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

[User]
RADIOLOGY NOTE:
A 49-year-old woman presented with a 3-month history of repeated ptosis of both eyelids and oral ulcers and erosions. Physical examinations revealed scattered ulcers and erosions in the mouth (Fig. ). Laboratory examinations showed that CA 125 was elevated (51.6 U/ml), while other tumor markers, including CA199, 153, CEA, and AFP, were normal. Autoimmune antibodies, including anti-CENP-B antibody, ANCA, anti-AchR antibody, and ANA, were all positive.
The patient was first diagnosed with an oral aphthous ulcer and ocular myopathy myasthenia gravis. She was treated with gentamycin and dexamethasone spray inhalation to improve her oral lesions and pyridostigmine to cure muscle weakness. However, the oral ulcers improved slightly and the myasthenia gravis persisted. An abdominal ultrasound showed a hypoechoic mass in the left adrenal gland. A further CT examination showed a 6 × 5 cm, well-defined round solid mass with central necrosis in the pancreatic tail. There was no calcification detected in the mass. The solid part of the mass had slight enhancement in the arterial phase with many serpentine feeding arteries, moderate enhancement with a draining vein around the tumor in the portal venous phase and persistent enhancement in the delayed phase (Fig. a-e). The fundus of the stomach was compressed by the mass. The boundary between the mass and the splenic artery and vein was not clear, and swollen lymph nodes were not observed in the posterior peritoneum. The mass was initially considered to be a neuroendocrine tumor in the pancreatic tail.
At the same time, the patient’s symptoms worsened. She could not swallow, and she felt severe pain in her mouth. She also developed a cough and expectoration. A chest CT revealed infection in the lower lobes of both lungs. Streptococcus was detected from a throat swab. Levofloxacin was administered to fight the infection, methylprednisolone to fight the inflammation, and thalidomide to alleviate the vascular inflammatory reaction in

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


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

[User]
RADIOLOGY NOTE:
A 52-year-old lady (para 1) presented to the gynecology clinic with a history of PMB. She had undergone menopause 2 years prior to the presentation. She described it as per vaginal spotting to heavier flow for 10 days. It recurred again after 1 month. There was no abdominal pain or other symptoms. She has a past history of thyroid nodules which she underwent thyroidectomy in 2013. She was hypothyroid since then on thyroxine. She was under regular follow-up with an endocrinologist and her last thyroid function test was normal. She was also a known asthmatic on Budamate inhaler. Her recent cervical smear and mammogram in 2017 was normal. She has a strong family history of malignancy in her paternal side which includes throat, rectal and stomach cancer while her aunt had breast cancer. She had a pelvic scan done which showed endometrial thickness of 8 mm, no lesions in the endometrial cavity, multiple uterine fibroids ranging in sizes from 0.9 to 4.7 cm. Both ovaries contained unilocular anechoic avascular cysts measuring 0.5 and 0.6 cm on the right and left side, respectively (). She underwent hysteroscopy, dilatation and curettage for assessment of her PMB. Intraoperative findings showed a 2-cm endometrial polyp which was removed uneventfully. Histology of the specimen showed endometrial stromal breakdown with no evidence of malignancy. In view of this, the plan was to observe and to report any further PMB. One month later, she presented with another episode of significant PMB lasting 3 days which she described as “like a normal period”. In view of the recurrent episodes of PMB, the patient was advised a hysterectomy as a form of management. Magnetic resonance imaging (MRI) pelvis done prior to her hysterectomy showed multiple fibroids with no focal endometrial lesion. A 0.9-cm hemorrhagic cyst in the left ovary likely to be functional was seen (). There was no lymphadenopathy. The patient underwent an uncomplicated total laparoscopic hysterectomy

