[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 Hausa apprentice boy was referred to us on account of failure to micturate and a discharging wound on the right side of the root of the penis. He was knocked off the road about six months prior to presentation, by a fast moving vehicle while riding bicycle on the highway. There was no known premorbid condition in him. He lost consciousness immediately and also sustained closed fracture of the left femur. He had initial resuscitation at the referring centre, where urethral catheter was passed among other things. The relation gave history of blood stained urine after the initial catheterization. He was on admission for about twelve weeks before he regained full consciousness. He was discharged against medical advice from the centre because he wanted to manage the bone fracture locally by the traditional bone setter.
He noticed difficulty with micturition soon after the urethral catheter was removed; this was characterised by occasional straining and passage of scanty urine. This necessitated presenting again in the hospital where he was recatheterised but no urine came through the catheter. At this time, he also noticed to have persistent and frequent passage of watery stool, appearance of boil at the root of the penis which later burst. There was associated fever with chills and he was unable to walk with the left lower limb.
At presentation to us, he was looking toxic, pale, and dehydrated with deformity of the left thigh the temperature was 38°C, pulse was 94 per minute, blood pressure was 110/60 mmHg and the chest was clinically clear, no murmur or gallop rhythm. There was right renal angle tenderness; the rectum was empty with no organomegaly. The urethral catheter was not functioning; a suspected urethrocutaneous fistula was noted on the right side of the root of the penis and a neglected malaligned fracture of the left femur ().
A clinical diagnosis of vesicointestinal and urethrocutaneous fistulae with urosepsis in a patient

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


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

[User]
RADIOLOGY NOTE:
A 6-year-old healthy boy was addressed to the Dermatology Outpatient Clinic for a patchy alopecia on the occipital area. Members of the family have noticed the alopecia and its slow progression over the past 2 years. The child was in good health state, receiving no medication, no allergy background, and no family history of alopecia.
At clinical examination, smooth, oval patches of nonscarring alopecia were seen on the occipital area []. The hair pull test was strongly positive in the perilesional skin. Trichoscopy revealed numerous exclamation mark hairs and confirmed the clinical diagnosis of AA []. At the edges of AA area white, short vellus hairs, and dystrophic hairs were noticed together with black and yellow dots.
On further examination, several tiny asymmetrical patches of alopecia measuring about 2–3 mm in diameter were also observed, associated with scratching marks and bleeding []. The hair pull test was negative in the perilesional skin. On trichoscopy, a number of broken hairs were observed. Direct mycological examination of the hairs from the lesional skin did not show any fungal elements. There were no other signs or symptoms of dermatological disorders either in the skin or nails or hair. The child had a positive family history of atopy. Extensive laboratory investigations such as complete blood cell count, serum chemistry, and thyroid function tests were all found to be within normal limits. Only slight anemia was proved.
Because of the suspicion of TT, an interview with the child's parents was asked and they approved that the child was hyperactive, and he was seen several times pulling out the hair. The patient demonstrated the self-injurious behavior on clinical examination which confirmed the clinical suspicion even at that point.
Treatment for iron deficiency anemia was started with Sorbifer accordingly to the age and recommendation of topical potent steroids for AA was prescribed. A psychiatric evaluation was asked, psychological counseling and

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

[User]
RADIOLOGY NOTE:
A 26 year-old woman was referred to our maternal and fetal unit for detailed ultrasonographic examination because of triplet pregnancy with threatened abortion at 15 weeks of gestation. Her obstetric history included two first trimester abortions. The patient had taken no medication or drug for ovulation induction. An inquiry into the family history revealed that her mother had delivered triplet babies all of whom died in the early neonatal period. In the present case, the attending obstetrician had performed an ultrasonography at 6 weeks of gestation demonstrating a single, 17 × 20 mm gestational sac (chorion) (Figure ).
Detailed ultrasonography at our maternal and fetal unit revealed a monochorionic triamniotic triplet pregnancy. Three thin amniotic membranes and an ipsilon zone were detected. The biometric measurements of the three distinct fetuses were appropriate for 15 weeks of gestation. The parents were informed about the risks of a multiple pregnancy and monochorionic placentation. After three days' hospitalization, the vaginal bleeding ceased and the patient was discharged to follow-up.
The obstetric course was unremarkable until 24 weeks, when ultrasonographic examination revealed that one of the triplet fetuses had developed a multicystic lung lesion suggestive of CCAM, with the largest cyst measuring 10 mm in diameter (Figure ). Until 30 weeks of gestation, the fetuses had appropriate growth, and follow-up of the pregnancy was uneventful except that the fetus with CCAM developed mild polyhydramnios. At 30 weeks, the patient presented with preterm uterine contractions that ceased after tocolysis with nifedipine 60 mg per day. Betamethasone (12 mg × 2 doses in 24 hours) was administered intramuscularly to the mother to promote fetal lung maturation. The patient was readmitted to our unit at 34 weeks for uterine contractions and impaired fetal growth. The size of the lung lesion remained the same at that time. At 35 weeks of gestation, the patient underwen

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

[User]
RADIOLOGY NOTE:
A 65-year-old man received a cadaveric kidney transplant after developing end stage renal disease. He had a longstanding history of hypertension and was receiving lithium therapy for many years for schizophrenia. Postoperatively, he established excellent graft function and was able to urinate normally. For long term immunosuppression, he was placed on oral prednisone, tacrolimus, and mycophenolate. In the months that followed, he continued to attend the transplant clinic on a regular basis. Six months postoperatively, he was noted to have elevated BUN and creatinine levels of 38 mg/dL and 1.86 mg/dL, respectively, from a previously normal baseline. Tacrolimus levels were checked to exclude its toxicity. A renal ultrasound was performed but was found to be negative for any leak or obstruction. BK levels were checked, and he was found to have a viral load greater than 400,000 copies/mL on two separate occasions. Doses of his immunosuppressant medications were immediately reduced. Over the next four years, he continued to undergo close surveillance with regular monitoring of serum creatinine and BK virus DNA levels. In spite of our best efforts, he eventually developed renal allograft failure. Histopathological specimens were sent. Immunohistochemical staining using the peroxidase test for SV-40 antigen was performed, and the diagnosis of renal failure secondary to BKVAN was confirmed. The patient was initiated on haemodialysis and placed on the transplant list once more. He continued to see his primary care physician on a routine basis. During one such visit, he complained of hematuria. Imaging studies of the abdomen including the transplanted kidney were unremarkable. A urinalysis showed 40–60 RBCs per HPF, mild proteinuria, but was otherwise negative. Retrograde pyelography was performed and revealed a medium sized sessile tumour. Cystoscopy showed it to be a tumour in the posterior wall of the bladder, and a transurethral resection of the tumour was done. Pathology

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

[User]
RADIOLOGY NOTE:
Susan is a 51-year-old woman. As an adolescent, she developed scoliosis. Working as a hairstylist when she was 18 or 19, she began to have severe pain in her hands, making her work very difficult. She had carpal tunnel surgery on her right hand which provided temporary relief. Her symptoms slowly returned and she continued to have intense pain and difficulty with her daily activities. Seeking relief from her symptoms, she received treatment from chiropractors and Chinese medicine practitioners with no significant benefit. She also tried yoga and swimming but depending on the yoga movements or swimming strokes, she began to have more pain.
When she was in her early forties, she began to have weakness in the lower half of her body. Her legs would frequently give out on the stairs, causing her to fall. Control of her bladder and bowel function also began to deteriorate. She had an MRI, and based on the results, she was scheduled for emergency surgery to stabilize her cervical spine and relieve spinal cord compression. She was informed that it would be an outpatient surgery and she would be home the same day.
In May 2011, Susan had a 6-level cervical spine fusion to stabilize her spine and relieve pressure on her spinal cord. When she woke up, she realized something was wrong. The entire right side of her body was paralyzed. What was supposed to be an outpatient surgery with a return home the same day ended up being an 8-week hospital and rehabilitation stay to learn how to walk again.
In August 2012, a second surgery was performed with the goal of pain relief. However, she reported her pain was significantly worse afterwards. She would receive weekly injections for pain relief that she reports would only marginally decrease her pain for about one week. She was also taking high doses of medication for nerve pain relief which she also reports provided marginal benefit. She had areas of heightened sensitivity on her legs where a bed sheet or even

