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

[User]
RADIOLOGY NOTE:
A 78 year-old male patient undergoing endoscopic mucosal resection of colon polyps had been incidentally diagnosed of a 4 cm-sized infrarenal AAA, 1.5 to 2 cm distal from the left renal artery, with extension to the right common iliac artery (CIA), 3.8 cm in maximal diameter on computed tomography (CT) scan. However the patient was asymptomatic and therefore the aneurysm was observed. The patient had a past medical history of hypertension (diagnosed 2 years ago) and gout (diagnosed 5 years ago), and both on medications. Two years later, the patient was diagnosed of prostate cancer and underwent robot-assisted laparoscopic prostatectomy. During the work-up for the operation, the aneurysm was detected on CT scan but the AAA size was unchanged (4 cm) and the patient remained asymptomatic. Postoperatively, the patient suffered from deep vein thrombosis (DVT) needing the insertion of an inferior vena cava filter and anticoagulation.
During the next 8 months, the maximum diameter of the aorta grew to 4.2 cm and that of the right CIA to 4.3 cm, with the aneurysm extending also to the proximal left common iliac artery (). Because of the large sized, rapid growth of right common iliac artery aneurysm, we decided to perform an EVAR procedure. It was planned and performed in two stages. The first stage was the embolization of the right internal iliac artery using a 16 mm vascular plug and the second stage was an EVAR procedure under general anesthesia using a bifurcated modular aortic stent graft (Zenith®, Cook Inc, Bloomington, Indiana, USA). During EVAR, intravenous 5,000 unit heparin injection was done for preventing graft thrombosis. Intraopertive minimal transfusion with red blood cell 1 pint was done, and hemoglobin was slightly dropped from 11.6 g/dL to 10.8 g/dL without definite change of vital sign after EVAR. The overall procedure was done without any other major complications and both lower extremity pulses 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:
The third patient case presents a 65-year-old female with a lesion in proximity to precentral gyrus (preCG, this patient is labelled as PAT_preCG in what follows). Her KPS decreased during the radiotherapy from 80 (pre-RT) to 70 (post-RT). RPA-class was evaluated to be V. In fact, during the first scan this patient was able to walk by herself, whereas during the last scan she used wheelchair and could walk small distance. This performance corresponds to lower KPS score of 50. PAT_preCG underwent three MRI studies: the first one 5 weeks post-surgery and the second one 5 weeks post-RT. Time between these scan points was 3 months. The third scan was done 4 months post-RT. This patient received chemotherapy between the 1st and 2nd scan points for 6 weeks.
In the first postoperative MRI study, the FLAIR scan showed a partial resection of the neoplasm with an area of hyperintense signal located in the right frontal lobe adjacent to the Rolandic fissure. A diffuse and irregular enhancing ring of the lesion was observed in the post-contrast T1-weighted scan with evidence of a fluid filled cavity located in the lateral side and a mural nodule located in the medial edge of the lesion. Maximum two dimension diameters of the lesion in the transverse plane were 30 × 24 mm and in plane area was 486 mm. A mild oedema surrounded the lesion without effect on the right lateral ventricle.
In the second post-RT MRI study a reduction in the lesion size was observed. Maximum two dimension diameters of the lesion in the transverse plane were 20 × 18 mm and in plane area of 274 mm. A diffuse, thick and irregular enhancing ring of the lesion was observed in the post-contrast T1-weighted scan. The peripheral oedema was reduced and the right lateral ventricle was slightly dilated.
In the third MRI study, the lesion showed a global increase in size

[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 year old male presented to the emergency department with the history of falling off a ladder 3 hours prior. He landed on his face on a wooden spike that embedded itself in the right orbit. His local hospital is not equipped to deal with ocular emergencies so he was transported by car for approximately 40 km to an eye hospital. Unfortunately, no anesthetist was available and the patient was referred to our emergency department. No treatment was instituted prior to referral. To reach our hospital, the patient had to backtrack 22 km and travel an additional 18 km, 40 km in total over rough roads (Figure ).
On arrival in our emergency department the child was fully conscious. He was hemodynamically stable with no airway or respiratory compromise. He had no past medical history and was not taking any regular medication. History revealed he was up to date with his immunizations, but history was considered unreliable. He lived with his parents and younger brother in a town in Eastern Nepal. On further examination, no other injuries were found specifically the cervical spine. Gross neurological examination was normal. The foreign body, still in situ, was a sharp wooden peg. It had penetrated the right orbit along the medial side. The cumbersome protruding object constituted a rock and a wire mesh attached to the wooden peg. The weight (approx. 1 kg) and shape of the object made stabilization of the object particularly difficult. It was impossible to evaluate the eye further due to the eye being obscured by the protruding object (Figure ).
Intravenous access was established. Pain was managed with morphine and prophylactic antibiotics were initiated. CT scan was arranged. Patient was sedated with ketamine and midazolam. The patient was transferred to CT scan with the relative supporting the foreign body all the time. The contrast CT was initially reported by a radiology resident as follows, “foreign body lateralizing globe and penetrating through the medial part of the or

[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 obtained the written informed consent to publication from the parent of the patient for this case report because the patient had slight mental retardation.
A 24-year-old man, with a height of 190 cm and weight of 52 kg, was admitted to our hospital with right neck of femur fracture to undergo closed reduction and internal fixation. He was diagnosed with WHS after birth. Although he had slight mental retardation, he was able to ambulate and perform simple commands. No specific problems were noted on the transthoracic echocardiography, although ventricular premature beats were present on the preoperative electrocardiogram. His blood tests and chest X-ray did not show any abnormal findings.
On the physical examination, the patient had facial features identical to patients with typical WHS. The Greek warrior’s helmet appearance, characterized by a prominent glabella, hypertelorism, micrognathia, low-set malformed ears, and a down-turned mouth, was present (). Although mouth opening was more than 3 fingers and neck extension had no limitation, his mandible was small and relatively pushed backward (). His tooth alignment and dental hygiene was under poor condition, and Mallampati score was class II. He had undergone an inguinal herniorrhaphy under general anesthesia two years prior without any complications. The information about the previous general anesthesia was limited because it was dependent on the memory from patient’s mother, but any complication has not occurred during anesthetic management including endotracheal intubation. However, as a long anterior-posterior diameter of chest was noticed on computed tomography (), difficult intubation and airway management were anticipated.
After entering the operating room, the hemodynamic status of the patient was stable with blood pressure of 115/91 mmHg, heart rate of 80 beats/min, and oxygen saturation of 99%. Total intravenous anesthesia was administered with 2% propofol and remifentanil to avoid malignant hypertherm

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


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

[User]
RADIOLOGY NOTE:
A 25-year-old male first visited our hospital in 1998 with the chief complaints of headache and dizziness of a remote onset. He had experienced the symptoms for about 4 years, but they were aggravated 4 - 5 months before the hospital visit and they were accompanied with pain on both eyeballs and bilateral intermittent tinnitus. Magnetic resonance imaging (MRI) of the brain and cervical spine revealed a 4×4.5×6 cm-sized cystic tumor with a 2×3 cm-sized enhancing mural nodule at the right cerebellar hemisphere (). The cystic tumor had a heterogeneous rim and accompanying hydrocephalus. There were also multiple small enhancing nodules in the left cerebellar hemisphere and cervical spinal cord. The pancreas and kidney showed multiple cysts and bilateral cortical simple cysts, respectively. He was diagnosed as having von Hippel-Lindau disease, based on all these radiographic findings. Under the impression of hemangioblastoma, he underwent a complete excision of the right cerebellar tumor. One month after excision, he received a conventional radiotherapy using 6 megavolume (MV) of photon on both cerebellar hemispheres and cervical spinal cords, with a total dose of 50.4 Gy being divided by 28 times for 47 days. The postoperative radiotherapy was performed to treat both the operated and non-operated multiple hemangioblastomas. The patient made an uncomplicated recovery for the excised hemangioblastoma and underwent an uneventful clinical follow-up for more than 7 years.
At the age of 32 years in 2005, however, he experienced headache and dizziness again for about 5 weeks before his latest visit to the hospital. Brain MRI revealed a big right cerebellar cystic mass with a total size of 5.8×3.7×3.1 cm. The mass showed heterogeneous and irregular-shaped enhancement along the thickened walls and the big non-enhancing necrotic center (). It was radiologically suspicious of malignant change, because of the increased size compared to the previous one, the irregular and heterogene

