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

[User]
RADIOLOGY NOTE:
An 81-year-old female patient presented to our emergency department with acute onset of hematemesis and melena. On admission, the patient appeared to have a poor general health condition and was hemodynamically compromised. Her initial laboratory exams revealed a hemoglobin concentration of 7.7 mg/dl without leukocytosis or C-reactive protein (CRP) elevation. The patient had a history of a 6.5 cm gastrointestinal stromal tumor (GIST) of the cardia, for which she initially received downsizing treatment with imatinib 400 mg/d, followed by surgical resection of the gastroesophageal junction and reconstruction with a jejunal interposition (Merendino procedure) 4 years earlier (). Histopathological studies of the tumor revealed a T3-tumor with a positive c-Kit mutation in exon-11 and a Ki-67 proliferation rate of 15%. The risk for disease progression based on Miettinen's criteria was determined as high (size > 5 cm; mitosis rate > 5/HPF), and the patient was subsequently placed on 1st line adjuvant therapy with imatinib 400 mg/d []. After two years on 1st line treatment, the patient developed hepatic and peritoneal metastasis and was placed on sunitinib as 2nd line therapy for metastatic GIST. Treatment with a proton pump inhibitor (PPI) was suspended for an unknown reason two years prior to presentation.
The patient was immediately transferred to our intensive care unit, where she was intubated and received two units of packed red blood cells (pRBCs). An emergency gastroscopy was carried out, which revealed active bleeding from a vessel stump in the jejunal interposition, corresponding to a Forrest stage I b upper gastrointestinal bleed. The bleeding was successfully stopped endoscopically by local injection of adrenaline and the application of polymer powder. A CT scan of the thorax and abdomen showed no signs of active bleeding or free abdominal fluid (). The known hepatic and peritoneal metastasis were described as constant in size, but increasingly necrotic compared

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


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

[User]
RADIOLOGY NOTE:
A 47-year-old woman was admitted to the Nagoya City University Hospital, Nagoya, Japan, complaining of an abdominal swelling that had been present for the past 12 months. Her abdomen was markedly swollen and felt hard without tenderness. Peripheral blood examination revealed slight anemia and slight elevation of C-reactive protein. No other disorders, including any tumor markers, were detected. A computed tomography scan (CT) showed two masses in the retroperitoneum, one of which was 26 × 15 × 29 cm and enhanced slightly, and the right kidney was involved and pushed aside. Almost all retroperitoneal cavities were filled with the giant tumor. The other mass was walnut-sized tumor adjacent to the large one, and mostly of low density. Magnetic resonance imaging (MRI) revealed the giant tumor was T1-low intensity and T2-high intensity, but the small tumor was T1-high intensity, with a changed low signal in fat suppression (). This indicated that the small tumor was mainly fat-containing, and the giant tumor appeared to be mainly composed of mucinous tissue. Under general anesthesia, the tumor was excised with the right kidney en bloc. There was not much adhesion to surrounding tissues. Upon gross examination, the tumor was well circumscribed and encapsulated and weighed 8.5 kg (). The tumor had two components as determined by CT and MRI. The two components were very clearly divided. The small one was yellowish, and histopathologically, they were mainly composed of fat cells that varied in size, that is, mature-appearing adipose tissue with scattered lipoblasts exhibiting large hyperchromatic nuclei. Immunohistochemical analysis revealed that the cells were strongly stained by S-100 protein which is a marker for fat (). Therefore, this small tumor was diagnosed as a well-differentiated liposarcoma. On the other hand, giant tumor was white and, histopathologically, mainly contained abundant mucinous mesenchyme and filled with atypical spindle cells. There was extensive in

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


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

[User]
RADIOLOGY NOTE:
A 53-year-old man was admitted to our cardiology department with exertional angina. He had hypertension and hyperlipidemia as cardiac risk factors. On physical examination, the patient’s vital signs were unremarkable and he had a New York Heart Association functional capacity of II. The respiratory and cardiovascular examinations were normal. The electrocardiogram showed nonspecific ST–T wave changes in leads V1–V6, and the laboratory work was within the normal range except for a low-density lipoprotein level of 170 mg/dL. The exercise stress test was nondiagnostic, and the myocardial perfusion scan revealed inducible ischemia in the anterior septum, mid, and basal portions of the anterior wall. Cardiac catheterization was performed and showed a giant left main coronary artery aneurysm ( and ). All of the left coronary system arose from the aneurysm. The patient had no history of Kawasaki disease in childhood, and nor was the type of the lesion compatible with Kawasaki disease. Multidetector computed tomography coronary angiography confirmed a huge left main coronary artery, measuring 33 × 28 mm in size ( and ). Because of the nonobstructive coronary artery disease in the other parts of the coronary system, the patient was managed with medical treatment. After 3 months of treatment, he referred to us again with exertional angina, which continued for more than 10 minutes. Coronary angiography illustrated no changes in his coronary system. After consultation with the cardiovascular surgery department, the patient was followed up with medical therapy. In the first hospitalization, medical therapy included acetylsalicylic acid (100 mg once a day), metoprolol (50 mg once a day), ramipril (5 mg once a day), isosorbide mononitrate (50 mg once a day), and trimetazidine HCL (35 mg twice a day). After the second hospitalization, warfarin treatment was added because of the giant aneurysm and slow flow. The patient’s first visit was in March 2013, and he was subsequently follow

[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 case illustrates a 20-year-old female diagnosed with MS at the age of 17. She was initially treated with tocilizumab as neuromyelitis optica was suspected due to bilateral optical neuritis and the presence of spinal cord lesions. However, antibodies against aquaporin-4 and myelin oligodendrocyte glycoprotein were not detected and the magnetic resonance imaging (MRI) of the brain and spinal cord as well as cerebrospinal fluid (CSF) findings were supportive of MS. Apart from persistent bilateral severely reduced visual acuity she had no other signs of neurological dysfunction. She had previously been in good health and had no family history of PID, or other systemic inflammatory diseases.
Eighteen months prior to the episode of arthritis and skin symptoms reported here, she was started on off-label treatment with rituximab (RTX). RTX is the most frequently used immunomodulatory drug for MS in Sweden according to the Swedish MS registry (). Initially, she received 1,000 mg of RTX followed by 500–1,000 mg every 6th month, resulting in depletion of circulating B-cells (<0.001 ×109/L). During this period, there were no signs of neuroinflammatory activity of MS.
A rheumatologist confirmed the diagnosis of monoarthritis. The right knee had typical signs of inflammation with rubor, tumor, and calor accompanied by a discretely reduced range of motion. The general status was good without fever. The lower right leg was diffusely swollen and two circular erythematous areas around the ankle were seen (). A dermatologist interpreted the skin symptoms as possible panniculitis with atypical erythema nodosum as a potential alternative diagnosis. There were no other clinical or laboratory findings of sarcoidosis.
Treatment with RTX had been ongoing for approximately one and a half year prior to the onset of arthritis and the cutaneous symptoms had been present for at least 6 months prior to the diagnosis. The last dose of RTX was given 1.5 months before the onset of symptoms rela

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


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

[User]
RADIOLOGY NOTE:
A 35-year-old gravida 3, parity 2 woman was admitted to the hospital for vaginal bleeding and severe abdominal pain. Her past medical history was free of any medical problems. On her obstetric history, she had a vaginal delivery following an uneventful pregnancy course 8 years ago. Her second pregnancy was terminated via hysterotomy at 18th weeks due to multiple fetal abnormalities including hydrocephalus. She was diagnosed to have total anterior placenta previa on her third pregnancy. This last pregnancy was otherwise uneventful and the patient gave birth to a term, healthy infant via planned repeat cesarean section in a private hospital. During the operation, partially adherent placenta had been detected and the adherent part of the placenta had been left in situ. Postoperative treatment had not been given. 20 days after the operation, she had been hospitalized due to massive vaginal bleeding and had been transfused four units of packed red blood cells since her blood count revealed severe anemia with a hemoglobin level of 5.6 gr/dL. She had been discharged from hospital three days later. However, one week later, she had presented to another center due to vaginal bleeding and pelvic pain. She had been referred to our hospital with a presumptive diagnosis of placental retention because ultrasonography showed soft tissue density with irregular contour in the endometrial cavity (). On her admission, she had findings consistent with acute abdomen and moderate abdominal distention was detected. Her blood pressure was 90/60 mmHg and heart rate was 110/minute. Hemoglobin was 8.5 gr/dL on complete blood count. Ultrasonography revealed free fluid filling the pelvis and lower abdomen. Her serum human chorionic gonadotropin was negative. After obtaining informed consent including hysterectomy, an emergency laparotomy was performed. Following drainage of approximately 1000 mL of free blood from the abdominal cavity, a full-thickness defect on the anterior wall of the uterus w

