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

[User]
RADIOLOGY NOTE:
A 25 years old lady P2+1, presented in the gynecology outpatient department with the complaint of abnormal uterine bleeding for the preceding one year. Her first two pregnancies were uneventful, both babies were alive and the last born was five years old. Her third pregnancy resulted in a missed abortion at 16 weeks followed by surgical evacuation of uterus at a private healthcare facility. She never experienced menstrual irregularity since menarche. After uterine evacuation, she was symptom free for a month or so. She then continued to have periods at regular intervals with variable intermenstrual bleeding. Bleeding used to be mild, painless and totally erratic. She never used any form of contraception. She went to different clinics for treatment. Her record showed that she had tried antibiotics, non steroidal anti inflammatory drugs (NSAIDs), tranexamic acid and progestogens but she could not get relief. She had a pelvic ultrasound done at a private facility which reported an intrauterine contraceptive device (IUCD) within the uterine cavity; despite there being no history of IUCD insertion.
On examination, her vital signs were within normal range, however she looked a little pale. Her thyroid was not enlarged. Abdominal examination was unremarkable. Speculum examination revealed healthy looking cervix and vagina. On bimanual examination uterus was bulky, anteverted, mobile and both lateral fornices were clear.
Transvaginal sonography (TVS) was done by a trained sonologist. On TVS hyper-echogenic foci with suspicion of fetal bone were seen. The sonologist advised pelvic radiograph where radio opaque shadows confirmed her findings ().
As hysteroscopy is not available in our setting, so we planned dilatation and evacuation (D & E) under general anesthesia. The uterine cavity had a gritty feeling which was bony hard in places. Fourteen tiny fetal bones were removed from the uterine cavity with the help of sponge holding forcep and curette (). Bleeding was minimal 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 78-year-old female who was a lifelong nonsmoker with a history of multiple medical problems, including TIA, was transferred to our facility with recent seizures and weakness. Her MRI demonstrated acute left sided CNS ischemic changes, consistent with acute ischemic infarction. With supportive care she had resolution of the neurological symptoms but she remained hypoxic. An arterial blood gas obtained on 10 liters/min of supplemental oxygen showed a PaO2 of 36, PaCO2 of 37, and pH of 7.47 with oxygen saturations of 70%. Upon review of her history, this hypoxia was likely long standing as the patient's family reported her having a feeling of “not getting enough air” for the prior few months. Her family also reported that the patient used a family members' pulse oximeter at home and her “blood oxygen” was in the 78% to 88% range. A CT angiogram of the chest did not reveal thromboembolic disease or an alternative finding that could explain her hypoxia. During the hospitalization the patient remained hypoxic in both the supine and upright positions with oxygen saturations in the 70% range. On breathing 100% oxygen the O2 saturation failed to improve. The patient received mechanical ventilation for persistent hypoxia.
With persistent hypoxia, a history of multiple TIAs, and a stroke, the possibility of right to left shunting was considered. A transthoracic echocardiogram with agitated dextrose demonstrated a large right to left intracardiac shunt at the atrial level with a persistent Eustachian valve (see Discussion). Right heart catheterization demonstrated pulmonary artery pressures in the normal range (16/4, mean 8). The defect was balloon sized at 15 mm. An 18 mm Amplatzer septal occluder was deployed under transesophageal guidance using percutaneous catheter closure (Figures , , and ). After the procedure, the patient had rapid resolution of her hypoxia and was promptly extubated. She was discharged home on the fourth day after the procedure. At a one-month follow-

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


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

[User]
RADIOLOGY NOTE:
A seventy-eight-year-old female patient with a previous medical history of diabetes mellitus, hypertension, ischemic heart disease, and Hypothyroidism presented with a one-week history of abdominal pain and nausea with vomiting following meals. Her symptoms progressively worsened to severe abdominal distention, anorexia and obstipation on the day of admission. She had no fever, chills, bleeding per rectum, or previous abdominal surgeries. Four weeks earlier the patient had similar symptoms. A plain abdominal X-ray and CT scan which were done at that time showed dilated small bowel loop in right lower quadrant without detected lesions or significant wall thickening, and she had been treated conservatively. After resolution of her symptoms—during the previous episode—an upper and lower GI endoscopy were done and revealed moderate erosive esophagitis, Helicobacter pylori positive gastritis and duodenitis, and an essentially normal colonic exam.
Her vital signs on admission were within normal limits. Examination showed a distended abdomen with hyperactive bowel sounds and generalized tenderness without peritoneal signs. Her laboratory investigations showed anemia with hemoglobin of 7.2 g/dL and white cell count of 9.9 × 103/mm3. Abdominal X-ray revealed dilated proximal bowel loops with multiple air fluid levels. Conservative measures with bowel rest, nasogastric intubation, and intravenous fluids failed to control her symptoms. Abdominal and pelvic CT-scan showed markedly dilated fluid filled small bowel loops with one loop showing central hyperdense area, and a thick soft tissue mass around it with multiple small hypodense areas, referred to as the target sign [] ().
Diagnostic laparoscopy which revealed a distal jejuno-jejunal intussusception was followed by limited laparotomy and resection then anastomosis was performed (). The leading point of the invagination was jejunal tumor (). Histopathologic examination of the resected specimen revealed a GIST of intermediate

[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 the year 2000, a 30 year old, otherwise healthy male presented with pain, swelling and redness in his left third toe. Radiological findings showed a pathological fracture of the proximal phalanx of the third toe on the basis of an intra-osseous lesion with a spotted and sclerotic aspect. An MRI was made showing a clear abnormality of the proximal phalanx of the third toe with oedema of the bone marrow and minimal reaction in the adjacent soft tissue. There was no extra-cortical expansion. Osteomyelitis or Ewing's sarcoma could not be excluded. (Fig. )
In January 2001 a biopsy was performed. Histopathology showed cortical and cavernous bone tissue with reactive changes and damaged cells of which identification was not possible. The bone abnormalities were considered to be reactive in nature and the diagnosis was set as osteomyelitis.
The patient's complaints diminished spontaneously. No antibiotic treatment was prescribed. In April 2001, a control radiograph showed a normal structure of the third proximal phalanx of the left foot. The patient was discharged from follow-up in the outpatient clinic.
At the time of the second presentation, in 2008 with the patient being 38 y, the same symptoms occurred. They were present since six weeks. Physical examination showed clear swelling and tenderness of the left third toe. There was no ulceration.
The conventional anteroposterior radiograph (Fig. ) of the left foot showed a moth-eaten aspect of the proximal phalanx of the third toe with cortical destruction. There is an infiltration in, and swelling of the soft tissue surrounding the lesion. The head of the third metatarsal bone is intact.
The total-body bone scintigraphy showed high uptake of TC-99M in the left third toe and was suggestive of osteomyelitis. There were no other hotspots.
The clinical diagnosis was set at osteomyelitis and the patient was surgically treated as such. In august 2008 the proximal phalanx of the left third toe was surgically removed. Macroscopi

[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 76-year-old man with a past medical history of coronary artery disease, hypertension, and severe septal hypertrophy suspicious for hypertrophic cardiomyopathy, presented to the hospital with progressive symptoms of heart failure. He had been suffering from worsening dyspnea and lower extremity edema for several months. Lab work over the preceding months had shown deranged liver function tests, concerning for right heart failure. He was admitted for intravenous diuretic and inotrope therapy. At his cardiology clinic appointment prior to this hospital admission, an ECG showed typical atrial flutter and diffuse low voltage []. A right heart catheterization showed moderately elevated right greater than left filling pressures with a right atrial pressure 18 mmHg, pulmonary capillary wedge pressure 21 mmHg and a Fick cardiac index 1.6 liters/min/m2. The ScvO2 was 48%.
Of note, a year prior to this admission, a transthoracic echocardiogram (TEE) had shown severe asymmetric septal hypertrophy (2.6 cm), suspicious for hypertrophic cardiomyopathy, but had not been further evaluated. A repeat TEE at the present admission showed a left ventricular ejection fraction (LVEF) of 35% as well as the aforementioned septal hypertrophy []. However, due to the significant low voltage on ECG, despite the significant LVH on echocardiogram and history of hypertension, a cardiac MRI was ordered to rule out infiltrative cardiomyopathy as opposed to hypertrophic cardiomyopathy.
The images showed normal left ventricular chamber size with severe, asymmetric left ventricular hypertrophy, primarily involving the septal wall with a maximum septal thickness of 27 mm []. The LVEF was measured at 40%. Also noted was diffuse, global late gadolinium enhancement of the left ventricular myocardium, consistent with a diagnosis of cardiac amyloidosis []. The only extracardiac clinical finding suggestive of systemic amyloidosis was carpal tunnel syndrome. Serum and urine electrophoresis did not detect a mo

