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

[User]
RADIOLOGY NOTE:
The first case is a 10-year-old girl who was referred to the oral radiology department of the dental school of Mashhad university because of a bony hard swelling in the buccal vestibule of the anterior region of the mandible. Clinically, the overlying mucosa of the lesion was intact and there was pain and tenderness. Except for three of the teeth, no reaction was obtained with an electrical pulp tester in the involved teeth within the lesion, but the teeth turned to be vital at follow-up.
According to the statement of the patient’s parents, the swelling started developing from approximately 4 months ago and in the last 2 months its growth caused asymmetry in the left side of the chin. In the panoramic radiograph (ProMax; (Courtesy Planmeca Inc., Roselle, lL)), a well-defined radiolucent lesion extending from posterior to the mandibular right first molar to the distal aspect of the left first premolar was evident.
The scallop outline in the superior border of the lesion and displacement of the right lateral and second premolar were evident. Lamina dura of some of the teeth was totally or partly destroyed. The internal structure of the lesion on panoramic view was as multilocular appearance that included wispy, ill-defined trabeculae and in some areas of the lesion there was evidence of fine, straight septa making a tennis racket-like or step-ladder like pattern (). On occlusal projection, some of the trabeculae were at right angles to the periphery. In addition, the occlusal view revealed a considerable expansion of the buccal and especially lingual cortical plates (). The differential diagnosis included central giant cell granuloma, aneurysmal bone cyst and odontogenic tumors (probably mural or unicystic ameloblastoma and odontogenic myxoma). The patient was operated after 30 days. During the operation an empty cavity without epithelial lining was exposed. Simple bone cyst was the diagnosis in surgical observation

[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 girl who was diagnosed with acute lymphoblastic leukemia and had been receiving maintenance chemotherapy was admitted to hospital with left knee pain and swelling. She had been on chemotherapy for two years. Her maintenance chemotherapy regimen consisted of dexamethasone, mercaptopurine and methotrexate. An initial evaluation revealed the presence of swelling, tenderness and reduced motion of the right knee joint because of pain. She was afebrile and did not have hepatosplenomegaly or lymphadenopathy. Her white blood cell count was 0,6×109/l, absolute neutrophil count was 0,3×109/l. Erythrocyte sedimentation rate was 82 mm/hour. Joint MRI revealed findings consistent with nonspecific severe inflammation of synovia (). We stopped her maintenance chemotherapy and performed bone marrow aspiration to see if it was a relapse of leukemia and its bone involvement, but bone marrow was completely in remission. After the consultation with the orthopedia department we decided to perform biopsy from the joint and bone. Biopsy was performed from distal femur and synovia. Surgical debridement of the joint was also performed at the same time.
Bone and synovium specimens examined in the pathology department were consistent with chronic granulomatous Aspergillus synovitis but no speciation was performed. Voriconazole was initiated immediately with a loading dose of 6 mg/kg intravenous every 12 h for two doses and because she was a pediatric patient we decided to follow by 6 mg/kg every 12 h. We also assessed our patient for other organ involvements for invasive aspergillosis but there were no other sites of infection evident on physical examination. A high resolution computed tomography (HRCT) was done to search for a pulmonary source of Aspergillus but it was normal. Hemocultures were negative. Galactomannan test was studied twice a week just after the diagnosis and tests results were negative. We could not find any evidence for a source which could cause a hematogenou

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


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

[User]
RADIOLOGY NOTE:
An 18-year-old unmarried young Asian female came through the emergency department (ER) with a history of hematemesis for last twenty-four hours. The patient reported that this was the third episode of hematemesis in one day. She was managed in ER for non-variceal upper gastrointestinal bleeding (UGIB) with fluid support and urgent transamine injections. Her blood pressure was 100/60mm Hg and pulse were 100 per minute. After stabilization, she was transferred to the inpatient ward for further investigation and management.
On examination, the patient was in acute distress due to her recurrent bleeding episode. She had elicited tenderness on palpation in right upper quadrant (RUQ) and left lower quadrant (LLQ) of her abdomen. Rest of the physical examination is unremarkable. Her weight was 45kg and height was 162.5cm. She had never been to school and her education took place at home by her family.
Previously, she had severe headaches with 8/10 in intensity for three months. She had a computerized tomography (CT) scan done two months ago for her headache in a different hospital where she was admitted due to her complaints of a headache and blurry vision. She further claimed that CT scan showed the blood clot in her head and she was taking a blood thinner (unknown anti-platelet agent) for it. The patient was unable to present the reports when a physician asked for it. She took a blood thinner which was available over the counter (OTC).
According to her, she had first episode of bleeding from the ear when she was two years old. She never had any bleeding episode afterward. She had menarche at an age of thirteen years and she had regular menstruation and reported the use of one pad per day for four days every month. For last three months, she had menometrorrhagia and she also had watery discharge along with it. Complete work up

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


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

[User]
RADIOLOGY NOTE:
A 16-year-old male with a history of synovial sarcoma of the right posteromedial knee undergoing induction chemotherapy presented with a one-day history of left upper quadrant abdominal pain and fever. Pain was not associated with eating, stooling, nausea, or vomiting and was only minimally relieved with oxycodone 5 mg. Physical examination revealed left upper quadrant tenderness, however, no guarding or rigidity. There were no other localizing signs of infection. The patient had his port accessed for labs recently, placing him at risk for bacteremia. Initial laboratory workup revealed a white blood cell count of 21 500, C-reactive protein (CRP) of 3.01, and a normal lactate. Blood cultures and urine culture were also obtained prior to antibiotic initiation. He was hospitalized and started on cefepime. Abdominal tenderness was attributed to constipation due to recent history of hard stools and was treated with a bowel regimen.
After three days of therapy, fever and abdominal pain persisted with a rising white cell count to 38 800 and CRP of 29.86. Blood cultures (including fungal culture) and urine culture showed no growth. Antibiotic coverage was expanded to include vancomycin. Abdominal CT was performed due to concern for an abscess, which revealed moderate retained fecal material, asymmetric thickening and edema of the left lateral abdominal wall musculature, reflecting myositis, and mild splenomegaly, however, no intra-abdominal abscess. He also developed 2-3 cm, tender, blanching erythematous patches on his abdomen and upper right arm (Figure ). Workup was initiated for septic emboli and was negative. New lesions continued to erupt, with expanding size of previous lesions. This included a large plaque on the left abdomen/flank where his previous abdominal pain was located. Further history revealed that a similar lesion occurred on his left chest wall after his second cycle of chemotherapy during an admission for febrile illness and resolved after discharge (Fig

[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 75-year-old woman had a large blue patch on the right shin for 3 years. She underwent a left total knee replacement 18 years ago and a right total knee replacement 14 years ago due to severe osteoarthritis of both knees. Each of the operations was carried out successfully without any serious adverse events. Eleven years after the right total knee replacement, she noticed a discoloration of her right shin, and the lesion continued to enlarge slowly over time. She was referred to a dermatology clinic where a large, well-demarcated bluish-gray patch was noted on her right shin. The surface of the skin was smooth with no palpable infiltration. For 1 year, she experienced pain when walking on the right shin. She had a 10×15 cm well-demarcated bluish-gray patch on the extensor surface of her right shin (). Routine laboratory tests, including complete blood count, liver function tests and urine analysis, yielded normal findings. Histopathologic findings from the skin lesion showed perivascular, fine black particles in the dermis (). The black particles were stained positive with both melanin and demelanin stains. Polarizing microscopy of the skin specimen revealed refractile foreign materials in the perivascular area of the dermis (). Further, energy-dispersive X-ray spectrophotometry revealed the presence of titanium and aluminium (). Metallic discoloration was diagnosed on the basis of clinical, histopathological, polarizing microscopy and energy dispersive X-ray spectrophotometer findings. The radiographs revealed loosened and dislocated tibial components of the right knee prostheses. Preoperative and intraoperative cultures were negative for bacteria. During surgical revision, marked loosening of the tibial component and wearing of polyethylene were found. Additionally, an intense black staining of a substantial amount of wear debris adjacent to the tibial components and tibial bone defect was observed (). The patient was treated by debridement, and the right tibial

