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

[User]
RADIOLOGY NOTE:
A 77-year-old female patient with a past medical history of chronic obstructive pulmonary disease, hypertension, hyperlipidemia who presented to our emergency room (ER) due to worsening of respiratory distress. Four days prior to admission, the patient was hospitalized for management of community acquired pneumonia and upper gastrointestinal (GI) bleed and was later discharged to a rehab center. During a physical therapy session at the rehab facility, the patient developed severe shortness of breath and was found to be hypoxic with an oxygen saturation (SpO2) of 75%, she was placed on a nasal cannula. Presenting vitals in the ER showed a blood pressure of 152/83 mmHg, pulse 137 bpm, respiratory rate of 18/min and SpO2 97% on a 15 litre nonrebreather, and the patient was found to be COVID-19 positive using the RT-PCR test. Initial computed tomography (CT) of the chest pulmonary embolism protocol found multiple small bilateral pulmonary emboli as well as elevated right ventricular to left ventricular ratio of 1.4 indicating right heart strain (). The patient was noted to have expressive aphasia and left sided flaccid paralysis, and an initial CT scan of the head without intravenous (IV) contrast showed no evidence of acute intracranial abnormality. A magnetic resonance imaging (MRI) of the head with and without gadavist intravenous (IV) contrast () done later on Day 1 found a large acute right middle cerebral artery (MCA) territory infarct. The patient was started empirically on IV dexamethasone, antibiotic therapy, aspirin, atorvastatin, and therapeutic enoxaparin. On Day 2, a CT angiography of the head and neck with IV contrast showed an abrupt vessel cut off of the right internal carotid artery at the level of the supraclinoid right ICA, and nonvisualization of the distal right internal carotid artery as well as the right M1 due to a non-occlusive thrombus ().
The patient was transferred to an acute care facility, and

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


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

[User]
RADIOLOGY NOTE:
A 9-year-old girl presented at the Emergency Department for SCH following a distortion of the right arm occurred in horse fall. She was admitted 1 h after the event complaining of severe pain, swelling arm, and numbness of the fingers. At physical examination, the hand was hypothermic and pulses were not palpable. Vascular examination showed good capillary refill but no flow at arterial Doppler ultrasound scan was detected. An X-ray documented a Gartland IIIB fracture (). The patient underwent a closed reduction of the fracture and percutaneous pin fixation. At the end of the procedure, the arterial pulses did not reappear. To rule out any vascular injury, arterial Doppler ultrasound was performed demonstrating brachial artery interruption at the fracture level associated with an intramural hematoma; an external hematoma compressing the artery, that could have been drained cutting lacertus fibrosus, was not identified.
With a percutaneous right common femoral arterial approach, digital subtraction angiography (DSA) was performed, showing occlusion of the distal brachial artery, with recanalization of the ulnar and radial arteries immediately below the bifurcation (). The occlusion was crossed with two 0.014ʺ guide wires positioned in the ulnar and radial arteries, respectively, to protect the bifurcation. A 3 × 28 mm BVS (Absorb; Abbott Vascular, Lakeside Drive, Santa Clara, CA) was released in the distal brachial artery (), followed by remodeling with a non-compliant 2.5 × 20 mm balloon catheter to solve residual in-stent stenosis (). The final angiography confirmed correct positioning and patency of the stent with restoration of distal flow (). The stenotic part was interpreted as a spasm of the artery and we decided to not treat it. At the postoperative ultrasound scan, the stenotic part was not detected anymore. A regular sphygmic pulse appeared on radial and ulnar arteries.
The arm was maintained with a 130° posterior splint for 40 days after surgery, to avoid

[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 male child was referred to our service with a history of membrane formation on the upper and lower palpebral conjunctiva of both eyes since 2 months after birth. Hemophilus influenzae was cultured from the conjunctival smear. Examination under general anesthesia revealed firmly thickened, sessile membrane and papillomatous lesion on the upper and lower tarsal conjunctiva in both eyes []. There was no involvement of the bulbar conjunctiva and cornea in both eyes, and the membranes and papillomatous lesions were excised. Postoperatively, the patient was treated with corticosteroid and antibiotic eye drops. Histological examination of the membrane was suggestive of LC []. Three months after the surgery, membrane and papillomatous lesion recurrence was noted in both eyes. The patient was started with CsA 2% drops in olive oil, four times daily. Local tolerability was excellent. The patient complained of a mild burning and sensation of a foreign body in the eye for a few minutes after application of the CsA drop. Excision of the membranes together with amniotic membrane (AM) transplantation for conjunctival reconstruction was decided upon. Before surgery, the ethics committee of our department approved the treatment, and the family provided written informed consent. The human AM was prepared according to Tseng et al.'s method.[] The new membrane and papillomatous lesion were excised under general anesthesia. The AM epithelium was secured up to the conjunctival edge at the mucocutaneous junction and the fornices with 8-0 polyglactin sutures in both upper and lower tarsal conjunctiva []. Two months postoperatively, the AM had dissolved. Topical application of CsA 2% four times daily was continued for 6 months. The patient was examined monthly for the first 6 months and then quarterly by the same ophthalmologist. At the end of 40 months follow-up, the membrane had resolved, leaving moderate residual conjunctival scarring on the upper and lower conjunctiva in

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

[User]
RADIOLOGY NOTE:
A 21-year-old Nigerian female with hemoglobin SS presented to a community hospital with a two-day history of left-sided headache and expressive aphasia. Her past medical history was notable for painful crises that occurred approximately once every 5 months and were managed at home with oral analgesics. Physical examination was remarkable for mild pallor and a severe expressive aphasia. She was transfused 2 units of packed red blood cells. The initial CT was normal, although an MRI showed an acute ischemic stroke in the distribution of the left middle cerebral artery. She was transferred to the Johns Hopkins Hospital for further evaluation and management. A complete blood count showed a hemoglobin of 9.9 g/dL, hematocrit of 27.4%, and reticulocyte count of 9.3%. Shortly after admission, she underwent an automated exchange transfusion to achieve a hemoglobin S concentration of 30%. The percent of hemoglobin S after the procedure was 17.0%.
A transthoracic echocardiogram and bubble study with agitated saline showed bidirectional flow consistent with a PFO. A CT angiogram showed evidence of moyamoya disease. Chronic hypertransfusion therapy was recommended, although the patient did not return for transfusion therapy. She was also placed on daily oral aspirin and folate.
Four months after the first stroke, the patient was readmitted with complaints of general malaise, weakness, intermittent confusion, and slurred speech noted four days before presentation. Physical examination was notable for a right facial droop, dysarthria, and a deviation of the tongue to the right. A complete blood count showed a hemoglobin of 11.5 g/dL, hematocrit of 32.5%, and reticulocyte count of 4.8%. The percent of hemoglobin S at presentation was 89.4%. She underwent another exchange transfusion to achieve a hemoglobin S of 30%. The day after the exchange transfusion, a doppler ultrasound of the lower extremities was performed to determine if a thrombus was present that could have provided a s

[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 male patient with a history of neck pain and numbness of extremities for 6 years presented with hypoesthesia below the inguinal plane. The right upper extremity numbness was heavier than the left. The abovementioned symptoms were aggravated for 1 year resulting in a walking disorder. The patient required crutches when walking, and the maximum distance that he could walk was 50 m. Physical examination showed grade III strength of each muscle in both upper extremities, grade II grip strength, and grade IV strength of each muscle in both lower extremities. Bilateral Hoffman tests were positive, whereas the tendon reflex of both lower extremities was hyperactive. Magnetic resonance imaging (MRI) of the cervical vertebra showed that abnormal odontoid in the occipitocervical junction area and severe surrounding hydrops. The atlantoaxial instability resulted in mild AAD, as detected via computed tomography (CT), and the spinal cord was compressed by the posterior atlas arch (Fig. ).
After failure of conservative treatment, we decided to perform surgical treatment on the patient to address the walking disorder. Preoperatively, we performed cervical CT angiography (CTA) to evaluate the relationship between the important blood vessels and bone in the cervical area. At the same time, 3D CT of the cervical region was performed to make a 3D print model of the patient's occipitocervical area (Fig. ). We simulated the depth and angle of cervical screw insertion according to the 3D print model, and finally determined the most suitable cervical screw for the patient. After adequate preoperative preparation, we performed posterior-only occipitocervical fusion combined with intraoperative 3D navigation system.
After induction of general anesthesia, the patient was placed in a prone position. The vertebrae were exposed through an approximately 25-cm longitudinal midline skin incision from the occipital tuberosity to the spinous process of C6. The skin, subcutaneous tissue

