[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 30-year-old male presented to emergency hospital complaining of penile pain, weak urinary stream and dribbling at the end of micturition for 2 months duration. The pain was constant pain and aggravated with movement, urination, and sexual intercourse and relieved by rest. The color of the urine was normal during this period.
In the last 2 weeks the patient developed severe dysuria along with development of a tender nodule over the dorsal surface of the penis. The patient visited the emergency department. An attempted urethral catheterization was failed at that time.
There was no history of urethral trauma or urethral instrumentation. The past medical and surgical histories were negative, and the drug history were negative.
The family history for any relevant genetic information and psychosocial history was negative.
The general examination was unremarkable. Examination of the genitalia revealed a normal urethral meatus but there was a fistula at dorsal mid penile shaft and the urine were coming out from that opening, there was surrounding redness and edema with palpable firm nodule in the penile shaft ().
The patient was then sent for investigations, the renal function was normal with normal complete blood count. The urinalysis showed full pus cells and red blood cells in urine. Ultrasonography of abdomen revealed normal bladder wall with normal ureters, no stones and no hydronephrosis. A pelvic x-ray revealed a mid-urethral radiopaque shadow ().
The patient underwent an emergency cystoscopy which revealed an impacted stone in mid bulbar urethra, attempts of stone extraction was failed, then decision was made to remove the stone by the open procedure ( & ).
An open urethral incision was made at ventral surface of the penis and then removal of the stone was done along with dorsal fistulectomy and repair was performed. The patients received broad spectrum antibiotics parentally. Foley's catheter was placed and removed later after 21 days ().
The patient had uneventf

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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:
An 85-year-old woman with no significant past medical history, including colon cancer but urethral caruncle two years ago presented at our office because of painless gross hematuria.
Physical examination showed no remarkable findings. Laboratory abnormalities were no pyuria but microscopic hematuria and mild anemia.
Initial ultrasonography examination (US) revealed a mass, 15 mm in diameter, on the right bladder wall. Subsequent cystoscopic examination detected two papillary tumors in the bladder. This confirmed that the bigger one was same size as that on US on the right upper wall with a peduncle. The second was 9 mm with some micro satellite tumors on the left wall. Both of them were typical papillary tumors morphologically (Figure A, B).
An enhanced computed tomographic (CT) scan of the bladder showed two masses. Larger one measuring 16 mm was in the right wall and the other was 9 mm mass in the left bladder wall, with enhancement. Moreover, no other masses or no enlarged lymph nodes were seen except for the bladder.
On magnetic resonance imaging (MRI), T2-weighted images revealed a solid, low intensity mass measuring 15 mm and the mass could be limited to the right bladder wall without muscle invasion. No urachal remnant was confirmed in a sagittal section. For the 9 mm mass, MRI revealed that it was limited to the left bladder wall and was also without muscle invasion.
At this point, we could diagnose multiple non-muscle invasive bladder cancer. Cold punch biopsy was performed at cystoscopic examination. We performed a biopsy only in the right side tumor. The histology confirmed it to be a villous adenoma. According to this result, a colonoscopy examination was then performed and no neoplastic lesion was found. TUR was performed after preoperative examinations. Each tumor was resected and diagnosed, respectively.
Histopathology confirmed that the resected tumor on the right wall was a villous adenoma, and the left one was urothelial carcinoma (T1, high grade).

[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 male patient, 46 years old, 192 cm height and 85 kg weight, in January 2016 comes to our observation in relation to the appearance of an acute pain in the anterior superior region of the left shoulder which radiated to the lateral cervical and deltoideal region with an increase of the painful symptomatology at night.
The CARE reporting guidelines were adopted for the presentation of this case report.[
The patient reported not having had any direct trauma or being affected by systemic, metabolic, or endocrine disorders. The patient had practiced rest for a week, local intermittent application of ice, and oral NSAID intake under medical indication, without substantial improvements in the painful symptomatology. At our observation, the clinical evaluation of the left shoulder highlighted: lack of presence of swelling, reddening of the skin, or alterations of surface temperature; severe functional limitation during passive and active movements of the shoulder on all the range of motion planes; and intense pain during palpation of the acromioclavicular joint.
The patient reported a pain value of 8/10 measured with the visual-analogical spatial (VAS) scale. A radiographic examination and an echotomographic examination of the shoulder were performed sequentially. Both instrumental examinations showed the presence of a calcific deposit inside the acromioclavicular joint (Figs. and 2) with the absence of significant alterations of the bone structures of the joint and of the rotator cuff tendons, neither the presence of a reactive bursitis.
In particular, the echotomographic examination, compared to the radiographic examination, better highlighted the exact intra-articular localization of the calcification in the left acromioclavicular joint. The calcium deposit had a hyperechoic appearance, homogeneous overall in the absence of a posterior shadow, thus creating an ultrasound picture of a fluid-soft calcific image (nubecular appearance) with a maximum diameter of 12.2 mm. T

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


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

[User]
RADIOLOGY NOTE:
A 62-year-old male patient presented with the chief complaints of swelling on the left side of face and neck region for 2 months, which was of sudden onset. Swelling started as a discomfort on the left side of the neck followed by the appearance of swelling, which gradually increased in size and associated pain for 1 month. Had multiple medical consultations and multiple courses of antibiotics and a course of antifilarial over the past 1 month, with no reduction in symptoms. There were no other associated signs or symptoms.
He was under medication for hypothyroidism and diabetes mellitus. History of filariasis 10 years back followed by 3–4 episodes of lymphadenitis and had antifilarial therapy during these episodes. He was a cigarette smoker for 20 years, smoking two cigarettes per day which he quit 3 years back.
Extraoral examination revealed facial asymmetry of the left side. Multiple lymph nodes were palpable, including left submandibular and level II cervical lymph node with the largest one measuring approximately 4 cm × 5 cm in size. Lymph nodes were non-tender, firm in consistency, mobile, and some were matted together. Skin over the lymph nodes appeared normal without any signs of inflammation or infection. Patient consent was obtained for taking photograph and using it for study and publication purposes [Figure and ].
Intraoral examination revealed poor oral hygiene with the presence of local factors and signs of periodontitis. On hard tissue examination, tooth number 36 had a crown with tenderness on vertical percussion. Thus by history and clinical examination, a differential diagnosis of cervical lymphadenopathy due to locoregional infection, filariasis, tuberculosis, NHL was given. Patient advised to discontinue all antibiotics and antifilarial drugs.
Panoramic radiograph revealed generalized horizontal bone loss and endodontically treated 36 with crown and periapical bone density []. Posterior-anterior chest radiograph was noncontributory []. All hemato

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


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

[User]
RADIOLOGY NOTE:
An 88-year-old male presented in the outpatient surgical setting with a chief complaint of a right groin bulge that had been present for 6 weeks. He had sharp pain initially when he first developed the abnormality but had been asymptomatic ever since. He did not recall any inciting factors. He was concerned that a previously repaired right inguinal hernia had recurred from its original tissue repair in 1977. Details of the original right inguinal hernia repair were unknown to the patient, other than no implantation of mesh occurred. On physical examination, a 3 cm × 3 cm firm, nontender mass was palpable in the right groin just lateral to the pubic tubercle. A computed tomography scan of the abdomen and pelvis was performed to elucidate the cause of the mass in his groin (Figs. , , and ). The imaging was relevant for a right inguinal hernia with the appendix present within the sac. Preoperative laboratory testing revealed a white blood cell count of 4.7 × 109/L. The patient elected to proceed with surgical intervention for hernia repair.
The patient presented to the hospital setting for his elective right inguinal hernia repair. A classic oblique incision was made in the right groin using the anterior superior iliac spine and pubic tubercle as landmarks. The external oblique aponeurosis was opened and the hernia isolated and examined. The hernia was noted to be comprised of an extremely hard and dense amount of omentum that had a chronic, scarred appearance. The base of the appendix could be seen exiting the internal inguinal ring, but the densely adhered omentum prevented reduction of the appendix back into the peritoneal cavity. Initially, there was no indication to perform an appendectomy at the time of the procedure if the appendix could be successfully reduced into the abdominal cavity. However, the chronic appearing adhesions in the area prevented this step. In order to reduce the appendix at that point, a relaxing incision was then made in the typical transve