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


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

[User]
RADIOLOGY NOTE:
A 55-year-old man presented to the emergency room complaining of lower back pain. He had a one-week history of pain in the left hip associated with difficulty in walking. He reported acute pain from the onset that progressed within a few days. The initial trauma to the left hip occurred ten years prior and caused AVN of both hips. He received native medical treatment at that time and was deferred for surgery. No other comorbidities or radiographic evidence of previous trauma was obtained during the visit.
The patient reported successful mobilization and discharge following therapy after the initial trauma, and since then, he had resumed daily activities. At approximately ten months following the initial injury, he returned to a local emergency department with vague complaints of lower back pain. After an unremarkable workup, he was prescribed analgesics and discharged.
At the presentation to our emergency department, his back pain was progressively increasing, and motor deficits in the lower limbs accompanied the acute onset of worsening pain. The patient appeared moderately built and nourished. The physical examination revealed apparent shortening of the left hip and pain during a range of movements. Distal pulses were found in both lower limbs.
A lumbosacral spinal radiograph (lateral view) revealed loss of normal lumbar curvature and collapse of multiple vertebral bodies accompanied by a reduction in vertebral body height. Degenerative changes in the left hip joint along with a reduction in the left acetabular femoral joint space were also observed on the X-ray (Figure ).
A lateral radiograph of the lumbosacral spine showed compression wedge fractures at the L1, L2, L3, and L4 levels (Figure ). Computed tomography of the spine revealed the collapse of multiple vertebrae and a marked reduction in the vertebral body height accompanied by a linear intraosseous cleft in the L2 intervertebral disc (Figure ).
An extensive workup was done to exclude malignancy and infec

[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 72-year old man, previously well, was admitted to a regional hospital with fever, recurrent bloody sputum, weight loss and left sided chest pain of 4 weeks duration. A chest radiograph showed a mass at the left hilum thought to be a neoplasm (see figure ). A misdiagnosis of haematemesis led to an upper gastrointestinal endoscopy showing oesophagitis. He developed respiratory failure requiring ventilation. A subsequent bronchoscopy excluded a central bronchial tumour, confirmed by histopathologic examination of biopsies. He was transferred to a specialist centre where a CT and MRT scans of the thorax showed the mass to be infiltrating the left upper lobe and was suspicious for an aneurysm of a coronary artery (see figure ). Transthoracic echocardiography and MRI confirmed this impression and he proceeded to coronary angiography, which demonstrated a giant aneurysm from the LAD (figure ). He developed cardiovascular instability and proceeded emergently to surgery.
The procedure was performed using right atrial to aortic cardiopulmonary bypass via median sternotomy and opening of the anterior pericardium. The aneurysm was adherent to the left anterolateral pericardial aspect and was not disturbed until cardioplegic arrest was achieved, to avoid distal embolization in a beating heart. After achieving myocardial arrest the dissection was completed, revealing the aneurysm to have entry and exit openings into the proximal and mid LAD (see figure ), and there was compression of the left upper lobe with airway inflammation rather than invasion. The adherent pericardium was removed together with the aneurysm and a large quantity of thrombus, leaving a significant pericardial defect requiring Supple-Guard patch closure. The proximal and distal communications from the LAD to aneurysm were closed. A single end-to-side vein graft was performed in the mid LAD distal to the aneurysm (see figure ). After reperfusion and rewarming cardiopulmonary bypass was weaned without difficult

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


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

[User]
RADIOLOGY NOTE:
A 48-year-old heterosexual African man presented as an emergency with a progressive disabling anal pain for three days on a background one-year history of a chronic anal ulcer. He has not been on highly active antiretroviral therapy (HAART) since being diagnosed human immunodeficiency virus (HIV 2)-positive 11 years ago. The exquisite anal pain was constant, exacerbated by bowel motions and not relieved by opiate analgesia. There was no altered bowel habit but the fear of defaecation made him constipated and exacerbated the symptoms. There was no anal discharge or rectal bleeding on defaecation. He had no fever, night sweats, or anorexia but had lost weight significantly. He has a long history of severe anal pruritus which he believes precipitated the anal ulcer. Physical examination revealed a wasted man in great anal distress but with normal vital signs. Chest, cardiovascular and abdominal examinations were unremarkable. There was no soilage on inspection of the perineum and underclothes but perianal examination revealed excoriation and ichthycosis indicating long-standing pruritus. There was superficial scarring with macular patches from probable chronic herpetic simplex lesions. There was no characteristic visible posterior anal fissure or reactive perianal skin tag. A digital rectal examination was not done because of severe anal pain and spasm. He consented to examination under anaesthesia and appropriate surgical treatment. His haemoglobin level was 9 g/L but white blood cell and CD4 counts were not available. Under general anaesthesia, in the lithotomy position a digital rectal examination revealed a posterior broad based anal ulcer. Proctoscopy showed the ulcer commencing above the dentate line in the lower rectum and ending below at the anoderm just distal to the internal anal sphincter. It was associated with an induration over a swelling which expressed copious pus and faeces on pressure into the intersphincteric space. There was no external opening into

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


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

[User]
RADIOLOGY NOTE:
A 33-year-old female was presented to our out-patient clinic with a history of left hemifacial spasm for 5 years. Her past medical history was unremarkable. The patient underwent microvascular decompression in 2010 at our medical center ().
Intra-operatively, bilateral facial electromyography and brain stem auditory evoked potential was monitored. After the dura incision, gentle retraction of the cerebellum was applied using Greenburg retractor and we have exposed the lower cranial nerves. Dissection of the arachnoid was done from the rostral border of the lower cranial nerves. The arachnoid band was very tough and difficult to dissect, but no obvious injury occurred to the lower cranial nerve during the dissection. The left anterior inferior cerebellar artery was the offending vessel compressing the facial nerve from the caudal side and decompression was successfully completed without any adverse events and with no change in the intraoperative monitoring of brainstem auditory evoked potential. Patient recovered well from anesthesia with reduced facial spasm, compared to the pre-operative state. Postoperatively, neurologic exam revealed no abnormalities and also patient's swallowing and vocalization function was intact. Immediate postoperative brain CT scan performed on postoperative day showed no sign of hemorrhage.
On postoperative 5th day, the patient started to exhibit hoarsness with swallowing difficulty. Barium swallowing test was done to evaluate dysphagia, and minimal nasal regurgitation was demonstrated due to unilateral soft palate palsy. On endoscopic exam, performed by an otolaryngologist, the vocal cord was intact in both sides with unilateral left soft palate palsy, which suggested tensor and/or levator veli palatini muscle weakness (). Under the impression of possible lower cranial nerve palsy caused by postoperative edema of the nerve, steroid (prednisolone) was prescribed and we decided to observe the symptoms. Symptoms persisted with slight improve

[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 63-year-old white male presented at the Emergency Department (ED) with abdominal pain and nausea. Detailed medical history revealed that the patient had suffered from loss of appetite, upper abdominal pain, and fever for two weeks. Apart from mentioned, the patient was previously in good general health and without any chronic therapy.
Initial physical examination at the ED showed an enlarged liver and jaundice. Laboratory tests indicated leucocytosis, increased creatinine and urea levels, elevated liver enzymes and hyperbilirubinaemia with cholestatic pattern, and impaired blood coagulation tests ( and , time point: pre-ICU). Radiology investigation included chest X-ray (CXR) and abdominal ultrasound, followed by computed tomography of thorax and abdomen. CXR was within normal limits and excluded acute inflammation or infiltration of the lungs. Abdominal ultrasound showed an enlarged spleen and liver, the latter without focal lesions or dilation of intra- or extrahepatic bile ducts and gall bladder of normal size and wall thickness. Moreover, a retroperitoneal mass of undetermined characteristics was visualized in close proximity to the left kidney, measuring 7 cm in diameter. In the right kidney, a parenchymal cyst was detected, measuring 4.5 cm in diameter. The remainder of the ultrasound examination was within normal limits. Subsequent computed tomography (CT) enhanced with orally administered diatriazoate meglumine and diatrizoate sodium solution revealed a retroperitoneal mass with complete infiltration of both iliopsoas muscles and posteromedial portions of both kidneys, separate mass in the ventral portion of the left kidney and enlarged liver and spleen (). No signs of urinary tract dilation were visible. Liver measured 25 cm in craniocaudal diameter and, despite cholestatic pattern in laboratory investigations, showed no signs of obstruction or dilatation in the biliary tract. Spleen measured 15.3 cm and had an infarction zone. Simultaneously with these d

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


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

[User]
RADIOLOGY NOTE:
A 64-year-old female who had hypertension was admitted with a growing asymptomatic mediastinal mass that was detected incidentally through a medical checkup. The mass had increased in size and appeared to be about twice as large as it had been 2 years earlier according to the chest radiographs. Chest radiography showed a round mass in the middle mediastinum abutting with the left cardiac border (). The blood pressure was 125/79 mmHg and the heart rate was 80 beats/min without any cardiac murmurs and with clear breathing sounds. Laboratory tests including a complete blood cell count, electrolytes, chemicals, and coagulation tests were unremarkable. Her electrocardiography showed a normal sinus rhythm. On 2-dimensional echocardiography, the large cystic mediastinal mass (5.0×4.7 cm) was adjacent to the main pulmonary artery. Computed tomography (CT) showed a 5-cm well defined homogenous enhancing mass attached to the anterolateral wall of the left ventricle and mildly compressing the main pulmonary artery (). Although the left anterior descending coronary artery was displaced posteriorly by the mass, the reconstructed CT image revealed that it had no significant narrowing (). Magnetic resonance imaging (MRI) showed a mildly enhancing cystic lesion with heterogeneous signal intensity on tumor 1 (T1), and tumor 2 (T2) images suggesting the possibility of a neurogenic tumor such as schwannoma with hemorrhagic degeneration ().
A median sternotomy was used and we could see the mass was attached to the epicardium of the right ventricle after pericardiotomy (). Dissection of the mass was difficult because of severe adhesion and proximity to the left anterior descending coronary artery. We decided to apply cardiopulmonary bypass because of a risk of perforation of the right ventricle. The ascending aorta and single right atrial cannulation was used. Except for the right ventricular adhesion, excision of the mass along the layer was simple. The cyst was connected to the epicar