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


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

[User]
RADIOLOGY NOTE:
A 73-year-old female with a past medical history of chronic pancreatitis, type 2 diabetes mellitus, gastroesophageal reflux disease, lower gastrointestinal (GI) bleed, hypertension, paroxysmal atrial fibrillation, cerebrovascular accident, seizure disorder, and pulmonary embolism (PE) presented to an outside hospital after a reported seizure at her nursing home. Emergency medical services were called at the nursing home and the patient was reportedly hypoxic with oxygen saturation in the 70s on room air with subsequent development of agitation and lethargy after the seizure. The patient was transferred to an outside hospital's emergency department (ED), where additional tonic-clonic activity was noted. She subsequently developed hypotension with a blood pressure of 52/36 mmHg that was refractory to crystalloid intravenous fluid resuscitation. Central venous catheter (CVC) was placed and norepinephrine was started for persistent hypotension. Labs were notable for leukocytosis, troponin elevation, and low mixed venous saturation on CVC venous blood gas. The patient was subsequently transferred to a tertiary care facility cardiac intensive care unit for evaluation of cardiogenic shock.
Upon arrival, the patient was alert and following commands, but disoriented. She was still requiring supplemental oxygen and norepinephrine for hypotension. Given the concern for cardiogenic shock, a stat bedside transthoracic echocardiogram was obtained, which demonstrated a large pericardial effusion with tamponade physiology. The patient was urgently taken to the cardiac catheterization lab for pericardiocentesis with a drain placement. This yielded 580 ml of hemorrhagic fluid with rapid improvement in hemodynamics following drainage. During the pericardiocentesis, fluoroscopy demonstrated two embolized fragments of the IVC filter within the right ventricle (RV). Review of past imaging revealed that the embolized fragment was visualized on computer tomography (CT) of the chest one yea

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


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

[User]
RADIOLOGY NOTE:
This is a 12-year-old girl who was referred from an outside hospital as a case of right mandibular and neck mass, which was rapidly progressive for the last 3 months (). The patient had a computerized tomography (CT) scan done outside, which revealed a destructive mandibular mass. The outside incisional biopsy was inadequate and showed changes suggestive of cemento-ossifying fibroma. The patient was subsequently admitted to the King Faisal Specialist Hospital and Research Center. Her physical examination shows stable vital signs with mild trachea displaced to the left by this large destructive mass. Repeated CT scan of the mandible and neck soft tissue showed a very large expansile lytic mass (7.3 cm craniocaudal × 5.1 cm transverse × 8.2 cm AP) involving the right side of the mandible, causing massive destruction of half of her mandible with extension into her condyle, neck, and medial side of the right mandible (). Areas of septations and bony erosions were seen peripherally. The enhanced study revealed multiple septations that contain wall enhancement within the lesion (Figures and ). The clinical diagnosis was high-grade malignancy, such as Ewing sarcoma. No significant major lymph node enlargement was detected. Visualized brain parenchyma showed no intra-axial or extra-axial masses. Under proper protocol, the patient was admitted to the operating room for biopsy. Intraoperatively, trachea and soft palate were displaced to the left. There was a large soft tissue mass located in the mandible, displacing her teeth all the way to the maxilla. The mass has expanded into the right neck area between sternocleidomastoid and trapezius muscles. Upon reflection of the mucoperiosteum on the lingual and buccal side, a soft tissue tumor was visible (). Careful dissection of the tumor from the lingual mucosa was performed removing a large specimen of approximately 6 × 6 × 3 cm, which was submitted for histopathology examination ( (inset)). Further intraoperative examination r

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


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

[User]
RADIOLOGY NOTE:
A 52-year-old lady with hypertension, diabetes, and asthma presented with a one-week history of left groin pain. The pain started insidiously and was localized to the left groin. She was otherwise well and asymptomatic prior to this. There was no history of preceding trauma. Of note, she had a dental extraction procedure two weeks prior to this. She was only on inhaled corticosteroids for her asthma, without any systemic corticosteroids.
On examination, she was found to have a tender left upper thigh mass that measured about 4 × 4 cm. Other than this, her lower limb neurovascular examination did not reveal any abnormalities. She did not have any features of distal emboli or splinter hemorrhages.
Initial blood investigations revealed a total white cell count of 18.6 × 109/L as well as a raised C-reactive protein of 247.7 mg/L. Her diabetic control was also poor with a glycosylated hemoglobin level of 15.4%. Initial blood cultures were also taken which did not reveal any microbes.
She underwent an urgent computed tomographic (CT) angiogram of the lower limbs which revealed a thin wall eccentric saccular pseudoaneurysm arising from the proximal third of the left SFA measuring 2.0 × 2.6 × 3.0 cm with a gas containing intramuscular fluid collection seen. Mass effect from the collection and pseudoaneurysm was compressing the adjacent femoral vein causing central intraluminal filling defects, suspicious of deep venous thrombosis ().
A CT aortogram was done to rule out any other mycotic aneurysms. This revealed moderated intimal calcification of the infrarenal abdominal aorta and bilateral common iliac arteries. In addition to this, a wedge-shaped hypoenhancing area in the right renal inferior pole with adjacent fat stranding was noted, suggestive of possible pyelonephritis. An echocardiogram was also done, which did not reveal any vegetations.
Urinalysis was performed but no microbes were detected. She was started on intravenous augmentin after the blood cultures were take

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


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

[User]
RADIOLOGY NOTE:
A 70-year old male patient reported to clinic with a chief complaint of swollen gums of 5 year duration and wanted to replace his missing teeth. Patient noticed swollen gums prior to his 4 years of edentulous state and the condition persisted to present. He was a known hypertensive and was on medication for the same since 7 years (10 mg Nifedipine/day).On intraoral examination- pink, firm, irregular, nodular, non- tender enlargements were found on labial aspects of maxillary and mandibular residual alveolar ridges. The enlargements were asymptomatic in nature with no history of bleeding. Both arches were completely edentulous (Fig. ). Panoramic radiograph showed no osseous deformities of maxilla and mandibular ridges (Fig. ). Patient’s complete blood count, bleeding time, clotting time and platelet count were with in normal limits. An incisional biopsy was obtained from anterior right side of the maxilla. Histological report revealed hyperplastic and acantholytic stratified squamous epithelium with elongated rete ridges extending into connective tissue which was fibro collagenous and showed focal areas of fibrosis. Infiltration of chronic inflammatory cells and congested blood vessels were seen which suggested of gingival hyperplasia (Fig. ). As patient wanted complete dentures, we planned to surgically excise entire overgrowth. Considering medical status of the patient, drug was not altered because, dose taken by the patient was low (10 mg/day). Local anesthesia devoid of vasoconstrictor was used to remove fibrous tissue from alveolar ridge with help of 15 no. B.P blade (Fig. ). To avoid any discomfort during the early phase of wound healing, a surgical splint was placed on both ridges after thoroughly covering the operated site with periodontal dressing (Coe Pack). The patient was recalled and followed at a period of 1 week, 3 months, 6 months and 1 Year intervals (Figs. , , and ). No recurrence of growth was observed during any of the recall visits. After 3 month

[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 Chinese female presented with blurred vision in the left eye for 50 days without any obvious inducement. Her medical history included high myopia for more than 50 years, but she had never had diabetes, hypertension, or other systemic illness. On admission, her blood pressure was 100/60 mmHg, her visual acuity was light perception, and her intraocular pressure (IOP) was 5 mmHg in the left eye. An ocular examination performed on the left eye showed a flare and was positive for cells in the anterior chamber. A fundus examination and B-ultrasound revealed retinal detachment with choroidal detachment (A, B).
All hematological and biochemical tests were within normal limits. After surgical contraindications were excluded, we performed a combined phacoemulsification without intraocular lens implantation and vitrectomy in combination with silicone oil injection. The choroidal detachment (C, star) was clearly visible before phacoemulsification was performed. After phacoemulsification, 20G and 23G vitrectomy cannulas were placed 3.5 mm from the limbus. The 20G cannula was left open, and the infusion line was placed in the anterior chamber through a clear corneal paracentesis with a bottle height of 40 mmHg. As soon as the infusion line was opened, a copious, thick flux of blood flowed out of the 20G cannulas and was followed a yellowish liquid (D). As the blood flow continued, the choroidal detachment visibly recessed. Though there was tight adhesion between the posterior vitreous and retina, the posterior vitreous cortex was completely separated from the inner surface of the retina. A 1/5PD hole was found in the arch of the vascular arch below the macula (E, black arrow), and a full vitrectomy combined with intravitreal silicone oil tamponade was performed. After surgical treatment, the retinal detachment and choroidal detachment were reduced (F). After treatment with a silicone oil tamponade, visual acuity was hand motion (HM) and counting fingers after 1 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:
A 52-year-old woman presented with pain and active function loss in her left shoulder, and was admitted to our hospital in June 2017. Her shoulder problem had started 3 months earlier, and there was no history of trauma or fracture. At first the pain was intermittent and bearable, but then gradually increased. On examination, there were no positive signs except for localized pain. A radiologic examination on 3 April 2017 found no destruction of the shoulder (Fig. ). Pain at the shoulder joint became gradually aggravated, together with the appearance of shoulder joint dysfunction. Two months later, physical examination revealed mild swelling of the shoulder, and markedly restricted shoulder and elbow motion. Mild distal nerve function defects appeared gradually. Radiography on 3 June 2017 showed that the head of the humerus had disappeared within the past 2 months (Fig. ), which was confirmed by magnetic resonance imaging (Fig. a, b).
The patient is a healthy, active individual with no history of weight loss, anorexia, or fever during this period. General and systemic examination findings were within normal limits. Routine laboratory investigations were also normal, including levels of serum calcium, phosphate, alkaline phosphatase, high-sensitivity C-reactive protein, and erythrocyte sedimentation rate. An open biopsy of the lesion revealed that the bony tissue had been replaced by fibrous connective tissue, and small areas of bony trabeculae with occasional osteoclasts were visible (Fig. ). There was no evidence of malignancy or tuberculosis. Because of the lack of any clinical findings or supporting data for other causes, the features were confirmatory of GSD. Computed tomography of the shoulder joint (Fig. ) revealed a bony defect of the glenoid cavity.
We performed surgery involving glenoid cavity amplification with an autologous iliac bone graft and a reverse total shoulder arthroplasty. The grafts were from autologous iliac bone (Fig. , Fig. ). A deltopectoral