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


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

[User]
RADIOLOGY NOTE:
A 38-year-old male presented with the complaint of right-sided cervical swelling over a duration of 4 months. There was associated discomfort and pain. There was no change of voice or difficulty in swallowing. There was no fever or a history of contact with tuberculosis. The patient was seroreactive for hepatitis B surface antigen. On examination, there was an enlarged right-sided Level III cervical lymph node measuring 4 cm × 3 cm × 1 cm. It was mildly tender. No sinus discharge was noted.
FNAC was done from the cervical lymph node. The smears were cellular and showed mixed population of small and large lymphoid cells with predominance of small, mature lymphocytes []. Follicular dendritic cells (FDCs) were present in clusters and single. They had abundant pale cytoplasm, with frequent streaking and indistinct cytoplasmic borders. Few plasma cells and tangible macrophages were noted in the background. There were no eosinophils, epithelioid giant cells, or necrosis. Based on cytological features, a diagnosis of follicular hyperplasia was offered.
A total excision biopsy of the lymph node was done. Grossly, the lymph node measured 4 cm × 3.2 cm × 1.2 cm and was gray white. Histopathological features were those of hyaline vascular type Castleman's disease, with broad mantle zone showing concentric layering of peripheral lymphocytes resembling onion skin and interfollicular areas showing increased thick hyalinized vessels and some penetrating into the germinal centers []. Some follicles showed a radially penetrating sclerotic vessel in the germinal center as evidenced by CD34 positivity []. Again, around the periphery of the lymph node tissue and also dissecting it at some areas was an abundant mass of hyalinized collagenous fibrosclerotic tissue with paucicellular spindle cell proliferation []. These hyalinized areas were punctuated by numerous dystrophic calcified areas, with some showing psammomatous changes.
Altogether, these features confirmed the diagnosis of a Ca

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


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

[User]
RADIOLOGY NOTE:
An 82-year-old female patient, ASA grade 3, a known case of coronary artery disease, arterial hypertension, atrial fibrillation on rivaroxaban, arterial hypertension, chronic obstructive pulmonary disease, obstructive sleep apnea, hypothyroidism, and chronic renal insufficiency; BMI 31 kg/m2. She underwent four years ago to open sigmoidectomy, then Hartmann reversal secondary to sigmoid perforation. The patient has been recently diagnosed with colon cancer. On physical examination, the patient was in good general and performance status. No signs of bowel obstruction. The abdomen was soft and lax without visible or palpable herniation. The colonoscopy showed a rectosigmoid mass at 15 cm above the anal verge; the rest of the colon was normal. The laboratory results show Hb 10 g/dl and known chronic renal impairment.
CT thorax and abdomen revealed no distant metastasis. The patient refused fecal diversion; we obtained informed consent to conduct our procedure. The patient underwent open high anterior resection with primary anastomosis just below sacral promontory, and a hidden ileostomy was performed at the right lower quadrant. The estimated operation time was 204 min with 500 ml estimated blood loss. Intraoperative air leak of bowel anastomosis showed no leak. The initial postoperative course was uneventful. The patient reported on the 7th postoperative day low-grade fever, abdominal discomfort, and increased inflammatory marker. The abdominal sonography revealed no free fluid or ileus. We started the patient on intravenous antibiotic and hidden ileostomy kept in place. On 10th postoperative day, we noted feculent material in the abdominal drain as well as generalized abdominal tenderness. Emergency CT-abdomen with the intravenous and rectal contract was done, showed contrast extravasation at the anastomosis and free fluid collection in the pelvis. The patient underwent emergency sigmoidoscopy and proximal fecal diversion in operating theater. The endoscopic evaluati

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


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

[User]
RADIOLOGY NOTE:
A 68-year-old Japanese man with a history of distal partial gastrectomy for gastric cancer 10 years earlier was admitted for surgical treatment of intrathoracic esophageal cancer (T3, N2, M0, stage III). He underwent subtotal esophagectomy with three-field lymph node dissection and removal of the remnant stomach with the abdominal lymph nodes. The alimentary continuity was reconstructed with a pedicled jejunal limb through the antethoracic route. When we separated the diaphragm from the esophagus and removed xiphoid surgically to prevent a pedicled jejunal limb injury, the pericardium was opened. Anastomosis of the esophagus and jejunum was carried out instrumentally with a circular stapler. A postoperative enteral contrast examination showed smooth passage and no deformity of the reconstructed jejunum. The patient was discharged about 4 weeks postoperatively. About 6 months after the esophagectomy, the patient was readmitted to our hospital because of abdominal discomfort and vomiting. His vital signs were stable and unremarkable. He was thin, with a body mass index of 18.6 kg/m2. Physical examination revealed that the pedicled jejunum through the antethoracic space was markedly dilated and the abdomen was soft and flat (Fig. ). Laboratory data showed only leukocytosis with no other remarkable findings. A chest roentgenogram revealed an increased cardiothoracic ratio of 70%, and an enteral contrast study showed a bird’s beak deformity. The swallowed barium remained static in the reconstructed jejunum. Computed tomography of the thoracoabdominal region showed the reconstructed jejunum within the pericardium anterior to the heart (Fig. ). We diagnosed the patient with IPDH after esophagectomy and performed an emergency laparotomy. Upon opening the abdominal cavity, we found that the reconstructed jejunum had herniated into the pericardium through an approximately 4-cm-diameter diaphragmatic defect without a hernia sac (Fig. ). The herniation was easily reduced, and t

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


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

[User]
RADIOLOGY NOTE:
A 25-year-old G2P1L1 with 25 weeks of pregnancy was referred to the emergency ward of our hospital at midnight from a peripheral rural health centre with a diagnosis of rupture uterus. Our hospital is a referral hospital attached to a government medical college which mainly caters to rural population. The lady had a previous uneventful vaginal delivery of a 2.5 kg baby 3 years back. This was her second pregnancy. She had antenatal checkups at a rural primary health centre. She went for an ultrasound examination at 25 weeks of gestation due to pain abdomen and absent fetal movements. The ultrasound examination done at the peripheral centre showed an intrauterine fetal demise of 24 weeks. In view of the fetal demise, the lady was induced with misoprostol for expulsion of the fetus. By twelve hours after induction she developed hypotension, tachycardia, and hypovolemic shock. In view of these features, a diagnosis of rupture uterus was made and the patient was referred to our hospital.
On examination, the lady was in hypovolemic shock with severe pallor and rapid feeble pulse. Her blood pressure was not recordable. The abdomen was tense and distended and the uterine size was not made out. Pelvic examination revealed fullness in the fornices with cervical movement tenderness. There was no vaginal bleeding. As the patient was in shock, she was taken for immediate laparotomy after resuscitation. Her hemoglobin was 3 gm% at the time of laparotomy.
At laparotomy, there was a rupture of right rudimentary noncommunicating horn of a unicornuate uterus () with the fetus and intact sac lying free in the peritoneal cavity with a hemoperitoneum of about three litres (). The fetus weighed about 600 grams (). The rudimentary horn was excised. After achieving hemostasis, abdomen was closed in layers after keeping a drain. The lady was transfused with 5 units of blood. Her postoperative recovery was good. She was later investigated for

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


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

[User]
RADIOLOGY NOTE:
A 40-year-old man visited the Chosun University Dental Hospital with a tender swelling on his anterior palatal area. The overlying mucosa appeared normal and all the teeth in the affected area were caries free and reacted positively to both thermal and electrical stimuli. His medical history was non-contributory.
A panoramic radiograph revealed a multilocular and mixed radiolucent/radiopaque expansile lesion extending from the right second premolar to the left canine of the maxilla, presenting a soap bubble appearance in the middle third of the lesion, and ill-defined radiopacity in the left third of the lesion (). The lesion showed an often curved and scalloped border extending to the middle portion of the roots of the upper anterior teeth. The lesion was diagnosed provisionally and radiographically as ameloblastoma with histological evidence of a developmental cyst showing a cystic structure lined by epithelium with incisional biopsy (). After endodontic treatment of multiple upper anterior teeth, he underwent enucleation of the lesion and an allobone graft by an oral surgeon. Histopathologically, the enucleated mass showed unicystic ameloblastoma with peripheral palisading of hyperchromatic epithelium and loose fibrous stroma (). The fistula formation process near the bone graft area was persistent. After being treated repeatedly with antibiotics and dressing for about 5 months, he finally underwent removal of the allobone.
Four years after the first surgery, a recurrent tumor was found in the same area. A panoramic radiograph showed a unilocular cystic radiolucency in the area corresponding to the right part of the primary lesion (), and re-enucleation of only the cystic lesion and Tutoplast grafting were performed. Histopathologically, the enucleated mass had changed from a developmental cyst to the desmoplastic type of ameloblastoma that contained small islands and thin cords of ameloblastic epithelium within a dense fibrous connective tissue stroma ().
The pa

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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 38-year-old Japanese woman was diagnosed as a BRCA2 mutation carrier after genetic counseling and testing and was referred to Kitano Hospital in April 2014 to undergo risk-reducing surgery. She had no past medical history and was in good health. Her father had been diagnosed with prostate cancer when he was 49 years old; he had died from the disease 2 years later. Her mother was alive but had a history of arrhythmia that was diagnosed when she was 64 years old. Her paternal grandmother had been diagnosed with breast cancer when she was 54 years old and had died from the disease 10 years later. Although her maternal grandfather died at the age of 72 years because of metastatic cancer, the precise details were not known. There was no family history of ovarian cancer. Her ancestry was Japanese, and she was unaware of any Ashkenazi Jewish heritage. Because of her family history, the fact that she was a widowed mother with three children, and her knowledge of hereditary breast and ovarian cancer, she worried about that, and consulted a genetic counselor to undergo BRCA mutation testing. Genetic testing revealed a BRCA2 mutation. After genetic counselor showed all of the risk management options for BRCA mutation carriers, frequent mammography, breast magnetic resonance imaging (MRI), clinical breast examinations, chemoprevention, and prophylactic surgery including extent of cancer risk reduction, risks associated with surgeries, reconstructive options, management of menopausal symptoms, and reproductive desires, addressing psychosocial, social, and quality of life aspects, she finally desired RRM and RRSO. The Ethics Committee granted permission for the RRM in May 2014, and we provided informed consent prior to the RRM.
The need for RRSO remained to be discussed because of concerns associated with RRSO such as menopausal disorders caused by iatrogenic fertility. Breast MRI showed rapid early enhancement with linear and ductal distribution in both the breasts, and the po