[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 man presented himself with the left hip pain with nocturnal exacerbation and difficulty in walking of 6-month duration. On physical exam, a firm painful mass was palpable in the posterior part of the left iliac wing. The tumor was fixed in relation to the adjacent structures. Also, the pain was exacerbated by the motion and prolonged orthostatism. Laboratory testing showed elevated levels of erythrocyte sedimentation rate and alkaline phosphatase. The lung X-ray exam was normal. The pelvis X-ray showed a highly destructive osteolytic zone in iliac crest above the acetabulum, close to the sacroiliac joint (). The CT scan showed the same lytic lesion measuring 5/3.8/4 cm with no invasion in periarticular areas. The decision was to perform first an open biopsy of tumoral mass. The result confirms that the tumor was a high-grade fibrosarcoma of the iliac bone. Based on the biopsy result and imaging testing, the lesion was staged as II B sarcoma, according to the Enneking classification of bone tumor.
Next, a type I pelvic resection was performed as a radical resection of tumor followed by a biological reconstruction of iliac wing using frozen allograft. The iliac allograft was fixed in place using 4 screws ().
Adjuvant chemotherapy was needed in 6 stages using doxolem, cyclofosfamide, and methotrexate. No neoadjuvant chemotherapy was used. The immediate postoperative period was complicated with local sepsis of reconstructed site treated with pediculate omentoplasty. After 1 year from surgery, the X-ray exam showed an integrated allograft. The walking was possible without crutches, and the patient returned to normal activity. The partial resorption of the graft was observed in the unloaded area (). Still, the pelvic ring was closed.
The hip was free of pain, and a shortening of 2 cm was assessed. The imaging studies showed no recurrence of the disease. After 20 years from the first surgery, the patient presented with the left hip

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


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

[User]
RADIOLOGY NOTE:
A 68-year-old Japanese man underwent resection of a leiomyosarcoma at the mediastinum. Dissemination in the pleura was observed, and thus radiation therapy (total dose: 40 Gy) and a second operation were performed. Pain and numbness of the left upper limb developed 10 months after the second operation and contrast enhanced CT scan was performed. Contrast enhanced CT scan showed a tumor at the apex of the left lung, accompanied by an enhanced solid lesion and a non-enhanced cystic lesion (Figure ). The development of pain and numbness was observed at the lateral side of left antebrachium, digitus medius and anularis. The patients had the motor function disorder of left arm that he could not have or hold by left arm. RFA was chosen because it was thought that radiation and chemotherapy would not be effective and that surgery has a high risk of bleeding.RFA was performed with patient consent. A LeVeen electrode was inserted in the tumor with CT guidance and retractable hooks were opened (Figures , ). The electrode was mostly located in the center of the tumor and it was confirmed that the electrode and plexus brachialis were fully separated on CT in order to avoid the damage of plexus brachialis by ablation. This procedure was performed under local anesthesia to monitor the appearance of sharp pain of left upper limb. The output was started at 20 W, and then increased by 10 W every 2 minutes. In each session, ablation continued until “roll off” and maximum ablation time was decided 20 minutes when “roll off” was not obtained. Ablation was interrupted if a sharp pain of left upper limb appeared. Ablation was performed three times. The output was started at 20 W, and then increased by 10 W every 2 minutes. Total ablation time was 57 minutes and 14 seconds, and maximum output was 80 W. “Roll-off” was obtained only in the third session of ablation.Contrast

[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 female with insignificant past medico surgical history presented with one day of acute onset pain in the periumbilical region that later migrated and confined to the RIF. She had associated intermittent fever, nausea, and loss of appetite. She did not have any urinary symptoms, bowel irregularities, or gynecological complaints. Abdominal examination was performed by two senior surgeons at two different occasions; the same day had findings of guarding and rebound tenderness at RIF. Hematological tests showed polymorphonuclear leukocytosis with left shift. Biochemical tests and urinalysis were normal. Urinary pregnancy test was negative. Abdominal radiographs were unremarkable. USG could not visualize appendix and was inconclusive except for probe tenderness in RIF. CT scan of the abdomen could not be done due to unavailability. A clinical diagnosis of acute appendicitis was made assigning an Alvarado score of 9/10. Laparotomy was performed using the Lanz incision in RIF. Intraoperatively appendix was found to be normal without evidence of inflammation or infection in RIF. In view of symptoms and signs, a possibility of other pathology was thought. Walking the bowel proximally up to 3 feet (1 m) did not show a Meckel's diverticulum or any other small bowel lesions. There were no obvious mesenteric lymph nodal enlargement and pelvic organs looked pristine. Approaching closure, just when the medial edge of the incision was retracted superomedially, a hemorrhagic lesion seemed to appear little deeper in the mid abdomen. Therefore, the incision was extended transversely from the medial edge to explore further. Entire bowel was explored and this revealed an ulcerated lesion measuring 7 × 5 cm arising from the antimesenteric border of the ileum 8 feet (2.5 m) from ICJ with localized interloop hemoperitoneum and inflammatory exudates as shown in . Resection of ileal segment containing the lesion was performed followed by restoration of bowel continuity and peri

[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 75 year old lady, felt excruciating pain on her right heel cord when she half -stepped on a pavement, over-flexing her right foot in an attempt to avoid a car. She was put in a back slab by her primary care physician and referred to our hospital where she presented 24 hours after the incident. On examination, there was swelling and bruising on the back side of the heel, but no skin blistering. Her right ankle plantar flexion power was markedly diminished. No ankle plantar flexion was demonstrated upon squeeze of her right calf. A bone fragment was palpable just under the skin above the heel bump. X-rays confirmed an avulsion fracture of the heel at the insertion of the Achilles tendon Fig. (). Urgent operative treatment was the only option for this displaced (type 2) fracture of the calcaneal tuberosity, in order to restore continuity of the gastrosoleus complex and avoid skin necrosis due to pressure by the displaced fragment. The patient’s past medical history was significant only for hypertension and hyperlipidemia.
Under general anesthesia, with the patient in a prone position and using a pneumatic tourniquet, the fracture was approached through a posteromedial lazy J incision, made with the longitudinal limb at the midline between the medial border of Achilles tendon and the posteromedial border of the distal tibia. The investing fascia was incised open, to expose the Achilles tendon and the avulsed bone fragment. The hematoma around the fracture was cleared, the calcaneal fracture was reduced and the bone fragment was fixed with a cancellous screw and a suture anchor, because the shape and thinness of the avulsed fragment did not allow the placement of a second screw. Satisfactory reduction of the fracture was achieved and the wound was closed in layers. Skin closure was performed with nylon sutures. Postoperative x-rays demonstrated adequate reduction of the fracture (Fig. ).
Postoperatively

[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 Caucasian male with a past medical history of mild degenerative joint disease presented to his primary physician with pain and swelling of the left knee without any history of recent injury. He did not have any history of alcohol abuse but noted history of dental abscess that was treated with root canal procedure approximately 4 months prior to the initial presentation. On physical examination, he had left knee joint effusion and about 35 ml of clear joint fluid was aspirated. Unfortunately, joint fluid was not sent for analysis or culture. Patient was diagnosed with possible degenerative arthritis with effusion and intra-articular steroid injection was given to reduce inflammation and alleviate pain. After a few days, patient presented with recurrence of left knee pain and progressive swelling in the left calf along with intermittent chills. On examination, he had left knee effusion, probable popliteal cyst along with erythema, tenderness, and induration in the calf region. Ultrasound noted a 6 × 2 × 3 cm complex fluid collection along the posteromedial aspect of left knee, suggestive of popliteal cyst with debris or hemorrhage. Magnetic resonance imaging (MRI) of his left knee confirmed the ultrasound findings and showed large radial tear through medial meniscus body, anterior cruciate ligament tear. Patient underwent left knee arthroscopy with partial medial meniscectomy, chondroplasty, and subtotal synovectomy. Intraoperatively, the joint fluid was noted to be cloudy but both aerobic and anaerobic cultures of joint fluid were negative.
About 6 weeks after the arthroscopic procedure, patient developed fever with recurrence of pain and swelling in left knee while he was on vacation. He declined any surgical intervention at the time and was prescribed oral amoxicillin-clavulanate 875–125 mg twice daily. Upon his return, he was evaluated in the orthopedic surgery clinic and was noted to have a large, firm, indurated subcutaneous mass measuring about 5-

