[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 17-year-old woman whose chief complaint was left wrist pain on the dorsal and ulnar side and anomalous appearance of the left wrist, presented at our institution. She was informed about deformity of her left forearm by a school physician when she was a junior high school student. However, she did not visit the hospital because her left wrist was asymptomatic. She had scoliosis (left thoracic–lumbar scoliotic curve extending from Th11 to L4 with apex at L1, measured as about 12° using Cobb method). No one in her family has this variant.
As a participant in a high school Japanese drum club, she often had wrist pain after playing the drums. Her wrist pain of the ulnar side had worsened gradually during activities of daily life, such as when opening a bottle lid. At first presentation, her wrist and hand translated the volar side relative to the longitudinal axis of the forearm; the ulnar head projected dorsally ( and ()). Clinical examination revealed that she had deep pain by pressure of the dorsally protruding ulnar head on the left side. However, she had not complained of any symptom in the right wrist. The posteroanterior and lateral radiograph of left wrist showed a 30° ulnar tilting angle, 5.7 mm lunate proximal subsidence and a distal radial notch and 50° palmar tilt angle (). On the right side were a 53° ulnar tilting angle, 2.0 mm lunate proximal subsidence and no distal radial notch and 80° palmar tilt angle ().
Left wrist extension and flexion were, respectively, 45° and 60°. Forearm pronation and supination were 90° and 90° (right side wrist extension and flexion were 60° and 60°, with forearm pronation and supination of 90° and 90°). Scores of QuickDASH of Japanese version and Hand 20 at the first visit were, respectively, 79.5 and 81. The Japanese version of QuickDASH

[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 woman presented with a painless movement restriction of both shoulder joints, complicating activities in daily life such as personal hygiene and lifting her child.
One year ago, 5 days postpartum, respiratory insufficiency developed. She was admitted to the ICU and diagnosed with metastasized choriocarcinoma (lungs, liver, and kidney). Curative chemotherapy was started. She developed ARDS, further complicated by multiple organ failure, critical illness polyneuropathy, and bowel perforations, necessitating mechanical ventilation, alternating prone, and supine positions for several months for a better ventilation of the lungs. After 3 months, she was discharged and rehabilitation was initiated.
On examination, there was a global atrophy of shoulder musculature, with a fixed position of both shoulders at 20° of abduction and 45° of internal rotation. Shoulder movement was exclusively scapulothoracic. Active abduction was 60° bilaterally, and anteflexion was 45° in the right shoulder and 90° in the left shoulder (). No neurovascular deficits were present.
X-rays of both shoulder joints showed an identical osseous mass between the humerus and scapula (). Magnetic resonance imaging (MRI) () and three-dimensional reconstruction computed tomography images () showed complete bony bridges, located in the teres minor muscles. Also, isolated ossifications in the subscapularis muscles and avascular necrosis (AVN) of both humeral heads were demonstrated. The AVN of the humeral heads was thought to be a consequence of the corticosteroid therapy at the ICU or, less likely, changes in vascularization due to compression or traction by the bony bridges.
Surgical resections of the osseous bridges via posterior approaches in 2 separate sessions were planned, starting with the left, nondominant side (). Five months later, her right shoulder was operated in the same manner.
A posterior vertical incision was made from the posterolateral edge of the acromion in the direction 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:
Case 1. A 67-year-old man presented with pain and swelling in the right shoulder. He was diagnosed to have metastatic thyroid carcinoma at another facility four years ago and was treated with radioactive iodine.
At initial presentation, he also underwent open reduction and internal fixation of the right proximal humerus for a pathological fracture with the T2 Humeral Nail (Stryker, Kalamazoo, Milwaukee, USA), followed by radiation therapy to the right humerus. He presented to our institution with plain radiographs of his right shoulder showing an osteolytic lesion of the head of the right humerus along with soft tissue swelling of the proximal arm. A computed tomography (CT) scan showed the disappearance of the proximal humeral cortex (). Magnetic resonance imaging (MRI) showed the lesion to have mild high signal changes on both T1 and T2 weighted imaging, extending to the surrounding muscles (). Needle biopsy confirmed recurrent metastatic thyroid carcinoma. After counseling the patient, a surgical resection and reconstruction were planned. Preoperative embolization of tumor feeding vessels was carried out by interventional radiologists. The surgical incision extended from the medial side of the right clavicle, across the coracoid process, extending to the distal end of the right humerus and included the needle biopsy tract. The tumor and surrounding muscles were carefully resected en bloc with a humeral intramedullary rod. The axillary nerve and posterior humeral circumflex vessels were sacrificed. The right clavicle was mobilized by freeing its medial attachments but leaving its attachments to the acromion intact. The floating clavicle was rotated by 90 degrees clockwise and was fixed to the distal humerus with an AO small fragment locking plate.
No postoperative complications were observed after the surgery. Radiographs taken 9 months after the operation showed callus formation between the clavicle and the distal humerus. The postoperative length of the reconstr

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

[User]
RADIOLOGY NOTE:
A 68-year-old woman presented to the Department of Oral and Maxillofacial Surgery at Nagoya Ekisai Hospital (Nagoya, Japan) with a chief complaint of malaise and a 7-month history of swelling of the left buccal mucosa. The patient had no congenital swelling of the left buccal mucosa at birth and no history of systemic disease or relevant family history. The patient had undergone maxillary molar restoration treatment 2 years earlier, after which she reported biting regularly on her buccal mucosa. On most occasions, the wound had healed within a week, so she had not sought medical treatment. An extraoral examination revealed no facial swelling or asymmetry. However, an intraoral examination revealed an area of diffuse swelling on the left buccal mucosa measuring about 15 mm × 30 mm and containing a papillary lesion with multiple red, blue, and clear pebble-like vesicles (Figure ). On palpation, the lesion was nontender and soft. The swelling had not expanded to the veins and was pulsatile. An orthopantomogram confirmed that the adjacent bone was intact. Magnetic resonance imaging revealed a soft tissue mass with a clearly distinguishable outline of the buccinator muscle (Figure ). The lesion was surgically excised under local anesthesia with a margin of 3 mm and a depth of 2 mm via the inside surface of the fascia of the buccinator muscle. The outcome was favorable. Pathologic examination of the specimen revealed expanded lymphatic vessels lined by thin endothelial cells and containing lymphatic fluid. A diagnosis of lymphatic malformation was confirmed on histopathology and immunohistochemical studies. Immunohistochemistry was negative for vascular markers such as CD31 and CD34, and the lymphatics stained specifically for D2-40 (podoplanin) (Figures , , ). On follow-up, the wound was found to have healed with no evidence of trismus or recurrence. The patient continued to be recurrence-free at her 2-year follow-up. Informed consent was obtained from the patient,

[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 14-month-old girl presented to a private hospital with bilateral DDH. Plain radiographs showed a complete dislocation of both hips (Fig. ). She underwent staged open hip reduction and acetabuloplasty. The left hip was treated first, followed by the application of a hip spica cast for 6 weeks. The right hip was operated afterward, followed by immobilization in a hip spica for 6 weeks and then in a broomstick cast for another 6 weeks. After the removal of the cast, the right hip was dislocated again. The patient was treated with closed reduction under anesthesia and immobilized in a hip spica for another 2 months. Upon removal of the cast, the right hip had dislocated again, and there was stiffness in both hips.
At the age of 20 months, the patient was referred to our hospital with severe stiffness of both hips and a dislocated right hip (Fig. ). Because of the stiffness, we referred her to the physiotherapist to improve the range of motion (ROM) in both hips. Four months later, the ROM was acceptable (Table ).
A computed tomography (CT) scan revealed a central acetabular bony prominence posterior to the triradiate cartilage that measured around 1.5 cm in width at its base and had an 8-mm long tooth-like end projecting into the joint. The femoral head was dislocated in the posterior-lateral direction (Fig. ). The parents were informed about the nature of their daughter's condition and the purpose of performing our novel operation, which, to our knowledge, has never been performed before, and they provided consent to perform our technique and for publication of the case.
Under general anesthesia, examination and arthrography of the right hip were performed and revealed an obliterated right acetabulum (Fig. ). We accessed the joint through the previous incision and excised all fibro-fatty tissue obliterating the acetabulum. Consecutively, we removed the bony