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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 54-year-old man came to the private dental clinic with complaint of difficulty in mastication and esthetical concern for his upper anterior teeth. He was a nonsmoker and was diagnosed with IgG-kappa type MM in November 2011. In the physical examination, he was diagnosed with MM. Bony metastasis was present at the time of diagnosis of the disease. A full radiographic skeletal survey showed multiple bony lesions at the ribs, femurs, and hip (Figures and ).
Panoramic view revealed bony lytic and punch out lesions at the right side of the mandible. This patient had no history of surgery. His weight had decreased by 7 kg, following 22 months of acute intravenous injection (IV) BP treatment after the last chemotherapy treatment session. His blood pressure was 130/80, and he had a normal breathing and pulse rate. Preoperative examination of his oral mucosa revealed no evidence of pathological lesions, and overall oral hygiene was good. The patient was felt healthy and was well nourished, alert, and cooperative. After thorough clinical examination, maxillary right first premolar was found missing.
After meticulous consulting sessions with the patient and discussing the advantages and disadvantages of all treatment options, he accepted to receive dental implant.
According to the patient's physician, the appropriate time for the surgery relied upon the patient's regular blood cell counts. This patient did not undergo any radiotherapy phases in the entire duration of his active IV BP treatment. He underwent chemotherapy for two separate sessions. After the last session of chemotherapy, the patient received monthly infusion of 3.5 mg of the IV BP drug zoledronate (Zometa; Novartis Pharmaceuticals Corporation) for a period of 22 months (from May 2014 to March 2016). As per the physician's recommendation, C-terminal cross-linking telopeptide (CTX) examination was carried out 6 months after stopping IV BP therapy. The CTX above of more than 150 was considered to be safe

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


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

[User]
RADIOLOGY NOTE:
A 15-month-old male presented to the Emergency Department (ED) with sudden onset of right arm and leg weakness beginning 3 hours prior to admission. His clinical history included a viral illness 5 days prior to admission, with malaise, fever, vomiting, and diarrhea. Early in the course of that illness he was seen by a pediatrician who noted mild dehydration, and suggested oral rehydration and antipyretics. He was otherwise healthy, with up-to-date immunizations.
On arrival to the ED physical exam revealed flaccidity in right upper and lower extremities. X-rays of right upper extremity obtained to rule out trauma were negative. Lab results showed microcytic anemia with hemoglobin of 6 g/dL, and thrombocytosis, with a platelet count of 512,000. The remaining labs were normal. Computed tomography (CT) of the head without contrast showed hypodensity of the left thalamus (). In addition, high attenuation was noted throughout the bilateral deep venous system, compatible with acute DCVT ().
Anticoagulation therapy and IV hydration were initiated immediately after radiologic findings were discussed with the ED physician. The patient was transferred to the Intensive Care Unit of our tertiary pediatric hospital. Magnetic resonance imaging (MRI) of the brain demonstrated restricted diffusion in the central aspect of the thalamus, surrounded by vasogenic edema, compatible with acute venous infarction (). No other parenchymal lesion was detected. Signal changes within the deep venous system were compatible with acute intraluminal thrombus (). MR venography confirmed lack of flow-related signal throughout the deep venous system ().
The patient had a follow-up MR venography done two days later before discharge but was found to have no significant interval change with relatively stable venous infarct in the left thalamus and posterior limb of the internal capsule. No other follow-up imaging was done since. His symptoms resolved completely after six months of physical and speech the

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


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

[User]
RADIOLOGY NOTE:
A 78-year-old Caucasian female was admitted to our Emergency Department after an accidental domestic fall on her left hip. The patient cannot bear any weight on her left leg that was painful, shorter, and in external rotation. Her general status appeared good, and she had no neurological symptoms. She had no significant past medical history apart from high blood pressure in treatment with angiotensin-converting-enzyme-inhibitor. Conventional radiograms of her left hip showed a transcervical fracture of the femur (AO classification 31-B2) (). Laboratory blood tests did not reveal any kind of alteration. The day after, the patient underwent left cemented hip hemiarthroplasty using a posterolateral approach and a spinal anesthesia (). According to our thromboembolism prophylaxis protocol, the patient received 4000 UI of enoxaparin (Clexane) subcutaneously once daily since the day of the trauma for a month. The post-operative course was regular apart from moderate anemia treated with blood transfusions. In the following days, hemoglobin level returned in the normal range, and the patient started are habilitation program. When the patient was discharged on the 5th post-operative day, she had no motor or sensitive peripheral deficit and was able to walk with a walker. 15days after surgery, the patient was admitted again to our Emergency Department because of worsening left groin pain and left leg muscular weakness. She denied any other trauma or fever episode. She could not bear any weight on her left leg. She had reduced sensibility in her left thigh and was unable to extend actively her left knee. From a clinical point of view, left patellar reflex was absent, left quadriceps force was 0/5 (Medical Research Council scale), while left tibialis anterior and left extensor long ushallucis were normal (5/5). Surgical wound was completely closed and showed no signs of infection. At that time, conventional X-rays of the hip and the pelvis showed no abnormalities. The hip prost

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


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

[User]
RADIOLOGY NOTE:
This is the case of a 51-year-old female with a past medical history of IPAH. This had been diagnosed by right heart catheterization 16 years previously when the patient collapsed at home shortly after childbirth. The patient’s condition was stable for many years, being medically managed with intravenous iloprost at 1300 μg once daily. This allowed the patient an acceptable quality of life maintaining a WHO functional class II.
A computed tomography pulmonary angiogram in 2013 diagnosed a 5.5 cm PAA, worst affecting the main and left pulmonary arteries. Right heart catheter performed at this time demonstrated pulmonary artery pressure of 90/39 mmHg (mean 31 mmHg), right ventricular pressure of 93/10, end diastolic diastolic pressure of 20 mmHg and a mean right atrial pressure of 13 mmHg. Due to the progression of the underlying pathology additional pulmonary antihypertensives were added to the treatment plan (sildenafil and ambrisentan). The patient was considered for bilateral orthotopic lung transplantation but after assessment was deemed too clinically well to list for transplant at that time and the patient continued to be monitored by their local hospital.
Clinical deterioration prompted review at our centre in 2019, which identified worsening symptoms of shortness of breath, causing severe limitation of daily function (WHO functional class III-IV), and left shoulder pain. Echocardiography revealed marked progression of the PAA causing dilatation of the pulmonary valve annulus and subsequent severe pulmonary regurgitation. There was also severe right ventricular impairment, moderate tricuspid regurgitation and a 4 cm pericardial effusion lateral to the left ventricular wall. Pulmonary artery pressure was estimated at > 65 mmHg.
Computed tomography pulmonary angiography confirmed a 12 cm aneurysm of the pulmonary artery mainly affecting the main and left pulmonary arteries. There was also a 6 cm aneurysm of the right pulmonary artery (Fig. ). Cardiac magnetic re

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


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

[User]
RADIOLOGY NOTE:
A 75-year-old Chinese man was admitted to our hospital with increasing chest pain and dyspnea upon exertion. The chest pain developed 4 weeks previously when he was climbing stairs, and this was relieved by several minutes rest. He also reported that 2 day preceding hospitalization, the pain was triggered by minimum exertion, appearing even at rest. His chest pain was characterized by a squeezing pattern and this was located in the substernal area and it radiated to his left arm. He had no history of hypertension, hypercholesterolemia, diabetes mellitus, smoking and drinking, and there was no history of ischemic heart disease in his family.
Eight years ago he was diagnosed of chronic ITP, but didn’t take any treatment. His platelet counts through the years had always been above 60 × 109/L. This earlier diagnosis of ITP was based on the observation of moderate thrombocytopenia and antiplatelet antibodies, with bone marrow findings consistent with the diagnosis. Five years ago primary PCI was performed in the proximal left anterior descending coronary artery using a drug-eluting stent (DES) because of acute anterior ST-segment elevation myocardial infarction at other hospital. At the time of the first PCI, his platelet count had been around 90 × 109/L. He received 300 mg of clopidogrel and 300 mg of aspirin along with 5000 units of heparin bolus before PCI. He was discharged on aspirin 100 mg and clopidogrel 75 mg orally daily for 1 year, and he never had bleeding before.
On physical examination, his blood pressure was 135/70 mmHg. His heart rate was regular at 76 beats/min. The chest was clear to auscultation and percussion bilaterally. There was no heart murmur. Findings of abdominal and neurological examinations were unremarkable, and lower extremities were without edema. A 12-lead ECG recorded on admission in the patient showed normal sinus rhythm and biphasic or inverted T waves in leads V1–3 (Fig. ). Blood examination revealed a platelet count of 18 × 109

