications. There is no recent acetaminophen intake or any other hepatotoxic medication. She does not consume any alcohol nor has she any history suggestive of a risk for viral hepatitis. Further workup included an ultrasound of the liver, viral hepatitis panel, and toxicology screening. Her viral hepatitis panel and the toxicology screening came back negative with normal serum acetaminophen levels. Ultrasound scan of the liver showed slight intrahepatic dilatation but normal common bile duct and no features of cholelithiasis. There was a 2.7-cm mass in the posterior segment of the right hepatic lobe and the same was confirmed in the CT scan (Figure ). Of note, there was hepatopetal blood flow seen during ultrasonography (USG)-Doppler and there were no features of portal vein thrombosis. The positron emission tomography (PET) scan which was done at this time revealed multiple new hypermetabolic metastatic lesions in the liver predominantly in the posterior right hepatic lobe (Figure ). There was increased hypermetabolic activity in the regi

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


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

[User]
RADIOLOGY NOTE:
In March 2015, a 41-year-old woman presented with a sudden headache associated with vomiting of gastric contents in the afternoon and was immediately sent to the hospital. She reported no coma, convulsions of the limbs, or inability to move. Her heart rate was 73 beats/min, blood pressure was 104/65 mm Hg, and her respiratory rate was 23 breaths/min. She was breathing ambient air with satisfactory air oxygen saturation. There were no lesions in the oropharynx, and her neck was supple. The lungs were clear, and her heart rate was regular, without any murmur. Physical and neurological examination at that time revealed no special abnormalities. Her medical history revealed a sulfanilamide allergy but no other diseases.
The emergent CT scan of her brain showed an occupying lesion about 4.9 × 4.3 cm in the left cerebellum accompanied by intracranial vascular bleeding. There was a destruction of occipital bone. The mass was noncalcified and slightly dense with severe peritumoral bleeding and edema (Fig. ). We did not perform MRI because of limited time and objective conditions.
The next day, this patient suddenly fell into a coma. We then performed an operation to excise the lesion, clear the intracranial hematoma, and performed ventricular drainage and tracheotomy. We used a transcortical approach to the left cerebellum. In the operation, we performed a left parietal craniotomy and made a Y-shaped incision in the dura under a microscope. We removed a 3 × 3 × 3 cm cystic lesion with poor dissection margins from the surrounding tissue and sent it for pathologic examination. The tumor was cystic and full of clear, yellow lipid matter, with attachments to the meninges and the occipital bone. The immediate postoperative course was uneventful.
Unfortunately, a postoperative intracranial infection developed, and the patient presented with shivering and hyperpyrexia. The cerebrospinal fluid (CSF) tested positive for a Gram-positive bacterial infection and targeted antibiotic was

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


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

[User]
RADIOLOGY NOTE:
A 59-year-old male patient with chronic alcoholism and hepatitis B virus carrier was diagnosed with alcoholic liver cirrhosis and hepatocellular carcinoma (HCC) two years ago. Then, he received transcatheter arterial chemoembolization therapy three times and has been living without recurrence. The patient visited our emergency department with the symptoms of headache beginning 10 days prior and progressive left hemiparesis, altered mentality occurring two days prior. He was afebrile and his vital signs were stable. There were no leukocytosis and C-reactive protein (CRP) was 4.04 mg/L of blood. Upon a neurological examination, he was drowsy with disorientation and revealed decreased upper and lower extremities motor power to grade IV. DWI of the brain was performed because of suspicion of cerebral infarction. It showed a multi-lobulated cystic mass lesion and associated mild edema located in the right parieto-occipital lobe. We considered the possibility of a metastatic brain tumor at the first impression owing to negative diffusion restriction sign and a history of HCC. Contrast enhanced MRI combined with DWI revealed a multi-lobulated cystic rim-enhancing mass with surrounding edema and hypointensity in the cystic cavity on the DWI (). Stereotactic biopsy with aspiration was performed on the assumption of HCC multiple metastasis in the brain and the result revealed BA involving multiple bacterial colonies. However, because the bacteria was not cultured, an initial antimicrobial therapy was started on the basis of the standard empirical treatment that consists of vancomycin plus a third-generation cephalosporin and metronidazole. Despite the use of the above antimicrobial therapy, clinical deterioration with an increasing abscess size on cranial imaging () made further stereotactic aspiration and cultures including fungus, parasite and tuberculosis mycobacterium. The amount of vancomycin dosage was increased in order to increase the CSF concentration of vancomycin b

