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

[User]
RADIOLOGY NOTE:
A 53-year-old man, who denied any underlying disease before, underwent colonoscopy for routine health examination. Several hours later, sudden onset of abdominal pain around left upper quarter was mentioned. He came to our emergency department with chief complaints of abdominal pain and left shoulder pain. On arrival, his vital signs were as following: body temperature 36°C, pulse rate 82 beats per minute, respiratory rate 22 breaths per minute, and blood pressure 110/76 mmHg. The physical examination revealed pink conjunctiva with unremarkable cardiovascular and pulmonary findings. On palpation, tenderness over the epigastric and left upper quadrants of his abdomen was noted. Involuntary muscle guarding was also noted.
Laboratory examination showed 17000/uL white blood cell (WBC) and normal hemoglobin (14.3 gm/dL). His ECG showed sinus rhythm with RBBB and his chest radiograph was normal without evidence of free air. During the observation period at ED, suddenly his systolic blood pressure was dropped to 90 mmHg with sinus tachycardia. Ongoing severe abdominal pain was mentioned. He received abdominal computed tomography (CT) under the initial impression of hollow organ perforation with septic shock. However, CT scan showed massive hyperdense ascites surrounded around the spleen without free air (Figures and ). Grade II of spleen laceration was found on this CT scan. Therefore, spleen laceration with hemoperitoneum as the complication of colonoscopy was impressed. General Surgeon was consulted at the same time. Due to the fact that severity of spleen laceration is grade II, conservative treatment was suggested. He received blood transfusion with PRBC 2U; then, he was admitted to ward. After admission, his hemodynamic status was stable with improving symptoms. So, he was discharged from our hospital 3 days later. However, LUQ pain was noted on the same day of discharge, so he came back to our ED immediately. Abdominal and pelvic CT was arranged again with progressin

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


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

[User]
RADIOLOGY NOTE:
A 58-year-old man was admitted to our hospital because of progressive dysphagia for >1 month. By oesophagogastroscopy, a ring uplift, 36–38 cm from the upper incisors was identified. Confirmed as high-grade oesophageal intraepithelial neoplasia by pathology. Chest and upper abdominal computed tomography showed wall thickening in the lower oesophagus, range about 56 mm, showed obvious enhancement. The density shadow of strip soft tissue in the right middle lobe of the lung could be seen enhancement; the bronchi of the lateral segment of the right middle lobe were partially cut off. By fibrobronchoscopy, in the lateral part of the right lung middle lobe, the bronchial opening in the subsegment of the lung shows the vegetative new organism, and the lumen is basically closed []. Confirmed as adenocarcinoma by pathology. To exclude N2 disease by positron emission tomography preoperative preparation, no distant metastases were detected in this patient before treatment.
To achieve a good prognosis, surgical treatment of the patient was indicated. An Ivor-Lewis and lobectomy were performed through thoracoscopic surgical approach. After successful anaesthesia with two-cavity endotracheal intubation, using a standard procedure with the patient in the supine position, as previously reported.[] After that, we performed thoracoscopic lobectomy and thoracic oesophageal mobilisation in the right lateral position. Based on our prior experience, a 1 cm incision at the 7th intercostal space, along with the middle axillary line, was selected as the observation port. The principal operating port with a 5 cm access incision. Dissection of the middle lung lobe was completed first. The posterior mediastinum was exposed by adjusted operating tab. The thoracic oesophagus, along with the peri-oesophageal tissue and mediastinal lymphonodus, is circumferentially mobilised from the diaphragm to the level of arch of the azygos vein. Mediastinal lymphadenectomy is performed in the patient. After

[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 48-year-old female was a front passenger in a van involved in a head-on collision with a car and was subsequently trapped in a sitting position for 75 minutes. On initial assessment she was able to respond to verbal commands (GCS 14; eyes 3, motor 6, verbal 5), and there was brisk bleeding from the nose and mouth as a result of extensive facial injuries. This bleeding was unusually persistent and was only later shown to be secondary to a low platelet count (69 × 109/L) due to idiopathic thrombocytopenic purpura. Other injuries included an open fracture of the left wrist and a fracture dislocation of the left elbow. She was given high-flow oxygen via an NRBM which initially maintained her SpO2 around 98%. However, bleeding into the airway became an increasing problem despite frequent suctioning, and her SpO2 was seen to fall to 88%. Extrication and transport in a supine position were considered to carry a major risk of aspiration if undertaken with an uncontrolled airway. Consequently, an iLMA was inserted after sedation with midazolam (two 5 mg IV boluses) with the patient still trapped in a sitting position (). Spontaneous respiration was augmented with a bag-valve-mask device (BVMD) fitted with an oxygen reservoir and the SpO2 rose rapidly to 100%. In view of the good response, it was judged unnecessary to intubate the patient via the iLMA either at the scene or en route to the nearby hospital. On arrival at hospital the duty anaesthesiologist requested removal of the iLMA in order that RSI could be performed under direct laryngoscopy. Despite the use of a gum elastic bougie, multiple intubation attempts by two experienced anaesthesiologists failed due to an anatomical anomaly (recession of the mandible) and the continuing bleeding into the oropharynx. The iLMA was therefore reinserted and, following a period of reoxygenation, the author intubated the patient via the i

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


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

[User]
RADIOLOGY NOTE:
A 40-year-old Indian female consulted our oral and maxillofacial clinic, complaining of discomfort during swallowing. The patient was apparently alright two months back when she developed mild discomfort during deglutition. Around the same time the patient also noticed a painless swelling over the upper left side of the neck, which gradually kept increasing in size. No significant medical history or history of previous trauma was reported. On extraoral examination, no gross facial asymmetry was noticed. Intraoral examination showed upper and lower jaws with normal teeth. No other mucosal abnormality was detected over oral and oropharyngeal mucosa. Palpation of the inferior border of the mandible revealed a painless bony hard mass over the inferior border of the mandible in relation to the left canine‒premolar region. The growth was fixed to the inferior border and lingual surface of the mandible and did not show any movement during deglutition (). Cervical lymph nodes were not palpable.
An orthopantomogram showed a well-defined homogenous radiopaque mass arising from basal part of the mandible below the apices of the left premolar and the first molar teeth with a continuous contour (). Computed tomography (CT) scan with sectional and 3D formatted images was obtained for further evaluation of the lesion. CT scan showed a well-defined, hyperdense mass measuring 2.5×2 cm in size, arising from the left lower border of the mandible. Coronal and sagittal sections showed the growth projecting slightly towards the lingual aspect and impinging over the muscle plane on the oral cavity floor and neck (). No other lesion was seen involving the craniofacial skeleton. Based on the clinical and radiological findings, provisional diagnosis of peripheral osteoma was made.
Surgical excision of the tumor was planned and executed under general anesthesia. The surgical approach used was submandibular incision placed in the upper neck crease. Upon layered dissection over the lower border

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


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

[User]
RADIOLOGY NOTE:
A 52-year-old Nigerian man of the Yoruba ethnic group, presented with severe breathlessness on exertion, paroxysmal nocturnal dyspnoea and bilateral pedal swelling of six weeks duration, having been referred from a private hospital. He was recently diagnosed hypertensive during consultation at the referring hospital, few weeks prior to presentation. He had smoked for 13 pack years and also consumed alcohol heavily (≥60 g/day) for thirty years. There was no history of food or drug allergy and no family history of atopy.
Physical examination revealed an acutely ill looking middle aged man. He was not pale. There was no periorbital or facial swelling. There was no significant peripheral lymphadenopathy. The main findings were in the cardiovascular system examination. The pulse was 106 beats per minute, regular and normal volume; the blood pressure was 145/100 mmHg supine. The apex beat was at the 6th intercostals space, immediately lateral to the mid-clavicular line. Heart sounds SI, S2 and S3 gallop rhythm were heard. Chest examination showed few basal crepitations bilaterally. Fundoscopy revealed a grade 2 hypertensive retinopathy. All other systems were essentially normal. A clinical assessment of Hypertensive Heart Disease in failure was made. Although an in-patient management was offered, the patient however decline. He was managed on an out-patient basis; he was placed on lisinopril 5 mg daily, frusemide 40 mg daily, aspirin 150 mg daily and digoxin 0.25 mg daily.
The patient re-presented at the medical emergency unit of the hospital two days later with swollen lips and lower face of 10 hours duration. There was associated difficulty in swallowing but no stridor or hoarseness of his voice. There was no swelling of any other part of the body. He had neither skin rashes nor pruritus. There was no previous history of similar episode of swollen lips. Other aspects of his medical history did not show any abnormality and were not significant