[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 44-year-old man was admitted to our clinic because of left knee pain. He had pulmonary tuberculosis at 6 years old. He presented pus-forming arthritis, which was presumably tuberculous arthritis, in the left knee after 2 years, with spontaneous remission after closure of the draining sinuses. Thereafter, no recurrent symptom of infection was observed. However, the deformity and growth disturbance progressed with the knee pain. He had limb lengthening and alignment correction for the leg length discrepancy and genu valgum. However, his left knee pain continued despite the deformity correction. Radiographs showed a fused knee with severe tricompartmental arthritis (Fig. ). Severe limitation in range of motion was observed on the left knee. We planned to perform one- or two-stage primary TKA depending on the presence of infection [].
Intraoperatively, a large subchondral abscess was found in the lateral femoral condyle and lateral tibial plateau after takedown of the fusion (Fig. d). On the basis of the necrotizing inflammation with granuloma in the frozen-section biopsy, active tuberculosis was suspected. Aggressive debridement and curettage of the infected and necrotic bone and soft tissues were performed.. After bone cuts and soft tissue balancing to prepare for TKA, articulating cement spacers (vancomycin 4 g and streptomycin 2 g per 1 batch) were made intraoperatively and applied to the tibial and femoral sides in sequence using intraoperative cement molds with a previously described technique [, ] (Fig. ). Relative medial and lateral stabilities were confirmed intraoperatively after inserting the articulating cement spacers. The diagnosis of tuberculosis infection was confirmed by isolating Mycobacterium tuberculosis from cultures. We decided to delay the TKA for at least 6 to 9 months to allow the administration of antituberculous drugs []. Evaluation at 1-year follow-up revealed no recurrent infection after sufficient antituberculous drug treatment. Therefore

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


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

[User]
RADIOLOGY NOTE:
A 57-year-old female visited a respiratory internal physician due to suspected lung cancer (based on a mass screening chest X-ray examination). She did not have any symptoms. The chest X-ray showed a tumor shadow in the upper-middle field of the right lung with pleural effusion and a tumor shadow in the upper field of the left lung (). Computed tomography (CT) of the neck and chest revealed that the tumor shadows had been caused by a substernal goiter connected to the thyroid gland in the neck. According to the patient, she had been diagnosed with a goiter about 23 years ago, and it was followed up, but the follow-up process had been discontinued several times. After about 20 years, she visited our hospital for surgical treatment.
In a physical examination, the palpable thyroid gland was found to be diffusely swollen and soft and exhibited poor mobility. The lower pole of the thyroid was not palpable.
A blood examination revealed normal thyroid function, a thyroglobulin level of 352 ng/ml, and negativity for the thyroglobulin antibody.
Ultrasound showed that the cervical thyroid gland was diffusely enlarged and exhibited multiple regions of cystic degeneration, but no obvious malignant findings were observed.
CT of the neck and chest () showed the diffusely swollen thyroid gland and a substernal goiter, which extended to both sides of the thorax. Specifically, it extended to the bifurcation of the trachea on the dorsal side of the superior vena cava, the innominate vein, the aortic arch, and the ventral side of the trachea. The width of the goiter at the mediastinum was 145 mm (length: 80 mm, thickness: 80 mm). The right side of the substernal goiter was bigger than its left side. The interior of the lesion was heterogeneous, and calcification was seen in part of it. The goiter had compressed the trachea in the mediastinum, and the lumen of the trachea measured 6 mm in diameter at its narrowest point. Pleural effusion was noted in

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


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

[User]
RADIOLOGY NOTE:
The previous pregnancy of a 37-year-old healthy Japanese woman (gravida 2, para 1) had been uncomplicated, and the resulting child was alive and well. She had no history of periconceptional tobacco smoking, alcohol intake, radiation exposure, or intake of other supplements and drugs. She had no clinical problems during the early period of the current pregnancy; however, she did not undergo an ultrasound examination during the first trimester. At 36 weeks of gestation of the current pregnancy, a routine ultrasound examination revealed an abnormal number of umbilical cord vessels. A fetal ultrasound examination was performed using a GE Voluson™ E10 ultrasound machine (General Electric Healthcare, Tokyo, Japan) with a 3.5-MHz convex-array transducer. The examination revealed the coexistence of a four-vessel part and a three-vessel part within the free loop of the umbilical cord (Fig. ). The fetal insertion site of the umbilical cord comprised four vessels (two arteries and two veins), whereas the placental insertion site comprised three vessels (two arteries and one vein). The blood flow was demonstrated in both veins by two sonographic specialists in maternal fetal medicine, and the flow was similar in each vessel. However, we were unable to prenatally detect the exact point at which the umbilical cord changed from a four-vessel to a three-vessel cord. The intra-abdominal umbilical vein was a single vessel that was connected to the ductus venosus and returned to the right atrium (Fig. ). No other sonographic congenital abnormalities were detected on fetal ultrasound screening performed in accordance with the recommendations of the International Society of Ultrasound in Obstetrics and Gynecology [].
At 38 weeks of gestation, a healthy female neonate weighing 2726 g was delivered by spontaneous vaginal delivery. The infant’s Apgar scores were 9 and 10 at 1 minute and 5 minutes, respectively. The neonatal physical examination at birth was normal.
Ultrasonographic examina