[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 female was transferred from a peripheral hospital 10 days after an elective lower uterine section caesarean section for a breech presentation for which she had an epidural anaesthetic. She presented to her general practitioner with a 2-day history of increasing right leg weakness. She was referred to her local hospital where she presented as no longer able to walk. Her examination demonstrated 0/5 power in right ankle flexion, extension, eversion and inversion with increased tone. Her cranial nerve examination was normal as was her tone and reflexes. An urgent MRI of the spine was undertaken that revealed no evidence of epidural collection or neural compression. She subsequently underwent a CT scan of the brain that demonstrated a dural-based lobulated, heavily calcified left parafalcine mass associated with extensive oedema consistent with a meningioma (). The bulk of the calcification was at the periphery of the lesion with relative sparing of the central elements. 8-mg dexamethasone was administered intravenously prior to transfer to a tertiary centre where an MRI of the brain was undertaken. This showed a left extra-axial parafalcine mass compressing the pre- and postcentral gyri and abutting the paracentral lobule. It was isointense to cortex on T2 weighted images with hypointense peripheral component corresponding to areas of calcification. The mass demonstrated peripheral enhancement and an enhancing dural tail. There was no evidence of restricted diffusion. Overall, it was felt most likely to be a meningioma with some atypical features. She underwent a left frontoparietal craniotomy and resection of the lesion. Histology demonstrated a meningothelial meningioma, WHO grade I with focal areas of necrosis and features, raising the possibility of embolization-related changes. She recovered well and was discharged home after brief inpatient rehabilitation. At her 4-month review, she was walking with 5/5 power in hip and knee flexion and extension an

[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 female had been suffering from dry cough, myalgia, and arthralgia since 2013 and was diagnosed as DM (Table ). Her symptoms were abated by combination treatment using prednisolone and tacrolimus. However, the cough, pyrexia, and arthralgia recurred due to the exacerbation of DM. The patient was admitted to our hospital for further checkup and treatment. Laboratory data showed that her white blood cell count and C-reactive protein levels were elevated. Her serum carcinoembryonic antigen and carbohydrate antigen 19-9 were not elevated (Table ). Enhanced computed tomography showed a 20-mm low-density tumor with a gradual enhancement in segment 4 of the liver (Fig. ). Ultrasonography showed a 20-mm tumor in segment 4 of the liver (Fig. ). In magnetic resonance imaging (MRI), the tumor had a weak signal intensity on T1-weighted images and a strong signal intensity on T2-weighted and diffusion-weighted images. In the dynamic study of MRI, enhancement of the edge of the tumor was gradually increased from the early to the late phase (Fig. ). Following the diagnosis of ICC in segment 4 of the liver, hepatic medial segmentectomy and cholecystectomy were performed. In the resected specimen, macroscopic findings consisted of a solid hepatic tumor with the diameter of 35 × 25 × 21 mm (Fig. ). The pathological diagnosis was moderately differentiated adenocarcinoma with vascular invasions and without lymph node metastasis (pStage III). The tumor consists of cells with coarse chromatin (Fig. ). Many of the tumors have tube formation and immunohistological findings of intrahepatic ICC and moderately differentiated adenocarcinoma with CK7 (+), CK 19 (+), and CK 20 (–) (Fig. ). The patient made a satisfactory recovery with no postoperative complications and was transferred to the Department of the Internal Medicine to treat DM with tacrolimus 5 mg/day and prednisone 20 mg/day. The patient was discharged on postoperative day 23. Since this case was a high-

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


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

[User]
RADIOLOGY NOTE:
A 61-year-old man accidentally hurt his head while cutting trees 3 months ago, followed by loss of consciousness and bleeding in the bilateral nasal and external auditory canal. He scored 7 on the Glasgow coma scale (GCS). CT examination revealed extensive subarachnoid hemorrhage, skull base fracture, intracranial pneumatosis, and double lung contusion. The patient was treated conservatively after admission. Physical examination showed 5-mm dilation in the left pupil, along with an absence of pupillary light reflex to direct and indirect light sources. The right pupil was dilated by 3 mm, and pupillary light reflex was slower than normal. Furthermore, bilateral eye movements could not be examined, and the bilateral eyelid and conjunctival edema were not obvious. On the 13th day of hospitalization, there was a marked improvement in the patient’s consciousness; he could automatically blink and was able to easily follow simple instructions. Consequently, we noted a swelling in the patient’s right eyelid, along with conjunctival congestion, edema, and exophthalmos. The eyes seemed to pulsate on touch and auscultation revealed vascular murmur. The patient presented with drooping of the left eyelid, dilation of the pupils, and loss of direct and indirect pupillary light reflex. Although he was able to perceive light, and there were no edema or congestion present on the conjunctiva, he was unable to move his eyeball (Fig. A, B).
Symptoms of his right eye were obvious and those of his left oculomotor nerve palsy appeared on admission. Therefore, we suspected that the patient had a CCF on the right side and a left oculomotor nerve injury associated with skull base fracture. Subsequently, we performed a CTA examination on the patient’s head and surprisingly observed that the contrast agent had extravasated from the cavernous segment of the bilateral internal carotid artery. Three-dimensional imaging revealed that the bilateral internal carotid arteries were swollen and irregu

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


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

[User]
RADIOLOGY NOTE:
The patient was a 28-year-old man treated with maintenance hemodialysis since 1998 because of ESKD of an unknown etiology discovered in 1997. Renal biopsy was not performed as both kidneys were small at presentation. Neither self nor family history of urolithiasis or renal disease was reported. In 1999, the patient received a living-related kidney transplant. The donor was his 51-year-old mother, who had a good health with no medical history or physical abnormality at the pretransplantation check-up. Immunosuppression treatment composed of ATG for 10 days, cyclosporin, corticosteroids, and azathioprine. Because of persistent anuria after surgery, duplex ultrasound examination was performed and showed no blood flow in the graft vein. Surgical exploration 6 h after graft found a pleated graft vein and it was corrected. Graft biopsies were performed at the same time. It showed a normal histological appearance with no features of rejection. Twenty-five days after transplantation, urine output improved despite persistent graft dysfunction with a SCr of 700 μmol/l. A second allograft biopsy, performed at day 33, failed to show any features consistent with acute or chronic rejection. Subsequently, graft magnetic resonance imaging examination suggested partial cortical necrosis. However, graft function improved (SCr decreased to 500 μmol/L) and he was free of dialysis. Five months later, the patient was hospitalized because of increment of SCr to 950 μmol/L, while urine flow was maintained at about 1.5 l/24 h. Ultrasound examination of the graft and duplex ultrasound examination of renal vessels were normal. Cyclosporin monitoring was at the therapeutic range. Acute rejection was suspected and treatment with 3 methyl-prednisolone pulses was instituted empirically without a satisfactory response. A third allograft biopsy was performed and showed mild chronic tubule-interstitial changes with CaOx crystal deposits within the interstitium and lumena of the renal tubules. Re-exa

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

[User]
RADIOLOGY NOTE:
On November 25, 2011, a 94 yr-old woman was referred for the management of erythematous to violaceous patches with bullae on dorsum of left foot. She repeatedly hit her left foot in which intravenous line was situated with the opposite side for days. She had a various underlying disease including Alzheimer's dementia, angina pectoris, type 2 diabetes, hypertension, chronic kidney disease (stage IV) and was in a bed ridden state. Because of the poor oral intake and noncompliance to the Levin-tube, the percutaneous endoscopic gastrostomy tube had been inserted on her abdomen and only minimal amount of nutrition was maintained.
Despite of the daily simple dressing and intermittent debridement about 2 weeks, the status of the wound was deteriorated and advanced to painful ulcerative patches with eschar and granulation tissues (). The results of the bacterial culture and gram stain were negative.
Autologous PRP were prepared for the alternative management of her worsening wound. 12 mL peripheral autologous blood was obtained and collected into tubes containing acid-citrate-dextrose solution formula (ACD-A) anticoagulant. The citrated blood was centrifuged for 7 min at 2,500 rpm. Subsequently, the yellow plasma (containing buffy coat with platelets) was separated from other components. The upper 3 to 4 mL plasma called platelet poor plasma was removed by micropipette. The remnant PRP was extracted by sleeve filter and mixed with CaCl2. Finally, The CaCl2-activated PRP was topically applied to the ulcerative wound.
The patient underwent a total of 7 PRP treatments over a span of 8 weeks (performed twice a week until 5th treatment and then weekly until 7th treatment). As described above, these treatments involved topically application of activated PRP as well as packing of the wound with aseptic film for the sustained effect of growth factors. The film was removed on next day and the top layer was covered with hydrofoam dressing material until subsequent PRP treatment.
Over