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

[User]
RADIOLOGY NOTE:
A 25-year-old male patient, a known case of extrahepatic portal venous obstruction and portal hypertension, was detected to have nephrotic syndrome during his pre-anesthetic evaluation for hydrocele surgery. He was told that his surgery was deferred till his kidney disease was evaluated and treated. It was felt that the worsening ascites and subsequent scrotal swelling was aggravated by the presence of his nephrotic state, and hence correction of his nephrotic state will reduce post-operative complications and recurrence of his scrotal swelling. He was subsequently referred to our hospital for his renal evaluation and management.
At the age of 12 years, he had an episode of hematemesis and was evaluated and found to have esophageal varices. Evaluation of his portal hypertension revealed the presence of extrahepatic portal venous obstruction. He was managed with oral propranolol. He stayed asymptomatic except for minimal ascites. His liver functions on regular follow-up stayed normal.
Three months prior to this admission, he started developing scrotal swelling, abdominal distension and pedal edema for which he consulted a surgeon. Physical examination revealed pallor, pedal oedema, tense ascites, splenomegaly and bilateral hydrocele. Laboratory investigations showed evidence of anemia, thrombocytopenia, renal insufficiency hypoalbuminemia, and normal liver enzymes. His coagulation work up was normal. His cardiac evaluation did not reveal any abnormality. His urine analysis revealed the presence of proteinuria. Ultrasonography of the abdomen showed massive splenomegaly, ascites and no evidence of liver cirrhosis. Liver biopsy showed normal liver architecture with no abnormality. Adiagnosis of nephrotic syndrome was made and the bilateral hydrocele repair was postponed, and the patient was referred to the Nephrology services of our hospital for the management of nephrotic syndrome and renal insufficiency.
The laboratory investigations in our hospital are shown in .
A r

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

[User]
RADIOLOGY NOTE:
A 28-year-old female visited our institute because of headache for a month. The consciousness level was alert and motor grades of the extremities were normal. However, she had repeated vomiting for several days. This symptom was likely due to increased intracranial pressure, and therefore brain imaging was performed. The brain CT scan showed abnormal low density on the right frontal lobe and bony thinning on the right frontal bone (). Brain MRIs revealed cystic and enhancing mass on the right frontal lobe (). Dural enhancement suspected to be the dural tail sign was identified (). Conventional angiography was performed and sunburst appearance through the right middle meningeal artery was confirmed (). These radiographic findings suggested a diagnosis of a cystic meningioma.
A surgical excision was performed. Intraoperatively, the dura was intact and there was no abnormal findings at the craniotomy eroded bone site. The mass had a well-defined arachnoid plane. Also, there was no dural attachment or adhesions (). A biopsy was taken and sent to the pathologist for intraoperative diagnosis, and the result of the frozen biopsy was a glioma. After cyst fenestration, the mass was totally removed. The final pathology findings described a proliferation of piloid glial cell with Rosenthal fibers and eosinophilic granular bodies (). Biphasic pattern was also identified. The Ki-67 was 1%. However, some scattered mitotic figures were identified. A maximum of 3 mitoses per 10 high power field showed that it was difficult to diagnose the patient as an anaplastic astrocytoma. Also, slightly increased cellularity was also shown, but there was no necrotic tissue. Therefore, the histologic findings confirmed a diagnosis of pilocytic astrocytoma with transformation to a more cellular and mitotically active lesion.
Postoperatively, enhanced CT scans revealed that the tumor was totally removed. The symptoms improved and there were no abnormal neurologic signs. Additional treatment such a

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

[User]
RADIOLOGY NOTE:
A 70-year-old nonverbal female presented to the emergency department (ED) from home with her daughter who had noted that the patient has been acutely grimacing in pain from even the lightest palpation over her right flank. She had decreased urine output for the prior two days and her family had noticed an enlargement on the right side of her back one day prior to her ED visit. Of note, the patient presented with poor functional status, was totally bedridden, and was on no antibiotics. She also had a renal flow scan several months prior to her presentation, which revealed the absence of blood flow to the left kidney. A nephrectomy was ultimately rejected based on her medical history and current health status. The patient's medical history was significant for CVA with left hemiparesis, sacral stage 4 pressure ulcers, DM, HLD, failure to thrive, and asthma. Her past surgical history included a left double J-stent placement, an appendectomy, and a tracheostomy that was reversed.
On physical examination, the patient appeared to be in mild distress with a blood pressure of 93/50, heart rate of 116, and otherwise normal vital signs. Abdominal examination was remarkable for tenderness to palpation over the right flank with visible erythematous skin seen in the same area. Results of the initial laboratory tests were significant for a lactate of 2.9, white blood cell count of 18.4, hemoglobin of 7.1, platelet count of 933, albumin of 2.3, and potassium of 5.8, yet with a creatinine of 0.62. She underwent an IV contrast computed tomography (CT) scan of the abdomen and pelvis, which revealed a right hydronephrotic kidney that contained numerous large calcifications (Figures and ). The right previously placed ureteral stent was in satisfactory position. There was an extremely large fluid collection in the right retroperitoneum extending into the right flank consistent with leakage of urine from the obstructed right kidney ().
While, in the ED, urolog

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

[User]
RADIOLOGY NOTE:
A previously healthy 6-year-old boy presented to a pediatric hospital with a 3-week history of torticollis. He had symptoms of an upper respiratory tract infection four weeks prior and had 2 days of documented fever at home during that time. He had been treated with a 7-day course of amoxicillin by the primary care physician for suspected streptococcal pharyngitis. Four days into the course of antibiotics, he woke up from sleep with pain on the left side of his neck. Despite taking ibuprofen and acetaminophen, he presented to the Emergency Department 3 weeks later due to persisting torticollis. Pain was worse with movement. There was no history of head/neck trauma. At the time of presentation, the infectious symptoms had resolved. Some fatigue was noted but he remained generally active, continuing to play hockey. There was no history of rash, peripheral joint pain, or weight loss. Past medical history and family history were unremarkable.
On examination, the patient was afebrile with normal blood pressure for age and a maximum heart rate of 110 beats per minute. The patient's head was tilted to the right with chin rotation to the left. No lymphadenopathy or masses were noted on palpation of the neck. There was no tenderness to palpation of bilateral sternocleidomastoid muscles. There was a limited range of motion in all planes of rotation of the neck secondary to pain, particularly in lateral flexion. Bilateral injected conjunctivas were present. The oropharynx was normal with no erythema or mucus membrane changes. Cardiovascular exam revealed normal peripheral pulses, a quiet precordium with normal heart sounds, and no murmur. Respiratory exam was normal. The abdomen was soft with no distension, tenderness, or hepatosplenomegaly. There were no bruits heard on auscultation of major vessel regions. There were no rashes or desquamation of the skin. Neurological exam was normal.
At the time of presentation, laboratory investigations

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

[User]
RADIOLOGY NOTE:
A 57-year-old man presented to the A&E with loss of consciousness due to a motorcycle collision 9 h prior. Upon initial examination, the patient had a GCS of E4M6V5. The patient had no other symptoms that required inpatient care. The patient also had no history of bloody discharge from the external auditory meatus. The patient's past medical examination shows no other history of past illness and surgery. He reported family history shows the patient's parents died due to heart attacks. Further examination with a head CT scan revealed minimal PNC forming in the right frontal region (, ). The patient was first admitted to the A&E then requested for discharge against medical advice after 5 days of inpatient care.
Ten days later, the patient then came to the outpatient clinic, complaining of severe headache and rhinorrhea developed, prompting the patient to return for re-examination. The patient exhibited right-sided hemipharesa with a GCS of E2V2M4 on the second visit. A second CT scan revealed massive PNC far more severe than evident in the previous CT scan (). Bone reconstruction showed a right frontal linear fracture ().
The final assessment concluded that the patient suffered from a tension PNC. An operation was then performed to drain the PNC and seal the cranial defect. The operation was performed via a bicoronal incision. A burr hole in the calvarium was created at the highest convexity to release the PNC, and the cranial defect was closed using a pericranial rotational flap (). The diameter of the defect was measured, and a flap with the same diameter was drawn adjacent to the defect. The pericranium was sacrificed to obtain clear margins, and the underlying bone was drilled.
He was given an intravenous broad-spectrum antibiotic ceftriaxone (1 g, administered for 5 days) and analgesics drugs (ketorolac, 30 mg intravenous if necessary, not exceeding 5 days). Post-operative was

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

[User]
RADIOLOGY NOTE:
A 61-year-old woman, with a history of squamous cell carcinoma of the lower extremity status post resection, stage IV renal disease secondary to lambda light chain multiple myeloma (diagnosed in February 2020), and poor initial response to systemic chemotherapy, presented to her primary care physician in August 2020 due to headaches and visual auras in her right eye. Within a week, the patient lost all vision in her right eye as well as extraocular muscle movement. Magnetic resonance imaging (MRI) of the brain showed a 2.3-cm right parasellar mass and the patient was referred to neurosurgery with a presumed diagnosis of a meningioma. A repeat MRI the following week showed a 4 × 3-cm extra-axial mass involving the right cavernous sinus with extension to the optic canal, frontotemporal base, and posterior ethmoid and sphenoid sinuses (Figures , ). The mass encased the cavernous right internal carotid artery abutting the right superior rectus muscle. Physical examination was significant for right extraocular muscle plegia, dilated and non-reactive right pupil, right afferent pupillary defect, right periorbital paresthesia, and cranial nerve II to VI palsy. The patient was diagnosed with cavernous sinus syndrome secondary to meningioma versus malignancy.
Neurointerventional radiology was consulted, and a CT-guided biopsy of the lesion was scheduled to identify the nature of the mass, that is, squamous cell carcinoma metastasis versus meningioma versus plasmacytoma, as treatment of a plasmacytoma would involve radiation and medical therapy as opposed to a craniotomy for tumor resection. The patient was taken to the radiology suite and positioned supine on the CT table. General anesthesia was used for the duration of the procedure. A CT of the base of the skull was conducted with intravenous contrast to identify the right internal carotid and right ophthalmic arteries and their branches. The images demonstrated an expansive enhancing mass in the right cavernous sinus, ext