[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 right-handed woman sustained a right intra-articular comminuted distal radius fracture with dorsal displacement (), a right femoral shaft fracture, and a hemothorax in a motor vehicle accident. Open reduction and internal fixation was performed using 3.5-mm T-LCP for the distal radius fracture at 12 days after the trauma, and the plate was covered by the pronator quadratus after fixation. Immediate postoperative plain radiographs revealed acceptable restoration of radial inclination, radial length, and volar tilting, except an approximate 2 mm step-off of the articular surface. The plate was placed tightly to the distal radius without any gap, and even though the distal edge of the plate was very close to the transverse ridge of the distal radius, it did not reach the distal portion of the transverse ridge. Plain radiographs at 8 months after surgery revealed bony union without further collapse of the distal fragment compared to that of the immediate postoperative radiographs, and range of motion of the right wrist was normal. Accordingly, we recommended plate removal, but the patient refused, stating that she was experiencing no specific discomfort.
She visited our hospital at 40 months after surgery and reported that she had a sudden thumb flexion limitation during washing 10 days ago. She had no associated pain and no warning symptoms such as tendon irritation. A physical examination revealed that she could not actively flex the right interphalangeal joint of her thumb, although the range of motion of her other joints and sensory findings were normal. Radiographic findings revealed no definite interval change (). Ultrasonographic findings showed that the FPL tendon had ruptured, and the proximal stump was found at the radiocarpal joint. We performed a surgical exploration and found that the distal edge of the plate was exposed even though the pronator quadratus was nearly completely covering the plate. The FPL tendon had ruptured over the distal edg

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


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

[User]
RADIOLOGY NOTE:
A 45-year-old female presented with three months' history of passing bright red blood per rectum, associated with tenesmus, but no history of abdominal pain, weight loss, or anorexia. She had a swelling on the right side of her neck for two years. No comorbid conditions were reported nor was there any family history of CRC. The physical examination showed a cervical lymphadenopathy on the right side of her neck. Chest and cardiovascular examination yielded normal results. Abdominal examination did not reveal any tenderness, organomegaly, or palpable masses. Digital rectal examination and rigid proctosigmoidoscopy revealed a rectal lesion that was 8 cm from the anal verge and was confirmed by colonoscopy. The rest of the colon was clear. Magnetic resonance imaging of the pelvis showed a rectal cancer confined to the wall. No evidence of any extrarectal involvement or regional lymphadenopathy was noted. Computer tomography (CT) of the abdomen and the chest did not reveal any metastasis. A rectal lesion biopsy showed the moderate development of adenocarcinoma. Unfortunately, transrectal ultrasonography was not performed because of the unavailability of the technology. Fine needle aspiration (FNA) of the cervical lymph node revealed a metastatic adenocarcinoma of colorectal origin []. The results of FNA were not convincing and were disregarded, especially as the lesion was more than two years old, with no other constitutional symptoms apart from the recent history of bleeding per rectum. A second physical examination of the neck was performed which revealed the same findings: cervical lymphadenopathy and no palpable thyroid mass. Neck ultrasonography was performed and confirmed a presence of nodularity in the right thyroid lobe []. FNA was performed again for both the thyroid nodule and the cervical lymphadenopathy. A second pathologist was asked to examine both FNA specimens and confirmed the diagnosis of a papillary carcinoma of the thyroid that had metastasized to th

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


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

[User]
RADIOLOGY NOTE:
A 29-year-old man of Asian origin was admitted with constant abdominal pain localising to the right upper quadrant with no radiation. There was no history of fever, haematuria, diarrhoea, vomiting or trauma. He had no significant past medical or family history. He had been a lifelong non-smoker, was not on any regular medications and had no known drug allergies. On examination, his vital observations and chest examination were normal. His abdomen was soft on palpation and right upper quadrant tenderness was elicited with no signs of peritonism.
Erect chest and abdominal radiographs were unremarkable. Serum biochemistry showed normal renal and liver function while full blood count showed leucocytosis (total white cell count 21.3 × 109/L) and normocytic anaemia (haemoglobin concentration 10.2 g/dL). Urine dipstick showed trace of protein only. Computed tomography (CT) scan (contrast enhanced) of the abdomen and pelvis showed a mixed attenuation lesion associated with a large perinephric haematoma ( and ). The patient was initiated on intravenous antibiotics.
After 48 h, the patient remained apyrexial and pain was well controlled while inflammatory markers improved. Four days following admission, the patient experienced severe acute onset right upper abdominal pain. Repeat blood tests showed a significant drop in the haemoglobin concentration to 6.3 g/dL. After resuscitation and blood transfusion, a repeat CT scan (contrast enhanced) showed a pseudoaneurysm in the inferior branch of the right renal artery (). The patient immediately underwent selective renal angiography confirming the presence of a bleeding 5.1 ×3.7 cm right renal artery pseudoaneurysm which was embolised successfully with two platinum coils ( to ).
The patient was monitored for further 48 h during which his pain improved, haemoglobin concentration remained stable and he was discharged from hospital. There was no evidence of undiagnosed hypertension as he remained normotensive prior to embolisation 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 15-year-old boy from rural West Bengal, India, presented with a history of a jellyfish sting on his lower limbs incurred while bathing in the sea in the Bay of Bengal about four weeks earlier. Initially he had an intense burning sensation and swelling of the affected parts along with a skin rash, comprising blisters, redness and superficial ulcerations. There were no systemic symptoms. The initial symptoms subsided with conservative management, including a systemic antibiotic, an analgesic and an antihistamine, but some peculiar asymptomatic skin lesions persisted, compelling him to seek a dermatological consultation. There was no history of any local application on the sites of the jellyfish sting and he reported no past history of any skin disease. In addition, there was no history of a similar illness in the family.
An examination revealed multiple small papules over the lower part of his left thigh on its anterior aspect and also over the patellar region (Figure ). The lesions had a distinct violaceous hue and were discrete as well as confluent in a linear fashion in parallel rows. The lesions on his right calf were small papules, grouped in clusters in a linear fashion. Some of these lesions showed crusted erosions. Other areas of his skin were uninvolved and his nails were normal. There was no regional lymphadenopathy or mucosal involvement.
Histopathology with hematoxylin and eosin stain revealed a dense perivascular accumulation of mononuclear cells immediately beneath the dermoepidermal junction underneath an acanthotic epidermis with tapering rete ridges (Figure ). Focally, a few mononuclear cells were seen infiltrating the basal layer, and vacuolar change of the basal layer was not seen. Perivascular sparse infiltrate was also seen in the deeper portion of the dermis and the subcutis was normal.
The skin lesions significantly subsided with a three-week course of a twice daily topical application of betamethasone dipropionate (0.05%)

[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:
On April 23rd 2015, a 47-year-old female patient with a surgical history of cesarean section in 1992 was admitted to our department complaining about postprandial pain and distention of the right lower abdomen for 17 years after the resection of most part of the transverse colon. She suffered from constipation since 1988, with the average defecation frequency once 3-4 d, and the lowest once a week, and received no special treatment then. However, she did not experience any abdominal symptoms during the first 20 years of her life.
On 10th February 1998, she was hospitalized in Department of Emergency Surgery in our hospital because of bellyache and constipation, and was discharged after conservative treatment. However, she was re-hospitalized due to intestinal obstruction and was suspected as “adhesive ileus” based on her operation history only 6 d later. The transverse colon resection was planned. The pre-surgical blood and urine tests were normal. The endoscopic pathological examination and the routine fecal examination were not conducted. The surgery was conducted on 12th March. During surgery, it was observed that the middle of the transverse colon was significantly distended to approximately 10 cm in diameter. Around 25 cm of the dilated colon was removed, and the splenic flexure was rectified. The post-operational pathological examination showed infiltration of acute and chronic inflammation cells and focal hemorrhage (the immunohistochemistry and specific staining tests were not performed, possibly due to the fact that HD was not considered, or to the unavailability of such a test then). However, after the first surgery, she still experienced constipation, and postprandial bloating and bellyache, and soon felt obvious aggravation of the symptoms. She was then prescribed with laxatives. She was hospitalized to our hospital again in 2000 due to ileus, and refused the suggested reoperation. She was discharged when feeling better after conservative management, and