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


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

[User]
RADIOLOGY NOTE:
A 38-year-old female presented with lower abdominal pain for 2 months. The patient had no significant medical or surgical history in the past except for tubal ligation done 5 years back as a measure of family planning. Physical examination was unremarkable with no lymphadenopathy or organomegaly. Urinary cytology showed no malignant cells and culture failed to grow any organisms. Ultrasound scan of the abdomen showed 7 × 4 cm size mass lesion in relation to anterior wall of the bladder. Contrast-enhanced computed tomography abdomen and pelvis showed irregular thick wall enhancing area with internal nonenhancing area in the anterosuperior wall of the bladder with perivesical fat stranding and extension of lesion into the right rectus abdominis muscle suggestive of malignant mass of possibly bladder or urachal origin with multiple enlarged enhancing lymphnodes in pre/paraaortic and iliac regions suggestive of metastasis. A flexible cystoscopy examination revealed 6 × 5 cm mass on the dome of the bladder. Blood counts, lipid profile and other hematological and biochemical investigations were within normal limits. Transurethral resection of the bladder mass was done, and histological examination lesion showed urothelial papilloma. Magnetic resonance imaging abdomen and pelvis of the patient was performed postoperatively which showed approximately 61 × 23 × 43 mm sized enhancing polypoidal mass lesion involving anterosuperior wall of bladder on the right side, the mass appeared hypointense on T1WI and T2WI and showed enhancement on post contrast study, there was focal loss of fat plane of the mass anteriorly suggestive of involvement of perivesical fat with invasion of perivesical fat, bilateral recti and subcutaneous fat present, there was peripheral rim enhancement with central nonenhancing necrotic areas, there was loss of fat plane with uterus and right fallopian tube, multiple enlarged pre/paraaortic, bilateral iliac and inguinal lymph nodes were noted []. Contrast-

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


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

[User]
RADIOLOGY NOTE:
A 48-yr-old woman presented with a huge necrotic mass in her left breast. She had first noticed the mass 1 yr before, since then it had rapidly grown and become necrotic. She was a mother of two children in good health, and had no family history of breast disease. On physical examination, the mass was seen to involve the entire left breast. The central portion of left breast including the nipple was rotted by severe necrosis, and the surrounding skin was erythematous. The tumor tissue was very friable with profuse foul-odored discharge (). Several lymph nodes were palpated in the left axilla.
A wide incisional biopsy of the mass was performed. The sarcoma was diagnosed, but the specific type could not be established. Chest computed tomography (CT) demonstrated a hypodense mass, 10×8 cm in size, with central necrosis and numerous enlarged lymph nodes in the left axilla, but there was no abnormal finding in the lung fields. The abdominal ultrasonography revealed gallstones, but no abnormalities in the liver parenchyma. The tumor markers were within normal limits, including CA15-3 (5.0 U/mL) and CA125 (7.2 U/mL). All laboratory findings, plain chest radiography film, and bone scintigraphy revealed no abnormalities.
Pseudomonas and Candida were grown on a bacterial culture containing discharge from the necrotic tumor. Although there were no symptoms or signs of generalized infection, systemic antibiotics were administered for fear of disseminating inflammation for several days before operation. At a later date, the patient underwent a radical mastectomy. In the operative field, numerous enlarged lymph nodes were observed in the left axilla. Among these, the largest one was more than 2 cm in diameter, and diagnosed benign in the frozen section examination. The axillary node dissection was performed to level I only. Because primary skin closure was impossible, the defect in the left anterior chest wall was covered with the myocutaneous flap using the left latissimus dorsi

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


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

[User]
RADIOLOGY NOTE:
Our case report describes a 32-year-old woman diagnosed with lymphangioleiomyomatosis who was placed on an organ transplant waiting list in February 2014, due to rapidly progressing respiratory insufficiency. Her history was significant for multiple lymphangioleiomyomas in the retroperitonium along with repeated spontaneous pneumothoraces that required drainage. Transesophageal echocardiography (TEE) was performed during preoperative assessment and the patient was found to have a low ejection fraction. In March 2014, the patient was intubated and ventilated due to respiratory failure. She went on to develop bronchopneumonia caused by multiresistant Pseudomonas aeruginosa, followed by sepsis and disseminated intravascular coagulopathy with severe bleeding from the nose, hypopharynx, and lower respiratory tract. At this point, mechanical ventilation was no longer sufficient to sustain oxygenation and venovenous ECMO (VV-ECMO) was commenced, as a bridge to urgent lung transplantation (). Six days later a donor was found and sequential bilateral lung transplant with a clamshell incision was performed with the support of the arteriovenous ECMO (AV-ECMO). The cannulae from the VV-ECMO were left in place and an arterial cannula was inserted centrally into the ascending aorta. Cannulation of the vena jugularis interna dextra was terminated. Due to anatomic disproportion, the donor lungs were partially resected at the right middle lobe and lingula.
Perioperative TEE showed severely hypokinetic right and left ventricles along with a large thrombus in the left atrium near the pulmonary veins (). The procedure was complicated by diffuse bleeding due to coagulopathy present in the septic state, which resulted in a 10 L blood loss. Postoperatively, the AV-ECMO was left in place due to the poor myocardial function; therefore, the sternotomy was not closed to allow the arterial cannula to remain in the aorta. During admission to the intensive care unit, severe pulmonary edema was n

[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 fourty-year-old man with DEB diagnosed at the age of eight was admitted to the department of gastroenterology because of the dysphagia for two previous months. The diagnosis of DEB was established due to the presence of single blisters on the whole body since the sixth month of life. His sister was also diagnosed with DEB and had similar symptoms of the disease. To our knowledge, the presented patient and his sister are the oldest diagnosed with EB living in Poland. At the age of four the patient started experiencing heartburn occasionally. Five years later dysphagia appeared for the first time. It was an episodal and periodical ailment. He reported a deterioration of dysphagia at the age of nineteen; he mostly consumed liquids and soft consistency meals during that time. Nonetheless, the patient admitted that this esophageal discomfort still was not a constant one and there were time intervals without this ailment. In the past there were also episodes of mild esophageal bleeding. The only one endoscopic esophageal dilatation in this patient took place in 1997; a stenosis was located then approximately 18 cm from incisors. The performed procedure ameliorated swallowing difficulty. A barium swallow test obtained one year after the endoscopic dilatation of the esophagus also revealed esophageal constriction on the same level. In 2014 the patient was diagnosed because of hematochezia and pain in hypogastrium. Tissue samples obtained in colonoscopy revealed the presence of nonspecific inflammatory infiltration in the ascending colon and terminal part of the ileum. Interestingly, 3 years ago he complained of hemoptysis and there was a suspicion of bleeding to pulmonary alveoli in the course of DEB. However, a CT scan did not confirm bleeding. On admission to our department the patient was complaining of painful swallowing of solids. Two months earlier he was diagnosed in the cardiology unit because of the chest pain and elevated level of troponin I. An electrocardiogra

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


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

[User]
RADIOLOGY NOTE:
An 8-year-old girl with a history of congenital profound hearing loss in the left ear presented to a local ENT hospital with an acute onset of ipsilateral facial palsy. She was treated with oral prednisolone; however, the facial palsy progressed to complete paralysis. Otoscopy revealed a pulsatile mass in the left middle ear. A detailed medical history revealed that she had been able to perform tandem walking at the age of four, but became unable to do so at the age of six. She had never been examined by MRI to find the cause of congenital hearing loss.
On physical examination, she had a left complete facial paralysis (House-Brackmann grade VI). Electroneurography showed no visible reaction on the affected side (0%). Her left tympanic membrane was swollen, and a pulsatile tumor was visible in the middle ear, which was first found since the diagnosis of congenital hearing loss. Pure tone audiometry showed profound hearing loss in the left ear and less than 20 dB in the right ear. Auditory brainstem response done at the age of five had revealed 100 dB hearing threshold in the left ear, and auditory steady-state response had showed hearing thresholds of the left ear as 80 dB at 1000 Hz, 85 dB at 2000 Hz, and 90 dB at 4000 Hz. Computed tomography (CT) examination revealed a multilocular tumor in the inner ear extending into the middle ear (Fig. a), and osteosclerosis around the edges of the tumor. In the middle ear, the tumor pressed on the ossicles, and the facial nerve canal could not be identified. On MRI, the tumor presented mixed signals of high and low intensities on T2-weighted images and was sparsely enhanced with gadolinium on T1-weighted images (Fig. b). We performed an endoscopic transcanal biopsy of the tumor. It was soft, with a thick fibrous capsule and filled with mucinous fluid (Fig. ). The pathological findings revealed only blood components in the tissue fluid, and the biopsy

