[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 37-year old homeless male, with a past medical history of peripheral vascular disease, type 1 diabetes mellitus, hypertension, and depression, presented to the emergency department with intermittent chest pain and progressive shortness of breath for a few weeks. The patient denied intravenous drug use, although admitted to the use of recreational marijuana. The patient’s vitals on admission were stable except for low saturation on a pulse oximetry of 86% on room air. On physical examination, the patient was tachypnic and had fine crackles in the bilateral lung fields on auscultation. Laboratory results on admission showed a normal complete blood count and basic metabolic panel, but a urine drug screen test was positive for opioids. Because of persistent hypoxia, a D-Dimer was checked and came back highly elevated. The patient underwent a computed tomography angiography (CTA) of the chest to rule out pulmonary embolism. The CTA was negative for pulmonary embolism, however, it displayed extensive miliary densities throughout the bilateral lung fields (). The patient was admitted to the floor with a differential diagnosis of military tuberculosis versus fungal infection. Human immunodeficiency virus (HIV), fungal, and Quantiferron testing were negative. The cardiac work up and autoimmune serology were also unremarkable. The patient was then started on intravenous steroids and inhaled albuterol, although no improvement was seen. The patient remained hypoxemic despite therapy, and, therefore, underwent a bronchoscopy with a lung biopsy to find out the etiology of the disease process. The lung biopsy showed alveolated lung tissue with a miliary pattern of perivascular foreign body histiocytes containing refractory material suggestive of microcrystalline cellulose material (). There was no evidence of malignancy and there were no fungal or acid fast bacilli organisms identified on special stains. The histological features suggested intravenous injection of foreign materi

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


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

[User]
RADIOLOGY NOTE:
A 25-year-old man was referred by his general dental practitioner to the Department of Oral and Maxillofacial Radiology regarding a periapical lesion related to the apex of the upper right molar teeth and prosthetic management. Intraoral examination revealed that there were a few teeth with caries in different regions. Panoramic radiography revealed a well-defined radiolucency involving the root apices of the upper right maxillary first molar (). The borders exhibited dense radiopaque features. Provisional diagnosis of the radicular cyst was established, and root canal treatment was carried out. Endodontic retreatment was initiated by his dentist, but after a followup of several months, no changes were observed in the ovoid radiolucency, and the patient was referred for consultation to our department. The patient's medical history was unremarkable, included no trauma of the jaws, and he had not undergone any jaw surgery. He was not aware of the radiolucent area before his routine dental examination and had no sensory or motor deficiency. The tooth was asymptomatic and it also presented with a poor root canal filling. The overlying mucosa of the lesion was quite normal, and there was no sign of infection or fistula. The overall appearance of the lesion seemed to be that of a radicular cyst of the right maxillary first molar. On performance of vitality tests, all the teeth except the first molar- in the mentioned area appeared to be vital.
To reveal the exact location definition of the pathologic features, he was referred for a CBCT (NewTom 5G, QR, Verona, Italy) scan. After this, a CBCT was taken which revealed the maxillary sinus with its border extending but not involving the roots of the mentioned teeth, which is one of the anatomical variations of maxillary sinus (–). The dimensions of the defect were 13.2 × 14.2 × 9.3 mm depth (mesiodistal length, inferosuperior height, and buccolingual depth).

[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 patient, who had discovered that he had a left axillary palpable lesion 2 years ago and had not seen a doctor about it, visited our hospital for further evaluation after an abnormality was found in his left axillary excisional biopsy 2 weeks before the visit. The patient had no history of cancer or other diseases, and had no family member who had been diagnosed with cancer. The patient was a non-smoker and was only a social drinker. In a physical examination, no abnormality other than a wound from the excisional biopsy was found in the left axilla, and no mass or suspicious skin change was detected on the breast. A review of the results of the histopathological examination performed at another hospital revealed a sign of adenocarcinoma, and the immunohistochemistry showed the following signs: TTF-1 (-), CK20 (-), and CEA (+). In the mammography, breast US, and breast MRI exams, no suspicious lesions on the breast or signs of lymphadenopathy on the axilla were observed. In addition, there was no evidence of accessory breast or ectopic breast on the axilla. The PET, chest CT, abdominal CT, and EGD exams, which were performed to determine the origin of the carcinoma, did not reveal any malignant lesion. In the right thyroid lobe, the thyroid US revealed a 0.5 cm-big hypoechoic nodular lesion that was suspected to have been malignant, but the fine needle aspiration cytology confirmed that the lesion was not malignant. In addition, all the tumor markers, such as serum CEA, PSA, CA 19-9, CA 15-3, and calcitonin, were within normal ranges. Based on all these results, the patient was diagnosed with occult breast cancer. Left axillary lymph node dissection (levels I and II) was performed on the patient, but not mastectomy. The post-surgery pathology revealed that four of the 26 dissected lymph nodes had signs of metastatic adenocarcinoma, and the immunohistochemistry showed the following results: estrogen receptor (+,

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


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

[User]
RADIOLOGY NOTE:
A 24-year-old white man, a middle-distance runner (800 m) competing at national level (seasonal best/personal best of 1 minute 52 seconds), developed severe left heel pain in the pre-season in March 2013. His maximum perceived pain intensity was 10 cm on a visual analog scale (VAS) that ranged from 0 to 10 cm, with 10 cm expressing the worst perceivable pain; the athlete had to interrupt all running activity, and severe pain was perceived even when walking or standing. He continued training with aqua jogging and cycling. He got personalized hand-crafted orthopedic gel peads. Two months later he was attended by an orthopedic surgeon, who additionally prescribed oral intake of nonsteroidal anti-inflammatory drugs (NSAIDs) for 8 weeks. The athlete could continue his training but was not free from pain. When discontinuing medication in July 2013, pain returned immediately, and perceived pain intensity during walking was 10 cm on a VAS (range 0–10 cm). Eight sessions of ESWT were thus added to his treatment plan, and were conducted at a German Olympic center. He did not feel better after the treatment and reported a high level of frustration. An MRI was performed in January 2014 showing a calcaneal spur, signs of inflammation at the calcaneal tubercle, and structural changes of the plantar fascia, surrounded by a large edema (see Fig. ). In February 2014 he underwent an open plantar fasciotomy. Four weeks later he was allowed to perform the first units of regenerative running. Pain returned after approximately 1 week of training. An X-ray revealed no pathology and he was recommended to continue with soft training sessions. He received a peppering injection that reduced pain for 12 hours, and NSAIDs were re-prescribed. His running performance remained at a remarkably low level in comparison to his non-injured state, despite regular personalized training sessions. He presented himself at our out-patient clinic in July

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


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

[User]
RADIOLOGY NOTE:
A 32-year-old male patient was diagnosed as a case of lepromatous leprosy and was on multidrug therapy (MDT) for the last 1 year. He presented to us with complaints of joint pain, swelling, and stiffness of both wrist and ankle joints for the last 2 weeks. On examination thickening and tenderness of the tendons were noted and there was no evidence of joint deformity []. However, he gave a history of recurrent crops of the tender nodular lesion during and after MDT. Magnetic resonance imaging of the right ankle joint was done for evaluation of tenosynovitis which showed small focal peritendinous fluid collection along the flexor digitorium longus tendon along with minimal fluid collection around the ankle joint. Fine-needle aspiration cytology (FNAC) was done from the affected nerve and cytology revealed the presence of foamy macrophages and acid-fast bacilli. PCR from the isolates confirmed the presence of Mycobacterium leprae. A diagnosis of leprosy presenting with tenosynovitis and erythema nodosum leprosum (ENL) was made and standard WHO MDT treatment for leprosy was started. Earlier, some of the authors have shown similar presentations of leprosy and with similar proven technologies.[] Though he was given a repeated dose of steroids for a short duration, with which tender nodules subsided, tenosynovitis kept on progressing. The patient was given combination therapy of thalidomide 200 mg per day plus prednisone 50 mg per day and MDT was restarted. However, no response was seen after 6 weeks of treatment and he complained of intense pain. We started with infliximab after doing a pre-biologic workup including chest X-Ray and viral serologies. Infliximab was given at a dose of 250 mg diluted in normal saline with dosing schedule at baseline and weeks 2 and 6. The treatment was well-tolerated and good improvement in symptoms was noted. The patient was followed up for 6 months, no recurrence of ENL was seen.