[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 12-month-old female underwent both cochlear implantation under general anesthesia due to bilateral hearing loss. Her weight was 9 kg, her height was 73 cm, and she was on no regular medications. She was born at 38 weeks of gestation with a birthweight of 3.5 kg via cesarean section to a mother who had no underlying disease. She showed no congenital anomalies or developmental disorders. She received scheduled MMR vaccination 1 week before surgery and did not have any symptoms of upper respiratory infection or fever. All results of preoperative laboratory tests were within the respective normal ranges, including an electrocardiogram, chest X-ray, and blood and urine examinations. Brain magnetic resonance imaging showed no contraindications for cochlear implantation mapping. The patient entered the operating room without any premedication. After entering the operating room, monitoring was initiated, including noninvasive blood pressure, electrocardiogram activity, oxygen saturation, and pediatric bispectral index (BIS). Anesthesia was induced with 50 mg of thiopental sodium and 10 μg of fentanyl, and 5 mg of rocuronium was administered intravenously to facilitate intubation. Endotracheal intubation was performed using a tube (internal diameter, 3.5 mm) with a cuff, and both lungs sounded well. An esophageal thermometer and forced air blanket were applied to manage the patient's body temperature. Her initial core body temperature was 36.4°C, and it was maintained between 36.1°C and 36.5°C (Fig. ). Anesthesia was maintained with 1.5 to 2.0 vol% sevoflurane (with 50% oxygen and 50% nitrous oxide) at a target BIS range of 40 to 60; the end tidal carbon dioxide tension was in the range of 35 to 37 mmHg. The surgery proceeded normally without any adverse events; the total anesthesia time was 3 hours and 20 minutes. Fentanyl (10 μg) was administered intravenously 10 minutes before the end of surgery for pain control and to prevent emergence agitation. At the end of the oper

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


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

[User]
RADIOLOGY NOTE:
We present the case of a 13-year-old female patient, known with severe visual field loss, who referred for another opinion regarding the ophthalmological diagnosis.
Anamnesis at presentation revealed that at the age of 9 years and 3 months, on a routine ophthalmological examination, papillary calcification and retinal hemorrhage were discovered in the left eye. At that moment, the suspicion of intracranial calcifications was raised. The patient underwent clinical neurological examination, EEG, and cerebral MRI, all of them revealing a normal aspect. The patient was also recommended fluorescein angiography, which showed papillary autofluorescence. The diagnosis established then was papillary drusen in both eyes, buried in the right eye and mixed in the left eye and the patient was recommended to keep it under observation, together with a periodical examination of the visual field.
The patient had had multiple examinations of the visual field over the time.
The first visual field examination of the right eye showed an arcuate nasal defect, in the superior nasal quadrant, sketching an aspect of nasal step, structure of the sensitivity defect that in 3 years time evolved into a quadranopsia.
In the left eye, the first visual field examination showed inferior nasal quadranopsia, extended superiorly with a nasal arcuate defect respecting 20° centrally, which after three years evolved into a paracentral diffuse defect with an island of central vision of 5°.
However, over the time, the examination of the visual field was made with different types of machines, and no correlation of the modifications could be made objectively.
The patient received several different diagnoses from several different ophthalmologists, among which optic nerve drusen; papillary oedema and hamartoma have to be mentioned.
At presentation, the patient’s visual acuity was 20/ 20 with correction for the RE and 20/ 20 without correction for the LE, with a refraction ROD: -1 DSf<> -0.75 DCyl, 179* and RO

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


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

[User]
RADIOLOGY NOTE:
A 39-year-old woman complained of neck pain and left scapular pain in January 2006. The symptoms gradually increased and she was eventually admitted to our hospital. Physical examination revealed deep tendon hyper-reflexia of the upper and lower extremities. Motor palsy was not evident and no sensory disturbance was found in the upper or lower extremities or in the trunk. The plain lateral radiography did not show any abnormality. The antero-posterior radiography showed enlargement of the left C3-4 foramen (). Cervical magnetic resonance imaging demonstrated a dumbbell type tumor compressing the spinal cord at the C3-4 levels (). The tumor was located on the left side of the spinal cord. The tumor showed low intensity on the T1-weighted image and iso-high or slightly high intensity on the T2-weighted image. Gadolinium enhancement was noted in the tumor ().
The patient underwent an operation in April 2006. Cervical laminectomy at C3-4 was carried out and total resection of the cervical tumor was performed. The tumor was encapsulated () and it involved the posterior ramus of the C4 spinal nerve, and so the nerve was resected. The dura mater was opened to identify the presence of any intradural tumor invasion, but no intradural invasion was observed. Thereafter, the dura matter was tightly sutured. The round-shaped dark red tumor mass was covered by a thin membrane. The size of the tumor was 2.6 × 2.4 × 1.3 cm. The histological examination revealed a schwanoma with both Antoni type A and type B areas. No malignant characteristics were found for the pathology.
The surgical drain was removed 2 days after surgery. The patient had a slight fever. On the 9th postoperative day, she displayed a high grade fever (> 39.0℃) and vomiting. The Kernig sign was observed. She had fluctuation near the surgical wound, and so a spinal cord puncture was carried out; 25 ml

[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 woman in her 40s noticed a left axillary mass in November 2013, and in January 2014 she underwent left axillary tumorectomy for suspected schwannoma at our Department of Plastic and Reconstructive Surgery. The tumor was 5.0 × 6.0 cm, and it was pathologically diagnosed as malignant meningioma (Fig. A). As metastasis from a primary site was suspected, imaging examinations, including head and neck magnetic resonance imaging and positron emission tomography (PET)-computed tomography (CT) examination, were carried out, but since all were negative, it was diagnosed as ectopic malignant meningioma of the primary axillary soft tissue. After surgery, 50 Gy radiation was locally administered, and she received follow-up outpatient observation. In June 2016, chest radiography showed a nodular shadow in the right lung, so she was referred to our department. There were no notable findings in the laboratory blood test results. Chest radiography indicated a similar circular nodule shadow, 1.1 × 1.0 cm in size, in the right lower lung field. Chest CT showed the 1.0 × 1.0 cm nodule shadow in the right S4; mediastinal and hilar lymph node enlargement was not observed (Fig. B). PET-CT demonstrated slight uptake in the nodule, with a maximal standardized uptake value of 2.94 (Fig. C). There was no evidence of distant metastasis. After the initial examination, it was considered to be a metastatic lung tumor, and we decided to perform surgery as there were no abnormal findings in other organs. Surgery was performed in the left lateral decubitus under differential lung ventilation and 3-port thoracoscopy. There were no adhesions or pleural changes, and the tumor was directly under the right S4 pleura. Thoracoscopic right middle lobe partial resection was performed and the tumor was resected. A diagnosis of meningioma was obtained by intraoperative rapid diagnosis. The operation time was 1 hour, and the bleeding volume was 20 mL. Macroscopically, the tumor, resected from the S4 of

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


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

[User]
RADIOLOGY NOTE:
An 8-year-old Caucasian male presented to our facility with a 2-week history of refractory clear rhinorrhea, facial pain, jaw pain, and somnolence. The patient had previously been diagnosed with sporadic GS after being found to have multiple basal cell nevi and pitting of the palms and soles at the age of 5, as well as more recently a second relapse of ALL and chemotherapy-associated neutropenia (absolute neutrophil count 0/mm3). Family history was negative for GS but revealed a maternal third cousin with osteosarcoma and a maternal second cousin with ALL. The patient denied double vision, decreased vision, and nasal obstruction but did have one episode of epistaxis on the day of admission. There was no known exposure to nickel or significant secondhand smoke exposure. At the time of evaluation he was receiving micafungin for anti-fungal prophylaxis. On physical examination there was a pale gray lesion on the palate suspicious for avascular tissue, versus underlying Gorlin-related cyst. Black debris in the nares was believed to be due to epistaxis; deeper examination revealed grey/brown tissue and nasal polyposis. Because of concerns regarding ionizing radiation, evaluation with MRI was pursued.
MRI demonstrated sharply delineated hypoenhancement of the nasal septum and bilateral inferior turbinates consistent with necrosis, which extended inferiorly to the hard palate and superiorly to the inferior aspect of the sphenoid body (Figures and ). There was no MRI evidence of intracranial extension. There was no significant mucosal swelling or edema, or other mucosal signal abnormalities, on short-tau inversion recovery (STIR) images (). A large cyst centered on the crown of a left maxillary molar consistent with odontogenic cyst extended into and expanded the left maxillary sinus (). Smaller cysts with a similar appearance surrounded the roots of a right maxillary molar (Figures and ) and a mandibular molar (not shown). A right convexity collection consistent with subdu