[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:
Sixty-three-year-old female patient was admitted to the Department of Endocrinology of Muğla Sıtkı Koçman University Research Hospital with the complaints of hoarseness and discharge from the anterior neck wall which were present for the last 6 months. The patient underwent a near total thyroidectomy 17 years ago but no surgery or pathology records were available. The neck ultrasound showed recurrent nodular goiter and a diagnostic FNAB guided by palpation was performed six months before. Two weeks later the patient had wound discharge and hoarseness which was not improved by a course of antibiotic therapy and was referred to our hospital. Physical examination of the patient revealed a sinus opening with seropurulent discharge located superior to the thyroidectomy incision and the tissue surrounding the sinus opening was moderately swollen and was hyperemic (). A 1 cm nodule was palpated in the left side of her neck. No cervical lymph adenopathy or any other systemic finding was found. White blood cell count, neutrophil, eosinophil, C reactive protein, sedimentation rate, liver and thyroid function tests, and antithyroid antibodies were all in normal range. Culture of the discharge did not grow any bacteria. A cervical USG showed a 9 × 7 mm nodule with mixed echogenicities in the left remnant thyroid tissue and a 9.5 × 3.5 mm fistulized fluid collection ().
Cervical MRI revealed a 10 × 6 mm subcutaneous tract that was opening to the skin and a minimal fluid intensity that was consistent with postoperative granulation tissue. The patient underwent surgery and the exploration revealed that the sinus tract was ending near the berry ligament close to the left thyroid cartilage and left recurrent laryngeal nerve with silk suture remains. The left recurrent laryngeal nerve was intact; however, it was thickened comparing to the right. The sinus tract and the remnant thyroid tissue were removed with laryngeal nerve monitoring. The pathology report showed that the sinus was

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


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

[User]
RADIOLOGY NOTE:
A 48-year-old man with a known history of hypertension and no known cardiac history presented to the ED with substernal chest pain radiating to the left jaw, axilla, and arm. It was sudden in onset; he reported the pain started while he was mowing his grass and was associated with shortness of breath and diaphoresis. He had no personal history of diabetes mellitus, hyperlipidemia, smoking, or use of illicit drugs and denied any family history of premature coronary artery disease. His vital signs were significant for elevated blood pressure of 202/126 mmHg with oxygen saturation >95% on room air. He was anxious and otherwise had an unremarkable examination with normal S1 and S2 with no murmurs, rubs, or gallops and no rales or rhonchi.
An electrocardiogram revealed ST elevations in lead I, V4-V6 suggesting anterolateral STEMI. He was loaded with aspirin 325 mg oral and 5000 units of IV heparin. He was emergently transferred to the cardiac catheterization laboratory for angiography. His coronary angiogram was done via the right femoral route and revealed right dominant coronary anatomy with no angiographic evidence of obstructive disease in the right coronary artery and left circumflex artery. His mid LAD had filling defect suspicious for plaque rupture and thrombosis (Figure ).
After administering additional heparin to achieve activated clotting time > 250, left main was engaged with extra backup (XB) 3.5 guide catheter and short runthrough wire advanced to the distal LAD. The wire advanced easily, and we navigated to the septal and diagonal branches, confirming the intraluminal location of the wire. On follow-up angiogram, we noted dissection in his middle LAD extending to the diagonal branch, confirming the diagnosis of SCAD.
We initially tried to wire the diagonal branch; however, we were unable to advance the wire to the diagonal branch. We then deployed a drug-eluting stent to seal the proximal end of dissection with a