[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 woman was admitted with complaints of fever, weight loss, decreased appetite, swelling in the left submandibular region, and painful swelling of the left breast. She was a known case of SLE who was on regular follow-up with the rheumatology department for the last 13 years and had her disease under control with prednisone, hydroxychloroquine, and azathioprine. On examination she was emaciated, with a body mass index of 16. She had mild pallor. There was an indurated swelling, consistent with matted lymph nodes, in the left submandibular region. The scar of a previous biopsy (performed 6 years back at another hospital) was present and the patient reported that she had received antituberculous medication for 1 month at that time. Two 1 × 1.5 cm lymph nodes were present in the left axillary region. The left breast revealed multiple lumps, the biggest being 4 × 3 cm in size. Cardiac examination revealed muffled heart sounds. A palpable liver was detected on abdominal examination. Complete blood count showed normochromic normocytic anemia and leucopenia. Serum chemistry was normal, except for a low albumin level of 2.6 gm/dl and mild elevation of transaminases. The ESR was 115 mm and the serum ferritin level was > 2000 μg/dl. A septic screen was negative, as was the Mantoux test. A plain radiograph of the chest showed cardiomegaly and diffuse calcifications in the region of the breast []. Echocardiography revealed mild pericardial effusion and an ejection fraction of 20%. CT scans of the chest and abdomen were performed and showed mild pericardial effusion and unusual calcifications in the breasts []. CT scan also ruled out any abdominal or mediastinal lymphadenopathy. A biopsy of the submandibular swelling showed features consistent with panniculitis.
In view of the constitutional symptoms, marked emaciation, past history of inadequate treatment for tuberculous lymphadenitis, and the breast swelling, we considered the possibilities of tuberculosis, lymphom

[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 report presents a 29-year-old G1P0 patient who presented to the obstetrics emergency room with severe abdominal pain of the left lower quadrant with signs of acute abdomen and knowledge of a 7 weeks’ intrauterine pregnancy. The patient was evaluated by the obstetric team upon arrival and her heart rate was 99 bpm, and blood pressure was 90/50 mm Hg. A transvaginal ultrasound was performed, which revealed a 7 weeks and 2 days estimated gestational age intrauterine pregnancy with fetal cardiac activity and was considered viable. Both of the patient’s fallopian tubes were dilated and showed evidence of a hydropic fallopian tube, which was evaluated as evidence of former pelvic inflammatory disease. Additionally, a 10.8-cm ectopic pregnancy was positioned on the left side with cardiac activity with an estimated gestational age of 7 weeks and 1 day. Blood products and abdominal free fluid were also detected. At the time, the patient’s hemoglobin and hematocrit levels were 12.2 g/dL and 35.4% respectively, and the other initial blood parameters checked were within the normal range (, ).
The patient’s condition was stabilized with a saline infusion and informed about her clinical condition. The patient expressed a desire to preserve the intrauterine pregnancy. Under close monitoring, the patient was admitted to the gynecology department and was given full information about her condition including the risk of miscarriage and more extensive surgery. After giving consent for the recommended surgery, the patient was taken to the operating room.
The patient was placed in the lithotomy position under general anesthesia. Following the sterile covering of the area, posterior colpotomy was used to enter the abdomen. Approximately 200 cc of blood containing clots was drained. The right and left ovary and right fallopian tube were observed in normal anatomic position and nature. The left tube was visualized, which had an approximately 5 cm ectopic mass with active bleeding. Afte

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


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

[User]
RADIOLOGY NOTE:
An 18 year old male fell from roof of a moving truck. The truck was moving at low speed and he fell on muddy floor from a height of approximately 12 feet and sustained impact over abdomen. He was admitted in Nepalgunj medical college where contrast enhanced computed tomography of abdomen showed grade III liver injury. He was managed conservatively with bed rest, 12 units of blood transfusion then discharged. He presented 15 days later to Alka Hospital emergency department with complaints of pain abdomen, excessive tiredness and vomiting of blood. His vitals in the emergency were pulse 100/min, blood pressure 90/60 mmHg, respiratory rate 20/min and temperature 99 degree F. Contrast enhanced computed tomography of abdomen was done which showed pseudoaneurysm of right hepatic artery with ruptured hematoma in segments VI, VII and VIII of liver (Figs. and ). Clot was present in the pelvis and lesser sac. Haemoglobin was 8 g/dL.
Patient was immediately transferred to intensive care unit and started on intravenous fluid, antibiotics. Blood transfusion was started but the patient became hemodynamically unstable. Patient was transferred to operation theatre and exploratory laparotomy was done. Intraoperative finding was approximately three litres of clot and blood in lesser sac and pelvis with approximately 5 cm laceration in segments VII and VIII of liver. Bleeding from the liver surface was controlled with gel foam packing, surgicell application. Drains were kept in Morrison’s pouch and pelvis. Five units of packed cell and two units of fresh frozen plasma was transfused intraoperatively. The pseudoaneurysm couldn’t be clipped intraoperatively due to the difficult location and hemodynamic instability of the patient. Postoperatively patient was transferred to intensive care unit. Patient was transfused with two units of blood postoperatively. Patient was transferred to the general ward on third postoperative day. Patient was discharged on eighth postoperative day.
On the 15

[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 4-year-old boy was brought to the Emergency Department (ED) from a rural area with complaints of fever, headache, and weight loss. He was suffering from these symptoms for the past 4 months, which had worsened in the past week. His brother informed that the child had been unwell since infancy with several episodes of respiratory infection and has had several hospital admissions. Recently, he had started complaining of severe persistent diffuse headaches along with nausea, vomiting, and anorexia. He also suffered from low grade fever intermittently over this period of time. Physicians in his locality who had treated him with antibiotic courses for chest infections started him on antituberculosis (ATT) drugs 2 months back after an MRI, which suggested meningeal enhancement and small ring enhancing lesions. He had no history of seizures or loss of consciousness. One of his brother had passed away at the age of 8 years who was considered to suffer from disseminated tuberculosis. On examination, the child was listless, emaciated, and extremely irritable. He had left-sided weakness in both the upper and lower extremities.
An urgent computed tomography (CT) scan of the head showed multiple rings enhancing the left parietooccipital region, with significant surrounding edema and mass effect []. His white blood cell count was 17900/uL, with neutrophils 77.4% and lymphocytes 15.7%. Hemoglobin was 10.9 and erythrocyte sedimentation rate (ESR) was 88 mm/h. We involved pediatric physicians and infectious disease specialists to perform a neuronavigation-guided craniotomy for the excision of these abscesses along with the walls, which contained thick purulent material. Microscopic examination revealed granulomas with fugal hyphae [Figure and ]. Presence of Aspergillus was further confirmed on culture. Postoperatively, he was successfully extubated and shifted to the intensive care unit for postoperative monitoring. His weakness also improved. Considering his chronic cough and rep

[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 43-year-old otherwise healthy housewife reported to a head and neck surgeon with a chief complaint of right nasal obstruction since 1 month. Routine paranasal sinus x-ray showed a dense sclerotic radiopaque mass obliterating the right maxillary sinus with deviated nasal septum. On clinical reevaluation at our primary health care center, a mild facial swelling along with mild proptosis of right eye with no apparent restriction of eye movements or vision was noted. Intraoral examination showed obliteration of the entire right buccal sulcus by a diffuse bony hard mass covered by a normal appearing oral mucosa; 16 (right maxillary first molar) had deep mesial class II carious lesion, with extrusion of 16 and 18 (right maxillary third molar). Grade I painless mobility of 16 and 15 was noted; 46 and 48 (right mandibular first and third molar) were missing with a history of extraction after carious exposure 6–8 years ago. Regional lymph nodes were not palpable. OPG showed dense to mixed sclerotic radiopaque mass of the right maxillary sinus along with widening of the periodontal ligament space of 15–18 []. CT scan showed mixed sclerotic mass involving the right maxilla and nasal cavity with involvement of infraorbital floor, nasal cavity, frontal, sphenoidal, and ethemoidal sinuses and was reported as osteoma of maxilla [].
The patient underwent excision and curettage of the mass through a Fergusons incision under general anesthesia. One single large mass of bone within the maxillary sinus and multiple bits of bony tissue were curetted piecemeal. The inferior orbital floor was involved and was reconstructed using mandibular cortical bone graft to prevent eyeball intrusion into surgical defect.
Given (H and E) sections showed sheets of disorganized woven immature bone and round cells having large vesicular nucleus and scanty cytoplasm []. Focal areas of few bizarre multinucleated giant cells were seen. Few areas of irregular calcified spicules along with many areas of dis