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

[User]
RADIOLOGY NOTE:
The patient was a 71-year-old man complaining continuous pain on the right back. Imaging studies showed that 10 cm of contrast-enhanced soft tissue mass on the right posterior chest wall was involving the 11th and 12th ribs, and developing to the spinal canal via the Th11–Th12 intervertebral foramen (Fig. a, b). The incisional biopsy was suggestive of peripheral nerve tumor or unusual vascular neoplasm with neuroendocrine marker expression.
The patient was anesthetized on prone position. Skin incision was determined to perform the posterior spinal fusion and prepare the skin and muscle flap for covering the chest wall defect after the tumor resection, i.e., longitudinal midline skin incision over the spine to expose the right side of the thoracic spine and the second incision along the rib and over the tumor. After splitting the spinalis thoracis muscle, the Th11–Th12 transverse processes and the Th11–L1 spinous processes were cut off at the levels of the base and the lamina was partially removed to approach the Th11 spinal canal. The Th11 thoracic nerve was dissected at the level of the root so that the proximal end of the tumor was clearly identified as developing to the exact proximity of the dura mater (Fig. c, d and Additional file : Video S1). The tumor end was separated together with the epidural venous plexus from the dura mater so that the resection margin was considered to be free from the tumor, but minimal. Then, the proximal ends of 11th and 12th ribs were separated from the vertebra. The posterior spinal fusion was established to mend Th9–L1 vertebras. Via thoracotomy, the distal portions of the 10th–12th ribs were cut with at least 2 cm of surgical margin and the resection line on the diaphragm and the paravertebral area was determined (Fig. e). There were no gross pleural dissemination and direct invasion to the right lung. The tumor mass was carefully separated from the vertebras so that

[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 25-year-old Chinese female patient had been amenorrheic for 2 months and was referred to the hospital because of painless vaginal bleeding that had lasted for 15 days. Four years ago she had a missed miscarriage at 9 weeks of gestation, which was managed by surgical curettage. Two years prior to presentation she had delivered a baby by elective cesarean. Twenty days before presenting at the hospital she had been diagnosed as 40 days pregnant based on elevated urinary levels of beta human chorionic gonadotropin (β-hCG).
The study was approved by the Institutional Review Board at the First Affiliated Hospital, College of medicine, Zhejiang University. The procedures were conducted according to the principles of the Helsinki Declaration. On presentation the vaginal bleeding was scanty and her serum β-hCG level was 1200 mIU/mL. Transvaginal ultrasonography showed that the uterus measured 106 × 64 × 60 mm. There was an echo-free area above the inner cervical os, measuring 43 × 23 mm, without any blood flow signal, yolk sac or embryo present. A mixed echo mass measuring 29 × 15 mm was detected in the uterine cavity but no blood flow signal could be found in it. The patient was diagnosed as having had a missed miscarriage in the cesarean scar region of the uterus and curettage was performed with ultrasound monitoring. During the procedure, massive bleeding (~600 mL) occurred but this was stopped with an intravenous injection of oxytocin and uterine massage. Chorionic tissue was aspirated and proven as such by histopathology. When the curettage was finished, the uterine cavity was revealed as a clear thin line by ultrasound and was considered normal. Vaginal packing was performed subsequently.At 18 hours after curettage, the serum β-hCG level was 1164 mIU/mL. A cystic lesion with an uneven wall in the lower part of the uterus measuring 71 × 44 × 39 mm was detected with gray-scale ultrasonography (Figure ). Color Doppler ultrasonography showed a swirl of col

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

[User]
RADIOLOGY NOTE:
A 34-year-old male patient presented with a 17-month history of intermittent left-sided upper abdominal and epigastric pain. The pain occurred one day following running, lasting three days. The pain was described as aching and stabbing in nature and radiated to the left flank, intermittently ranged in severity from 3/10 to 6/10 on the visual analog scale when present, and affected his ability to participate in recreational as well as physical activities.
Symptom onset was correlated to ingesting a heavy meal consisting of biscuits and gravy with reported abdominal pain and sweats requiring urgent care. In the emergency department (ED), evaluation included a negative abdominal CT and he was discharged on antibiotics. The patient continued to have intermittent symptoms and self-managed by removing meats from his diet and intermittently taking dicyclomine and polyethylene glycol 3350.
Ten months later, the patient was seen for continued epigastric and left upper quadrant pain occurring randomly and not related to meals. The patient was subsequently referred to as gastroenterology. Upon examination, the pain was not provoked with abdominal auscultation. Murphy’s sign was negative. The workup included an assessment of H pylori to rule out peptic ulcer disease and an endoscope to assess for evidence of candidiasis or obstruction. Red flag symptoms to include anemia, blood in the stool, and weight loss were not present. Labs to include a complete blood count and comprehensive metabolic panel were negative. The working diagnosis was gastritis, and he was treated with pantoprazole 40 mg daily for two months. The patient followed up with gastroenterology as the pain worsened after running four miles and intense workouts. CT of the abdomen and pelvis with contrast, abdominal MRI, magnetic resonance cholangiopancreatography, MRI enterography, and nuclear medicine hepatobiliary studies were all normal. The patient was instructed to follow-up with his primary care provider as the

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

[User]
RADIOLOGY NOTE:
A 44-year-old woman was admitted to the hospital for evaluation of pulmonary nodule detected on computed tomography (CT). She had a history of total thyroidectomy for PTC, which was performed 8 years ago. The primary PTC measured 2.4×1.3 cm in dimension with invasion into adjacent muscle and had metastasized to several regional lymph nodes (pT4N1) (). After total thyroidectomy the patient had taken neck and chest CT scan at an interval of one year. The PTC recurred in the cervical lymph node after 2 years of total thyroidectomy. There was no evidence of lung metastasis. A follow-up CT scan taken after postoperative 6 years demonstrated the presence of two nodules in both the lower lobes of lungs. Both the nodules were 0.6 cm in the longest diameter. At the 2 years follow-up CT scan after detection of the pulmonary nodules, there was a slight increase in the size of right lobe nodule from 0.6 to 0.8 cm (). Consequently, the patient underwent wedge resections of both lobes. The resected right lower lobe measured 5.8×3.3 cm in dimension and it contained a small nodule measuring 0.8×0.5 cm in dimension. Microscopically, the main part of the nodule showed typical histologic features of nonmucinous AIS. Single layer of cuboidal cells grew along the thick-ened alveolar walls in a lepidic pattern. There was no stromal or vascular invasion. Within the AIS area, there was a 0.2×0.1 cm sized lesion, which exhibited papillary structures with typical nuclear features of PTC. The papillary carcinoma was composed of enlarged cells with clear nuclei and occasional intranuclear inclusions (). In addition, multiple microscopic foci of metastatic PTC were also observed in the surrounding normal lung tissue. Immunohistochemical staining for thyroid transcription factor-1 (TTF-1) and thyroglobulin was performed on both thyroid and lung tumor. Immunohistochemically, PTC of the thyroid gland was positive for both thyroglobulin and TTF-1

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

[User]
RADIOLOGY NOTE:
A 65-year-old Asian woman was admitted with exertional dyspnea. She had a medical history of hypertension, hyperlipidemia, and coronary artery disease that had required transcatheter intervention. Her family history also included coronary artery disease. Her social history was unremarkable with respect to environmental and workplace exposures, and she did not smoke or consume alcohol. A physical examination upon admission revealed no signs of cardiac congestion or neurological deficits. Her vital signs were a systemic blood pressure of 143/86 mmHg, pulse rate of 89 beats per minute, and a body temperature of 35.9 °C. Chest x-rays at the time of admission showed cardiomegaly with protrusion of the right first aortic arch, and electrocardiography showed an incomplete right bundle branch block of normal sinus rhythm. Coronary angiography performed because of her history of coronary artery disease revealed no significant coronary arterial stenosis. However, a concurrent pressure study revealed oxygen step-up in gas sampling between the SVC and right atrium (RA) with a pulmonary blood flow/systemic blood flow ratio (Qp/Qs) of 2.07, even though pulmonary artery pressure was normal in the pressure study and the atrial septum was intact on echocardiography. Contrast-enhanced computed tomography (CT) revealed that the RUPV flowed into the SVC (Fig. ) without any other congenital heart conditions, including an ASD and a dilated RA and right ventricle (RV). Isolated PAPVR was diagnosed on the basis of CT imaging findings, and surgery was indicated on the basis of the patient’s symptoms and the hemodynamic pressure findings.
The surgical approach was via a median sternotomy. The SVC was cannulated near the confluence of the innominate vein, sufficiently above the RUPV. A cardiopulmonary bypass was established, and cardiac arrest was applied. The RA was incised longitudinally. The intact atrial septum was incised in the cranial direction from the superior aspect of the fossa ova