[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 44-year-old Asian female, gravida 2, para 2, with no significant previous medical history, presented to urologist and complained that she had experienced dyspareunia over the preceding several months. The nature of the pain was a deep pain, which she experienced every time she attempted intercourse. She did not have vaginal discharge. No psychological factors can be found for her painful intercourse. She denied any episodes of gross hematuria, fever, chills, or irritative urinary symptoms. A pelvic bimanual examination was difficult to perform because of the patient's discomfort. No significant findings were detected on physical examination. Urinary tract infection was excluded as results of urinalysis and urine cytology were normal. The results of other laboratory tests including renal function, liver function, complete blood cell count, and coagulation function were also within the normal range.
A pelvic ultrasonography revealed a 6.6 × 5.8 cm2 mass lesion located in the trigone of urinary bladder. The mass lesion was confirmed on contrast-enhanced CT to be an enhanced 7.2 × 6.1 cm2 soft tissue mass in the right paravaginal area. CT scan also revealed a lobulated and enlarged uterus consistent with uterine leiomyoma (Fig. ). There was no evidence of thickening of the urinary bladder wall and locoregional invasion. Flexible office cystoscopy was attempted and revealed a rounded, smooth, submucosal mass arising from the trigone of urinary bladder distorting the medial margin of both ureteric orifices. Double J stents could be passed with ease bilaterally. Retrograde pyelogram demonstrated no filling defects or dilation of the both ureters. The biopsies taken with a transurethral resection (TUR) loop showed a benign proliferation of smooth muscle in a connective tissue stroma suggestive of leiomyoma. After a careful discussion about the 2 options of further treatment, open surgical excision, and repeated TUR, the patient opted to receive open surgical excision. 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 thirty-three year old gentleman initially presented to Prince of Wales Hospital with a diagnosis of SLE/dermatomyositis overlap syndrome. He was treated with steroid and hydroxychloroquine 200 mg twice daily since 1997. He had a flare up of disease in May 1998 with active vasculitis and myositis, for which he was put on prednisolone and azthioprine 50 mg and 100 mg daily respectively. Upon reassessment one month later, disease activity was under control, and the dosage of prednisolone was reduced to 45 mg daily.
Twelve day after reducing the immunosuppressive regimen, he was admitted to hospital for treatment of left buttock abscess. The CXR taken on admission was unremarkable. An aspirate of the pus from the lesion grew methicillin-sensitive staphylococcus aureus; he was treated with cloxacillin 1 g intravenously every 6 hourly, together with incision and drainage of the buttock abscess. In view of the underlying active pyogenic infection, the steroid dosage was rapidly tapered from 45 mg to 15 mg daily within the next four days. However, he was noted to have persistent fever associated with mild unproductive cough. A repeat chest radiograph showed new infiltrates over the right upper and left lower zones, and he was empirically treated with intravenous ceftazidime 1 gram every 8 hours, cloxacillin 1 gram every 6 hours and netimicin 100 mg every 8 hours. As there was no clinical response after 5 days of treatment, bronchoscopy and bronchoalveolar lavage (BAL) was performed, which was positive for Pneumocystis jiroveci. Investigation for the presence of co-existing opportunistic pathogens such as cytomegalovirus and aspergillus was negative. On the day after bronchoscopy, he was commenced on intravenous cotrimoxazole 1.3 grams every 6 hours. He remained stable initially with fever on downward trend. However, on the 3rd day of treatment, he developed sudden desaturation with resurgence of high fever, and required supplemental oxygen therapy. Repeat chest radiograph

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


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

[User]
RADIOLOGY NOTE:
A 36-year-old female with no contributing medical history was referred to the Endodontic Department of Qazvin School of Dentistry. She proclaimed that her left maxillary central incisor underwent incomplete root canal therapy five months ago. She stated that she could not continue the treatment due to financial problems. After clinical examination, a longitudinal fracture on the facial surface of the tooth was observed; also a solitary pocketwith a depth of 8 mm was detected in the facial region (). Radiographic examination revealed that the canal has been over-prepared during previous endodontic treatment but it has not been obturated. In addition, periapical radiolucency was observed at the apex of the left maxillary incisor (). The presence of a deep pocket along a longitudinal fracture convinced us to extract the tooth and treat the patient with an implant placement, but as was mentioned above the financial problems were the main patient's limitation for the desired treatment plan.
In view of this limitation we decided to extract left maxillary incisor, reconstruct the fracture with adhesive resin cement, perform a root end resection, prepare a retrograde cavity and fill it using filling material, and replant the tooth. A written informed consent was obtained and the patient was scheduled for treatment.
At the patient's return, antisepsis was carried out using 0.2% chlorhexidine gluconate; left maxillary incisor was anesthetized using an infiltration and nasopalatine nerve block injection (lidocaine 2% with epinephrine 1 : 80000; Daroupakhsh, Tehran, Iran). The tooth extraction was gently performed using forceps with no intraoperative complications; subsequently tooth structure was carefully examined and it was found that fracture line has been originated from the apex and propagated coronally (). Extracted tooth was kept in moistened gauze using normal saline, and in order to remove inflamed tissue, socket walls adjacent to the fracture region were curetted 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 14-year-old male patient who had been followed up for 3 years with a diagnosis of Joubert syndrome and chronic renal failure and was receiving peritoneal dialysis treatment was brought into the pediatric emergency service due to vomiting and intolerance to food intake persisting for 1 week. Upon the development of hyponatremia and hypopotassemia, he was hospitalized and the appropriate supplementation treatment was instituted. Blood, urine, and peritoneal fluid cultures were obtained because of febrile episodes. Intravenous (IV) antibiotherapy with tazobactam-ampicillin was initiated. Growth of Candida spp. in his peritoneal culture necessitated the inclusion of liposomal amphotericin B in his treatment, and the peritoneal dialysis catheter was removed. The patient was anuric and had volume overload, so intermittent hemodialysis therapy was initiated and maintained in 3-hour sessions 3 days a week. An abdominal ultrasound was performed, which revealed complicated, lobulated, fluid-filled cystic lesions, the largest with dimensions of nearly 8x5 cm (pseudocyst) in the pancreatic loge, and multiple cortical cysts in both kidneys. An abdominal computed tomography (CT) scan indicated large cystic lesions localized in the anterior abdominal region that were compressing portions of the gastrointestinal system and intraabdominal organs, and which extended from the subhepatic region to the pelvis. Loculated fluid collections that were connected with each other in the peripancreatic area were noteworthy. The patient was evaluated by the department of pediatric surgery, and surgery was planned. During the operation, a cyst on to the anterior abdominal wall and extending from the pelvis to the epigastric region was observed. During attempts to resect the cyst, which was very strongly adhered to the anterior abdominal wall, the cyst ruptured and nearly 2500 cc serohemorrhagic fluid was aspirated. During the intervention, the patient suffered cardiac arrest. Erythrocyte suspen

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


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

[User]
RADIOLOGY NOTE:
A 64-year-old woman with a medical history consisting only of hypertension came to the emergency room (ER) with complaints of chest pain and shortness of breath for 4 days. On admission, she presented with vague discomfort in the right upper abdomen, anterior chest tightness and exertional dyspnea (class III according to the functional classification of the New York Heart Association). Physical examination revealed a blood pressure of 100/80 mmHg, a pulse of 88 beats/min, respiration of 34 breaths/min and a body temperature of 36.2℃. There were crackling sounds in both lower lung fields, but the cardiac sounds were normal. Various laboratory tests were performed on admission, including a blood chemistry profile, coagulation studies and a complete blood count, in which the cardiac enzymes revealed leukocytosis and elevated hepatic enzymes without evidence of myocardial infarction. A chest X-ray taken on admission showed the presence of cardiomegaly without mediastinal widening, patch infiltration in the right lower lobe and blunting of the bilateral costophrenic angles (). The electrocardiogram disclosed sinus tachycardia of 100 beats/min with no S-T or T wave changes. The Doppler echocardiography revealed an ejection fraction (EF) of 56.4%, moderate to severe tricuspid regurgitation, scanty pericardial effusion and bilateral pleural effusions, hepatic congestion, and an increased systolic pulmonary arterial pressure (SPAP) of 75 mmHg (normal range; 15-30 mmHg), suggesting the presence of severe pulmonary hypertension. After a preliminary diagnosis of "idiopathic right heart failure", the patient was admitted to the medical intensive care unit for treatment. On the 4th day following admission, atrial fibrillation and a sudden drop in systolic blood pressure to 70 mmHg appeared simultaneously. A follow-up transthoracic echocardiography taken 4 days later again showed a dilated ascending aorta and an intimal flap in the proximal ascending aorta (). The computed tomogra