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


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

[User]
RADIOLOGY NOTE:
A 10-year-old boy presented to the emergency department (ED) one day after sustaining a closed right forearm fracture due to a fall. He was admitted in another hospital the day prior, where he underwent closed reduction and received an above-elbow slab. He was referred to our hospital due to the inability of the former to achieve a good reduction. Examination at our ED revealed intact vascularity and nerve function. No signs of compartment syndrome were evident in the form of excessive pain or tense swelling. Radiography showed malreduction (). Re-reduction and casting were successfully performed (). Assessment of the ulnar nerve post-reduction was not possible as the boy was uncooperative due to pain. The patient was discharged and scheduled for a follow-up visit in the outpatient clinic 2 days later. The visit was rescheduled, and he was seen 7 days after discharge.
At the follow-up visit in the clinic, the patient still complained of sharp pain. Physical examination showed no swelling suggestive of compartment syndrome, pulses and capillary filling were normal, and median and radial nerves were intact; however, signs of ulnar nerve palsy in the form of decreased sensation in the little finger and weak abduction and adduction of the fingers were present. Radiography showed loss of reduction. Redisplacement could be explained by the fact that the patient was 10 years old, and as described by the study by Bowman et al stating that reduction of both bone forearm fractures in children 10 years and older are more likely to fail. The patient was admitted and closed reduction with percutaneous ESIN under general anesthesia was performed. Two 2.5-mm elastic nails were used, retrogradely for the radius and anterogradely for the ulna. The postoperative radiograph is shown in .
No improvement in the patient’s sensory or motor deficit was seen after the surgery. As there were no available radiologists with experience in musculoskeletal ultrasonography in our hospital, and an

[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 patient, not known to have any medical illness, was brought to the emergency room by his wife and daughter due to decreased oral intake since three days. The decreased oral intake was associated with vomiting. The patient had a normal state of health until 2 months prior to his visit, when he started to develop changes in his behavior. According to his wife, the patient became more aggressive, had reduced sleep, had stopped going to work, and became isolated. He also had hallucinations and episodes of short-term memory loss. The above symptoms were accompanied by generalized body weakness, mainly in the lower limbs. The body weakness was associated with pain; the patient became wheelchair-bound. During the last two months, the patient visited many physicians, but no definite diagnosis was determined. He was examined by a psychiatrist and was diagnosed with organic mood disorder. He was prescribed quetiapine (antipsychotic), mirtazapine (antidepressant), and lamotrigine (mood stabilizer). However, according to his wife, he showed no improvements after taking the medications.
Three months prior to his visit, the patient was admitted by the gastroenterology team due to biliary obstruction and endoscopic retrograde cholangiopancreatography (ERCP) was performed; biliary stricture was observed and he underwent stent insertion. At this time, he was also found to have a focal hepatic lesion. He did not have any past psychiatric history, a history suggestive of diabetes mellitus, autoimmune diseases, or any past gastric or ileal surgeries. He had a brief history of alcohol consumption but had stopped drinking 20 years ago. He was not a vegetarian. His daily diet was predominantly carbohydrate-rich and contained adequate animal protein.
An initial examination indicated pale mucous membranes, but no jaundice. The patient was conscious, but disoriented to place, time, and person. He said irrelevant words, was unable to comprehend others, and had bouts of cryi

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

[User]
RADIOLOGY NOTE:
A 61-year-old previously healthy female was transferred from an outside hospital for a second opinion for a liver transplant. She first noticed fatigue, weakness, and abdominal swelling three months prior to her admission at the outside hospital. CT of the abdomen with contrast showed cirrhosis and multiple masses with arterial enhancement in her liver. She underwent a liver biopsy. Pathology was reported as a low-grade vascular tumor. She presented to a larger academic center where she underwent an exploratory laparotomy with open liver biopsy to further investigate the liver lesions. There was no visual evidence of omental spread. The pathology was reviewed by multiple tertiary centers specializing in hepatic malignancies and was reported as a low-grade vascular lesion, which was likely small vessel neoplasm. After denial for LT secondary to an unknown low-grade vascular tumor, she presented to our medical center. MRI of the liver showed multiple enhancing liver masses (Figure ). Oncology was consulted and she was diagnosed with benign liver vascular tumors with an overall favorable prognosis.
She was listed for liver transplant with a model for end-stage liver disease-sodium (MELD-Na) score of 25. The patient had normal renal function prior to her admission with a creatinine level of 0.79 mg/dL, which increased to 3.3 mg/dL after her admission which was thought to be secondary to hepatorenal syndrome (HRS) type I. Her creatinine level did not improve despite medical management and hemodialysis (HD) was initiated prior to transfer to the University Medical Center. She continued on HD for approximately 10 weeks prior to her LT and was listed for combined liver and kidney transplant.
She underwent an orthotopic liver transplant 10 weeks after presenting to the UNMC. Microscopic evaluation of the tumor cells showed positive immunohistochemical staining for the ETS-related gene and was negative for human herpesvirus-8. A Ki-67 labeling index of the solid areas was app

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

[User]
RADIOLOGY NOTE:
This was a 68-year-old man in whom medical checkup revealed pelvic lymphadenopathy; his PSA level was 3.92 ng/mL. Prostate biopsy was performed, and prostate cancer with a Gleason score of 3 + 4 = 7 was detected in 4 out of 10 biopsy sites (right: 1/5, left: 3/5). MRI also revealed a mass (38 × 31 mm in diameter) in the left pelvis. Because lymph node metastasis of prostate cancer could not be ruled out, endocrine therapy with bicalutamide and leuprorelin was started. Although his PSA level decreased to 0.248 ng/mL, the mass in the left pelvis remained unchanged and was unlikely to have metastasized from the prostate cancer. Pelvic MRI findings revealed a well-circumscribed mass on the ventral side of the left piriformis muscle measuring 38 × 31 mm in diameter (Fig. ).
The prostate and the left pelvic tumor were resected under robotic assistance. As with case 1, the patient was placed in a 25-degree head-down tilt, ports were placed according to the usual procedure of RARP. Surgery was performed via a transperitoneal approach and pelvic tumor was resected by robot-assisted surgery (Fig. ). No large nerve was observed in the proximity of the tumor unlike those observed in case 1. After prostatectomy and right and left lymphadenectomy were subsequently performed under robotic assistance, surgery was completed. The operative time was 4 h and 45 min. The console time for the left pelvic tumor was 1 h and 38 min and that for the prostate was 1 h and 57 min. Blood loss was 100 mL; no other intraoperative complications were observed.
Histopathological findings were consistent with schwannoma. There were no malignant features (Fig. ). In the prostate, the glandular epithelial components were markedly atrophic, and mild lymphocytic infiltration and fibrosis were observed, but without residual tumor cells. The histological therapeutic effect was grade 3b (no residual cancer cells were seen after hormonal therapy

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

[User]
RADIOLOGY NOTE:
A 49-year-old Japanese woman on renal dialysis had a 4-month history of tinnitus and hearing loss. Computed tomography (CT) showed a high-density 35-mm diameter tumor in the pineal region and obstructive hydrocephalus []. The tumor was heterogeneously hyperintense on T1-weighted magnetic resonance imaging (MRI) scans and low- and iso-mixed intense on T2-weighted images. On T2* images, it contained very low intensity areas suggestive of hemorrhagic components []. No other intracranial lesions including lesions underlying her acoustic symptoms were identified. Her chronic renal failure ruled out enhanced imaging studies. On the basis of our neuroimaging findings, we made a preoperative diagnosis of pineal parenchymal tumor with hemorrhagic components and melanoma.
We used the left occipital transtentorial approach with the patient in the three-quarter prone position.[] To reduce occipital lobe retraction, an operated side-down approach was used. The incision extended from the inion along the midline and then was curved in a horseshoe fashion back behind the ear. The craniotomy was performed to visualize the transverse and sagittal sinuses through extent in the operative field by rongeur or airdrill. Then, a catheter was placed in the left lateral ventricle. The dura mater was opened with two triangular flaps based on the superior sagittal sinus and the transverse sinus. The incision of the tentorium was made at an angle of 15° to the straight sinus, starting from a point, 15 mm lateral and 15 mm anterior to the junction of straight and transverse sinus, extending upto the tentorial free edge, and then the lateral flap was reflected laterally. After the dense arachnoid over the quadrigeminal cistern was opened, a dark red, easily bleeding solid tumor was found in the pineal region []. We successfully dissected the feeders arising from posterior choroidal arteries, removed the tumor subtotally. After 2 weeks later from first operation, endoscopic third ventriculostomy w

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

[User]
RADIOLOGY NOTE:
We discuss a 59-year-old female who presented for planned PICC insertion for chemotherapy administration. Her medical history consisted of sigmoid adenocarcinoma with a Hartmann’s procedure the month before and subsequently commencing chemotherapy a week before. She was a non-smoker and had no familial history of coagulation disorders.
The PICC line was inserted into the right arm under ultrasound guidance, without any immediate concerns noted during the procedure. An X-ray revealed the PICC tip to be in a satisfactory position, but potentially a little too deep (). There were no symptoms of chest discomfort or palpitations.
Approximately an hour later, she developed symptoms of pain and weakness to her left arm (the opposite side). Her arm was clinically assessed as cool to touch with a delayed capillary refill with pulses absent. A computed tomography angiogram (CTA) of her left arm was arranged which revealed an abrupt stop in the left axillary artery ( and ) with reconstitution of the vessels in the antecubital fossa. She was taken to theatre for a brachial embolectomy to re-establish blood flow to her acutely ischaemic arm.
Brachial access was obtained over the antecubital fossa, the brachial artery was controlled and incised. Proximal embolectomy with balloon catheter retrieved a long segment of thrombus, with resulting good inflow and back bleeding. Post-operatively she was commenced on therapeutic low molecular weight heparin (LMWH).
She was subsequently worked up for a cause for this limb threatening pathology. Echocardiogram revealed unremarkable cardiac valves without evidence of an embolic source. A bubble study was also performed which showed no evidence of right to left shunt or patent foramen ovale. Histology confirmed recent blood clot without organization. At follow up she had a good radial pulse and her LMWH was switched to rivaroxaban.
PICC lines are generally considered safe, with delayed complications including occlusion, accidental withdrawal,