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

[User]
RADIOLOGY NOTE:
A 67-year-old Caucasian man presented to the emergency room because of a 4 days’ history of abdominal pain, with one episode of vomiting.
The patient’s past medical history was significant for colonic diverticulosis and an episode of gastrointestinal bleeding one year before. The event had been investigated by two different gastroscopies, a colonoscopy and a MDCT, which produced inconclusive results. Ten months later he was newly admitted because of abdominal pain and fever at 38.0 C°, with valid urination and defecation. A CT of the abdomen was performed, which confirmed the colonic diverticulosis and revealed the presence of multiple diverticula of the small intestine, fat stranding, signs of inflammation as well as a small amount of free liquid in the abdomen. The patient was hence diagnosed with jejunal diverticulitis and managed conservatively with intra-venous antibiotics, with an apparent complete recovery.
He re-presented to the emergency department two months later with acute abdominal pain. The pain was described as severe and constant, localized mainly in the lower abdomen with clinical signs of peritonitis. No change in bowel habits nor urinary symptoms were complained. His vital signs were stable, with a temperature of 37.2 C°; he appeared fully oriented and not in any acute distress. Laboratory examination reported a hemoglobin of 121 g/dL, a WBC count of 12.2 × 10E9/L and a CRP of 249 mg/L. Other laboratory data were within normal limit. An abdominal and pelvic contrast-enhanced computed tomography, with administration of oral contrast, was performed. Jejunum and ileum showed several diverticula as well as an inflammatory thick-walled mass involving different loops of the intestine. In addition, free fluid in the abdomen and a small amount of subdiaphragmatic air were reported (, ). On the basis of these findings, the diagnosis of perforated diverticulitis was hereby proposed.
The patient underwent a diagnostic laparoscopy which revealed plenty of pur

[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 74-year-old Caucasian female with a body mass index of 29.3 and chronic AF underwent an uneventful VATS-LA maze procedure under general anesthesia. The procedure involved sequential one lung ventilation which was accomplished using an EZ-Blocker endobronchial blocker (Teleflex Inc., Morrisville, NC, USA). Transesophageal echocardiography (TEE) was used to guide exclusion of the LA appendage as well as to assess the flow in the pulmonary veins both before and after ablation. The ablation lesions were created with a bipolar radiofrequency catheter, however due to the presence of the TEE probe, an esophageal temperature probe was not inserted.
Six weeks later, the patient presented to the emergency department with persistent fever, altered mental status, and left upper extremity weakness. Neither initial computed tomography (CT) nor magnetic resonance imaging/angiography (MRI) of the head indicated any acute intracranial process. A CT of the thorax, however, revealed that air had collected in the posterior LA, raising the suspicion for an LA wall abscess or an AEF [].
A surgical exploration through median sternotomy with cardiopulmonary bypass (CPB) on standby was planned. The patient had already been intubated the night prior due to worsening mental status. In the OR, a 9F double-lumen central venous catheter was inserted in the right internal jugular vein under ultrasound guidance. Due to poor distal circulation in both upper and lower extremities, an 18-G catheter inserted in the right axillary artery was used for blood pressure monitoring as well as blood sampling. Before the sternotomy, an esophagogastroduodenoscopy (EGD) was performed to rule out any esophageal pathology. This decision was influenced by a higher degree of suspicion for an LA wall abscess based on the interpretation of the CT scan. While no obvious esophageal pathology was detected, toward the end of the EGD, the patient developed sudden severe hypotension which was treated with multiple boluses

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


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

[User]
RADIOLOGY NOTE:
An 8-month-old male infant developed a perianal mass during the first week of life which was treated as an abscess. The infant at that time had a full septic work-up that was negative and it was decided to treat him conservatively with antibiotic without incision and drainage. At the age of 2 months, he started having recurrent subcutaneous lumps on the lower extremities. At 5 months of age, he was provisionally diagnosed to have panniculitis and was hospitalized at that time for a muscle biopsy from the right thigh to confirm the diagnosis of panniculitis and evaluate other possible etiologies. After the muscle biopsy, he developed rapidly progressive bluish discolorations and indurations in the upper thighs which extended to the buttocks and scrotum over a period of 2 days (). The skin lesions progressed to hemorrhagic necrosis on the 8th day of hospitalization (). When the hemorrhagic necrosis developed, purpura fulminans was considered and protein C deficiency was suspected. He was started on regular fresh frozen plasma transfusion and later started on protein C concentrate and low-molecular-weight heparin. His course was complicated by compartment syndrome that required bilateral lower extremity fasciotomy followed by extensive debridement with artificial dermis (Integra®) application (Figures and ). Additionally, he developed anemia requiring multiple blood transfusions, thrombocytopenia, consumptive coagulopathy (prolonged prothrombin time (PT), activated partial thromboplastin time (aPTT), and low fibrinogen), and fibrinolysis (increased D-dimer) which were consistent with disseminated intravascular coagulation (DIC). His illness was further complicated by Gram-negative sepsis (Klebsiella oxytoca and Enterobacter cloacae), hypertension, and respiratory failure requiring ventilatory support. The infant was hospitalized for 3 months during which he gradually improved while receiving protein C concentrate. He was transferred to another facility for further care

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


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

[User]
RADIOLOGY NOTE:
A 57-year-old man with cough and minimal whitish expectoration was diagnosed with adenocarcinoma after a biopsy was conducted on the upper lobe mass of his left lung on March 4, 2016. Mutational analysis revealed that he lacked EGFR mutations or ALK gene rearrangements. CT scans showed that this patient had developed multiple metastases, including mediastinal and hilar lymph nodes, and also to the right intrapulmonary lymph nodes. He received 6 cycles of Pem-Cis chemotherapy, followed by thoracic radiation. Review of the CT scan at completion of sequential chemoradiotherapy treatment resulted in a significant shrinkage in the primary tumor in his left lung, while simultaneously resulting in a slight increase in metastatic lymph nodes (Fig. ). In February 6, 2017, CT scans showed that the tumor progressed rapidly. He was then scheduled to receive gemcitabine plus nedaplatin (Gem-Ndp) chemotherapy. However, the patient had to discontinue the planned 2nd cycle of this regimen as he developed moderate pneumonia. After systemic antibiotic treatment, the patient improved symptomatically and became increasingly energetic. However, CT scans on March 29 revealed that his tumors had progressed further. Owing to his poor physical condition after Gem-Ndp treatment, the chemotherapy regimen was changed to Pem-Cis. However, CT scans on May 11 failed to detect any shrinkage in his tumor. In addition, lymph node metastases increased post-treatment. The patient subsequently started standard of care pembrolizumab treatment at 2 mg/kg intravenously every 3 weeks for 6 cycles. During hospitalization, the general condition of the patient was good, with signs of fatigue only present at the first 2 days after each pembrolizumab infusion. The treatment failed to result in an anti-tumor response. The patient then received 2 cycles of initially used chemotherapy regimen Pem-Cis. Interestingly, we detected a significant shrinkage in the enlarged mediastinal and hilar lymph node metastases, wi

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


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

[User]
RADIOLOGY NOTE:
RC is a 62-year-old male who initially presented with a T3N2M0 midrectal cancer and underwent neoadjuvant chemoradiation four weeks prior to a laparoscopic low anterior resection with diverting loop ileostomy. He completed adjuvant chemotherapy and returned for an elective reversal of his ileostomy nine months postoperative. His preoperative workup included a colonoscopy which revealed exclusion colitis for which he was treated. He also underwent a gastrografin enema and computed tomography (CT) imaging of his abdomen and pelvis with no evidence of recurrence, obstruction, or distant metastases. On CT imaging, the proximal ileum appeared normal, but the distal ileum was not imaged. After his reversal, his postoperative course was complicated by persistent small bowel obstruction, for which he was managed conservatively for two weeks. He subsequently underwent a CT abdomen and pelvis, which was highly suspicious for anastomotic stricture.
On postoperative day 14, the patient underwent a diagnostic laparoscopy showing multiple adhesions around the previous reversal site with normal-appearing dilated proximal and collapsed distal small bowel. There was no localized stricture in the defunctionalized distal ileum. He underwent a resection of the prior reversal site and creation of a new side-to-side primary anastomosis. Despite creation of new anastomosis, his small bowel obstruction continued for additional two weeks. CT imaging and small bowel series were obtained, both modalities showing a narrowing of the ileum distal to the previous anastomosis (Figures and ). On hospital day 27, the patient underwent a final exploratory laparotomy with intraoperative findings of persistent collapsed bowel loops distal to the new anastomosis. The collapsed distal segment was resected, and an ileocolic anastomosis was created. On gross examination, the entire distal ileum was thickened without stricture (Figures and ). The pathology of the distal ileum showed submucosal fibrosis with