[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 85-year-old Caucasian female presented to the emergency room (ER) with a three-day history of right lower quadrant and periumbilical abdominal pain. Her primary care physician had prescribed oral levofloxacin 750 mg once daily for seven days, for a presumptive diagnosis of diverticulitis. Since antibiotic did not seem to bring about a change in her clinical status, the patient decided to seek help at the ER. She was known to have diverticulosis, several past episodes of left sided diverticulitis, hypertension, hyperlipidemia, hypothyroidism, esophageal reflux, a hiatal hernia, and chronic obstructive pulmonary disease (COPD). Surgery for the recurrent diverticulitis was not done because of the old age of the patient who preferred to use antibiotics and be on follow-up. On chart review, there was a mention of supraventricular tachycardia but the patient had no recall of its nature and records were not available. She had had a cholecystectomy in 1991 and prior colonoscopies which had revealed extensive diverticulosis throughout her descending and sigmoid colon. Her medication list included omeprazole, levothyroxine, and vitamin D. Of note is the fact that she was not on medications for hypertension, hyperlipidemia, and COPD. She had no known allergies. She had 50 pack-year smoking history but quit 10 years ago. Family history was notable for coronary artery disease in her father who died of an acute myocardial infarction.
On exam, her vital signs were found to be normal. The only significant finding was periumbilical and right lower quadrant abdominal tenderness, without rebound, guarding, or rigidity of the abdomen. Initial testing showed mild leukocytosis with all other laboratories including hemoglobin, platelet count, renal, and kidney chemistries being within the reference ranges. Lipid panel was as follows: total cholesterol 212 mg/dL, triglycerides 167 mg/dL, LDL cholesterol 151 mg/dL, and HDL cholesterol 43 mg/dL. Patient was on diet modification for hyperl

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


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

[User]
RADIOLOGY NOTE:
A 21-year-old woman presented with left upper quadrant pain. She underwent routine blood tests and non-contrast computed tomography (CT). The blood tests did not show any abnormalities, and the CT showed the presence of three, similarly sized spleens, but no other abnormalities. As the patient did not have any other symptoms, she was sent home with a prescription for an analgesic. However, the abdominal pain did not improve and she returned to the hospital 2 days later. Her inflammatory markers were somewhat elevated, and an enhanced CT showed that one of the multiple spleens did not pick up the contrast (Fig. a). We diagnosed her with splenic infarction; however, the cause of the infarction was unclear, and torsion or embolism was considered possibilities. The patient was admitted and began conservative therapy, including fasting and antibiotic administration. However, neither her abdominal pain nor inflammatory marker levels improved (Fig. b). Hence, we performed a follow-up enhanced-CT scan, 2 days after admission, which showed that the splenic infarction had not improved and that ascitic fluid was present around the spleen and in the pelvic space (Fig. ). At this point, we decided to surgically remove the infarcted spleen. Considering that the patient was a young woman, we elected to perform a laparoscopic splenectomy after receiving informed consent.
The surgery was performed under general anesthesia, with the patient in a supine position and her legs spread apart. We created an umbilical incision and inserted three operating ports along the left subcostal margin (5 mm, 12 mm, and 5 mm in size), and a 5-mm operating port on the left side of the abdomen (Fig. ). The port sites were selected along the lines of a left subcostal incision, in case conversion to open surgery became necessary. These port sites were also in a co-axial position to the surgeon. There were no adhesions observed in the abdominal cavity. First, we incised the omentum and opened the burs

[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 28-year-old male presented with the chief complaint of fever with chills along with cough and breathlessness for five days. He had a history of being diagnosed with acute myeloid leukemia three months ago, for which he had received chemotherapy cycle of 7+3 with daunorubicin and cytarabine. He had no history of hypertension, diabetes mellitus, tuberculosis or bronchial asthma. On general examination, the patient was febrile with a temperature of 101 °F, pulse of 106 beats per minute, blood pressure of 110/70 mm Hg in right arm supine position; pallor was present and SpO2 was 91 percent on room air. On systemic examination, trachea was centrally placed, there were fine crackles heard in the inframammary region of the chest, a systolic murmur was heard in the left second intercostal space which was functional, the abdomen was soft and non-tender with no hepatosplenomegaly and the patient was conscious and oriented. The patient was admitted for further evaluation and his nasopharyngeal swab for COVID-19 came positive by reverse transcriptase-polymerase chain reaction method. Blood investigations of the patient revealed pancytopenia and raised inflammatory markers with normal renal and liver function test (Table ). HRCT chest was suggestive of bilateral lower lobe ground-glass opacities with an HRCT score of 5/25 and CORAD 6 (Figure ). Patient was started on oxygen support along with remdesivir and steroids (Methylprednisolone 40mg twice Daily). He was given blood transfusion with two units of packed red cells transfusion in view of anemia. The patient was having persistent fever spikes along with lymphocytopenia in the blood picture. Hence, a careful risk-benefit assessment was made and granulocyte colony-stimulating factor was given to the patient for three days. Remdesivir was also given for 10 days. The patient improved clinically and oxygen was tapered. After 13 days of admission, the patient was ultimately discharged in stable condition with no fever spikes and

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


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

[User]
RADIOLOGY NOTE:
A 62-year-old Caucasian man with advanced hepatic fibrosis secondary to hepatitis C viral infection was scheduled for a four-phase CT to screen for HCC, but was denied insurance pre-approval for the imaging study. He was diagnosed with hepatitis C viral infection a decade earlier, which was subsequently treated and cleared with interferon and ribavirin. Cirrhosis was confirmed via biopsy at that time, and stage III fibrosis diagnosed via biopsy four year later. At the time of his screening request, he had no additional medical problems or sequela of advanced liver disease. His physical exam was essentially normal—including vital signs and for stigmata of chronic liver disease. His alpha-fetoprotein (AFP) was 3.0 ng/mL with normal liver function tests, albumin, and platelets.
Routine US showed a heterogeneous, coarsened liver parenchyma with a suspected 2.2 cm hypoechoic structure in the right lobe on a background of geographic hepatic steatosis (). Contrast was then administered intravenously with targeted imaging of the lesion to determine if it was focal fatty sparing or tumor. The lesion markedly enhanced () and began washout rapidly, and on delayed imaging, showed intense washout. It was deemed a LI-RADS M because of its early enhancement and for its marked washout (). Given the LI-RADS M designation and for treatment planning, a four-phase CT was then approved by his health insurance company. Despite its size, the lesion was poorly visualized on the well-timed late arterial phase (). It was equally subtle on the portal venous and 3 min phases. Knowing where the lesion was on CEUS allowed the radiologist to confirm the findings on CT, where it was deemed a LI-RADS 5 lesion. However, without the pre-existing knowledge of its presence in that location, the lesion was initially missed. The late arterial phase on the CT was bolus-triggered, which resulted in scanning occurring at 35 s post injection. Interestingly, on the CE

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


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

[User]
RADIOLOGY NOTE:
A 46-year-old white woman with no medical history presented to our hospital with complaints of dyspnea, chest pain, dysphagia, cyanosis of the trunk and head, and distended superficial veins over her neck and chest of 3 weeks’ duration; these were all features of superior vena cava obstruction. She had no history of tobacco smoking, alcohol consumption, or illicit substance use. A physical examination showed decreased breathing sounds and dull percussion on the lower lobe of her right lung as well as diffuse wheezing of her right hemithorax. Laboratory tests did not reveal anemia, hydroelectrolytic, or coagulation disorders. A chest X-ray revealed widening of anterosuperior mediastinum (Fig. ). A contrast-enhanced chest computed tomography (CT) scan revealed a mediastinal mass with right-sided pleural effusion (Fig. ). No evidence of distant metastases was found. Fiberoptic bronchoscopy showed infiltration of the bronchial wall of her carina and her right main bronchus. However, histology of bronchial biopsies did not reveal any tumor infiltration. Mediastinoscopy was therefore performed and histological examination of right laterotracheal lymphadenopathy specimens demonstrated undifferentiated malignant tumor with solid growth composed of cells larger than lymphocytes with a round nucleus, variably prominent nucleoli, with dissociated growth pattern due to the presence of inflammatory cells, polymorphonuclear neutrophils, lymphocytes, and extensive necrosis (Fig. ). Immunohistochemistry revealed tumor cells diffusely positive for p40 with some reactivity for vimentin. Tumor cells were negative for CK and epithelial membrane antigen (EMA) and for lymphocyte surface markers. Due to these typical findings, subsequent immunohistochemistry for NUT protein was performed and demonstrated marked nuclear positivity (Fig. ).
After multidisciplinary cancer team meeting discussions, our patient underwent a course of radiation therapy to her chest (20 Gy in five fractions) and

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


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

[User]
RADIOLOGY NOTE:
A 54-year-old woman was admitted to our hospital complaining of intermittent palpitation which began 6 years ago and aggravated during the last 2 months. After the first symptom, she visited a local clinic and her symptom was managed under the impression of cardiac arrhythmia. But one year later, she discontinued anti-arrhythmic medication on her own. Until two months before admission, she had experienced intermittent palpitation again but it did not interfere with her life. Afterwards, palpitation became more severe suddenly and squeezing anterior chest tightness radiating to the left axilla developed and continued for about 10 minutes.
The patient was a housewife and had no history of smoking or alcohol consumption. There was no specific problem in her past medical and family history. The body temperature was 36.5°C and the heart beats were irregularr and rated over 140/min. On physical examination, mild moist crackling sounds were heard below a third on the back bilaterally. Neck vein engorgement was also seen. Considering the chest pain as ischemic in nature, nitroglycerin was given sublingually and the pain subsided. ECG showed atrial fibrillation with rapid ventricular response. Cardiomegaly with pulmonary vascular blurring and redistribution was seen on chest X-rays (). Other laboratory data, including cardiac enzymes and thyroid function tests, were within normal limits. Initially, cardiac tumor was not considered as the differential diagnosis. Transthoracic echocardiography, which was performed after her symptom had disappeared, showed normal global left ventricular systolic function (ejection fraction: 63%) with left ventricular enlargement and hypertrophy, and also showed trivial mitral regurgitation. On coronary angiogram, the left coronary arteries showed normal findings. But in the right coronary artery, we could find two tumor blushings which were supplied by a conus branch (). The one was on the right atrial side of the interatrial septum draining di