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


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

[User]
RADIOLOGY NOTE:
An 8-month-old, asymptomatic male child presented with a history of incidentally detected abdominal cysts on ultrasound scan done elsewhere a month and a half earlier. Contrast-enhanced computed tomogram (CECT) scan of the abdomen also confirmed the presence of a dumbbell-shaped cystic mass located posterior to the stomach with a separate cystic mass located in the right iliac fossa (RIF) [].
On examination, the child was cheerful, active, and weighed 9 kg. Physical examination revealed a nontender 7 × 5cm mass in the left upper quadrant, which had restricted mobility, and a 5 × 2 cm nontender mass in the RIF. On investigation, his Hb was found to be 12 gm%, had normal total and differential leukocyte counts, electrolytes, and renal function tests. We reviewed the CECT scans and concluded that the cyst in the left upper abdomen could be a gastric duplication or a lymphatic cyst, while the latter etiology seemed most likely for the cyst in the RIF. Both the kidneys appeared normal on CECT.
At surgery, there was a dumbbell-shaped cyst arising from the greater curvature of the stomach, burrowing into the transverse mesocolon and also into the stomach bed. The cyst was dissected off from the transverse mesocolon and a tongue of pancreatic tissue draped over the isthmus of the dumbbell was found, at a right angle to the normal position of the pancreas. This tongue was dissected off, and fell back into a normal anatomic position of the pancreas. The cyst was then enucleated from the musculature of the greater curvature without breaching the gastric lumen. Through the same incision, the RIF was explored and a tubular cystic structure was found with a blind end close to the internal iliac vessels. Superiorly the cyst was arising from the surface of the lower pole of the right kidney, but without any apparent pelvic connection. Further dissection revealed a normal right-sided pelvis and normal ureter

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


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

[User]
RADIOLOGY NOTE:
A 53-year-old female patient consulted physical medicine, rehabilitation and rheumatology department due to the pain radiating from the right inguinal region and the right hip to knee while she was being followed by general surgery clinic because of solid mass in the liver. During the assessment, patient complained of having an intermittent backache for a long time; she described a constant pain in her right hip and groin spreading to right knee that started 1 week ago and was increasing with rest. Patient also reported there was pain and slight swelling in the right ankle 10 days before that lasted for 3 days. In her background no previous illness is noted. Patient had an abdominal pain lasting for the last 6 months and abdominal ultrasound was performed; a solid mass was detected in the liver. We learned that the patient had no history of arthritis, gastroenteritis, urinary tract infection, psoriasis, or previous operation. She has not been using any medication except for analgesic. The patient had no relatives with history of inflammatory disease or malignancy in her family history. In the physical examination loss of lumbar lordosis was detected. Waist movement was slightly restricted to all directions due to pain, hand fingertip-to-floor distance was 10 cm, sacroiliac compression test was positive on the right, FABERE test was positive on the right, her right knee was warm and tender, there was no rash on the skin, local sensitivity was detected in the right upper quadrant with palpation, and other system evaluations were normal. Sacroiliac MRI was seen because of the suspicion of sacroiliitis. The sacroiliac MRI, which was assessed independently by radiology department, showed a signal enhancement consistent with the right iliac focal bone marrow edema adjacent to the right sacroiliac junction () and there were 2 cystic lesions at iliac front adjacent to the right hip joint. Abdomen tomography of our patient, which was requested by general surgery department,

[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 years-old unmarried premenopausal female presented in the emergency of our hospital with complaints of bleeding from ulcerative lesion in the left breast for a couple of hours. The patient had history of ulcer in the left breast for past 2–3 weeks which developed over the underlying huge breast lump. The lump was present for past 5 months but rapidly grew over the last 3 months to current size. There was no history of coagulopathy, trauma, chronic liver disease or history of similar illness in first degree relatives. The patient attained menarche at the age of 15 years. She is a non-smoker and denies history of contraceptive use or alcohol intake.
On examination in our emergency there was severe pallor with tachycardia. However the blood pressure was maintained. There was an oozing ulceration in upper outer quadrant of the left breast with underlying huge lump measuring 15 × 15 cm occupying the upper outer, lower outer and upper inner quadrants with deformed shape of the breast (a). The skin surrounding the ulcer was erythematous and edematous. Axilla did not show lymphadenopathy.
Before the development of breast lump, the patient had itchy lesion at the same site. The patient unfortunately attributed all these events to that itchy lesion and sought help late. There was no history of headache, shortness of breath, abdominal distension or bone pain.
On investigating the patient, she was severely anemic with hemoglobin of 5 gm% with normal total and differential counts. Coagulation parameters and liver function tests were normal. Chest X-ray showed no evidence of metastasis other than dense breast shadow on left side due to huge breast lump(a).
Mammogram revealed homogeneous radiodense lobulated mass occupying whole of left breast with subcutaneous thickening on the background of dense breast (b). Ultrasound (USG) of abdomen and pelvis did not reveal any abnormal findings. Trucut biopsy from the

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


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

[User]
RADIOLOGY NOTE:
A 71-year-old Chinese man who was previously healthy presented to our clinic with a 3-month history of episodic cough with the production of thick yellow sputum. This was accompanied by generalized fatigue, subjective fevers, weight loss and night sweats. Symptoms improved somewhat with over-the-counter antipyretics and cough suppressants. One month prior to the visit, he noticed streaks of bright red hemoptysis, which prompted him to seek medical care. Shortly after an initial chest radiograph (CXR) showed a left upper lobe cavity, a finding later confirmed by computed tomography (CT) scan (Figure ), he was referred to the chest clinic for further evaluation.
The patient was born and raised in China, where he had lived and worked as a veterinarian for most of his life until he moved to the US in 1981. He had a negative purified protein derivative upon arrival to the US. He had no prior medical problems and was not taking any medication at the time of his visit. He denied any history of alcohol, tobacco or recreational drug use and had no knowledge of sick contacts. On physical examination, he appeared younger than his stated age and in no apparent distress. His examination was relevant only for bronchial breath sounds over the left upper hemithorax.
His CXR and CT scan showed a well-defined left upper lobe cavitary lesion with associated contralateral mediastinal lymphadenopathy. Due to the suspicious appearance of the lesion, a positron emission tomography (PET) scan was ordered along with induced sputum for cultures. Diagnostic bronchoscopy or percutaneous needle biopsy were discussed with the patient and his family, but he did not want any invasive tests. The PET scan showed increased metabolic activity in the left upper lobe lesion as well as in areas of lymph nodes in the contralateral mediastinum; in addition, an area in the left lobe of the thyroid also showed a strong signal which prompted a referral to the thyroid clinic.
During this time, the first sputum

[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 man presented to emergency department with an anterior shoulder dislocation () after a ski fall without loss of consciousness. At the initial management, the patient did not show any neurological dysfunction or pulse deficit. The first reduction attempts were unsuccessful and the patient was put under general anesthesia before trying again. During the new attempt to reduce the shoulder dislocation, we observed the occurrence of a hematoma in the deltopectoral region (). At the same time, loss of palpable peripheral pulse and upper limb ischemia appeared. A CT scan was performed and showed a compressive hematoma in the axillary region, a disruption of the axillary artery flow, and a bilateral pulmonary embolism (previously unknown). The patient was transferred to a university hospital to be supported by vascular and trauma surgeons. The patient was still under general anesthesia. The dislocation was successfully reduced in the operating room. Upper limb ischemia with persistent pulseless and cold arm led to an emergency vascular management. The humeral artery was dissected through the brachial tunnel and a thromboembolectomy was done. An arteriography was performed due to the persistence of pulsatile hematoma, which revealed a disruption of the axillary artery with extravasation of contrast near the humeral head (). An angioplasty balloon was introduced to control the proximal bleeding. After the introduction of the occlusion balloon, an incision was performed at the pectoralis major muscle and the hematoma was decompressed. The artery was deteriorated over about 1 cm and an end-to-end anastomosis was performed. The bilateral pulmonary embolism was probably due to the compression of the axillary vein during the shoulder dislocation. Nevertheless, no examination has confirmed this hypothesis. The patient received an intravenous anticoagulant therapy by heparin and then by an oral anticoagulant. Postoperatively, Doppler ultrasound showed a good morphologi

[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 31-year-old Saudi male patient presented to a restorative clinic at the College of Dentistry, King Saud University, Saudi Arabia. The patient was seeking permanent restoration of an endodontically treated tooth on the left side of his lower jaw which had undergone significant decay many years prior.
The dental history of the patient included extraction of a mandibular left molar, multiple restorations, and a root canal treatment. The patient stated that he underwent a surgical procedure to the gingiva to help his anterior permanent teeth erupt during childhood. Medical history revealed no significant reports. The family history for the patient also revealed no evidence of any medical condition.
Height and weight recorded for the patient were 185 cm and 114 kg, respectively. A head and neck extraoral examination revealed a mandibular protrusion leading to a straight facial profile () and tight lips upon closure with a thick lower lip. An intraoral examination showed racial melanin pigmentation, especially on attached gingiva, with anterior and bilateral cross bites (Figures and ). Generalized gingivitis with bad oral hygiene and heavy plaque accumulation were observed in the crowded anterior segments. Areas of deep pockets and bleeding were also noted. Tooth #32 presented hypomineralization, while a very deep vault in the hard palate and bony enlargement of the posterior areas of the maxillary arch were also observed (). Crowded teeth characterize both of the patient's arches since the patient has a full set of teeth and narrow upper and lower arches.
A panoramic view of the patient's teeth show long roots (radiculomegaly) for most of the teeth, especially for the molar teeth (). Periapical radiographs also show unusually long roots (). Cone beam computed tomography (CBCT) software was used to measure the length of the patient's entire set of teeth. Measurements were made from the apex to the tip of the cusps in a slice orientation manner ().