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


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

[User]
RADIOLOGY NOTE:
A 69-year-old woman was referred to our institute for further evaluation of a tongue mass. She had a 5-year history of pain involving the right lateral tongue edge, and the lesion had been diagnosed as lichen planus by incisional biopsy performed by her dentist. The disease was stable for a long time; however, the tongue pain suddenly worsened. Physical examination revealed an elastic, hard, 1.2 × 0.7 cm mass of the right tongue (Fig. ). There was no palpable lymphadenopathy in the head and neck area. The patient was being medically treated for hypertension and diabetes mellitus, both of which were well controlled. She denied using tobacco or alcohol but had been exposed to smoke from her family. She had no history of exposure to ionizing radiation or having undergone cancer chemotherapy. Regarding her family history, her younger brother had been treated for rectal cancer and liver metastasis.
Contrast-enhanced CT scans of the head and neck, chest, and liver were performed as a routine procedure in patients with oral cavity cancer. CT showed no lesions in the tongue, cervical lymph nodes, lungs, bone, or liver; however, three masses were detected in both breasts and the right kidney. Whole-body FDG-PET was performed to identify any other lesions; no other lesions were found. An upper gastrointestinal examination, indirect laryngoscopic examination, and bone scintigraphy revealed no abnormalities. The patient had no breast- or kidney-related signs or symptoms before we identified the masses. Fine-needle aspiration cytology was performed to confirm the diagnosis of the bilateral breast masses and revealed malignancy on both sides. Renal cancer was suspected based on the CT findings (Fig. , arrow). All four lesions were diagnosed as early-stage cancers at the initial presentation.
We removed the four tumors over three surgical procedures because the patient had diabetes mellitus. The patient underwent wide local excision of the tongue tumor. Histopathological examinati

[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 32-year-old, previously healthy, African American man presented to an emergency department 45 minutes after the acute onset of left facial droop and right-sided weakness (Fig. ). A thorough history confirmed an episode 1-week prior, during which he developed sudden onset of dizziness associated with nausea and vomiting that resolved within hours. He denied any past medical or surgical history and was taking no medications. He has no family history of tumors. In the emergency room, his vital signs were within normal limits. His physical examination was significant for a left facial droop and right hemiparesis. Auscultation of his chest revealed a regular rate and rhythm with no appreciable murmur. No additional significant findings were noted. Stroke protocol was initiated. A chest X-ray was normal and an electrocardiogram showed normal sinus rhythm. A head computed tomography (CT) scan was negative for signs of intracranial hemorrhage. He was subsequently started on tissue plasminogen activator (tPA) therapy. Magnetic resonance imaging (MRI) of his brain demonstrated a right basal ganglia infarct and an old left cerebral infarct. A carotid ultrasound was negative. TTE demonstrated a 1 cm by 1 cm mass on the posterior leaflet of the mitral valve with a moderate mitral regurgitation In addition, TTE revealed a questionable mass on the left coronary cusp of the aortic valve. These findings were confirmed with TEE (Fig. ), which verified no sign of endocarditis and no atrial septal defect. A complete hypercoagulable workup was negative. Stroke protocol continued with the working diagnosis of cerebrovascular accident secondary to emboli from the mitral valve mass. Within 24 hours, he regained function of the right side of his body and had complete resolution of symptoms. He was diagnosed as having transient ischemic attack (TIA) and discussion was undertaken regarding surgical excision of his mitral valve mass.
A median sternotomy was performed and cardiopulmonary bypa

[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 male, employed as a manual laborer in Indian Railways. Patient presented in emergency with severe abdominal pain, multiple episodes of vomiting, abdominal distension, and obstipation. He had a history of recurrent attacks of colicky abdominal pain, nausea, and vomiting over the last 2 years. There was a history of hospitalization for occasional episodes of severe abdominal pain and distension and obstipation over this period. The frequency of these attacks had been progressively increasing over the last 2 years with the patient requiring weekly admission for the preceding two months before coming to our centre. There was history of loss of weight and appetite. There was no associated history of fever. There was no contributory past or family history. He was a chronic smoker of 80 packet years and a social alcoholic. He was investigated by CT scan of the abdomen and Thorax and MRI of the abdomen during his previous admissions and was diagnosed as a case of hiatus hernia with retroperitoneal fibrosis/diffuse lymphoproliferative disorder. CT chest showed nodularity indicative of infective pathology. However, these investigations were not available with the patient at the time of admission to our hospital. He was normotensive and afebrile but was having tachycardia and tachypnoea (pulse: 108/minute and respiratory rate: 22/minute). His nutritional status appeared adequate. His general physical examination was essentially normal.
His systemic examination of chest, CVS, and CNS revealed no obvious abnormality. On abdominal examination he had a distended abdomen with stretched umbilicus. There were no visible scars. Abdomen was diffusely tender and guarded with no palpable organomegaly. Examination of external genitalia, hernial orifices and renal angles revealed no abnormality. On a digital rectal examination the rectum was empty and ballooned. A provisional diagnosis of acute intestinal obstruction with impending strangulation was made and c