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


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

[User]
RADIOLOGY NOTE:
A 42-year-old G2P1001 presented for a routine growth ultrasound at 36 wk 5 d. The fetus was found to have a vein of Galen malformation, which had not been identified during the 20-wk anatomy scan (Figure ). A review of her medical history was significant for a prior uncomplicated full-term vaginal delivery. Her living child is alive and well, meeting all appropriate milestones. The patient denied any significant family history for congenital anomalies or social history for toxic environmental or occupational exposures. Prenatal care was otherwise uneventful. Fetal MRI confirmed the diagnosis of VOGM, demonstrating a persistent median prosencephalic vein, which measured up to 22 mm in the transverse dimension and 74 mm in length (Figure and C). There was a network of feeding vessels (greater on the right as compared to the left) in the region of the medial temporal lobe, midbrain, and thalami, which likely represented feeder vessels emanating from the posterior cerebral arteries. Torcula and bilateral transverse sinuses were also enlarged. The lateral ventricles and cortical sulci were appropriate for the patient's gestational age. The infratentorial brain appeared normal, with no mass effect or midline shift.
A fetal echocardiogram showed cardiomegaly with preserved biventricular systolic function. The superior vena cava (SVC) was moderately dilated. The right atrium was severely dilated whereas the left atrium was only mildly dilated and there was an aneurysmal patent foramen ovale (PFO) with right to left shunting. The right ventricle (RV) was moderately dilated with qualitatively good RV systolic function. There was marked reversal of flow in the distal aortic arch, apparently draining predominantly to the brachiocephalic artery.
Over the next 2 d, repeat sonographic evaluation demonstrated new polyhydramnios and abnormal Doppler studies. The fetus developed an abnormal fetal heart rate tracing with areas of minimal variability and non-reactivity. At this point,

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


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

[User]
RADIOLOGY NOTE:
This is the case of a 50-year-old female, with a family history of pancreatic cancer, who was found to have a chest lesion on chest X-ray carried out in 2006 because of intermittent cough since 2000. A subsequent CT scan of the thorax confirmed a 13-mm nodule on the upper right lobe of the lung, which did not seem suspicious for malignancy. Following a FDG-PET, which did not pick up on the nodule (SUV max 1.25), observation of the lesion was decided with yearly scans. Up until 5 years later, the lesion seemed to have remained unchanged. However, the imaging follow-up of December 2010 showed a new lesion in the right breast. In January 2011, she underwent right breast quadrantectomy for a lump histologically perceived as an infiltrating triple negative lobular carcinoma, with a negative sentinel node. This result was confirmed from a second pathologist later on. Surgery was followed by adjuvant chemotherapy and radiotherapy, completed in July 2011. In August 2012, a left breast nodule was detected on mammogram and confirmed on MRI. Biopsy of the lesion resulted in a triple negative invasive ductal carcinoma. A PET/CT with FDG was carried out which surprisingly showed a high uptake only on the old pulmonary nodule, which had increased in the meantime, becoming 3 cm in diameter (SUV max 5.9). Biopsy of the lesion was suspicious for a carcinoid. In June 2012, the patient underwent a right lobectomy and right hilomediastinic lymph node dissection. Histology reported a neuroendocrine neoplasm with Ki67 of 18%. Clinically, the patient showed PD from the left breast with subcutaneous nodules formation. It was decided to proceed to a bilateral mastectomy with subcutaneous nodules removal in July 2012. The histological result showed a neuroendocrine tumour, Ki67 of 12% and negative left sentinel node. A second pathology opinion was concluded for breast metastases and subcutaneous nodules from a moderately differentiated NEN of pulmonary origin, with Ki67 of 14% positive for C

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


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

[User]
RADIOLOGY NOTE:
A 50-year-old woman was referred to our hospital for treatment of a duodenal tumor. She had a 13-year history of left nephrectomy for RCC. The histologic diagnosis was clear cell carcinoma of grade 2, pT2N0M0, and pStage II (according to the current TNM staging of the Union for International Cancer Control, 7th edition). The postoperative course was uneventful, and no adjuvant therapy was administered.
Three years after nephrectomy, the patient underwent external beam radiation therapy (a total of 46 Gy) for a solitary metastatic bone tumor in the seventh thoracic vertebra. A further 7 years later, a solitary metastatic tumor was detected in the tail of the pancreas, and resection of the pancreatic tail and spleen was performed. Since the histologic findings of the pancreatic tumor were similar to those of the kidney, metachronous metastasis of RCC to the tail of the pancreas was assumed. A further 3 years after resection of the pancreatic tail, severe anemia was detected during a regular examination. The patient mentioned the presence of persistent tarry stools for 3–4 weeks. Esophagogastroduodenoscopy (EGD) was performed and revealed a mass in the descending portion of the duodenum.
The patient was admitted to our hospital and underwent detailed examinations. Her hemoglobin level was 7.5 g/dl. A subsequent EGD revealed an ulcerated polypoid mass in the descending portion of the duodenum; the mass was adjacent to the oral side, but did not involve the papilla of Vater (fig. ). Endoscopic ultrasonography showed the tumor to be partially invading the head of the pancreas (fig. ). Duodenography revealed a protruding lesion at the wall of the pancreatic side of the descending portion of the duodenum (fig. ). Abdominal enhanced computed tomography depicted a well-contrasted, hypervascular mass (fig. ). Magnifying endoscopy showed a diminished mucosal surface pattern of the gastrointestinal epithelium across the surface of the tumor (fig. ). Furthermore, combined with na

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


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

[User]
RADIOLOGY NOTE:
Patient is a 35-year-old male who was transferred to our hospital with a diagnosis of abdominal mass after presenting to an outside hospital (OSH) for abdominal pain. Patient reports a three-month history of abnormal bowel movements and a 3-week history of an enlarging, palpable abdominal mass. A CT scan obtained at the OSH revealed a 14 × 18 × 20 cm abdominopelvic mass causing ureteral obstruction and bilateral hydronephrosis, with no retroperitoneal lymphadenopathy (). Physical examination revealed the patient had an undescended left testicle, palpable in the left inguinal canal. Serum tumor markers for testicular cancer were obtained and beta HCG was found to be 10 mIU/ml (upper limit of normal), AFP was within normal limits, and LDH was elevated at >6x the upper limit of normal. The patient underwent a percutaneous biopsy of the mass by interventional radiology, and he subsequently underwent cystoscopy with bilateral ureteral stent placement and radical left inguinal orchiectomy. The percutaneous biopsy returned positive for metastatic seminoma (). The left radical orchiectomy specimen contained no tumor (). Ultrasound of the right testis revealed no lesions (). CT of the chest was negative for metastatic disease. The patient underwent 4 cycles of BEP. Two cycles were given without bleomycin, the first due to PFT abnormalities and the last due to rash development with bleomycin during the 3rd cycle. Follow-up imaging revealed decrease in mass size to 5 × 3.4 × 5 cm and an incidental pulmonary embolism (PE), which was asymptomatic. He was treated for the PE with therapeutic low molecular weight heparin for 3 months. PET imaging demonstrated pet avidity in the region of the residual mass, so the patient was taken back to the operating room, 5 months after completion of chemotherapy. Pathology from this specimen showed no viable tumor (Figures and ) but did contain testicular parenchymal tissue. Based on the totality of pathologic findings, we believe this to be a

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


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

[User]
RADIOLOGY NOTE:
A 78-year-old Caucasian female smoker was referred to our clinic with a non-tender left facial swelling that had been present for approximately three years. The patient was otherwise asymptomatic. She had no history of malignancy or autoimmune diseases. A firm mobile mass was present in the left parotid gland.
Examination revealed a 5 cm firm mobile mass in the superficial lobe of the left parotid. The left facial nerve was intact (House-Brackmann scale Grade I). No other abnormalities were found in the nasopharynx, oral cavity, larynx or ears. There was no pathological enlargement of the cervical lymph nodes. Laboratory tests were within normal limits. Hepatitis B virus (HBV) and hepatitis C virus (HCV) serologies were negative.
The patient had undergone ultrasonography-guided fine needle aspiration of the left parotid gland several months before. The cytological examination revealed mononuclear and inflammatory cells and a diagnosis of a chronic parotiditis was made. The patient was given antibiotics but with little effect. Unfortunately, the mass on the left parotid continued to enlarge. After admission to our clinic, a helical CT scan was performed which revealed a solid mass with an irregular surface in the left parotid gland (Figure ).
The patient underwent resection of the left parotid gland with preservation of the left facial nerve through a preauricular incision (Figure ). Identification of the branches of the facial nerve was made by using loupes magnification and with intraoperative electric stimulation of the identified branches of the facial nerve. The size of the resected tumor was 5 × 7 cm (Figure ). The surgical specimen was sent for a histopathological examination.
The pathology report was consistent with a low-grade marginal-zone B-cell non-Hodgkin lymphoma (MALT lymphoma) following BLL of the gland. According to the report, there was infiltration of the normal salivary tissue by a heterogenous mixture of lymphocytes and isolated blastic cells.
Po