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


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

[User]
RADIOLOGY NOTE:
Esophageal bypass surgery with gastric tube was planned for a 77-year-old man with esophagobronchial fistulae. He had undergone chemotherapy and radiotherapy for esophageal cancer with possible invasions to the descending aorta and left main bronchus at another hospital, resulting in the formation of fistulae. Since clip plication was unsuccessful and the fistulae remained, he was referred to our hospital for surgical treatment.
The patient had a past history of hypertension, diabetes mellitus, bladder cancer, and cerebral infarction. Preoperative arterial blood gas analysis showed a partial oxygen tension (PaO2) of 80.5 mmHg, partial carbon dioxide tension (PaCO2) of 38.8 mmHg, and pH of 7.44. Preoperative computed tomography showed two esophagobronchial fistulae, with diameters of 7 and 3 mm, located in the proximal part of the left main bronchus, and also demonstrated pleural effusion in the left thoracic cavity (Fig. ). No bullae were evident in the lungs.
After the patient entered the operating room, an epidural catheter was inserted at the eighth and ninth thoracic interspace. Because no endoscopic images were available, we confirmed the exact location of the esophagobronchial fistulae at the proximal part of the left main bronchus using bronchoscopy after intravenously administering 35 mg of pethidine. Tracheal intubation was performed nasally under bronchoscopic guidance using a long spiral tube with a short cuff (6.0 mm internal diameter, 400 mm length; Phycon, Tokyo, Japan) to a depth of 26 cm. The tip of the tracheal tube was confirmed to be above the carina on bronchoscopy. One-lung ventilation with this tube was planned as an emergency backup by advancing the tube into the right main bronchus in case spontaneous respiration ceased. We chose respiratory management with spontaneous respiration rather than one-lung ventilation in this case since we believed that further damage to the tissue around the fistulae should be avoided. Thus, we decided not to att

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


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

[User]
RADIOLOGY NOTE:
A 67-year-old man was admitted to out hospital because of a 5-month history of pain in his left ankle. Physical examination revealed partial limitation of motion of the left ankle joint. On palpation, a tender, subtle swelling on the anterolateral lower third of the patient’s left leg, just proximal to the ankle joint was noted. There was no palpable lymphadenopathy in the draining regional lymph nodes. The serum alkaline phosphatase, phosphorus, calcium, and uric acids levels were within normal limits. X-A 67-year-old man was admitted to out hospital because of a 5-month history of pain in his left ankle. Physical examination revealed partial limitation of motion of the left ankle joint. On palpation, a tender, subtle swelling on the anterolateral lower third of the patient’s left leg, just proximal to the ankle joint was noted. There was no palpable lymphadenopathy in the draining regional lymph nodes. The serum alkaline phosphatase, phosphorus, calcium, and uric acids levels were within normal limits. Xrays of the left leg with ankle revealed a poorly defined permeative osteolytic lesion in the distal third of the fibula. The tumor had mainly a metaphyseal location and extended into the epiphysis. This neoplasm occupied the medullary canal, breaking through the cortex and extending to surrounding soft tissue with slight periosteal new bone formation ().
Computed tomography (CT) and Magnetic Resonance (MRI) confirmed the presence of an osteolytic fibular mass, which was expanding the medullary canal, destroying the lateral as well as the medial cortex and involving the surrounding soft tissue (). A periosteal bone reaction was clearly Seen in CT. Magnetic resonance imaging of the lesion showed it to be hypointense on Tl-weighted image and heterogeneous on T2-weighted image with isoand hyper-intense areas. The histological diagnosis of leiomyosarcoma was made on the basis of an open incisional biopsy. The most direct approach to the distal Fibula was selected, the

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


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

[User]
RADIOLOGY NOTE:
A 29 years old male patient was taken to our emergency department within one hour of following motor vehicle accident. He complained of severe chest and back pain. On examination he was alert, conscious with pulse rate of 134 per minute, blood pressure of 86/64 mm/Hg, the extremities were cold and clammy. On auscultation, the heart sounds were audible without any adventitious sounds. The breath sounds were diminished in the left lower chest. A chest x-ray was done which revealed multiple rib fracture with mediastinal widening and left pleural effusion. In view of excruciating chest and back pain with features of hemorrhagic shock, a suspicion of aortic injury was made and hence an urgent emergency department CT scan was done after that the patient was shifted quickly to the emergency operation theater without waiting for the reports and the CT film. While shifting to the operation theater the film was obtained on the operation theater console which revealed a contained ruptured aortic rupture immediately below the level of isthmus (). An intervention cardiologist opinion was sought for endovascular stenting but in view of lacerated aorta involving more than 50% of its circumference at the site of injury, it was not possible and hence an urgent open surgical technique was advised. The patient was taken to operation theatre and intubated with single lung tube. He was positioned in right lateral position. A left posterolateral thoracotomy was done and the chest cavity was entered through the fifth intercostal space. A huge contained hematoma was noted. The patient was heparinized a plan to conduct surgery on left heart bypass on normothermia was decided. One of the 16Fr aortic cannula was inserted to the left superior pulmonary vein as outflow circuit and another 18Fr aortic cannula was inserted to the descending thoracic aorta just above the level of diaphragm as inflow circuit and the circuit was connected to the heart and lung machine. The bypass was initiated at fl

[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 45-year-old male patient presented to our institution with a 3-week history of diffuse abdominal pain, tenesmus, and over 10 episodes of non-bloody diarrhea per day. The patient did not have nausea or vomiting nor did he report fever, chills, or unintentional weight loss. In the week prior to his presentation, he was assessed by his family physician who had ordered a panel of stool nucleic acid amplification tests which were negative for gastrointestinal infections. He was then trialed on a brief course of proton pump inhibitor as an outpatient with no improvement in his symptoms before presenting to the emergency department.
The only significant past medical history for our patient was a long-standing history of plaque psoriasis for which he was being treated with Ixekizumab. He had previously undergone multiple courses of biologic treatments with adjunctive phototherapy but did not achieve reasonable control of his disease until he was switched to Ixekizumab approximately 9 months ago. The patient did not have a family history of IBD or early onset colorectal cancer. He is a life-long non-smoker and he does not report excessive alcohol use. There was no history of recent travel, blood transfusions, intravenous drug use, or new sexual contacts.
On initial assessment, the patient was hemodynamically stable with diffuse non-peritonitic abdominal pain on physical examination. His laboratory investigations demonstrated marked elevation in his inflammatory marker (C-reactive protein of 388 mg/L) as well as a hepatocellular pattern of liver enzyme elevation (aspartate aminotransferase 234 U/L, alanine aminotransferase 142 U/L, alkaline phosphatase 143 U/L). A computed tomography (CT) of the abdomen and pelvis was performed revealing continuous circumferential bowel wall thickening of the left colon from the rectum to the splenic flexure on a background of reactive retroperitoneal lymphadenopathy (Fig. ). The patient was admitted to the internal medicine service and our

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


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

[User]
RADIOLOGY NOTE:
This 15-year-old Malay boy born to non-consanguineous healthy parents presented seizure and developmental regression. He was well until 6 months of age when he developed fever associated with one episode of seizure. Since the age of 2 years, he started to have frequent episodes of generalized tonic clonic seizures (GTCS) without fever (afebrile seizures). His general physical and neurological examination was normal. His psychological examination revealed a good space-temporal orientation and social interaction. Motor examination revealed normal strength and muscle tone in all extremities. By the age of 2 years 6 month, he had experienced approximately 10 episodes of GTCS per day with 1-hour interval between seizures, lasting 1–2 minutes. His seizures had improved with 400 mg sodium valproate and 150 mg syrup carbamazepine. The frequency of his seizures had varied from seizure free to several episodes per day. His parents had noticed that his seizures were exacerbated 5–6 am during his sleeping and at day time. Since then, he gradually experienced acute cerebellar ataxia with instability during walking and his developmental and speech gradually regressed and there were no signs of improvement. At the same time, his speech worsened from few words to bubbling. His electroencephalogram (EEG), computed tomography (CT) scan, and magnetic resonance imaging (MRI) brain at 8 years of age were normal. Currently, he continues to experience GTCS approximately 2–3 times every month, with abrupt onset and characterized by impairment of consciousness. Those seizures lasted about 1–2 minutes and aborted spontaneously. The doses of carbamazepine were increased to 300 mg and topiramate 25 mg was added to control the seizure, which did not decrease the frequency of the seizures. His current intellectual disabilities revealed mental retardation, developmental delay and autism features. At 11 years, he was still unable to speak with no verbal communication. His other neurological impair