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


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

[User]
RADIOLOGY NOTE:
A 57-year-old man was evaluated in the emergency room (ER) of our hospital for complains of dizziness and near syncope while walking home earlier that day. He had started feeling generalized weakness and fatigue after he underwent neck surgery for a tonsillar lesion at another hospital 6 months earlier. He also reported unintentional weight loss of 20 pounds over 6 months along with loss of appetite. He denied any loss of consciousness, palpitation, shortness of breath, chest pain, hearing difficulty, headache, vision changes, nausea, vomiting, diaphoresis or fever. He had human immunodeficiency virus infection/acquired immunodeficiency syndrome (HIV/AIDS) with a CD4 count of less than 20. He was non-adherent to the anti-retroviral therapy. He also had chronic obstructive pulmonary disease and was using albuterol and steroid inhalers. His social history was significant for active cocaine abuse. He reported smoking one pack of cigarette per day for more than 35 years. Family history was significant for prostate cancer in father. His surgical records from the previous hospitalizations were obtained and revealed robotic resection of the left tonsil lesion and selective neck dissection 3 months prior with biopsy results showing left tonsillar SCC, P16+, stage T1N3M0. He did not receive any radiation or chemotherapy.
In the ER, his vitals were recorded as: pulse of 75 beats/min, blood pressure 125/75 mm Hg with no orthostatic hypotension, respiratory rate of 16 breaths/min and oxygen saturation of 98% on room air. His physical exam was significant for severe cachexia with body mass index (BMI) of 19. Conjunctival pallor was noted. His neck exam showed staples on left side with a clean wound site. He was also noted to have left second toe swelling and tenderness with clammy extremities and adequate pulsations bilaterally. A computed tomography (CT) scan of head was done to evaluate dizziness and near syncope that showed old ischemic changes. Initial electrocardiogram

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


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

[User]
RADIOLOGY NOTE:
Our work is a single case report and has been reported in line with the SCARE criteria [].
A 50-year-old man complained of a painless slow swelling in the left cheek, which had increased in size in the last four months, tobacco smoking, and alcohol intake for 15 years, without any chemical exposure. There was no history of local trauma, radiotherapy, HPV infections, or family history of malignancy. He was referred to our department's consultation for specialized care. No other personal or family history was raised during the patient interrogation.
Clinical examination showed painless swelling in the left cheek, a 3 × 3 cm mass presenting with irregular borders ().
There were no palpable neck lymph nodes on the left side.
A biopsy of surgical material was performed, showing a well-differentiated squamous cell carcinoma.
The definitive diagnosis of malignancy was made; metastatic investigations were performed, including chest radiography, abdominal echography, PET scan. The results of these exams were normal.
The computed tomography (CT) was performed and revealed a 4 × 4 cm mass along the cheek, and the alveolar bone was eroded.
Based on the positive medical history and clinical examination, surgery was indicated and performed by the chief professor of our department who has 15 years of operative experience. The surgical procedure had the aim of the restoration of the anatomic landmarks after a large excision of the tumor and reconstruction of full-thickness cheek defect with a deltopectoral flap under general anesthesia. (, , ).
Duration of surgery: 120 min; estimation of blood loss: 350 ml; duration of hospital stay: 4 days.
The patient received amoxicillin/clavulanic acid 1g twice daily and antalgics for 8 days.
Post-operative histopathology confirmed SCC proliferation ().
The multidisciplinary team deciding on the treatment options included surgeons, oncologists, radiotherapists, ENT surgeons, radiologists. The decision was made to treat the patient with the surg

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

[User]
RADIOLOGY NOTE:
A 76-year-old woman sustained a slip-down injury while performing daily work. She was diagnosed with a three-part fracture of the surgical neck of the right humerus. The glenohumeral joint showed grade 4 osteoarthritis on the glenoid articular surface and humeral head, with a lot of osteophytes. The fractured shoulder joint had an irreparable massive rotator cuff tear involving the subscapularis, supraspinatus, and infraspinatus and showed fat degeneration (Goutallier classification grade 4). We decided to perform RTSA on posttrauma day 5. She was placed in the beach-chair position and operated on under general anesthesia with associated local interscalene block. A deltopectoral approach was used and the fractured greater and lesser tuberosities were retracted to allow for the removal of the head of the humerus for wider exposure of the glenoid. The supraspinatus tendon and the long head of the biceps were divided. The glenoid baseplate was implanted flush to the inferior, anterior, and posterior rims of the glenoid with an inferior inclination of approximately 10° and was secured using 4 lag screws inserted though the glenoid. We inserted the hemisphere and confirmed the stability of the implant. The humeral component was inserted using intramedullary cement in 5° retroversion. We inserted a 6-mm polyethylene bearing after trial reduction. The fractured tuberosities were then sutured to each other and around the neck of the prosthesis in their anatomical position. After the operation, the shoulder was immobilized for 2 days and remained in an ultra-sling for 3 weeks postoperatively before passive ROM was started. Active, active assisted, and isometric exercises were started at 6 weeks, with progression to strengthening exercises at 12 weeks. The shoulder had a dislocation of the glenohumeral joint on postoperative day 7 and she experienced a sharp pain and limited motion. Plain radiographs revealed anterior dislocation of the humerus and polyethylene bearing. We re

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


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

[User]
RADIOLOGY NOTE:
A 22-year-old right-handed paratrooper was presented to the orthopedic emergency department because he fell on his outstretched right hand after having attempted a wrong landing technique. The accident took place in the island of Rodos where he received first aids and was then transported to our hospital for further treatment.
On physical examination, there was swelling and pain over the dorsum of the hand. Despite the swelling, it was feasible to notice deformity and to palpate the characteristic step-off created by the bases of the metacarpals. Active movement of the wrist and the fingers was limited while the patient was unwilling to cooperate due to pain. Neurovascular assessment revealed both a strong palpable radial pulse and a lively capillary refill while sensation of the hand was normal.
Plain radiographs (a dorsopalmar and an oblique view) of the right hand showed complete dorsal dislocation of the three ulnar CMC joints (). In order to achieve a better assessment of the injured joint surfaces, an additional CT scan of the right hand was conducted. The latter not only confirmed the diagnosis but also revealed a bony fragment at the base of the fifth metacarpal that originated from the hamate (Figures and ).
At the emergency department, closed reduction was attempted by applying longitudinal traction to the involved digits with pressure over the bases of the dislocated metacarpals. After that, the wrist was immobilized with a plaster. Three days later, the patient was operated under general anaesthesia in supine position. The surgical treatment chosen was open reduction and internal fixation (ORIF). Two longitudinal incisions were made over the second and fourth web spaces addressing adjacent respective joints. At this point, it is of note that when the subcutaneous hematoma was evacuated and the extensor tendons were retraced with the surrounding loose connective tissues, we noticed that our initial closed reduction which took place in the emergency room h

[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:
Written informed consent was obtained from the patient for her anonymized information to be published in this article.
A 46-year-old female dental hygienist with no history of rheumatoid arthritis or trauma presented with metatarsalgia of the right foot. She was diagnosed with interdigital neuroma at a nearby hospital and received a local steroid injection on the plantar aspect of the second web space. The use of an insole was also prescribed. For 2 years thereafter, steroid injections were administered to treat any exacerbation of the metatarsalgia (10 injections of triamcinolone and one of betamethasone were administered). At 1 year after the primary injection, the second and third toes became bent and developed swelling, especially at the third MTP joint; she was subsequently referred to our department.
Physical findings indicated flexible hammertoe deformities of the second and third toes. The ranges of motion of the right second and third toe MTP joints at extension were 90° and 70°, respectively, whereas the corresponding ranges at flexion were both 0°. The ranges of motion in the proximal interphalangeal joints at extension were −30° and −60° in the second and third toes, respectively; the corresponding ranges at flexion were 70° and 90°, respectively.
The initial non-weight-bearing radiographs revealed no dislocation or arthritic changes in the second and third MTP joints (). After 2 years, dorsal dislocations of these joints were noted on a lateral radiograph (). Although no bone cyst or sclerosis was observed on the dorsoplantar radiograph, mild hallux valgus deformity was found. Magnetic resonance imaging revealed synovial fluid retention in the second and third MTP joints, and the plantar plates of both joints were ruptured from the proximal phalanx and retracted under the metatarsal head ().
Surgery was performed for the second and third MTP joints and the hallux valgus deformity. The plantar plate disappeared, and the flexor digitorum tendon