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


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

[User]
RADIOLOGY NOTE:
A 70-year-old woman presented with metastatic colorectal adenocarcinoma. She had a primary hemicolectomy in 2013 with local recurrence and secondary surgery and liver metastases treated with radiofrequency ablation in 2016. A computed tomography (CT) scan of her chest revealed the progression of her disease via multiple lung metastases in March 2017. The patient had a history of deep vein thrombosis three months earlier (right calf) and received rivaroxaban with good clinical and ultrasound outcome. She was admitted to our hospital for TIVAP insertion and polychemotherapy initiation.
Surgery was performed under local anesthesia (April 2017). Initially, the right subclavian blind cannulation by the surgeon was ineffective. An experienced anesthesiologist was invited into the operating room, but multiple ultrasound-guided cannulation attempts failed bilaterally. The patient was transferred to the radiology department, and a chest CT scan revealed subclavian vein hypoplasia (vessel diameter was up to 4 mm). We decided to use right common femoral venous entry and discussed the situation with the patient. The patient provided additional informed consent to proceed. A catheter was inserted via femoral access without complications. In the operating room, the venous catheter was replaced by tubing from the port system kit.
Catheter tip positioning was performed using transabdominal ultrasound guidance (with a convex probe). The capsule was implanted subcutaneously on the front lateral side of the right hip. Postoperatively, a whole-body CT scan allowed us to assess the TIVAP position and identify possible complications. Technical success was confirmed, and the patient was discharged from the surgery department. Anticoagulation therapy with rivaroxaban was prolonged to avoid a thrombosis recurrence.
As a routine practice, we include all patients with implanted ports in the observational venous thromboembolism monitoring program. This patient visited our hospital for follow-u

[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 man was incidentally found to have a liver tumor measuring 20 mm by abdominal ultrasonography during a routine company health examination in 2004. The tumor grew in size over the next 2 years, and closer inspections were conducted by a previous physician in 2006. Enhanced computed tomography (CT) of the abdomen showed a 70-mm mass with hemorrhagic and necrotic changes in the right lobe of the liver (segment 5), with early arterial phase staining and late phase washout, which seemed to be consistent with hepatocellular carcinoma (HCC) (Fig. ). Anterior segmentectomy of the liver was performed. Macroscopically, non-encapsulated tumor had irregular borders. Sectioning of resected specimen revealed a white to yellow, friable, hemorrhagic mass measuring 63 × 50 mm (Fig. ). Microscopically, hematoxylin and eosin staining showed atypical epithelioid cells containing abundant clear to eosinophilic granular cytoplasm arranged in nests and sheets. The cells were unevenly distributed and had pleomorphic nuclei of varying sizes. Blood vessels were inconspicuous and mature adipose tissue was not detected. Both bile ducts and portal tracts were involved in the tumor. Immunohistochemically, the tumor cells were negative for hepatocyte paraffin 1 (HepPar 1) and alpha fetoprotein. In contrast, the tumor cells were scatteredly positive for melanocytic markers including human melanoma black 45 (HMB-45) and Melan A, but negative for smooth muscle antigen (SMA) and S100 protein, together with negative for c-kit and moderately high Ki-67 labeling index (12.9 %) (Fig. ). Accordingly, primary hepatic eAML was diagnosed at that time.
After hepatectomy, the patient was referred to our hospital and followed every 6 months on an outpatient basis. No hepatic recurrence was observed over nearly 7 years. In 2013, a chest X-ray showed a well-defined nodule in the right lung field (Fig. ). Chest CT showed two round nodules in segments 1 and 3 of the right lung, measuring 10 and

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


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

[User]
RADIOLOGY NOTE:
A 37-year-old Bangladeshi male sustained a fall during work. He fell off an 8–10 m high scaffold on his left foot and then on his left side. Subsequently, a heavy object fell on his left foot. He was complaining of severe pain in the left foot and inability to bear weight on it. He was brought by the ambulance to the emergency department. On arrival, the patient was conscious, oriented with Glasgow Coma Scale 15/15. Physical examination showed severe tenderness over the left foot with deformity. Neurovascular status of the foot was intact. There was moderate-to-severe swelling with soft compartments of the left foot. He was cleared by the trauma team and investigation showed isolated left foot comminuted intra-articular calcaneal fracture along with Lisfranc fracture with dislocation of the tarsometatarsal joints. X-ray of the left foot is shown in . 1day after presentation to the emergency department, the patient under went open reduction and internal fixation (ORIF) of the left foot Lisfranc fracture and dislocation with cortical screws for the first to fourth metatarsal and 2 mm K-wire for the fifth metatarsal. A below the knee back slab was then applied and the patient was admitted to the orthopedics ward. The post-operative course of the patient was unremarkable except for swelling over the left foot. However, on the 4thpost-operative day, the patient developed clear skin blisters over the posterior aspect of the calcaneus. The skin condition of the patient deteriorated to skin necrosis as shown in . A computed tomography (CT) scan of the left foot was carried out in preparation for ORIF of the calcaneus. Cut sections of the CT scan demonstrating a fragment of the calcaneus pressing over the posterior soft tissue are shown along with other cuts in . The patient then underwent ORIF utilizing an extended lateral approach. Using a 3.5 mm K-wire inserted posteriorly

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

[User]
RADIOLOGY NOTE:
This 16-year-old male presented to the emergency department with new onset headache and visual changes of 2 days duration. The headache was described as sudden in onset, constant in nature, and bitemporal in location. This was associated with development of vision loss 1 day characterized by darkening of his vision, progressing from the superior to the inferior visual fields that lasted approximately 30 minutes with subsequent persistence of blurry vision. Without resolution of his symptoms, he presented to the emergency department.
On questioning, there was no prior history of seizure activity or of precocious puberty, or of genital abnormalities at birth. He had undergone corrective surgery for polydactyly of the left hand at 9 months of age. Polydactyly was also reported in his mother and elder brother.
His neurological examination was benign without abnormalities of extraocular movements, pupillary reflexes, facial motor strength, or sensation; he did not have papilledema. His genitourinary examination was normal and appropriate for age. Inspection of the left hand revealed webbing between the 3rd and 4th digits, with a well-healed scar on the ulnar aspect over the 5th metacarpophalangeal joint.
CT scan of the head without contrast identified a 30 mm mass in the suprasellar region. Follow-up MRI of the brain with and without contrast confirmed this, identifying a nonenhancing, 30 x 27 x 30 mm mass along the midline of the posterior aspect of the suprasellar cistern contiguous with the posterior floor of the hypothalamus and tuber cinereum (). The mass was isointense to the gray matter on all sequences and appeared to produce significant mass effect on the posterior aspect of the optic chiasm and both optic tracts, with anterior displacement of the pituitary stalk.
Hormonal testing revealed intact anterior pituitary gland function. There were no symptoms suggestive of central diabetes insipidus. Serum germ cell markers were negative. Formal visual field testing d