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


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

[User]
RADIOLOGY NOTE:
The patient is a 46-year-old right-handed female with a past medical history of hypertension (HTN), hyperlipidemia (HLD), diabetes mellitus type two (DM2), obesity, and hemorrhagic stroke who was transferred from an outside facility to be evaluated for CNS vasculitis. She was admitted to this outside facility for a four-week period prior to being transferred to the primary facility for further evaluation over a subsequent 23-day period. Total duration of hospitalization at both the facilities was close to 7.5 weeks. Approximately one week into the initial four-week admission, her family found that she was very lethargic with diminished responsiveness and pronounced difficulty speaking. In the emergency room (ER), her blood pressure was measured at 243/129 mmHg with a blood glucose value greater than 400 mg/dL. She was started on aggressive antihypertensive therapy and underwent a series of diagnostic tests. Dual antiplatelet therapy (DAPT) consisting of aspirin and clopidogrel was initiated in combination with high-dose atorvastatin. With respect to her lethargy and fluctuating cognition, there was concern that she may be experiencing complex partial seizures, so lacosamide was also started.
A baseline computed tomography (CT) scan of the head without contrast showed multiple indeterminate lacunar infarcts involving the head of the right caudate nucleus and left corona radiata. The same day, a magnetic resonance imaging (MRI) was performed and elicited similar findings with the addition of bilateral punctate infarcts of the left thalamus, right periventricular white matter, and right centrum semiovale. Magnetic resonance angiography (MRA) done on the following day showed high-grade stenosis of the left middle cerebral artery (MCA), in addition to markedly diminished caliber of the right MCA and high-grade stenosis involving the left posterior inferior cerebellar artery (PICA). Bilateral carotid ultrasounds showed very mild plaques. An angiogram exhibited an occluded

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


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

[User]
RADIOLOGY NOTE:
An 8-year-old girl with a rapidly increasing valgus angle of the right elbow presented at the out-patient clinic of our hospital. No evident trauma of the affected elbow had occurred. In another hospital, she had been diagnosed with a unilateral congenital radial head dislocation of the right elbow at the age of 3 months, for which a conservative treatment was initiated. Besides the increasing deformity, the patient had no complaints of pain or limitations. On physical examination, the patient was found to have a full and painless ROM and a normal carrying angle of the left elbow. The right elbow showed a cubitus valgus with clinically a carrying angle of 32°. The dislocated radial head was not painful on palpation. The range of motion was nearly full: flexion 130°, extension 10°, pronation 75° and supination 80°, compared with a flexion of 140°, extension of 0°, pronation of 80° and supination of 80° of the contralateral elbow. Plain radiographic evaluation of the right elbow showed an anterior dislocation and deformation of the radial head, with a long narrow neck and a hypoplastic capitellum and an increased valgus angle (Figs. and ). The left elbow showed no abnormalities. Radiographs of both forearms show a mild ulnar bowing on the right side, as compared to the left side (17 and 12°) (Figs. and ). This is probably due to chronic dislocation of the radial head. CT imaging of the elbow showed the anterior dislocation of the radial head with an overgrowth of the radius of 8 mm and a normal ulnohumeral joint. There is a premature ossifying physis of the lateral humeral condyle (Fig. ). Whilst no complaints or limitations were present, treatment was non-operative with clinical observation. No restrictions in daily elbow use were advised. The result of this treatment strategy was satisfactory after a follow-up of 18 months. No increase in valgus angle was seen, and elbow function was not painful. Treatment of the valgus angle can be

[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 September 2007, a previously healthy 48-year-old man presented with gross hematuria and right flank pain. He was found to have a 6.6 x 6.1 x 5.9 cm (CC x TR x AP) mass in the right kidney on CT imaging (Figure ).
One week later, he underwent a laparoscopic nephrectomy, where a 5.5-cm renal cell carcinoma (RCC) was found on pathology. Histologically, it was a clear cell carcinoma with a Fuhrman grade of 3/4. Resection margins were widely negative.
In May 2015, he was admitted to hospital for diverticulitis. A CT scan performed incidentally showed multiple bilateral pulmonary nodules. These were biopsied, confirming recurrence of his RCC. No other sites of metastasis were observed.
He was referred to the regional cancer center and a decision was made not to initiate systemic therapy after discussion with the patient, who was completely asymptomatic at the time. Instead he was scheduled for monitoring.
In January 2016, surveillance imaging showed progression of the lung metastases and evidence of bone metastases. The patient also reported lower back pain consistent with his imaging findings. A bone scan showed an iliac lesion, as well as disease in his right rib, humeral head, distal femur, olecranon, and left ribs. He was initiated on Sunitinib. A referral was made to radiation oncology for a course of palliative radiotherapy to his symptomatic sites of bone metastasis.
The patient continued his follow-up in clinic with medical oncology and palliative care. He did develop a pathologic fracture of the right humerus requiring orthopedic intervention in August 2016. Subsequently, he had a spinal cord compression in November 2017 treated with laminectomy. In June 2018, he underwent excision of a metastasis in his right distal femur followed by total right knee arthroplasty.
His systemic therapy was switched from Sunitinib to Nivolumab after four cycles, then to Everolimus after seven cycles, and finally to Axitinib after nine

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


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

[User]
RADIOLOGY NOTE:
A 19-year-old young man status post repair of transposition of the great arteries (TGA) had a coarctation repair using a subclavian flap procedure at 3 months of age. During a recent follow-up exam at 18 years of age, he was noted to have mild upper extremity hypertension, good femoral pulses, and a mild discrepancy in his blood pressures and pulses with right arm greater than the left. He was placed on enalapril for his hypertension. Cardiac catheterization showed findings consistent with previous repair of his TGA, dilated aortic root with aortic incompetence, and no residual coarctation. A year later, he developed gradual onset of dizziness that was exacerbated by the use of his left arm. The patient also developed headaches, blurring of vision, confusion, and an acute syncopal episode while walking to school, which prompted admission and work-up. On examination, a grade 2-3/6 diastolic murmur was noted. His blood pressure in the right arm (127/72) was higher than the left (113/69) and the right arm pulse was stronger than left arm. Neurologic exam at baseline was unremarkable. The patient reported that his dizziness improved when the left brachial artery was compressed.
Brain MRI with angiography showed no acute changes. Chest CT angiogram [] demonstrated the patient's anatomy status post subclavian flap, with the proximal left subclavian artery dissected away from the aorta and the left vertebral arising distally from the subclavian. shows the patient's carotid artery Doppler ultrasound, which demonstrates retrograde flow in the left vertebral artery consistent with left subclavian steal and continued retrograde flow in the left vertebral artery with left arm exercise. The patient underwent a hyperemia test with no significant change in his systolic blood pressure (SBP) in right arm (119 mmHg to 118 mmHg). However, his SBP dropped from 107 mm Hg to 102 mmHg in the left arm. shows the patient's aortic angiogram demonstrating prograde flow across the right common

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


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

[User]
RADIOLOGY NOTE:
A 78-year-old right hand-dominant woman suffered a fall on her right side in a bicycle accident, and presented at our institution on the same day with severe arm pain. Her medical history included internal fixation for a glenoid fracture 7 years ago, and also hemiarthroplasty (bipolar humeral head type) for a proximal humeral fracture 5 years back. She had also undergone coracoid tip transfer to the glenoid rim for atraumatic postoperative dislocation. All the previous operations had been performed at other hospital. Upon initial presentation, the patient had severe pain in the right arm without vascular or neurological abnormalities, and the right arm was swollen, with deformity. She was not aware of any pain around the shoulder. She stated that although her range of motion in the arm had been limited before the accident, she had been able to live without assistance. Standard radiographs of the humerus revealed a periprosthetic fracture, which was centered at the tip of the prosthesis stem with minimal proximal extension, chronic anterior dislocation, proximal medial side osteolysis, and a thin cortex with osteopenia ( and ) We considered that surgery might have a considerable risk of complication because of the patient’s advanced age, poor bone condition, and history of multiple operations on the shoulder. Therefore, we decided to follow her up conservatively using functional bracing with routine periodic X-ray examinations. Her arm was immobilized using a plaster U-slab in a sling, to rest the arm and allow the swelling to subside for 2 weeks after the injury. After the swelling had improved, we modeled a functional brace. At 2 weeks after injury, the functional brace was applied without a sling, and physiotherapy was started, with very good patient compliance. The arm pain gradually resolved on a daily basis, but after 3 weeks, radiography showed that the fracture gap had widened. Therefore, we treated this fracture using a sling to prevent any traction force on