[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 woman presented with rapidly progressing, asymptomatic skin lesions on the chest followed by similar nodules over the occipital and left parietal area of her scalp. She had a significant loss of weight of 6 kg over the last 6 months. General examination revealed a firm left supraclavicular lymph node. Cutaneous examination revealed the presence of multiple tender nodules with a soft, rubbery consistency with overlying superficial telangiectasia scattered on the scalp [], face [], upper chest [], and lower back, varying in size from 0.5 cm × 0.5 cm to 2 cm × 2 cm.
The differential diagnoses considered based on her clinical presentation were cutaneous lymphoma, cutaneous metastases, and histiocytosis. Her blood investigations were within normal limits. A skin biopsy from one of the nodules showed hyperkeratosis with prominence of the granular layer. The dermis was infiltrated by a tumor composed predominantly of loose clusters of round cells with eccentrically placed, hyperchromatic nuclei, and abundant amounts of cytoplasm containing neutral mucin [Figures –]. On immunohistochemistry, the cells were pancytokeratin positive. A diagnosis of metastatic poorly differentiated signet cell carcinoma was made based on the histopathological findings. A gastroscopy-guided biopsy done from the gastric mucosa showed poorly differentiated signet cell-type adenocarcinoma. A computed tomography scan and positron emission tomography scan done showed thickening of the cecal wall and omentum with enlarged para-aortic lymph nodes. An explorative laparotomy was done, which showed an obstructive growth in the short segment of the ascending colon with extensive nodal involvement. She was diagnosed to have a synchronous adenocarcinoma of the stomach and cecum. A palliative ileotransverse anastomosis was done. She was started on chemotherapy. She however did not show any response to first-, second-, and third-line of chemotherapeutic drugs. After 6 months of being on chemother

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


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

[User]
RADIOLOGY NOTE:
A 71-year-old male presented to an outside institution in 2015 for evaluation of slowly enlarging bilateral cervical lymphadenopathy, parotid swelling, and night sweats. Medical history was significant for melanoma removed from the bridge of his nose in 2015, and active smoking for over 40 years.
During his initial workup at the OSH, computed tomography (CT) imaging showed multiple enlarged bilateral parotid lesions, scattered enlarged level I and II nodes, and upper mediastinal lymph nodes. He underwent ultrasound-guided fine needle aspiration (FNA) and core needle biopsy of a large left neck lymph node measuring 4.0 × 1.9 cm. Cytology was consistent with WT. Additionally, a level IA neck dissection was performed. Pathology revealed WT and no evidence of malignancy or lymphoma. Six-month follow-up imaging showed stable appearance of the bilateral parotid masses and cervical lymph nodes; however, there was interval enlargement of right upper mediastinal paratracheal lymph nodes.
He relocated in September 2016 and transitioned care to our institution. Thoracic surgery performed endoscopic bronchial ultrasound and transbronchial biopsies of the right paratracheal node. Cytopathology revealed absence of malignant cells. Flow cytometry was negative for lymphoma. He elected for close surveillance with serial imaging in lieu of mediastinoscopy. Six-month follow up imaging showed stable size of the mediastinal lymph nodes and slight enlargement of a left neck lymph node () and he was subsequently referred to the Department of Otolaryngology.
Physical examination revealed bilateral enlarged parotid glands and bulky cervical lymphadenopathy slightly larger on the right. Facial nerve function was intact bilaterally. The patient was counseled on smoking cessation. He was discussed at our multidisciplinary tumor board. Given the progression of cervical disease, he underwent level II lymph node dissection with removal of a large nodal conglomerate and culture of cystic contents.

[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 man was involved in a motor vehicle accident resulting in an isolated fracture of the right mid femur. The patient was awake and had a Glasgow Coma Scale (GCS) of 15 at admission to the emergency department. The patient was examined and stabilized according to the advanced trauma life support (ATLS) principles. Whole-body computerized tomography did not show any head injury. There were multiple displaced costal fractures on the right side with lung contusion and minimal pneumothorax that did not need drainage.
The patient was admitted to the intensive care unit (ICU) while waiting for surgical stabilization of the fracture. During the 6-hour preoperative stay in the ICU, the patient was stable and awake. The patient was operated upon in general anesthesia. Intramedullary insertion of a femur nail was attempted but was quite difficult to achieve. A great deal of manipulation and drilling was required in order to insert a 400 mm nail. The patient was stable peroperatively.
Three hours later he was transported back to the ICU, still intubated and on 0.5 fraction inspired oxygen (FiO2). A wake-up test was performed at arrival to the ICU, and the patient seemed to be awake but suffered from pain. The patient deteriorated during the next 6 hours. He developed a high fever, and his oxygen saturation decreased. A new chest X-ray showed 2.5 cm pneumothorax that was drained successfully, but saturation continued to decrease during the next 6 hours. His oxygen demand increased ending up at 0.9 FiO2. A decision was made to increase sedation and apply a higher positive end expiratory pressure. In addition the patient was turned into a prone position.
The patient was kept sedated during the next 24 hours, and the FiO2 was decreased to 0.4. Moderate hypercapnia was tolerated (7.5–8.5 kPa). A wake-up test was not performed while the patient was in the prone position but the patient's pupils were examined

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


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

[User]
RADIOLOGY NOTE:
In August 2013, a 63-year-old woman presented with a gradual onset of decreased exercise tolerance, dyspnea, and a heavy feeling in the chest. Otherwise she was in good health with no relevant concomitant diseases. She denied fever, hemoptysis, weight loss, or other constitutional symptoms. There was no drug, alcohol, or nicotine abuse. She took no medication and there was no recent surgery or trauma. On physical examination we found a decreased breath sound over the right hemithorax and dullness to percussion at the right side of the thorax. There were no signs of peripheral oedema or ascites. She did not have any peripheral lymphadenopathy or enlarged spleen and liver. Laboratory values were normal for a white blood cell count of 5.9 × 109/L, a hematocrit of 44%, and a platelet count of 192 × 109/L. Her creatinine was within normal range and albumin was 42 g/L, with a total protein of 76 g/dL. Furthermore lactate dehydrogenase and tests for glutamic-oxaloacetic transaminase, serum glutamic-pyruvic transaminase, alkaline phosphatase, and bilirubin were all normal. The posteroanterior chest radiograph on admission confirmed a large right pleural effusion (). On admission, the effusion was drained showing a turbid and milky white appearance. Biochemical tests on the fluid showed a high triglyceride content (79 mmol/L) in the form of chylomicrons with cholesterol levels as low as 4.6 mmol/L. Further cytological analysis showed the presence of lymphocytosis but no malignant cells. Flow cytometry confirmed the absence of B-cell or T-cell lymphoma. Further imaging with PET-CT was initiated searching for the underlying disease. This revealed a PET positive bulky intraperitoneal tumour around the abdominal aorta and pancreas extending to the pelvic inlet (). There was a heterogeneous contrast enhancement and clear encasement of nearby arteries and veins. No enlarged mediastinal lymph nodes or suspect gynaecological malignancy was seen. In our case, the disruption occurred

[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-years-old man with past medical history significant for mild mental retardation, obsessive compulsive disorder, and attention deficit hyperactivity disorder was admitted to our service after falling at his workplace after rising from a chair. It was a witnessed fall. Patient collapsed after rising from his chair after eating lunch at work. There was no urinary of fecal incontinence, no tongue biting, no jerky movements, and no loss of consciousness. There was no confusion or altered mental status afterwards.
However, interestingly, the patient was tachycardic from 120 s to 140 s on presentation and was also noted to have orthostatic hypotension, despite IV hydration in the ED. Of note, patient's intake has always been good and rather he enjoys drinking plenty of fluids. The review of systems was negative, and the patient did not have any other signs or symptoms concerning any infection. Physical exam was significant only for mildly dilated pupils.
Electrocardiogram (ECG) revealed sinus tachycardia, with no ST changes, and QTc interval was noted to be within the normal limits. Echocardiography showed a normal left ventricular size with mild hypertrophy with a low normal systolic function (ejection fraction of 50–55%). Segmental LV function was normal. Right ventricular size and function were normal, and no valvular abnormalities were noted. A head CT done in the emergency department also did not reveal any masses or lesions, and there were no fractures or hematomas. Thyroid studies were also within normal limits.
As per the patient's parent, who has been taking care of him for the past 26 years, the patient has never had these symptoms. The patient apparently has been on atomoxetine (Strattera; Eli Lilly and Company), for the last 6 years without any problems. When asked about any new changes or additions to his medications, the patient was recently started on fluoxetine (Prozac) couple of months ago to help him with the “tic