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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 36 year old Caucasian male presented with a mass in the right wrist and paraesthesia in the distribution of the median nerve. The mass had been noticed four years prior to presentation and over this time had increased in size. On examination the mass projected from the volar aspect of the wrist but was poorly demarcated. It was firm to palpate and non-tender. Hand examination revealed attachment of the mass to the flexor digitorum profundus tendon of the index finger. Paraesthesia was exacerbated by repetitive use of all the long flexor tendons. No thenar eminence wasting was noted but some mild clinical weakness was evident in this muscle group.
An initial MRI scan performed outside our institution demonstrated a T2 hyperintense lesion, 50 mm long by 14 mm wide, arising from the index finger profundus tendon within the palm and displacing the median nerve. Thallium-201 scintigraphy (Fig. ) demonstrated initial tracer uptake in a small focus corresponding with the mass described on MRI. Images at four hours post infusion revealed complete washout of the abnormal tracer activity in this region. These images indicated a likely benign diagnosis of a ganglion or pigmented villonodular synovitis (PVNS), while synovial sarcoma was considered to be unlikely given the thallium washout at four hours.
A CT guided core-biopsy of the lesion was performed. The lesion could not be aspirated and two 18 gauge cores of gelatinous material were taken. Microscopic examination of these cores revealed a chondroid matrix and bland cells suggestive of synovial chondromatosis.
A second MRI scan (Fig. ), performed 12 months later, showed the tumour size had not changed from the previous scan and the long axis of the mass remained parallel to that of the profundus tendon. Fluid signal was noted predominantly but with the addition of irregular T2 hypointense septations within it, which enhanced with contrast. The mass was also found to displace flexor digitorum superficialis (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:
This case details a 54 year old woman who was referred to our clinic by her general practitioner for investigation of bilateral breast pain that she had for 6 months.
Her past medical history included hypertension for which she took a single anti-hypertensive. She had no familial history of breast or gynaecological malignancy. On clinical examination pathological nodes were palpated bilaterally in the axillae. There was left sided nipple inversion with a palpable mass in the upper outer quadrant of approximately 3 cm diameter.
On examination of the right breast there was skin tethering of the nipple and 3 masses were palpated, the largest being in the upper inner quadrant at 5 cm diameter.
Ultrasound and mammography of bilateral breasts demonstrated advanced bilateral breast cancer with axillary node metastases.
The right breast had a large lesion consistent with primary breast cancer at 12 o’clock measuring 44.3 mm in diameter. An additional 7 smaller lesions were distributed through the right breast consistent with satellite lesions. The largest pathological node in the right axilla measured 42 × 30 mm.
In the left breast at the 2 o’clock position there was a lesion consistent with breast carcinoma measuring 31.2 mm. The largest node in the left axilla measured 13.1 × 10.2 mm.
There was skin thickening of both breasts consistent with oedema, the right side was most pronounced. Core biopsies from lesion on right breast at 12 o’clock and the left breast at 2 o’clock demonstrated invasive carcinoma. , : (H&E x10) Left/right core biopsy show invasive carcinoma, no special type
The hormone receptor status was identified with right breast lesion being ER negative whilst the left breast lesion was ER positive.
, , : (x10) Positive staining for ER and PR. HER2 Immunohistochemistry score 3 + .
, , : (x10) Negative staining for ER and PR. HER2 Immunohistochemistry score 3 + .
The patient was

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


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

[User]
RADIOLOGY NOTE:
A 53-year-old woman referred to our department with the complaint of clear watery discharge from the right nostril. She gave a history of head trauma due to car accident 6 years ago that underwent surgery for the evacuation of right temporal intraparenchymal hematoma.
She suffered from intermittent rhinorrhea starting 5 years after trauma which had lasted for 1 year and had been continuous for the previous 3 months. She had two bouts of meningitis after rhinorrhea that was treated conservatively in a different hospital.
She had no anosmia, and other neurological examinations were normal.
Routine biochemical and hematological investigations were within the normal range.
The image findings of axial brain and coronal sinus computed tomography (CT) scans were evidence of previous right temporal craniotomy and adjacent parenchymal changes. CT cisternography, after intrathecal injection of 20cc Visipaque (VISIPAQUE Injection 270 mgI/ml, 20 ml, GE Healthcare, Norway), did not show bony defect on the anterior cranial fossa or detectable contrast leakage into the paranasal sinuses and nasal cavity (not shown).
Beside the mentioned findings, coronal T2-weighted magnetic resonance images depicted the high signal intensity area in favor of encephalomalacia in the left inferior temporal region associated with fluid signal in the left tympanic cavity and mastoid air cells []. It was the only clue to reassess the axial brain CT scan which revealed partial opacity of left mastoid air cells [], and further evaluation with coronal images of the petrous bone which depicted large bony defect of the left tegmen tympani, tegmen mastoideum associated with opacity in the middle ear cavity, and lateral displacement of the ossicles [].
The patient suspected to have paradoxical CSF rhinorrhea through eustachian tube from the defect of left temporal bone.
For further documentation, she underwent endoscopic transnasal examination after intrathecal injection of fluorescein dyes, which showed lea

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


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

[User]
RADIOLOGY NOTE:
A 66-year-old male patient complained severe back pain and radiating pain to both leg for several days. Spinal MRI demonstrated a huge intradural mass compressing conus medullaris and cauda equina at the L1-2 level, with slight ring enhancement on the surroundings (). He was very healthy previously and did not have any risk factor for stroke.
A laminotomy on the appropriate level was done and dura was opened vertically. On the ventral side, there was a large dural opening and through the defect a large intradural disc material was extruded. The ruptured disc was removed totally with microsurgical piecmeal technique. In order to minimize post operative CSF leakage ventral defect and dorsal dural opening was closed watertightly. Fibrin sealant was covered on the sutured area and lamina was replaced with miniplate fixation. On postoperative MRI, it was removed successfully ().
On the day after surgery, blood mixed with CSF came through the drainage bag, and the patient was instructed to take a rest in lying position. After operation his back pain was minimized and radicular pain was disappeared and the patient frequently took a sitting position against medical advice and about 300 cc of CSF was drained just within 4 hours.
Two days after the surgery, the patient complained unexpected headache, dizziness, nausea and vomiting, while neurological condition was stable, pupillary reflex on both eyes were normal as well as limb motor power, but horizontal nystagmus was detected on both eyes. From the urgently conducted brain CT, it was reported that the patient had cerebellar hemorrhage with size of 3×3 cm on the right cerebellum and 1.5×1 cm on the left cerebellum. While brain stem was not compressed, fourth ventricle was distorted and headache was aggravated, leaving the decision to surgery (). Suboccipital craniotomy and hematoma evacuation was performed, and hemorrhagic lesion on the right cerebellum was effectively removed (). After craniotomy, the patient showed clinic

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


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

[User]
RADIOLOGY NOTE:
A 38-year-old non-smoker and teetotaler male diagnosed with PSC without inflammatory bowel disease (the latter ruled out by colonoscopy-directed mucosal biopsy at 3 months prior to current presentation), for 3 years and on ursodeoxycholic acid (UDCA) at 15 mg/kg/day had developed three episodes of BC within the prior 6 months, with the last episode requiring intensive care unit admission for septic shock. Magnetic resonance cholangiography revealed mucosal irregularities in the right and left hepatic duct with areas of beading in segments 3, 6 and 8 of the liver in the absence of dominant strictures. Test of immunoglobulin type G4 serum level was normal, and its associated systemic manifestations were absent. Level of carbohydrate antigen 19-9 was within normal limits in the absence of cholangitis, and parenchymal or bile duct lesions suggestive of cholangiocarcinoma were not evident on serial follow-up imaging.
In view of the recurrent BC, the patient was listed for LT. While on the wait list, the patient developed persistent pruritus (Itch score 6/10) and jaundice lasting for 3 months and experienced a fourth episode of BC. Two out of three prior episodes of BC were associated with Escherichia coli bacteremia sensitive to cephalosporins and carbapenems, respectively. The recent episode of BC was associated with Enterococcus fecalis sensitive to linezolid, to which the patient responded clinically. Considering the high mortality associated with being on an LT wait list, manipulation of the intestinal microbiota through healthy donor FMT (to potentially influence the disease process in PSC) was considered, with informed consent from the patient and his wife. The patient’s nephew was identified as the potential donor, after standard screening protocol.
Sixty grams of freshly collected stool sample was obtained 6 hours before the procedure and homogenized in a blender with 250 mL of normal saline for 2–4 minutes. Two hundred milliliters of the strained and filtered st

[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 previously well 72-year-old female presented to a tertiary hospital for an elective colonoscopy. The indication was anemia, intermittent abdominal pain, and recently altered bowel habits. The patient had had several colonoscopies in the past although not for a number of years. Her previous colonoscopies were noted as being difficult and on the most recent attempt, the endoscopist failed to reach the cecum. The difficulties encountered in those procedures were attributed to significant diverticulosis.
In anticipation of a challenging colonoscopy, a pediatric colonoscope was used. Per rectum exam was unremarkable, and the bowel prep was described as average. After some initial difficulties, the endoscopist had some success advancing the scope using water irrigation to distend the bowel. However, due to significant looping, the scope could not be advanced past the splenic flexure. At this point, the endoscopist encountered resistance and was unable to retrieve the colonoscope. Fluoroscopy was performed, and a tight angulation in the sigmoid colon was observed.
The patient was given a general anesthesia and paralyzed in an attempt to retrieve the colonoscope. However, this too was unsuccessful. In conjunction with the on-call colorectal surgeon, a decision was made to transfer the patient to the operating theater for an exploratory laparotomy. Intraoperatively, significant intraabdominal adhesions were encountered, and a large phlegmonous mass was noted abutting and constricting the patient's sigmoid colon. It became apparent that the adhesion between the patient's sigmoid colon and this inflammatory mass were responsible for the unusual predicament. The scope had looped in the sigmoid colon, and both the afferent and efferent limbs were fixed at the same level. Furthermore, the loop had twisted in a volvulus-type configuration. This meant that as the surgeon tried to either withdraw or advance the scope, the whole loop would move against the fixed adhesions, and 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 three-year-old male presented to the emergency department (ED) with the chief complaint of one episode of hemoptysis that occurred just prior to arrival. His adopted mother stated that he had cold-like symptoms for the past few days prior to arrival, and on the day of arrival, he began to cough up blood. She brought the blood-tinged rag with her to the ED. He had vomited the night prior, as well as on the morning prior to arrival, and had diarrhea during that same time frame. His adopted mother said that the diarrhea and vomit were not blood-tinged. There had been no change to his urine output. She stated that he had a fever the night prior, as well as on the morning of presentation, with a maximum temperature of 101º F. His adopted mother said that he attends daycare, and that multiple children in his daycare had recently come down with respiratory syncytial virus (RSV).
His adopted mother stated that he was born full term with no complications. She also said that he had multiple bronchitis infections since his adoption, which she stated was at a few months of age. According to her, he is up to date on all vaccinations. Due to his adoption status, his family history was unknown.
His temperature on arrival to the ED was 98.7º F. He had a pulse rate of 131 beats per minute, a respiratory rate of 22 breaths per minute, and a blood pressure of 89/60. Physical exam revealed the presence of clear rhinorrhea as well as diffuse crackles and expiratory wheezing in all lung quadrants.
A complete blood count and comprehensive metabolic panel were all within normal limits. Chest radiographs in two views were performed, and it was determined that no acute lung abnormalities or pulmonary infiltrates were present (Figures -). A hemoccult test was done on the blood-tinged rag which confirmed that the substance was blood. It was