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


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

[User]
RADIOLOGY NOTE:
A 22-year-old man, weighing 65 kg, was admitted to our hospital to evaluate a murmur in the routine examination. He had complained of mild shortness of breath on physical exertion for one month. Physical examination on admission revealed a systolic murmur in the left para-sternum, trans-thoracic echocardiography showed a subarterial VSD with a diameter of 8 mm, left to right shunting, pressure gradient via the defect was 70 mmHg. The left ventricle dilated mildly with left ventricle end-diastolic diameter was 57 mm and left ventricular ejection fraction was normal range. Pulmonary artery systolic pressure was 33 mmHg at rest. Mild aortic regurgitation was present.
The patient was conducted under general anesthesia with a single-lumen endotracheal tube and placed in supine position as for standard median sternotomy with two arms along the body. Defibrillation pads were placed on the right and left chest before sterile draping. The femoral artery and vein were dissected in preparation for cannulation with a 2–3 cm oblique right groin incision. A 4 cm left parasternal thoracotomy was used to enter the thorax via the third intercostal space (ICS). The left internal thoracic artery was preserved carefully. The third costal cartilage was divided close to the sternum, without resection, to increase exposure. The ribs were slowly spread with a mini-thoracic retractor. The pericardium was opened longitudinally and suspended with stay sutures. The femoral artery cannula was inserted directly into the common femoral artery. A multi-stage venous cannula was inserted using the Seldinger technique with the tip of cannula advanced to the superior vein cava under transesophageal echocardiography guidance. After femoral arterial and venous cannulation, cannulas were secured, and cardiopulmonary bypass (CPB) initiated. CPB was initiated with vacuum-assisted venous drainage and body temperature maintained at approximately 34 °C A long cardioplegia needle (Livanova, London United Kingd

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


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

[User]
RADIOLOGY NOTE:
A 55-year-old female, P3003, presented with postmenopausal spotting on and off for the past 6 months, cough with expectoration, and significant weight loss for past 2 months. For these complaints, she had been put on empirical antitubercular drugs at some outside hospital. She took these medications for 2 months but had no improvement in her chest condition and rather the bleeding episodes and pain in lower abdomen increased significantly. She was then referred to our center. The patient was nondiabetic and nonhypertensive, and there was no history of long-term exposure to estrogen. She was postmenopausal for 3 years. On examination, her general condition was poor. She was cachexic with weight 27 kg and body mass index of 15 kg/m2. On auscultation, bilateral air entry was decreased and rhonchi were present. Abdominal examination revealed a scaphoid abdomen and a lump corresponding to 14 weeks size gravid uterus, hard in consistency, and restricted mobility in the suprapubic region. On per speculum examination, the cervix could not be visualized as it was pointing acutely forward. Hence, cervical screening and endometrial biopsy could not be done. On bimanual examination, a hard mass of around 14 weeks was felt, which was nonmobile and nontender.
Her hemoglobin was 7.1 g%. Rest all investigations were within normal limits. Ultrasonography showed evidence of a well-defined heterogenous hypoechoic mass lesion 20 mm × 17 mm in part of the myometrium of the fundal region likely intramural fibroid and bulky uterus. However, the magnetic resonance imaging (MRI) report was suggestive of endometrial carcinoma involving more than half of the myometrium. Computed tomography (CT) of the chest was advised to rule out metastasis. However the patient was lost to follow-up for about 2 weeks when she returned back with CT report suggestive of traction bronchiectasis and discrete random nodules with feeding vessel signs in the right lower lobe of lung, likely

[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 baby with a birth weight of 750 g and a male baby with a birth weight of 930 g were born at the gestational age of 26 weeks from a 29-year-old mother. Pregnancy was complicated by the preterm rupture of the membranes. The twins were resuscitated after birth, and they were intubated and surfactant therapy was administered. The male patient was extubated on the fourth day and was started to be followed up with nasal continuous positive airway pressure (CPAP). On the postnatal 28th day, the male patient was separated from CPAP and was started to be followed up with free oxygen. However, mechanical ventilation was continued in the female baby. The patients’ lung radiographic and clinical findings were compatible with severe BPD. It was decided to give MSC treatment on the postnatal 32nd day to both patients. Mesenchymal stem cells (2x106/kg) were given by the intravenous route and 1x107/kg MSCs were given by the intrathecal route. The patients were monitored using lung USG and the images were recorded.
Atelectasis, consolidation, pleural line abnormalities, alveolar interstitial syndrome (AIS), B lines, and air bronchograms were seen on USG examinations of the lung in both patients before treatment. No significant change was found in lung USG repeated twelve hours after stem cell treatment (, ). Ultrasound examination of the lung performed in the female patient three days after treatment and revealed pulmonary consolidation, partial resolution in divided areas, atelectatic regions, and also, it was observed that pleural line abnormalities persisted. In the male patient, lung USG revealed that B lines and AIS disappeared, but pleural line irregularity persisted.
Lung USG of the female patient performed nine days after the treatment showed that pleural line irregularity reduced, A lines became prominent, and AIS areas gave place to B lines, and the patient’s need for oxygen decreased. A USG examination of the male patient revealed that A lines started to become p

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


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

[User]
RADIOLOGY NOTE:
A 26-year-old woman of Cypriot origin presented with an acute onset of palpitations and chest tightness. She reported several weeks’ history of similar palpitations, however, this was the first occasion that the sensation had not self-terminated within minutes and had been associated with discomfort.
There was no further medical history of note, no relevant family history, and no regular medications. Our patient admitted to a moderate alcohol intake although no recent intoxication and no recreational drug use.
On assessment in the Emergency Department, her electrocardiogram (ECG) demonstrated a narrow-complex tachycardia with a rate of 194 beats per minute (bpm) (Fig. ). Her heart rate varied between 180 and 210 bpm and her blood pressure was 187/101 mmHg on first recording. Suspecting SVT, the assessing emergency physicians proceeded with vagal maneuvers, to no clinical effect. Next, an intravenous bolus dose of 6 mg adenosine was administered. This was followed by immediate development of coarse VF (Fig. ) and circulatory collapse. Rapid deterioration to a fine VF ensued. She was successfully defibrillated with a single 150 J direct current shock. There was immediate return of spontaneous circulation and hemodynamic stability. A 900-mg loading dose of intravenous amiodarone was commenced and our patient was admitted to the cardiac high dependency unit. No further arrhythmias were identified.
Investigations revealed normal serum electrolytes, negative serial troponin measurements, normal thyroid function, and negative blood ethanol level. A urine drug screen was negative. A chest radiograph demonstrated clear lung fields. The presenting ECG was reviewed, and was likely to be that of AF with a rapid ventricular response, but with no clear ventricular pre-excitation. Similarly, her ECG in sinus rhythm had no features of ventricular pre-excitation (Fig. ). The Q-Tc interval was within normal range and there were no features of Brugada syndrome. In view of the developm

[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-month-old female infant had coronary reimplantation at age 3 months for ALCAPA. Postsurgical ejection fraction showed early improvement with subsequent deterioration. A diagnostic left heart catheterization performed as part of a heart transplant evaluation revealed severe ostial stenosis of the LMCA. She was referred for PCI of the left main coronary artery to relieve her heart failure and preempt transplant. Her physical exam was significant for congestive heart failure and failure to thrive. The patient's echocardiogram showed markedly depressed left ventricular function. A cardiac computed tomography angiography (CTA) and initial diagnostic nonselective root aortogram demonstrated stenosis of the LMCA at the site of ALCAPA reimplantation. Selective left coronary angiogram revealed severe kinking of the reimplanted LMCA at the ostium ().
The procedure was performed in the Pediatric Cardiology interventional suite after extensive discussion and planning with Pediatric and Adult Interventional Cardiology, Pediatric Cardiac Anesthesia, Pediatric Cardiothoracic Surgery, and Pediatric Cardiac Radiology. General anesthesia and a femoral arterial approach were utilized. An ascending aortic root angiogram was obtained in 2 planes to assess the ostial left main stenosis. Due to the small size of the infant aorta, a 6 Fr JR-4 guide was reshaped to engage the left main coronary artery. A BMW wire was used to cross the lesion. Since the infant left main coronary artery was small but was expected to grow with age, a somewhat larger (3.0 × 8 mm Vision bare metal) stent was carefully implanted in the proximal LMCA at less than nominal pressure to avoid distal dissection. A poststent angiogram showed that the stent had moved during implantation and missed the ostium with residual stenosis of the LMCA origin. Hence, a 3.5 × 8 mm Vision bare metal stent was placed into the LMCA ostium overlapping with the previous stent distally and protruding 1-2 millimeters in the aorta pro

[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 case describes a 23-year-old male who was struck by a motor vehicle. Upon arrival at our hospital, the patient had a GCS of 8. FAST exam, chest radiograph, and computed topography (CT) of the head and cervical spine were obtained and were negative.
Exam of the lower extremities revealed abrasions over the left knee and tenderness over the lateral joint line with an effusion. The right knee was diffusely tender to palpation without effusion. The patient had palpable pulses in both feet with well-perfused extremities. Ankle brachial indices were performed and found to be >0.9. He demonstrated guarding and pain with the attempted Lachman maneuver of the left knee and slight opening of the left knee joint with varus stress. Radiographs were obtained and revealed a left knee Segond fracture ().
Magnetic resonance imaging (MRI) of both knees was performed to evaluate for ligamentous injury. Left knee imaging demonstrated the Segond fracture along with a grade III lateral collateral ligament (LCL) tear with retraction (), a grade II tear of the popliteus tendon and anterior cruciate ligament (ACL) (), and a grade I medial collateral ligament (MCL) injury (), as well as partial thickness tears of the biceps femoris and vastus medialis. Right knee imaging revealed a grade III tear of the ACL and MCL (), grade II tears of the posterior cruciate ligament (PCL) (), LCL, and popliteus tendon, and a medial meniscus tear. The patient was placed in bilateral hinged braces with the left knee unlocked and the right knee in locked extension to aid with transfers from a bed to a wheelchair. The patient was also given a left foot drop boot for a foot drop discovered during a secondary exam. On hospital day three, the patient was discharged home.
Nine days after the accident, the patient presented to the clinic. He noted that the left-sided foot drop was improving.