[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 Caucasian male patient was brought to the resuscitation bay of our Emergency Department after a syncopal episode and was noted to be in shock. His initial observations include Heart Rate 126/min, Blood Pressure 102/79 mmHg, Respiratory rate 32/min, temperature 36.8C and oxygen saturation of 98% on 2 L of nasal prongs. The patient had a Glasgow Coma Scale of 14 and was clinically dehydrated. Abdominal examination revealed a distended abdomen that was tender in the left upper quadrant with no evidence of peritonism. Laboratory tests showed polycythaemia with Haemoglobin of 189 g/L and white cell count of 20.3 × 109/L with preserved renal and hepatic functions. Arterial blood gas analysis was consistent with normal anion gap metabolic acidosis with a pH of 7.28 and lactate of 4.5. The patient responded to initial fluid resuscitation.
Further history was obtained: he had a 2-day history of progressively worsening upper abdominal pain associated with multiple episodes of dark coloured emesis and loose bowel motions. The pain was exacerbated by oral intake. He had a background of ulcerative colitis diagnosed at the age of 40 which required one course of oral steroid with no further follow up or treatment.
As the patient remained in a stable state, a CT abdomen was performed which demonstrated a long segment of superior mesenteric vein (SMV) thrombus extending into the portal vein. This resulted in venous engorgement with associated thickening of jejunal wall and extensive mesenteric stranding suggestive of intestinal ischemia. There is also a moderate amount of free fluid with no evidence of intramural gas or perforation (, ).
Acute mesenteric venous thrombosis was diagnosed and management options were explored. Although the CT appearances were sinister and suggestive of intestinal ischemia, the patient had no signs of peritonism. Thus, decision was made for conservative management. Heparin infusion was commenced, nasogastric tube was inserted and the patien

[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 64-yr-old male patient with arterial hypertension and four previously recurrent VTE episodes with onset at the age of 48. The patient has no children, and no familial history of VTE, thrombocytopenia, or bleeding was found. Repeated thrombophilia investigations were negative, and there were no clinical indications of an underlying malignancy. Although the patient was treated with anticoagulants, he developed recurrent VTEs; therefore, the level of international normalized ratio was kept between 3.0 and 3.5. The patient also had a history of chronic thrombocytopenia with an element of pseudothrombocytopenia, as the platelet count was consistently higher when measured in citrated whole blood with added paraformaldehyde (PFA). Consequently, all platelet counts were measured in triplicats (EDTA, citrate, and citrate with PFA) and agglutination occurred in EDTA and citrate tubes. Therefore, in the following paragraphs, all mentioned platelet counts are counted in citrate tubes with added PFA. The patient developed a subdural hematoma during an episode with a very low platelet count of 30 × 109/L and therefore warfarin treatment was discontinued. Successive treatments with prednisone, dexamethasone, intravenous immunoglobulins, romiplostim, and rituximab were initiated on suspicion of immune thrombocytopenic purpura; however, a substantial increase in the platelet count was not achieved. Consecutive bone marrow examinations performed in 2002, 2009, and 2015 showed no dysplastic features. During a period with headache and severe thrombocytopenia (9 × 109/L), a cerebral computed tomography (CT) scan revealed progression of the persistent subdural hematoma and a new subdural hematoma in the opposite hemisphere (A). The patient did not present any neurological deficits at the time and the Glasgow coma score was 15. Treatment with platelet transfusions and tranexamic acid was initiated. During the next 24 h, he developed epistaxis, increasing headache, dyspnea, an

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


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

[User]
RADIOLOGY NOTE:
Our patient is a 76-year-old woman with a past medical history of complete infranodal heart block diagnosed in the year 2000 with an electrophysiology study. She underwent the implantation of a dual-chamber pacemaker, and in 2003 she presented with sudden cardiac arrest (in the setting of preserved left ventricular (LV) systolic function) that was attributed to long QT syndrome. She was upgraded to a dual-chamber implantable cardioverter-defibrillator (ICD) at that time. She did well for 12 years, until she presented in late September 2015 with RV lead fracture and total failure to capture. She was lightheaded with activity, and her electrocardiogram (ECG) demonstrated marked bradycardia and complete heart block (. She had a right bundle branch block (RBBB) pattern escape rhythm, and was monitored for 48 hours on telemetry prior to revising her lead as she was hemo-dynamically stable. Also, she had been developing progressive HF symptoms over the past three years, along with a cardiomyopathy. She was diagnosed with right breast cancer in 2012 and was treated with doxorubicin. An echocardiogram in early 2015 demonstrated that her LV ejection fraction had decreased to 35%. It was unclear if her cardiomyopathy may have been related to chemotherapy, or was due to pacing-induced cardiomyopathy.
Given this patient’s complete heart block and worsening HF symptoms in the setting of a wide QRS RVP morphology, it was elected to upgrade her pacing system to a biventricular (BiV) ICD (. During the proce-coil was in the middle cardiac vein. Additionally, she had dure, a temporary pacing wire was initially placed from suboptimal coronary venous branches and LV pacing the right femoral vein. It was discovered that her old RV requiring very high outputs (4.5 V at 1 ms), resulting in left phrenic nerve capture. Her options included surgical placement of an epicardial LV lead or attempts at HBP. However, it was unclear whether HBP would help

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


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

[User]
RADIOLOGY NOTE:
A 64-year-old male farmer presented to our outpatient clinic with a 2-day history of foot drop and tenderness in the region of the left fibular head. He complained of mild pain radiating from the knee to the ankle and numbness affecting the dorsal aspect of his left foot. The patient reported no history of trauma. In his examination, there was no evidence of degenerative disc disease of the lumbar spine. Careful physical examination revealed nebulous soft swelling below the fibular head. There were no signs of tibialis anterior or peroneal muscle atrophy. However, there was weakness in foot eversion, ankle dorsiflexion, and great toe extension. Plantar flexion and foot inversion were normal. We also found diminished sensation in the first web space of the left foot and positive Tinel’s sign near the fibular head.
Electromyography (EMG) findings demonstrated denervation of the anterior tibial and peroneus muscles. No abnormality was found in the conduction velocity of the tibial and sural nerves. Radiographs of the knee showed normal findings. Ultrasonography (USG) revealed the 38 × 21 × 16 mm cystic mass localized between the muscle structures. Magnetic resonance imaging (MRI) revealed the presence of a fluid-filled mass, likely presenting a ganglion cyst, around the fibular neck, which compressed the common peroneal nerve ().
Surgery was performed with a lateral approach under a pneumatic tourniquet. The cyst was seen to arise from the anterior aspect of the proximal tibiofibular joint with a distinct pedicle. It was compressing the peroneal nerve at the level of the fibular neck (). Careful dissection was carried out under loupe magnification to preserve all nerve branches, and the cyst was completely removed after its pedicle was ligated (). The histopathologic evaluation confirmed the diagnosis of a ganglion cyst.
Postoperatively, the patient was mobilized with an antifoot-drop peroneus splint and treated with intensive physiotherapy. In the early days after

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


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

[User]
RADIOLOGY NOTE:
The present case report is about a 40-year-old female patient with the complaints of a swelling in the mandibular angle region of 5 months duration she was referred to our department by her oncologist with the differential diagnosis of osteomyelitis or osteogenic sarcoma. On palpation a hard, non-tender, localized, round swelling of size 4 cm × 3 cm on left angle-ramus region was felt []. There were no palpable regional lymph nodes. Oral cavity examination did not reveal the existence of any ulcer, fistula or wound except missing lower left first molar.
Her medical history revealed a modified radical mastectomy 2 years back for invasive ductal carcinoma of the left breast. The tumor was positive for c-erbB-2(HER-2/neu) assay with score 3 plus in immunohistochemistry. Hence, she was on adjuvant hormone therapy.
A panoramic radiograph showed a retained root remnant of left mandibular first molar, carious second molar and an area of rarefaction on left angle region with indistinguishable margin [].
Serial axial and coronal computed tomography (CT) scan of mandible (1 mm-thick slice) showed destructive lesion on left angle of mandible extending in to the ramus []. Features like Codman triangle and sunray appearance were seen in the margins of the lesion and minimum soft-tissue component were seen adjacent to it [ axial view, coronal view].
The CT scan differential diagnosis included chronic osteomyelitis, osteogenic sarcoma and secondary metastasis. A fine-needle aspiration cytology (FNAC) revealed loosely cohesive group of epithelial cell having increased N: C ratio and hyperchromatic nuclei in adenoid pattern []. It was diagnosed as infiltration from poorly differentiated adenocarcinoma, possibly of mammary ductal origin.
A full body radionuclide scan was carried out and it was suggestive of skeletal metastases. A technetium-99m-methylene diphosphonate bone scan located a region of increased radioisotope uptake in the ramus of mandible on the left side as well as in t