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


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

[User]
RADIOLOGY NOTE:
A 25-year-old male patient presented with complete flaccid paralysis and numbness of right upper limb. One day earlier, he had been electrocuted while holding a telephone pole with his right hand during the lightning. Immediately, following this he developed complete paralysis of right side upper limb with loss of sensation. There was no loss of consciousness, disturbance of speech, or seizure. The right side upper limb was normal on general examination with no entry burn points, bluish coloration, and all the peripheral pulses were normal. On neurologic examination, there was complete loss of all movements with power around all joints being grade 0 in right upper limb []. All modalities of sensation were absent in the same limb, excepting a very small patch in the uppermost part of right arm where it was reduced to 20% of that on left side. Nerve conduction study done on 5th day after the lightning injury, showed grossly diminished conduction velocity and increased distal latencies in all the major nerves of right upper limb without any decrease in amplitude. Electromyography showed no fibrillations. Magnetic resonance imaging (MRI) neck showed normal brachial plexus with no avulsion or pseudomeningocele formation []. Patient was put on steroid therapy (20 mg prednisolone thrice daily for 2 weeks) followed by tapering doses for a total of 6 weeks. An arm sling was given to support the paralysed limb. On follow-up, 1 week after starting the steroid therapy, power in right hand had improved; he could open and close his fist, write with bad hand writing (with support from left hand). However, there was no recovery of muscle function in forearm and arm muscles. There was restoration of sensations in right side upper limb to 30% of normal. On completion of 2nd follow-up week, power in right hand grossly improved with ability to write properly and do routine activities. Patient was able to raise his forearm against gravity (Grade 3 power

[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 83-year-old man with left ventricular dysfunction due to hypertensive cardiomyopathy was admitted to the ED for acute heart failure. Although in chronic atrial fibrillation, he was not in anticoagulation therapy because of neurological contraindication due to the presence of cerebral venous angiomas found several years before.
The urgent ultrasound scan performed at the ED showed bilateral intra-atrial masses mainly involving the left atrium. Haemodynamic impairment caused by the size of the left atrial mass could not be excluded, subsequently, in accordance with the neurologist, unfractionated intravenous (IV) heparin was started and the patient was admitted to the cardiology ward.
The day after, a complete transthoracic echocardiography (TTE) was performed () showing within the left atrium an isoechoic and not pedunculated mass with lobulated margins attached to the anterior wall of the left atrium and extended also inside the left atrial appendage. The mass was not mobile, without evidence of haemodynamic impairment on mitral inflow. A smaller mass with the same characteristics was attached to the anterior wall of the right atrium (). There was no pericardial effusion and left ventricular ejection fraction was 40% with a normal right ventricular function.
A transoesophageal echocardiogram confirmed these aspects and showed also vacuolated and inhomogeneous areas inside the lobulated masses resembling the morphology of cardiac myxomas; no valvular abnormalities nor atrial septal defects were found ().
To further evaluation, cardiac magnetic resonance (CMR) was proposed but could not be performed due to patient claustrophobia and sedative refusal.
Therefore, electrocardiographic gated cardiac computed tomography (CCT) was carried out for a better differential diagnosis between thrombi vs. myxomas vs. malignant tumours as well as to look for possible embolization or primary tumours (in the hypothesis of cardiac metastases). Considering the atrial masses, they app

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


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

[User]
RADIOLOGY NOTE:
A 13-year-old boy presented with severe loss of vision in the right eye (RE) over the last month, not associated with penetrating injury or any ocular surgery. Best-corrected visual acuity (BCVA) was light perception in RE and 20/20 in the left eye (LE). RE showed relative afferent pupillary defect and vitreous cells. IOP of both eyes was 20 mmHg. The patient was diagnosed as Coats' disease with exudative retinal detachment (RD) in RE. There were no pathologic findings in LE. Over a period of 18 months, he developed neovascular glaucoma in RE with an IOP of 45 mmHg. His BCVA in LE was 20/20 and an IOP of 20 mmHg. The patient was treated with DLCP to superior and inferior half (120° each) of RE ciliary body. Twenty-five diode laser burns of 2000 ms duration and using a power of 2000 mW were applied.
Six weeks after cyclophotocoagulation, he experienced photophobia and sudden deterioration of vision in his LE and mild pain in RE. BCVA in LE was 20/63 for distance and near vision was N18. IOP of RE was 21 and in LE 15 mmHg. Slit lamp examination revealed anterior chamber cells, flare and keratic precipitates in both eyes, and a dense cataract precluding fundal view in RE. Fundus examination of LE revealed disc hyperemia and yellow-white subretinal infiltrates that partly obscured choroidal vasculature []. Ultrasound B-scan of RE showed total RD with increased choroidal thickness, and LE showed shallow RD with increased retinochoroidal thickness. Ocular coherence tomography showed retinal elevation due to the accumulation of subretinal fluid in LE []. Fluorescein angiography of LE revealed multifocal punctate hyperfluorescent spots in the early venous phase which then continued to late leakage [].
A diagnosis of SO was made, and the patient was treated with intravenous methylprednisolone (500 mg/day for 3 consecutive days) followed by oral prednisone. Over

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


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

[User]
RADIOLOGY NOTE:
A 32-year-old woman was admitted to the emergency room with suddenly occured dispnea and orthopnea. On admission she had a blood pressure of 110/70 mmHg, a regular pulse of 134 beaps per minute, and a breath rate of 34 per minute with 68% of partial oxygen saturation. There was a grade 2 midsystolic murmur in the mesocardiac region and bilateral pulmonary ralles throughout the lung fields.
The electrocardiogram (ECG) revealed sinus tachycardia (). Chest X-ray showed bilateral extended hilar and paranchimal infiltration and lines of Kerley B. The patient was dramatically rapidly improved with diuretic therapy and partial oxygen saturation increased up to 95%. Transthoracic echocardiography (TTE) showed normal left ventricle ejection fraction with severe hypertrophy of left ventricular posterior, lateral free wall, and mid ventricular septum ( A, B). The maximal wall thickness of posterior free wall and mid ventricular septum were 25 mm and 19 mm respectively. There was a significant peak intraventricular gradient of 91 mmHg at rest (). The color doppler imaging demonstrated flow acceleration due to mid ventricular obstruction (). The coronary angiography performed because of elevated troponin I levels, that was demostrated normal coronary arteries. Left ventriculography showed totally midventricular obtruction at systolic phase (). The cardiac MRI was also performed to confirm the diagnosis. The cardiac MRI images were clearly showed the asymetric thickening of the left ventricular posterior, lateral free wall, and mid ventricular septum (). The 24 hour Holter ECG monitoring performed and any significant arrhythmias was detected. She was discharged with the prescription of metoprolol and acetyl salisilic acid. After one month of discharge she was admitted to the emergency room with palpitation. The ECG showed atrioventricular nodal reentrant tachycardia. The rhythm was converted to sinus after the administration of metoprolol. The control ECG revealed short PR interv

[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:
Pleural effusion of usually greater than 500 ml that develops in a patient with cirrhosis and portal hypertension, in the absence of cardiopulmonary disease, is termed hepatic hydrothorax.
We report the case of a 56-year-old Caucasian male with hypertension and progressive painless jaundice who presented with shortness of breath of two weeks duration. The patient had a four year history of progressively increasing alkaline phosphatase of etiology for four years. There was no history of significant alcohol abuse or risk factors for viral hepatitis. On examination, his sclerae were icteric and there were spider naevi on the back. There was decreased air entry and dullness to percussion in the right lower lung field. Abdominal examination did not show organomegaly or free fluid. Labs showed direct bilirubinemia with a total bilirubin of 11.7, alkaline phosphatase 1261, AST 122, ALT 254, albumin 2.4 with normal platelet count and coagulation profile. Chest X-ray showed moderate pleural effusion (). ERCP revealed stricturing in the proximal and distal intrahepatic ducts with a beaded appearance. Common bile duct brushings were negative for malignancy. Liver biopsy showed findings suggestive of primary sclerosing cholangitis, prolonged obstructive biliary tract disease and moderate portal-periportal fibrosis. CT thorax and echocardiogram were negative for any mediastinal, pulmonary, pleural or cardiac pathologies that could cause pleural effusion. Thoracentesis revealed a transudative fluid with a serum-pleural fluid albumin gradient greater than 1.2, suggesting a diagnosis of hepatic hydrothorax. CT abdomen obtained at the time of admission did not show any ascites. The interesting aspect of this presentation was the absence of clinical or radiographic evidence of ascites.
The pathophysiology of hepatic hydrothorax involves the leakage of ascitic fluid from the peritoneal cavity into the pleural space through the embryologic defects, which are more prevalent in the right