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


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

[User]
RADIOLOGY NOTE:
This is a 60-year-old right-handed man with past medical history of relapsing-remitting multiple sclerosis diagnosed 20 years ago with prior beta interferon treatment for 8 years and with chronic left residual hemiparesis who presented to the emergency room after experiencing generalized weakness followed by a fall to the ground with apparent loss of consciousness. While the patient reported no loss of consciousness, he did not have memory of the events surrounding the fall. EMS was called and patient was airlifted to the nearest percutaneous intervention-capable center after the ECG showed a ST segment elevation in the leads V1 to V3, so the ST segment elevation myocardial infarction (STEMI) alert was activated. In the emergency department, the patient was without chest pain. Upon further questioning, he denied any family history of heart disease including no cardiomyopathy, heart failure, arrhythmias, or premature or sudden cardiac death. Vitals demonstrated mild tachycardia to 105 beats per minute and a temperature of 38 degrees Celsius, and labs revealed a negative troponin level. Ultimately, the ST segment elevation myocardial infarction (STEMI) alert was cancelled due to the high clinical suspicion of the type 1 Brugada pattern in a syncopal patient with anteroseptal ST elevations without chest pain. Workup for the febrile episode revealed positive serology for influenza B. Oseltamivir was started and the patient completed 5 days of treatment. The patient was no longer febrile and his tachycardia had resolved, but he continued to show a persistent type 1 Brugada pattern on the ECG during the entire hospitalization course as seen below (). The patient subsequently went for a transthoracic echocardiogram which demonstrated a normal left and right ventricular function and no structural abnormalities. He also underwent coronary angiography, which revealed nonobstructive coronary artery disease.
Ultimately, the primary concern was to elucidate, whether 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:
The patient is an obese, but otherwise healthy, 34-year-old male presenting for a robotic laparoscopic inguinal hernia repair. A preoperative electrocardiogram (EKG) revealed a third-degree atrioventricular (AV) block, which was not recorded in the preceding surgical preoperative note. Our patient knew of his condition but did not disclose this information to anyone until it was discovered via history, physical, and chart review on the day of surgery. He was not aware of the risks associated with the anesthetic procedure and did not have an established cardiologist following his condition. The last echocardiogram was nine years ago in 2011, which revealed no systolic, diastolic, or valvular abnormalities. His last visit to a cardiologist was five years ago in 2015, during which he obtained an EKG unchanged from the normal preoperative EKG he received on the day of his elective surgery. While his EKG on the day of surgery was normal, anesthesiology preoperative history and physical revealed that he has a history of congenital complete AV block. He has no current pacemaker in place and his complete AV block was not followed by a cardiologist when he presented for surgery.
Our patient's past medical history was significant for bradycardia, chest pain, dyspnea on exertion, hypertension, and complete heart block. However, even though our patient's past medical history was significant for the above, his present medical status and vitals were within normal limits, with the exception of his elevated blood pressure at 169/110. History and physical revealed that he was able to do heavy work around the house, such as lifting furniture and running for exercise, which would classify the patient as having greater than 10 METs. However, even though he was presently asymptomatic with greater than 10 METs, the fact that he had no current establishment of cardiac care warranted further investigation, especially with his concurrent hypertension. A cardiologist was called preoperativel

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


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

[User]
RADIOLOGY NOTE:
This is a 50-year-old right-handed male, with 33-year history of T6 AIS A SCI from a gunshot wound complicated by chronic pain, left hip and knee heterotophic ossification, and a chronic dislocation of his right hip, who initially presented to the emergency room with a right shoulder mass in September 2014. While he initially noticed the mass about 2 months earlier, he presented for evaluation now because of acute onset of pain, weakness and paresthesias in the right arm. He was admitted to the general medicine service for pain management and underwent an initial work up for his right shoulder mass, including advanced imaging and a core biopsy. Physiatry was consulted due to his functional deterioration that precluded him from returning to his previous independent living arrangement. He demonstrated diffuse, mild weakness throughout the right arm that was variable and seemed to be correlated with his reported pain level, but his most consistent and weakest movement patterns were his grade 4/5 weakness in finger abduction and distal interphalangeal joint flexion. He had reduced pin prick sensation over the volar surface of digits 3–5, palm and forearm of the right arm and hand. He was not able to perform transfers to or from his manual wheelchair due to his level of pain. The magnetic resonance imaging (MRI) revealed a heterogeneously enhancing mass with a maximum diameter of 6.9 cm (Fig. ) that involved the right deltoid and pectoralis major muscles. His core biopsy demonstrated a STS that was classified as a high grade (III) spindle cell sarcoma.
Oncology recommended treatment for his STS with a course of outpatient neo-adjuvant radiation therapy followed by gross total resection with wide margins. Physiatry pre-operative consult focused heavily on functional prognostication. The patient expressed multiple times that he placed the highest priority on return to his previous modified independent living arrangement and not only survival after his STS treatment course.

[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 27-year-old woman presented to a local physician with an intermittent epistaxis and a facial pain around her nose. Her medical history was unremarkable. Computed tomography (CT) scan demonstrated a heterogeneously enhanced mass lesion centered in the left nasal cavity [].
She was referred to our institute for surgical treatment of a nasal cavity tumor. On admission, she suffered from anosmia and diplopia. CT scan, performed 3 months after the first scan, demonstrated that the enlarged mass lesion breaking through the medial wall of the left orbit and pushed the eye laterally []. We considered this might be the reason for her diplopia. For tissue diagnosis, the patient underwent endoscopic exploration from the nasal cavity. Because of heavy nasal bleeding, we combined midfacial degloving approach. Although we could control the bleeding, we could not resect the complete tumor.
Hematoxylin and eosin-stained sections showed neoplastic cells forming small intracellular lumina that included red cells. The endothelium covering blood vessels was hyperplastic. No mitosis and necrosis were observed []. The Ki-67 labeling index was 28%. Immunohistochemical analysis was positive for factor VIII-related antigen, vimentin, CD34, and CD31 []. EHE was diagnosed on the basis of the aforementioned findings.
Magnetic resonance images indicated that the tumor had invaded the anterior skull base dura matter []. Digital subtraction angiography indicated bilateral ethmoidal arteries as major feeding arteries to the tumor. Because of the aggressive nature of EHE, the cancer board of Tohoku University Hospital agreed radical surgery of the tumor utilizing anterior skull base dissection and endonasal endoscopic exploration.
Before the operation, spinal drainage was introduced to reduce brain retraction. Neurosurgeons conducted bilateral frontal craniotomy and excised the anterior skull base dura where the tumor had invaded. The left anterior and posterior ethmoidal arteries were coagulated

[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 female with no previous history visited a local hospital due to right wrist pain and swelling caused by falling. She was diagnosed with a distal fracture of the right radius, underwent splinting, and returned home. When she visited the local hospital again 2 days after the injury, blister formation on the right forearm was observed, and she was referred to our hospital. The blister was observed along the splint application area () and was considered to be due to the heat and stuffiness of the splint. Plain X-ray examination revealed a distal radius fracture accompanied by dorsal displacement of the distal bone fragment (AO classification: type A2) (Figures and ). Based on the skin condition, we considered conservative treatment by external fixation using a splint or cast to be difficult, and surgery after improvement of the skin state would be more invasive due to bone union and, therefore, planned minimally invasive locking plate osteosynthesis.
As we previously reported, surgery was performed using the Henry approach through a 10 mm incision starting from 15 mm proximal to the radial styloid process at 9 days after injury []. In this patient, there was no skin lesion at this incision site, which allowed this surgical technique (). After reduction of the distal bone fragment using a Kirschner wire, osteosynthesis was performed using a volar locking plate (Acu-Loc 2 proximal plate standard, Nihon Medical Next, Osaka Japan) (Figures and ). After the operation, a favorable alignment was obtained (Figures and ). The wrist was immobilized postoperatively in a bulky dressing without an arm splint until the tissue swelling had decreased.
All muscles, vessels, and nerves of the anterior compartment—except the radial artery—were retracted ulnarly. The pronator quadratus was incised transversely at its distal portion and dissected off the periosteum using a periosteal elevator preserving its ulnar and radial insertions. Therefore