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


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

[User]
RADIOLOGY NOTE:
A 24-year-old Chinese man was admitted to our Emergency Department presenting with a neck wound that had been slightly bleeding for six hours. The neck trauma occurred in a chaotic fight. The patient could not describe details of the injury, but he reported that the wound might have been caused by fragmentation of a beer bottle. On physical examination, there were no signs or symptoms of respiratory distress. The wound opening, measuring one cm, was identified at the submandibular area of the left side of the patient’s neck below the border of the mandibular angle. No glass fragments or other foreign bodies were detected, but slight swelling and bleeding were noted. Examinations of the oral cavity and pharynx revealed no abnormalities.
Anteroposterior and lateral X-rays of the patient’s neck revealed subcutaneous emphysema and no foreign body in the soft tissues (Figure ). The wound was closed by suturing. The patient was then given antibiotics and referred to the Department of Stomatology ward for observation. There was significant relief of the subcutaneous emphysema and wound swelling in the first two days. However, he still felt pain and the movement of his neck was restricted. On the third day after a bout of violent coughing he had an abrupt onset of left-sided neck swelling with neck pain and shortness of breath. Physical examination discovered that the trachea was deviated to the right without any neurological deficit. A computed tomography (CT) scan revealed extensive subcutaneous emphysema in the neck and upper breast region, and a dense linear shadow at the level of the 7th cervical vertebra and 1st dorsal vertebra whose ends were embedded in the pre-vertebral soft tissue and parapharyngeal space (Figure ).
A tracheotomy was promptly performed to relieve his shortness of breath. Once the skin and subcutaneous tissue were opened, a massive amount of fresh blood and blood clots poured out of the incision. Our initial clinical impression was that he had rupt

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


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

[User]
RADIOLOGY NOTE:
A 12-year-old female was referred to the Oral and Maxillofacial Surgery Department by an orthodontist regarding an ectopic upper left canine and buccal alveolar expansion from the 22 and 24. On examination there was firm, bony expansion between these teeth with associated root displacement. The 22 and 24 were not mobile. The overlying mucosa was normal and the patient was asymptomatic.
Radiographic examination revealed an ectopic 23 which appeared to be within the maxillary sinus or a possible large cystic radiolucency surrounding the canine as well as an indistinct area of bony expansion between the 22 and 24 (). There was no evidence of root resorption of the 22 and 24. A cone beam computed tomography (CT) was carried out and showed expanded bone in the 23 region with normal trabecular pattern with intact buccal and palatal cortices, but some buccal cortical expansion. The 23 was located in the left zygomatic bone, with the crown facing buccally and causing dehiscence of the zygomatic bone. The roots were facing toward the left maxillary sinus with the dilacerated apex projecting into the sinus (). The cause of buccal alveolar expansion and migration of the 23 was unclear.
The patient had the 23 region explored under a general anesthetic, as well as a bone biopsy of the lesion and a left middle meatal antroscopy. The 23 was not visible during examination of the left maxillary sinus. The expanded buccal bone appeared firm but abnormal looking with slight bleeding (). A differential diagnosis of a fibroosseous lesion was made.
Histopathology results showed vital lamellar bone with uniform osteoblast layer with minimal evidence of resorption. The soft tissue component was a mixture of adipose and highly vascular fibrous tissue. Numerous blood vessels ranged widely in size, some having muscle wall and appeared to be displacing adipose tissue. These finding were compatible with a diagnosis of an IH.
On review, there was no further evidence of bony expansion or active h

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


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

[User]
RADIOLOGY NOTE:
A 71-year-old female came to our institute after falling down from her bed in September 2016. She sustained an injury on her left thigh. She also gave a history of taking bisphosphonates (alendronate, 70 mg weekly) continuously for the past five years. On examination, she was unable to walk or put any weight on her left leg. Her left leg was in complete external rotation, and she was unable to do active straight leg raises (SLR). With the help of an X-ray, a subtrochanteric fracture of the left femur was diagnosed (Figure ). The right thigh X-ray also showed thickening of the lateral cortex, which was indicative of the changes occurring due to the bisphosphonates. The patient was a known case of controlled diabetes mellitus and hypertension.
After the necessary preoperative investigations, the patient was taken up for fixation with close proximal femoral interlock nailing of the trochanteric fracture of the left femur (Figure ). As there was no breach in the cortex seen on the right side, no operative intervention was planned. After fixation, the patient was started on partial weight-bearing walking after three weeks. After reaching the required serum calcium, serum Vitamin D, and serum parathyroid hormone (PTH) levels, the patient was started on teriparatide, 8 IU subcutaneous daily injections, along with elemental calcium, 500 mg, and Vitamin D, 60,000 IU weekly, for six months.
On the subsequent X-rays, it was seen that the bone was not uniting; after nine months, the fracture was labeled as a nonunion subtrochanteric fracture (Figure ). The patient was taken up for surgery after one year for the same. The fracture site was exposed and after freshening of the fracture ends it was seen that fixation was stable with intramedullary nail. However, additional stability and compression were achieved at the fracture site with a 6 hole 3.5 mm LC-DCP which was then fixed with four cortical screws

[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’s course is outlined in Fig. .
A 58-year-old, previously healthy, white female presented to her primary care provider (PCP) with the desire to remove a right posterior scalp cyst for cosmesis. This non-inflamed, non-draining, painless, 1–2 cm cyst had been present for close to 10 years without change in size or fluctuance. The cyst was initially drained by the PCP, but, when it recurred 6 months later, the PCP excised the cyst and sent the specimen for routine pathology. The initial read of the tissue sample was high-grade invasive carcinoma with squamous features and arising in association with a PTT. Based on the pathology, the PCP referred the patient to a plastic surgeon for a more definitive excision of the lesion and repair of the defect. The lesion was excised with negative margins and pathology read as invasive high-grade squamous cell carcinoma (SCC). Eight months post resection, the lesion recurred locally along with a palpable right posterior cervical lymph node (LN). A positron emission tomography (PET) scan at that time demonstrated hypermetabolic activity in the posterior occiput and in a posterior neck LN. Fine needle aspiration (FNA) of both the primary scalp lesion and LN were completed, and pathology was reported as SCC, similar to the primary lesion.
With a working diagnosis of locally advanced SCC, the patient’s care was referred to a tertiary care center. There, a dermatopathologist re-evaluated the previous biopsy specimens and altered the diagnosis from SCC to MPTT (Fig. ). Subsequently, the patient was referred to a head and neck surgeon for modified radical posterior neck and lymph node dissection. Intraoperative findings uncovered the presence of nodal metastases to the posterior neck with extranodal extension, extensive perineural invasion of the spinal accessory nerve, and jugular venous invasion of the MPTT. After surgery, the case was discussed at a multi-disciplinary tumor board, and a common

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


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

[User]
RADIOLOGY NOTE:
A 13-year-old Caucasian girl, who was otherwise healthy, presented with intermittent swelling, erythema, tingling and numbness of the palmar aspect of her left hand. The nature of the pain was described as dull and shooting. These symptoms lasted for 7-10 days, even though regular analgesics were used.
On examination, the patient was found to be in excellent physical condition. Left hand pulses were easily felt. She had a slight functional limitation of her left hand grip due to pain and stiffness. The left hand was slightly cold to touch compared with the right hand. On examination, the patient was found to be in excellent physical condition. A positive Tinel test and elevated arm test was noted in the clinically affected arm. There was no asymmetry of clavicles noted. There was no muscle atrophy identified.
In view of these symptoms, neurovascular TOS was considered. X-ray of her cervical spine revealed an anomalous first rib that was fused to the second rib []. Magnetic resonance imaging of her brain, cervical spine and brachial plexus was normal. She also had a nerve conduction study, which interestingly revealed bilateral ulnar sensory and motor conduction abnormalities as well as early bilateral median sensory nerve conduction changes.
In view of the neuropathic nature of the intermittent pain, she was started on amitriptyline and gabapentin. This had a variable effect on her pain. Following a surgical opinion, a left-sided supraclavicular approach for exploration was undertaken. During the surgery, there was no apparent bony structure compressing the brachial plexus, nor was there any fibrous band. On moving the arm around, it was evident that the brachial plexus was entirely free. The scalenus anterior itself was impinging on the brachial plexus; hence, she underwent left anterior scalenectomy. She showed good response following the surgery. This was evident from the reduction of her symptoms of pain, swelling and tingling. Postoperative sensory and motor ne

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


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

[User]
RADIOLOGY NOTE:
A previously healthy 34-year-old Korean female was admitted to a regional hospital for fever, myalgia and severe headache that had started 2 weeks ago. Brain MRI showed a high T2 signal intensity change and diffuse swelling of the right temporal lobe, insula and hippocampus (Fig. ). Lumbar puncture showed lympho-dominant pleocytosis. The patient was started on intravenous (iv) dexamethasone and acyclovir under a high suspicion of viral encephalitis.
She was transferred to our institution 4 days later due to persistent headache despite treatment. A noncontrast computed tomography (CT) brain scan taken at our institution showed a hemorrhagic transformation of the right temporal lobe, which was not observed on the initial MRI (Fig. ). Follow-up lumbar puncture showed 510 white cells per mm3 (82% lymphocytes), 144 mg/dL protein and 61 mg/dL glucose. CSF culture studies were negative for bacteria, fungi and tuberculosis. PCR of the CSF confirmed the presence of HSV1. The patient was free of neurological symptoms, with a Glasgow Coma Scale of E4M6V5, and was admitted for close observation and continuation of iv acyclovir. Corticosteroid treatment was discontinued upon her admission. On day 3 of hospitalization, the patient presented with a sudden onset of vomiting and severe headache. Brain CT showed an increased amount of temporal lobe hemorrhage and a leftward shift in the midline (Fig. ). Mannitol was administered but did not seem to have a significant effect. The patient became increasingly drowsy, and her right pupil became dilated. She underwent emergency right decompressive craniectomy, expansile duraplasty and ICP monitor insertion. Postoperative brain CT showed alleviation of midline shifting (Fig. ). The patient recovered fully 5 days after the surgery. Apart from mild intermittent headache and dizziness, she did not show any other significant clinical symptoms, including neuropsychological problems. There were no significant neurologic deficits upon neurologica