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


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

[User]
RADIOLOGY NOTE:
A 15-year-old Caucasian female presented with an intra-articular fracture and adjacent laceration at the distal portion of the proximal phalanx of the thumb resulting in near complete loss of the interphalangeal joint (Figures and ). The injury was incurred from a table saw accident. The patient had an initial pain level of 4/10 and was unable to flex her thumb. The patient and her family were offered a joint arthrodesis for joint stability, but they did not desire a fusion. The patient felt a fusion would limit activities important to her such as texting, playing video games, and applying cosmetics. Joint replacement was offered to the patient as an alternative treatment. In the present case, an HUD was utilized in an off-label manner and inserted into the interphalangeal joint of the patient's thumb. The patient and family were counseled that this was not a standard treatment option and that if fusion was needed in the future, it could be more complicated and require bone grafting compared to using fusion as the initial alternative.
The patient was followed for 22 months postoperatively and has remained happy with her choice of procedure. The patient's motion in the thumb IP joint is currently a 40 degree arc which is very reasonable given the repair of the flexor pollicis longus tendon and collateral ligament as well. There was excellent range of motion (ROM) in the metacarpophalangeal joint (MCP) which is comparable to the contralateral side. Radiographs demonstrated good seating of the joint implant with no evidence of loosening or periprosthetic fracture (Figures and ). The collateral ligaments were all stable at the IP joint, and the scar on the left volar thumb was well-healed. The patient reported pain of 0/10 at her most recent follow-up and recorded a DASH score of 6.82. No known complications have arisen as a result of the surgical reconstruction to this point in time.

[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 man was diagnosed with anemia by his family physician towards the end of 2017. In February of 2018, an upper GI endoscopy and colonoscopy were performed which showed a right colon cancer. CEA was 40.4. CT of the chest, abdomen, and pelvis was obtained in February of 2018. This showed a mass 7 cm in greatest diameter that was immediately adjacent to the undersurface of the right liver and contiguous with numerous loops small bowel and the lowest part of the second portion of the duodenum (). There were mildly prominent mesenteric lymph nodes but no evidence of distant metastatic disease.
In February of 2018, the patient underwent a single port laparoscopic right colon resection. The surgeon described the tumor as stuck to the undersurface of the liver with adhesions taken down without difficulty. On histopathologic examination, the tumor was PT3N0M0 with 0/16 positive nodes. Perineural invasion was identified. The cancer was moderately to poorly differentiated. Systemic chemotherapy was not recommended.
In June of 2018, the patient began noting problems with digestion and pain after eating. CEA had increased to 940 ng/ml. Repeat CT scan showed multiple nodules within the greater omentum compatible with peritoneal metastases. The liver, kidneys, and ureters were normal. There was marked stranding within the right colon resection site (). Bowel loops proximal to the prior ileocolic anastomotic site were moderately dilated and fluid-filled. A mass was noted in the abdominal wall at the laparoscopic port site. There was also a mass in the rectovesical space immediately adjacent or invading the right and left seminal vesicles.
In July of 2018, the patient underwent exploratory laparotomy. The posterior surface of the liver was layered by cancer. The undersurface of the right hemidiaphragm was covered by tumor nodules. The pelvis contained a 4 cm tumor mass invading into the seminal vesicles. The old ileocolic anastomosis was involved and needed to be resecte

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


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

[User]
RADIOLOGY NOTE:
A 46-year-old healthy female patient was evaluated at our institution for a perirectal mass of unknown etiology. Her past medical history was unremarkable. The patient reported a perineal mass in the standing position. Her only other symptom consisted of mild occasional dysuria. Rectal and vaginal examinations were normal.
An endovaginal ultrasound performed one year before the present events to assess a known voluminous fibroma made no mention of a pelvic mass. An ultrasound of the perineal soft tissues found a hypoechogenic and heterogeneous mass of 4 x 5 cm beneath the paramedian region of the buttock. Endoscopic ultrasound showed a pelvic heterogenous mass that did not seem to originate from the rectal wall. A pelvic MRI and scan were performed and revealed a tubular structure of 13 x 7.5 x 3.5 cm in the right parametrium. It was centered around the right adnexal region, crossing the pelvic floor, reaching the ischiorectal fossae, and continuing as digital extensions in the soft tissue of the buttock (Figure ). No invasion of the muscles, sphincters, or vaginal wall was noted. The possible suspected etiologies included an endometrioma, a parametrial cyst, a low-grade sarcoma, or another mesenchymal tumor. The absence of soft tissue infiltration ruled out an inflammatory cause. A PET scan showed a mild metabolism in the tumor, suggesting a cystic lesion. The diagnosis of a low-grade mesenchymal tumor could not, however, be excluded.
This unusual case was discussed at the institutional tumor board meeting and the decision was to proceed with surgical excision. The patient underwent an open surgical resection of the tumor. Due to a voluminous uterine fibroma that limited access to the pelvic cavity, an abdominal hysterectomy was performed. The pathological examination found a lesion with a proliferation of paucicellular spindle cells in a myxoid stroma and medium to thick-walled vessels of variable caliber. The stroma was without atypia. No mitoses or necrosis were

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


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

[User]
RADIOLOGY NOTE:
We are reporting a case of 45-year-old female with the complaints of painful swelling in the right palm for the past 8 months and had difficulty in making a fist. The size of the swelling increased gradually over the duration. On examination, a firm, tender, and nonpulsatile swelling of approximately 2 cm × 3 cm in size was felt in the center of the right palm and skin was free []. There were paresthesia and weakness in grip strength.
Preoperative X-ray of the right hand showed a soft-tissue shadow without bony involvement. Preoperative magnetic resonance imaging (MRI) showed a well-defined lesion with intermediate-to-hyperintense signals on T1, hypointense signals on T2, and bright signals on the short-tau inversion recovery images. On the postcontrast study, the lesion showed mild peripheral enhancement. The lesion located in the subcutaneous plane of flexor compartment measured about 3 cm × 2 cm × 1.5 cm in size and did not involve extensor compartment []. The Doppler study was also done to aid in the diagnosis that revealed a well-defined hypoechoic lesion with little to no vascularity over the palmar region. The radiologist gave a provisional diagnosis of infected ganglion cyst or neural tumor.
Excision of the tumor was done under general anesthesia. Tumor was found to be close to the under the surface of the common digital branches of the median nerve. The nerve was stretched over the tumor but was easily separated. Tumor was well-circumscribed and was dissected from the nerve []. The wound was primarily closed.
A 3 cm × 2.5 cm × 1.5 cm soft, grayish tissue was sent to the pathologist, which on microscopy showed well-encapsulated tumor comprising elongated to spindle-shaped cells arranged in intersecting fascicles and bundles. These cells had oval chromatin nuclei with blunt ends, vesicular chromatin, and inconspicuous nucleoli. Mitotic activity varied from 2 to 4/10 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:
The patient was a 51-year-old woman who consulted our department in February 2013 about discomfort in the mandible. She had no medical history. Ameloblastoma was diagnosed during the first oral surgery in 2006, and she underwent fenestration procedures. The tumor recurred frequently, and she underwent repeated fenestration. She was dissatisfied with the outcomes of previous hospital's treatment policy and came to our department hoping for the complete resection of the tumor.
At the first visit, she described discomfort in the right side of the mandible and the perceptual abnormality of the mentum. Her face was symmetrical, but the mandibular right molar aspect bulged slightly; the swelling seemed like a parchment. On orthopanoramic radiographs (Figure ), a multilocular radiolucent lesion was observed at the teeth position of 43 to 46 and extending to the lower edge of the mandible. Computed tomography (CT) images (Figure A, B) revealed that the right mandible was filled with tumor; multifocal resorption was evident, and the buccolingual aspect of the mandible was bulging. The inferior alveolar tube could not be distinguished from the lesions.
We diagnosed recurrence of ameloblastoma and proposed a treatment protocol of radical resection and immediate bony reconstruction. The graft donor site selected was a nonvascularized iliac bone. She consented to our surgical plan.
In March 2013, the patient, under general anesthesia, underwent right mandibular resection (teeth 43 to 46; length 35 mm) and reconstruction with nonvascularized free iliac bone. The mandibular defect classification was “L”: lateral defect without the condyle and not crossing the midline. Before resection of the mandible, a memory plate was installed to maintain the shape of the mandible. The memory plate was prepared prior to surgery by modifying the surgical model to mirror the healthy side of the mandible. A 4 × 4 cm2 section of the iliac bone was harvested at the inner plate (Figure ). The iliac c