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


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

[User]
RADIOLOGY NOTE:
An 84-year-old female, nursing home resident, with a past medical history of type II diabetes mellitus, hypertension, cerebrovascular accident, anoxic brain injury with permanent percutaneous endoscopic gastrostomy (PEG) tube and tracheostomy to ventilator was noticed to have a high peak pressure on the ventilator on a routine check by the nursing home respiratory therapist. Suctioning was attempted but was unsuccessful. The tracheostomy tube was changed and during the process, increased resistance was felt. Soon thereafter it was noticed that blood was leaking from around the tracheostomy tube. Emergency medical services were called and the patient was brought to the emergency department. On arrival the patient was found to be hypertensive with a blood pressure of 160/74 mmHg, heart rate of 80 beats per minute, respiratory rate of 18 breaths per minute, O2 saturation was 100% on 100% FiO2 fraction of inspired oxygen (FiO2) on assist control-volume control + ventilator mode and a temperature of 37.8°C. On examination, the patient appeared to be generally edematous and was found to have crepitus on palpation starting at the forehead proceeding all the way down to the chest, abdomen, pelvis and upper thighs. In addition, her upper arms bilaterally also appeared swollen with crepitus present on palpation. Examination of the head and neck revealed a tracheostomy with tracheal tube in place with slightly pink secretions and what appeared to be dried blood on gauze surrounding the tube. On auscultation of the chest Hamman’s crunch, a crunching sound, synchronized with the heartbeat was present, as well as slightly decreased breath sounds at the right apex. Stat chest X-ray was performed which revealed extensive PM associated with subcutaneous emphysema in the neck and right chest wall (Figure ).
The patient was emergently assessed by an otolaryngologist and tracheoscopy was performed through the stoma with the tracheal tube in place. It was determined the tracheal tube 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 67-year-old man was admitted at 3 h after the onset of severe back pain and bilateral lower limb swelling. He had a history of stroke and hypertension. On arrival at our hospital, his systolic blood pressure was 80 mm Hg, and he had bilateral leg edema with cyanosis. There was no abdominal bruit, elevation of the jugular venous pressure, or dyspnea. Enhanced CT showed an infrarenal AAA (92 × 75 mm2) and a short fistula (7 mm) running between the right lateral wall of the AAA and the inferior vena cava (IVC) ( and ). The IVC was compressed by the aneurysm (). Angiography was not performed. Just after CT scanning was completed, circulatory collapse occurred, and the patient was rushed to the operating theater. The AAA (90 × 70 mm2) was identified via the transperitoneal approach, but there was no retroperitoneal hematoma. After heparinization, the infrarenal aorta was clamped, the aneurysm was opened, and the bilateral common iliac arteries were occluded with balloon-tipped catheters. Then, we detected a fistula communicating with the IVC via a 7-mm defect in the right lateral wall of the aorta at 3 cm proximal to its bifurcation (), corresponding to the lesion detected preoperatively by CT. There was considerable atheroma around the defect. As soon as the atheroma was removed, massive venous bleeding occurred. Despite digital compression, we could not identify the fistula accurately because of massive bleeding. Accordingly, two balloon-tipped catheters (balloon size: 12 Fr) were inserted through the fistula, and the bleeding was controlled. The fistula was found to measure 22 × 35 mm2 in diameter. It was closed with running sutures of 5-0 polypropylene and a Dacron patch (). Then, the AAA was replaced with a 16 × 8 mm2 bifurcated Hemashield graft (Boston Scientific, Boston, MA, USA). The aortic clamp time was 60 min, and operating time was 161

[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 female patient aged 1 year 8 months old presented to the emergency department after falling on an outstretched hand. On radiograph imaging (Figure ), a supracondylar fracture Gartland type III was diagnosed. On her first neurovascular survey, no abnormalities were noticed. The patient was operated on the next day. After closed reduction, two 1.4-mm Kirschner wires in a cross-configuration were placed to stabilize the fracture. On the lateral side, the wire was inserted percutaneously, and the medial pin was placed under direct bone vision. Good and stable fracture reduction was achieved (Figure ). After surgery, the patient was placed in a posterior splint with 60° flexion at the elbow. A neurovascular examination was done, but no neurologic deficit (motor or sensory) was identified, although no documentation of specific sensation testing is found. Active finger movements were observed. The child was released from the hospital on the second day after surgery, with an outpatient clinic follow-up visit programmed 3 weeks after surgery.
No motion was allowed at the elbow joint for all this period. The pins were removed after 3 weeks at the outpatient clinic visit (Figure ).
About 6 weeks after surgery, the child began oral antibiotic treatment (Augmentin), which was prescribed by a physician in the community because of a skin infection on the fifth fingertip, on the fractured side. The mother saw the child bite her finger continuously. After a few days of treatment, the child was referred to the hospital because of lack of response to the antibiotic treatment. On her admission to the pediatric orthopaedics unit, amputation of the distal phalanx was noted, and radiograph imaging confirmed the diagnosis (Figures and ). A child abuse workup (total body examination and a social worker inquiry) that was done after admission ruled out this option. We started treatment with systemic intravenous antibiotics (Cefamezin 30 mg/kg) and topical treatment (Syn

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


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

[User]
RADIOLOGY NOTE:
A 24-year-old man visited the hospital with oval shape mass in right mandibular angle, which had grown slowly from 3 years before the visit to the hospital as main complaint. There were no particular apparent traumas and no other medical history other than asthma. A soft mass of 5×4 cm in size on physical examination was palpated, there was no presence of facial nerve weakness, and he was complaining that he felt as if the face of the affected side, was turned to ipsilateral direction ().
A well-defined lobulated mass of 4 cm in size was found in the deep lobe of right parotid gland from Magnetic resonance imaging (MRI) scanning and a pleomorphic adenoma was suspected (). We planned a total parotidectomy and decided to use the ADM to correct for the predicted depression. The mass was located at deep lobe as shown in the MRI images and a total parotidectomy was performed. 5 branches of facial nerve were identified during the surgery and all of them was preserved. The material known as ADM of 4 cm×7 cm in size, 3.4 mm thickness (Flex HD, Ethicon Co. LLC., Somerville, New Jersey and Cincinnati, OH, USA) were adequately trimmed for the depressed part from where the mass was removed. The part between the cheek flap and nerve were augmented centering the depressed site after the mass was removed. After the closed draining tubes were inserted over and under the ADM, the site was sutured (, ).
Drains were drained by 27 mL/day a day after surgery in bloody character, gradually became serosanguineous, and decreased in volume and drained to less than 10 mL/day 3 days after surgery, but were removed somewhat later. We removed superficial one and cut deep one to allow drainage naturally 5 days after surgery, and removed deep one 7 days after surgery. The surgery site was healed well without any complications such as seroma or

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


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

[User]
RADIOLOGY NOTE:
A 19-year-old male was referred to the Department of Conservative Dentistry and Endodontics with a chief complaint of pain and swelling in his upper right front region. His medical status was noncontributory. After questioning, it was learnt that 5 years back he had got his upper jaw hurt in an accident. After 3 years, he developed swelling in the upper front region and consulted a local dentist. The dentist did root canal treatment of right central and lateral incisors. For next 1 year, the patient was asymptomatic, but there after, he again developed swelling and pain in the upper front region. It was at that point of time he came to our department.
An extraoral examination revealed a diffuse swelling on the right side of upper lip. An intraoral examination showed discolored and tender maxillary right central and lateral incisors. Periapical radiographs showed poorly obturated canals and a large radiolucent lesion with a well-defined margin around the apices of teeth 11 and 12 []. The lesion was approximately 13 × 17 mm in maximum diameter. After evaluating all the data, a root canal retreatment of teeth 11 and 12 was planned. A rubber dam was applied, and the access cavities were prepared. The drainage of pus was noted from both teeth. Both teeth were instrumented to ISO size 60 by using the step-back technique. During instrumentation, the canals were irrigated with 3% sodium hypochlorite and then dried and dressed with calcium hydroxide. During the next 3 weeks, the patient was examined weekly, and in each visit the calcium hydroxide dressing was changed. After 3 weeks, the swelling had subsided, but the patient complained of constant dull pain and heaviness in the concerned region. The canals were wet and showed mild discharge. The treatment procedure was changed. The canals were irrigated and dried, a triple antibiotic paste was placed, and the teeth were temporized. The paste was changed every month for a

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


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

[User]
RADIOLOGY NOTE:
A 78-year-old male was brought to our department with the complaint of painful, progressive, and nonhealing ulcerated lesion of the tongue for 2 months. He did not give any history of fever, night sweats, cough, decreased appetite, or significant weight loss. There was no history of change in voice or choking. He did not give history of traumatic episode preceding the development of that wound. He denied any history of similar lesions in the past. He was a known case of hypertension taking antihypertensive medications. Besides having hypertension he denied history of other systemic illnesses including pulmonary tuberculosis. He admitted to smoking and drinking alcohol occasionally. The rest of his medical and surgical history was unremarkable. His past dental history was not significant. There was no history of TB in his family members. He was repeatedly treated in a local hospital with topical antiseptics and oral antibiotics (ampicillin plus cloxacillin and metronidazole) and analgesics but the lesion did not subside so he was referred to our hospital for the further management.
On general examination he was thin built with general conditions being fair, while, on examination of oral cavity, there was an indurated ulcer measuring 1.0 cm × 0.5 cm on the left lateral border of tongue on the anterior two-third part of tongue (). It was tender with irregular border. It did not bleed on touch. The remaining part of the tongue was normal in texture and color. Mobility of tongue was normal. It was not deviated to either side on protrusion. He had poor orodental hygiene along with sharp tooth adjacent to the ulcerated lesion although the multiple teeth were absent. There were no palpable cervical lymph nodes and no similar ulcers in any other body parts.
Provisional diagnosis of traumatic ulcer was made as the possibility of ulcer due to repeated trauma by the sharp tooth could not be ruled out based on the physical examination alone. As we thought it could be due to chro