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

[User]
RADIOLOGY NOTE:
A 62-year-old caucasian woman came to the emergency room with fever for a month and pain in the left upper quadrants of the abdomen and lower left back pain. She had no other systemic symptoms or comorbidity. Routine blood tests were in the normal range with no evidence of infectious diseases. On clinical examination there were no signs of peritonitis but we found a palpable large mass in left flank. We performed a CT abdominal scan that demonstrated a voluminous solid oval mass (11.2 cm × 7.5 cm × 12 cm) in the left perirenal space with dislocation of the kidney and in continuity with the anterior renal fascia. After iodinated-contrast we observed a progressive, inhomogeneous enhancement of the lesion with peripheral vascularization () [,]. After a percutaneous CT-guided biopsy of the mass the histopathological diagnosis was a dedifferentiated retroperitoneal liposarcoma. Considering the site of the neoplasm in left renal loggia and the absence of others repetitive local or distant lesions our tumor board decided for surgical resection of the mass in block with kidney and left adrenal gland. We chose the possibility of laparoscopic approach with conversion to open surgery in case of muscle infiltration or vascular invasion. After preoperative clinical study [] the surgical procedure was carried out with a transperitoneal approach with the patient in right lateral decubitus position to obtain a large surgical field with well known anatomic landmarks and possibility of exploration of peritoneal organs. We used a laparoscopic 3D vision system [,] with three trocars in the left subcostal region, but during surgical procedure we positioned another 5-mm trocar for spleen retraction. We performed an adequate mobilization of the splenic-pancreatic block in order to identify infiltration of peritumor tissues. We found a well-capsulated mass. The dissection was done with Harmonic scalpel™ (Ethicon Endo Surgery INC – Johnson & Johnson, NJ, USA) from up-to-down until the left

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


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

[User]
RADIOLOGY NOTE:
A 34 years old woman was admitted to our emergency room, brought in by ambulance; she complained of 3 syncopal attacks at home as well as an abdominal pain lasting over a period of 2 days.
In her medical history, she did not report any previous disease or surgery. She had both a 4 and a 2 years old child, who had been vaginally delivered with no complications. She had never used any contraceptive and did not have any history of pelvic inflammatory disease. She only suffered from oligomenorrhea and her last menstrual period was unknown.
When she arrived in the emergency ward, the patient was severely pale. Her pulse rate was 100/minute and her blood pressure was 125/80 mmHg.
Abdominal assessment appeared slightly tender. No particular pain was evocated and no masses were found. The examination was limited to patient's elevated body mass index of 40. Bi-manual vaginal examination revealed a normal uterine size and a palpable and painful left adnexal mass; the right ovary was not detected. Digital palpation of the punch of Douglas was deeply painful. No vaginal bleeding was observed. At vaginal and abdominal ultrasound examination (), we saw an anti-verted uterus of 97×57 mm, with decidual reaction, a left adnexa with a hyperechoic mass of 68×56 mm, with no univocal interpretation and a normal right ovary of 32×13 mm. There was a moderate amount of free fluid in the pelvis, in the Morrison's pouch and in the paracolic gutters. We also identified a rounded image with hyperechoic boundaries, which led us to believe that there was a suspicion of a fetal head in the upper right side of abdomen, which was difficult to study taking into consideration also the bowel movements and the patient's habitus. The woman did not know her eventual obstetric status. Thanks to blood tests, we were able to confirm our hypothesis: beta human chorionic gonadotropin (hCG) was 78,

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


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

[User]
RADIOLOGY NOTE:
A 64-year-old Japanese woman visited our hospital with an initial symptom of dyspnea on exertion. For the past 4 months she had shortness of breath when she walked approximately 100 meters or went up 10 to 20 steps of a staircase. She visited her neighboring hospital 1 month before visiting our hospital where she received a diagnosis of bilateral pleural effusions and seven sessions of thoracentesis; however, no clinical diagnosis could be made although her dyspnea on exertion was slightly improved by the frequent thoracentesis. When she visited our hospital for the first time, she felt dyspnea on exertion on the ground level after several hundred meters. Before she had dyspnea on exertion, she had not had any diseases including sarcoidosis nor had she received any continuous medications such as immunosuppressive drugs. She had no previous history relating pleural effusion, and no family history of sarcoidosis. She did not have any past history for opportunistic infections. A chest radiograph showed the enlargement of bilateral hilar shadows, reticulonodular shadows in bilateral lung fields, and dullness at the right costophrenic angle (Fig. ). Her serum angiotensin-converting enzyme (ACE) level was elevated to 44.2 IU/L. Her immunoglobulin G (IgG) and sIL2R levels were also elevated (Table ). Bacterial culture for sputum resulted in negative findings for tuberculosis. Polymerase chain reaction (PCR) analysis also showed no tuberculosis in her sputum.
Three weeks later, she was admitted to our hospital for diagnosis and treatment. Neither restrictive pulmonary function disorder nor remarkably reduced diffusing capacity of her lungs was observed. The 6-minute walk test revealed that she could walk up to 370 meters with a minimum blood oxygen saturation (spO2) of 93%, maximum pulse of 126 beats per minute and the worst modified Borg scale of perceived dyspnea of 1. Chest computed tomography (CT) showed multiple skin nodules, bilateral hilar and mediastinal lymphadenop

[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:
52 year old female presented to the department of otorhinolaryngology with complain of unilateral gradually progressive swelling over the left side of the nose below the eyes since 2 months. The swelling was painless to begin with, but patient gives history of pain over the swelling since 2 weeks.
There are no aggravating or relieving factors. No history of radiation of pain. No history of recent trauma. Patient also gives history of watering of left eye since 2 days. Not associated with nasal obstruction, nasal discharge. No history of visual disturbance. There was no history of significant weight loss or loss of appetite. No significant medical history (past history of tuberculosis, exposure to patients with tuberculosis), or family history.
On examination she was conscious cooperative and well oriented to time place and person. Vitals were stable.
A swelling measuring 1.5 x 2 cm was noticed on the lateral aspect of the nasal bridge, inferior to the infraorbital ridge. Firm in consistency, irregular surface, ill-defined margins, non-tender, mobile in horizontal and vertical direction, no local rise of temperature, no skin changes and skin was pinch able.
Rest of the ear, nose, throat and neck examination were within normal limits. No palpable neck lymph nodes.
On investigation
Blood parameters were within normal limits except for ESR, which was 76mm/hr.
HIV, HbsAg and HCV were negative.
FNAC was done from the lesion which showed multiple inflammatory cells- suggestive of chronic inflammation. A plain CT scan was done which showed- soft tissue density noted adjacent to anterior wall of left maxillary sinus. The lesion is not involving the anterior wall of sinus. ().
Chest x-ray PA view was normal
Patient was planned for excision of the lesion under ga and was taken up for surgery after anaesthetic pre-op fitness. A cosmetically better approach was planned for this case i.e endoscopic sublabial approach to the swelling

[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 40-year-old female diagnosed with breast cancer in 2019. She underwent modified radical mastectomy in July 2019 and was on trastuzumab chemotherapy. She was referred to the neurosurgical service for a right parietal tumor on metastatic workup [] and was scheduled for craniotomy for tumor resection. Before surgery, she underwent two COVID-19 polymerase chain reaction (PCR) tests in accordance with our preoperative protocol, and both were negative. During surgery, gross total tumor resection was achieved and the dura was closed in a watertight fashion using absorbable 4–0 sutures. The bone flap was anchored using silk 2–0 sutures. The postoperative course was uneventful and she was discharged home on the 3rd postoperative day. Histopathology confirmed the diagnosis of metastatic breast cancer.
One week after discharge, the patient experienced severe and persistent cough that kept her awake at night. She self-medicated with antitussives with minimal relief. Three days later, she noted a gradually bulging fluid-filled mass at her postoperative site, as well as the sensation that there was something moving underneath the fluid collection. After a 2 more days, fluid leaked from the surgical incision, prompting the patient to consult at the emergency department.
On examination, the patient was awake, oriented, and able to follow commands. She did not have fever or nuchal rigidity. She had a pseudomeningocele over the postoperative site, with dehiscence of a portion of the inferior limb of the surgical incision and watery fluid draining from it. On palpation, the bone flap was found to be mobile and displaced inferiorly. As part of the hospital protocol for admission, the patient underwent a COVID-19 PCR test, which was positive. She was thus transferred to the COVID-19 isolation unit.
A contrast cranial computed tomography (CT) scan showed postoperative changes at the right parietal area and no evidence of enhancing tumor. There was also no evidence of