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


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

[User]
RADIOLOGY NOTE:
A 58-year-old male presented to the emergency department with a left eyelid swelling associated with mild to moderate pain for a 2-week duration. The patient did not have any visual changes, sinonasal symptoms, and neither fever nor constitutional symptoms. The patient’s past history was only significant for left parietal craniotomy due to head trauma 40 years ago.
The left eyelid swelling was causing inferior globe dystopia with mild tenderness on palpation, but no redness, fluctuation or cutaneous changes (). The extraocular muscle movements were intact, except for limited left supraduction due to the eyelid swelling. The pupils were equal and reactive, and visual acuity and color vision were normal. Transnasal endoscopic examination was unremarkable bilaterally. Contrasted sinus computed tomography (CT) scan showed an expanding left frontal sinus hyperdense opacification with peripheral enhancement and extension to the left orbit (). Magnetic resonance imaging (MRI) showed a loculated mucocele in the left frontal sinus with hypertense T1 signal and extension to left orbit but no intracranial extension ().
TOEA was selected after consulting the oculoplastic surgeon due to the lateral location of the frontal mucocele in addition to being an isolated mucocele with frontal sinus outflow obstruction. The frontal mucocele was successfully removed using TOEA through superior lid crease (SLC) incision followed by orbicularis oculi dissection, which exposed the orbital septum. The dissection until the superior orbital rim was exposed. The periosteum of the orbital rim was incised and peeled off, which exposed a bulging mass medially. The mass with surrounding fibrosis was excised completely and sent for histopathological evaluation. A bony defect was revealed at the lower aspect of the left frontal sinus measuring around 1.5 × 2.0 cm (). The left frontal sinus cavity was visualized completely through the bony defect using a combination of 0-degree and angled endoscopes. T

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


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

[User]
RADIOLOGY NOTE:
A 41-year-old female presented with right neck dull pain for 20 days. She denied any associated difficulty with headache, dizziness, pain, fever, or swelling. She was a nonsmoker and non-drinker and denied any drug abuse. Physical examination revealed a firm, well-defined, tender, non-mobile mass in the right neck with dimension about 10 × 10 × 10 mm. The mass did not move up or down with swallowing. Laboratory data were within normal limits. A computed tomography angiography (CTA) demonstrated the right jugular vein filling defect at the level of the cricoid cartilage–thyroid plane (). The grayscale ultrasound and color Doppler flow imaging showed the right internal jugular vein had a hypoechoic mass about 10 × 11 × 11 mm with a clear boundary, and the mass had a 3.9-millimeter-wide base located in the posterior wall of the internal jugular vein with a linear blood flow signal in this mass (). The pulse Doppler ultrasonography detected arterial spectrum in the mass with the peak systolic blood flow velocity: 24 cm/s, the end-diastolic blood flow velocity: 6.87 cm/s, and the resistance index: 0.71 (). The ultrasound indicated neoplastic lesions originating from the internal jugular vein (). After medical clearance, the patient received complete surgical excision with the internal jugular vein reconstructed under monitored anesthesia care. In the operation, the mass filled the entire lumen of the internal jugular vein, and compensated distention of the proximal part of the internal jugular vein was observed. The specimen excised was a 13 × 10 × 18 mm mass without extravascular invasion and involvement of any surrounding structures ().
Histopathological investigation revealed that a well-circumscribed nodular growth of fibroblasts and myofibroblasts in a collagenous stroma in large areas and nuclear fission was evident. Immunohistochemically, the cells in the lesion and the blood vessel wall were diffusely positive for smooth muscle actin (SMA). S100, Desmin,

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


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

[User]
RADIOLOGY NOTE:
The patient is a 32-month-old male with a history of asthma who had been born at 36 weeks gestation via an unremarkable induced vaginal delivery secondary to oligohydramnios, with a birth weight of 5 pounds 12 ounces. The patient's asthma history is significant for multiple emergency room visits and one prior non-PICU admission for an asthma exacerbation. His maintenance medical regimen includes daily inhaled corticosteroids and albuterol as needed. The patient lives with his mother, father, an older sister who is healthy, a maternal grandmother who smokes in the house, and a cat.
The patient presented to a nearby emergency room seven days prior to presentation with worsening respiratory distress in the context of two weeks of upper respiratory symptoms and diarrhea. On initial presentation at the nearby emergency room, he was diagnosed with bilateral pneumonia and treated as an outpatient with amoxicillin, azithromycin, oral steroids, and nebulized albuterol treatments. Four days after the initial emergency room visit, his respiratory symptoms progressed, necessitating emergency intubation and high frequency oscillatory ventilation at the outside hospital. The patient was positive for human metapneumovirus and had healthy appearing airways on bronchoscopy. After three days of progressive worsening on increased respiratory support, the patient was transferred to the JHH Pediatric Intensive Care Unit from an outside hospital and venovenous extracorporeal membrane oxygenation was initiated. Please refer to for the chest radiograph prior to ECMO initiation.
The patient was initially treated with vancomycin, piperacillin/tazobactam, and fluconazole for presumed superinfection in addition to the HMPV pneumonia. After the blood cultures were negative for bacteria, fungi, and viruses for 48 hours, vancomycin and fluconazole were discontinued. However, due to the severity of his illness and concern for bacterial suprainfection, he completed an 11-day course of piperacillin/

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


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

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

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


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

[User]
RADIOLOGY NOTE:
A 53-year-old woman, resident in Germany, was admitted to the emergency department because of confusion, aphasia and agitation. Her partner reported that she had complained about neck pain for a few weeks which had been interpreted as being related to a herniated cervical disk in an X-ray examination seven days ago and treated with analgesics. Furthermore, the patient had suffered from unspecific flu-like symptoms in the previous week and intermittent diarrhea during the previous two months. Her past medical history revealed a chronic obstructive pulmonary disease based on nicotine addiction, a chronic pain syndrome following repeated vertebral disk herniation, obesity, and appendectomy as well as surgical repair of an epigastric and umbilical hernia six years ago. Because of the chronic lumbar pain, she had been under long-term morphine treatment with suspicion of morphine addiction, but had not received intraspinal steroid/analgesics injections for several months.
On physical examination, she had a body temperature of 38.6 °C; pulse rate and blood pressure were within the normal range. In the examination of respiratory system, cardiovascular system, and abdomen, no abnormalities were detected. The neurological examination also showed no abnormalities, especially no meningism and no neurological deficits, apart from the confusion, aphasia and agitation. Laboratory analysis at admission (Table ) revealed a pronounced leukocytosis with an increase mainly in the neutrophil granulocytes, and a strongly elevated serum C-reactive protein level, indicating an infectious cause of the patient’s symptoms. Furthermore, a rise of lactate dehydrogenase, liver enzymes and cholestasis parameters, and a hyponatremia were observed. In the emergency department, a magnetic resonance tomography of the brain was performed, but demonstrated no abnormalities apart from first signs of a subcortical arteriosclerotic encephalopathy.
An immediate lumbar puncture was not successful because of