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


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

[User]
RADIOLOGY NOTE:
A 56-year old woman was presented to the orthopaedic department with a 3-month history of a painless mass in the upper external area of the left gluteus.
Two years, previously she underwent an abdominal hysterectomy because of an enlarging mass found in the pelvis, located between the uterus and the recto-sigmoid area. CA 125 was moderately elevated at 61.9 U/ml. The resected mass was bilobular (9 × 7 × 6, 5 cm and 5, 2 × 5 × 5 cm) with hard and partially soft elements. Multiple intramural uterine leiomyomas were also identified. The tumor was diagnosed as "a leiomyosarcoma" composed of cellular bundles of spindle cells with medium grade atypia and presence of giant cells. The range of mitosis was very high, up to 50/10 H.P.F (high power field). Immunohistochemical analysis with avidin-biotin-peroxidase complex showed positive reaction for vimentin, smooth muscle actin and desmin (Fig and ). The patient was treated post-operatively with radiotherapy and chemotherapy (Gemcitabine and docetaxel).
One year after the hysterectomy, a single metastasis was diagnosed during a routine follow up in the left upper lung lobe treated surgically with lobectomy. The histological diagnosis was compatible with the known primary tumor. One year later, the patient was presented in the orthopaedic department with a painless mass in the left gluteus area. The clinical examination revealed a focal lump in the left gluteal area. The subsequent magnetic resonance imaging study, showed a mass with central necrosis located in the subcutaneous fatty tissue, in close proximity to the gluteal muscles. In addition, a second small lesion with similar findings was detected in the right gluteal muscle (Fig ).
A diagnosis of soft tissue metastasic disease was suggested and a surgical resection of both masses was undertaken. The post-operative period was uneventful. The histological diagnosis confirmed the presence of a spindle cell sarcoma with central necrosis and morphologic features similar to t

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

[User]
RADIOLOGY NOTE:
A 43 year-old female was admitted to our hospital with a chief complaint of right upper pain and palpable mass. On physical examination, there was slight tenderness and semimobile mass in the right upper abdomen. Clinical examination did not demonstrate any persistent weak abdominal pain and mass. Her past medical and surgical history was unremarkable. Moreover, Family history and psychosocial history were also not particular.
In abdominal contrast-enhanced computed tomography (CT), 130 × 100 × 90 mm huge cystic mass was demonstrated in right upper peritoneal cavity. The cyst had thickened wall and many enhanced nodules. Many nodules and the thickened wall were slightly enhanced in early phase (A) and gradually enhanced in delayed phase (B). Gadolinium-enhanced magnetic resonance imaging (MRI) showed that intra-cystic fluid was bleeding or mucinous fluid as the intensity was slightly high in T1WI (C), high in T2WI (D), and slightly high in fat suppression T1WI. The thickened wall of the cyst and mural nodules were high intensity in Diffusion-weighted MRI. The findings of connection with pancreatic head suggested a tumor originated from pancreas. The differential diagnoses were MCN, mucinous cystic adenocarcinoma and hemorrhagic cyst. After an extensive discussion in our institute, we planned pancreaticoduodenectomy for this abdominal tumor.
She was taken to the operating room by a surgical oncologist who primarily specialized in pancreatic resections and had been in practice for over 10 years. In surgical findings, this tumor did not attach to gastrointestinal tract and originated from pancreatic head (A). The aspirated fluid was bloody and the cyst had re-increased for short time in operation. In these reasons, we diagnosed the tumor as hemorrhagic cyst and selected partial pancreatectomy because this tumor was resected completely (B). The cystic wall was thickened and elastic soft. No tumoral change found in the surface of cystic wall (C). Post-operative course wa

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

[User]
RADIOLOGY NOTE:
A 53-year-old man noticed some swelling of his face. A chest x-ray showed a large mass projecting over the right lung field (fig ). A CT scan of the chest showed an enormous anterior mediastinal mass contiguous with the posterior aspect of the sternum and the right ribs, occluding the superior vena cava and compressing the heart (fig ). Blood tests were normal, tumor markers and Acetyl Choline Receptor Antibodies were negative. The patient underwent bronchoscopy and the biopsy showed the features of a carcinoid tumor.
He underwent excision of the tumor, which required resection of the superior vena cava and insertion of a graft, resection of the right phrenic nerve and plication of the diaphragm.
The finding at surgery was an enormous spherical tumor with an extremely vascular capsule due to the venous collaterals. The tumor was 20 cm from pole to pole and 15 cm in diameter. On the left it bulged into the left pleural space, displacing the phrenic nerve laterally. Superiorly it obliterated the left innominate vein and extend into the strap muscles. There was an enlarged lymph node. On the right it had obliterated the confluence of the innominate veins and the first centimeter or so of the superior vena cava. It enclosed the phrenic nerve over its complete length and was adherent to the medial aspects of the upper and middle lobes of the right lung. There was some thickening of the visceral pleura in this area and there appeared to be some superficial infiltration. Posteriorly it was adherent to the pericardium and there was some thickening of the ascending aorta, consistent with longstanding pressure effects. There was a small bloody pericardial effusion and a rather large right pleural effusion. There was no evidence of any pleural deposits or intrapericardial deposits.
The histology of the resection specimen showed a tumor weighing 2.1 kg. The tumor appeared encapsulated with an irregular surface. The tumor invaded the surrounding fat and pleura. There was infiltr

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

[User]
RADIOLOGY NOTE:
Two years ago, an 80-year-old man with intermittent abdominal discomfort in the right lower quadrant of the abdomen was admitted to our department via a local clinic. Although he complained of intermittent abdominal pain and diarrhea, the physical examination and blood test findings were normal. The patient had undergone an intestinal resection at the age of 35 from complications due to tuberculous enteritis. He was currently taking medication for hypertension. A physician in our department performed computed tomography (CT) because of a cystic lesion found within the right lower quadrant of the abdomen through ultrasonography at the referring clinic. The CT scan showed a 5-cm regular hypodense lesion near the cecum without enlarged lymph nodes (). The radiologist indicated that the lesion resembled an AM, but was most likely terminal ileitis due to a postoperative adhesion or the tuberculous enteritis.
The patient did not come to hospital for checking the CT results. He then experienced chest pain and visited the Cardiology Department. Coronary angiography revealed angina pectoris, for which he was treated for 3 months. His cardiac problems were resolved, and he revisited the outpatient Gastroenterology Department. At that time, his physician recommended surgery, but he and his guardian refused because of his medical history of cardiac problems. They requested medication instead. For 1 year, the patient was regularly followed up by the outpatient Gastroenterology Department. We repeated the CT scan at 1 year and found that the mucocele had increased to 6 cm (). Again, we recommended surgery, which the patient refused. Three months later, he was admitted to the Emergency Department with abdominal pain and a fever of 38.3℃. His white blood cell (WBC) count was 15.8×103/µL, and his C-reactive protein (CRP) level was elevated (146 mg/L). On physical examination, we found a 7-cm cavity in the right lower quadrant that showed tenderness, heat, and erythema. We performed

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

[User]
RADIOLOGY NOTE:
A 31-year-old female patient complained a mass in her maxilla and mandible. The mass was gradually increasing in size over the last 6 months. The mass caused talking disturbances, swallowing difficulty, dilating gap between upper teeth, and narrowing gap between lower teeth. She also complained hard masses in her fingers and the middle of chest. There was a decrease in height (15 cm in 8 years) and weight (19 kg in 8 years). The patient was on end stage of renal failure and has been treated with hemodialysis 2 times per week for eight years since 2008. The patient was planned to be performed renal transplantation. Comorbidities were reported among this patient, which are chronic heart failure, grade II hypertension, lung tuberculosis on therapy, and hepatitis C. The physical examination showed facial asymmetry with mass in the palatum durum, measured 4 × 3 cm in size (). Palpation revealed hard consistency originated from the bone, smooth surface, and no tenderness.
X-ray of the maxilla and mandible showed diffused decreasing bone density and multiple lytic lesion, which suggest metabolic bone disease or renal osteodystrophy or hyperparathyroidism (). BNO showed compression fracture in thoracolumbar vertebrae and multiple calcification in soft tissue abdominal and pelvic region compatible with renal osteodystrophy. Bone survey also showed the decreased bone density. Facial CT with contrast showed diffuse hyperostosis, lytic lesion in the mandible bone, maxillary bone, cranium, and multiple calcification in the soft tissue which is compatible with osteorenal dystrophy (). Thyroid ultrasonography showed bilateral multiple cysts in the thyroid, a firm lesion with calcification in the left parathyroid fossa, and oval lesion in the left pericarotid. Parathyroid scan showed an increased activity in the inferior aspect of left thyroid which was suggestive of parathyroid adenoma.
Laboratory examination showed the elevated ureum (202 mg/dL), creatinine (11.1 mg/dL), and norm