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


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

[User]
RADIOLOGY NOTE:
A 65-year-old male presented to the emergency department with a complaint of nausea and vomiting and reported no bowel movement or passing of flatus for 5 days. Upon further questioning, he recalled that he fell from a tractor while working in his farm 2 months earlier and sustained blunt trauma to his abdomen for which his initial evaluation revealed no serious injury except some bruises.
On physical examination, the patient was alert and responsive, his vital signs were stable, and dry mucous membranes were noted. Abdominal examination revealed distended abdomen, increased bowel sounds, and generalized tenderness without rebound tenderness, guarding, or any other significant findings. Fluid resuscitation and nasogastric (NG) tube insertion were initiated for a patient with a suspected diagnosis of intestinal obstruction. His initial lab tests on admission were normal except a mild increase in amylase level (Table ).
The patient underwent an upright abdominal X-ray and chest X-ray. On the abdominal X-ray, multiple air-fluid levels were observed (Fig. ). Both chest and abdominal X-rays revealed the niveau formation of the small intestine on the right side above the liver and right hemidiaphragm (Fig. ). Abdominal sonography reported the presence of dilated intestinal loops. Further evaluation with CT scan confirmed the presence of a few small intestinal loops behind the liver and also in the chest through a rupture in the right hemidiaphragm (Fig. ).
The patient opted for the surgery and exploratory laparotomy was performed. Some small intestine loops had gone behind the liver and through 4 cm rupture in the posterior aspect of the diaphragm into the chest. Displaced intestinal loops were relocated and no sign of ischemia or necrosis was observed. Afterward, the ruptured portion of the diaphragm was closed with Prolene 1 suture by using continuous suturing technique. No other complications were found.
The patient had no postoperative complications and he was symptom

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


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

[User]
RADIOLOGY NOTE:
We present the case of a 71-year-old Portuguese male with a past medical history of hypertension, hyperlipidemia, and gout with no significant family history. He presented with 8-week history of persistent right lower quadrant pain, anorexia with 20 pound weight loss. Vital signs were stable and normal.
On physical examination, a firm, tender, fixed abdominal mass in the right lower quadrant was palpable. Computed tomography (CT) scan of the abdomen showed evidence of multiple masses in the peritoneum and mesentery. A necrotic mass on the right side of the abdomen measured 10 cm with communication to the small bowel and a suggestion of a walled-off perforation. The patient underwent CT-guided biopsy of the abdominal mass. Pathology revealed a tumor consisting mixed spindle and pleomorphic cells with focal rhabdoid features, high-grade nuclear features, and brisk mitotic activity. Ki67 expression was up to 70% []. Initially, a differential diagnosis of poorly differentiated synovial sarcoma of the colon was considered, but fluorescence in situ hybridization (FISH) studies for Ewing sarcoma and synovial sarcoma were negative.
A week later, the patient presented with symptoms of small bowel obstruction. In addition to the previous masses, the CT scan at this time showed a left-sided abdominal mass measuring 8 cm with communication to the small bowel with dilation of the jejunum suggesting a new partial obstruction []. Three lesions were also identified on the liver [] at this time measuring 7 mm, 11 mm, and 1.3 cm as well as a 2.6 cm low-density mass in the spleen. The patient (at this time-delete) underwent an exploratory laparotomy with palliative debulking of the tumor. Multiple large obstructive masses were found in the Ligament of Treitz, proximal jejunum, significant portion of the small bowel, right colon, left ascending colon, and omentum. For palliation purposes, these masses were resected and primary anastomosis was performed. In addition, 300 cc of bloody as

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


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

[User]
RADIOLOGY NOTE:
A 60-year-old Chinese woman presented with the symptom of bloody sputum, which she had noticed for 2 weeks. Enhanced computed tomography (CT) showed an irregular abnormal soft tissue mass located in the left upper lobe that was approximately 1.7 cm× 0.8 cm in size and obviously enhanced with contrast medium (). The CT value in the enhanced arterial phase was approximately 40–60 Hounsfield units, while the venous phase CT value was approximately 72 Hounsfield units. Minimal calcification was not apparent in the tumor. The patient denied any history of gastric carcinoma or digestive symptoms. On the basis of her history and imaging studies, the patient was diagnosed with a malignant pulmonary tumor and underwent lobectomy. The tumor had a heterogeneous off-white appearance and was solid with unclear boundaries. No depressions or varicose veins were found in the pleura.
Hematoxylin and eosin-stained sections showed that the alveolar structure had disappeared within the tumor and that the tumor cells were distributed into round or oval glands with a central lumen. There was no mucin in the tumor cell cytoplasm or glandular cavity. The tumor cell nuclei were ovoid and dark-stained, with prominent nucleoli. The mitotic activity was approximately two mitoses per ten high-powered fields. New bone formation was observed at the center of the tumor (approximately 1.25 mm × 0.85 mm, ). The bone island consisted of mature bone tissue and was surrounded by osteoblast cells that were accompanied by proliferating fibroblasts (). No bone marrow cells were present in the bone tissue. Immunohistochemical staining showed that the tumor cells were positive for cytokeratin-7 () and thyroid transcription factor-1 (), but the metaplastic bone tissue was negative for these factors. However, the tumor cells were negative for caudal-related homeodomain protein 2, which ruled out the possibility of gastrointestinal adenocarcinoma metastasis to the lung, and the Ki-67 labeling index was approxi

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

[User]
RADIOLOGY NOTE:
A 34-year-old woman presented for evaluation of central chest pain followed by a large left-sided pleural effusion causing pleurisy and dyspnoea. Her past medical history included autoimmune hepatitis, premature ovarian failure, and possible myelodysplastic disease with Trisomy 8 on bone marrow examination. She gave no history of trauma, no family history of lymphatic disorder, and there was no evidence of yellow nail syndrome. She was born in Macedonia, emigrated to Australia at the age of 20, and was a lifelong non-smoker. The effusion was treated with therapeutic drainage with the temporary intercostal catheter and fluid with a milky appearance was visualized. Analysis of pleural fluid demonstrated chylomicrons, reactive mesothelial cells, and negative microbiology. Initial chest computed tomography (CT) scan demonstrated normal pulmonary parenchyma. There was no pleural thickening, mass, or nodules. Over the next year, she presented on three more occasions for drainage of left-sided chylous pleural effusions. In order to further elucidate the cause of her pathology she underwent a number of imaging investigations. Lower limb lymphoscintogram demonstrated delayed movement on the right and accumulation of tracer in the abnormal soft tissue in the left superior mediastinal area. Positron emission tomography (PET)/CT scan demonstrated multiple enlarged superior mediastinal lymph nodes anterior to the great vessels of the neck and lateral to the aortic arc, measuring up to 15 mm in size with abnormal uptake in the mediastinal nodes and in the lower neck soft tissue masses. Mediastinal magnetic resonance imaging (MRI) demonstrated a complex multi-lobulated high T2-weighted structure extending from the anterior triangles of the neck down to the superior mediastinum where it surrounded the great vessels (Fig. ). Initially, this appearance was thought to be consistent with a congenital lymphatic malformation and fine-needle aspiration biopsy of a left-sided cervical lymp

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

[User]
RADIOLOGY NOTE:
A 27 year old nulliparous woman presented in November 2008 with a 2 month history of intermenstrual/postcoital bleeding. All previous smears were negative and she is a non-smoker. Clinically on examination there was a 2 × 2.5 cm exophytic lesion on the anterior lip of the cervix. Biopsy taken was inconclusive but suggestive of severe cervical glandular intraepithelial neoplasia (CGIN). The patient was subsequently seen in colposcopy clinic in December 2008 and a superficial LLETZ (12 × 10 × 8 mm) was performed which revealed a moderately differentiated adenocarcinoma of the cervix (10 mm horizontal width × 5 mm depth), incompletely excised, with lymphovascular space invasion (LVSI). The patient was then referred to a cancer centre with the expertise to perform fertility-sparing surgery.
At the cancer centre review the pathology and MRI of the pelvis were suggestive of stage 1b1 cervical cancer with a suspicious right obturator node. An endovaginal MRI pelvis was performed in order to obtain the following two measurements to determine that the correct cervical length was excised: the endocervical canal measured 2 cm and the length from the internal os to the top of the uterine cavity 4.2 cm. At the time of referral the patient was not pregnant and detailed counselling of the patient and her partner not only included the standard treatment but also fertility-sparing surgery. They were warned about the risks of prematurity but also the need for completion treatment by chemoradiation.
In January 2009 the patient underwent a laparoscopic pelvic lymphadenectomy and all 39 nodes were negative. At that time the pregnancy test was negative. In February 2009 a radical vaginal trachelectomy was scheduled but on the morning of her operation the pregnancy test was positive despite having used condoms for contraception. The first day of her last period was 28/12/08.
The case was re-discussed at the weekly multidisciplinary meeting and the following options were discussed:Terminat