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


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

[User]
RADIOLOGY NOTE:
A 69-year-old man with a history of hypertension, bilateral thalamic hemorrhage, and decreased kidney function was admitted to our hospital because of congestive heart failure with extracellular volume overload. Volume control with drugs, such as diuretics, was unsuccessful and he was started on hemodialysis. Thereafter, he received various antibiotics for bacterial infections, including pneumoniae and urinary-tract and catheter-related infections. Simultaneously, he had continuous watery and sometimes bloody diarrhea, the etiology of which was considered to be CDAD due to a positive stool test for CD toxins. Despite treatment with metronidazole and vancomycin, the severity of the diarrhea was not ameliorated. Abdominal X-ray and computed tomography did not reveal any causal factors, and laboratory tests showed only slight elevations in the white blood cell count and C-reactive protein level. We suspected involvement of uncontrollable CDAD or other type of infection (such as mycosis, tuberculosis, or cytomegalovirus infection) and inflammatory bowel disease (IBD).
Colonoscopy showed multiple segmental ulcers in the ascending, transverse, and sigmoid colon, but not the rectum, which suggested infectious colitis or ischemic colitis (Fig. ). A biopsy specimen showed loss of glands, fibrosis, congestion, and edema, suggesting ischemia, with no findings of infection (Fig. ). Given these results and the fact that the patient was on dialysis and had severe arteriosclerosis, we provisionally diagnosed ischemic colitis caused by arteriosclerosis and hemodialysis. We stopped or adjusted enteral nutrition, avoided low blood pressure, and withdrew antibiotics; however, his diarrhea persisted. It was impractical to perform a second colonoscopy, as his performance status was severely worsened. Finally, he died of cardiac arrest 193 days after admission. The autopsy showed longitudinal and annular ulcers in the sigmoid colon. An autopsy specimen of the ulcers showed inflammatory p

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


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

[User]
RADIOLOGY NOTE:
A 30-year-old female with a past medical history significant for protein C deficiency and a history of pulmonary embolism comes with an urticarial rash associated with arthralgia. She did not have any history of fever or joint pain at that time. The episode started recently and was associated with high fever and significant joint pain and stiffness. She was seen in urgent care and treated with prednisone 20 mg. Her rash remained stable but she still had swelling and tenderness of bilateral knee and ankle joints and bilateral wrist and elbow joints.
She was seen for the same complaints in the emergency department. An X-ray of the bilateral knee was unremarkable; she was given morphine for pain and was sent for follow-up in the clinic. Meanwhile, suspecting a broad differential of autoimmune etiology, workup was done, including complete blood count, basic metabolic profile, liver function test, urine analysis, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), ANA, complements, rheumatoid factor, hepatitis panel, human acquired immunodeficiency virus (HIV) rapid antigen test, and blood cultures. She was admitted to the hospital for increasing pain and fever of 101 F. Her white blood cell (WBC) count at that time was 30.1, with a neutrophilic predominance and significant bandemia; the liver function test was abnormal. Bone marrow biopsy was not performed because of no lab or physical findings of any hematological malignancy. Suspecting infectious etiology she was started on broad-spectrum antibiotics, vancomycin, and cefepime. Her blood cultures and urine cultures were negative. Suspecting infectious endocarditis, echo was done, which was again negative for vegetations, with preserved ejection fraction and normal valves and wall motion. With the given amount of tachycardia, she was also having an elevation of D-dimer. Computed tomography (CT) chest with contrast was done, pulmonary embolism (PE) was ruled out, and the lungs were unremarkable for any pathol

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


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

[User]
RADIOLOGY NOTE:
Patient 1 was a 39-year-old male non-smoker who had been diagnosed with HoFH at 14 years of age. He had a positive family history of HoFH in his uncle and three of his first-degree cousins. The patient had been initially treated with oral simvastatin (80 mg) once daily. As the drug had gradually failed to maintain the total and the LDL cholesterol levels within the normal range, he had begun to undergo total plasma exchange and subsequent LDL plasma apheresis at 17 years of age. The combination of LDL plasma apheresis and statin therapy had been effective at that time.
At 24 years of age, he had presented with symptoms of heart failure class II according to the New York Heart Association (NYHA) functional classification, namely, angina and shortness of breath, and physical examination had been unremarkable apart from ejection systolic murmur over the second right intercostal space at the right sternal border. Coronary angiography had revealed an ostial right coronary artery (RCA) lesion with approximately 50% blockage and a left anterior descending artery (LAD) lesion with approximately 55% blockage. His echocardiography had revealed valvular aortic stenosis and SVAS with a pressure gradient of 73 mmHg and a mean gradient of 41 mmHg. The aortic annulus had been 1.6 to 1.8 cm, and his ejection fraction had been more than 55%.
The patient had been admitted at 25 years of age and undergone the Bentall procedure for SVAS, and he had tolerated the procedure very well. On postoperative day three, the patient had collapsed and had been intubated. Coronary angiography had shown stenotic ostial LAD and RCA. The patient had then undergone emergency CABG with the left internal mammary artery (LIMA) to LAD and saphenous vein graft (SVG) to RCA and obtuse marginal artery (OM). Three years after that, the patient had undergone mechanical mitral valve replacement and CABG reoperation (LIMA to diagonal and SVG to RCA

[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 22-year-old female patient with a medical history of infectious mononucleosis at age 16 and without any personal or familial history of neurological diseases was admitted with a newonset movement disorder. She presented with brief attacks of involuntary, sudden and painful hyperkinetic movements of the left limbs (hyperextension and external rotation of the lower limb and extension-pronation of the upper limb) and a left rotation of the head. She had twenty to thirty attacks daily for two days, lasting twenty to forty-five seconds. There was neither loss of consciousness nor postictal confusion or amnesia. The attacks occurred during position changes or sudden movements or even in cases of emotional stress. She was able to predict the occurrence of the attacks and even trigger them with specific movements of her left leg. Her relatives and her general practitioner thought it might be psychogenic movement disorders or epileptic seizures. The neurological examination was unremarkable between the attacks.
Blood tests were normal. The electroencephalogram (EEG) showed neither asymmetric nor epileptiform activities. Her brain magnetic resonance imagery (MRI) revealed more than twenty hyperintense lesions in the supratentorial white matter in T2 and fluid attenuated inversion recovery sequences (, , and ). The largest (14 mm) was located in the left semi-oval center. Others were located in the right parietal, left cingular and left frontal areas. One left frontal lesion was enhanced after contrast (Gadovist®, Bayer Pharma AG, Leverkusen, Germany) injection (). Others were within and at the border of the corpus callosum. There were also periventricular lesions with radial disposition (). The spinal cord MRI showed several T2 lesions in the medulla oblongata and the cervical and thoracic spinal cords ( and ), with a discrete enhancement of a lesion facing the third and fourth cervical vertebras.
The 2010 McDonald diagnostic criteria of MS were fulfilled, so we did not per