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


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

[User]
RADIOLOGY NOTE:
A 66-year-old male with hypertension and type 2 diabetes mellitus was referred to our institution in June 2015 for investigation of haematuria, urinary retention and lower abdominal pain with associated PR bleeding. CT scan revealed a large prostatic abscess, invading into rectum. A TURP was performed to de-roof the abscess. Histopathology demonstrated a poorly differentiated prostatic adenocarcinoma with extensive necrosis. Colonoscopy was arranged to investigate the extent of invasion into rectum and the patient was presented at a multidisciplinary team meeting. The consensus decision was to perform a total pelvic exenteration, abdominoperineal resection with end sigmoid colostomy and ileal conduit formation. Histopathology confirmed a Gleason 5 + 5, T4N0M1 prostatic adenocarcinoma with six liver metastases on further imaging. The patient was started on hormonal therapy with Firmagon and Zoladex and completed six cycles of chemotherapy by 2016.
In 2017, repeat imaging showed resolution of all liver metastases, and the patient’s PSA was <0.1. While he had responded excellently to treatment, the patient had developed parastomal hernias around both the colostomy and ileal conduit. Between 2015 and 2017, the patient presented to hospital twice with features suggestive of small bowel obstruction. At the time, this was believed to be related to the hernias and therefore, the patient was planned for surgical repair of these hernias. During pre-operative workup, investigations revealed the patient to be anaemic with a haemoglobin of 80 and a ferritin of 11. Gastroscopy and colonoscopy revealed no abnormality; however, a pill cam demonstrated a single large lesion in the jejunum (Fig. ). An MRI enterography was arranged to further characterize the lesion (Fig. ). Given the excellent response to treatment, resolution of all liver metastasis and undetectable PSA levels a prostate cancer metastasis was not suspected. As the nature of this lesion was uncertain, a decision 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 78 year old Caucasian male referred to our department because of a history of recurrent jaundice and periodical appearance of right upper quadrant pain. The patient had undergone a post-Billroth II gastrectomy for peptic ulcer disease and cholecystectomy 48 and 7 years ago respectively. On admission, physical examination was unremarkable and laboratory evaluation showed no abnormalities with liver function tests being normal. Ultrasonography (U/S) of the liver revealed a common bile duct stone with no dilation of the common bile duct. Computed tomography (CT) showed the same findings as well. Magnetic resonance imaging (MRI) and magnetic resonance cholangiopancreatography (MRCP) revealed the existence of a common bile duct stone and confirmed the U/S and CT findings. The patient underwent an ERCP with the purpose to remove the offending stone and to perform endoscopic sphincterotomy. A long afferent limb of the Billroth II gastroenterostomy made locating the duodenal papilla technically difficult. After several attempts with no success, the procedure was abandoned for a few days later. The whole procedure had no obvious mediate complications. Immediately after the examination and for the rest of the day, there were no abnormal signs or symptoms. The morning after, the patient complained for crepitus in the soft tissues of the supraclavicular fossae and neck. Physical examination confirmed this finding. Plain radiographs of the chest and abdomen revealed subcutaneous emphysema, pneumomediastinum and pneumoperitoneum (Figure ). An esophagogram with water-soluble contrast showed no evidence of perforation. Abdominal and chest CT-scan showed no evidence of retroperitoneal or peritoneal perforation but air was noted in the peritoneal cavity, the mediastinum and in the soft tissues of the neck (Figure ). In the absence of revealing a site of free perforation, the patient was managed conservatively with gastric aspiration using a large-bore nasogastric tube, intravenous

[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 73-year-old man with past medical history of stage IV bladder and prostate cancer, status post cystoprostatectomy with ileal conduit, left orchiectomy, and subsequent left radical nephrectomy (for recurrent left hydronephrosis and pyelonephritis), presented with worsening right leg edema and pain for 2–3 weeks which confined him to bedrest. On examination, there was severe pitting edema of the right leg associated with erythema and warmth.
Duplex ultrasound examination of the lower extremities revealed a nonocclusive thrombus extending from the right external iliac to the central (cranial) segment of the femoral vein and an occlusive thrombus in the central segment of the deep femoral (profunda femoris) vein. A non-contrast CT scan of the abdomen and pelvis revealed an increase in the size of a pelvic retroperitoneal nodal mass inseparable from the right common iliac artery and right ureter, with no clear visualization of the right iliac venous system (Fig. ). The patient was placed on therapeutic low molecular weight heparin in preparation for right lower extremity catheter-directed thrombolysis and stenting.
Pre-procedural ultrasound examination of the access site confirmed findings seen on lower extremity Doppler examination and revealed extension of the venous thrombosis into the femoral and deep femoral vein precluding femoral vein access. The patient was then placed in prone position under general anesthesia and the right popliteal vein was accessed. Venography showed extensive thrombosis and strictures of the right common iliac, right external iliac, and right femoral veins with collateralization (Fig. ). Pharmacomechanical thrombolysis using the Trellis Thrombectomy System (Formerly Covidien, Boston, MA, now discontinued) was performed in the right femoral vein through the popliteal vein access to clear the acute thrombus. Repeat venography showed resolution of the acute DVT in the right femoral and external iliac veins with minimal residual stenosis. Ther

[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:
At 35 weeks of gestation, a 37-year-old (height 162 cm and weight 85.1 kg) primigravida visited the emergency department with complaints of unceasing palpitations, without associated symptoms such as dizziness, syncope or dyspnea. She had no history of any significant disease and her pregnancy had been uneventful. Upon questioning, she described a history of occasional palpitations over the past few years, which went away spontaneously in minutes.
EKG showed the presence of a SVT at a rate over 160 beats/min with stable blood pressure (). Three boluses of IV adenosine (6 mg → 12 mg → 12 mg) were injected after unsuccessful carotid sinus massage. The SVT reverted to a normal sinus rhythm for only several minutes with adenosine, and SVT recurred. IV verapamil (5 mg) and two trials of synchronized electric cardioversion (150 J → 200 J) were also unsuccessful. Emergency Cesarean delivery was then performed because of uncertainty about the maternal health and concern for the fetus.
A spinal anesthesia was performed using 10 mg of bupivacaine and 20 µg of fentanyl after 500 ml of 6% HES 130/0.4 infusion. Phenylephrine (0.2 µg/min/kg) was given to prevent spinal anesthesia related hypotension and 50 µg of phenylephrine was occasionally administered when systolic blood pressure was lower than 100 mmHg. The systolic blood pressure maintained between 90-120 mmHg. Total infused dose of phenylephrine before delivery of a baby was 350 µg with bolus and 60 µg with continuous infusion. A healthy baby was delivered uneventfully, and 100 µg of carbetocin was infused slowly without any complications. Her heart rate was around 150 beats/min throughout the operation, which suddenly dropped to 80-90 beats/min at the end of surgery. A normal sinus rhythm was maintained during the postoperative period (). A 24-hour Holter monitor and a cardiac echography were performed the next day, but no abnormalities were found. She 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 12-year-old boy presented at the Paediatric Department complaining of severe headache without any other symptoms. He had a past medical history of congenital hypothyroidism and idiopathic growth hormone insufficiency. His body mass index (BMI) was 13 and he was under thyroxine treatment. He was also on the 8th week of recombinant human growth hormone (rhGH) treatment on a dose of 1.5 mg daily (or 4.5 IU daily). On the same day he was referred to the Eye Department for further assessment.
On initial examination his best corrected visual acuity was 6/9 in both eyes. His intraocular pressures (IOPs) were 12 mmHg in the right eye and 15 mmHh in the left. Color vision tested via Ishihara plates showed no defects in either eye. Moreover, the anterior chamber and the papillary reflexes were normal and a relative afferent papillary defect (RAPD) was not revealed in either eye. Fundoscopy revealed bilateral hyperaemic optic nerve edema, with no spontaneous venous pulsations and with increased retinal vessel tortuosity. Elevation of nasal and temporal circumference of the optic nerve obscuring some segments of the major retinal vessels and a halo surrounding the disc were apparent in both eyes (Stage 3, staging scheme of swelling of the optic nerve head by Frisen) [] (Figures and ).
Visual field testing was inconclusive because the patient was uncooperative. There was a second effort of visual field testing which showed an enlargement of the blind spot in both eyes without any other abnormalities. Further investigations were performed including blood pressure measurements and blood tests which were within normal limits. An assessment by a neurologist took place and a brain computed tomography (CT) scan was ordered. The CT scan showed normal ventricular size, swelling of optic nerve heads, and a partially empty sella without any evidence of mass, haemorrhage, edema, or midline shift. Lumbar puncture revealed an elevated opening pressure of 36 cm water and a normal spinal flu