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


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

[User]
RADIOLOGY NOTE:
A 68-year-old woman was referred to our department after gastroscopy, which showed a mass in the stomach. She had undergone total abdominal hysterectomy with bilateral salpingo-oophorectomy because of an ovarian serous carcinoma (stage IIIa) nine years ago. On routine workup, gastroscopy showed a round mass, approximately 3 cm in diameter, in the upper body on the greater curvature side of the stomach ().
A biopsy was performed and histologic examination indicated a poorly differentiated adenocarcinoma. Tumor markers including carcinoembryonic antigen and carbohydrate antigen 19-9 were within the normal ranges. Contrast-enhanced computed tomography showed focal, eccentric, enhancing wall thickening in the greater curvature of the stomach body and no significantly enlarged perigastric lymph nodes (). We diagnosed the patient with gastric adenocarcinoma and performed a laparoscopic-assisted total gastrectomy with D2 lymphadenectomy. No ascites or peritoneal lesion was observed. Reconstruction was performed with a Roux-en-Y anastomosis.
The resected specimen contained a polypoid tumor with central ulceration 3 cm in diameter (). Tumor cells had spread through the submucosal layer of the stomach with clear resection margins (). None of the 44 resected lymph nodes were positive for metastasis, but lymphatic tumor emboli were detected by immunostaining with CD-31 and D2-40 antibodies (). The tumor cells showed atypical hyperchromatic nuclei () and accompanying melanin distribution within the tumor nest (). Immunohistochemical examination revealed a positive reaction to HMB-45 antibodies and S-100 proteins and a negative reaction to cytokeratin antibodies ().
Based on these findings, we diagnosed the patient with malignant melanoma. In the pathologic examination, the depth of tumor involvement was to the submucosal level and no metastasis showed in 44 lymph nodes. Therefore, the final pathologic tumor's TNM stage was pT1bN0M0. Postoperatively, further examinations were per

[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 65-year-old male patient presented at the outpatient clinic 4 days after a closed right foot injury. The injury was due to loss of step during a curb descent. The result of the injury was the immediate onset of pain in the mid foot and the ankle joint, with accompanying swelling and difficulty in walking. The patient had free medical history apart from a 2-week treatment with ciprofloxacin for chronic inflammation of the prostate 3 months before the injury. During clinical examination, the patient walked with the right drop foot. Furthermore, severe swelling and bruising under the medial malleolus were present. Dorsiflexion of the foot without resistance was possible to some extent due to the contraction of the toe extensors, but heel walking on the right foot was impossible. Dorsiflexion with the foot in inversion was also impossible.
A gap was palpated along the course of the tibialis anterior tendon. The clinical diagnosis was rupture of the tendon of the anterior tibialis muscle. X-rays of the foot were normal, while the magnetic resonance imaging (MRI)scan confirmed the diagnosis (). The patient was relatively young (65 years old),active, and athletic (daily walks of 10 km); therefore, surgical treatment of the rupture was decided. The operation took place on the 9th post-traumatic day, after the swelling had subsided.
Under spinal anesthesia with the patient in supine position, an 8 cm incision was performed along the course of the tendon from the medial malleolus to the base of the first metatarsal. After partial opening of the tendon sheath of the tibialis anterior tendon, drainage of the hematoma was performed. The proximal stub of the tendon was found at the level of the ankle joint. The tendon was completely detached from its insertions (at the base of the first metatarsal– first cuneiform) ( and ). With the foot in dorsiflexion and inversion, anchoring of the tendon on the first cuneiform bone was performed

[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 10-year-old male child was brought for enlarged feet and hands since birth. He was delivered normally at term with birth weight of 3.8 kg. There were no neonatal or maternal complications. At birth, parents noticed mildly enlarged feet and hands, and at 3 months, striking enlargement of feet and hands was observed. The enlarged extremities had always been disproportionately large and were progressive and fast growing in relation to the remaining body. His physical and mental developmental milestones were normal, and there was no difficulty in playing or carrying out day-to-day activities. There was no visual impairment or any comorbidity. There was no family history of similar symptoms, and he was born to non-consanguineous parents. On general examination, his weight was 22 kg and height was 127 cm. Feet were hypertrophied, especially second and third toes were more enlarged in both feet [], and there was no tenderness or warmth. Similarly, both hands were enlarged [], and there were no functional restriction in both lower and upper limbs. Arterial pulsations were normally felt. Sensation was normal in all the extremities. There were no nodules or pitting edema or café-au-lait spots seen. No audible bruits or thrills were noticed over extremities. There were no other musculoskeletal abnormalities found. Although there was gigantism, no discrepancy in limb length was noticed. Cognition and higher mental function were normal for his age and education. Nervous system and other systems were clinically normal.
His investigation results were as follows: basic blood and urine investigations were normal. Plain radiographs showed enlarged metatarsal and phalanges in the second and third toes of both feet with soft tissue hypertrophy []. Similar to that, plain radiograph of hands demonstrated enlarged metacarpal and phalanges in the index finger as well as enlarged phalanges in the middle and ring fingers of both hands with soft tissue hypertrophy []. Non-contrast-enhanced

[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 first case is a female aged 3 years (y) and 7 months (mo), the second child of a young, unrelated, apparently healthy couple. There are no similar cases in the family. Pregnancy was uneventful, however fetal sonographic evaluation (2nd trimester) revealed enlarged cerebral ventricles. The child was born by C-section at 39 weeks, with an overgrowth of weight 5310 g (+5.3 SD), length of 57 cm (+4.3 SD), head circumference of 38 cm (+3.3 SD), and Apgar score of 8, with difficult respiratory adaptation immediately after birth. She presented with hypotonia and marked developmental delay (at 3 y 7 mo of age she could raise the head with difficulty, was able to sit with support, but spoke no intelligible words). Myoclonic jerks were noted from the first day of life and intensified after 1 y of age (with EEG expression). More complex seizures were noted after 3 years. The child was suspected of deafness at 2 mo, which was confirmed by ASSR with bilateral moderate sensorineural hearing loss. A hearing aid was inserted at 8 mo and frequent otitis media were recorded in time. No visual (object) reaction was noted at 2 mo, however the ophthalmologic examination was relatively normal (interpreted as cortical blindness). The child was diagnosed at 2 mo with a congenital heart defect. Oxygen desaturation during the night was observed after 1 y of age. Recurrent infections (without fever) in different locations were diagnosed over time (otitis, urinary tract infection, pneumonia). During an episode of pneumonia (at 1 y 3 mo) in the ICU, she was given several albumin infusions, and every time she developed a fever after a few hours. Left hip dysplasia was diagnosed at 1 mo of age. Delayed and abnormal teeth eruption (but all teeth buds were present upon radiography) was noted, as well as slow growth of hair and nails. The mother noted slow bowel movements after 7 mo of age (f

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


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

[User]
RADIOLOGY NOTE:
A 57-year-old Asia male with a history of bronchiectasis presented with sudden onset of massive hemoptysis. The patient was sent to our emergent department and emergent endotracheal intubation was performed for airway protection. Chest plain radiography showed increasing opacity in the left lower lobe with bronchial dilatation (Figure A). Chest computed tomography (CT) demonstrated bilateral bronchitis with cystic dilatation in the lingula and left lower lobe with numerous small vessels in the left hilar region (Figure B). Bronchoscopy revealed a large amount of fresh blood over the lower trachea, and the examination could not be completed. Pulmonary angiography demonstrated a plexus of proliferating vessels around left bronchus artery (Figure C).
After adequate resuscitation with blood products, embolization of the left brachial artery was performed. However, some proximal collateral vessels which could not be embolized remained. After the procedure, persistent hemoptysis was noted, and therefore surgical intervention was taken.
After induction of general anesthesia, the patient was intubated with a double-lumen endotracheal tube and placed in the right decubitus position. Two trocars were inserted at 6th and 8th intercostal spaces, respectively, and a 15-cm thoracic incision in the 5th intercostal space was made and a rib retractor was placed. Severe adhesions in the pleural space were found, and all were detached. The major fissure and pulmonary artery were difficult to identify because of severe consolidation of the left lung. The border between the left upper lobe and left lower lobe was unclear. Enlargement and marked tortuosity of the bronchial arteries were also found, and these vessels were ligated with sutures. Pneumonectomy was considered, however, it was not performed in consideration of the high potential mortality. The inferior pulmonary vein was transected to allow identification of the left lower lobe bronchus. The bronchus of the left lower lobe was