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

[User]
RADIOLOGY NOTE:
An 80-year-old man with Marfan syndrome and no previous cardiac history collapsed on hospital grounds after complaining of bilateral shoulder pain. Within a few minutes, two doctors at the scene started performing chest compressions. The patient was immediately transferred to the emergency room where he was intubated and defibrillated twice due to ventricular fibrillation (), with return of spontaneous circulation (ROSC) in between the two shocks (). During resuscitation, he was treated with adrenaline and amiodarone.
After a second ROSC, cardiac rhythm converted to atrial fibrillation with ST segment elevation in the leads corresponding to the anterior wall. As part of the treatment, he received magnesium 2 g, heparin bolus 5000 IU, and 300 mg aspirin by nasogastric tube.
The patient was admitted to the intensive coronary care unit. On admission, the electrocardiogram showed rapid atrial fibrillation with ST segment ele-vation resolution (). Due to hemodynamic compromise, electrical cardioversion was performed, converting to sinus rhythm with diffuse ST segment depression and an ST elevation in lead aVR (). The patient was taken urgently to the cardiac catheterization laboratory due to ST changes and hemodynamic instability. The angiography demon-strated significant two-vessel disease, and a drug-eluting stent was implanted successfully to the proximal to mid-left anterior descending artery (LAD).
During the early post-procedural period the patient became hemodynamically unstable; bedside echocardiography demonstrated accumulation of a new pericardial effusion. The differential diagnosis included coronary artery perforation versus cardiac laceration. After a brief discussion with the heart team, the patient was transferred for a second time to the catheterization laboratory in order to implant a cover stent in case there was indeed a coronary perforation and pericardiocentesis was needed for the accumulated pericardial effusion.
During angiography, instant stent th

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


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

[User]
RADIOLOGY NOTE:
A 23-year-old male was referred to the emergency unit because of rapidly progressive gait difficulties with subacute onset.
The patient had a history of depression and substance use disorders (alcohol and amphetamine). He was treated as an outpatient at the department of psychiatry. Current medications included citalopram 40 mg, hydroxyzine 25 mg and quetiapine 50–100 mg per day, and oxazepam 15 mg as needed. A year before presentation, the patient had a transient episode of mild gait difficulties with unclear aetiology that had resolved spontaneously. At that time, he had gait ataxia with signs of upper motor neuron damage in all extremities. Brain and cervical spinal cord MRI were unremarkable, except for mild atrophy of the cerebellar vermis and frontal cortex, which were interpreted to be related to the long-term alcohol abuse.
The patient presented at the university hospital emergency care unit (ECU) with a 2–3-week history of progressive, painless gait difficulty associated with numbness in the hands. The patient had been abstinent from alcohol and amphetamine at least for the past 6 months, which was confirmed by regular laboratory investigations. However, the patient reported having replaced these substances with excessive daily ‘whippet’ abuse. He had discontinued ‘whippet’ use and started oral vitamin B12 substitution based on the information he found on the Internet a couple of weeks before presenting to the ECU. At the time of presentation, the gait difficulty had progressed to a state that he was unable to walk unaided.
In the ECU, the patient showed bilateral lower extremity weakness that was the most prominent in distal lower limb muscles. In addition, there were minor distal paraesthesias in all extremities. Vibration sense was absent up to the knee level, but all other sensory modalities were intact on clinical examination. Deep tendon reflexes were 2+ in the upper limbs but absent in the lower limbs. Plantar reflexes were evaluated as extensions in

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


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

[User]
RADIOLOGY NOTE:
Mr. R, a 21-year-old gentleman from South India, who worked in a cellphone shop, was brought to the hospital with sudden onset breathlessness gradually worsening for the last 2 days. He also complained of generalized weakness and muscle pains. There was no premorbid illness or history of drug intake. On arrival to the hospital, he was found to have tachypnea, tachycardia, and was in hypotension. Chest examination revealed bilateral crepitations. Cardiovascular system did not reveal any murmurs. Abdomen and central nervous system (CNS) examination did not reveal any abnormality. His oxygen saturation was low, and the arterial blood gas analysis (ABG) was done which revealed type 1 respiratory failure with severe metabolic acidosis and lactic acidosis [].
The patient was immediately intubated and given fluid resuscitation and shifted to the medical intensive care unit (ICU). His initial hemogram and biochemical investigations revealed leukocytosis, with acute renal failure and deranged liver function tests [].
Chest radiograph revealed bilateral lower zone haziness and electrocardiogram revealed sinus tachycardia. Cardiac enzymes and echocardiogram did not reveal any abnormality.
In the ICU, he was investigated for his oliguric renal failure. His creatinine phosphokinase (CPK) was high, which was suggestive of rhabdomyolysis. In view of the worsening renal function and oliguria with severe metabolic acidosis, he was dialysed after consultation with the nephrology team. He continued to require daily dialysis in the ICU. His ventilatory parameters improved gradually, and he was extubated on the 7th day of the admission and shifted to the ward on the 9th day.
He was worked up extensively for his renal failure and rhabdomyolysis, including a muscle biopsy which was inconclusive. After ruling out infectious and autoimmune causes, a heavy metal screen was requested. The heavy metals were checked in the patients' blood by inductively coupled plasma mass spectrometer (ICP-MS)

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

[User]
RADIOLOGY NOTE:
A 73-year-old Asian woman with an underlying anxiety disorder, functional headache, and hypertension was prescribed escitalopram and lorazepam when she presented with progressively worsening headaches to her primary care doctor. Her symptoms did not improve with the medications, and she was unable to eat well and required bed rest. She was transported to our hospital 4 days later after developing chest and back pain with altered consciousness. She was a housekeeper, had no allergies, and had no alcohol or tobacco smoking history. On arrival, her Glasgow Coma Scale score was 3/15 (E1V1M1); both pupils were approximately 4 mm in diameter and reactive. Her blood pressure was too low to be measured, her carotid artery pulse was palpable, her heart rate was 112 beats/minute, and her respiratory rate was 30 breaths/minute. Her conjunctiva was pale. An auscultation of breath sounds did not reveal upper and lower airway obstructions and was within normal limits. Her abdomen was soft and flat without tenderness. She had no skin abnormalities (such as rash). Both legs had no edema. Echocardiography on arrival was performed as point of care ultrasound and revealed a hypercontractile left ventricle with an eliminated left ventricular cavity and a collapsed inferior vena cava without right ventricular dilation. There was no pericardial effusion or obvious large regurgitant jet observed on color Doppler. In response, we immediately inserted a peripheral venous catheter and began introducing fluid resuscitation; however, she developed PEA. Conventional CPR according to the adult advanced cardiovascular life support guidelines (including adrenaline) was initiated and a return of spontaneous circulation (ROSC) occurred. However, her blood pressure was unstable and PEA returned, prompting repeated CPR with immediate administration of fluids and three adrenaline injections. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) was initiated for refractory PEA. Whole-body contrast

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

[User]
RADIOLOGY NOTE:
A 78-yr-old woman presented with gross hematuria for 2 weeks on November 23, 2009. There was no history of urologic problems. The patient was a non-smoker and had not been exposed to carcinogen. Physical examination and vital sign were normal
At the time when the patient was admitted to this hospital, numerous RBC were observed on urinalysis. There were no notable findings on blood test and chest radiography. On cystoscopy, a frond-like mass was observed at the bladder trigone, which measured about 1 cm (). Since hematuria continued, Foley catheterization was performed.
On computerized tomography (CT) of the abdomen and pelvis, the findings of enhancement and a small-sized mass were observed on the inner surface between posterior walls in the bladder trigone. The findings of perivesical infiltration and lymph node metastasis were not observed.
On the authority of above findings, the authors suspected the case to be carcinoma in situ of the urinary bladder or transitional cell carcinoma, and thus transurethral resection of bladder tumor (TURBT) was performed.
On histopathological examination, it was found that 90% of lesions were LELCA and a few lesions were non-invasive transitional cell carcinoma.
On microscopy, syncytial growth pattern and indistinct cytoplasmic borders were observed with the severe infiltration of lymphoid cells. The findings of necrosis and mitosis were observed in many regions. It was found that tumor cells invaded the whole lamina propria. Non-invasive transitional cell carcinoma was concomitant fractionally ().
On immunohistochemical staining, tumor cells were positive for cytokeratin 7 but were negative for cytokeratin 20 (). The infiltrated lymphocytes were composed of abundant CD3 positive T cells and CD20 positive B cells. For leukocyte common antigen (LCA), lymphoid cells were positive but tumor cells were negative (). In situ hybridization for Epstein-Barr virus was negative.
The patient has been without recurrence and metastasis for 3

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