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


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

[User]
RADIOLOGY NOTE:
The patient in this study was a 39-year-old Chinese woman who presented with a painful right breast lump on April 5, 2008. She had a history of schizophrenia for over 20 years and had been receiving risperidone (2 mg bid) for more than 3 years. She had developed a lump in her right breast a month before her visit and had noted a progressive worsening tenderness with erythematous changes around the lesion. She had no systemic symptoms nor did she have any known previous fungus or tuberculosis exposure. The patient had a gestational history of G0P0 and had amenorrhea for approximately a year. She had no history of any other breast disease or receiving any breast surgery, and her medical history was otherwise unremarkable. She had never consumed tobacco, alcohol, oral contraceptive pills nor did she have any family history of breast cancer. On physical examination, a 9-cm × 6-cm breast lump with localized redness over the right breast lateral aspect with an ill-defined margin was noted with no palpable lymphadenopathy at the axilla. There was no splenomegaly or hepatomegaly. She did not have fever, joint pain, airway or urinary tract bleeding. No other skin lesion was found. The patient's blood count was normal. Breast ultrasound images revealed a large ill-defined area with heterogeneous echoes in the right upper and lower outer quadrants, associated with increased vascularity. Micro-calcification and tissue edema were noted. No enlarged lymph node was noted in the right axilla, and there was no dilatation of the lactiferous duct. CXR didn't show any lung lesions. Mammography showed asymmetry with increasing radiodensity at the outer upper quadrant of the right breast with nipple retraction. Mastitis with edema and micro-abscess in the right upper and lower quadrants was suspected. However, inflammatory carcinoma could not be ruled out. All other laboratory and other radiological studies including C-reactive protein (0.8 mg/L) were

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


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

[User]
RADIOLOGY NOTE:
A 24-year old male patient presented with history of gradually increasing size of left ear with skin discoloration. On examination it was a pulsatile, compressible, spongy, non-tender swelling with pigmentary changes of skin. Thrill was easily felt and continuous bruit was heard on auscultation. Patient denied bleeding, ulceration or discharge from the lesion. The malformation was involving the whole external ear extending from the helical rim to lobule, neck inferior to the ear and post auricular region. External auditory canal and tympanic membrane were normal. Clinical diagnosis of high flow arterial malformation was made on history and examination ().
The diagnosis was confirmed by MRI and MR Angiography which showed feeding vessel arising from the left external carotid artery (). Preoperative coil embolization was done to reduce vascularity and obtain blood less field during excision (). The surgery was scheduled 48 hours after embolization (). Per-operatively all the large tortuous blood vessels around the affected ear were ligated. The whole lesion was resected along with skin, subcutaneous tissue preserving the auricular cartilage with intact perichondrium (). Reconstruction done with split thickness skin graft harvested from thigh covering the ear cartilage ().
There was partial graft loss in subsequent days but the cartilage was found viable which was re-grafted. Patient was followed for three months with aesthetically acceptable ear. The surgical procedure could be carried out with precision and the auricular cartilage could be preserved with intact perichondrium because the bleeding was controlled by pre-operative embolization. In spite of this there was more than 500 ml blood loss. Post operatively patient lost a significant amount of cartilage as expected due non-vascular skin graft used as cover. This can be well appreciated in the follow up pictures. (Figure 7,8) In spite of offering the patient a reconstruction for the ear, he chose not to go for ea

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


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

[User]
RADIOLOGY NOTE:
A 12 years old female child reported to the Department of Periodontics, Government Dental College and Hospital, Nagpur complaining of gingival swelling, which caused severe compromise in her speech, mastication and aesthetics and led to considerable disfigurement of her facial profile, owing to the severity of gingival enlargement. The patient reported that the gingival enlargement started with the eruption of permanent dentition but progressed slowly to cover the entire permanent dentition. No single tooth was visible due to enlargement in anterior region whereas only occlusal portions of teeth were visible in posterior region. It was difficult to predict whether the positions of teeth were hampered due to massive gingival mass. However, the panoramic radiograph revealed normal bone height and tooth positioning.
The extra oral examination revealed an exaggerated convex profile with highly incompetent lips as the tissue bulge was protruding out of the mouth. The intra oral examination revealed generalised gingival overgrowth including both maxillary and mandibular arches extending into the vestibular areas []. The pink, leathery consistency tissue was hard on palpation and covered complete crowns of the entire dentition. The intra-oral examination confirmed that the patient used to masticate with assistance from the gums, however, no ulcerations were found on the occlusal surfaces of the enlarged tissue. A scanty amount of plaque and food debris was entrapped into the posterior teeth which were partially visible amongst the entire dentition with no significant inflammation present around them.
Routine blood investigations were done and values were found within normal range although haemoglobin values was slightly below normal range (8.5 gms%). The blood group examination was also done owing to the need for blood transfusion which was deemed necessary for maxillary arch gingivectomy after complete clinical evaluation. Based on the provisional diagnosis, an incisional

[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 1-year 3-month-old girl was admitted to our hospital on August 29, 2019, 3 h after sustaining an OPI where a plastic rod pierced her orbital cavity via the lower left eyelid and penetrated the brain. The patient had no previous medical, family, or neurological disease history. Physical examination revealed that the patient was experiencing impaired consciousness, with a Glasgow Coma Scale score of 9. There was neither bleeding in the nasal cavity nor in the auditory canal. While the right pupil was 2 mm and sensitive to light, the left pupil was dilated and did not react to light. Movement in the right eye was normal; however, the left eye did not move. The patient demonstrated soft neck, and negative Kernig's and Brudzinski's signs. The right limbs were unresponsive to pain and the left limbs exhibited an avoidance reaction.
X-ray revealed an intracranial FB of ~130 mm in length. Fortunately, there was no sign of fracture. Computed tomography (CT) indicated that the FB had penetrated the medial, inferior portion of the eyeball; superior orbital fissure; parasellar region; circular cistern; and left cerebellar hemisphere. A hematoma was located in the cerebellar hemisphere and the cerebellar vermis, with edematous surrounding brain tissue and high density of the tentorium cerebelli. Three-dimensional CT reconstruction of the skull confirmed that the orbital wall was intact, with no sign of fracture or bone destruction. CT arteriography (CTA) revealed that the FB was close to the inner wall of the cavernous sinus segment of the left ICA. CT venography (CTV) showed that the tip of the FB was compressing the left transverse sinus (). Digital subtraction angiography (DSA) suggested that compressive stenosis had occurred in the C4 segment of the left ICA with no sign of rupture, and the distal branches of left ICA were slightly sparse (). The left transverse sinus was also compressed but no rupture was observed (). 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:
An 81-year-old British Caucasian male presented to the physicians with a cough, haemoptysis and an irregularly irregular pulse rhythm. A CT chest and upper abdomen demonstrated consolidation of the right lung base and he was treated for his pneumonia and atrial fibrillation. Shortly after admission he developed abdominal pain, diarrhoea and a low-grade pyrexia. His CT scan was reviewed and it was noted that there was a small amount of intra-abdominal fluid with several retroperitoneal lymph nodes. The right kidney had an atypical area of calcification within its upper pole and he was subsequently referred to the urologists for further evaluation (). As his condition failed to improve he underwent a further CT scan that demonstrated a large right psoas abscess (). This was drained under CT guidance and he was eventually discharged with a urology outpatient follow up as it was thought his renal problem was the cause of the abscess. Upon review the patient was symptomatically better, a diagnosis of an old calcified cyst in the right kidney was made and he was discharged to his GP.
Eight months later, after a permanent pacemaker had been fitted, an interval USS showed no residual psoas abscess. However, one month subsequently he was admitted under the general surgeons with a 3-week history of mild back pain, diarrhoea and rigors. He also had a discharging abscess in his right lumbar region which contained gas bubbles. A CT scan revealed sigmoid diverticulosis () with a recurrence of the extensive right-sided retroperitoneal abscess and a tract connecting it to the sigmoid colon ().
As an interim measure whilst being optimised for surgery, the abscess was drained with a 14F pigtail drain. At laparotomy the sigmoid colon was found frozen in the pelvis with perforated sigmoid diverticulosis noted to be the cause of the right sided retroperitoneal abscess. A sigmoid colectomy and primary anastomosis was performed and he was treated post-operatively with antibiotics. He made