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


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

[User]
RADIOLOGY NOTE:
A 48-year-old woman, gravida 1, para 1, visited the internal medicine department at another hospital with a complaint of abdominal fullness and weight loss of 10kg during the last year. A huge abdominal mass was palpated, and she was referred to the gynecology department to search for a tumor of uterine origin. She was premenopausal and had no significant past medical history. Physical findings revealed a large elastic hard mass extending from the xiphoid to the pubic bone. The magnetic resonance imaging (MRI) examination revealed a huge tumor on the uterine corpus, and a number of dilated vessels were observed between the tumor and the myometrium. Therefore, the tumor was suspected to derive from the uterus. The tumor showed an uneven signal on T2-weighted sagittal section (), and the enhanced MRI study showed that the tumor edge but not the center was enhanced (). As such, necrosis was suspected to have occurred in the center of the tumor. Uterine sarcoma was primarily suspected due to the large size, degeneration, and necrosis on MRI imaging. Computed tomography (CT) examination showed no lymph node swelling or distant metastasis. Preoperative laboratory testing revealed anemia (hemoglobin level, 5.6g/dl). We transfused 18 units of RCC before surgery. CT examination and ultrasonography on lower extremities indicated an absence of thrombosis. Preoperative serum levels of CEA, CA 19-9, CA 125, and LDH were within normal limits. A biopsy of the endometrium was not collected as the sounding examination of the endometrium was unsuccessful due to a deviated uterine cervix. At this point, preoperatively, we suspected the tumor was a leiomyosarcoma or leiomyoma with degeneration.
The patient underwent laparotomy, where we identified a huge tumor occupying a space from the pelvis to the diaphragm. The tumor surface was smooth and hard with many dilated veins (). A massive tumor with a diameter of 30 cm was observed arising from the posterior uterine wall with a smooth 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:
The patient, a 6-year-old female, presented impairment of the visual function and headache. The brain MRI, performed in another hospital, revealed a suprasellar/parasellar tumor with an enhancing solid portion with associated multiple cystic structures. The lesion was treated with surgical debulking and subsequent adjuvant chemotherapy and radiotherapy (Society of Paediatric Oncology low-grade glioma 2004 protocol). The final diagnosis of pilomyxoid astrocytoma of the hypothalamic-chiasmatic region was made histopathologically. After about 2 years, the patient presented headache and paresthesia in the right upper limb. The brain MRI revealed some new small areas of T2-hyperintensities in the left perirolandic region suspected for ischemic vascular lesions. The diagnosis of MMS was done basing on the arterial MRI angiography which detected the narrowing of the left ICA and the occlusion of the ipsilateral MCA [Figure –].
After about 3 months from the onset of symptoms, the patient, admitted at another institution, underwent an indirect surgical revascularization with burr holes technique in the left frontal, parietal, and temporal bones.
At the follow-up controls performed every 6 months in our hospital, the neurologic symptoms persisted and the patient showed a rapid impairment of cognitive functions, showing a loss of 10 points at the full-scale intelligence quotient (wechsler intelligence scale for children V). MRI brain perfusion confirmed the hypoperfusion of the left MCA territory with minimal improvement only in the left temporal lobe. Therefore, a new indirect revascularization was planned to guarantee an adequate perfusion. Before the surgery, it was necessary to determine which burr holes developed angiogenesis and which was the relationship between the successful burr holes and the brain areas that remained hypoperfused. A CT scan [] with CT angiography was performed to evaluate the anatomy of the angiogenetic vessels and a MRI perfusion study, with arteri

[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 52-year-old woman presented to the emergency department with 3 days of diffuse abdominal pain that started during a dance class. The pain had a sudden onset with radiation to her back and did not worsen with meals. She had mild associated nausea and bloating but no other symptoms including emesis, hematochezia, melena or diarrhea. Her medical history was notable for former smoking history (10 pack-years, quit 5 weeks prior to presentation), but she was otherwise healthy and was taking no medications. Her surgical history consisted of laparoscopic appendectomy and diagnostic laparoscopy for endometriosis, both of which occurred more than a decade prior to presentation. She was hemodynamically stable with systolic blood pressure ranging from 100 to 120 s mmHg, and her exam was notable for mild diffuse abdominal tenderness without evidence of peritonitis. Her complete blood count and basic metabolic panel were within normal limits, and a venous blood gas demonstrated no evidence of lactic acidosis. A computed tomography (CT) angiogram of the abdomen and pelvis demonstrated a 5–6 cm length proximal SMA dissection with high-grade stenosis of the true lumen as well as a short-segment right external iliac artery dissection with mild narrowing of the true lumen (). There was no radiographic evidence of bowel ischemia.
She was admitted and maintained on bowel rest and heparin infusion. Given persistent pain after 2 days of non-operative management, an abdominal arteriogram was performed through a left axillary artery cutdown. The dissection was identified 1.5 cm distal to the origin of the SMA (). Intravascular ultrasound was used to determine diameters and landing zones for stent placement (). The dissection was initially treated with a 6 mm × 40 mm self-expanding stent followed by post-dilation with 4 mm × 40 mm and 6 mm × 40 mm balloons. A 5 mm × 19 mm stent graft was deployed proximally with small overlap and ~3-mm extension into the aorta. Completion angiogram 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 diabetic 90 years old woman with cough and diffuse abdominal pain was admitted into our hospital with an initial diagnosis of sepsis. Blood sample investigation revealed mild leucocytosis with PRC augmentation and normal AST, ALT and bilirubin levels. Preoperative ultrasound revealed thickened gallbladder wall suggestive of acute cholecystitis. She has had previous sigmoid resection for diverticulitis and ERCP for choledocholithiasis without any mention of biliary abnormality. She was scheduled for a laparoscopic cholecystectomy during which the incidental intraoperative finding of a left sided gallbladder was made. Standard trocar positions were used (A) without any variation of technique, simply following the Strasberg criteria for safe cholecystectomy []. Having seen the anatomical variation (B), a careful dissection of Calot’s triangle was carried out, the cystic duct and artery were identified and isolated, and subsequent complete dissection of the gallbladder from the liver was done (C). This manoeuvre allowed us to demonstrate a right sided positioning of the cystic duct. Furthermore, a safe clipping and transection of the cystic duct and artery was achieved (D), and the gallbladder was extracted in an endobag. The postoperative course was complicated by an aggravation of diabetes and basal pneumonia which were controlled postoperatively in the intensive unit. The patient was discharged on postoperative day 16, in good condition. Retrospective analysis of the clinical case was done and a previous CT scan was reevaluated. Even with the knowledge of a left sided gallbladder, the CT scan was unable to demonstrate its attachment to the left side of the liver. This was probably due to the presence of a hypertrophic left lobe mimicking only a contiguity with the gallbladder, which itself appeared to be in a physiological position (). A vascular and biliary reconstruction was then evaluated with evidence of agenesis of the right anterior sector of the liver () wit

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


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

[User]
RADIOLOGY NOTE:
A 50-year-old healthy female came with a complaint of gradual painless diminution of vision associated with a floater in her left eye from the last one month. On examination, her visual acuity was found to be CF 3/4M Vision in the Left Eye and CF — M in the left eye. Anterior segment examination was unremarkable with intraocular pressure 19 mmHg in the right eye and 9 mmHg in the left eye. Fundus examination revealed myopic tessellated fundus with macular degeneration with the presence of an oval greyish lesion inferior to the macula within the deep posterior staphyloma symmetrically in both eyes [Fig. and ]. The right eye also showed macular hole with retinal detachment. The left eye showed macular hole with Bullous Retinal Detachment extending from 11 to 7’o clock hr with choroidal detachment as evident on Bscan [Fig. , , and ].
A spectral domain OCT was performed and confirmed the presence of macular hole with retinal detachment in both eyes along with the presence of deep macular staphyloma []. Interestingly, deep within the base of the staphyloma on SD–OCT, there was further deep excavation within the staphyloma with thin RPE and choroid which was bilaterally symmetrical suggestive of choroidal coloboma [Figs. , , and ]. This coloboma was corresponding to the oval dark grey excavation seen clinically inferior to the macula and was found to be symmetrical in both eyes. She underwent Encirclage with Pars Plana Vitrectomy with Silicon oil injection. The ILM peel was not done in this case as the posterior staphyloma was too deep and could not be reached.
She improved to 6/36 in the left eye three months post-surgery with maintenance till the last follow up six months later. After surgery, the thin retina was seen to be completely reattached along its contour without any gap even over the colobomatous area