[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 man was referred to our hospital because of a 1-month history of cough. He had smoked one pack of cigarettes per day for the past 20 years. A mass shadow in the hilum of the right lung with an enlarged subcarinal lymph node was found by contrast-enhanced computed tomography (CT) of the chest. A bronchoscopic biopsy yielded the diagnosis of SCC. After metastatic workup with abdominal ultrasonography, magnetic resonance imaging of the brain and bone scan, the patient was staged with T3N1M0 disease. Thereafter he underwent definitive right-middle lobectomy, revealing well- to moderately differentiated SCC and multiple lymph node metastases. He received four cycles of adjuvant chemotherapy comprising taxotere and cisplatin. Five months after his lobectomy, an enlarged mediastinal lymph node was discovered on a routine follow-up chest CT scan. Solitary lymph node recurrence was diagnosed by coincidence circuit single-photon emission CT assessment. The patient then underwent a course of conformal external beam radiation to the mediastinal lymph node at a dosage of 6,000 cGy in 30 fractions. He complained of dysphagia without melena or hematemesis during the fourth week of radiotherapy, which was attributed to radiation esophagitis. However, the patient’s symptoms worsened despite symptomatic treatment. A gastroduodenoscopy performed 10 days after the completion of radiotherapy revealed a giant gastric ulcer in the greater curvature of the stomach with mucosal edema and congestion as well as a huge cauliflower-like mass in the descending part of the duodenum (Figure ). Biopsies of both lesions revealed SCC. On histopathological examination, hematoxylin and eosin–stained sections of gastric and duodenal biopsies revealed typical SCC and large, eosinophilic cells with distinct cell borders growing beneath the normal gastric and duodenal mucosa (Figure ). Keratinization, formation of small horn pearls and malignant squamous cells in capillaries were also observe

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


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

[User]
RADIOLOGY NOTE:
We report a case of A 29-year-old woman living in a rural area and working as a farmer, with no significant pathological history. She was presented to our hospital for right hip pain. A physical examination revealed a right hip pain at mobilisation, with a normal range of motion. Plain X-rays and a Computed tomography of the right hip showed a lytic bone lesion well limited at the level of the upper metaphysis of the right femur without periosteal reaction or a weakening of the cortex ().
The diagnosis of the unicameral bone cyst was retained based on the radiological aspect.
A gamma nail osteosynthesis was performed to prevent the risk of fractures. The surgery had an immediate simple operative sequence, but the patient didn't present to the late follow-up.
Five years later, she was admitted to our hospital for a recurrence of the right hip pain and tumefaction, which is progressively getting worse and restricting the daily activity. The physical examination revealed a tumefaction at the level of the femoral greater trochanter. The right hip joint was painful and stiff. The scar was good, and there were no signs of inflammation of the superficial skin. Conventional radiology showed extensive lysis of the right trochanteric region and the femoral neck. And the loosening of osteosynthesis material ().
Computed tomography (CT) revealed a bone loss in the trochanteric region, cystic lesion of the peri-trochanteric soft tissue, calcified in some places and with an outline delineating it from the surrounding muscles (). Findings were compatible with a hydatid cyst.
So, we decided to remove the osteosynthesis material () and make a bone biopsy.
The biopsy brought membranous elements of white-pearly colour, and microscopic histopathological examinations confirmed the diagnosis of a hydatid cyst.
Magnetic resonance imaging (MRI) was performed to evaluate the local extension. It showed multiple cystic lesions. These cystic lesions were extending from the upper 1/3 of the fem

[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 15th January 2015, a 29-year-old man visited the hospital with a 1-year history of weakened muscle strength of the proximal portion of the left upper extremity. The patient was diagnosed with Hirayama disease 9 years previously in China. He had a muscle weakness in the distal portion of the left upper extremity, while there was no further progression of the muscle weakness afterward. Although he had weakness, it was not bad enough to be functional. Recently, however, he felt that the functionality and power of the proximal upper extremity was falling. He reported no muscle weakness aggravation during winter, pain, dysesthesia, hypoesthesia, or dysuresia. He also had no extraordinary family history.
The physical examination results indicated the following: blood pressure, 120/70 mmHg; pulse, 77/min; height, 170 cm; and weight, 59 kg. Apparent oblique atrophy was observed in the left forearm except for the brachioradialis muscle and in the hand muscle compared to the right side (). Moreover, atrophy was observed in the left biceps and deltoid muscles (). Fasciculation in left hand muscle and irregular tremor of the fingers during finger extension were also observed. Range of motion of the joint was normal, and in an evaluation using the Medical Research Council (MRC) scale for muscle strength, left wrist flexor and extensor muscle strengths and left finger flexor, extensor, and abductor muscle strengths decreased to the 3/5 level, while those of the left elbow flexor and extensor and shoulder abductor decreased to the 4/5 level. The deep tendon reflex was normal, and no pathological reflex was observed.
Magnetic resonance imaging (MRI) of the cervical vertebrae in the neutral position showed loss of normal lordosis in the cervical vertebrae but no spinal cord atrophy. MRI of the cervical vertebrae portion in maximum flexion showed neither clearly anterior shifting of the dural sac nor expansion of the epidural venous plexus behind it.
Nerve conduction study finding

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


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

[User]
RADIOLOGY NOTE:
A 55 year old man was diagnosed with anemia by his family physician towards the end of 2017. In February of 2018, an upper GI endoscopy and colonoscopy were performed which showed a right colon cancer. CEA was 40.4. CT of the chest, abdomen, and pelvis was obtained in February of 2018. This showed a mass 7 cm in greatest diameter that was immediately adjacent to the undersurface of the right liver and contiguous with numerous loops small bowel and the lowest part of the second portion of the duodenum (). There were mildly prominent mesenteric lymph nodes but no evidence of distant metastatic disease.
In February of 2018, the patient underwent a single port laparoscopic right colon resection. The surgeon described the tumor as stuck to the undersurface of the liver with adhesions taken down without difficulty. On histopathologic examination, the tumor was PT3N0M0 with 0/16 positive nodes. Perineural invasion was identified. The cancer was moderately to poorly differentiated. Systemic chemotherapy was not recommended.
In June of 2018, the patient began noting problems with digestion and pain after eating. CEA had increased to 940 ng/ml. Repeat CT scan showed multiple nodules within the greater omentum compatible with peritoneal metastases. The liver, kidneys, and ureters were normal. There was marked stranding within the right colon resection site (). Bowel loops proximal to the prior ileocolic anastomotic site were moderately dilated and fluid-filled. A mass was noted in the abdominal wall at the laparoscopic port site. There was also a mass in the rectovesical space immediately adjacent or invading the right and left seminal vesicles.
In July of 2018, the patient underwent exploratory laparotomy. The posterior surface of the liver was layered by cancer. The undersurface of the right hemidiaphragm was covered by tumor nodules. The pelvis contained a 4 cm tumor mass invading into the seminal vesicles. The old ileocolic anastomosis was involved and needed to be resecte

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


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

[User]
RADIOLOGY NOTE:
We present a case of a 58-year-old, right-handed gentleman with a medical history of Type II diabetes, obstructive sleep apnea, gastroesophageal reflux disease, asthma, gout, anxiety, and depression. He was an ex-smoker with a 40 pack-year smoking history. His oncologic family history was significant for his father dying from bladder cancer.
In the spring of 2014, the patient initially presented to his local emergency room with progressive frontotemporal headaches, a right visual field deficit, decreased appetite, weight loss, and a fall without sustaining traumatic injuries. On a review of systems, no respiratory, genitourinary, or additional neurological symptoms were described aside from increased daytime urinary frequency.
Physical examination revealed an obese gentleman (BMI of 41) with normal vital signs. The patient was alert, oriented to person, place and time, and ambulatory with a normal gait. Cranial nerve exam revealed right visual field deficits. Auscultation of the lungs revealed clear, equal air entry bilaterally without any adventitious sounds appreciated. No masses, organomegaly, or pelvic lymphadenopathy were appreciated on the abdominal exam, but this was limited due to his large body habitus. Digital rectal exam revealed a small, smooth, firm prostate without rectal masses.
A CT and MRI of the head was completed with the latter revealing a heterogeneous mass in the left occipital lobe with solid and cystic components measuring 2.9 cm. There was associated cerebral edema with a 0.2 cm right-sided midline shift and no hydrocephalus identified (Figure ).
The leading differential diagnosis at the time was a primary brain malignancy, and accordingly, referral to neurosurgery at the same tertiary hospital was arranged. The patient subsequently underwent left occipital craniotomy and resection of the mass within five weeks of the initial referral. Pathology returned as metastatic adenocarcinoma, suggestive of a lung primary as it stained positive for cy