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


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

[User]
RADIOLOGY NOTE:
A 64-year-old female nurse suffered from severe left heel pain for half year after a long period of walking and standing. She mentioned that the dull pain was induced after ankle sprain with a “pop” sound when traveling in a bus, and she still could walk at that time. She did not receive any treatment or take rest at that time. Two days later, the pain became severe and radiated to soleus muscle, especially when walking, accompanied with sharp pain sensation especially when climbing stairs. Swelling around the heel to leg was also noted with mild ecchymosis at that time. Before visiting, she received cold or hot packing, electric therapy, stretching exercising, manual therapy, massage, acupuncture, oral and topical medicines at other clinics. All modes of treatment were less effective and the symptoms progressed.
Half a year later, she could not even walk or stand when first visiting at our department. The activity of daily living (ADL) and working performance were affected. The visual analog scale (VAS) was nine. At the first visit, granulation like lesions and tenderness was observed at surface of the heel skin, compatible to Haglund’s deformity and spurs formation as revealed on the image taken through X-ray. No bony fracture was noted at tibia, fibula, or calcaneus bone. Active ankle dorsiflexion and plantar flexion would induce painful sensation during examination. Passive range of motion could be smoothly completed when gently performed on the ankle, but positive finding of Thompson test was noted when the calf was squeezed. Pain would also generate when the area around the insertion site of Achilles tendon was compressed and knocked. Taut band with referred pain to the ankle and twitch sign was noted at soleus muscle. Soft tissues around the heel showed mild swelling, but no wound or ecchymosis was noted at that time. Muscle power of the lower limb was within normal limit except 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 22-year-old previously healthy female presented with an intermittent pinching pain in the lower right shank that had lasted for three months, progressive lower right extremity weakness and instability while standing. The onset of the shank pain and weakness occurred without any obvious cause. After one month, the patient experienced a shooting pain from the right shank, which traveled towards the right groin, foot and thigh. The patient had not received spinal surgery or any other spinal procedures, and did not complain of lower extremity numbness or urinary incontinence. The physical examinations revealed that there were no motor or sensory deficits in either extremity, and no palpable midline spinal displacement. Upon neurological examination, the patient demonstrated normal physical reflexes and the pathological examinations revealed no cutaneous abnormalities or dermal sinus tracts. In addition, the routine laboratory examinations were normal.
The magnetic resonance imaging (MRI) results revealed a lobulated, intradural, heterogeneous, 6.0×1.5×1.7-cm mass between T12 and L2 levels of the lumbosacral spine (). The lesion was located in the middle of the spinal canal and extruded the spinal cord, and could not be separated from the conus medullaris. No centrum erosion or other abnormalities were identified.
The patient underwent a total resection of the tumor by means of a T12-L1 laminectomy performed under a surgical microscope. Through an incision into the dura, three connected cystic tumors were observed. A portion of the mass was in contact with the medullary and conus medullaries, and a yellow, oval-shaped, fatty cyst extruded to the cauda equina where it had become inseparable. Following the incision into the tumor cyst wall located in the conus medullaris, a white fluid containing hair follicles and gray soft tumor tissue was observed. A histopathological examination of the excised mass revealed the presence of elements from multiple germ cell layers. Und

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


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

[User]
RADIOLOGY NOTE:
A 60-year-old female presented to the outpatient cardiology clinic for evaluation of worsening chronic hypertension for which she had been on hydrochlorothiazide/Valsartan for 10 years. Her systolic blood pressure exceeded 200 mmHg in the office, and aggressive medical therapy was initiated in the outpatient setting. She returned to the emergency department the following day with headache and malaise and systolic blood pressure above 200 mmHg for which she was treated and discharged.
She returned to the emergency department again 5 days later, this time with complaints of word finding difficulty, blurred vision, and lower extremity tingling. Her blood pressure on presentation was 216/81 mmHg. She was admitted, and workup demonstrated no acute intracranial process or carotid stenosis. Echocardiography revealed mild concentric left ventricular hypertrophy with a preserved ejection fraction. Her blood pressure continued to be refractory to medical therapy despite five antihypertensive agents and eventual initiation of an esmolol infusion. A renal artery ultrasound identified renal artery stenosis with flow at the arterial origin measuring 350 cm/s on the right and 208 cm/s on the left (); flow velocity in the supraceliac aorta was also noted to be elevated. She had no history of kidney disease and no elevation of her creatinine. Vascular surgery was consulted and a history of lower extremity claudication was elicited. On exam she had weak but palpable femoral pulses and an audible abdominal aortic bruit; ankle-brachial index measurements were deferred and the patient was scheduled for angiogram.
The patient underwent aortography the following day and on selective angiography the renal arteries were found to be widely patent. Significant stenosis was identified at the distal thoracic aorta extending into the abdominal aorta but terminating proximal to the celiac trunk. The degree of stenosis was deemed to be greater than 90% and a pressure gradient between the upper ext

[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 62-year-old male patient presented with the history of diabetes mellitus and hypertension along with abdominal pain and a palpable pulsatile epigastric mass. The patient had undergone bilateral total hip replacements, which subsequently got infected. He was initially treated with levofloxacin, teicoplanin, and vancomycin. The implants were removed and joint spacers were implanted. Blood and tissue cultures demonstrated methicillin-resistant Staphylococcus aureus (MRSA) and proteus mirabilis. Although all prosthetic materials were removed, the patient continued to develop fever for several weeks. Computed tomography (CT) demonstrated a septic spleen without other pathologies. A splenectomy was performed.
Two months later, the patient showed clinical signs of recurrent sepsis with a white blood count of 12,000/mm3. CT angiography (CTA) revealed a 60-mm paravisceral aortic pseudoaneurysm at the origin of the celiac artery (CA) (Fig. .
The patient was transferred to our tertiary care vascular surgical center. Written consent was obtained from the patient. Placement of a covered stent into the CA was attempted to prevent aneurysm rupture but this was technically unsuccessful.
Through a midline laparotomy, the paravisceral aorta was exposed through the lesser sac and the infrarenal aorta was exposed distal to the pancreas (Fig. . The crura of the diaphragm were divided to facilitate aortic clamping. The aorta was clamped proximal to the CA and below the renal arteries. Then, the pseudoaneurysm was opened and all infected tissues and necrotic aortic wall were removed. The reconstruction of the CA was not feasible due to the necrotic tissues and the infected environment. The patient had a well-developed gastroduodenal arcade to the common hepatic artery from the superior mesenteric artery (SMA) and the splenic artery was ligated earlier during splenectomy; therefore, we ligated the distal CA. The pseudoaneurysm was excised to healthy-appearing aortic tissue. The aorta pro

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


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

[User]
RADIOLOGY NOTE:
A 58-year-old Haitian female with known history of hypertension was admitted for severe bilateral lower extremity weakness. CT scan of the thoracolumbar spine revealed severe kyphosis of T10-T11 secondary to anterior collapse of the T11 vertebral body. She received intravenous steroids and was evaluated for surgical intervention. She eventually underwent T11 corpectomy, fusion of T10-T12, implantation of biomechanical device at T11, anterior instrumentation of T10-12, and posterolateral fusion of T8-L3. Bone biopsy revealed evidence of osteomyelitis. She was started on a 42-day course of antibiotics. After surgery, she was noted to be increasingly lethargic and confused. Rapid response was called when she developed a complex partial seizure with secondary generalization. The seizure was terminated upon administration of intravenous Ativan. She was given a 1500 mg loading dose of Keppra followed by 500 mg twice daily maintenance dose. EKG monitoring during the seizure episode revealed sinus bradycardia, which eventually progressed to a 10-second sinus pause, approximately 20 seconds after seizure onset (). She had 2 more similar seizure episodes during the same day. In each seizure episode, she would develop sinus bradycardia, followed by sinus pauses a few seconds after seizure onset. Interictal EKGs revealed normal sinus rhythm. She was started on a dopamine infusion and transferred to the ICU. EEG revealed periodic lateralized epileptiform discharges and a single seizure emanating from the right posterior temporal region (). The seizure observed during the EEG focally originated from the T6 area and then had secondary generalization. It lasted around 75 seconds and clinically manifested as blank staring. MRI revealed a large area of gyral edema, sulcal effacement, and cortically based diffusion restriction involving the right occipital lobe and right posterior temporal and parietal lobes (). Lumbar tap revealed normal findings. She did not have any further seizure

[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 33-year-old female with a history of hepatitis C and active intravenous heroin use presented to an outside facility with complaints of worsening shortness of breath. A transthoracic echocardiogram (TTE) was done and showed tricuspid valve (TV) vegetation measuring 3 × 1.5 cm with severe tricuspid regurgitation (TR). CT scan of the chest revealed signs concerning septic pulmonary emboli. She was also found to have severe sepsis and was transferred to the coronary care unit for further management. Blood cultures on admission yielded Streptococcus pyogenes, and she was empirically started on vancomycin, linezolid, and cefepime until organisms were shown to be pan-sensitive after which antibiotic coverage was narrowed to penicillin G. Clindamycin was added for synergism, given her extensive septic pulmonary emboli. Repeat blood cultures revealed the same organism for 3 consecutive days. Her respiratory status continued to worsen, and she was consequently intubated. No source other than intravenous drug use (IVDU) was found to be the cause of the bacteremia. Due to the size of the vegetation and persistent bacteremia despite appropriate medical therapy, cardiothoracic surgery was consulted for the possibility of surgical intervention, but the patient was deemed a poor surgical candidate due to her poor nutritional state and hemodynamic instability. After discussion with the family regarding the patient's critically ill state and poor prognosis, a decision was made to transfer her to our facility for debulking of the tricuspid valve vegetation using the AngioVac system. A repeat TTE at our facility confirmed prior findings of TV vegetation measuring 3 × 1.5 cm and moderate TR (). Blood cultures repeated at our facility revealed no growth. The patient was immediately taken to the catheterization laboratory for vegetation debulking using the AngioVac system.
The patient arrived in the catheterization laboratory intubated and sedated. Bilateral femoral veins were accessed