[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 26-year-old pregnant women of Asian Indian origin was referred to the obstetric casualty by the general practitioner with a provisional diagnosis of placental abruption in view of abdominal pain, pallor and inability to find fetal heart. The women had insidious onset of pain for 12 hrs, and with reduced fetal movements for the same duration. The woman was third gravida with 32 weeks gestation, with previous two normal deliveries and an uneventful antenatal period. Her dating and anomaly scan were normal. There was also no history of trauma, any diagnostic or therapeutic intrauterine intervention, vaginal bleeding or labor pains. She had no significant past medical, surgical history or gynecological history.
On examination, she was pale with respiratory rate of 28 per minute, pulse rate of 110 per minute and blood pressure of 90/60 mmHg. On abdominal examination, uterus measured 30 weeks, with mild abdominal tenderness and no increased tone. The uterine wall felt thin but with regular outline and no fetal part was palpable. Fetal heart could not be localized. Speculum examination showed no vaginal bleeding and there was marked tenderness on internal examination and cervix was uneffaced and os admitted tip of finger.
Ultrasound scan revealed fetal demise. An intact amniotic sac with fetus and normal volume of amniotic fluid, without any echogenecity to suggest blood, was seen lying outside the uterus. Uterus was deviated towards left iliac fossa. Diagnosis of rupture uterus with fetal demise was made and the woman was prepared for laparotomy. Blood investigations revealed hemoglobin of 7.7 gm% with no evidence of coagulopathy.
After resuscitation with intravenous fluids, the patient was taken for surgery. Emergency exploratory laparotomy was done with consent for hysterectomy or uterine repair with tubal sterilization under intravenous antibiotic cover. An intact amniotic sac with fetus was found along with 1.5 liter of haemoperitoneum. Membranes were ruptured and m

[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 30-year-old African-American male patient presenting to the hospital for trauma injuries to his abdomen. He had sustained a gunshot wound, which necessitated an exploratory laparotomy along with a small bowel resection. The patient had to have an ileocecostomy done. He initially improved but on the third day post operatively he became very short of breath and hypoxic. High flow cannula was initiated and a work up for the possible etiologies of hypoxemia was undertaken. Computed tomographic (CT) scan of the chest with intravenous contrast was performed and was notable for a pulmonary embolism (PE) in third and fourth order segmental branches of the right upper lobe pulmonary artery. Heparin infusion was started for treatment.
The usual protocol with aPTT monitoring, for the dose appropriation of heparin infusion, was initiated. During the following period it was found to be difficult to achieve a therapeutic range for anticoagulation based on the aPTT. During this time he had only been therapeutic once following the transfusion of one unit of fresh frozen plasma. The heparin was titrated up with increasing dose of heparin. However, suspicions for heparin infusion became a concern when the dose required approached 50,000 IU/24 h without aPTT being therapeutic. Haematology was consulted for evaluation and guidance.
At the time of evaluation patient was in no acute distress without any significant physical findings except for tachycardia and abdominal distention with midline scar closed with mesh. The former was likely explained with the PE the latter was secondary to the surgery. The trend for aPTT was noted to be in a sinusoidal pattern ranging between 51 and 27. Since the patient had multiple factors because of the acute situation, it was decided to check for factor 10 levels. Also factor VIII levels were checked. Because of the acute trauma to the abdomen it was suspected the factor VIII might be abnormal. His factor VIII levels were 400% (normal range of 50–200%)

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


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

[User]
RADIOLOGY NOTE:
A 46-year-old lady was referred for investigation of a change in bowel habit. A computerised tomography (CT) colonography was performed and excluded any colonic pathology but did identify that the common bile duct was mildly dilated with a diameter of 8 mm, although no clear cause was found. Some reactive celiac lymph nodes were also seen and so the patient underwent an endoscopic ultrasound (EUS) scan to exclude a malignancy. The latter showed sludge and stones within the common bile duct and gallbladder. A subsequent endoscopic retrograde cholangiopancreatography-(ERCP-) guided sphincterotomy and balloon trawl of the common bile duct were performed leaving the common bile duct clear. Given the previous presence of gallstones within the common bile duct, it was decided to proceed to elective laparoscopic cholecystectomy. Laboratory investigations on the day before surgery revealed normal liver biochemistry (alkaline phosphatase 120 IU/L, bilirubin 3 umol/L, and alanine aminotransferase 23 IU/L).
The patient's medical history was remarkable for excision of an intracranial epidermoid cyst in 1993. The patient developed nonobstructive hydrocephalus following this procedure and required the insertion of an LP shunt. The shunt ran from the subarachnoid space at the level of fourth and fifth lumbar vertebrae, around the right flank, through the right rectus abdominis muscle and peritoneum and the tip lay within the peritoneal cavity in the pelvis. In addition to the hydrocephalus, the patient suffered from chronic chemical meningitis and headaches, which were managed with an occipital nerve stimulator and oral analgesia. The generator for the occipital nerve stimulator lay within the subcutaneous tissue in the right paraumbilical region and the wires ran cranially in the subcutaneous plane from this generator (). The patient otherwise had a history of well-controlled asthma, depression, gastroesophageal reflux disease, and coeliac disease.
The patient was admitted for an

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


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

[User]
RADIOLOGY NOTE:
A 50-year-old woman, Gravida 3, Para 1, presented to our department with irregular genital bleeding for 2 months. Her last menstrual period had been 2 months before. Her obstetrical history included a normal vaginal delivery 13 years before and two spontaneous abortions 8 and 11 years previously. Transvaginal ultrasonography showed an enlarged uterus with endometrial thickening with an echogenic pattern (Fig. ). As endometrial cancer was suspected first, an endometrial biopsy and magnetic resonance imaging (MRI) were performed. The endometrial biopsy revealed decidual tissues, and the MRI revealed invasion of a uterine corpus tumor into the myometrium (Fig. ). A week later, the patient admitted to the hospital with continuation of irregular vaginal bleeding. Second endometrial biopsy was done and serum β-human chorionic gonadotropin (hCG) level was also measured owing to suspicion of a hydatidiform mole. The serum hCG level was over 225 000 mIU/mL, and the endometrial biopsy revealed a complete hydatidiform mole. Because the patient's hemoglobin level was 7.0 g/dL, owing to the continuation of uterine bleeding, we transfused 800 mL of red cell concentrate and discharged the patient. A lung metastasis, 1 cm in diameter, was observed on a contrast computer tomography scan (Fig. ), and an invasive mole with lung metastasis was diagnosed. Because the patient did not desire preservation of her uterus or adnexa, we offered her a total abdominal hysterectomy (TAH) and bilateral salpingo-oophorectomy (BSO). At her next consultation for the continuous genital bleeding, a tumor of the right labium minus was recognized and histologically confirmed as a metastatic lesion of the mole (Fig. ). The patient underwent TAH and BSO. Unfortunately, a tumor of right labium minus had spontaneously fallen off during surgery. In a gross specimen, molar vesicles were recognized at the uterine corpus with the right ovary a little swollen (Fig. ). The invasions into myometrium by both villi 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 55-year-old man was admitted to our hospital with sudden pulsatile headache and pulse-synchronous tinnitus on the left occipital. Bruit was audible mainly on his left retroauricular area. He had past history of right ACC DAVF at 50 years of age (). Its clinical manifestation was right-sided tinnitus and it was similar to the present symptoms. His right ACC DAVF was treated with transvenous coil embolization in another hospital and its obliteration was angiographically confirmed. He had resolved clinical symptoms and stopped visiting the hospital 1 year after the treatment.
The diagnostic angiography in our hospital revealed a high flow DAVF close to left jugular foramen, and it was mainly fed by meningeal branch of bilateral ascending pharyngeal arteries. It was not only drained to left internal jugular vein and vertebral artery venous plexus, but also refluxed to contralateral transverse-sigmoid sinus and to cavernous sinus via inferior petrosal sinus. Those findings suggest this lesion to have high volume arteriovenous shunt flow (). The shunt point could not be identified by routine angiography because blood flow to the lesion was very high. The right ACC DAVF treated five years earlier was not depicted on the four vessels' study (). The shunt point was evaluated by angioarchitecture demonstrated by three-dimensional angiography and by time-of-flight magnetic resonance angiography (MRA). Shunt point was identified on left ACC (), and transvenous coil embolization was planned. Under general anesthesia, a 6 Fr guiding catheter was placed adjacent to the jugular bulb via right femoral vein, and a microcatheter was advanced into the left ACC. Superselective angiography of left ascending pharyngeal artery confirmed that the microcatheter was accurately placed in ACC that is forming venous pouch, and then coil packing was carried out. Excess coil packing in hypoglossal canal results in hypoglossal nerve palsy; therefore, coil embolization was finished with angiograph

[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.