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


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

[User]
RADIOLOGY NOTE:
A 49-year-old man with British ethnicity was referred to a respiratory physician with cough, shortness of breath, and weight loss in February 2021. His CT chest showed mild centrilobular emphysema with scattered lung cysts bi basal dependent changes but no evidence of malignancy. Subsequently, CT abdomen and pelvis demonstrated an incidental finding of a 37 mm x 50 mm x 48 mm right iliac fossa well-defined mass highly suggestive of right SMA branch pseudoaneurysm with surrounding localized bleed showing contrast enhancement on arterial phase.
Further patients came under the care of the Vascular team. An urgent CT abdominal angiogram taken in February 2021 showed a pseudoaneurysm arising from a terminal branch of SMA in the right iliac fossa, further suggesting an increase in size from 37 mm x 50 mm (anteroposterior [AP] × transverse [TV]) to 47 mm x 53 mm in maximum axial diameter since last CT scan and concluded as progressing SMA pseudoaneurysm (Figures -).
After discussion in the angiogram meeting in February 2021, by the team of Vascular consultants and Interventional radiologists, the decision was made in favor of endovascular embolization of pseudoaneurysm as an urgent procedure, due to the progression in size of SMA pseudoaneurysm. Supra selective embolization of the SMA pseudoaneurysm was done by the Interventional Radiology team using Right Common Femoral Artery 5F access, and MynxGrip assisted hemostasis in local anesthesia (20 mL of 0.5% levobupivacaine). The SMA and subsequently ileocolic artery were accessed using a Terumo wire and Cobra catheter. Selective SMA angiogram confirmed a right iliac fossa pseudoaneurysm supplied by the terminal branch of the SMA (Figure ). Two fine platinum coils (Spirale) were used to embolize the pseudoaneurysm front and back door with good results and no complications (Figure ).
A post angiography run confirmed the coil successfully deployed and excluded flow into the pseudoaneurysm. His vital signs remained stable throug

[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 male was referred to the Oral Medicine Department by Dermatology in July 2008, with an 8-month history of blistering and soreness of the oral mucosa. On examination, there were small erosions and ulcers present on the soft palate and bilaterally on the buccal mucosae. The patient had been under the care of Dermatology since 2003 for an itchy rash on the legs, scalp and chest. A biopsy from a crusted lesion on the scalp (Fig. ) in 2003 revealed acantholysis of the keratinocytes in the upper part of the prickle cell layer (Fig. ), and direct immunofluorescence studies showed IgG positivity around the upper epidermal cells. These features were consistent with a diagnosis of PF. He was started on Mycophenolate Mofetil (MMF) 500 mg twice a day and Prednisolone 10 mg once a day by Dermatology in 2006, which had resulted in excellent control of his cutaneous lesions. Prior to this, Azathioprine alone had been introduced on two occasions by Dermatology, however the patient failed to tolerate it due to nausea and vomiting. Oral involvement only began in January 2008 which required hospital admission for a short period.
His only other relevant medical history was hypertension, for which he took Nifedipine. At initial presentation, he was also taking Ranitidine and Alendronic Acid for protection against osteoporosis with prolonged systemic corticosteroid use. He was a non-smoker and had low alcohol intake.
At initial appointment, MMF dose was increased to 1 g in the morning and 500 mg in the evening for 2 weeks, and thereafter 1 g twice a day. Full blood count, urea and electrolytes and liver function tests were normal, and regular blood monitoring was carried out appropriately. In light of good response to systemic therapy and as only very small erosions/ulcers were present at this point, oral biopsy was not arranged. He was seen regularly on the joint Oral Medicine/Dermatology clinic and complete resolution

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


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

[User]
RADIOLOGY NOTE:
A 30-year-old nulliparous Caucasian woman had a normal vaginal delivery in hospital at 38-week gestation. She had a spontaneous rupture of membranes and onset of labour 10 hours later. First stage of labour was 4.5 hours and second stage 1.5 hours. Although she did not have a prolonged second stage of labour she had been crying out loudly during the labour, as she had declined an epidural anaesthetic and all other forms of analgesia. She delivered a healthy boy weighing 3500 g.
Her husband noted that she had a swollen neck on the first postpartum day, and relatives who had been speaking with her over the telephone had commented that her voice was altered. The patient reported that when she first stood up after the delivery she had felt a tight sensation in her neck and upper chest which worsened with deep inspiration. However, she denied any shortness of breath. She did have some difficulty swallowing initially and a sore throat but felt that this had improved and was tolerating a normal diet.
On examination she was not in respiratory distress, and oxygen saturation was 98% on room air. She did not appear pale or cyanosed. Blood pressure was 110/70 mmHg and heart rate 90 bpm. She was afebrile. There was palpable crepitus over both sides of her neck up to the level of the preauricular region on the right.
There was isolated T wave inversion in lead III of the electrocardiogram which is not unusual in pregnancy. Chest X-ray revealed extensive subcutaneous emphysema in the neck and over the right chest wall with a small pneumothorax on the right and minor pneumomediastinum []. Arterial blood gas analysis was normal.
She was transferred to a tertiary centre where she underwent a gastrografin swallow fluoroscopy to exclude oesophageal perforation. The swallow was normal, and she requested discharge from the hospital the next day. However, home reviews by the midwife reported that the subcutaneous emphysema had resolved by day 5 postpartum.

[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 order was received for microarray based, comparative genomic hybridization (array CGH) on a 3 year-old female due to a delay in social and language development and question of features of autism spectrum disorder. The patient received regular speech therapy due to speech delay (reported to not speak) and occupational therapy. Review of medical records revealed that a hearing evaluation had not been performed due to lack of cooperation. Her diagnoses included attention deficit-hyperactivity disorder, autism spectrum disorder and sensory processing disorder, and developmental language disorder. The patient’s gross motor skills were within the normal range. Normal vision was reported by the parents, but no formal evaluation had been performed. Normal muscle tone and growth was reported by the pediatrician. Orthopedic evaluation revealed no orthopedic concerns. Genetics evaluation revealed no dysmorphic features. The patient was reported to have a latex allergy. Echocardiogram was performed with a normal result. Magnetic resonance imaging (MRI) of the brain revealed Chiari I malformation resulting in moderate effacement of the cerebrospinal fluid space at the cervicomedullary junction. Findings revealed that the cerebellar tonsils project approximately 9 mm into the foramen magnum. See Table for a comparison of the patient’s features to features of 22q11 duplication syndrome described previously.
The patient had one full brother who was 4 years-old and was reported to be healthy with no developmental concerns. Her mother was reported to have had a patent ductus arteriosus (PDA) and patent foramen ovale (PFO) not requiring surgical repair and a history of migraines. She was currently 23 years of age with no major health or developmental concerns. Maternal family history was significant for a cousin with a 5 year-old daughter with autism. Maternal ethnic background was Caucasian (German and Irish) and Native American (Comanche). The father was 25 years of age and repor

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


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

[User]
RADIOLOGY NOTE:
An 18-year-old male suffered a valgus injury to the right knee due to a fall during a bigfoot race he took part in when he was 15 years old. He visited a different hospital because of right knee pain and effusion. However, no obvious ligament injury or fracture was noted on MRI and physical examination, and the patient was followed up at the hospital. At the age of 17, the patient gradually became aware of the valgus deformity of the right knee. At the age of 18, the valgus deformity had further progressed, and the patient visited our department due to continuous right knee pain. There were no comorbidities in particular and no past medical history of note. At the time of his initial visit, the patient was the manager of a high school baseball club. A physical examination revealed that the valgus deformity of the right knee was visibly obvious (). Joint effusion of the right knee and tenderness on the lateral condyle of the femur were noted. The range of motion was 0 (extension) to 140 (flexion) degrees denoting a slight flexion restriction. Lower limb length discrepancy (spinomalleolus distance (SMD)) was −3.0 cm in the right lower limb. X-ray images at the time of the initial visit to our department showed severe valgus deformity with a femoro-tibial angle (FTA) of 160 degrees and % mechanical axis (%MA) of 100% from the medial edge of the tibial plateau (). Valgus deformity of the right knee was pronounced with a mechanical lateral distal femoral angle (mLDFA) of 71 degrees in contrast to that of left mLDFA which was 87 degrees, whereas the medial proximal tibial angle (MPTA) was normal at 85 degrees (left: 85 degrees), suggesting that the femur side was at the center of valgus deformity. X-ray images taken at the time of injury (at age 15) showed no obvious fractures or growth plate fractures (). MRI at the time of injury (T

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


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

[User]
RADIOLOGY NOTE:
A 34-year-old Hispanic female presented with complaints of progressive nasal congestion and mass in the right nasal cavity. Initial biopsy of the mass was felt to be benign. A year later, her right nasal mass recurred and again was reexcised with pathology reported as benign. A few months after her second surgery the mass had rapidly grown in size filling her mouth and causing right facial swelling (). She had difficulty eating and swallowing. CT scan of the neck showed an extensive destructive mass measuring 5.5 cm × 5.3 cm × 7.1 cm with extension into the medial wall of maxillary sinus and extending to the inferior orbit (Figures and ). She had evidence of metastases to her right neck but there was no intracranial extension.
The lesion was biopsied and sent to two referral centers for assistance in making the diagnosis. The first referral center determined that the lesion consisted of a “polypoid sinonasal mucosa with ulceration, with acute and chronic inflammation and spindle cell proliferation, favoring reactive changes.” Immunohistochemical stains including smooth muscle antibody (SMA), desmin, S100, and keratin were all negative.
The patient went to second referral center for further treatment. At this institution, the report was slightly different, determining the sample to be consistent with an IMT, but found it had scattered positivity for ALK-1 and SMA within spindled cells. This is significant, because a diagnosis of IMT is quite difficult; however, one would expect samples from the same tumor biopsy to show similar SMA staining. The complexity of this tumor is further noted in that another biopsy, three years following the initial pathology report, differed from both of the previous reads.
Most recently, the second referral center reported immunohistochemistry stains demonstrating a profile different than the prior biopsies, with rare tumor positivity for SMA, and negativity for S100, pan-keratin, p63, and ALK-1. Next-Generation Sequencing- (NGS-) based