[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 male patient presented with pulsation of the skull and dizziness during bending down. Neurological examination revealed a dysdiadochokinesia on both sides, no further neurological deficits. The scalp was soft. A bone resistance was not palpable. Cranial magnetic resonance imaging (MRI) showed an extensive growing, contrast enhancing lesion expanding at the supra- and infratentorial convexity, infiltrating and destroying large parts of the skull, and infiltrating the skin (). CT scanning and 3D-reconstruction images stress out the massive destruction of the calvarian bone (Figures and ).
A surgical procedure with the aim of complete tumor resection in a curative manner was not possible, so that a digital subtraction angiography (DSA) was done to identify the arterial blood supply of the tumor. The tumor was fed by branches of both internal and external carotid arteries and additionally by the right vertebral artery. The feeding branches were embolised to induce decrease of tumor size and growth. The patient was discharged and was followed closely in our out-patient department.
Two months later, the patient presented with progressive ataxia and dysarthria. On examination, we discovered circumscribed skin necrosis of the skull in consequence of embolization of the feeding arteries and the skin infiltration of the tumor. Despite previous embolization, MRI showed marked increase of the infratentorially localized tumor with cystic components with compression of the fourth ventricle and the brainstem. In consideration of the new findings, we resected parts of the tumor located in the posterior fossa and at the occipital convexity via an extended sub-occipital approach. During surgery, the tumor was located in the epidural space with diffuse infiltration of the bone and the skin. Histopathological work-up revealed an anaplastic meningioma WHO grade 3 with high cell density, tall polymorph nuclei and high mitotic rate with a high proliferation index of 60% ().

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


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

[User]
RADIOLOGY NOTE:
A 29-year-old male with a history of right tibial shaft and lateral malleolus fractures following a fall injury underwent open reduction and internal fixation with a locking plate for the fibula fracture and minimally invasive percutaneous osteosynthesis for the tibial shaft fracture at another hospital. Postoperatively, the patient was followed up at our hospital for 1 year due to residential issues, and the removal of the plate was scheduled after confirmation of bone union. According to the previous hospital’s medical records, a 9-hole locking plate (APIS®, Gwangju, Republic of Korea) was used for the distal tibia, with three 5.0-mm locking screws for proximal fixation and six 3.5-mm locking screws for distal fixation. Under spinal anesthesia, a plate removal surgery was performed, following which the fibular plate was easily removed. However, five of the six distal locking screws were damaged, and they could not be removed with a screwdriver. This situation was explained to the patient during the operation, and we could confirm that the patient wanted to remove the plate irrespective of the amount of time required. At the time, a tourniquet was used for approximately 1 h, and screw removal was attempted using a conical extraction screw, but only one of the six screws could be removed. Previously proposed techniques requiring additional skin incisions were not considered because there were multiple damaged screws that could not be removed, these techniques would require extended amount of time for removal, and the surrounding soft tissues could be damaged. Hence, we decided to use a screw extractor (IRWIN®, Huntersville, NC, USA), a non-medical instrument, following sterilization with ethylene oxide. In brief, 6-mm drill bit of the extractor was used, four screw heads were drilled, the locking screws and locking plate were separated, and the plate was removed. Of the remaining four screws, one was removed using a vice grip; the remaining three screws