[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 6-hour-old female neonate born from a 22-year-old Para 1 mother after term pregnancy. The newborn had protrusion of mass per vagina since birth; she also has a defect at the lower back with no discharge since the time of birth. Additionally the mother has noticed deformity on both legs and feet which barely move. The baby was active since the time of delivery and is sucking well and she passed meconium. The mother had two ANC visits and was vaccinated according to the national schedule and she reported the whole course of the pregnancy as uneventful. She did not have any known medical illness and has never taken any medication during the entire course of the index pregnancy except iron folate which was prescribed during the ANC visit.
She had spontaneous onset of labor and the membrane was ruptured spontaneously intrapartum. She gave birth to a 2330-gram female neonate after 5 hours of labor at a local health center. Baby had good APGAR score. Health care providers at the health center noticed defect at the back of the baby and referred her to Hawassa University Comprehensive Specialized Hospital (HUCSH) with the diagnosis of spinal bifida.
During the initial evaluation at HUCSH the baby was active, vital signs were in the normal limits, and all neonatal reflexes were intact. There was 4x4 cm pink mass protruding through the introitus, cervical os is noted at the tip of the mass, the external genitalia appears normal, no discharge or bleeding from the mass, and the mass was reducible digitally and increases in size when the baby cries (see ). There was also 4x4 cm defect at the lumbosacral region the major portion of which is covered with skin while the lower edge is open, no discharge from the mass (see ). Additionally the newborn had bilateral club foot deformity (see ).
On investigation, the complete blood count was normal, creatinine level was 0.4mg/dl, and transf

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


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

[User]
RADIOLOGY NOTE:
A previously healthy 14-year-old woman of Jewish descent presented to hospital in April 2010 with sudden bilateral vision loss. She had an uneventful family history, no siblings and no evidence of consanguinity. She was a lifetime non-smoker and denied use of alcohol and drugs. Her past medical history included an unremarkable childhood with no developmental problems. She was known to have hypothyroidism and ovarian cysts.
Upon admission, she was found to be severely hypertensive and fundoscopy showed hypertensive retinopathy with retinal hemorrhages and bilateral retinal detachment. A cranial magnetic resonance imaging was done, which showed normal findings. Laboratory studies showed acute renal failure, thrombocytopenia and microangiopathic hemolytic anemia. Serum complement levels were normal. Although the ADAMTS13 (a disentegrin and metalloproteinase with a thrombospondin type 1 motif member 13) level was <5%, no antibodies were detected and genetic studies confirmed no mutation. Genetic testing for atypical HUS was also negative. She was screened for membranoproliferative glomerulonephritis, but there was no disease-causing mutation found in the C3, APLN or THBD gene. A renal biopsy showed severe thrombotic microangiopathy with 3 out of 24 glomeruli globally sclerosed with moderate interstitial fibrosis and tubular atrophy (Figure ).
Given these findings, she was treated for suspected thrombotic thrombocytopenic purpura (TTP) with a course of steroids and 12 sessions of plasmapheresis. She initiated hemodialysis, which was discontinued after 6 months as she recovered some renal function. Four months later she was thought to have a relapse of TTP and again was treated with steroids and plasmapheresis for a few days. Of note, a repeat ADAMTS13 level done at that time was normal.
In 2013, she remained stable with Stage 4 chronic kidney disease (CKD). Her vision returned to normal with a normal eye examination that showed resolution of her retinal hemorrhages. An a

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


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

[User]
RADIOLOGY NOTE:
A 32-year-old woman, para 1, presented with mild pain abdomen and slight bleeding per vaginum for 5 days. Other relevant history included amenorrhea of 8 weeks' duration with a positive urine pregnancy test, following which she had vaginal bleeding for 12 days. She assumed that she had complete abortion and did not seek medical advice. When spotting resumed 3 weeks later, she presented to the hospital. Her previous menstrual cycle was regular. She had one child conceived through intrauterine insemination (IUI) and delivered by lower segment uterine section (LSCS) 3 years back. There was no history of contraceptive use. She refused a vaginal examination.
Transabdominal and transvaginal ultrasonography (TVS) examination revealed a ballooned-out cervical canal with a gestational sac of 4.7 cm × 4.1 cm [] and an empty uterus with thickened endometrium [], respectively. The sac contained a fetus with a crown rump length of 2.33 cm, corresponding to 9 weeks' gestation [] with the presence of cardiac activity []. A presumptive diagnosis of CP was made. Magnetic resonance imaging (MRI) was used to confirm the diagnosis of CP and to rule out uterine scar pregnancy. The findings on MRI included a typical hour-glass configuration of the uterus with thickened endometrium, a ballooned-out cervix containing the gestational sac with fetal pole and closed internal os []. Thus, the diagnosis of CP was confirmed.
Single-dose intramuscular methotrexate 50 mg was administered the next day and manual vacuum aspiration (MVA) was performed on the third day. Cervical tamponade was performed with a Foley catheter, with its bulb inflated with 30 mL normal saline. At 4 weeks' follow-up, the patient was asymptomatic with a review TVS showing organized blood clot measuring 3.3 cm × 2.4 cm in the cervical canal []. Six weeks after the procedure, the patient resumed her periods and the review scan showed a resolving blood clot measuring 2.6 cm ×

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


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

[User]
RADIOLOGY NOTE:
We present a case of 40-year-old building and construction male worker who slipped and fell from a height of three (3) meters and sustained a deep penetrating wound on the right side of the anterior neck a week prior to presenting at our facility. He was apparently working from the above height when he slipped and fell on a sharp piece of iron rod which penetrated deep into the right anterior neck. He quickly pulled the sharp iron rod out when he got up from the floor. According to him, the bleeding was not profuse and stopped when he arrived at the local hospital to search for remedy (). He did not have hemiplegia, paraplegia, or quadriplegia when we saw him. He is not known to be hypertensive. He did not take alcohol prior to the fall although he takes alcohol occasionally. He had a left femoral fracture at the age of 24 and a right femoral fracture at the age of 32; both incidences were operated on successfully. On examination at our facility we saw a middle aged man who was conscious and alert but however acutely ill with his neck fixed in cervical collar. General as well as systemic examination did not yield much. All the systems where grossly normal. Neurological examination revealed normal pupils which reacted normally to light. Cranial nerves examination was unremarkable. Power on four limbs as well as reflexes was normal. Digital rectal examination revealed a normal spinster tone. Routine laboratory as well as other ancillary (ECG, CXR, etc.) investigations were normal.
Neck CT-scan done at the local hospital revealed C2-C4 transverse process fractures on the right side, fracture at the right lamina of C3, and right common carotid artery dissection. CT-scan of the head showed no abnormalities (Figures and ). Explorative three-dimensional reconstruction plain and enhanced scan imaging of the cervical spine, chest, and abdomen done at our facility revealed two segmental stenoses of the right common carotid artery with very

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


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

[User]
RADIOLOGY NOTE:
A 74-year-old male with past medical history of atrial fibrillation, hypertension, dyslipidemia, and benign prostatic hypertrophy presented to the emergency department with testicular swelling and pain for four days. Physical exam was notable for an abscess on the inner gluteal fold of the perineal region that was spontaneously draining serosanguinous output. His left hemi-scrotum appeared erythematous and indurated without overt signs of cellulitis. There was mild tenderness to palpation of the scrotal area although no crepitus was felt in the thighs or scrotum. He also endorsed blood-tinged drainage from the wound for several weeks. He was admitted for the management of his scrotal wound. He was evaluated by urology and general surgery who had low suspicion for Fournier’s gangrene. Medical records demonstrated several urological procedures for ureterolithiasis and nephrolithiasis in the few months prior to this admission. The procedures included a bilateral ureteroscopy with laser lithotripsy followed by stone removal, stricturotomy, and placement of ureteral stents to prevent the progression of hydronephrosis. He had developed iatrogenic urinary incontinence after the procedures and had an indwelling Foley catheter inserted in view of incontinence.
He also reported a fall at home three weeks ago, following which he developed persistent back pain but did nothing about it. On our evaluation the computed tomography (CT) scan of the spine (Figure ) revealed a recent L1 vertebral compression fracture with sclerosis and slightly ill-defined margins with additional lumbar spine compression fractures of T12 , L3 and L4 with several other multilevel degenerative changes in the lumbar spine. The patient also reported a gradual drop in height from 6 feet 3 inches to 5 feet 9 inches over the course of many years.
Upon admission to our inpatient department, review of his CT findings was out of proportion to age-related bone changes which led us to go back and do an extensive