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


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

[User]
RADIOLOGY NOTE:
A 41-year-old man was admitted with a 3-day history of severe sore throat and painful swallowing. According to him, it started as a mild sore throat but rapidly worsened despite taking oral penicillin for 3 days from his general practitioner (GP). There was no significant past medical history. On examination, his temperature was 38.3°C and he was tachycardic (102/min). His neck movements were markedly restricted by pain and he had a spiking fever. The skin on the front of his neck was red, hot and tender down to his clavicles, with no evidence of localised swelling or ischaemia/necrosis. Oral examination showed a markedly inflamed right tonsil covered with patchy grey exudate. There was no clinical evidence of peritonsillar abscess. The left tonsil appeared remarkably normal. Flexible nasendoscopy showed normal epiglottis and larynx.
Blood tests revealed leukocytosis of 22.3 × 109 cells/L and a high C-reactive protein (CRP) of 421 mg/L.
A lateral X-ray of his neck showed air and swelling in the pretracheal soft tissues and loss of normal cervical lordosis. These findings prompted an urgent CT scan of his neck and chest, which demonstrated air shadows and diffuse swelling and enhancement of cervical fascia extending from skull base to upper mediastinum. Similar changes were also seen in the pretracheal soft tissue (figures , and ).
Throat swabs and blood cultures were sent for microbiology and intravenous (I.V.) therapy with broad spectrum antibiotics was commenced as it was decided to initially treat the condition medically. Surgical debridement was not carried out at this stage because there was no skin necrosis and no collection was shown by the CT scan.
His general condition showed improvement. His temperature came down and his oral intake improved but over the next 3 days a tender and fluctuant swelling appeared in the suprasternal region with diffuse margins.
A repeat CT scan of the neck and chest

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


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

[User]
RADIOLOGY NOTE:
A 50-year-old male was brought to the emergency department after he jumped from a 5-meter bridge in an attempted suicide and fell on the hard concrete below. Upon admission, the patient was agitated, disoriented, and in intense respiratory distress. Examination revealted that the patient’s airway was clear, but there was a bilateral absence of breath sounds and hyperresonance on percussion. The patient was hemodynamically stable. He was intubated due to respiratory failure. Bilateral chest tubes were inserted based on a high clinical suspicion of pneumothorax. Thereafter, the patient developed a large subcutaneous emphysema, despite the fact that the chest tubes were functioning with his severe air leakage. Past medical history was unremarkable with no previous formal depression diagnosis. A social history check showed daily marijuana and tobacco use.
The patient was sent for a head, neck, thorax, abdomen, and pelvis CT scan. The scan revealed giant bullous emphysema on the superior lobes bilaterally, right pneumothorax with a collapsed lung, along with multiple rib fractures, and lung emphysema (, ). A hip dislocation was detected, and closed reduction was performed.
The patient was sent to the ICU, where he improved clinically after conservative treatment with continuous negative pressure suction using a 20 cm water column. He was extubated after 48 h, with persistence of the air leakage on both chest tubes.
On the day following extubation, he developed hypoxia associated with disorientation and agitation and had to be intubated again. Hypoxia was postulated from pulmonary contusion and ventilator-associated pneumonia worsening his already baseline compromised lung. He developed sepsis, and subsequently acute kidney injury with the need for dialysis.
During the course of 5 days, the patient presented hypoxia and a severe mixed metabolic and respiratory acidosis, despite the use vancomycin and piperacillin/tazobactam. The treatment with bilateral chest tubes associ

[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 female patient presented with a 5 months history of constant pulsatile frontal headache. The headaches were only somewhat responsive to paracetamol but she had to take narcotics to get to sleep. Recently, she had noticed that she was unable to distinguish smells while cooking and the food had a different taste for her.
Neurological exam revealed anosmia and bilateral papilledema more severe on the left side. Visual acuity was 20/20 and 20/40 in the right and left eyes, respectively. The remainder of the physical exam and the laboratory tests were all within normal range.
Axial brain CT scan was performed and demonstrated an extra axial hyperdense interhemispheric space-occupying lesion within the anterior cranial fossa. Surrounding vasogenic edema was evident. Brain magnetic resonance imaging (MRI) with and without contrast revealed the mass that was isointense relative to the gray matter on T1 and T2-weighted images. The tumor showed a homogenous contrast uptake with gadolinium injection suggesting anolfactory meningioma [].
The patient was operated in the supine position and the head was placed in the neutral position. A bifrontal craniotomy was performed over the superior sagittal sinus (SSS). The dura was opened in a linear fashion on both sides of SSS and it was ligated at its anterior third. Gross total resection of the firm tumor was made, the infiltrated dura was resected and the tumor's adhesions to the anterior skull base were coagulated (Simpson grade II).
The patient awoke with sudden bilateral blindness. Her vision was no light perception (NLP) in both eyes. Extraocular movement and IOP were normal. Fundoscopy revealed no apparent change. The anesthesiologist records documented no intra-operative hypotension. Early axial brain CT scan excluded the possibility of developing mass effect and 24 h brain MRI showed no residual tumor. One main concern was the possibility of inadvertent surgical trauma to the optic nerves or chiasm. Review of

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


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

[User]
RADIOLOGY NOTE:
A 13-year-old right hand-dominant girl had fallen on her hand and injured the right elbow during her way to school and visited our clinic soon after. Her chief complaint was a severe pain of the right elbow that was apparently swollen. Active and passive motion of the elbow was not possible due to pain, but no neurovascular deficits were observed in her left arm. She had a history of dwarfism and had been undergoing growth hormone replacement therapy since she was 7 years old at our hospital. She also had a history of developmental dysplasia of the left hip and a habitual patellar dislocation of the right knee. For the patellar dislocation, she underwent reconstructive surgery of the medial patellofemoral ligament when she was 12 years old, and at that time, her general joint laxity was diagnosed with the Beighton score of 6 points.
In plain X-ray and CT scan of the elbow, apparent displaced medial epicondyle fracture (Watson-Jones classification type 2) together with an avulsed thin fragment of the lateral epicondyle was detected; however, no proximal radial fracture or a coronoid fracture was observed (). She could not undergo MRI because of her panic disorder and claustrophobia.
The next day after the injury, her surgery was performed under general anesthesia. Prior to skin incision, ultrasonography and stress X-rays of the elbow were evaluated. Proximal avulsion of LCL from the epicondyle was clearly seen in the ultrasonography (). Valgus and varus stress tests were performed bilaterally with her elbows at a 20-degree flexed position. The side-to-side differences of the joint space widening were 8 mm in the valgus stress and 3 mm in the varus stress, which were significantly worse in the right elbow ().
For the medial epicondyle fracture, conventional open reduction and internal fixation was performed using tension band wiring technique. Then, the lateral epicondyle was exposed and there was a complete avulsion of 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:
Our patient was a 63-year-old Caucasian woman. She does not smoke cigarettes or drink alcohol. She measures 162.5 cm in height and weighs 66 kilograms. She had no significant family history. She was initially diagnosed with stage IIIA endometrial carcinoma for which she underwent a hysterectomy and bilateral salpingo ophorectomy followed by pelvic external beam radiation therapy. Two years later, she developed recurrent disease with widespread peritoneal carcinomatosis. An incidental mucinous carcinoma of the appendix was also found during surgical exploration. A central venous catheter port was placed and she received chemotherapy with 5-fluorouracil, leucovorin, and later, irinotecan, capecitabine and oxaliplatin. Her disease progressed despite multiple lines of chemotherapy. During the course of her cancer treatment, our patient also developed a series of complications which included tumor-related right ureteral obstruction requiring a nephrostomy placement, a sigmoid-vaginal fistula necessitating a colostomy with reversion of the ureteral stent, small bowel obstruction and ileostomy placement, short bowel syndrome and significant weight loss requiring total parenteral nutrition. Our patient recovered gradually and was able to receive subsequent courses of chemotherapy consisting of capecitabine, an oral chemotherapy agent classified as an antimetabolite, and oxaliplatin, an intravenous platinum-based chemotherapy agent classified as an alkylating agent. She developed predictable chemotherapy-related adverse events including diarrhea and hand-foot syndrome, but was able to continue her treatment intermittently. She started developing fever and tenderness at the site of her central venous catheter. Blood cultures were repeatedly negative. Our patient had not received antibiotics within the eight weeks prior to this event. She was not neutropenic. Laboratory results reflected a white blood cell (WBC) count of 12,100 cells/μL, with 87% neutrophils. Urine and stool e

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


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

[User]
RADIOLOGY NOTE:
A 41-year-old female patient was admitted to the emergency department with shortness of breath, blunt chest pain, and fatigue. In examination of the respiratory system, there were no breath sounds in the right middle and lower zones. Abdominal distension, umbilical hernia, and edema of the lower limbs were present. She had multinodular goitre. In her medical history, there was a lung pathology for which surgery was recommended three years ago. Laboratory findings were CRP: 243 mg/L; pulmonary function tests: restrictive pulmonary dysfunction; arterial blood gas analyses: respiratory acidosis and hypercarbia; thyroid function tests: euthyroid. Opacity was seen in the right hemithorax extending from the anterior branch of the 2th rib to the diaphragm in radiological studies. Thorax CT showed a giant mass that almost completely filled the right hemithorax, right pleural effusion, and right lung atelectasis. A 20 cm diameter mass that filled the whole right hemithorax extending from the upper mediastinum to the left of the midline was seen in thoracic magnetic resonance imaging. Right hilus and heart were pushed to the the left, and there was no evidence of mediastinal invasion. Inferior vena cava and hepatic veins were enlarged, and congestion of the liver, splenomegaly, and multinodular goiter were reported (Figures and ).
Abdominal ultrasonography revealed hepatosplenomegaly. Transthoracic biopsy was reported as benign mesenchymal tumor. Explorative thoracotomy revealed a huge extrapleural mass, and right upper lobe was adherent to the mass, and there were a large number of vascular structures. The relation of the mass with mediastinal structures and diaphragm and the vascular structures between the tumor and cardiac, mediastinal, and diaphragmatic surfaces could not be the evaluated through the thoracotomy incision. Hemorrhage developed during the separation of adhesions, and hemodynamics deteriorated because of the mass pressure on the heart. The existence of multi