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


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

[User]
RADIOLOGY NOTE:
A 38-year-old woman presented in the gynecological emergency unit complaining about massive upper abdominal pain and vomitus. The pregnancy to date of admission developed without any pathological findings in preventive medical examinations. When premature contractions in cardiotocography were seen, a primary tocolysis was started. Results of blood tests and abdominal ultrasonography lead to the strong suspicion of a severe exsudative pancreatitis (Table 1 ). The patient was transferred to the intensive care unit immediately. Due to a silent cardiotocogram during following surveillance an emergency caesarean section was performed in spinal anesthesia. In the following hours the clinical situation aggravated rapidly. The performed computer tomography showed a massive necrotizing pancreatitis. The further decay of vital signs (systolic blood pressure 70 mmHg) and development of a fulminant abdominal compartment syndrome (bladder pressure higher than 40 mmHg) necessitated emergency laparotomy. Intraoperative about 12 liters of hemorrhagic ascites could be aspirated, the whole greater omentum was covered with calcifications and the necrotic areas expanded down to the lesser pelvis (Figure 1 ). We performed a necrosectomy with the evacuation of the tissular debris and the abscesses followed by a vacuum assisted closure (VAC) of the abdomen. Subsequently, the patient’s vital signs could only be stabilized with high doses of catecholamines. Additionally, haemofiltration was necessary to control an increasing acidotic metabolism as well as the hypercalcaemia. As hypercalcaemia is an unusual finding in pancreatitis we performed an ultrasound of the neck and found an adenoma of the left lower parathyroid gland. The strong suspicion of a primary hyperparathyroidism was confirmed with parathormone measurement which showed a massively increased level of 1,330 pg/ml (normal range 15–65 pg/ml). As a result of these findings we performed a relaparotomy postoperative day one. Intraop

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


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

[User]
RADIOLOGY NOTE:
A 27-year-old male presented after a motorcycle versus semi-trailer truck at freeway speed. He complained of left thigh and abdominal pain. The patient had no comorbidities and presented with Glasgow Coma Scale score 15 and was hemodynamically stable. Radiographs demonstrated a comminuted displaced and bayoneted acute left femoral subtrochanteric fracture with extension into the lesser femoral trochanter and a complex left ankle fracture. A full computed tomography (CT) scan with contrast demonstrated a grade 2 liver laceration, grade 3 left kidney laceration, bilateral first rib and scapula fractures, a left pelvic retroperitoneal hematoma with hemoperitoneum (Figure ) and a traumatic left lumbar hernia (Figure ). Shortly afterwards the patient became hypotensive and developed peritonitis; therefore, massive transfusion protocol was initiated and the patient was transferred to the operating room. On exploration, a left-sided traumatic abdominal wall hernia was identified with significant bleeding. The left colon was medialized exposing the abdominal wall hernia and the left iliac vessels. A full-length longitudinal tear along the anterior aspect of the left common iliac vein was noted with significant bleeding. The left hypogastric artery was ligated, transected, and mobilized to expose the full extent of the injury. Distal and proximal digital control was achieved, and the vein was ligated. There was no further bleeding and hemostasis was obtained. Total estimated blood loss was 2,000 cc. The remainder of the abdomen was inspected and did not require intervention. The abdomen remained open postoperatively due to massive resuscitation resulting in coagulopathy and hypothermia. The abdomen was closed on the following day and the traumatic hernia left in situ for potential future repair due to his concurrent injuries. His multiple orthopedic injuries were repaired and he received surgical debridement of a thigh, pelvic, and arm degloving injury. He was diagnosed with

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


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

[User]
RADIOLOGY NOTE:
A 53-year-old African-American woman with ESRD was transferred from dialysis clinic to the emergency room (ER) for evaluation of non-radiating and dull epigastric pain for two weeks associated with fever and chills during hemodialysis (HD). Three months ago, she was hospitalized and treated for Streptococcus pneumoniae and Enterobacter cloacae bacteremia. A year ago she was treated for S. maltophilia bacteremia secondary to an infected dialysis catheter. Past medical history was also significant for hypertension, atherosclerotic vascular disease pending elective coronary artery bypass graft (CABG) surgery, and sudden cardiac arrest followed by ICD placement. With the current presentation, both blood and catheter cultures obtained at the dialysis clinic were positive for S. maltophilia, prompting her subsequent arrival to the emergency room. She presented with a continuation of fever and chills, as well as tachycardia and episodic hypotension. She was noted to have mild epigastric tenderness. There was no surrounding erythema, discharge, or tenderness noted around the tunneled dialysis catheter on the right anterior chest. Initial workup showed elevated troponin and procalcitonin. Chest X-ray findings were suggestive for left lower lobe pneumonia. Within the ER, the patient's hypotension resolved with fluid resuscitation and intravenous levofloxacin therapy was started with blood cultures drawn.
Cardiology was consulted for persistent elevation of troponins and it was presumed secondary to impaired clearance in ESRD. Transthoracic echocardiography (TTE) was done to evaluate for endocarditis given the presentation of bacteremia and fevers. TTE revealed artifact noted on an abandoned ICD lead in the right heart concerning for possible vegetation. Repeat blood cultures were positive for S. maltophilia and the patient was continued on levofloxacin. Infectious Diseases was consulted and as per their recommendation the infected tunneled dialysis catheter was removed on the

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


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

[User]
RADIOLOGY NOTE:
A 63-year-old Hispanic female, with a past medical history of chronic obstructive pulmonary disease (COPD) and a 60 pack-year smoking history, presented to the emergency department (ED) complaining of new-onset generalized weakness for the past three days with associated frontal headaches. The remaining review of systems was reported as negative and she was vitally stable.
She was alert and cooperative. Her cranial nerves were intact. Her motor exam, however, was abnormal, with motor strength in the left upper extremity (LUE) being 4/5. The strength and tone of the other extremities were normal throughout. Deep tendon reflexes were decreased bilaterally, but her gait could not be evaluated. Her sensory function was decreased to pin sensation at the LUE and bilateral lower extremities (LEs). Normal sensation was noted in the right upper extremity and face. Laboratory testing was normal. Computer tomography (CT) of the brain was done, revealing a large area of intraparenchymal hemorrhage within the right parietal lobe and a smaller area within the right frontal lobe with surrounding vasogenic edema and a mild rightward midline shift, suggestive of an underlying neoplastic lesion, as can be seen in Figure . Brain magnetic resonance imaging (MRI) of the brain delineated a right parietal lobe rim-enhancing lesion measuring up to 39 x 27 mm and a right frontal lobe rim-enhancing lesion with increased enhancement at the anterior aspect measuring up to 21 x 17 mm, as observed in Figure . Computed tomography (CT) of the chest with contrast demonstrated multiple pulmonary masses with a dominant left upper lobe of 4 cm mass, as well as a complex septate cystic 2.5 cm mass in the right kidney, as can be observed in Figure .
In order to improve the patient's clinical status and obtain an accurate diagnosis, the patient underwent right frontoparietal craniotomy and resection of the hemorrhagic brain lesion. Pathology was amended as poorly differentiated non-small cell type carcin

[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 23-year-old man presented to the emergency department following an alleged assault with a knife sustaining three stab wounds to his left upper limb. On examination, the patient was hemodynamically stable and afebrile. Physical examination revealed a 6-cm injury over the bicep area and two 2-cm wounds over the deltoid area. On palpation, a foreign body of firm and non-mobile consistency was palpated under the skin on the deltoid area. There was no evidence of a neurological deficit in the left upper limb. Radial and ulnar pulses were with good intensity and good rhythm. Laboratories showed normal hemoglobin of 14.7 g/dl, an elevated white blood count of 14.5×10^10, with no other alterations. Chest and left arm radiography were performed on different projections, identifying a broken blade impaled in the humerus bone with the tip of the blade completing penetrating the bone ().
The patient was transferred to the operating room. Under general anesthesia, and with the patient in a supine position, we chose to make our approach from the lateral side of the arm, incorporating the original stab wound, allowing circumferential access to the humeral shaft, performing a lateral incision on the deltoid area, extending it proximally and distally, exposing the foreign body entry point. The broken piece of the blade was pressed with the surface of the bone and was strongly fixed in the area of the crest of the greatest tubercle of the humerus (). The humeral artery was unharmed, with an adequate pulse. No lesions to the axillar, radial, or ulnar nerve were seen. Neurological examination of the left upper extremity revealed no motor or sensory deficits. We were not able to pull it out with any surgical instrument, so with the aid of an orthopedic surgeon, the surrounding bone tissue was osteotomised until the blade was released. The blade was then removed (). The wound was closed in layers, with