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


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

[User]
RADIOLOGY NOTE:
A 73-year-old woman with past medical history of hypertension, hyperlipidemia, and hypothyroidism presented with chief complaint of worsening low right-sided back pain for one week. She had not had any trauma or injury to the area prior to onset of pain. She then developed right-sided leg weakness, right thigh numbness, and perianal numbness in a progressive fashion. She also reported urinary retention.
On further questioning, she reported numbness of chin on both sides which started two weeks prior. She did have a left molar tooth extraction one week prior to the onset of all symptoms, and did receive local anesthesia for that. However, she confirmed that the numbness of chin was present prior to tooth extraction as well.
Her vital signs at the time of presentation were: blood pressure 124/58 mmHg, heart rate 89 beats/min, temperature 98.3°F, and respiratory rate 22 breaths/min with oxygen saturation of 95% on room air. Her physical exam was significant for tenderness to palpation of lower lumbar spine, decreased motor strength, and sensation of the right lower extremity. She also had decreased sensation to touch and pain around her lips and on chin bilaterally.
Laboratory investigations at the time of presentation and on Day 4 and Day 5 are listed in Table .
She had a CT scan of lumbar spine without contrast which showed multilevel chronic changes without any acute pathology. She underwent a CT myelogram of the lumbar spine, which also did not show any acute pathology.
She then underwent MRI of the thoracic and lumbar spine with and without IV contrast, which showed extensive epidural and possibly subdural enhancement at multiple levels of canal. A lesion within the canal at L2 level was causing severe compression of the cauda equina just below the level of conus and extending into the right foramen at L2-3. These findings were highly suggestive of a neoplastic process (Figure ).
The patient was admitted to the hospital 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:
We present a case involving a 76-year-old female patient who was first seen by her doctor for problems and discomfort with deglutition. Upon an objective examination, the thyroid gland appeared to be mildly enlarged (more on the right side of the neck) with a hard consistency, but mobile relative to the underlying tissues. The only comorbidity was a mental illness.
An ultrasound (US) of the neck was immediately performed and revealed a multinodular retrosternal goiter, for which the larger nodule in the right lobe presented with a diameter of approximately 6 cm and complete ring calcification. The goiter extended into the upper mediastinum and was lying on the aortic arch.
Due to the goiter’s retrosternal configuration, we performed a CT scan of the neck and thorax. The scan showed the posterior dislocation of the epiaortic vessels and lateral dislocation and compression of the pharynx. The large nodule described previously based on US exhibited a mixed type of calcification; in fact, in the context of a large egg-shell calcification, multiple spots with microcalcifications were observed (A and B).
Given the notable dimensions of the goiter, its symptomatic disposition and the extreme calcification of the nodule, we chose to avoid an ultrasound-guided ago-biopsy due to the low probability of obtaining a good tissue sample and the consequent diagnosis, and in agreement with the patient’s endocrinologist, we decided to directly perform a standard thyroidectomy through a cervicotomy. The primary difficulty during the operation was the complete calcification of the entire right lobe, which was adherent to the trachea and vascular structures (A and B). However, no major bleeding or complications occurred during surgery.
Macroscopically, the pathologist described a nodule with a weight of 130 g that was partially cavitated and extremely hard when cut (A and B).
A microscopic histological examination excluded the presence of atypical cells and revealed nodular hyperplasia

[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 previously well 87-year-old Caucasian woman living in a senior assisted care center presented to the neurology clinic with complaints of six months of slowly progressing left sided weakness. Initial difficulty in ambulating and using the stairs progressed to being wheelchair bound. Neurologic exam revealed diffuse 3/5 left sided weakness, left leg drift, and left facial droop. Brain magnetic resonance imaging (MRI) revealed a large confluent white matter T2-hyperintensity in the right frontal lobe with multifocal nodular enhancement of the left cerebral hemisphere (). Foci of enhancement were also identified in the cerebellum and leptomeninges. The radiologic differential diagnosis included vasculitis, lymphoma, and CNS sarcoidosis as the most probable causes of the multifocal disease process, with glial neoplasm, demyelination, and metastases considered less likely.
All sample analysis described below were performed on material obtained by brain biopsy as part of clinical care. All samples were obtained with appropriate consent.
A biopsy of the mass was performed and revealed extensive parenchymal lakes and vascular and perivascular deposition of amorphous, amyloid like material (). Congo-red positive staining and apple-green birefringence (not shown) of the amorphous material upon polarization confirmed that the amorphous material was amyloid (). Also present in the resected tissue were a number of small intraparenchymal blood vessels with perivascular lymphoplasmacytic infiltrates (). The initial histologic differential diagnoses included cerebral amyloid angiopathy-inflammatory type (CAA-I) and lymphoma associated amyloidoma. To identify the underlying etiology of the amyloid accumulation, a number of additional analyses were performed.
Liquid chromatography tandem mass spectroscopic analysis identified the amyloid as AL λ-type and not β amyloid or an amyloid associated with a hereditary amyloidosis. Further analysis of the perivascular lymphoid populations wa