[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 26-year-old Thai woman presented with a foreign body in her left orbit that had been retained for 8 months. Eight months previously, she had sustained a gunshot injury to her left eye. There was only a small wound on her left eyelid (Fig. ); she had normal eye movement, a normal visual field, and no pain. A plain radiograph was performed at that time; it detected a round-shaped metallic foreign body located medially in her left eye globe. She was then diagnosed as having a retained foreign body in her left orbit and she was advised to have clinical observation. However, 8 months later, she developed pain in her left eye without any sinonasal symptoms. After discussion about the risk of surgery and retention of an orbital foreign body, an ophthalmologist referred her to our department for the minimally invasive procedure option of removal of the foreign body using an endoscopic transnasal approach. On examination, the movements of her left orbit were not restricted and there was normal visual acuity (20/20) with no proptosis or chemosis. A computed tomography (CT) scan of her left orbit revealed a round-shaped metallic foreign body in the medial intraconal space, and lateral attachment of posterior ethmoid sinus, measuring 6 mm (Fig. ). A transnasal endoscopic approach, with navigator assistance (Brainlab), was used to remove the bullet. Uncinectomy and anterior-posterior ethmoidectomy were performed. The location of the intraconal metallic foreign body was confirmed with a navigator system, then part of the lamina papyracea was removed and the periorbita incision was done. The defect was enlarged and the fibrotically encapsulated bullet was found lying in the orbital fat (Fig. ). The fibrotic capsule was dissected, and the bullet was delivered through her left nostril with probes and curetted (Fig. ). No intraorbital bleeding or damage to any soft ocular structures was noted. A relative afferent

[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 with a medical history significant for hypertension, hyperlipidemia, and chronic smoking underwent evaluation for recurrent chest pain symptoms with coronary angiography. Access was obtained through the right femoral artery and six French sheaths were placed over the guide wire. Coronary angiography did not reveal any evidence of significant coronary artery disease. The sheath was removed without significant problems. A Mynx closure device was deployed and manual pressure was held for five minutes at the access site. The patient tolerated the procedure well and was discharged home the same day and recommended to follow up in the clinic. The patient returned to the clinic two weeks later with complaints of right groin pain, redness, and swelling that has been worsening for last one week. The patient reported that he had groin pain that started a week after the procedure which initially happened during exertion or ambulation and then progressed slowly at rest as well. Follow-up examination revealed a 2 cm mobile, pulsatile, and non-tender right groin mass in the instrumented area with associated bruising of groin and inner thigh and significant edema of the right leg. Lower extremity Doppler ultrasound was performed that showed DVT of the common femoral, superficial femoral and profunda femoral veins (Figure ).
The patient did not report any history of trauma, intravenous drug abuse, prolonged immobilization, family history of blood clots, and recent travel. The patient had computed tomography (CT) scan of the chest, abdomen, and pelvis to further evaluate the etiology and extent of the thrombosis. A CT scan of the pelvis showed right groin pseudoaneurysm 3.1 cm x 2.8 cm. The pseudoaneurysm was compressing the femoral veins which were responsible for DVT in the right common femoral and superficial femoral veins (Figure ).
The patient was started on low molecular weight heparin drip and evaluated by vascular surgery for thrombin injection the next da

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


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

[User]
RADIOLOGY NOTE:
We present a case of a 32-year-old immunocompetent Iranian male who presented to the emergency room with a generalized tonic-clonic seizure lasting for 3 minutes. He denied any history of trauma, fever, or previous seizures. Furthermore, he did not have any genitourinary symptoms, including dysuria, hematuria, or penile discharge. A computerized tomography (CT) scan of the head failed to show any acute central nervous system insult.
After that, the patient was admitted to the hospital. Prior to this admission, he gave history of an admission 12 months ago to a hospital outside the country, where he complained of fatigue, weight loss, and fever. Reports from the hospital showed that he also had chronic moderate ascites and a left pleural effusion. However, several laboratory and imaging tests were done and it was concluded that there was no evidence of infectious disease, chronic liver disease, or malignancy. It was recommended that he may need more investigations or a laparoscopy with peritoneal tissue biopsy, which was not done.
Upon the latest admission, the respiratory rate was 12 breaths per minute, the body temperature was 36.9°C, and the blood pressure was 112/70 mmHg. The patient had mild tachycardia of 109 beats per minute. Physical examination was unremarkable including the respiratory system examination. Digital rectal examination was not performed since the patient did not have any genitourinary or gastrointestinal symptoms. During this hospitalization, the patient received anti-epileptic treatments and multiple investigations were done. The laboratory investigations, urine routine and microscopy, cultures, virology screen, including human immunodeficiency virus, as well as the autoimmune markers did not show any significant issues. Also, three sets of sputum acid-fast bacilli smears were done, which were all negative. Further invasive tests were performed including endoscopy and colonoscopy which were unremarkable. A lumber puncture was also performed wi

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


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

[User]
RADIOLOGY NOTE:
A 27-year-old male presented with a 1-day history of intermittent gross painless hematuria. His past medical history included herniated lumbosacral disk with radiculopathy, otherwise unremarkable. Social history included current smoking, 6 pack/year, and occasional EtOH. The patient was single and had no children; family history was negative for genitourinary malignancies. Physical examination was unremarkable with BMI 23 and BP 120/86 and no prescribed medicines or drug use. Laboratory tests showed normal CBC, normal coagulation profile, and normal renal function.
Axial, contrast-enhanced CT demonstrated a centrally located, 4 x 4 x 4.6 cm, lobulated mass invading the renal vein and extending into the lumen of the infrahepatic inferior vena cava (). CT angiography of the chest showed no evidence of detectable pulmonary emboli and bone scan was negative for metastases.
Right radical nephrectomy, partial adrenalectomy, inferior vena cava tumor thrombectomy (infrahepatic), and extended retroperitoneal lymphadenectomy were performed; flexible cystoscopy performed during this surgery showed a bulbar urethral stricture (not clinically significant) and otherwise normal bladder. The intravascular tumor pedicle was easily removed intact from the vein lumen by pulling.
Gross examination of the nephrectomy specimen demonstrated a centrally located tumor with no gross invasion of adjacent tissue but with the pedicle extending into the inferior vena cava (). Grossly, the tumor pedicle had a smooth surface and no attachment to the renal vein. Grossly, the mass was partially cystic with variably sized cysts with a smooth lining. The intervening stroma formed grossly discernible nodules of variable thickness. No tumor necrosis was grossly apparent. The lesion appeared to be well demarcated with no invasion of adjacent kidney parenchyma.
Microscopically, the tumor was well demarcated with an elongated pedicle bulging into the renal pelvis and renal vein and a biphasic morphology wi

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


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

[User]
RADIOLOGY NOTE:
A 38-year-old male with a history of chronic pain secondary to idiopathic retroperitoneal fibrosis (RPF) was referred to our tertiary cancer pain clinic for pain management. The pain started in his low back and primarily radiated across his abdomen and into his lower extremities. His abdominal and pelvic MRI showed an enhancing retroperitoneal mass surrounding the aorta with compression of the ureters and inferior vena cava.
After a complete evaluation, the patient was placed on oral opioids, including methadone and hydromorphone, as well as adjuvant medication therapy, including baclofen and gabapentin. Despite this treatment, he continued to have intractable pain and a decision was made to offer an IDDS trial after a few months. The trial was successful, and he subsequently had a permanent IDDS implantation with morphine infusion. After about two years, his pain symptoms progressed and he was offered a spinal cord stimulator (SCS) as an off-label use for the intractable abdominal, pelvic, and back pain. SCS was implanted after the completion of a successful trial.
Over the course of treatment, his intrathecal medications were escalated to morphine 33.08 mg/day, clonidine 661 mcg/day, and baclofen 248 mcg/day. Initially, his pain was managed well, but he eventually showed declining functional status with progressive weakness in his lower extremities and increasing pain. At this point, it remained unclear whether his pain and neurological symptoms were due to catheter-tip granuloma, worsening RPF, or a non-functioning SCS. Therefore, a CT myelogram was ordered. The risks of paralysis were explained to the patient; however, he deferred imaging at that time. Later, the patient also reported that his SCS was causing pain at the implantation site and he wanted it removed. Since he began developing progressive neurological deficits, a decision was made to explant his non-MRI compatible SCS. After this surgery, the patient refused to obtain imaging studies as ordered. For