[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 72-year-old male patient with low back and right buttock pain was examined. He could not walk more than 100 m because of the pain. He did not have any common symptoms of thyroid disease or malignancy such as weight loss. There were no abnormal laboratory findings. Neurologic evaluation revealed motor weakness in the right leg, especially weakness of big toe dorsiflexion and there was hypoesthesia in the right side below the L5 dermatome. A lumbar spine X-ray revealed only an L4 compression fracture, and the pedicles were preserved (). The whole body bone scan showed an active bone lesion in L4 vertebra, only. MRI findings were suggestive of an infectious spondylitis such as tuberculous (TB) spondylitis associated with a pathologic fracture rather than a metastatic bone tumor because vertebral involvement by metastasis may occur without collapse or subligamentous spread and disks are usually preserved. Additionally, the imaging features that support TB spondylitis over spondylitis caused by other infections include larger paraspinal involvement, the presence of subligamentous spread, more bone destruction, a paucity of sclerosis and local periosteal reaction ().
After the patient was transferred to the department of neurosurgery, a TB study was performed, showing no evidence of TB of any organ. The lumbar spine CT showed a markedly collapsed L4 body with an ill-defined intramedullary mass formation with cortical bone and bone marrow destruction, which suggested a malignant compression fracture with a large anterior epidural mass and perispinal extension. Investigations were performed to rule out multiple myeloma or metastasis. He went through L4 corpectomy with mass removal, and expandable cage insertion with posterior spinal fusion. A frozen biopsy during surgery revealed metastasis of the thyroid glands. Histologically, the mass in the vertebral body demonstrated well-differentiated follicles containing colloid invading the surrounding trabecular bone (). The tum

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


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

[User]
RADIOLOGY NOTE:
A 56-year-old Caucasian woman with a history of hypertension and migraine headaches was found by her husband walking in circles and acting strangely. She was last acting normally the night before and there were no signs of trauma. She was evaluated in an emergency department and found to have an intracerebral hemorrhage (ICH) in the left frontal cortex on head CT (Fig. ). She had a history of mild hypertension but had not been on antihypertensive therapy.
She had not taken any anti-thrombotic medications prior to the ICH except for occasional aspirin-containing migraine therapy. Her coagulation profile was normal except for elevated activated partial thrombin time (aPTT). CT angiogram and MR angiogram did not detect any abnormal blood vessels. MRI of the brain did not show an underlying tumor or infarction. She was discharged on a low-dose antihypertensive agent. A repeat MRI of the brain was done a month later (Fig. ) and showed 9 microhemorrhages and superficial siderosis meeting the Boston criteria for probable CAA []. Five months after the ICH, a repeat brain MRI showed a new area of encephalomalacia in the left occipital cortex that was not present on the prior MRI (Fig. ). The radiological features indicated a chronic infarction []. The MRI also showed an area of encephalomalacia of the right frontal cortex/subcortex that had been seen on the initial CT and MRI but had unclear significance. With the development of the left occipital encephalomalacia, it became apparent that the right frontal lesion was also a chronic infarction. A transthoracic echocardiogram was done as part of the ischemic stroke investigations and showed an echogenic structure on the atrial aspect of the anterior mitral leaflet. Transesophageal echocardiogram was done on the same day and showed a 6-mm, sessile, thickened mass on the mitral valve (Fig. ). She was admitted to the hospital for expedited workup. She was asymptomatic, did not show any systemic manifestations of infective endocar

[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 presented to the emergency room with upper abdominal pain and epigastric fullness. She had no associated nausea or vomiting and denied any alcohol consumption or cholecystectomy. Blood work showed elevated amylase and lipase levels consistent with pancreatitis. Serum beta-HCG was negative. She was admitted for acute pancreatitis and treated supportively with pain management and hydration. Her amylase and lipase levels returned to normal within 36 hours.
Ultrasound revealed a normal gall bladder and a large cystic mass in the epigastrium prompting further imaging. A contrast enhanced CT confirmed the presence of a large, complex cystic mass with septations measuring 15 × 15 cm in close proximity to the pancreas and extending to the liver and stomach (). No biliary or pancreatic duct dilatation was observed. The mass was suspected to be of hepatic orpancreatic origin; however this could not be determined on CT alone.
On MRI of the abdomen, the locules of the cystic mass were shown to be homogeneously T2 hyperintense and T1 hypointense with the mass overall measuring up to 14 cm in greatest dimension. The mass also demonstrated multiple low T2 signal septations measuring up to 4 mm in thickness () and showed enhancement following gadolinium administration (). No nodules were seen. MR images favored the mass to be of hepatic origin. No upper abdominal lymphadenopathy was observed and the suspicion was raised for a biliary cystadenoma or cystadenocarcinoma prompting surgical consultation.
General surgery described a complex cystic mass on CT occupying parts of segments 3, 4a, 4b, 5, and 8 without any involvement of major vessels. Endoscopic US revealed a normal pancreas and confirmed the hepatic origin of the cystic mass. Tumor markers (CEA, AFP, and CA 19-9) were normal and the patient was sent for definitive treatment with hepatobiliary surgery.
Patient consent was obtained for a planned central hepatectomy or mesohepatectomy of segments 4a, 4b, 5,

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


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

[User]
RADIOLOGY NOTE:
A 49-year-old woman visited the emergency room for acute chest pain radiating to the back. She had known hypertension: the blood pressure in the left upper limb, right upper limb, left lower limb, and right lower limb was 210/65, 218/60, 176/90, and 175/90 mm Hg, respectively. The D-dimer level was normal at initial admission. An electrocardiogram showed a normal sinus rhythm. Considering that the patient had typical clinical symptoms of acute chest pain radiating to the back, with asymmetry of limb blood pressures, and a normal D-dimer level and electrocardiogram, the diagnosis of IMH was suspected. Chest nonenhanced computed tomography (CT) was performed, which showed crescent-shaped thickening of the thoracic aorta wall with the same attenuation as that of the lumen and linear calcification ingression (). Computed tomography angiography (CTA) revealed an intimal flap and expanded false lumen with slight enhancement (). Digital subtraction angiography showed mild stenosis in the thoracic aortic lesion without an obvious intimal flap (). Based on both the clinical symptoms and diagnostic test results, only thoracic IMH was considered by both radiologists and cardiothoracic surgeons; hence, thoracic endovascular aortic repair and not surgery was considered at that time. Then, an endovascular stent (30 mm × 200 mm, Medtronic) was implanted into the patient. Completion angiography demonstrated that the thoracic aorta and branches were patent, with no obvious endoleak or extravasation (). The prevalence of acute chest pain radiating to the back decreased after treatment, and the patient recovered well and was discharged home.
Three months after endovascular stent graft implantation, follow-up CTA () showed enlargement of the false lumen with nonhomogeneous enhancement and mediastinal extensions. The patient was interpreted by radiologists as having an endoleak and periaortic/mediastinal hematoma, which were also considered by other medical centers during follow-up. How

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


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

[User]
RADIOLOGY NOTE:
A 68-year-old man who was otherwise well, presented with mild shortness of breath with 6 months duration and a recent onset of chest pain. Physical examination showed dullness on percussion and decreased breath sounds in the lower zone of the left lung. Laboratory data, respiratory function tests and arterial blood gas analyses were within the normal limits. Chest x-ray showed a large, well defined soft tissue mass in the anterior mediastinum (Figure ). On computed tomography (CT), an inhomogeneous fatty mass in the left hemithorax showing invasive features to the heart and left hemidiaphragm was defined (Figure ). Detection for distant metastases including bone scan, cranial and abdominal CTs showed no abnormal findings. Esophagoscopy and bronchoscopy revealed extrinsic compression effects, but no evidence of intraluminal tumor. Therefore surgical intervention was proposed. On the beginning the patient underwent a left anterolateral thoracotomy but due to diaphragmatic invasion, an abdominal extension of the incision was needed. A large, well-demarcated and slightly lobulated mass located in the left hemithorax showing invasive features to the heart and left hemidiaphragm was explored. The tumor was attached to the inferior pericardial wall causing significant compression to the heart. A pericardial incision was necessary to check possible myocardial infiltration. This manipulation revealed that the tumor was in close association with the left atrium and ventricle anteriorly but showed no invasion to these vital structures.
En bloc resection of the tumor with part of pericardium and the left hemidiaphragm was performed. The diaphragmatic defect was covered with bovine pericardium. The patient tolerated operation well and had an uneventful postoperative recovery. Nine months later he is free of disease and in a very good condition.
The entire tumor measured 9 × 7 × 5 cm in diameter and weighed 430 g in total. The mass was soft and pale yellow in color on cut section