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


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

[User]
RADIOLOGY NOTE:
A 52-year-old female was referred to our hospital with the diagnosis of LAM. She had pneumonia 3 months prior to admission. The diagnosis of myxoma was made during the workup of shortness of breath that persisted despite the treatment of the pneumonia with antibiotics. The patient was a heavy smoker. On admission the patient appeared ill with a blood pressure of 130/86 mmHg and a heart rate of 105/min. Clinical examination revealed a mid-diastolic murmur increasing on expiration with a grade 2/6 pan systolic murmur located at the sternal border increasing on inspiration and bilateral basal crepitations on chest auscultation. Chest X-ray showed some atelectasis with right blunting of the costophrenic angle. ECG showed sinus rhythm with ST segment depressions in the lateral leads.
Transthoracic echocardiogram (TTE) revealed a 4.8 × 2.5 cm mobile mass arising from the interatrial septum of a severely dilated left atrium, causing moderate left ventricular inflow obstruction with a mean gradient of 12 mmHg and trace mitral regurgitation (Fig. A and B). There was severe tricuspid regurgitation with a systolic pulmonary artery pressure of 61 mmHg. The patient described symptoms of angina before her current hospitalization for shortness of breath. For that reason, a coronary angiogram was ordered before her surgery and revealed 80% lesions in the mid-left anterior descending artery and a 70% stenosis at the origin of the posterior descending artery of a dominant left circumflex artery.
The next morning after her coronary angiogram, the patient suddenly showed signs of confusion and began to experience slurred speech and left-sided facial droop with left-sided hemiplegia. She was intubated to protect the airway and was sent for an urgent computed tomography (CT) scan of the head, which revealed a hyperdense minute clot lodged at the right internal carotid artery bifurcation. Accordingly, tissue plasminogen activator thrombolytic therapy was initiated. A repeat TTE showed tha

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


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

[User]
RADIOLOGY NOTE:
A 56-year-old Japanese woman had visited a local clinic, complaining of a two-month history of a painless cutaneous fistula in her anterior neck with pus discharge. She was diagnosed with a pyogenic granuloma [] by her previous doctor. The pus discharge temporarily subsided after antibiotic treatment, but the cutaneous fistula persisted. She was then referred to our department for further advice. On physical examination, a non-tender reddish lesion with a fistula and granulation was seen on her anterior cervical skin. Our patient reported that she had suffered from the sensation of a foreign body in her throat after eating fish approximately one year prior to the present onset, but the symptom had spontaneously improved after a few days. Taking her anamnesis into account, a fish bone foreign body was suspected.
Endoscopic examinations of her laryngopharynx and esophagus showed no abnormality. However, computed tomography (CT) revealed a bone-density needle-shaped foreign body sticking out anteroinferior from the esophageal wall, penetrating through the superior pole of her left thyroid lobe, and extending nearly to the anterior cervical skin (Figure ). The foreign body was surrounded by a low density area, suggesting abscess formation (Figure ). The results of a blood examination were unremarkable, with normal thyroid and parathyroid functions.
Our patient underwent the removal of the foreign body combined with left hemithyroidectomy under general anesthesia 20 days after her initial visit to our department. A horizontal cervical incision with the spindle-shaped excision of the orifice of the fistula was made, and the skin flap was elevated. Considerable cicatricial adhesion was seen around the fistula. The fistula passed through the infrahyoid muscles and was connected to her left thyroid gland. The tip of the fish bone was exposed by cutting her infrahyoid muscles open. As seen in the preoperative imaging, the fish bone penetrated through her thyroid gland, reachi

[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 50-year-old female patient was admitted due to cough that had persisted for several weeks. Her past medical and surgical history was unremarkable. Laboratory data, chest X-ray, and chest CT did not reveal any significant findings. Abdominal US incidentally identified a 42 × 38 × 35-mm multilocular cystic lesion surrounded by the liver, stomach, left kidney, and pancreas (Fig. ). Multiphasic contrast-enhanced CT imaging revealed that the cystic lesion was unilocular, without separation or mural nodules, and it was located in the lesser curvature of the stomach (Fig. ). A thin cyst wall had no contrast enhancement. A multilobulated cyst with a thin internal septum spread outward from the pancreatic tail on MR images, but did not appear to communicate with the main pancreatic duct (Fig. ). Endoscopic US showed a multilocular cystic lesion along the pancreatic tail with a thin multiple septum and mural nodules (Fig. ). These findings could not confirm that the cystic lesion was derived from the pancreas, and a mucinous cystic neoplasm was a possibility considering her age and sex. Therefore, she provided written, informed consent to undergo laparoscopic resection. Laparoscopy confirmed the multilocular cyst in the lesser curvature of the stomach (Fig. ). The gastrocolic ligament was divided, and the body and tail of the pancreas was exposed in the omental bursa. Further observation revealed that the cystic lesion was derived from the lesser omentum. Although the cyst was located directly beside the left gastric artery, enucleation proceeded without sacrificing the artery. Macroscopically, the 4.8 × 4.5-cm cyst had multiple septae (Fig. ). Microscopically, the inner surface of the cyst was lined by a single layer of flattened cells without atypia and focal smooth muscle (Fig. ). The lesion was diagnosed as cystic lymphangioma. The patient was discharged on postoperative day 4 without complications. The patient was free of recurrence after 1 year 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:
A 19-year-old man presented to our division for the management of severe right lower quadrant pain. His previous history was remarkable for juvenile rheumatoid arthritis starting at 12 years of age, involving the sacroiliac and mandibular joint as well as the right ankle and hip. He was tested positive for HLA-B27, but tests for antinuclear antibodies and rheumatoid factor proved to be negative. At 16 years of age etanercept 50 mg s.c. was started which initially relieved the symptoms, so the dose was reduced to every 2 weeks after 1 year of treatment. However, 1 year later the joint pain recurred and was refractory to etanercept dose escalation (weekly) and add-on naproxen. Two months before the onset of abdominal pain the treatment regime was changed to adalimumab 40 mg s.c. every 2 weeks and the patient remained free of rheumatologic problems for the next year.
During evaluation for abdominal pain, lower right quadrant tenderness and a palpable tumor were noted. Blood work revealed systemic inflammation (C-reactive protein 46 mg/l and leukocytosis with 13.7 × 109 leucocytes per liter with 84% neutrophils). Ultrasound and computed tomography suggested terminal ileitis and abdominal lymphadenopathy. Stool tests for microorganisms including Clostridium difficile were negative. Colonoscopy demonstrated an ulcerated ileocecal valve with a narrow opening that could not be intubated. Histology confirmed granulomatous inflammation and acute inflammation, and all tests for infectious diseases, including acid-fast staining, mycobacteria cultures and immunohistochemistry for cytomegalovirus, were negative.
Since the patient's presentation was consistent with new-onset CD, we continued adalimumab treatment and started budesonide at 9 mg/day. Subsequently, abdominal pain improved; however, surveillance of small bowel inflammation by abdominal ultrasound continued to show wall thickening >6 mm, consistent with active inflammation, and budesonide was increased to 15 mg/day. Due

[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.L., male, suffering from type 1 diabetes mellitus since he was 7 years old; the disease was metabolically compensated with stable insulin doses. At the age of 12 he was admitted for abdominal pain and a voluminous mass in right hypochondria was found; he was in good general conditions (32 kg of weight) and remaining physical examination was normal. His insulin requests were: regular insulin 5 IU before breakfast, 10 IU before lunch and 6 IU before dinner; NPH insulin 16 IU at bedtime. The liver ultrasound scan showed, at the VI liver segment, two hypo-isoechogenous oval lesions whose diameters were, respectively, 83 × 43 mm and 77 × 38 mm. CT scan (Fig. ) confirmed the presence of two masses, with an evidence of tumor capsule, that, after contrast injection, were hyperdense in early (arterial) phase and isodense, compared to the remaining liver parenchyma, in venous phase; it also highlighted a central hypodense "scar".
Routine blood tests were all normal and the detection of serological markers of HAV, HBV, HCV, HIV and CMV was negative: CEA and αFP were also negative. On the basis of the mild abdominal pain, and also for a formal request of parents, the child underwent surgical intervention: the two masses were completely removed. The gross appearance was that of lobulated, well circumscribed masses, lacking a fibrous pseudocapsule and showing a central scar with fibrous septa running to the periphery and partially demarcating nodular structures. At histologic analysis, both lesions were classic FNH showing a nodular hyperplastic parenchyma with a typical central fibrous scar, containing a proliferation of small bile ducts, irregular tortuous arteries with thickened walls, veins and capillaries. A discrete inflammatory infiltrate filled the fibrous septa surrounding the hepatocytic nodules (Fig. ). The child had a fully satisfactory post-surgery course in terms of metabolic compensation. The outbreak of fever justified a treatment with