[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:
Case 1 is a female, 68-year-old. She complained chronic cough, expectoration, and wheezing for more than 10 years, with recurrence associated with intermittent fever for 1 month. She was hospitalized. The patient denied particular exposure history and tuberculosis infection history. Symptoms were cough, expectoration, and wheezing with large amount of white mucilage phlegm that occurred intermittently more than 10 years ago. Symptoms tended to reoccur during cold weather in autumn and winter. She was diagnosed with chronic bronchitis at a local hospital. Her symptoms were relieved after treatment in the local hospital for an exacerbation. No bronchoscopy had been performed during the course of her illness. Due to the aggravation of symptoms, she was treated in a local hospital 7 months prior to admission. The usual treatment had poor effects this time, and she came to our hospital for further diagnosis and treatment. Chest CT revealed large exudative foci and consolidation in the left lower lung. Bronchoscopy revealed stenosis in the left upper and lower lobes with pigmentation. The initial diagnosis was community-acquired pneumonia [Figures and ]. Cefoperazone sulbactam and levofloxacin were given empirically. The patient was discharged after 10 days’ treatment. Symptoms were greatly relieved at discharge.
One month before the second admission, the patient presented with intermittent low fever in the afternoon. Levofloxacin were given in the local hospital for 1 week. The patient was hospitalized in our hospital again because her body temperature was unstable. Physical examination showed slight dullness to percussion in the left lower lung, dry rales scattered in both lungs, wet rales in the left lower lung, no pleural friction. Chest CT showed that there remained a large exudative lesion and consolidation in the left lower lung, which had no significant improvement compared with previous chest CT []. Bronchoscopy showed that the left bronchus was narrow with pigme

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


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

[User]
RADIOLOGY NOTE:
A 35 yr old male patient presented with complaints of pain and swelling on the distal aspect of the left leg. The patient suffered a twisting injury to the leg one year ago and had mild pain and swelling for which he took treatment from an osteopath. The pain reduced but the swelling persisted. One month ago, the swelling increased in size and was associated with severe pain which was exaggerated on walking. There was no history of fever, night cries, loss of weight, and loss of appetite present. History of massage therapy was present which was done 4-5 times.
On examination, swelling was present over the distal aspect of the leg about 6 × 4 cm with well-defined margins, smooth surface, and bony deep. The skin over the swelling was normal. Tenderness was present over distal tibia. Ankle movements were normal.
X-ray showed well-defined expansile lytic lesion at distal end of left tibia suggestive of giant cell tumor of distal end tibia. CT () ankle shows morphology of subarticular expansile lytic lesion in lower end of left tibia suggestive of giant cell tumor.
The condition and routine investigations done in preparation for operative procedure were explained to the patient. Patient was treated with intralesional excision and curettage and the cavity was filled with bone cement. Specimen was sent for histopathological () examination which confirmed giant cell tumor. The patient was immobilised in an above knee cast for one month and converted to a PTB cast later. Sequential X-rays () were taken to confirm the union and cast removal was done at the end of three months postoperatively. The patient was started on regular physical therapy and was allowed weight bearing when the patient was comfortable. Patient was followed up for one year at regular intervals and the patient was ambulatory without any evidence of recurrence at the end of one year.

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


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

[User]
RADIOLOGY NOTE:
A 34-year-old female was seen in the emergency department for abdominal pain. Her workup included a CT abdomen where she was found to have bilateral renal masses: 2.4cm on the right and 7.6 cm on the left (). Also noted were multiple small cysts in the lung bases. The rest of the workup was unremarkable and her abdominal pain resolved with conservative management alone. She was referred to urology where it was recommended that her left kidney tumor be resected and to defer the right pending pathology results. Notably, she had no prior medical history and no relevant surgical history and had otherwise been healthy and well. She has two siblings without lung, skin, or kidney symptoms and her parents are likewise healthy. She has a 15-year-old son who is healthy. There were no consistent skin findings on exam.
Pulmonary evaluation with a CT of chest identified basilar predominant multiple lung cysts with the largest cysts measuring approximately 1.6cm. Several <6mm partially solid nodules were noted as well. Spirometry, diffusion capacity, and plethysmography were all within normal limits. She did complain of mild dyspnea, but that this was intermittent and had a significant anxiety component.
She eventually underwent resection of the left kidney mass with a partial nephrectomy and a final pathologic diagnosis of an oncocytoma, which is a typical tumor type for Birt-Hogg-Dubé syndrome. Her postoperative course was unremarkable with a planned sequential right nephrectomy pending further evaluation.
Birt-Hogg-Dubé syndrome was suspected given this patient's basilar predominant multiple lung cysts and bilateral renal masses, but without skin findings the diagnosis was in question. There are no universally accepted diagnostic criteria, but typically either skin findings or a pathologic mutation must accompany the lung and kidney pathology to solidify the diagnosis. Genetic testing was thus obtained via a blood sample. The FLCN gene of the patient was sequenced with any del

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


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

[User]
RADIOLOGY NOTE:
A 58-year-old male was diagnosed with left maxillary sinus squamous cell carcinoma and underwent a surgical operation in September 2013. He complained of nasal obstruction, facial swelling and intermittent epistaxis three months later. Dark red neoplasm located in the patient left nasal cavity was observed. CT scan showed the invasion of multiple structures including anterior left frontal sinus, ethmoid sinus, maxillary sinus, nasal septum, pterygopalatine fossa and hard palate. The patient received tumor radical excision and confirmed to be squamous cell carcinoma by pathological examination.
After the surgery, the patient received radiotherapy of 70 Gy in fractions of 2 Gy. However, one year and five months after post-operative treatment, the patient presented with complaints of intermittent epistaxis and decreased vision of the left eye for two months. Examination showed that he had loss of vision and a tumor was located on the top wall of the left residual hard palate. The patient agreed to receive extended resection of the left maxilla. After that, he received radiotherapy of 50 Gy in fractions of 1.3Gy and 5 courses of chemotherapy, including paclitaxel (IV, once every three weeks, 240mg at a time) (135 mg/m2) and nedaplatin (IV, once every three weeks, 140mg at a time) (80 mg/m2). The complication of leukopenia was observed and it was recovered after using recombinant human granulocyte colony-stimulating factor. Oral ulcer healed, but hair losing because of early chemotherapy. Nausea and vomiting were disappeared after injection of antipathectic.
Three years after the first surgery, the patient came back and complained of hearing loss and otorrhea for 10 months. White neoplasm located at the patient left EAC was observed. CT scans showed the invasion of multiple structures including EAC, tympanic cavity, mastoid and occipital. MRI distinctly showed that there was a lesion occupying the left temporal bone nearby the left middle fossa of skull (size:27.5mm x 38

[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 Japanese man with lower abdominal pain underwent lower endoscopy, revealing a type 2 lesion with the entire circumference raised in the rectosigmoid colon. He was diagnosed with rectosigmoid colon cancer and underwent endoscopic stent placement as a bridge to surgery for large bowel obstruction. He was found to have multiple lung metastases and a horseshoe kidney on CT scan (Fig. ). 3D-CT angiography showed an aberrant renal artery at the isthmus from 3 cm under the inferior mesenteric artery (IMA) branch of the aorta (Fig. ). Laparoscopic anterior rectal resection was performed with a five-port conventional technique in which sigmoid colon and upper rectum were mobilized via a medial approach. During the operation, the IMA, left ureter, left gonadal vessels, and hypogastric nerve plexus were identified and preserved (Fig. , ). The root of aberrant renal artery was not visualized. The root of the IMA was located considerably cephalad to the renal isthmus, and the left branch of aberrant renal artery that was close to IMA was detected and preserved (Fig. ). The specimen was removed through a small laparotomy wound, and intraperitoneal reconstruction was performed according to the standard double stapling technique. The patient recovered uneventfully and was discharged on postoperative day 16. Pathological examination demonstrated no metastasis of the lymph node.
Horseshoe kidney is rare, with an incidence of 0.25%, and the incidence is higher in males than in females at a ratio of 2:1. Horseshoe kidneys are fused at the lower pole in 95% of cases, and the isthmus is composed of fibrous tissue alone or contains parenchyma. The horseshoe kidney is located at a level lower than the normal kidneys because elevation of the kidneys interferes with the isthmus at the origin of the IMA.
A literature search revealed 23 patients who underwent surgery for colon cancer with concomitant horseshoe kidney including our patient, from 1983 to 2017 [–].