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


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

[User]
RADIOLOGY NOTE:
A 70-year-old male was referred to our hospital complaining of left flank pain. At physical examination, nothing relevant was observed and laboratory findings were within normal limits. A CT examination of the abdomen and the pelvis was performed with a multidetector scanner, before and after contrast media administration. Portal phase images showed a large amount of solid tissue in the left perirenal space, infiltrating the renal capsule and the main renal vessels; the tissue did not show significant contrast enhancement. Similar findings were detected also in the right perirenal space (). CT images also revealed a partial stenosis of the common bile duct, with intrahepatic bile duct ectasia owing to hypervascular eccentric tissue (). Hence, a diagnostic integration with endoscopic retrograde cholangiopancreatography was performed to exclude an intraductal proliferation. A biopsy was also performed in the left perirenal space; the pathological samples were composed of connective and adipose tissues, revealing the histological features of a DT or abdominal fibromatosis and also showing immunohistochemical markers typical of muscular tissues, such as actine. The tumour was considered unresectable and medical therapy was started with tamoxifen (20 mg die–1); after an episode of thrombophlebitis, the patient asked to suspend tamoxifen and accepted a new therapeutic regimen (docetaxel 75 mg m−2 every 3 weeks); unfortunately, even this treatment was discontinued after only 4 weeks owing to neuropathy. A new CT examination was then performed to assess the results of the treatment. Unexpectedly, on venous phase images, the perirenal tissue showed a remarkable reduction on the left side and had almost disappeared on the right side (). The peribiliary tissue had equally decreased in size and thickness (). The treatment was then discontinued in accordance with the patient’s decision. 1 year later, both the left perirenal and peribiliary tissues demonstrated no progression 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:
The second case involved a 70-year-old Native American man presenting with upper back pain and numbness of his right foot for approximately 10 days. The symptoms had worsened, and he noticed some difficulty with walking. He did not have any past medical or surgical history. He was a former tobacco smoker and stopped smoking approximately 20 years ago, but it is unknown how many packs or cigarettes per day he smoked. He drank alcohol very rarely and not significantly. He did not have family history of any significance. He was never on medications until he was diagnosed as having HCC. He worked at a warehouse in the past. His job position was unknown. He has no known environmental or drug allergies. On admission, his BP was 166/119 mm Hg, HR was 97 beats per minute, and temperature was 36.7 °C. His physical examination had the following results: he was normocephalic, he had a non-traumatic skull, he had normal hearing, he had no nasal discharge, his chest wall movement was symmetric, his breath sounds were clear, he had no rales/wheezing, his HR was within the normal limit and had regular rhythm with no murmurs or thrills, his abdomen was soft with no distension, there was no palpable mass, there was no hepatomegaly or splenomegaly, a bilateral pedal pulse was present, there was no visible joint swelling, his skin was warm to the touch, he had normal color, and he had no rash/ulcers. A neurological examination had the following results: he was alert and awake; he was oriented to time, his name, and his location; his cranial nerves were grossly intact; he had no gait disturbance or motor deficits; his superficial reflexes were intact; a slight decrease in sensation over his right lower extremity was noted. Abnormal laboratory results were as follows: aspartate aminotransferase level of 104 U/L and alanine aminotransferase level of 90 U/L. CT of his chest

[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 twenty-five-year-old female was injured after falling from the back bumper of a moving truck. Her past medical history was significant for unspecified anemia and her surgical history included four previous cesarean sections. The patient presented to the emergency department of our level 1 trauma center and was evaluated by the orthopaedic trauma service and the general surgery trauma service. She was found to have an isolated injury to the left knee. Plain radiographs and computer tomography (CT) scans of the knee showed a lateral split depression type fracture of the tibial plateau (Schatzker type 2), mostly in the anterior portion with a vertical split (Figures and ). Upon application of a knee brace in the emergency department, obvious posterolateral instability was noted. A detailed ligamentous exam in the emergency department was deferred due to the acute injury and the patient's significant discomfort. Based on the physical exam findings, Magnetic Resonance Imaging (MRI) of the knee was indicated. The results of the MRI showed no injury to the anterior cruciate ligament, posterior cruciate ligament, medial collateral ligament, or meniscal damage (Figures and ). However, the MRI demonstrated a concomitant injury to the posterolateral corner (Figures –).
The patient was taken to the operating room on the first day after her injury. Open reduction and internal fixation was performed through a standard lateral approach to the proximal tibia including a submeniscal arthrotomy. Surgical fixation was achieved using a precontoured lateral proximal tibia plate by the manufacturer Smith and Nephew. After the fracture fixation, a detailed ligamentous exam was performed. This physical examination showed joint laxity to varus stress, 1+ at zero degrees and 2+ at thirty degrees. In addition, she had a positive tibial dial test at thirty degrees. These findings confirmed the diagnosis of posterolateral knee instability and established the indication for a PLC repair. A for

[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 65-year-old lady reported to our Department of Oral and Maxillofacial Surgery with a chief complaint of swelling in the left preauricular region since six months. The swelling was first small and then gradually increased in size and was not associated with pain []. She gave a history of surgery in the left parotid region, which was done about 10 years prior, but we could not get the details as she had misplaced the previous records.
On inspection, there was deformation of the left parotid gland region by a mass measuring about 5.8 × 4.9 cm in dimension. The patient did not present with facial palsy or ear sensory disturbances. The classical sign of parotid swelling, which was elevation of the left ear lobe, was present.
On palpation, the swelling was firm in consistency, fixed to the deep planes, and the superficial skin was normal, with no ulceration. In the cervical region level, the I, II, and III region lymph nodes were hard in consistency and fixed, the largest measuring about 3.5 × 2.3 cm in dimension. The level V region lymph nodes were palpable and mobile. Preoperative chest and vertebral radiographs and ultrasonography (USG) of the breast and ovaries were performed, to rule out metastasis. All the three scans showed no distant metastasis. A preoperative CT scan was taken, with contrast, which showed a heterogeneous ill-defined lesion, seen in superficial part of the left parotid gland, with few areas of low-density necrosis. A contrast CT showed heterogeneous enhancement, which did not enhance further on delayed images.
Fine needle aspiration cytology (FNAC) of the parotid gland swelling, from the level V lymph node region, was performed, which showed cells in clusters and singly scattered, round to oval cells, with a pleomorphic vesicular nucleus, prominent nucleoli, and scanty cytoplasm. The background showed necrosis mixed with blood. The Level V lymph node showed numerous aggregates of ductal epithelial cells, showing cellular pleomorphism

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


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

[User]
RADIOLOGY NOTE:
We report a case of an 11-year-old girl who presented to the Emergency Department for diffuse pain of the left hip after a fall. Her medical and family history was unremarkable. A clinical examination showed mild, diffuse swelling of the left hip. The swelling was firm and non-tender, with moderate to severe painful manipulation. This was associated with pain-related decreased mobility of the hip. The patient was unable to walk. Plain radiography of the left hip in the frontal and lateral views showed an extensive osteolytic lesion in the proximal metaphyseal femur and femoral neck with thin sclerotic margins, with no invasion of the growth plate (). Magnetic resonance imaging and a computed tomography (CT) scan of the hip showed the presence of an ABC in the proximal third of the left femur, with no extension in the adjacent soft tissue. Selective arterial embolisation was performed to devascularise the tumour, promote healing, and decrease the risk of high bleeding during the biopsy procedure. For this purpose, absorbable gelatine sponge particles were used. A biopsy was achieved through a lateral approach centred on the greater trochanter. A hole was drilled at the inferior pole of the cyst, thus reaching the haemorrhagic lesion where blood and cystic soft tissue were obtained for a histopathological exam. After the diagnosis was confirmed, we performed a second selective arterial embolisation to limit development of the ABC. The patient’s progress was favourable, with decreased local pain, and she gradually regained mobility.
One month later, local progression of the ABC was favourable. Radiographic findings showed osteosclerotic margins at the tumour site. Pain in the left hip was further diminished and the full range of motion was regained. At the 8th and 12th weeks of check-up, plain radiography was performed and showed no progression of the bone cyst. After approximately 16 weeks, the patient experienced moderate local pain. An X-ray showed that the osteolyt