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


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

[User]
RADIOLOGY NOTE:
A 72-year-old male patient visited SMG-SNU Boramae Medical Center with exertional chest pain, which had been aggravated during the most recent 3 months. The initial electrocardiogram revealed sinus bradycardia with a heart rate of 50 beat per minute, and there was no ST segment elevation. The serum cardiac enzyme level was within the normal range, and there were no abnormal findings except mild functional mitral regurgitation in transthoracic echocardiography, which showed a left ventricular ejection fraction of 67% and no regional wall motion abnormality. Myocardial single-photon emission computed tomography showed a reversible perfusion decrease at the basal inferior wall. Preoperative coronary angiography showed 70% to 80% stenosis of the left anterior descending coronary artery (LAD), 90% stenosis of the proximal ramus artery, 50% stenosis of the proximal left circumflex artery, 95% stenosis of the distal right coronary artery, and 90% stenosis of the posterolateral branch artery (PLB). According to the patient’s past medical history, he had undergone right upper lobectomy for squamous lung cancer 3 years ago. In addition, arteriosclerosis obliterans of both the lower extremities had been treated medically for 6 years.
Diagnosed with unstable angina with three-vessel disease, the patient underwent off-pump coronary artery bypass graft surgery (CABG). Under general anesthesia, an advanced venous access catheter and a Swan-Ganz (SG) catheter were inserted via the right internal jugular vein by the anesthesiologist. Several premature ventricular contractions (PVCs) occurred during the insertion of the SG catheter. We used the left internal mammary artery as a pedicled graft and anastomosed it to the mid-LAD. We also harvested the saphenous vein from the left lower leg and anastomosed it to the left internal mammary artery to make a Y-shaped composite graft. Subsequently, the vein graft was anastomosed to the ramus artery and PLB sequentially. During the operation,

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


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

[User]
RADIOLOGY NOTE:
A 43-year-old man with a 5-year history of gluten intolerance and bullous dermatosis had been treated for recurrent conjunctivitis. He came to us with progressive vision loss, photosensitivity, foreign body sensation, and burning sensation in both eyes. He presented bullous and papular lesions with erythematous base in periocular tissues, limbs, thorax (). Two years before, a previous diagnosis of dermatitis herpetiformis in another center was given and was treated with 50 mg per day of oral dapsone and 5 mg per day of oral prednisolone.
The visual acuity was light perception in each eye. Slit lamp examination showed dysfunctional meibomian glands, conjunctival hyperemia, subconjcuntival fibrosis, corneal superficial vascularization, and opacification with epithelial defects, and the rest of the anterior segment was difficult to evaluate (). The ocular ultrasound was unremarkable in both eyes. A histopathological examination of the skin biopsy revealed neutrophil alignment along basal membrane and subepidermal cleavage with inflammatory cells in the superficial dermis; immunofluorescence confirmed IgA deposits along the basal membrane ().
We decided to continue with dapsone and started him on a topical erythromycin ointment, lubricants, 50 mg per day of systemic prednisolone, 50 mg per day of sulfone, and 75 mg daily of azathioprine. A keratolimbal allograft transplantation was performed, with superficial keratectomy that underwent histopathological studies. We observed a complete destruction of Bowman's layer, replaced by fibrotic tissue with perforant vessels, and immunofluorescence studies confirmed IgA deposits over this area ().
A monolayer of cryopreserved amniotic membrane was implanted in his right eye. We suggested immunoglobulin therapy, but the patient could not obtain the treatment. Four months after the surgery, a corneal melt was noted and eventually he needed two more amniotic membrane patches for immanent perforation. Unfortunately he persisted with