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


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

[User]
RADIOLOGY NOTE:
Our patient was a 32-year-old previously healthy female at the 39th week of gestation who accessed the first aim department of a primary healthcare centre of a peripheral hospital for severe dyspnoea and chest pain. Her past medical history did not present other hospitalizations for the same symptoms. Due to the clinical manifestations, the patient was initially treated as a case of pulmonary embolic disease and subjected to a massive anticoagulant therapy. Considering the clinical diagnosis and the child to term, an emergent caesarean delivery was performed in order to avoid foetal complications. The caesarean section was successfully performed under general anaesthesia using Stark's method due to the urgency related to the patient's clinical condition of increasing dyspnoea. Moreover, although the pAVM was still unknown at time of the caesarean section, the execution of spinal anaesthesia seems to be not indicated because of the risk of pAVM association with other AVMs, such as those located in the spinal cord, especially in case of HHT.
The foetal outcome showed an Apgar index of 3, 6, and 9, respectively, at minutes 1, 3, and 5; these data are in line with the administration of general anaesthesia and the acute maternal condition of severe dyspnoea.
Taking into account the foetal weight at birth, it showed a restriction of the expected value. The child weight was in fact 2590 gr at 39 weeks of gestation. However, ultrasounds performed during the pregnancy reported a reduction of the potential foetal growth from the 33 weeks of gestation without any Doppler alteration. This phenomenon should be the result of the chronical adaptation of the pregnancy to the unknown pAVM.
As far as the macroscopic exam of the placenta is concerned, a percentage of cotyledons infarcts inferior than 10% was reported.
Considering the patient's postoperative course, it showed a subsequently worsening of the clinical conditions, resulting in an acute distress syndrome that required an 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 man in his 60s with prostate cancer metastatic to bone and end-stage renal disease was brought to the hospital by his wife due to several days of reduced appetite and inability to ambulate independently. He had a history of strokes suffered 2 years ago and 10 months ago, with residual aphasia. Five months ago, he was admitted for sepsis associated with his tunneled dialysis catheter, with catheter tip and blood cultures having grown Enterobacter cloacae.
On presentation, he was febrile to 104°F, normotensive, had a heart rate of 134 beats per minute, and oxygen saturation was 95%. He possessed a right chest dialysis catheter tunneled to the right internal jugular vein, and a left chest subcutaneous chemotherapy port entering the left subclavian vein. Neurologic examination confirmed expressive aphasia. Antibiotics were started, and he was admitted to the hospital for probable catheter-associated sepsis.
After the patient’s arrival at the medical floor, an intern embarked to obtain differential blood cultures. A large-bore needle was inserted into the chemotherapy port and gentle negative pressure was applied to the syringe, with no return of blood. The attempt was aborted and the intern moved to the right side to inspect the dialysis catheter; however, the patient was found to have lost consciousness. Vital signs were normal, and examination revealed torticollis and gaze deviation to the right; a stroke code was promptly called. After evaluation by the neurologist, the patient was transported for head computed tomography (CT). Approximately 20 minutes later, the patient regained consciousness while on the CT table. The scan showed no acute changes. Ultimately, the event was suspicious more for complex seizure than stroke; therefore, thrombolytic treatment was not given. Nonetheless, follow-up brain magnetic resonance imaging revealed new ischemia in the right and left frontal lobes (). Neurological examination progressed to prominent right-sided weakness, which wa

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


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

[User]
RADIOLOGY NOTE:
A 77-year-old female presented to the orthopedic hand clinic with a three-year history of an extremely sensitive small mass on her right wrist. The mass had subjectively grown over this period of time. The pain had progressively worsened over time, and she had developed significant hypersensitivity to light contact. There was no complaint of cold sensitivity to the mass. The pain occasionally radiated down the ulnar aspect of her wrist. She had no known history of previous trauma to this area; however, she did have a history of squamous cell carcinoma to the dorsal-radial aspect of that hand. This had been treated previously for which she subsequently developed a reflex sympathetic dystrophy (RSD), resulting in a delayed recovery in the range of motion. A previous stellate ganglion block did not provide relief for her RSD, and her range of motion had been slowly progressing with home exercises.
On physical exam, a small round nodule approximately 5 mm x 5 mm was palpable dorsal to the extensor carpi ulnaris and 1 cm proximal to the ulnar styloid. There was significant point tenderness that did not radiate or display a Tinel’s sign. Her imaging included plain films of the affected extremity that showed no abnormality outside of diffuse osteopenia.
The location and exam were consistent with a neuroma that had evolved from a cutaneous nerve or possibly from the dorsal sensory branch of the ulnar nerve. The patient was taken to the operative theatre and deep dissection revealed a maroon-colored mass approximately 5 mm x 5 mm, connected to a cutaneous nerve branch. The nerve and mass were excised and sent for histopathological review. The ulnar nerve and dorsal sensory branch were visualized and confirmed to have no involvement with the mass. At her first postoperative visit, she reported no pain and that she was very satisfied with the results of her surgery. Diagnostic pathological stains were consistent with a glomus tumor. This was confirmed with strong reactivity to

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


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

[User]
RADIOLOGY NOTE:
A 66-year-old woman presented with severe osteoarthritis of both knees. Her weight was 89 kg and body mass index was 33. She had no other medical or surgical history. She subsequently underwent bilateral simultaneous total knee replacement surgery under general anaesthesia and with the use of tourniquet throughout. A standard medial parapatellar incision was used. A rotating platform prosthesis (LCS, Depuy, Warsaw) with uncemented femoral and tibial components was utilised, and the patellae were resurfaced with a cemented all polyethylene patella components. A satisfactory intraoperative result was obtained in both knees with a range of movement from 0 to 125. The deep layer of the medial collateral ligaments was partially released from the tibia for access during the procedure but no other soft tissue releases were required. The patient made an uneventful initial postoperative recovery and was discharged at day five after surgery. At 2 weeks after operation, she had obtained a range of motion of 0 to 90. At 10 weeks after operation she presented with a range of motion of 30 to 75 affecting the left knee only. By 12 weeks, she had decreased this range of motion of 40 to 75 with the left knee and 5 to 75 affecting the right knee. She had suffered no trauma to the knee. Blood tests revealed a CRP of 9, ESR of 85, and WCC of 4.7. Aspiration of the joint did not reveal any evidence of infection. X-rays showed calcification around the knee including the quadriceps tendon (Figures , , and ). After a review of the literature, a decision was made to treat the loss of range of motion nonoperatively, with nonsteroidal anti-inflammatory medication (Diclofenac 50 mg tds) and other regular types of analgesia and physiotherapy. Physiotherapy consisted of weekly session focusing on range of movement exercises with additional sessions of hydrotherapy. Symptoms gradually improved and by 8 months she had regained a range of motion of 10 to 100 degrees in the left knee and 5 to 105 de

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


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

[User]
RADIOLOGY NOTE:
A 27-year-old woman applied for a breast reshaping surgery for aesthetic purposes. There were no other complaints in her medical history. The patient underwent simultaneous mastopexy according to classical Lejour vertical scar technique and breast augmentation surgery using round silicone TSF - 415 mL implants under the pectoral muscle and a breast lift under general anesthesia (). During the operation proper hemostasis was achieved using electrocoagulation. Drains were removed next day after the operation with minimum serohemorrhaging fluid volumes. The later postoperative period was also uneventful.
The patient was discharged from the clinic on the second day after the surgery. Five weeks after the operation patient arrived at the clinic because of tenderness and swelling of the right breast. The patient stated that she had not sustained any traumas. During clinical examination, the upper right breast area was found to be significantly swollen and firm (). Ultrasound examination showed a 2.5 cm heterogeneous liquid strip accumulated around the implant (). The implant was intact. Complete blood count showed an increased amount of leukocytes, and red blood cells and hemoglobin were at the lower limit of the normal level.
No coagulopathies were found. The patient was taken to the operating room where she underwent revision surgery. The purpose was to remove the fluid and to find and stop the cause of its accumulation. During the operation (), a blood clot of 650 mL was removed (). Bleeding from one of the internal mammary artery branches in the implant pocket between the rib cage and the pectoral muscle lower pole was detected and stopped. After the revision, the implant was returned to the lodge. Vacuum drainage was used for one day only. One year after the surgery, there was no recurrence of bleeding, also no clinical evidence of the implant capsule contracture formation was found ().
All procedures performed in this study were in accordance with the ethical standa

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


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

[User]
RADIOLOGY NOTE:
A 22-year-old female with morbid obesity and bipolar disorder presented to the emergency room with new onset bilateral nystagmus, and bilateral lower extremity weakness progressing over 4 weeks making her bedbound. Her family also reported mild confusion. There was no known family history of neurological disease, and she had not reported any recent diarrheal illness preceding her symptoms. She was admitted to the hospital with initial diagnosis of possible MS. The patient also had dysuria and urinalysis was consistent with urinary tract infection on admission. She was started on intravenous antibiotics and IV fluid resuscitation for the urinary tract infection.
While on the floors, a detailed history and physical examination was done. The patient had a history of a gastric sleeve surgery 2 months prior and was taking her supplements (including vitamins) as prescribed. Comprehensive neurological examination revealed the evidence of psychomotor slowing with disorientation to time, poor recall and recollection, and short attention span for age. She was also noted to have 4/5 muscle strength proximally, decreased hip flexion and extension with appropriate effort. The range of movements of knee were intact but poorly sustained. Plantar reflexes showed normal flexor response bilaterally. Eye examination showed intact visual fields and no afferent or efferent pupillary defects but was positive for prominent vertical upbeat nystagmus, horizontal gaze evoked nystagmus with torsion bilaterally.
The initial differential diagnosis for her neurological symptoms included possible MS. High-dose intravenous steroids were considered but were deferred initially because of the active urinary tract infection. MRI brain showed non-specific T2 FLAIR signals in periventricular, juxta-cortical, and bilateral medial thalamic regions. Cervical and thoracic spine MRI were normal. Lumbar puncture showed no evidence of infection or malignancy. No oligoclonal bands were observed in cerebrospinal