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


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

[User]
RADIOLOGY NOTE:
In June 2014, a 79-year-old male patient underwent right parotidectomy and ipsilateral modified radical neck dissection after the diagnosis of a parotid carcinoma. Pathological staging demonstrated high-grade salivary duct carcinoma and locally advanced disease with the involvement of 13 lymph nodes at levels I, II, III, and IV, with extracapsular extravasation. As an adjuvant treatment, he underwent radiotherapy, ending in December 2014.
A PET scan performed in March 2015 diagnosed local recurrence and systemic disease involving the neck lymph nodes, bone, and hepatic metastasis. At that time, we conducted immunohistochemistry (IHC) of the primary lesion, which demonstrated HER2 receptor overexpression (+3/+3) (Fig. , Fig. ).
As a first-line treatment, the patient received trastuzumab plus paclitaxel from April 2015 until February 2016. After the first 6 cycles, the new PET scan showed excellent partial response. The treatment was changed to trastuzumab alone, but after 3 months, the disease progressed. Then, he was rechallenged with paclitaxel plus the antibody. In February 2016, the patient experienced symptoms of progressive disease such as fatigue and cervical pain. A PET scan revealed progressive disease in the neck (local), bones, and liver. Because the expression of androgen receptors was observed in the salivary tumor, he started treatment with bicalutamide from February until April 2016. He underwent a rapid worsening of symptoms, weight loss, and neck skin progression, and scans showed progression in all lesions.
He started T-DM1 in April 2016. The skin lesions on the neck disappeared after 6 cycles. PET scans were performed every 3 months and showed response in the liver and bone lesions. The performance status and symptoms improved. In March 2017, 1 year after the T-DM1 response, the patient presented worsening of the neck skin lesions with local bleeding, suggesting disease progression. A new scan showed stable disease in the liver but progressive dise

[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 60-year-old man. Abdominal ultrasonography indicated that he had an abdominal mass. He reported having perceived lower abdominal pain 7 months before the initial examination, but it spontaneously remitted. The patient had no fever nor any history of conditions such as hypertension. A blood test revealed that he did not have anemia, thrombocytopenia, or coagulation abnormalities. The patient demonstrated slightly elevated levels of carcinoembryonic antigen (4.7 ng/ml) and soluble interleukin-2 receptor (603 U/ml), tumor markers that are elevated in gastrointestinal cancers and malignant lymphoma. Contrast-enhanced CT showed a 33× 31 mm abdominal aortic aneurysm and a 106 × 81 mm mass peripheral to the abdominal aorta. The mass did not feature a contrast effect, and its margin was enhanced in the venous phase (Fig. ). Sigmoid wall thickening and inferior vena cava thrombosis were also observed (Fig. ). We suspected the patient had a neoplastic disease, such as a malignant lymphoma or sigmoid colon cancer. Detailed examinations were consequently performed, and direct oral anticoagulant therapy was initiated to treat the inferior vena cava thrombosis.
The FDG-PET revealed an abnormal accumulation of FDG in the margin of the mass and the sigmoid colon, but not in any other organs. Colonoscopy showed only mild inflammation in the sigmoid colon, and a sigmoid colon biopsy revealed no significant findings. Chronic inflamed fibrous connective tissue was harvested from the periaortic mass using CT-guided biopsy. There were no findings indicative of infection or neoplastic disease, thus precluding a pathological diagnosis.
At 1 month after the initial examination, intermittent claudication occurred, prompting the performance of follow-up contrast-enhanced CT scanning. On CT scanning, we found an arterial occlusion from the infrarenal abdominal aorta to the bilateral common iliac arteries, the right external iliac artery, and the right internal iliac artery (F

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


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

[User]
RADIOLOGY NOTE:
A 60-year-old female patient with a history of nephroureterectomy and cuff excision due to renal pelvic TCC was admitted to our outpatient clinic with complaints of red skin lesion in the near vicinity of the operational incision scar for 3 months. Her medical history revealed nothing but nephroureterectomy operation on her upper urinary system; moreover, it was learned that she had been ignoring what was recommended to her for routine controls. A thorough search through the database regarding patient's past medical reports revealed that the pathology report about the past operation had been compatible with high-grade TCC and that the tumor had been multifocally located in the renal pelvis with the largest one to be 2.5 cm in diameter. The past pathology report had further indicated presence of lymphovascular invasion, compatible with pT2 stage (Muscle invasion is present in the absence of parenchymal and peripelvic fat tissue invasion) and absence of tumoral tissue within the surgical border. In the physical examination, a hard, painless and immobile mass of 2*2 cm dimension was palpated 3 cm below the incision line. Thoraco-abdominal computed tomographic (CT) examination performed on the basis of the aforementioned findings depicted a mass lesion of 78*65*50 mm dimension with heterogeneous contrast uptake, which originated in the abdomen at the level of left renal vein drainage into the inferior vena cava, completely surrounding the inferior vena cava and extending inferiorly to the level of aortic bifurcation. In addition, a mass lesion of 24*20 mm dimension with high-contrast uptake was detected within the subcutaneous fat tissue in the right abdominal wall. The other abdominal and thoracic structures were evaluated to be normal [].
The skin lesion depicted in CT was surgically excised. The pathological examination of the excised material was reported to be compatible with TCC metastasis localized within the reticular dermis and hypodermis without any invasion i

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


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

[User]
RADIOLOGY NOTE:
The first case shows a 30 year old female. Clinical and radiographic examination showed a skeletal Class II pattern with an anterior open bite and a transverse maxillary deficiency with a lateral posterior crossbite on the right and the tendency to a lateral crossbite on the left (Fig. ).
The treatment plan involved a first stage of maxillary expansion with SARME to correct the transverse discrepancy followed by the leveling of the dental arches with lingual fixed appliances and finally two jaw surgery to correct the open bite as well as the Class II malocclusion.
Impressions of the upper and lower arches were obtained for the lingual appliances.
During the planning for the production of the lingual brackets, it was noted that a surgically assisted rapid maxillary expansion takes place. In the set-up, therefore, the transverse width of the upper jaw should be adapted to the lower jaw.
Four Benefit mini-implants were inserted: two in the anterior area of the T-Zone and two 12 mm distally on each side of the midpalatal suture. A silicon impression was taken and the laboratory analogues were placed on the transfer caps. The maxillary expansion appliance was manufactured using a Hyrax screw anchored only to the four mini-implants, named the Quadhyrax.
During the same appointment the lingual appliance was indirectly bonded using a dual cured composite (Fig. ) and the Quadhyrax was inserted and attached to the mini-implants using Benefit fixation screws. The first lower arch wire 14 NiTi was placed while the upper brackets were securely ligated with a continuous steel ligature in each quadrant to prevent accidental dislodgement during surgery (Fig. ).
The surgery for SARME was performed on all three patients according to the same procedure: First Le Fort I osteotomy with an oscillating saw. After that, the sutura palatina mediana was chiseled up for the midpalatal split. The tuber region was also

[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-month-old male presented to the Emergency Department (ED) with sudden onset of right arm and leg weakness beginning 3 hours prior to admission. His clinical history included a viral illness 5 days prior to admission, with malaise, fever, vomiting, and diarrhea. Early in the course of that illness he was seen by a pediatrician who noted mild dehydration, and suggested oral rehydration and antipyretics. He was otherwise healthy, with up-to-date immunizations.
On arrival to the ED physical exam revealed flaccidity in right upper and lower extremities. X-rays of right upper extremity obtained to rule out trauma were negative. Lab results showed microcytic anemia with hemoglobin of 6 g/dL, and thrombocytosis, with a platelet count of 512,000. The remaining labs were normal. Computed tomography (CT) of the head without contrast showed hypodensity of the left thalamus (). In addition, high attenuation was noted throughout the bilateral deep venous system, compatible with acute DCVT ().
Anticoagulation therapy and IV hydration were initiated immediately after radiologic findings were discussed with the ED physician. The patient was transferred to the Intensive Care Unit of our tertiary pediatric hospital. Magnetic resonance imaging (MRI) of the brain demonstrated restricted diffusion in the central aspect of the thalamus, surrounded by vasogenic edema, compatible with acute venous infarction (). No other parenchymal lesion was detected. Signal changes within the deep venous system were compatible with acute intraluminal thrombus (). MR venography confirmed lack of flow-related signal throughout the deep venous system ().
The patient had a follow-up MR venography done two days later before discharge but was found to have no significant interval change with relatively stable venous infarct in the left thalamus and posterior limb of the internal capsule. No other follow-up imaging was done since. His symptoms resolved completely after six months of physical and speech the

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