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


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

[User]
RADIOLOGY NOTE:
A 73-year-old male was referred to the spinal team with a presentation of becoming “off legs” with progressive difficulty in walking. He had a prior history of vertebral PD, diagnosed 11 years ago, but had reported no symptoms of back pain in the interim.
In the recent months, he had started developing paraesthesia in both lower limbs, with progressive leg weakness and difficulty walking.
There was no bowel or bladder involvement. His past medical history included chronic kidney disease, Type II diabetes mellitus and vitamin D deficiency. He was also noted to be human leukocyte antigen B27 positive.
Clinical examination revealed a rigid thoracic kyphosis and spastic paraparesis. Lower limb power was globally reduced to Medical Research Council grade 4/5. Altered sensation to fine touch was demonstrated below the level of T7.
Subsequent investigations included whole-spine MRI and CT. This demonstrated the features of AS with multilevel syndesmophytes and interspinous ligament calcification. There was cortical thickening, sclerosis and vertebral squaring of T10, consistent with the known history of PD. However, in addition, there was contiguous spread of the pagetic changes across the diffusely ankylosed thoracic segments (). The combination of these pathologies produced a marked kyphotic deformity, with extensive bony expansion of the pagetic thoracic spine that resulted in significant central canal stenosis ().
An MRI confirmed the extent of canal stenosis and cord compromise, with intramedullary T2 hyperintensity extending from the cervicothoracic junction to T11 (). There was sparing of the lumbar segments, with a normal appearance of the distal cord and conus ().
Following discussion at our regional spinal multidisciplinary team, it was decided that surgical decompression would likely result in poor outcome, given the extent and severity of the disease. Multiple infusions of zoledronate were administered, in addition to three courses of calcitonin, in an attempt

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

[User]
RADIOLOGY NOTE:
A 72-year-old female with a past medical history of hypertension and diabetes was admitted with COVID-19 bronchopneumonia. Her hospital course has been complicated by respiratory failure requiring mechanical ventilation, septic shock requiring norepinephrine. During the admission, she was bradycardic in the 50s in sinus rhythm. Her heart rate dropped down to 30 for a short time of about six seconds. The rhythm strip showed AV dissociation consistent with complete heart block, as shown in Figure .
The bradycardia episode did not last long enough to obtain 12 lead EKG. She was then back in sinus rhythm. Her transthoracic echocardiography was unremarkable with normal ejection fraction and no segmental wall motion abnormality, brain natriuretic peptide (BNP) within normal limits, troponin I elevated up to 50 ng/ml. Troponin elevation was attributed to demand-mediated myocardial ischemia.
The decision was made to follow up, given that the complete heart block was for a short time and did not recur. The patient was not on any medication or sedation that can cause bradycardia and was oxygenating well on the ventilator. The next day she had pulseless electrical activity (PEA) cardiac arrest related to complete heart block, and return of spontaneous circulation (ROSC) was achieved after three minutes, and a temporary trans-venous pacemaker was placed, and she was paced most of the time because of persistent bradycardia and complete heart block. Later, when her condition improved and she was extubated, her heart rate started recovering gradually. At first, she was in junctional tachycardia, as shown in Figure , and there were no further bradycardia episodes.
She remained in hospital because of poor physical condition and need for rehabilitation placement, and all that time, she was on continuous telemetry. One week later, she was back in sinus rhythm, as shown in Figure . the temporary pacemaker was removed, and she was discharged on a ZIO monitor for two weeks with no furthe

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

[User]
RADIOLOGY NOTE:
A 62-year-old man presented at the Neurology consultation with a six-week history of a severe, strictly left orbitotemporal headache, with a frequency of three attacks per week, occasionally more than one at the same day. Most of them occurred in the first half of the night, waking him up, and lasted between thirty minutes and one hour. He used to take ibuprofen as acute treatment, with unsatisfactory response, since he did not notice a significant difference between treated and untreated attacks in terms of duration and pain intensity. To relief the pain, he used to open the window to get some fresh air. The headache was always associated with ipsilateral conjunctival injection and lacrimation. Pain triggers were not identified by the patient. He had no personal or familial history of headaches. His medical history was remarkable for hypertension and asthma, with a past surgical history including septoplasty and bilateral middle turbinectomy and uncinectomy due to nasal respiratory insufficiency. By the time of medical evaluation he was asymptomatic and neurological exploration was unremarkable. The clinical picture was suggestive of a CH and the patient was medicated with verapamil 120 mg daily. A MRI scan was performed, which revealed a sphenoid sinus mucocele, without secure expansion of the sinus. Two weeks later the patient came to the Emergency Department with complaints of horizontal diplopia that he noted when he woke up in that morning. He maintained the headache attacks, with similar characteristics, despite prophylactic therapy. Neurological examination revealed left eye adduction palsy and ptosis. A brain CT scan was performed and excluded lesions other than the mucocele. Paranasal sinus MRI revealed molding of the medial wall of left cavernous sinus by the sphenoid mass (). A paranasal sinus CT scan was also performed to allow for a better characterization of the lesion, showing sclerosis and interruption of the roof and posterior wall of the left sphe

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

[User]
RADIOLOGY NOTE:
A 50-year-old man presented with progressive hearing loss in the right ear and vertigo for the past 6 months and facial numbness and unsteady gait for the past 15 days. Upon physical examination, he was found to have right ear sensory hearing loss, ataxia, diminished sensation in the right face (supplied by the third branch of the trigeminal nerve), and high frequency hearing loss in the right ear, as revealed by brain stem auditory evoked potential examination. MRI examination revealed a lesion in the CPA with solid and cystic components, which compressed the brain stem and the cerebellum. The anterior portion of the lesion was solid and showed signs of cystic changes, whereas the posterior portion of the lesion was cystic. The solid component of the lesion showed hyper- and isointensity on T1WI images and mixed hyper- and hypointensity on T2WI images, and it was significantly enhanced after contrast administration. The size of the solid component of the lesion was about 2.2 cm × 2.2 cm × 2.3 cm (Figure ). Surgery was performed via a right suboccipital retrosigmoid approach, and intraoperative monitoring of cranial nerves was conducted. The lesion was revealed to be red, well margined, firm, vascular, anteriorly solid with cystic changes, and adherent to the brain stem and the cerebellar hemisphere, the trigeminal nerve, and facial and acoustic nerves. Following separation of the lesion from adjacent nerves and tissues along the border of the lesion under microscopy, the lesion was totally resected in a partitioning manner. The xanthochromic fluid in the back of the lesion was drained during surgery. The patient recovered well after surgery and presenting symptoms were significantly relieved. Postoperative CT scans demonstrated that the lesion was completely resected (Figure ). The histopathological features of the lesion were consistent with a CM (Figure ). At 1-year follow-up, this patient's symptoms at presentation had resolved.

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

[User]
RADIOLOGY NOTE:
A 68-year-old female was referred from an ENT specialist practitioner to the ENT-department due to multiple enlarged cervical lymph nodes located bilaterally and an involuntary weight loss of 10 kilograms over the last 6 months. There was no significant previous medical history. Fine needle aspiration biopsy (FNAB) suggested lymphoma and subsequent histological examination of an excised lymph node between level two and three from the left side of the neck confirmed the diagnosis of mantle cell lymphoma (MCL). PET-CT and bone marrow examination further demonstrated bone marrow involvement. Accordingly, the lymphoma was staged as Ann Arbor IVB and AJCC stage IV. The patient received eight series of R-CHOP followed by a scheduled 2-year-period of maintenance therapy with rituximab. Twelve months into maintenance therapy the patient developed a tender swelling of the right submandibular- and left sublingual gland. On clinical examination, a one-centimeter process with normal overlying mucosa was found in the left sublingual gland () along with a similar process in the right submandibular gland. Ultrasound of the left sublingual- and right submandibular gland revealed two hyperechoic one-centimeter tumors. Further examination and ultrasound of the neck revealed no enlarged lymph nodes. A magnetic resonance imaging (MRI) of the head and neck was performed (). PET-CT revealed a process of the sigmoid colon, but the bone marrow examination showed no signs of infiltration. MCL relapse was confirmed by subsequent excision and histological examination of the sublingual- and submandibular gland, as well as histological examination of a biopsy specimen taken from the sigmoid colon via colonoscopy. Histological examination of the excised sublingual gland showed salivary gland tissue infiltrated by lymphoid tumor cells appearing as blastoid cells with multiple membrane bound nucleoli (). Mitotic figures were seen in several of these cells. Immunohistochemistry showed positive reac