[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 48-year-old woman presented to the Accident and Emergency department (A&E) with a two-day history of swelling and pain in the left buttock. She had a past history of hypothyroidism, depression and a hysterectomy for menorrhagia. Clinically there was a soft, diffuse, tender mass in the left buttock, with no evidence of abscess or cellulitis. Blood tests including inflammatory markers were normal. The surgical team suspected a diagnosis of a lipoma and discharged the patient with an outpatient ultrasound scan (USS).
The patient re-attended A&E three weeks later with increased buttock swelling and discomfort. The USS reported an irregular hypoechoic mass 6.9 × 4.5 × 3.2 cm in size situated 2 cm deep to the skin and extending towards the medial aspect of the left buttock, suggestive of an abscess. However, the clinical examination did not correlate with the radiological diagnosis and the patient was discharged following a brief admission for analgesia. An outpatient magnetic resonance imaging (MRI) scan was arranged.
The MRI suggested a large pelvic liposarcoma and hence a staging CT scan was done (Figures , and ). This reported the soft tissue mass displacing the bladder and rectum as it extends from the level of sacroiliac joints and through the greater sciatic notch into the buttock. The CT concludes that a sarcoma is less likely a diagnosis than a cystic neoplasm. The patient was referred to a consultant surgeon at a regional Sarcoma Unit for treatment.
An elective admission was arranged for full excision of the tumour via an incision into the buttock, and the patient was discharged at day 10. The main complications postoperatively were pain and a haematoma which discharged spontaneously. Histology confirmed an aggressive pelvic angiomyxoma. The patient is currently under follow-up with repeat MRI scans to assess for local recurrence and is awaiting further investigation of a suspicious lesion seen at her most recent scan, only 12 months post-

[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 40-year old woman with a history of endometriosis and infertility. In the spring of 2014 she developed pelvic pain. Trans-vaginal ultrasound revealed endometriosis and a complex cystic mass of the right ovary consistent with possible malignancy. The CA-125 was 32. She was taken to the operating room for a laparoscopic right ovarian cystectomy. Based on visible tumor within the ovary at surgery, the operation was converted to a staging laparotomy with traditional cytoreductive surgery with total abdominal hysterectomy, bilateral salpingo-oophorectomy, bilateral pelvic and para-aortic lymph node dissection, peritoneal biopsies, and peritoneal washings. No residual disease remained after surgery. Pathology disclosed clear cell carcinoma of the right ovary. Examination of the uterus revealed adenomyosis and endometriosis with focal clear cell carcinoma near the parametrial margin; 13 pelvic and para-aortic lymph nodes from the right and 15 from the left side showed no evidence of metastatic disease. The omentum contained a small focus of malignant cells, however the remainder of samples from the pelvis, paracolic gutters, and the undersides of the diaphragms revealed no cancer. She was staged as having FIGO stage IIIA2 clear cell carcinoma of the ovary.
Beginning in June 2014 she was treated with post-operative, adjuvant, dose dense paclitaxel and carboplatin x 6 cycles, which were completed in October 2014. A post-treatment PET scan in October 2014 revealed metastatic progression with hypermetabolic metastatic disease in the liver and multiple sites of hypermetabolic lymphadenopathy throughout the pelvis including the vaginal cuff. Chemotherapy utilizing pemetrexed and bevacizumab was administered the following week for three treatment cycles until December 2014. In January 2015, another PET scan disclosed new hypermetabolic disease in the left lung measuring 8 mm, additional new hypermetabolic lymph nodes in the left iliac chain, and progression in th

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


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

[User]
RADIOLOGY NOTE:
A 68-year-old Bosnian female with prior aortic valve replacement with a bioprosthetic valve for aortic regurgitation was admitted to our facility for worsening shortness of breath, fever, and lethargy. She was on a vacation in Bosnia, where she fell ill, was hospitalized for 1 month, and was treated for suspected sepsis and renal failure. Medical records from her prior hospitalization in Bosnia were not available. She had an extensive past medical history, pertinent for coronary artery disease, diastolic congestive heart failure, atrial fibrillation, chronic kidney disease, systemic hypertension, cerebrovascular accidents, and chronic urinary tract infection (UTI). Physical examination revealed neck vein distention, bibasal crackles, and bilateral pitting edema. Auscultation revealed an irregularly irregular heart rhythm, a grade 3/6 systolic ejection murmur in the left lower sternal border, and a grade 2/6 early diastolic murmur. EKG revealed atrial fibrillation with low voltage QRS, without evidence of bundle branch blocks or conduction delays. Within an hour, she became markedly hypotensive and hypoxic. She was subsequently intubated and started on a dopamine and norepinephrine infusion. The patient was treated for septic shock with intravenous vancomycin and meropenem. Two sets of blood cultures showed growth of Enterococcus faecalis that was sensitive to penicillin and vancomycin. A bedside transthoracic echocardiogram (TTE) revealed new paravalvular leakage around the bioprosthetic aortic valve, raising concern for an aortic root abscess. She was transferred to a tertiary care facility for possible surgical intervention. A transesophageal echocardiogram (TEE) revealed an extensive aortic root abscess involving the entire root and base of the anterior mitral leaflet. The abscess had ruptured into the left atrium, which contained a 5–7 cm cystic mass, with a fistula connecting from the aortic root to the left atrial cavity, running through the mass. The abscess

[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 with medical history of hypertension, dyslipidemia, strokes, initially presented to the Neurology clinic with new transient episodes of gait disturbance, left-sided dysmetria, intermittent diplopia, and vertigo. His symptoms were attributed to recurrent transient ischemic attacks involving the posterior circulation. Computed tomography angiogram (CTA) of the neck showed moderate left vertebral artery (VA) V4 and origin stenoses. His symptoms persisted despite being on aspirin, clopidogrel, and atorvastatin. After 4 months, a repeat CTA neck showed progression of left VA stenoses with development of a V4 segment intraluminal thrombus (). He was started on oral anticoagulation for 2 weeks without symptoms improvement; therefore, a decision was made to proceed with elective cerebral angiogram with the intent to treat the left VA origin.
Cerebral angiogram one week later showed 90% left VA origin stenosis and distal V4 segment occlusion. Final angiography following left VA angioplasty revealed markedly improved VA flow, and 50% remaining stenosis of the proximal left VA.
A few hours postoperatively, the patient developed new onset left upper extremity dysmetria and paresthesia that resolved after 10 minutes. He was discharged from the hospital after 2 days without needing physiotherapy. On the following day, he returned to the emergency room with left hemibody paresthesia and gait unsteadiness. MRI brain showed acute posterior upper cervical cord infarction, confirmed with a dedicated MRI cervical spine (). CTA neck showed no restenosis of the left VA origin and patent V4 segment with resolution of previously seen thrombus (). His physical examination revealed decreased vibration and proprioception and dysmetria on the left upper and lower extremities, with positive Babinski sign ipsilaterally, and no loss of temperature or pain sensations. He was discharged home the following day with the plan to continue aspirin and clopidogrel and outpatient physio

[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 are reporting a 57-year-old Arabic female who noticed a lesion of the right side of the scalp in July 2019, it was not tender and measured approximately 1.5 cm. She underwent a partial excision at a local hospital with a preliminary diagnosis of a benign lesion. The final pathology was a malignant lesion. No official pathology report was available for review. She refused further management. The lesion progressed again rapidly within one month; she presented herself to another private hospital where more radical surgery was carried out with left selective neck dissection, this was done on October 16, 2019. The pathology report was spindle cell squamous cell carcinoma, all margins were negative and all the lymph nodes were negative. She was referred to King Fahad Medical City, Riyadh, Saudi Arabia, in November 2019 for further management. She was a fit lady, not a smoker or drinker, however, was a known diabetic on oral hypoglycemic drugs for 10 years with fair glycemic control. She was complaining of mild pain at the site of the lesion with no other associated symptoms. On examination, there were two small nodules at the margins of the previous surgical scar. The superior nodule measure 1 cm x 1.5 cm and the other was 1.5 cm x 2 cm at the inferior surgical margin (Figure ).
She underwent full reevaluation with magnetic resonance imaging (MRI) of the head and neck and computer tomography (CT) of the chest, abdomen, and pelvis. The MRI showed that there was evidence of residual/recurrent soft tissue tumor at the superior and inferior aspects of the surgical bed. The first lesion at the high left parietal area measured 1.2 cm x 2 cm x 2.1 cm, it demonstrated features of internal hemorrhage. The other lesion noted at the left occipital region measured about 1.2 cm x 2.3 cm x 2.5 cm. Both lesions demonstrate post-contrast enhancement. There was no evidence of underlying bony involvement

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


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

[User]
RADIOLOGY NOTE:
A 46-year-old otherwise healthy female presented to the clinic with complaints of progressive breast enlargement and pain over the past 3 months. Specifically, she described a more pronounced acutely developing enlargement of the right breast when compared to the left, associated with worsening discomfort and pain. Of note, the patient underwent bilateral augmentation mammoplasty using PAAG injections in China 18 years ago. She denied other associated symptoms such as fevers, chills, shortness of breath, or nipple discharge, as well as any new palpable breast masses or previous trauma to the breasts.
On physical examination, she was afebrile and well-appearing with stable vital signs. The patient had significant breast asymmetry, with the right breast markedly larger than left, as well as associated tenderness to palpation, enlargement of nipple areolar complex and presence of dilated superficial veins (). The right breast was noted to be more erythematous and warmer to touch when compared to the left. There were no palpable breast masses, axillary lymphadenopathy or inversion of the nipples.
Diagnostic work up included mammography and magnetic resonance imaging (MRI) of bilateral breasts. Mammography demonstrated presence of breast implants with extensive fibrous capsule discontinuity, suspicious for foci of intracapsular rupture that were more pronounced on the right. There was an air-fluid level within the implant of the right breast, representative of an extracapsular rupture which likely accounted for the size discrepancy between the breasts. MRI demonstrated diffuse nodular thickening of both capsules surrounding the PAAG implants, which was associated with mural nodules with nonvascularized finger-like projections ranging in size from 3 mm to 1.4 cm. Although these findings were benign, the patients acute breast enlargement, pain and evidence of extracapsular rupture with extravasation warranted surgical management.
The decision was made to proceed with remov