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


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

[User]
RADIOLOGY NOTE:
A 43-year-old male patient presented to our centre, with chief complaint of sudden onset, progressively worsening binocular diplopia in the right eye for the preceding 1 month. No history of any trauma or similar complaint was elicited in the past. The patient was found to be adequately built, with vital signs being normal and had no evidence of systemic abnormality. On ocular examination, best-corrected distance visual acuity and near vision in both the eyes were 6/6 and N6, respectively. Anterior and posterior ocular segment evaluation was unremarkable. Although the eyes were aligned in primary position, horizontal gaze palsy was noted with loss of saccades and pursuit movements in levoversion. On attempted dextroversion, the right eye was abducting with associated abduction nystagmus, in the absence of left eye adduction []. Both vertical gaze and convergence were normal. Based on ocular findings, the diagnosis of ipsilateral one-and-a-half syndrome was made.
Magnetic resonance imaging (MRI) was advised following clinical evaluation, which revealed an irregular complex cystic enhancing space-occupying lesion measuring 42 mm × 39 mm × 35 mm, in the region of fourth ventricle closely abutting the brain stem posteriorly [Fig. and ]. Multiple small ring and disc enhancing lesions were also seen in the bilateral cerebellar hemispheres and right occipital lobe. Radiological findings suggested brain metastasis.
Further evaluation was supplemented with 18F-fludeoxyglucose positron emission tomography/computed tomography (CT) imaging to locate the primary pathology. Abdominal CT scans showed primary neoplastic lesion, arising from the upper pole of the right kidney and another exophytic mass in the lower pole of the left kidney. In addition, metastatic lesions in the right adrenal gland, pancreas, and brain were seen. Based on examination and investigations, diagnosis of Stage 4 RCC (inoperable) with brain metastasis with associated ipsilateral one-and-a-half syndrome was

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


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

[User]
RADIOLOGY NOTE:
Our patient is a 54-year-old female with a past medical history of hypothyroidism and very severe obesity (BMI 48 kg/m2). She underwent laparoscopic gastric sleeve surgery in the year 2012. Results were non-satisfactory in terms of weight loss with a difference of 6 kg/m2 in BMI post-procedure. So after six years, she underwent a laparoscopic biliopancreatic diversion with a duodenal switch. She had an uneventful postoperative recovery period. An upper gastrointestinal (GI) study contrast post-procedure did not reveal any evidence of obstruction or leak. The patient was discharged home two days after the procedure. A few days later, she started experiencing three episodes of nausea with brown-colored vomitus. She was found to be septic, with a heart rate of 110 beats per minute and temperature of 100.2oF. Her white blood cells count was 12/mm3.The source of infection was presumed to be intraabdominal considering her symptoms. Computed tomography (CT) of the abdomen and pelvis showed mildly dilated proximal small bowel loops. The patient was started on empiric antibiotic therapy with ceftriaxone 1 gm intravenous (IV) daily and metronidazole 500 mg IV every eight hours. Symptoms did not improve, so she was taken back to the operating room for diagnostic laparoscopy. Partial small bowel obstruction was noted along with ischemia of a segment of the ileum that was part of the duodenoileostomy due to mesenteric dissection. She underwent an open revision of the small bowel anastomosis with resection and anastomosis for the obstruction revision of the duodenoileostomy. Her hospital stay post-surgery remained uneventful. Diet was advanced gradually throughout the hospital course and a week later, the patient was discharged home with outpatient follow-up. Three weeks after that procedure, she noticed a productive cough with thick, yellow, foul-smelling phlegm and shortness of breath. She saw her primary care physician. A chest X-ray performed showed a right lung infiltrate wi

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


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

[User]
RADIOLOGY NOTE:
A 61 year-old man was admitted with a 103 ° F fever, confusion, weakness and slurred speech after hemodialysis. He had a history of viridans streptococcal mitral valve endocarditis, end stage renal disease on hemodialysis, atrial fibrillation not on anticoagulation due to GI bleeding, and monoclonal gammopathy of undetermined significance. He had a productive cough for a week without any identifiable sick contact. Physical examination was notable for an agitated edentulous man with a left central facial palsy, severe dysarthria, and a systolic murmur at the left lower sternal border. His lungs were clear to auscultation and there was no stigmata of endocarditis.
The patient was initially treated empirically for pneumonia and worked up for stroke. However, the treatment plan was quickly modified when a transthoracic echocardiogram on day two of admission revealed two echogenic structures consistent with vegetations: 0.4 × 0.4 cm on the anterior leaflet of the mitral valve, and the other 0.7 × 1.8 cm attached to left coronary cusp of the aortic valve (Fig. ). There was also thickening of the aortic root suggestive of abscess formation. Two sets of blood culture grew Gram-positive rods after 37.5 h incubating in anaerobic bottles (Fig. ), and after 86 h in aerobic bottles. The organism was identified as A. neuii by MALDI-TOF MS on day five of admission. Serial brain MRI scans revealed multiple bilateral infarcts on day two with increased number of infarcts and a small focus of hemorrhage on day five. The patient was diagnosed with infective endocarditis by A. neuii complicated by aortic root abscess and presumed cerebral septic emboli.
The patient was initially treated with vancomyin and piperacillin/tazobactam until A. neuii was identified. Subsequently, he was treated with ampicillin and gentamicin for two days, followed by ampicillin for the rest of his hospitalization. The choice of ampicillin was based on a large series that studied susceptibility to antibiotics o

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


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

[User]
RADIOLOGY NOTE:
A 67-year-old female with past medical history of congenital deafness presented to the emergency room with complaints of right-sided facial droop and right upper extremity weakness, tingling, and numbness. These symptoms were sudden in onset and lasted for a few minutes. Symptoms had completely resolved at the time of presentation. She did not have a history of any atherosclerotic risk factor including hypertension, diabetes, or hypercholesterolemia. The initial set of vital signs were normal; routine laboratory tests including complete blood count and basic metabolic panel were unremarkable. A computed tomography (CT) of the head without contrast as well as a magnetic resonance imaging (MRI) of the brain with and without contrast did not show any acute intracranial hemorrhage or infarction.
The patient was diagnosed with TIA, and further investigations were planned to determine the etiology. A magnetic resonance angiogram (MRA) of the head and neck with and without contrast did not show any arterial flow limiting stenosis or occlusion. A transthoracic echocardiogram (TTE) with bubble study using agitated normal saline contrast was performed and was found to be normal. Patient's heart rhythm was monitored with continuous cardiac monitoring, and no arrhythmias were noted during her stay at the hospital. At this point, the patient was identified as having cryptogenic TIA, having failed to determine the precise etiology from routine workup. Patient was started on aspirin therapy and discharged from the hospital on day 3 with further outpatient workup planned. Outpatient workup for hypercoagulability showed a high factor VIII activity of 153%, which potentially put her at increased risk of venous thromboembolism. However, this test was performed just one week after the thrombotic event and was hence difficult to interpret. Subsequently, a transesophageal echocardiogram (TEE) was performed that revealed a patent foramen ovale with right-to-left shunt. This raised the con

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


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

[User]
RADIOLOGY NOTE:
A 62-year-old otherwise healthy woman presented with three to four months of mechanical right groin pain radiating to the right buttock. She had a history of a benign soft-tissue mass in the right thigh that had been biopsied 10 years earlier, and the patient was told it was a myxoma. No other workup was done at the time, and no other lesions were clinically detectable. She had been very active and played tennis regularly. She was assessed with a hip ultrasound for her right groin pain and was prescribed physiotherapy. During physiotherapy, she felt a snap in her right groin and was no longer able to ambulate without a walker. Initial radiographs demonstrated a lucent intramedullary lesion within the subtrochanteric region—further characterized by a focally aggressive appearance with cortical destruction and lytic expansion of the lesser trochanter (Figures and ). A ground-glass appearance, typical of fibrous dysplasia, was also noted in the mid-femoral shaft ().
Further workup included a Computed Tomography (CT) scan of the chest, abdomen, and pelvis which showed multiple hepatic and renal cysts but no evidence of a primary carcinoma or lung metastases. Bloodwork including serum protein electrophoresis was normal. A Total Body Bone Scan (TBBS) revealed increased uptake in the right proximal femur and two areas of relatively mild uptake in the mid femur. Fat-suppressed T2 Magnetic Resonance Imaging (MRI) displayed an intermediate to high signal lesion within the medullary cavity of the proximal and mid right femoral shaft (). In line with the initial radiographs in which two benign sites of fibrous dysplasia were noted, in the third proximal lesion, there was cortical destruction with an extraosseous soft-tissue mass in the region of the lesser trochanter. Additionally, in keeping with the known myxoma, a soft-tissue T2 hyperintense mass within the medial distal thigh was also present (). On further review of the MRI images, five other myxomas were seen