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


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

[User]
RADIOLOGY NOTE:
A 27-year-old male patient was admitted to the emergency room of this hospital with shortness of breath that started a week before admission. A chest x-ray performed at emergency room showed a left-sided pneumothorax (Fig. A), and the patient was referred to the department of thoracic surgery. The left lung of the patient was totally collapsed, and there was a high possibility of REPE upon chest tube insertion with the symptom onset of a week. Accordingly, after explaining this situation to the patient and his caregivers, a 12 French trocar tube was inserted into the left thoracic cavity of the patient. In order to allow the lungs to expand slowly, natural drainage was performed without suction, and the rubber tube connecting the chest tube and the water seal bottle was partial clamped. On the day after chest tube insertion, there was an finding of air leakage through the chest tube, but the lungs were not found to expand much as a result of chest x-ray (Fig. B), thus the partial clamped rubber tube was de-clamped. However, about an hour after de-clamping, the patient suddenly complained of severe respiratory distress, cough with foamy sputum, and vomiting. Immediately the chest tube was clamped to stop drainage. With oxygen saturation measured 75%, oxygen was administered to the patient via an oxygen mask, but no improvement was observed. In turn, a chest x-ray was followed during additional high flow nasal prong (HFNP) therapy, exhibiting REPE findings such as newly developed ill-defined consolidation in the left lung (Fig. ). Oxygen saturation did not improve even after HFNP therapy, and further, persistent cough with foamy sputum, shortness of breath, and a drop in blood pressure occurred. With the need for intensive care recognized, the patient was immediately transferred to the intensive care unit and then was sedated and intubated to perform mechanical ventilation. After supportive care including mechanical ventilation, the condition of the patient was improv

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


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

[User]
RADIOLOGY NOTE:
Our patient was a 42 years old male admitted to the Department of Neurosurgery, University Hospital “Sestre Milosrdnice” manifesting symptoms of raised intracranial pressure including severe occipital headaches and nausea caused by a brain tumor. The symptoms lasted for 10 months. The patient was without clinical NF1 or NF2 and had no family history of brain tumors. Using the magnetic resonance imaging (MRI) a tumor lesion was found in the right anterior intraventricular region. The well circumscribed tumor was located from the III ventricle all the way to the foramen of Monro and cranially to the corpus callosum. During the operative procedure the astrocytoma was maximally reduced using a microneurosurgical technique. The surgical access route was the interhemispheric transcallosal approach, passing through the corpus callosum and entering intraventricularly in the corpus of the right lateral ventricle. The foramen of Monro was freed to the right and the communication between right lateral ventricle and the third ventricle was established. On the frozen and subsequent permanent sections tumor was made of alternating areas of densely and loosely packed fibrillary neoplastic cells with long, hair-like cytoplasmic processes. Microcystic-clear cell features (Figure A) and Rosenthal fibers (Figure B) were also present. In some areas hyalinized blood vessels and glomeruloid microvascular proliferation was also observed. Mitoses, anaplastic cells as well as necrosis were not found. Immunohistochemically, the tumor cells were strongly positive for glial fibrillary acidic protein (GFAP). Neuropathological examination revealed pilocytic astrocytoma and classified the tumor into grade I according to the WHO criteria []. The follow-up was 10 years without recurrence.
The result of aCGH analysis demonstrated differences in the tumor tissue when compared to normal control on the array. The total number of aberrations found in our case was 56, among which deletions dominated. Who

[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, a 62 years-old Caucasian male of Greek, was referred to our center due to progressive dysphagia since 2 years, an episode of regurgitation of a fleshy mass into the mouth and occasional attacks of dyspnea. Previous consultation to an Ear Nose and Throat specialist suggested a psychiatric evaluation.
On admission to our hospital the patient underwent radiographic study of the esophagus using barium as contrast medium. The esophagogram demonstrated a contrast-filling defect from the cervical esophagus till the Cardioesophageal junction ().
A mobile, elongated endoluminal polypoid mass was revealed during esophagoscopy, arising from the level of the upper esophageal sphincter and extending till just above the Cardioesophageal junction. This soft tissue polypoid mass caused a marked dilatation of the proximal and mid esophagus. Attempt to excise the polyp endoscopically was not performed due to inability to visualize adequately the base of the polyp and therefore the patient was recommended to be operated.
MRI of the neck and thorax demonstrated that the origin of the pedicle was pointed to the right anterior mucosal wall of the cervical esophagus (,).
Knowing preoperatively the site of origin of the polyp, a cervical incision was decided opposite to the origin.
For this reason through a left lateral cervical approach a longitudinal esophagotomy, 5 cm in length, was performed to the left posterior esophageal wall. The mucosal origin of the stalk was completely visualized, resected and suture-closed. The mucosal defect was repaired by single interrupted absorbable stitches. The polyp was tracted and removed. The esophagotomy was sutured in a two-layered fashion.
The dimension of the polyp was 10.5 × 5.5 × 3.5 cm ().
A nasogastric feeding tube was introduced and left in place for 4 days.
Histopathologic examination revealed that the specimen corresponded to a fibrovasular polyp () lined with reactive squamous epithelium, with focal ischemic obstruction and ne

[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 lady sustained posterior dislocation of right elbow following a fall at home. She underwent closed reduction for dislocation elsewhere, and above elbow slab application (,). She was referred to our hospital three days later with complaints of severe pain, swelling around the right elbow and numbness of fingers. As per the treatment notes there was no obvious neuro vascular injury and radialartery pulse was felt immediately after reduction of elbow dislocation. On examination, We noted that the elbow was swollen, there were superficial blebs, forearm was tense, and there was mild stretch pain. Vascular examination showed good capillary refill with palpable radial artery pulse and decreased sensation over fingers. We evaluated the patient using X-ray of the right elbow -which showed well reduced dislocation and no evidence of fracture. To rule out any vascular injury, arterial doppler scan was performed which showed -large hematoma causing extrinsic compression over distal end of brachial artery with minimal monophasic flow in distal arteries. We took the patient for brachial artery exploration to clear-the hematoma under general anesthesia. A two cm vertical incision was made over medial aspect of lower arm and hematoma was removed. We were surprised to note a pulsating tubular structure with occluded lumen, which led to our suspicion of a complete brachial artery rupture. Immediately, the patient was referred to a vascular surgeon for CT-angiography and for further management. CT angiography showed complete right brachial artery transection five cm above the elbow with thrombus in both ends and significant blood flow in distal arteries through collateral circulation (). The patient was further treated with excision of injured segment of vessel and right transbrachial proximal and distal thrombectomy. The artery was reconstructed by interposition repair of right great saphenous vein graft and forearm fasciotomy () in anticipation of compartment syndrome

[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 5-year-old asymptomatic female was hospitalized in our center for surgical intervention for ALVT with AORCA and BAV. Tracing back to nearly 1 year, this entity of congenital cardiac abnormalities was accidentally detected by a routine echocardiography at a local hospital, with a misleading preliminary diagnosis as BAV with accompanying aortic regurgitation (AR). The patient and her parents reported no evident symptoms, concomitant congenital dysplasia, noteworthy past medical history and family history of inherited cardiac defects. Physical examination showed a grade IV/VI diastolic murmur at auscultatory area of aortic valve. Detailed results from a repeated echocardiography demonstrated: 1) an abnormal tunnel communicating the aortic root and left ventricle, with the opening of aortic segment at the level of the right posterior sinus (0.63 cm at width) and the opening of ventricular segment at the level of membranous interventricular septum (0.43 cm at width); 2) BAV without evident aortic stenosis or AR; 3) the left and right coronary arteries both originating from the left anterior sinus; 4) an enlarged left ventricle (LV) with normal left ventricular function (LV ejection fraction (LVEF) estimated as 65%). The chest X-ray found no significant aberrance (Fig. ). Additionally, a cardiac CTA further confirmed the diagnosis and revealed an abnormal tunnel between the right coronary sinus and left ventricle (Fig. and ). Because the patient presented no obvious symptoms, no medical treatment was perfomed before the surgery.
The patients underwent the surgical repair for ALVT under general anesthesia and cardiopulmonary bypass (CPB). After a median sternotomy was performed and CPB was established, cardiac arrest was achieved using antegrade cardioplegia infusion at the root of aorta for myocardial protection. Subsequent to the horizontal incision at the aortic root, a good view for those anatomical abnormalities was obtained. Except that the AORCA and BAV were confi