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


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

[User]
RADIOLOGY NOTE:
A 21-year-old female patient visited the orthodontic clinic with a chief complaint of frequently biting her cheek. Her medical and dental history was insignificant except for the extraction of the upper and lower left first molars and the upper right third molar. The anterior teeth were restored by ceramic veneers, which were not satisfactory. She had undergone multiple root canal treatments. Temporomandibular joints were healthy except for TMJ clicking. The patient was periodontally healthy
Extra-oral examination revealed good facial proportions with a slightly convex profile and an acute nasolabial angle. The upper midline was centered to the facial midline, and the lower midline was deviated 2 mm to the right of the upper midline. (Figure )
Dentally, the patient had Class I canines and buccal segment relationships, a 4-mm deep bite, a normal overjet, and a normal curve of Spee. There was 2 mm of crowding in the lower anterior segment, while the remaining space for the missing tooth number 37 was about 4 mm. There was a unilateral posterior crossbite on the right side due to unilateral constriction of the maxillary arch, compensated for by lingual tipping of the lower right first and second premolars and lower right second molar (Figure , , ).
Radiographically, the patient had a Class I skeletal relationship with normal mandibular plane and lower facial height. Upper and lower incisors were retroclined and retruded (Table ). The lower left third molar was partially impacted and in a mesioangular direction. The lower right third molar was mesioangularly impacted (Figure , ).
- To correct posterior crossbite via unilateral CAE.
- To resolve crowding, eliminate rotations, and correct lower midline deviation.
- To close the residual spaces of old extraction sites.
- To correct the deep bite.
- To upright the lower left third molar and extract the contralateral one.
- To achieve functional occlusion with maximum intercuspation,

[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 20-year-old male patient presented with complaints of pain in the left hip since 1 year and difficulty in walking for 6 months. There was no history of trauma, fever, weight loss, and not a known case of diabetes and hypertension. The patient was diagnosed as tuberculosis left hip in the outside hospital without any biopsy, for which he had taken anti-tubercular treatment for 9 months, and still patient was not relieved of pain and stiffness. On examination, the patient had mild tenderness over the left hip with the restriction of joint movements. He had flexion deformity of 30°, adduction and external rotation deformity of 10 and 15° respectively. Wasting of the thigh and leg was present with no true shortening. X-ray of the pelvis with both hips anteroposterior and lateral view revealed calcified nodular mass over superior, inferior part of the femoral head, and anterior part of the neck with decreased joint space (). Computed tomography (CT) pelvis showed multiple intra-articular loose bodies with largest measuring 3*2.2 cm with early changes of secondary osteoarthritis and no evidence of joint effusion and erosion (, ). Magnetic resonance imaging (MRI) was suggestive of early arthritis with intra-articular loose bodies. There was <10% of articular erosion of postero superior part of acetabulum. As the patient was disabled with pain, stiffness especially restricted flexion and abduction and difficulty in daily routine activities, we planned for surgical excision of the loose bodies and cheilectomy of the overgrown/ossified femoral head on superior part of the femur to improve the stiffness of affected hip joint.
The patient was operated in lateral position under spinal anaesthesia using the lateral approach to the hip. Fascia lata was cut along the line of incision and retracted anteriorly to expose the anterior capsule. Arthrotomy was done using 2 cm incision over the anterior capsule and the anterior, inferior loose bodies were removed. Superior loose bodies

[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 38-year-old previously healthy male () presented with 2 months of MRC grade 3 dyspnea and 9 kg weight loss with no fever or night sweats. On arrival to the emergency room, he was requiring 6 L/min oxygen via nasal prongs to maintain saturations greater than 90%. Chest X-ray and chest computed tomography (CT) () suggested possible pneumonia overlying interstitial lung disease and pulmonary hypertension. CT and ultrasound showed small left axillary lymph nodes unamenable to biopsy. Abdominal ultrasound was grossly normal. Thus, the patient was diagnosed with presumed pneumonia and started on antibiotics, antiviral agents, inhaled corticosteroid, and bronchodilator therapy, with enoxaparin for venous thromboembolism prophylaxis.
Over the next 5 days, the patient's oxygen saturation was kept above 90% with 8–10 L/min oxygen via nonrebreather mask. Barriers to diagnosis included inability to produce sputum despite induction, high oxygen demands contraindicating bronchoscopy, small lymph nodes unamenable to biopsy, and intolerance of supine position needed for perfusion scans. The patient was transferred to the Thoracic Surgery service for a surgical lung biopsy on day 6. However, the patient experienced right-sided chest pain, diaphoresis, and tachycardia of 160 beats per minute, followed by a convulsive episode with no postictal symptoms. After transfer to the intensive care unit, mean systemic arterial pressures were found to be low, with transient reduction to as low as 40 mmHg when the patient coughed or spoke. Transthoracic echocardiography () showed a dilated right ventricle with globally reduced systolic function. Right ventricular systolic pressures were shown to be 170 mmHg. Milrinone and epinephrine were started for hemodynamic support.
Due to progressive symptomatic and hemodynamic deterioration, he was transferred to the Cardiovascular Intensive Care Unit under the cardiac surgery service at another hospital to facilitate Novalung insertion via central cann

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


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

[User]
RADIOLOGY NOTE:
We report a case about a 65-year-old male patient with pseudoarthrosis of the first MTPJ, who suffered from a nonunion 12 months after a fusion made of two crossing screws (). Postoperative x-rays showed a correct position of the two crossing screws and a correct position of the dorsiflexion (). The x-ray revealed a nonfusion during follow ups; we recommended the possibility of an extracorporeal shockwave therapy but the patient refused. The blood samples which we had taken before the revision surgery didn’t show any infection signs; additionally, there was no fever or any clinical sign of infection. The patient is a high demand patient, who does sport (hiking and cycling up to 20 km) and gardening quite often. Twelve months after the fusion he still had severe pain and was not satisfied at all with the result of the surgery. At this time the x-ray showed a persistent nonunion. We discussed the pros (definitive solution, a greater load-bearing capacity for our active high demand patient) and cons (a long follow-up treatment) of a revision fusion. On the other hand we informed him about the stability, function, the faster healing and mobilization of the prosthesis. Our patient refused a revision because of the previous failed MTPJ fusion; for this reason we decided to use this new device.
The two screws and the connective tissue were removed. We took care that enough resection of the bone and a capsular release of the metatarsal head was made in order to achieve a dorsiflexion of more than 90 degrees intraoperative. Afterwards a hemicup Biopro prosthesis (Biopro, Farmingdale, NY, USA) 18.5 mm was implanted. Intraoperative the final check up showed a dorsiflexion of 80 degrees and a good stability of the joint.
Immediately, the patient received postoperative-physiotherapy treatments. During hospitalization he learned how to do exercises for mobilization of the great toe, which 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 44-year-old, single, woman presented to the chiropractic office with ongoing headaches of 2-year duration. Her headaches were on a daily basis and varied in intensity. The pain was described as disabling, going across the forehead, to her nuchal area and right shoulder. She could not maintain daily activities without acetaminophen and aspirin. The patient initially consulted her family physician to rule out possible pathological causes. Her blood tests, brain magnetic resonance imaging, and cervical radiographs all came back unremarkable. She was diagnosed with TTH and then sent for physiotherapy a couple of times, but it did not help. She had also tried acupuncture, traditional Chinese therapy, and alternative medications for quite some time; but nothing had changed her headache pattern. She worked as a primary school teacher and lived alone. She denied substance abuse or any systemic disorder. There was no family history of mental illness.
Sometime later, she started experiencing episodes of extreme low moods, characterized by feelings of overwhelming sadness and seeking an immediate sense of relief. She was referred to the psychiatry services and was diagnosed with a major depressive disorder without psychotic features. Over the past 6 months, a combination of Deanxit (Flupentixol + Melitracen) for treating depression, alprazolam for anxiety, and acetaminophen for pain had been used at different doses at different times. Both disabling headache and severe depression led to impair her job and regular activities. Under stress of health and financial impacts, she had recurrent thoughts of death. She reported that she had once been getting ready for charcoal-burning to end her life at home. A primary concern for her was ending of troubles at all.
For evaluation and treatment of neck pain and headache, the patient presented to our clinic with a guarded neck posture. She rated her peak headache intensity to be 6–8/10 on the numeric pain rating scale. Spinal ranges of

[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.