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


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

[User]
RADIOLOGY NOTE:
A 58-year-old male presented with decreased vision in his left eye, without redness or floaters, which had persisted for three days. His medical history detailed a diagnosis of nephrotic syndrome (membranous nephropathy), which had been treated with prednisone for a period of four months. Drug-induced diabetes was subsequently detected one month after the onset of corticosteroid treatment. The patient developed productive cough, pyrexia, and night sweats, and was further diagnosed with pneumonia three weeks before the admission. His medications at the time included prednisone 20 mg daily, insulin and oral cefdinir. He had no history of ocular trauma or surgery.
An ophthalmic examination revealed visual acuities of 20/20 in the right eye and counting fingers at 2 ft in the left. Pupils were 3 mm and reactive in each eye without relative afferent pupillary defect. The right eye was normal. Slit lamp examination of the left eye was unremarkable. Fundus examination showed clear media and a creamy-white and raised subretinal lesion located at the posterior pole, with the lesion being five disc diameters in size. Additionally, multiple retinal hemorrhages were seen in the overlying retina (Fig. ). The intraocular pressures were normal in both eyes. Optical coherence tomography (OCT) demonstrated a hyperreflective substance located in the subretinal space, between the outer retina and retinal pigment epithelium (Fig. ). Although a further diagnostic workup was requested on the follow day of presentation, the patient was lost to follow-up and presented five days later with reduced vision in the affected eye. On examination, slit lamp examination of the left eye showed mild conjunctival injection and anterior chamber cells of 2+. Fundus examination revealed mild vitritis and further, the area of the retinal lesion had expanded over the superior and inferior arcades (Fig. ).
The patient was admitted for further workup. All vital signs were stable and within normal range. The

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


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

[User]
RADIOLOGY NOTE:
A 56-year-old Chinese male patient was admitted to our center with left sided chest pain for one year. A computer tomography angiography (CTA) demonstrated an aortic arch aneurysm, aortic arch coarctation and LICA aneurysm. The CTA also showed a 50 mm sized saccular aneurysm 3 mm distal to the left common carotid artery (LCCA), the left subclavian artery (LSA) arose from the aortic arch aneurysm and the size of aortic arch coarctation was 12 mm (Figure A-C). The patient refused to undergo conventional surgical repairment, however, endovascular therapy alone would not treat all the lesions of this patient. Therefore, we decided to perform a hybrid procedure that consisted of a LICA aneurysm resection and revascularization, carotid to carotid bypass operation and the placement of stent graft in the aortic arch aneurysm to save the LCCA, coils embolization of the aortic arch aneurysm and aortic arch coarctation dilatation. The procedure was performed under general endotracheal anesthesia with full hemodynamic monitoring one week later after admission. We performed LICA aneurysm resection and the carotid to carotid bypass operation connecting from the right carotid artery to the left carotid artery in advance for revascularization of the post-stent grafting in the hybrid room one step. The right femoral artery was exposed through a groin oblique incision and cannulated with a 10-French catheter sheath from which an angiographic mark catheter was put into the ascending aortic artery via a 0.035 inch guidewire. A digital subtraction angiography (DSA) was performed which was in agreement with the CTA images. It also confirmed the patency of the carotid to carotid bypass graft and showed dominant right vertebral artery (Figure D, E). The “C” arm was locked at left anterior oblique (LAO) 50° projection to thoroughly unfold the aortic arch that was cannulated with a 21-French delivery introducer sheath via a 0.035 inch Lunderquist super stiff guidewire (COOK, USA) through the

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


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

[User]
RADIOLOGY NOTE:
A fit and healthy 12-year-old white boy (height 150cm, weight 40kg) underwent elective removal of a 2×2cm benign skin lesion from his anterior abdominal wall. He had no past medical history and was not on any medications. His physical examination preoperatively was normal. Surgery was scheduled for the late afternoon. He was fasted for 6h for solids and 2h for clear fluids. The World Health Organization surgical checklist for safety in the operating room [] was complied with intraoperatively, which included the prohibition of jewellery and other constrictive clothing items worn during surgery. After establishing intravenous access with a 22-guage cannula in a vein in the cubital fossa of his left arm, anaesthesia was induced with propofol (140mg) and fentanyl (50ug). A size 3 classic laryngeal mask was inserted for airway management, and spontaneous ventilation was maintained with 1 minimum alveolar concentration sevoflurane in a 50% oxygen to air mixture. Five millilitres of a local anaesthesia solution (lignocaine 2% with 1:200,000 adrenalin) was injected into the surgical area for local anaesthesia and postoperative analgesia. During surgery both of his arms were positioned by his side in a neutral position, supported by foam padding on the operating table to minimise pressure. The abdominal lesion was removed uneventfully and the procedure took 22min. Continuous electrocardiography, pulse saturation monitoring, and intermittent blood pressure measurements every 3min were normal. After uneventful emergence from anaesthesia, the laryngeal mask was removed, and he was transferred to the postoperative recovery unit for a 30-min observation period. He was haemodynamically stable, with normal arousal to voice and command. He required no further analgesia and was transferred to the ward at 1830 hours. On the ward his observations remained stable. After a light meal and when completely conversant and cooperative, he was discharged home under parental supervision.
He pre

[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 female with a history of hypertension, migraines, anxiety, and depression presented to the Emergency Department with a left-sided occipital headache for one hour (thought to be consistent with her usual migraine presentation) with accompanied numbness of the left face and lips, vertigo, and lightheadedness. Her initial blood pressure was 172/85, and cranial nerves II through XII were intact except for some mildly decreased sensation to light touch on the left side of her face. The patient did note that she felt less vibration from the tuning fork on the left forehead as compared to the right forehead. Cognitive status and language were grossly intact and muscle strength was 5/5 in all extremities. Initial NIH stroke scale was 1. On cardiac examination, the patient had an extra diastolic heart sound, interpreted as a splitting of S2, without murmurs, gallops, or rubs. Given concern for a stroke, an initial computed tomography (CT) scan of the head was performed and was found to be negative for an acute, evolving cerebrovascular accident. It was thought that the symptoms were most likely related to a migraine, but the patient was admitted to the floors for further workup. Over the next 24 hours, the patient's clinical condition continued to deteriorate with a worsened neurological exam now including diplopia, left-sided dysmetria, more pronounced vertigo, and difficulty swallowing. A stroke alert was called and magnetic resonance imaging (MRI) of the brain was performed, which showed focal restricted diffusion within the left posterolateral aspect of the medulla with associated focal heterogeneous hyperintense signal, indicative of an evolving focal subacute cerebrovascular accident (). The patient was transported to the step-down unit with an NIH stroke scale score of 2 for neurological checks every two hours. It was noted that the patient was not a candidate for tPA at this time due to presence of symptoms ongoing for over 24 hours.
Given her presentat

[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 40-year-old nulliparous woman with no past medical history, other than endometriosis, presented to the emergency room with severe chest tightness of one day duration. She described chest tightness while exercising on a bicycle after 10 minutes. The next day she developed a severe hacking cough at work during a conference call. The cough was associated with disorientation and severe chest tightness. This prompted her to present to the emergency department in February 2018. The patient is a pharmacist, nonsmoker, and denies illicit drug use or recent travel. She had endometrial laser ablation with myomectomy in 2006. Hormonal contraceptives have been used since 2004 and were stopped three months before presentation in hopes of conception. Her last menstrual period was four days before the onset of symptoms. On physical examination, she had chest tightness localizing to the right side and decreased right sided breath sounds. All the routine laboratory work and vital signs were normal. The CXR showed a large right spontaneous pneumothorax with what approved to be a 5.6 cm pleural mass at the right lung base ().
Following the pneumothorax diagnosis, the patient underwent emergent right thoracostomy with pigtail catheter placement. A repeat CXR revealed marked re-expansion of the lung but persistence of the right cardiophrenic opacity of unclear etiology. A follow-up CTof chest showed a 33 mm diaphragmatic defect with a 5.8 x 4.6 x 3.9 cm area of herniated liver corresponding to the presumed pleural mass ().
Following complete thoracic imaging the patient underwent video-assisted thoracoscopic surgery (VATS), mechanical pleurodesis, and open repair of the right diaphragmatic defect by Dr. Emily Cassidy (Figures and ). Intraoperatively, the lungs appeared grossly normal. An obvious diaphragmatic defect was noted in the posteromedial portion of the central tendon of the diaphragm with a sizable protrusion of liver in to the chest cavity. There was an attempt to dissect li