[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 male with repeated episodes of forehead swelling was referred to our department. He had no history of sinus surgery but had undergone microsurgical aneurysm clipping at the age of 47. He did not have diabetes or other immunocompromising disorders. Axial computed tomography demonstrated an intracranial metal-density spot, indicating the site of previous clipping (). The posterior wall of the left frontal sinus was deformed as a result of the previous neurosurgery (). The left middle meatus was opacified with homogeneous density (). The left frontal sinus had heterogeneous opacity including a high-density spot. Three-dimensional reconstruction showed the postoperative change of the frontal bone ().
Surgery was performed under general anesthesia. The mucosa of the frontal recess was edematous and obstructed the drainage pathway of the frontal sinus. Total removal of the anterior ethmoid cells revealed the frontal sinus ostium, but this ostium was too narrow to introduce any instrument into the frontal sinus (). Therefore, the EMLP was performed. The bilateral frontal sinuses were opened and the frontal beak and intersinus septum were drilled out. The left frontal sinus was filled with cheesy brown material (). Most of the material could be removed with curved instruments and flexible suction devices, but a portion of the material was located in the fissure of the bone. Even meticulous lavage with saline and extensive adjustment of flexible instruments failed to remove all of the remnant material (). Therefore, a small skin incision was made at the eyebrow and the frontal wall of the frontal sinus was trephined. Through this direct and close approach, the entire remainder of the material could be removed (). We preserved the mucosa of the frontal sinus to prevent postoperative scarring at the surgery site. The nasal cavity was packed with Sorbsan (calcium alginate) []. Histological examination revealed that the purulent material was formed by mixed bacteri

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

[User]
RADIOLOGY NOTE:
A 52-year-old male was admitted to an outside institution with lethargy, weight loss of 30 kg, and severe unexplained anemia (hemoglobin 4.5 g/dL; hematocrit 15%). The patient felt better after transfusion of 4 units of packed red blood cells, and gastroscopy performed at the time revealed a healed duodenal ulcer and erosive gastritis.
When he lost his medical insurance, he was discharged and advised to have further workup performed elsewhere. During a difficult colonoscopy at a charity clinic, a large tumor was found in his right colon that precluded passage of the scope to the cecum (see ). Biopsy confirmed an infiltrating adenocarcinoma. Polyps in the sigmoid and transverse colon were also removed and found to be tubular adenomata. The patient was then referred to our institution, a safety-net hospital, where a CT scan was performed. The imaging demonstrated a 5 × 5 cm mass in the mesentery with spiculated calcifications, as well as an additional mass near the ileocecal valve that had the appearance of an intussusception (see ). Malrotation was not suspected, although later review of the imaging with a specialized CT radiologist demonstrated inversion of the normal SMA to SMV configuration (see ). Malrotation was not suspected. The liver was free of metastases. His past medical history included no prior surgery.
A laparoscopic right hemicolectomy was scheduled and commenced with introduction of a 10 mm optical trocar and two 5 mm ports. Upon entry, most of the small bowel was found plastered to the right flank, and the right colon was not visible. The left colon was visualized, but even after releasing adhesive bands holding the small bowel to the right side and mobilizing these loops to the left of midline, the ascending colon was not visible. It was decided that laparotomy was required to elucidate the findings. The abdomen was entered through a midline incision, and after mobilizing and packing off the small bowel to the left, the right paracolic gut

[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 ophthalmologist was seen at the Ophthalmic Accident and Emergency Department with a five-hour history of a right watery red eye. He had been exposed to several conjunctivitis patients during the preceding few days, whilst working at the same department.
An initial diagnosis of probable viral conjunctivitis was made, and the patient was prescribed chloramphenicol eye drops. Conjunctival swabs were taken and sent to the microbiology laboratory for analysis. A day later the conjunctivitis had become bilateral and purulent. Several hours after the conjunctivitis became bilateral the patient also developed a sore throat. The previous swab cultures isolated Streptococcus pneumoniae as the infective pathogen. Three days later, the patient noticed tenderness and swelling of the proximal interphalangeal joint of the index finger in the left hand, which became progressively more swollen and tender over the next couple of days. The patient had become febrile; however, there were neither chills nor rigors. He was prescribed oral amoxicillin 500 mg TID and flucloxacillin 500 mg QID, in the belief this was septic arthritis.
Two days after the swelling started he was seen by a rheumatologist, who made a diagnosis of reactive arthritis. The patient was fully investigated (see following text and Table ). Plain X-ray showed a little soft tissue swelling over the proximal interphalangeal joint of the left index finger. The patient was negative for antineutrophil cytoplasmic antibodies (ANCA), rheumatoid factor (RF), anti-DNA antibodies and antinuclear antibodies; complement factors C3 and C4 were within the reference range. No pathogen could be grown in blood culture and joint aspiration (performed by the rheumatologist) yielded no synovial fluid. The patient was HLA-B27 negative. A firm diagnosis of reactive arthritis as a sequel to pneumococcal conjunctivitis was made. Anti-inflammatory drugs resolved the swelling and pain within 48 hours. The conjunctivitis had a

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


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

[User]
RADIOLOGY NOTE:
A 22-year-old male nursing student presented to the emergency department with complaints of retrosternal pain and dyspnoea for one day. The patient also complained that he could feel some air passing through the tissues below the skin in the neck. The patient had a history of throat pain and intermittent cough for three days and a history of ingestion of hot water a day before the presentation. He denied any history of trauma to the neck or any strenuous activity over the past one week. His other medical history was unremarkable. He had no addictions and not undergone any surgeries in the past.
Physical examination revealed a healthy-looking young man with tachypnoea. His pulse rate was 112 beats/min and blood pressure was 120/70 mmHg, his respiratory rate was 24/min. Crepitations were felt in the neck region extending up to the left nipple over the chest. The breath sounds and heart sounds were normal. Other systemic examinations were within normal limits.
Laboratory values (complete blood count, renal function test, electrolytes) and arterial blood gas were within normal limits. His electrocardiogram (ECG) was normal. X-ray neck and chest showed pneumomediastinum and subcutaneous emphysema (Figures -). Laryngoscopic examination did not reveal any mucosal lesion or foreign body. Computed tomographic scan of the head, neck and chest with oral gastrograffin was done which was suggestive of pneumomediastinum (Figures -). There was no evidence of any oesophageal perforation, pneumothorax, pleural disease and lung pathology. Upper gastrointestinal endoscopy and bronchoscopy was also normal. The patient was admitted and managed conservatively. He was given oxygen by mask, analgesics, cough suppressants, and steroid nebulisation. His symptoms settled with conservative management in three days and hence the patient was discharged. The patient was followed up for six months and there was no recurrence of symptoms. Chest X-ray was repeated after three and six months and ther

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


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

[User]
RADIOLOGY NOTE:
A healthy 8-year-old female child was noted have a growth on her right iris. The asymptomatic lesion was followed for 3 months and demonstrated slight enlargement, leading to suspicion of JXG. She was referred for diagnosis and management.
On examination, visual acuity was 20/20 in each eye and intraocular pressures were normal. The only abnormal ocular finding was a minimally pigmented, vascular iris mass, measuring 6.0 mm in diameter and 2 mm in thickness, located in the nasal aspect of the iris []. Gonioscopy and ultrasound biomicroscopy revealed that the lesion was confined to the iris with no extension or seeding into the angle or ciliary body. Fluorescein angiography revealed intense vascularity confined to the mass and not involving the surrounding normal iris []. Our differential diagnosis included amelanotic iris melanoma versus JXG.
FNAB was performed for diagnostic purposes. Using an operating microscope, a 27-gauge needle was passed through the clear cornea 1 mm from the limbus and directed into the tumor with aspiration using standard technique.[] Cytopathology revealed atypical cells with spindle morphology, ovoid nuclei, and prominent central nucleoli, which were immunoreactive for melanocytic markers melan-A and HMB45, consistent with spindle B malignant melanoma cells [].
Based on the cytopathological diagnosis of melanoma, basal sector iridectomy was performed. Histopathology revealed an amelanotic neoplasm, composed predominantly of spindle B melanoma cells and few cells with intermediate morphology between spindle B and epithelioid melanoma. There was one mitotic figure per 40 high-power fields []. There was minimal invasion into the trabecular meshwork and base of the pars plicata. The tumor appeared to be completely removed. The tumor was classified as pT2a based on the American Joint Committee on Cancer classification (8th edition).[]
One week after surgery, the visual acuity was 20/40, and 6 months later, it remained 20/25. Local and systemic

[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, para 5, postmenopausal black African woman who was human immunodeficiency virus (HIV)-negative presented to our casualty department with a 5-year history of progressive abdominal swelling. Five years prior to presenting, which was 1 year before she reached menopause, she had noticed that her abdomen was gradually distending. Her symptoms were associated with constipation, feeling of incomplete rectal emptying, early satiety, vomiting, and urinary frequency and urgency. She did not have any chronic illnesses and had a negative personal and family history of ovarian, uterine, bowel, and breast cancers. She was not receiving any medication prior to this presentation. She had delivered five children by cesarean section, and they were all alive and well. She lived in a rural area and was a subsistence farmer. She did not smoke and did not drink alcohol.
She had ascitic taps three times in 1 week at a district hospital before referral to a higher-level hospital because of recurrent reaccumulation of ascites. A transabdominal ultrasound scan (USS) showed generalized ascites with a thick fluid with septa, as well as bilateral mild hydroureter and hydronephrosis. Again, the ascites was drained twice. One month later, she underwent computed tomography (CT), which showed a large predominantly cystic lesion that occupied almost the entire abdominal and pelvic cavities, which were distended, causing a marked mass effect on surrounding organs and bowel. The lesion had areas of internal septation predominantly on the right flank with no features of metastatic disease. Tumor markers measured during this admission are shown in Table .
The patient was referred to a tertiary hospital but only went 5 years later. Upon admission, she had marked temporal wasting, with bilateral pitting lower limb edema extending to her sacrum. She had a normal breast examination. Her blood pressure was elevated at 167/93 mmHg, with tachycardia of 150 beats/min. Her body temperature was 36.