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


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

[User]
RADIOLOGY NOTE:
A 41-year-old man, a known case of AS for nine years, was referred to the emergency department with diffuse painful swelling of his left lower limb and scrotum since two weeks prior to admission. He had a history of intermittent mild left lower limb extremity edema in the recent ten months, but no history of a long trip or any recent immobility or hospital admission. Furthermore, no recent trauma history was mentioned and he had no documented history of a previous DVT. Examination of the left lower limb showed diffuse tender swelling in the thigh with a bluish discoloration, while arterial pulses were normal. Factor V leiden, anticardiolipin antibody, serum homocysteine and protein C level were normal in the laboratory evaluation and lupus anticoagulants were negative, but protein C level was prominently reduced. He was under treatment with indomethacin, prednisolone, methotrexate and omeprazole since the beginning of the disease. A Doppler ultrasound demonstrated deep venous thrombosis involving the left common iliac, external iliac and all left lower extremity veins. The diagnosis of phlegmasia cerulea dolens was made based on clinical findings. Systemic anticoagulation therapy was established on the day of admission (500 IU, IV heparin/hour) followed by systemic thrombolysis with 50 mg of rtPA (Actylise, Boehringer, Germany), but no response to treatment was noted. The patient was referred to our department for catheter directed thrombolysis. Before intervention, he filled the informed consent form. Because of kyphosis and joint deformities of prolonged AS, the patient could not tolerate complete prone positioning; therefore, the patient was placed in the semi-prone position on the angiographic table. Subsequently, the left popliteal venous access was obtained under sonographic guide and 6-French arterial sheath (Cordis, USA) was inserted (). The venogram showed thrombosis of the popliteal, superficial femoral, common femoral, external and common iliac veins 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 42-year-old man presented to our pancreas multidisciplinary clinic after a computed tomography (CT) scan (), prompted by a 2-month history of generalized bloating and epigastric discomfort, that demonstrated a 11.2 × 9.6 cm heterogeneous solid appearing mass in the tail of the pancreas. The irregular mass had several small peripheral calcifications and lobulated contours abutting the spleen, stomach, and splenic flexure of colon without any direct invasion. He underwent a distal pancreatectomy and splenectomy with splenic artery lymph node dissection. Intraoperatively the large soft lobular cystic mass at the pancreatic tail was locally contained without any obvious invasion of surrounding structures or gross metastasis. Histopathological assessment of the mass established it as a pT3pN0pMx SPNP (CD56pos nuclear β-cateninpos chromograninneg and synaptophysinneg). Margins were negative without any lymphovascular or perineural invasion. The patient was discharged home after an uneventful period of convalescence in the hospital.
Four years later, he was referred back to our clinic after discovery of a biopsy-proven recurrence in the splenic fossa (). The bulk of the tumor was densely adherent to the splenic flexure and gastric fundus and was resected with wedge gastrectomy and partial colectomy. A 4 cm nodule of tumor adherent to the diaphragm as well as omentum was removed by dividing the omentum and stripping the superficial layer of diaphragm. The tumor was soft, extremely friable, and fractured with minimal manipulation. It remained densely adherent to the left diaphragm, left kidney, and left adrenal gland. Eventually, we were able to dissect down through the Gerota's fat and strip the anterior capsule of the kidney clean to dissect the tumor off the kidney and the adrenal gland. The other end of the mass remained adherent to the diaphragm and was removed along with a portion of the diaphragm.
Final pathology report confirmed the presence of recurrent metastatic

[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 man presented to the emergency room at our institution with the complaints of dizziness and a near-syncopal episode. This episode was preceded by a 1-week history of nausea, vomiting, and dysarthria. He also reported a 2-month history of new headache. The patient denied any visual disturbances, hearing changes, recent seizures, loss of consciousness, weakness, or sensory changes. Medical history was significant for a diagnosis of TSC with mild mental retardation and seizures in the distant past as well as hypertension. The patient had had a cataract removed remotely. Physical examination revealed adenoma sebaceum on the patient's malar surfaces. Complete neurological examination revealed no focal deficits. The results of laboratory tests were within normal ranges. A computed tomography (CT) of the head from an outside hospital demonstrated a brain mass with high attenuation. The mass appeared adjacent to the left cerebellar hemisphere near the Foramen of Lushka and extending into the foramen magnum. The patient had mild hydrocephalus evidenced by the prominence of his ventricular system. Periventricular calcifications were consistent with his diagnosis of TSC []. The patient was admitted for work-up of this brainstem mass. Magnetic resonance imaging (MRI) of the brain with contrast demonstrated deep cortical white matter changes typical of patients with TSC []. MRI also showed an extra-axial, irregularly shaped, well-marginated mass with heterogeneous enhancement in the left aspect of the medullary cistern with displacement of the brainstem and cerebellar peduncle to the right []. Further careful review of the imaging showed that the majority of the clivus also demonstrated uptake and enhancement of contrast. Increased T2 signal in the brainstem and cerebellum was consistent with edema. The patient was administered steroids and discharged with a plan to return to the hospital for elective removal of the brain mass.
The patient was taken to the operatin

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


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

[User]
RADIOLOGY NOTE:
A 60-year-old post-menopausal female presented to her primary care provider for intractable nausea, diarrhea, vomiting, and unintentional weight loss of 25lb over 2 months. She had a history of poorly controlled type II diabetes mellitus with peripheral neuropathy, and previous cholecystectomy. The patient was adopted, and thus her family history was unknown. Her physical exam was unremarkable. Her primary care provider referred her to a gastroenterologist for an endoscopy due to her clinical picture and a screening mammogram due to never having received one before.
Screening mammography performed six weeks after her initial encounter showed an oval mass in the upper outer quadrant and focal asymmetry with architectural disturbances in the anterior third of the left breast. Subsequent diagnostic mammography was concerning for breast cancer and biopsies of the mass and suspicious lymph nodes were performed. Her pathology demonstrated the lesion to be grade 2 ER positive (90%), PR positive (2%), HER2/neu positive invasive ductal adenocarcinoma with a Ki67 of 20% (). Due to the size of the oval mass and the presence of cancerous cells on lymph node biopsy, her initial stage was T2N1 stage II triple positive adenocarcinoma of the left breast.
A week later, an abdominal ultrasound demonstrated a dilated common bile duct of 14mm without obvious stones. Further work-up included an MRI of her abdomen, which demonstrated liver enlargement and a 3.5cm mass in the uncinate process of her pancreas, and diffuse thickening of the stomach wall (). The MRI also demonstrated enhancing vertebral lesions concerning for metastatic disease. Esophagogastroduodenoscopy was performed, visualizing the lesion in the stomach wall (). To determine if the gastrointestinal lesions represented another primary cancer, biopsies of the lesions in the stomach and pancreas were taken. The lesion biopsies were demonstrated to be metastatic breast adenocarcinoma due to immunohistochemical staining posit

[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 female was admitted to our hospital suffering from 48 h of acute abdominal pain, characterized by epigastralgia without radiation and no response to spasmolytics or analgesics.
The patient had been suffering intermittent episodes of mild discomfort of the gastrointestinal tract such as bearable diffuse abdominal pain and feeling of flatulence that persisted for one year. The pain pattern was not related to defecation or eating, there was no nausea, vomiting, weight loss, melaena, change in bowel habit, urinary symptoms, or fever. She was managed conservatively as thought to be a functional gastrointestinal disorder.
She describes the pain as aggravating suddenly and sharp in nature. She presented to the emergency department after 48 h of the pain acutely worsened. The pain was in the epigastrium and across the anterior abdomen, was sharp and constant without radiation.
She had no antecedents of alcohol, tobacco, or drug abuse.
She had a medical history of arterial hypertension and trigeminal neuralgia and had no surgical history. In her family history, there were two cases of colorectal cancer (mother and sister) without other illnesses.
The patient experienced epigastric tenderness upon palpation, although she had no rebound tenderness, muscle tension, or a palpable mass. She had no other relevant findings.
Laboratory test results including complete blood count, liver function tests, serum amylase and lipase, biochemistry, were within normal ranges.
An abdominal computed tomography (CT) scan showed a solid mass of the tail of the pancreas that contacted the lesser curvature of the gastric body. Magnetic resonance imaging (MRI) showed a pancreatic head, uncinate process, neck, and body of normal morphology. A solid nodular mass 29 mm in diameter was confirmed in the pancreatic tail, hypointense in T1, heterogeneous with hyperintense areas in T2, with enhancement after the administration of i.v. contrast predominantly towards the latter phase. Severe at