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


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

[User]
RADIOLOGY NOTE:
The patient was a 74-year-old woman who had undergone colectomy for adenocarcinoma of the sigmoid colon at the age of 72 years. Before the colectomy, she had been found to have a tumor measuring approximately 25 mm in the left lobe of the thyroid that was diagnosed as an adenomatous goiter by fine-needle aspiration. Two years after her surgery, a 6-month follow-up computed tomography (CT) scan revealed enlargement of the thyroid tumor, but she remained asymptomatic. Blood tests revealed a small increase in CA 19-9 (from 3.5 ng/ml 6 months earlier to 8.9 ng/ml) and in carcinoembryonic antigen (CEA) (from 1.7 ng/ml to 4.6 ng/ml). Her thyroid function tests were normal. Physical examination and laryngoscopy revealed a firm elastic nodule in the thyroid gland and left vocal fold paralyzed in the midline position. The maximum phonation time (MPT) was 10 seconds. There was no cervical lymphadenopathy. Ultrasonographic examination of the neck revealed a solid tumor in the left thyroid lobe with a diameter of 35 × 25 × 20 mm. CT showed spread of this mass to the tracheoesophageal groove, suggesting invasion of the left recurrent laryngeal nerve (RLN; ). Fine-needle aspiration cytology of the thyroid tumor showed a few clusters of elongated tumor cells with hyperchromatic dark nuclei on a background of benign hepatocytes, and the mass was reported as metastatic adenocarcinoma. Positron emission tomography-CT showed focal uptake in the left thyroid lobe with no evidence of distant metastasis (). Therefore, the diagnosis was metastasis of adenocarcinoma to the left thyroid gland. We then performed a hemithyroidectomy with resection of the left RLN and immediate reconstruction using the ansa cervicalis nerve (). The tumor was observed to be adherent to the adjacent structures, i.e., the trachea and external muscle of the esophagus as well as the left RLN. The surgical margin was confirmed to be adequate, and the decision was made not to

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


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

[User]
RADIOLOGY NOTE:
The patient is a 29-year-old G3P2002 woman at 39-week and 1-day gestation, who was referred from a health center for management of fetal demise. She had attended 03 antenatal visits at the same health center wherein the fundal height was documented at each visit and routine care given. Except for occasional painful fetal kicks, she was otherwise well throughout the antenatal period. Three days prior to admission into our service, she experienced reduced fetal movements for which she consulted at the said health center and a diagnosis of fetal demise was made. On admission to our unit, she had stable vital parameters. There was no abdominal tenderness and an apparent fundal height of 32cm was measured, fetal parts were not easily palpable, and fetal heart tones were not perceived. There were no signs of per vaginal bleeding. Her cervix was long, posterior, firm, and closed. An emergency ultrasound scan was requested which confirmed fetal demise (gross cranial deformation was noted) but failed to diagnose an intra-abdominal location.
Cervical ripening was started with 50µg of misoprostol vaginally every 6 hours and after 4 applications; the cervix remained unchanged. A decision for operative delivery was made, indicating failed induction and in a bit to reduce the risk of disseminated intravascular coagulation. The intraoperative findings were a third-degree macerated female fetus floating freely in the peritoneal cavity, weighing 2650g with a tight cord round neck and with no amniotic sac (). The uterus was about 14 weeks () and the fallopian tubes and ovaries were normal. The placenta was implanted on the ascending colon and mesocolon. The placenta was left in place. No intraoperative complications were encountered. Postoperatively, she was placed on ampicillin, gentamycin, and metronidazole parenterally for five days. She also received 50mg of methotrexate every other day (04 doses) with 5mg of folinic acid each day proceeding the methotrexate. She was discharged o

[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 82-year old female with a past medical history of alcohol abuse, chronic kidney disease, and right total knee arthroplasty 11 years prior presented to the emergency department after a ground-level fall during a syncopal episode. Her initial complaints included right hip and knee pain, left shoulder pain, and left-sided forehead pain. Radiographs of the left shoulder revealed an acute fracture of the distal clavicle with no additional findings found on radiographs of the right hip, left lower leg, or right knee (). Computed tomography (CT) imaging of the head showed a left frontal scalp hematoma without any acute intracranial abnormality; thus, she was admitted for management and workup of her syncopal event.
On the second day of admission, the patient was noted to have increased tenderness to her left lower leg. A radiograph at this time was negative for acute fracture but demonstrated extensive chondrocalcinosis () of the knee joint. Also, at this time she began complaining of increased pain and swelling to her right knee. The following day, these symptoms continued to worsen and she subsequently underwent further imaging with a right knee CT scan. The scan revealed a large joint effusion without evidence of acute injury. Although she did experience mild intermittent hypertensive and tachycardic episodes, she was afebrile throughout her entire admission and her white blood cell count ranged from 9.5 to 14.4 × 109/L. At this time, the orthopedic surgery service was consulted to assess her right knee symptoms and evaluate for a PJI.
Upon evaluation by the orthopedic service, the patient complained of severe right knee pain that worsened with flexion and extension. Prior to this, she denied any problems with her knee replacement or any history of gout. Physical exam of the right knee was significant for a marked effusion, diffuse tenderness to palpation, and restricted range of motion with guarding. Further workup included erythrocyte sedimentation rate (ESR) and C

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


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

[User]
RADIOLOGY NOTE:
A 51-year-old male patient with sudden onset of acute right lower abdominal pain and gross hematuria was admitted to the Emergency Department on 1 June 2019. An abdominal examination showed tenderness in the right side of pelvic cavity, as well as a huge mass. The pain radiated to the right side of the lower back, along with percussion pain over the right kidney region. A routine blood test showed normal findings. Urinalysis showed that the red blood cell count was 61.50/µL. Tumor biomarkers, including α-fetoprotein, cancer antigen 125, and carcinoembryonic antigen, were within normal limits. The patient had no medical history of splenectomy or trauma.
During the first check-up, an ultrasonographic examination showed a pelvic mass of 7.0 × 6.5 cm in size and it was situated directly in front of the iliac blood vessels. The mass was grossly well circumscribed by a capsule, and the interior echo of the mass was solid and homogeneous. Color Doppler ultrasonography showed large vessels entering the mass, but tracing the origin of these vessels was difficult because of the influence of intestinal gas (). A calculus in the lower segment of the right ureter was also detected, as well as mild hydronephrosis of the right renal pelvis (pyelic separation of 18 mm, ). The spleen was in the regular site and was normal in size in the left upper abdomen.
On the third day of admission, magnetic resonance imaging (MRI) (1.5T; Signa GE Healthcare, Milwaukee, WI, USA) showed a 6.8 × 6.0-cm round mass on the right side of the pelvis (). On the fourth day of admission, a computed tomography (CT) scan showed a well-defined, homogeneous, round mass in the pelvic space (). The mass was approximately 6.7 cm in diameter and adjacent to the right iliac blood vessels. A normal-sized spleen was detected in the left upper abdomen. CTA clearly showed

[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 woman was referred to our outpatient clinic with a one-month history of vague pelvic pain not associated with urinary symptoms or gross hematuria. The patient had a past history of a well-controlled hypertension and five uncomplicated vaginal deliveries. Physical examination was unreliable due to sever obesity. Abdomino-pelvic sonography and DMSA scan performed at another institution demonstrated a normal located left kidney with a proper cortical function and an ectopic right kidney in the bony pelvis with a 7.8 × 4.3 cm heterogeneous mass in its lower portion. The patient was admitted in our department for further evaluation. Metastatic work-up was negative. A Multi slice CT and 3D-CT angiography of abdomen and pelvis was obtained. No oral agent was administered. After performing an unenhanced CT, 150 ml of contrast material was injected intravenously. Arterial phase images were obtained after a 20-second delay with a collimation of 3 mm, table speed of 1 mm per revolution and an image reconstruction interval of 1 mm. The arterial phase was used to depict the renal arteries. Parenchymal-phase imaging was initiated 240 seconds after injection of contrast material with a collimation of 3 mm, a table speed of 2 mm per revolution, and an image reconstruction interval of 2 mm. Multi-slice parenchymal-phase CT scanning of the pelvis showed a heterogenous mass consisting of multiple solid and cystic areas arising from the lower portion of the ectopic pelvic kidney replacing most of the normal renal parenchyma []. In addition, 3D-CT angiography demonstrated the blood supply of the pelvic kidney to arise from a single renal artery originating from the right common iliac artery just below the aortic bifurcation []. In axial and coronal images there was an artery suspected to supply the renal mass but after 3D reconstructions was proved to cross just parallel to the kidney [].
The patient underwent radical nephrectomy without any peri-operative complication and

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


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

[User]
RADIOLOGY NOTE:
The patient is a 61-year-old Korean male with a significant past medical history of rheumatoid arthritis, hypertension, and diabetes mellitus who presented to the hospital with sudden onset of blurry vision in his left eye three days prior. A head CT had been performed at an outside facility, which was negative for acute ischemia, hemorrhage, midline shift, or extra-axial fluid collection. The patient denied visual complaints in his right eye and had no history of similar events.
Ophthalmologic and Neurologic consultations initially revealed visual acuity was 20/40 on right eye; however, on the left eye, there was an apparent left-sided visual loss. Patient's intraocular pressure was normal in both eyes, pupils were equally round and reactive to light, and no afferent pupillary defect was observed. Moreover, the extraocular muscles were intact and with full range of motion. In the right eye, visual fields were full to finger count. In the left eye, the acuity in the nasal visual field was greater than that in the temporal visual field. In the nasal visual field, the patient was able to count fingers; however, in the temporal visual field, the patient could barely detect gross hand movement at one foot out. External examination was within normal limits, and pen light examination was only remarkable for nuclear sclerotic cataracts bilaterally. Dilated fundus examination demonstrated no evidence of pathology to the vitreous, optic nerve, or retina that might explain the vision loss. Four days later, repeat examination by Ophthalmology demonstrated a stable right eye; nonetheless, the left eye temporal visual field was 20/25 and patient was able to count fingers without mistake on left visual field. Pupil and retina examination were unchanged from previous examination. However, visual field mapping could not be done as this patient was seen in the inpatient setting.
Consequently, an initial head MRI with and without contrast was performed, which showed focal areas of re