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


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

[User]
RADIOLOGY NOTE:
A 25-year-old Japanese female presented to our emergency department with the chief complaints of dyspnea and palpitations on exertion, starting 1 month ago. Upon arrival, physical examination revealed systolic murmur. The bedside ultrasound examination demonstrated moderate tricuspid regurgitation and possible pulmonary hypertension and the patient was hospitalized. A contrast-enhanced chest CT showed dilatation of the main PA, filled with a hypodense area with calcification adjacent to the right and left PA. The lumens of the main PA and the hilar areas of the right and left PA appeared almost obliterated by the mass; however, the mass was not attached to the pulmonary valve and did not extend into the peripheral parts of the right and left PA (Fig. ). The differential diagnosis included primary PA tumor and pulmonary thromboembolism, but we suspected it to be a PA tumor based on the radiological findings: a relatively poor contrast effect on the lesion with calcification. Lung perfusion scintigraphy revealed decreased blood flow in the whole bilateral lungs, except for the left lung upper lobe. Due to critical symptomatic obliteration of the pulmonary circulation, an emergency surgery was performed on the second day of hospitalization. Preoperative FDP D-dimer was 1.9 μg/mL, slightly higher than the normal limit (within 1 μg/mL).
Following a median sternotomy and institution of cardiopulmonary bypass, deep hypothermic circulatory arrest was induced for the removal of the tumor. The longitudinal incision was made on the main PA extending into the left PA (Fig. ). A whitish shiny mass filled the lumens without any attachment to the surrounding intima, except that the tumor was attached to the intima of the left interlobar PA. The tumor was completely removed from the vessel lumen (Fig. ). Next, the longitudinal incision of the right PA behind the aorta and the superior vena cava was extended to the right interlobar PA. The neoplasm had no attachment to the intima in

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


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

[User]
RADIOLOGY NOTE:
In September 2010 a 78 years old man was diagnosed with an adenocarcinoma of the right-sided colon. Initial staging by abdominal and pulmonary CT revealed a lesion in the right-sided colon penetrating the visceral peritoneum with infiltration of the abdominal wall (cT4b) and a single metastatic lesion in the liver, in segment VII, with a diameter of 1.5 cm (M1a) according to a stage IVA disease.
After right-sided hemicolectomy together with a simultaneous atypical resection of the single liver metastasis adjuvant chemotherapy (CTX) with capecitabine and oxaliplatin was started. After 5 cycles of adjuvant CTX the patient complained about a considerable increase of his abdominal girth. An abdominal CT in March 2011 yielded peritoneal nodules and ascites (Figure ).
After confirmation of a mutated K-RAS gene a palliative first line CTX with capecitabine and irinotecan in combination with bevacizumab was started. However, treatment was interrupted right after the first cycle because of an episode with neutropenic fever and resumption of CTX was refused by the patient until June 2011.
CT imaging in June 2011 showed a disease progression with a new solitary pulmonary lesion with a diameter of 3.3 × 2.8 cm (Figure a) and ascites in all 4 quadrants of the abdomen (Figure b). As the patient refused biopsy of the pulmonary lesion and the radiology report stated that the lung lesion was radiological consistent with a pulmonary metastasis a biopsy was not performed. Tumor markers CEA and CA 19.9 were within normal range at the time of diagnosis and during the whole course of disease. Clinically, the amount of ascites was increasing and required abdominal punctures on a weekly basis. Therefore the first line CTX with capecitabine, irinotecan and bevacizumab was reinitiated. Despite administration of granulocyte colony stimulation factor another episode of neutropenic fever occurred and CTX was discontinued after a total of 3 cycles in August 2011. As the patient refused to receiv

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


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

[User]
RADIOLOGY NOTE:
A previously healthy 49-year-old male was the unrestrained, ejected driver of a single car rollover accident. He was found unresponsive but hemodynamically stable and was taken to the local rural hospital in a Philadelphia collar where he was initially awake and following commands and found to be neurologically intact. He became combative and was nasally intubated for airway protection. He was noted to have severe facial trauma and complex neck lacerations (). Given his mechanism of injury and significant soft tissue trauma and deteriorating clinical picture, a whole body computed tomography (CT) scan was performed. Imaging showed multiple facial and rib fractures, a Type II odontoid fracture and thoracolumbar spine injuries. The decision was made to transfer the patient to a level 1 trauma center for further management.
The patient arrived intubated and sedated with C-collar in place. There were no spontaneous movements of his extremities or withdrawal response from painful stimulus secondary to sedation, but he maintained hemodynamic stability. illustrates his significant facial trauma.
The patient was noted to have an 18 cm anterior neck wound with degloving down to the carotid artery. Gross contamination and glass were evident in the wound but no significant active bleeding. Appropriate antibiotic and tetanus prophylaxis were administered. Physical examination of his spine with log roll and palpation did not identify stepoffs or deformity of the patient's spine. His posterior neck displayed significant swelling. His rectal tone was intact but diminished. Bulbocavernosus reflex was intact.
The patient's cervical spine CT from the outside facility demonstrated a moderately distracted but relatively well-aligned Type 2 dens fracture (). There was no evidence of obvious distraction or translation at either the occipital-C1 junction or the C1-C2 joints on either the sagittal or coronal reformats (Figures and ). Initial review revealed no other injury, but several sub

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


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

[User]
RADIOLOGY NOTE:
A-64 year old female patient presented initially with dysuria for one month. She was suffering from hypertension controlled on different types of antihypertensive drugs with no attacks of headache, palpitation and sweating. She underwent diagnostic cystoscopy which revealed hyperemic velvety area at the bladder. Transurethral Resection of Bladder Tumor (TURBT) was done and pathology was carcinoma in situ. Patient received full course of vesical installation of BCG for 1 year (Six doses weekly as induction and nine doses monthly as maintenance treatment). No obvious complications were noticed during installation period. Follow up cystoscopies, urine cytology and radiology were free during BCG installation. However, patient developed sever irritative LUTS, in time of intravesical installation and post installation with poor improvement on anticholinergics. So, a decision was taken by bladder 100 IU BTX injection aiming to decrease symptoms bother. Bladder was inspected and biopsy was taken 2 weeks before injection with evidence of chronic cystitis. Follow up revealed improvement of suprapubic pain and LUTS. She had not attend for follow up for one year when she developed recurrent attacks of hematuria with developing attacks of headache, palpitation and sweating with no history of syncopal attacks during micturition. Outpatient cystoscopy showed nodular lesion at the trigone near left ureteric orifice with smooth outline (I). MRI for clinical staging revealed presence of diffuse thickening of the bladder base with bilateral external iliac lymphadenopathy and normal both ovaries (II and III). In addition, complementary bone scan was also done and was free. During resection hypertensive episodes reaching 220/120 mmHg were recorded. Pathology was high grade muscle invasive UC with neuroendocrine differentiation. Patient was planned for open radical cystectomy and ileal loop conduit. Notable bouts of hypertension on manipulation of the bladder were recorded intraoperative

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


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

[User]
RADIOLOGY NOTE:
A 47-year-old male presented to the emergency department at a primary care hospital complaining of sudden onset, severe chest pain radiating to his back. Four years prior, the patient suffered a type A aortic dissection and underwent emergency surgery that included Dacron graft replacement of the ascending aorta and a mechanical aortic valve. The patient was anticoagulated with warfarin for his mechanical valve. INR 2 days before presentation was 4.3; the patient was advised to reduce his warfarin dose by one half. Vital signs at the outside hospital were reported as temperature 37.1°C, heart rate 86 bpm, blood pressure 141/89 mmHg and oxygen saturation 98% breathing ambient air. The patient appeared comfortable. Cardiopulmonary examination was benign and consistent with a normal mechanical aortic valve. The remainder of the physical exam was unremarkable. Electrocardiogram showed normal sinus rhythm. Complete blood count, electrolytes and renal function were within normal limits; however, hemoglobin was 40 points lower than 2 days before. Troponin was negative. INR was 3.0.
Workup at the outside hospital included computed tomography (CT) of the chest with administration of contrast material. This revealed a heterogeneous collection in the right prevascular space immediately anterior to the ascending aorta measuring 6.0 × 3.2 × 12.8 cm3, concerning for aortic rupture with contained hematoma (Fig. , top left and right). Vitamin K 10 mg IV was administered, and the patient was urgently transferred to our tertiary care hospital.
Upon arrival, the patient was hemodynamically stable with no signs of acute hemorrhage or cardiovascular compromise. The patient was admitted for monitoring and further evaluation. Contrast-enhanced CT scan of the chest was repeated at our hospital. The aortic graft appeared intact with no evidence of contrast extravasation. The configuration of the mediastinal process was stable compared to the outside study 6 h earlier. Furthermore, the appea

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


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

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

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