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


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

[User]
RADIOLOGY NOTE:
A 68-year-old male, ex-serviceman, presented with a history of open prostatectomy (Millins). The procedure was operated elsewhere and presented with a complaint of a bulge in the abdomen along a previous scar site. He did not have any complaints of altered bowel and bladder habits. He did not have any other specific complaints. On evaluation, he gave history of surgery 1 year back. One year ago, he underwent Millins procedure for benign prostatic enlargement (BPE). This procedure involves removing part of the prostate using a transcapsular retro pubic approach (extra peritoneal) through a cut in the abdomen. Two weeks after the surgery, he developed abdominal wound dehiscence. Once the wound granulated well, he underwent secondary suturing of the abdominal wound after 2 months of surgery. He developed incisional hernia 3 months later. He continued to have protuberant abdomen with visible bowel peristalsis. He was reassured and advised to wear abdominal binder. On examination, his general condition was good. There was a bulge of size ~25 × 10 cm projecting from his anterior abdominal wall at the site of the previous scar ().
A palpable midline rectus defect of 10 cm was noted. Visible bowel peristalsis was seen. Other system examinations were normal. Routine laboratory investigations were normal, and he did not have any comorbid illness. Computed tomography (CT) of the abdomen confirmed thinning of the rectus sheath with focal outpouching of rectus in the infra-umbilical region and herniation of small bowel loops with loss of domain (LOD) ().
He was planned for surgical exploration. On exploration, a defect in midline for ~8 cm in width was noted. Rectus was retracted laterally and could not be brought easily to the midline. Adhesiolysis was done. It was decided to go ahead with posterior component separation with TAR since the defect was very wide. The procedure commenced with the separation of posterior rectus

[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 Caucasian female presented to the emergency department with complaints of right hemiparesis, numbness, dysphagia, and ataxia. These complaints began as numbness over her right scapular area two weeks prior, and the numbness later progressed to include the right leg. Additionally, she reported five days of waking up during the night with severe headaches. Although she reported a history of migraines, which were usually accompanied by an aura, she stated that these new headaches were different in nature. She also had no known allergies and no previous surgeries. Her mother had a history of breast cancer, and her father had a history of ischemic heart disease. A review of systems was otherwise negative. After workup in the emergency department and consultation by neurology, she was referred to neurosurgery for management of a high-grade brainstem tumor.
Examination
On initial presentation, the patient was alert and oriented to person, place, and time with a Glasgow Coma Scale (GCS) score of 15. Her pupils were equal, round, and reactive to light. Cranial nerves II-XII were grossly intact. Motor testing revealed that strength was 5/5 in both upper and lower extremities. Pronator drift was noted in the right upper extremity. Dysmetria was noted in the right upper extremity during finger-to-nose testing, and discrimination of fine touch was subjectively diminished on the entire right side from the zygomatic process to the foot. Patellar reflexes were 3+ bilaterally. Over the course of her initial admission, the patient demonstrated a progressive decline, to include mild left facial droop, dysarthria, and a worsening dysphagia. A percutaneous endoscopic gastrostomy (PEG) tube was placed because the patient was unable to swallow without effort. These findings continued until her initial discharge. Upon readmission, the patient displayed similar findings. Left lower quadrant abdominal pain radiating to the shoulder and acute numbness of the left chest and shoul

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


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

[User]
RADIOLOGY NOTE:
A 64-year-old male with a known VSD, who had not experienced any previous VSD-related complications, underwent a dental crown implantation without antibiotic prophylaxis in September 2016. Three months later he experienced fevers, sweats, and a dry cough, which spontaneously resolved after several weeks without antibiotic treatment. His symptoms recurred in June 2017 and at this time were associated with raised inflammatory markers. Further investigation, including a computed tomography (CT) chest, identified multiple peripheral lung lesions that were initially presumed to be malignant. Once again, his symptoms spontaneously resolved without any antibiotics. A follow-up CT chest in August 2017 identified resolution of the peripheral lung lesions, challenging the initial presumed diagnosis of malignancy.
A further CT chest was organized in November 2017, and on this occasion there was recurrence of lung lesions in new areas, suggestive of septic emboli with internal cavitation (Fig. A, B). At this time that patient complained of sweats and lethargy, and was consequentially hospitalized for further investigation of his relapsing remitting lung lesions.
On admission, four blood cultures all identified Streptococcus mutans. A transthoracic and transoesophageal echocardiogram was completed, which identified a perimembranous VSD but no endocardial vegetation (Fig. C). A CT pulmonary angiogram was performed to exclude a pulmonary embolus and to identify an appropriate lung lesion to biopsy.
A thoracoscopic lung biopsy was completed, which isolated S. mutans from the necrotizing lung abscesses. Furthermore, the patient complained of lower back pain, which was investigated with spinal magnetic resonance imaging and identified early L3-4 osteomyelitis without a complicating epidural abscess. As the patient was not haemodynamically compromised during admission, there was no need for urgent surgical repair of the VSD. The decision was made to treat the VSD-related IE medically,

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


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

[User]
RADIOLOGY NOTE:
A 69-year-old woman was admitted to hospital due to sternotomy site pain that had exacerbated 2 days prior. She had a 15-year history of hypertension and diabetes mellitus. The patient had undergone coronary artery bypass graft (CABG) surgery for triple vessel disease 2 months prior to presentation. She was discharged 9 days after the CABG surgery without complication. One week prior to the admission for the worsening sternotomy site pain, the patient presented in the outpatient clinic due to CABG operation site pain, but the pain was not relieved by opioids. Two days prior to admission, she developed redness, tenderness, and pus on the operation site, as well as wound dehiscence. At the time of admission, the patient was afebrile and complained of operation site pain with a slightly elevated C-reactive protein (CRP) level of 1.74 mg/dL. After obtaining specimens for ordinary bacterial, fungal, and mycobacterial culture, empirical therapy with vancomycin and cefotetan was initiated. The Gram stain showed many white blood cells, few epithelial cells, and only rare Gram-positive rods. Chest computed tomography on the second day of admission demonstrated cellulitis and focal osteomyelitis around the sternotomy site (), as well as focal fibrosis and linear atelectasis in the right-upper lobe, which were thought to be inflammatory sequelae. Her CRP level was normalized to 0.62 mg/dL on the sixth hospital day. On the eighth hospital day, wound closure was performed for wound dehiscence.
The wound culture on blood agar showed small, orange colored convex colonies without aerial hyphae after 5 days of incubation (). The organism was catalase-positive, oxidase-negative, and urease-positive gram-positive rod. It was preliminarily identified as an actinomycete, and as the treating physician believed the organism to be an anaerobic actinomycete, the antibiotics were changed to penicillin G for empirical therapy. The isolate was identified as a Rhodococcus species by a commercia

[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 May, 2015, a 61-year-old right-handed woman presented at our clinic complaining of dull right posterior pain and intermittent radiating pain from the shoulder to the anterior aspect of the upper extremity with a 3-year history. She often performed repetitive tasks in the overhead position as an orchard farmer. She complained of difficulty in performing work because of the loss of muscle strength in her right upper limb while working for a prolonged time in the overhead position 6 months prior to visiting our clinic. She was diagnosed as having impingement syndrome at another clinic and was treated with physical therapy, medication, and steroid injection. However, no improvement of the symptom occurred. The patient had no trauma history or evidence of systemic diseases. The range of motion in the involved right shoulder was 180° of active forward flexion, 50° of external rotation, and T7-level internal rotation at the back. The range of motion in the uninvolved left shoulder was 180°, 85°, and T7 level, respectively. The impingement signs I and II were positive, but no signs of instability were found. The Obrien test was positive but other rotator cuff tests were negative.
Plain radiography of the right shoulder showed a radiolucent, elliptical-shaped lesion with a well-defined margins and sclerosis of the surrounding bone (Fig. ). Cervical spine plain radiographs did not show abnormal findings. Computed tomography of the right glenoid revealed a cystic lesion with sclerotic margins measuring 25 × 20 × 20 mm in diameter in the posterosuperior border of the glenoid, but with no communication between the cyst and the glenohumeral joint (Fig. ). Magnetic resonance imaging (MRI) of the lesion demonstrated a low signal intensity on T1-weighted spine-echo images and a high signal intensity on T2-weighted spine-echo images within and around the scapular neck. The cystic lesion within the scapular neck was a multilobular lesion and protruded into the spinoglen

[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.