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


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

[User]
RADIOLOGY NOTE:
We present a 47-year-old woman who had balance problems for three months. In January 2015, imaging techniques revealed multiple brain metastases and a right lung malignant lesion with mediastinal and supraclavicular lymph nodes. A supraclavicular biopsy revealed an adenocarcinoma histopathology with thyroid-specific transcription factor-1 (TTF-1) and cytokeratin-7 (CK-7) positivity. She had imbalance with gait disorder and no other complaints. She was admitted to our hospital for the treatment of the brain metastases. A cranial magnetic resonance imaging (MRI) revealed that she had six metastases. Two of them were large in diameter and one of them was creating pressure on the brainstem with an edematous zone surrounding the core lesion (Figure ). For this reason, she was advised to have WBRT first and robotic radiosurgery boost one month later according to the response. The patient did not agree to undergo WBRT because of concerns and anxiety about potential side effects. Between January 22, 2015 and January 28, 2015, the patient had robotic radiosurgery for her six brain lesions. Two lesions were treated with 25 Gy in five fractions and the remainder were treated with 18 Gy in one fraction. Her imbalance and gait disorder improved rapidly. As the epidermal growth factor receptor (EGFR) was positive (subtype of exon 19 or 21 deletion was not known), the patient started to use the first line TKI; erlotinib (Tarceva©, Roche Genentech Inc., CA, USA) 150 mg per day orally as a systemic therapy.
The patient continued treatment with erlotinib without any complaints for two years and four months. In May 2017, 29 months after radiosurgery, the patient developed sudden left upper extremity paresis. A multiparametric cranial MRI including perfusion, diffusion MRI, and MR spectroscopy demonstrated that all treated lesions had regressed, but a lesion at the right frontal lobe, 24 x 33 mm in diameter, had increased vascularization peripherally and had progressed, and it was acce

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


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

[User]
RADIOLOGY NOTE:
A 22-year-old man was referred to our hospital with complaints of left eye redness and swelling for more than a month. He had no history of nausea or vomiting, but he also complained of mild blurred vision, double vision and occasional headache for more than a week.
On further questioning, the patient revealed a history of a trauma. He was involved in a motor vehicle accident and received a head injury that involved basilar skull fractures and resulted in a subarachnoid haemorrhage and epidural haematoma. The patient received conservative treatment and was discharged from a local hospital following the alleviation of symptoms. However, the patient developed symptoms in the left eye 4 months after the injury. These symptoms included blurred vision, swelling, and hyperaemia of the left eye.
He denied a history of diabetes and hypertension. There was no history of pneumonia, tuberculosis, or any other infectious diseases. There was also no history of fever, sickness or any surgery. There was no loss of appetite or loss of weight. He was a non-smoker with no allergies to any medications.
On examination, the visual acuity and intraocular pressure in the right eye of the patient were 6/5 and 17 mmHg, respectively, and the corresponding values for the left eye were 4/5 and 25 mmHg. On physical examination, there was no eyelid swelling, exophthalmos, ptosis or visual decrease of the right eye, and this eye was almost normal except for slight hyperaemia (Fig. ). Extraocular muscle movement showed no limitation in the right eye (Fig. ). However, the left eye exhibited eyelid swelling, mild ptosis, exophthalmos, chemosis, and corkscrew hyperaemia centred on the cornea (Figs. and ). Furthermore, there were some limitations of eye movement, and abduction and elevation of the left eye was − 1, yet movement on adduction and depression were normal (Fig. ). The left anterior chamber was slightly shallow and

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


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

[User]
RADIOLOGY NOTE:
A 55-year old man was hospitalized for congestive heart failure due to combined severe stenosis and regurgitant aortic valve disease. The patient’s medical history included rheumatic heart disease requiring a 23 mm aortic root homograft implantation 21 years earlier. The patient was referred to our center for surgical intervention. Transthoracic echocardiography showed severe aortic valve regurgitation (pressure half time < 200 ms), moderate aortic stenosis (mean gradient 38 mmHg), left ventricular ejection fraction of 0.50 and a moderate mitral regurgitation and stenosis. Coronary angiography showed no significant stenosis, however aortic calcifications were visible and a computed tomography (CT) scan was performed to access the ascending aorta. The CT scan showed severe calcifications at the level of the annulus and distal part of the homograft (Fig. ). A transcatheter aortic valve implantation was considered, however, due to the young age of the patient, concomitant mitral valve surgery and a strong preference for mechanical valve prostheses the patient was accepted for surgical correction. The calculated logistic EuroSCORE was 5.6% and the Society of Thoracic Surgeons calculated risk of mortality was 3.2%.
The operation was performed through a median sternotomy and cardiopulmonary bypass was established with cannulation of the proximal aortic arch and bicaval venous cannulation. The body temperature was actively cooled to 33 degrees Celsius. A left ventricular vent was inserted through the right superior pulmonary vein. After clamping the aorta, an oblique aortotomy was made distal of the homograft due to severe aortic calcifications. Custodiol cardioplegia was administered selectively in both coronary ostiae. Sondergaard’s groove was dissected and a rheumatic mitral valve was identified with low likelihood of repair. Therefore, a 31 mm St. Jude Medical Regent mechanical mitral valve prosthesis was implanted (St Jude Medical, Inc., St Paul, Minn, USA). Afterward

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


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

[User]
RADIOLOGY NOTE:
A 78-year-old Caucasian gentleman presented with a painful 2 cm irregular swelling in the nail bed of the distal phalanx of the right middle finger, with brown discolouration of the nail bed. The swelling in the digit had been present for ∼30 years, which had begun following a fracture of the terminal phalanx and had gradually increased in size over the preceding 6 months. There was no axillary or cervical lymphadenopathy and the patient was fit and well.
Clinically a differential diagnosis of an aggressive adenocarcinoma was suspected, but this was not supported by multiple radiological investigations. CT and MRI of the lesion showed a vascular destructive lesion that was causing severe erosion of the distal interphalangeal bone (Figs and , respectively). A plain chest radiograph at that time showed no pulmonary metastasis.
As the radiological investigations had shown that the distal phalanx was not viable and a lack of proximal invasion, it was felt appropriate to perform an amputation at the level of middle to distal third of the middle phalanx. Such an amputation was aimed at being curative, in addition to providing a definite diagnosis, maintaining function and allowing for primary closure.
The patient underwent an amputation of the middle phalanx of the right middle finger. Histopathology of the specimen showed a high mitotic grade lesion with a small focus of lymphovascular invasion, diagnostic of ADPA (Fig. ). The tumour was 0.7 mm from the nearest resection margin. The high rates of recurrence and metastasis were explained to the patient, who declined further surgical treatment.
Seventeen months following initial presentation, the patient developed a mass in the right axilla. In addition, subsequent plain chest radiograph (Fig. ) and CT of the thorax showed multiple pulmonary metastasis. An axillary clearance was performed and one of the ten nodes confirmed metastatic disease. Shortly after this, the patient suffered an intracranial haemorrhage into the rig

[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 girl who suffered second- to third-degree burns over 20% of her total body surface area after an automobile accident 14 years ago presented at our clinic. She had undergone previous multiple scar revisions and contracture releases in order to correct the burn scar contracture and was seeking further reconstructive treatment.
The girl presented with severe scar contractures that mainly affected her posture, but also affected the movement of her head and neck, resulting in abduction of her right arm (). In addition to functional impairment, she complained of social isolation and avoidance behavior caused by the physical disfigurement of her breasts.
A very rigid scar was present, spanning both breasts and resulting in symmastia and a downward shift of the right inframammary fold by about 3 cm relative to the left side. There were vestigial remains of the nipple-areolar-complex on the right breast and a complete absence of the nipple-areolar complex on the left breast.
Severely contracted burn scars were found on the right side of the neck and on the right trunk down to the abdomen and right groin. Scar contraction impaired the reclination of the head and abduction of the right arm, as well as resulting in an inclined posture.
Two separate operations were conducted to recover adequate head, neck, and right arm mobility, and a third operation was conducted for breast reconstruction. During the first operation, the scar contractions of the neck and right axillary region were treated with Z-plasties. Split skin grafting was performed to release the contracture of the right flank and to improve the patient’s posture, and a tissue expander was implanted in the right parascapular region. After sufficient tissue expansion, we performed the second operation. During this procedure, a free parascapular flap was harvested to improve and reconstruct neck movement and reclination, and plastic surgical reshaping and remodeling of both breasts with local skin flaps was

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