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


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

[User]
RADIOLOGY NOTE:
An 83-year-old female was brought in by ambulance due to rapid cognitive decline leading to decreased oral intake. Her past medical history includes Parkinson's disease, severe dementia, atrial fibrillation, coronary artery disease, coronary artery bypass surgery, permanent pacemaker placement, mitral valve replacement, hypertension, and glaucoma. The patient's oral intake decreased significantly over a two-week period. During the initial assessment, patient was alert, not oriented to person, place, or time, and confused. Her neurological exam was also significant for reactive aphasia and inability to follow commands. Vital signs were stable. Physical exam showed cachexia, no acute distress, bilateral air entry, and soft nontender abdomen with normal bowel sounds. No edema or bruising was noted on skin examination. Patient exhibited full range of motion. On the second day of admission, patient failed a dysphagia screening and began receiving fluid hydration intravenously. A 5% dextrose-0.45% saline infusion was started at 10 p.m. that evening at a rate of 100 mL/hour. The IV was checked at midnight, and the infusion rate was maintained. At 4 a.m., nursing staff noticed IV line infiltration. The patient was then found to have large blisters on the ventral side of her forearm. The IV line was immediately removed. On exam, serous blistering of various sizes distributed across the skin of the affected right forearm and significant swelling of the soft tissue was noted. A rigid nursing home identification bracelet proximal to midforearm was identified that was restricting the swelling to the distal forearm (). Her skin was tense from the tips of her fingers to the midforearm with swelling visible in her knuckles as well as palmar and volar surfaces of the hand. Patient's sensory exam was indeterminate due to her baseline dementia. Her radial pulse was palpable. Surgical team was notified for suspected ACS of the forearm and the compartment pressures were measured with a

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


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

[User]
RADIOLOGY NOTE:
A 15-year-old girl reported to the Department of Oral Pathology and Microbiology, in January 2007, with the complaint of a painless, slow growing swelling on the right side of her face, which she had first noticed one month ago. The general condition of the patient was good on initial clinical examination.
The physical examination showed an immobile, nontender mass, approximately 4 × 3.5cm, in the right zygomatic region extending up to the lateral canthus of the right eye. The ocular mobility was preserved and no other ophthalmic manifestations were present. The borders of the swelling were poorly defined. The consistency of the swelling was relatively soft below the lateral canthus of the eye and hard elsewhere. On intraoral examination, no findings of clinical interest were seen. There was no regional lymphatic involvement.
On a computed tomography scan an expansile, lytic lesion, measuring 4 × 3 × 2.5cm was seen, which involved the right zygomatic bone and lateral wall of the right orbit. The lesion had a heterogeneous matrix with soft tissue density. It had resulted in cortical thinning with discontinuity of the cortex at multiple sites []. There was displacement of the lateral rectus muscle medially and compression of the right eyeball. The rest of the orbital structures were normal.
A complete haemogram, chest radiograph, and ultrasonography of the abdomen revealed no abnormal findings. Fine needle aspiration cytology (FNAC) of the lesion showed few clusters of pleomorphic round cells with mostly round nuclei, irregular nuclear chromatin, and nucleolus at places. Cells showed scanty amount of cytoplasm with nuclear pleomorphism []. The overall impression was suggestive of round cell malignancy.
Considering the size of the lesion and to avoid repeated surgical trauma, the surgeons decided to excise the lesion with wide surgical margins without performing incisional biopsy. The gross specimen was of size 5 × 4 × 3 cm, irregular in shape and reddish-white in colo

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


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

[User]
RADIOLOGY NOTE:
We present the case of a 28-year-old male who suffered a high-energy motorcycle accident. At admission, the patient was conscious, Glasgow coma scale (GCS) 15, hemodynamically stable, and presenting superficial excoriations on the trunk and lower limbs. However, there was a wound of approximately 20 cm on the lateral aspect of the right hip at the level of the greater trochanter, exposing the entire proximal end of the femur (Figure ).
After a clinical evaluation and imaging tests that excluded cranial or abdominal disorders, we prioritized the neurovascular examination of the affected limb, which did not present complications, and the protection of the femoral head with the use of moistened gauze and saline solution. Radiographs in the anteroposterior view of the right hip showed a hip dislocation with a greater trochanter fracture (Figure ).
An exhaustive irrigation of the acetabular cavity and the exposed femur was performed, using 10 liters of saline solution at 9% when the patient was in the surgical room. The procedure happened under sedation and spinal anesthesia. A large debridement of muscle, fascia, and bone tissues was required to remove all the devitalized tissue, considered viable only when active bleeding and the clean appearance of the open wound was observed through direct vision by the surgeons.
The fractured fragment of the greater trochanter was fixed with two 6.5 mm cancellous screws and washers at the proximal end of the femur (Figure ). After a revision of the debridement sites and radioscopic control of the hip reduction and fixation, the wound was closed (Figure ).
After the first 48 hours of surgery, the wound was releasing a significant amount of secretion, bloody and serum like, and a strong odor was observed, with no laboratory exams indicating infection. At this time, a new surgical procedure (second look) with greater aggressiveness was obtained, removing all devitalized tissue and bad-in-appearance cutaneous cover

[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 85-year-old woman was referred to our institution because of inferior ST-segment elevation myocardial infarction (STEMI) with a moderate troponin peak of 10.88 μg/L (N < 0.04 μg/L). Angiographic data showed a two-vessel coronary artery disease with a proximal occlusion of the right coronary artery (RCA) and a complex highly calcified bifurcation stenosis involving the left anterior descending artery (LAD segment 2) and the ostium of the second diagonal branch. The patient underwent angioplasty of the infarct-related RCA. Decision was made to refer the patient within a month to our cath lab for secondary treatment of the LAD bifurcation lesion. The discharge TTE disclosed inferior wall akinesia, small basal inferior aneurysm, and normal left ventricular ejection fraction (LVEF). The patient was readmitted 17 days after discharge due to recurrent acute anterior STEMI and cardiogenic shock (severe left ventricular (LV) dysfunction with LVEF of 25% at the time of admission in the cath lab).
Urgent coronary angiography was performed 4 h after symptoms onset and showed a complete occlusion of the proximal LAD, well above the bifurcation lesion. Percutaneous coronary intervention with stenting of the culprit lesion was performed, but revascularization of the bifurcation lesion was considered too high risk. Transthoracic echocardiography disclosed a large defect (8.5 mm) of the basal inferior wall (Figure ), with extension in to a pseudoaneurysm. A colour Doppler analysis (Figure ) showed shunt flows passing from the LV to the aneurysmal pouch.
2D and 3D maximum intensity projection (MIP) multiphasic cardiac CT images provided a non-invasive modality for the evaluation of the pseudoaneurysm. It helped to define the anatomy, size, course, relationship of the pseudoaneurysm and determine further therapeutic strategies. Cardiac CT revealed a giant pseudoaneurysm (31 × 47 mm) running the length of the right ventricle (Figure ). The final diagnosis was cardiogenic shock relat

[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 March 2020, a 76-year-old woman with a past medical history of MBD from breast cancer presented to the emergency department of our hospital with a spontaneous left femur fracture. The breast cancer was diagnosed in 1985 and treated with partial mastectomy, chemotherapy and hormonotherapy with Tamoxifen for five years. In 1997 the patient underwent total mastectomy due to local recurrence of the cancer and she was administered chemotherapy and hormonotherapy with Tamoxifen for another five years. Bone metastases were found in January 2012 and she received zoledronic acid (4 mg monthly) until April 2015 when she presented acute renal failure. She continued receiving zoledronic acid in lower dose (5 mg every two months) until October 2018 when BPs were switched to denosumab in oncologic dose (120 mg monthly) due to MBD recurrence. She received eleven doses of denosumab until September 2019 when she underwent hysterectomy with the suspicion of endometrial cancer. Although the histopathology was negative, she presented serious wound infection. Additionally, the patient was suffered from diabetes mellitus and psoriatic arthritis.
Upon her arrival at the emergency department, she reported that was experienced continuous pain in her left thigh, for a period of eight months. Although an initial frontal radiograph of the left hip showed localized thickening of the lateral cortex in the subtrochanteric region of the left femur, the examination was misinterpreted as normal (). Moreover, bone scan obtained in November 2019, two months since the patient discontinued denosumab, showed increased tracer uptake at the subtrochanteric area, while the previous bone scan obtained in July 2018 was negative ().
The recent serial hip radiographs revealed a complete non-comminuted transverse subtrochanteric fracture at the left femur with focal lateral cortical thickening and a small medial spike (), while radiographs at the contralateral femur were negative. At the time of fracture, 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.