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


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

[User]
RADIOLOGY NOTE:
A three and a half month old female child being treated in another hospital was referred to us. This child had complaints of cough, coryza, fever, and respiratory distress since day 10 of life. The child was admitted in another hospital and was treated for pneumonia. Chest X-ray (CXR) at that time showed collapse consolidation of the apical segment and lower lobe of the right lung which was misread as lobar consolidations []. She was given intravenous antibiotics and was discharged. Subsequently, this child required four more readmissions and was suspected of having recurrent pneumonia. During this course, her blood investigations were essentially normal. Two-dimensional echo was normal. A cystic fibrosis screening was done which also was normal. This child was then referred to Lok Nayak Hospital, New Delhi. On examination, the child was alert, active with stable vitals. Blood investigations were essentially normal. Venous blood gas showed pH 7.2, PCO2 54, and BE 5.4. CXR showed hyperlucency in the right upper and middle zone with slight mediastinal shift to the left. An inhomogeneous opacity was noted in the right middle zone along with a thin linear opacity in the left hemithorax which led to the suspicion of right lobar emphysema []. Computed tomography (CT) scan was planned which showed collapse of apical and posterior segments of the right upper zone along with hyperinflation of the right middle lobe. Consolidation with subsegmental collapse was seen in the apical segment of both lower lungs []. A diagnosis of CLE was made. As the child was clinically stable, a decision to manage her conservatively was taken. However, on the 7th day of admission, the child's condition deteriorated with worsening respiratory distress and was unable to maintain saturation even with oxygen support. The child developed severe chest retractions. The child was then taken up to the emergency operation theatre for urgent thoracotomy and exploration. Right middle lobe was found emphysem

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


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

[User]
RADIOLOGY NOTE:
A 23-year-old male professional hockey player suffered a fall on ice during a game, which resulted in a flexion-external rotation injury to his left lower extremity. At the time, he felt a pop and developed immediate onset of the left knee pain. Plain films and magnetic resonance imaging (MRI) revealed anterior dislocation of the proximal tibiofibular joint (). The patient had subsequent spontaneous reduction while entering a car the following day. 3 days after injury, the patient had persistent the left knee pain and difficulty with the range of motion to terminal flexion and extension and presented to clinic. At presentation, the patient was unable to comfortably bear weight on the extremity. On examination, he had tenderness to palpation at the fibular head but no tenderness over the ankle. His left knee had a range of motion comfortably from 10 to 90° and full strength in all muscle groups, as well as intact sensation in all nerve distributions in the lower extremity. Initially, the patient elected for nonoperative treatment and was advised to remain non- weight- bearing for 1week followed by a repeat MRI. This study revealed a small amount of lateral subluxation of the left fibular head. At this point, the patient had persistent pain and difficulty with extension, and so elected to undergo surgical treatment. 12 days after injury, the patient underwent ORIF of the proximal tibiofibular joint. The joint was noted to be resting in a laterally subluxed position. It was manually reducible but unstable (). A single 3.5 mm cortical lag screw was inserted from the fibula to the tibia parallel to the knee joint, after which the joint remained anatomically reduced. Postoperatively, the patient remained non-weight-bearing with passive range of motion limitations for 4 weeks, after which weight-bearing and active range of motion were allowed. At 8 weeks, his physical examination included minimal edema about the head of the fibula; active range of motion from 0° to 135° wi

[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 72-year-old man was followed up in our clinic for two years for early cervical myelopathy secondary to C3 to C5 stenosis. His medical history was significant for dialysis-dependent end-stage renal disease due to chronic allograft nephropathy despite cyclosporine therapy for a living-related donor kidney transplant. He suffered a previous myocardial infarction treated with percutaneous coronary intervention and sick sinus syndrome, which required a pacemaker that was removed due to a postoperative abscess. He survived squamous cell carcinoma of the parotid gland with lymphatic involvement that necessitated radical resection and radiation of the head, neck, and axilla. He was also diabetic. At the time of his initial presentation to our clinic, his symptoms included very slight loss of coordination in his left hand and a mild sense of imbalance. He could still ambulate and live independently and therefore did not wish to proceed with cervical decompression and fusion.
He was lost to follow-up but returned to our clinic two years later. At this time, he presented with loss of coordination in both hands and could no longer ambulate. As a result, he was no longer able to care for himself. He remained dialysis dependent and was oliguric, but not completely anuric. Repeat cervical MRI revealed worsening stenosis at C3-5 compared to the MRI scan performed two years earlier. At this point, he wished to proceed with surgery. As per standard protocol, he was given 1 gram of intravenous cefazolin immediately prior to incision. He underwent posterior C3-5 laminectomies and instrumented fusion with lateral mass fixation. In an attempt to preserve his remaining kidney function and reduce his risk of SSI, we applied 1 gram of vancomycin powder over the instrumentation and soft tissues of the surgical exposure. Although there were not any previous reports of intrawound application of vancomycin powder in patients on dialysis, we felt it was a justified treatment to minimize his ch

[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.