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


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

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

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


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

[User]
RADIOLOGY NOTE:
A 39-year-old man complaining a chronic progressive right leg pain was referred to our outpatient clinic on 28 July 2013 to perform a whole body bone scan. He denied any history of acute trauma.
At the first visit, physical examination was unremarkable. Both lower extremities were apparently symmetrical without any inflammatory sign or tenderness. There was no apparent neurological impairment or musculoskeletal abnormality in his legs. Range of motion for the knee joints and as well for ankle joints were in normal limits both in active and passive movements.
A whole body bone scan was performed 3 h after injection of 20 mCi 99mTc-methylene diphosphonate using a single-photon emission computed tomography/CT gamma camera equipped with low energy high-resolution collimator.
Whole body bone scan revealed a disseminated parenchymal uptake of the bone-seeking agent in bilateral lung fields [Figure and ]. There was also increased radiotracer uptake in the right proximal tibiofibular joint, which was more likely due to an inflammatory and/or traumatic process [].
Based on the pulmonary abnormal findings on the bone scan images, a detailed history was taken more focused on the history of any pulmonary disease. He did not complain any severe pulmonary symptom except for somewhat intolerance to severe exercise. In addition, he mentioned that he had an abnormal CXR when he was 14 years old. His past medical history included an indolent subclinical pulmonary disease, which was not followed due to the stable X-ray findings and unremarkable clinical complaint.
A plain radiography, as well as CT, was obtained from his chest to characterize the parenchymal lung disease. Chest radiograph demonstrated a characteristic diffuse sand-like micronodulations (sand-storm appearance) throughout both lung fields
[]. CT of the chest also showed an extensive infiltrative dense calcified micronodulations in the parenchyma of both lungs []. The routine serum calcium and phosphorus laboratory profi

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


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

[User]
RADIOLOGY NOTE:
A 49-year-old male with no significant past medical history presented to our emergency department with a 5-day history of sudden-onset and persistent abdominal pain. His pain began acutely following a strenuous bike ride and had not improved throughout the week. He described constant epigastric pain rated 7/10 with radiation into his back that worsened with eating. He denied nausea, vomiting, constipation, or diarrhea. He also denied chest pain, palpitations, shortness of breath, or any recent history of trauma. His past surgical history was only significant for a remote knee arthroscopy. Upon initial examination, he was afebrile and alert with the blood pressure of 139/95. His cardiopulmonary examination was normal. His abdomen was tender upon palpation of the epigastric region; however, there was no notable distension, no pulsatile abdominal mass, and his abdomen was soft with positive bowel sounds. Initial laboratory tests including troponin levels, complete blood count, and renal function tests were within normal limits.
A contrast-enhanced CT of abdomen and pelvis was ordered and showed a pseudoaneurysm involving the ostium of the celiac artery with focal dissection (Figure ). There was no evidence of thrombosis or infarction to the liver, spleen, or bowel. Ultrasound studies of the abdominal aorta demonstrated a prominent celiac artery measuring 1.4 cm consistent with pseudoaneurysm; the abdominal aorta was normal with a patent celiac artery showing adequate distal flow (Video ). Velocity at the celiac artery was minimally elevated at 142 cm/s and there was no evidence of a dynamic intimal flap. Due to these findings of isolated celiac artery dissection without evidence of further complications, the patient was managed conservatively with clopidogrel 75 mg and percocet 5 mg/325 mg and discharged after two days of observation. Follow-up repeat ultrasound three weeks following discharge showed no evidence of dissection flap, stenosis, or thrombosis and no increa

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


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

[User]
RADIOLOGY NOTE:
A 19-year-old nulliparous Chinese woman presented to the emergency room of our institution under sedation due to unconsciousness and convulsions. Her body mass index was 34.5. Her medical history was notable for a 6-month history of abnormal uterine bleeding (AUB) that persisted despite oral contraceptives use. She had no history of exposure to the AstraZeneca COVID-19 vaccine or other high-risk drugs for thrombosis. Two days prior, she was admitted to a local hospital with severe headaches, nausea, vomiting, delayed reactions, expressive aphasia, and seizures, and was diagnosed with CVT. Intravenous administration of heparin and symptomatic treatment were administered, which were ineffective. The patient continued to have seizures. Then she was transferred to our institution. A computerised tomography (CT) scan of the head demonstrated venous sinus thrombosis (Fig. a). Emergency cerebrovascular angiography with femoral artery and femoral vein intubation was performed. The patient received thrombolytic therapy via femoral intravenous urokinase on the same day that she presented to our institution and this was continued for 7 days. Subsequently, her general condition improved. On the 9th day of hospitalisation, the patient developed vaginal bleeding. Considering this is a common complication of thrombolytic therapy, physicians did not treat the vaginal bleeding. On the 11th day of hospitalisation, she developed massive vaginal bleeding and inspection revealed a mass protruding from the vagina. Her haemoglobin level dropped from 10.8 g/dL to 6.3 g/dL in 3 h, and a gynaecology review was requested. Physical examination revealed pallor of the skin and mucous membranes, with no signs of visceromegaly, ascites or palpable masses on abdominal examination. Gynaecologic examination revealed that the vaginal mass was approximately 17 × 15 × 10 cm, and the tissue showed local congestion, infection, and necrosis (Fig. ). Digital vaginal examination revealed that the mass was oc

[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 16-year-old male patient was referred to our institution with the chief complaint of pain in the right temporomandibular joint (TMJ) region and difficulty in mastication and mouth opening. He had sustained a trauma to the right temporal region because of a traffic accident. Patient did not present an initial loss of conscience or anterograde amnesia. Clinical examination showed little swelling over the right TMJ region with an inadequate mouth opening. No facial palsy was observed. Intraoral examination showed abnormal occlusion, restricted mouth opening, deviation from the midline to the right side, protrusion, absence of lateral movement to the left side and on palpitation, tenderness and pain over right ascending ramus and right temporal region. A computed tomography (CT) scan showed unilateral fracture of the right coronoid and condylar processes []. There was no evidence of direct trauma or fracture to the zygomatic region or mandibular symphyseal and corpus area. Radiological examination revealed a well-defined radiolucent line at the base of both condylar and coronoid processes []. Under nasal intubation, arch bar was fixed in the maxillary and mandibular dental arches and the inter-maxillary fixation was done with elastic bands. The fractures were corrected using the help of the patients’ occlusion as a guide. Pre-accident occlusion was achieved. Local analgesic with epinephrine (adrenaline) was infiltrated into the submandibular incision site. A mini submandibular incision was made 2 cm below the angle and inferior border of the mandible. Sharp dissection was performed down through the platysma, and then blunt dissection was begun to minimize risk to the marginal mandibular branch of the facial nerve. Periosteum and attachments for the masseter were completely stripped off the lateral cortex of the vertical ramus up to the level of the sigmoid notch. The subcondylar and coronoid region was exposed and fracture lines were seen. Because of insufficient visi

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


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

[User]
RADIOLOGY NOTE:
A 47-year-old woman came to our center with an increase in volume of her left breast without sign of infection. She is the mother of two children, without hormonal treatment. She has no hereditary history of breast cancer. In 2004, a breast augmentation was performed using retropectoral textured silicone gel implants, Allergan style 110, 330cc. The clinical examination revealed that her breasts were slightly dissymmetrical. The left breast was much larger than the right without suspicious mass detected and no palpable lymphadenopathy. On the mammography, the mediolateral oblique (MLO) view without compression demonstrates that the left prosthesis is deformed on its anterior pole and a periprosthetic collection developed mainly on the anterior surface of the prosthesis (). In Eklund incidence, no lesion is observed. We then performed a bilateral ultrasound. This exam did not show any tumoral lesion or cyst in both breasts. But it confirmed the existence of a significant left periprosthetic fluid reaction predominant in the inner region (). To get a diagnosis, a partial evacuation by fine needle aspiration is performed. The bacteriologic analysis of a part of this sample demonstrated no infectious sign. The pathologic evaluation of the second part of this sample identified atypical cells () and a positivity for CD30 (). Immunohistochemical analysis demonstrated an expression of CD45 and CD3. The cells did not express ALK and CK7. This sample was also submitted for a blind analysis to four independent anatomopathologists who all came to the conclusion of a breast implant-associated anaplastic large cell lymphoma. For this patient, the BIA-ALCL-specific TNM staging system is T1N0M0 (Stage IA). The patient underwent bilateral implant removal and capsulectomy. The total samples were analyzed. Similarly to the first case, no lymphomatous infiltration was found in the periprosthetic capsule and CD30 remained negative on each slides. Fifteen days after the surgery the patien

[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.