[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 right-handed white woman with no significant medical history was diagnosed as having MS in 2013 at age 22 and experienced ongoing radiologic activity on both glatiramer acetate and dimethyl fumarate. She transitioned to natalizumab in July 2014 to stabilize disease activity, and her JCV antibody index was positive at 3.58 prior to starting natalizumab. She became clinically and radiologically stable with the initiation of natalizumab until November 2016 when a surveillance MRI of her brain showed asymmetric confluent non-enhancing hyperintensities in the bilateral subcortical precentral gyri consistent with PML (Fig. , ). Cerebral spinal fluid (CSF) showed quantitative polymerase chain reaction (PCR) for JCV of 15 copies/ml, and other CSF studies were within normal limits. A diagnosis of PML was made based on the compatible neuroimaging findings along with the presence of JCV DNA in the CSF. Natalizumab was discontinued after 27 total treatments. Our patient was asymptomatic at the time of PML diagnosis, and she was highly functioning with an Expanded Disability Status Scale (EDSS) of 0. A decision was made to defer plasmapheresis at the time of diagnosis given her high functional status, subtle radiological change, and low viral titer. She was treated with orally administered mefloquine loading dose followed by 250 mg weekly and mirtazapine 15 mg daily.
Repeat MRI at 2 months following diagnosis showed no changes in her brain lesions. She remained asymptomatic until 3 months after diagnosis when she noticed mild dysmetria of her left hand that progressed to a tremor. The following month a repeat brain MRI revealed a few small enhancing lesions in her left frontal lobe suggestive of IRIS (Fig. , ). The hyperintensities in the bilateral precentral gyri remained stable. Imaging of her cervical spine revealed a new non-enhancing cord lesion. She was then treated for 5 days with intravenously administered immunoglobulin and restarted on glatiramer

[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 female presented with pain in the lower back radiating to the right leg. Her symptoms first developed three years ago. When she walked for 10 minutes, her pain was aggravated and accompanied by numbness with a cramping sensation in the right leg. There was no weakness or sensory changes. No abnormal signs were seen on physical examination. For three years, she had been treated with oral medication and three sets of epidural steroid injections. The effect of the third epidural steroid injection did not last for more than one month. Moreover, PEA with the Racz catheter did not effectively reduce her pain level. The patient continued to complain of pain with a score of 8 on the NRS and she could not walk for more than ten minutes. His functional score on the ODI was 64. Her lumbar MRI revealed central disc extrusion at the L4-5 level with central canal stenosis, and bilateral L5 nerve root compression.
We planned PEA and decompression with the inflatable balloon neuroplasty catheter, and prepared as described above. A caudal epidurogram showed a filling defect from the central epidural space at the L4-5 level to both L5 intervertebral foramina (especially the preganglionic area). Gentle adhesiolysis of the preganglionic area at the right L5 level by intermittent balloon inflation was performed as described above, and the preganglionic spread of contrast medium was confirmed. At the end of the procedure, a Perifix epidural catheter was left at the target site through the balloon catheter lumen. After test injection of 1 ml of lidocaine, 6 ml of a mixture of 1% lidocaine and 1,500 IU hyaluronidase was administered through the Perifix catheter. After 10 to 15 minutes of monitoring, another 4 ml of a mixture of 10% hypertonic saline and 20 mg triamcinolone was injected through the catheter. The Perifix catheter was left in place for a 2-day drug injection. The catheter was then removed on

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


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

[User]
RADIOLOGY NOTE:
A 29-year-old Hispanic gravida 3, para 2-0-0-2 at 32 weeks of gestation presented to an outside hospital with a 3-day history of worsening chest pain, dyspnea, orthopnea, and shoulder pain. She was previously in good health without comorbid medical issues. Initial work-up at the outside hospital included a computed tomography (CT), which was significant for a large pericardial effusion with no evidence of pulmonary embolism (). She was transferred to our institution for further management.
On arrival, the patient was uncomfortable and leaning forward, with a blood pressure of 127/80 mmHg, pulse of 124 beats per minute, respirations of 24 times per minute, and an oxygen saturation of 97%. She appeared in distress. There was tachycardia and distant heart sounds on physical examination, but no jugular venous distension noted. Laboratory evaluation revealed no significant abnormalities. Arterial blood gas analysis demonstrated a mixed metabolic and respiratory acidosis. Cardiac ischemia markers were negative. An electrocardiogram (ECG) demonstrated sinus tachycardia and electrical alternans.
A transthoracic echocardiogram showed a large pericardial effusion with tamponade physiology and a left ventricular ejection fraction of 50% (). The patient had worsening chest pain and discomfort. The obstetric team performed fetal monitoring which demonstrated no abnormalities. A multidisciplinary team met at the patient's bedside and consisted of maternal fetal medicine (MFM), cardiothoracic surgery, neonatology, cardiac anesthesia, and cardiology specialists.
It was decided that surgical pericardial window and drainage with drain placement was the most appropriate treatment because the majority of the pericardial effusion was posterior and would not be amenable to percutaneous drainage. The patient received a dose of betamethasone for fetal benefit, and underwent an uncomplicated pericardial window and drainage under general anesthesia with standard monitoring and continuous fet

[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 male presented to the emergency with the chief complaints of recurrent postprandial epigastric pain for three days. On scrutiny of previous records, it was discovered that this was his third hospitalization for the same complaint. On all three occasions, the patient reported that his complaints were triggered after fasting for religious reasons. He had also undergone a gastroduodenoscopy three months back revealing gastric erosions for which he had been prescribed omeprazole. At the time of the admission, this was the only drug he had been taking. No history of previous abdominal surgery was noted. On examination, apart from tachycardia, other vitals were stable. The abdomen was distended but tenderness could not be elicited. On digital rectal examination, there was rectal ballooning without any soiling of the examining finger. All hematological investigations were within normal limits and an ultrasound of the abdomen was also normal. The abdominal radiograph showed multiple air fluid levels suggestive of intestinal obstruction. A computed tomography of the abdomen was also suggestive of subacute intestinal obstruction. The patient was started on intravenous fluids and a nasogastric tube was inserted. Twelve hours later, the patient underwent an exploratory laparotomy for worsening abdominal pain, signs of peritonitis and non-resolving small bowel obstruction. On opening the abdomen, the ileum had twisted along its mesenteric axis in the clockwise direction (Figure ).
Mild distention of the stomach and proximal ileal loops was noted. The large bowel distal to the site of twisting was collapsed. No perforation or band was found. The volvulus was untwisted, and a line of rotation was seen. No fixation of the twisted segemnt was done. The bowel was slightly discoloured, but viable and started to return to its normal colour and shine (Figure ).
The patient was given 100% oxygen and the bowel was covered with warm moist sponges till the serosa returned to i

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


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

[User]
RADIOLOGY NOTE:
A 36-year-old man, originally from Latin America, presented at our outpatient department with complaints of abdominal pain that had persisted for 2 months. The patient had first noticed right lateral abdominal pain 2 months prior to the visit, and the pain was gradually worsening. The abdominal pain was localized in an area ranging from the right upper to the right lateral abdomen. The patient had undergone cholecystectomy for acute cholecystitis as a 32-year-old in Latin America and had moved to Japan for work approximately 3 years prior to his initial visit to our hospital. He had returned to Latin America once about 6 to 7 months before presenting at our clinic. When he went back to Japan, his weight had increased from 130 kg to 145 kg. He did not experience abdominal pain immediately after his return to Japan, but, as noted above, he started to gradually feel pain in the right lateral region about 2 months prior to presentation.
He first visited another hospital emergency department 1 month after onset of the pain. Initially, gastrointestinal tract spasm was suspected, and he was treated with tiquizium bromide. Though the medication partially relieved his abdominal pain, most of the pain persisted. The result of a workup by a urologist was negative, even though nephrolithiasis was suspected. His abdominal pain was exacerbated upon changing posture, and thus it was suspected to be of somatic rather than visceral origin. Abdominal pain persisted despite treatment with loxoprofen sodium hydrate, and any cause of abdominal pain was not detected on further evaluations, including hematologic laboratory analysis, urine analysis, gastroscopy, or abdominal computed tomography (CT). Finally, he was referred to our hospital for further examination.
The results of screening for depression were negative, and the patient did not have symptoms such as loss of interest, depressed feelings, or any specific changes of surrounding conditions, such as family or work environment cha

[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.