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


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

[User]
RADIOLOGY NOTE:
A 52-year-old man with no significant prior medical history was brought to our emergency room with drowsy mental status that lasted ten hours after the onset of left hemiparesis and dysarthria. The patient's left extremities were weak, and muscle power was of grade 4 in upper and lower limbs. Brain computed tomography (CT) and magnetic resonance examinations revealed acute cerebral infarction in the right MCA territory and an extra-axial mass with homogenous enhancement in the medial portion of the right sphenoid ridge (). Magnetic resonance angiogram showed complete occlusion of the right ICA terminus (). The infarction included the right uncus, insula, medial occipitotemporal gyrus, basal ganglia, corona radiate, and precentral gyrus (). The tumor, which was consistent with a sphenoid ridge meningioma, encased and compressed the right ICA terminus. Cerebral angiography demonstrated complete occlusion of the right proximal M1 portion with slightly limited collateral circulation to the right MCA territory and a radiographic blush from the surrounding meningioma (). Flow in the right MCA had been partially reconstituted by supply from the ipsilateral anterior cerebral artery and the posterior cerebral artery, but was much reduced. A CT perfusion study obtained shortly after arrival showed dramatic prolongation of time to peak and mean transit time of the right MCA territory, indicating obviously decreased regional cerebral blood flow in the involved territory ().
The patient was admitted and started on dual antiplatelet therapy, induced hypertension, and volume expansion. However, over the ensuing 48 hours, the left hemiparesis deteriorated steadily to muscle power grade 2 in upper and lower limbs, and follow-up magnetic resonance imaging demonstrated enlargement of the area of the diffusion weighted abnormality (). Emergency extracranial-intracranial (EC-IC) bypass was performed uneventfully. We have adopted a "double-barrel" technique whereby both branches of the s

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


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

[User]
RADIOLOGY NOTE:
A 70-year-old man was admitted to our hospital for the evaluation of a pancreatic mass that was incidentally detected during a screening abdominal sonographic examination. He was asymptomatic and he did not have any specific medical history. He had a habit of drinking one or two cups of alcohol daily for several decades. The laboratory tests at the time of admission revealed that the CA19-9, CEA, alpha-fetoprotein, amylase and lipase levels were within the normal limits. The ultrasonographic images showed a hypoechoic mass in the uncinate process of the pancreas, and this was not accompanied by dilatation of the main pancreatic duct. There was no discernible vascularity within the mass on the color Doppler image (). We then performed contrast-enhanced multidetector-row CT. The contrast-enhanced dynamic CT images revealed two round masses with one each in the uncinate process (about 2 × 1.8 cm for the mass size) and tail (about 1.8 × 1.5 cm for the mass size) of the pancreas; these isodense masses on the unenhanced CT images were slightly hypodense, slightly hyperdense and slightly hyperdense, respectively as compared to the pancreas parenchyma on the contrast-enhanced arterial, portal, and delayed-phase CT images that were obtained at 30 seconds, 75 seconds and 180 seconds, respectively, after the injection of contrast agent (). There were no enlarged lymph nodes in the abdomen. MR imaging was performed to further evaluate these pancreatic masses. The MR images demonstrated that the two masses were hypointense and hyperintense on the T1-and T2-weighted images, respectively (). Although subtle enhancement of the two masses was detected, these lesions were shown to be of slight hypointensity as compared to the intensity of the pancreas parenchyma on the gadolinium-enhanced arterial phase T1-weighted image obtained at 25 seconds after the injection of contrast agent (). Meanwhile, the mass lesions were more enhanced than the pancreas parenchyma on the portal and delaye

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

[User]
RADIOLOGY NOTE:
An 85-year-old woman presented to the emergency room with progressive dyspnea for 4 wk with abdominal distension and lower extremity swelling for 2 wk. Past medical history was significant for hypertension and atrial fibrillation, which were being managed with low dose metoprolol succinate. Physical examination revealed moderate respiratory distress and irregularly irregular rhythm with the heart rate ranging 70 to 90 beats/min. Rales were noted over the both lower lung fields, with raised jugular venous pressure, tender hepatomegaly, abdominal distension and bilateral lower extremity edema. The cardiac exam was notable for harsh grade III/IV holosystolic murmur that was loudest at the apex. A bruit was heard in the posterior abdomen loudest at the right costovertebral angle. However no palpable thrill was felt. The electrocardiogram showed atrial fibrillation with the ventricular rate of 80 however without ST/T wave changes. Laboratory analysis revealed elevated b-type Natriuretic Peptide (BNP) of 4497 pg/mL (reference range < 100 pg/mL).
Transthoracic echocardiogram, performed as part of workup for heart failure, showed moderate concentric left ventricular hypertrophy with preserved left ventricular ejection fraction of 55%-60%. However, the patient was noted to have right heart failure with dilated right atrium and ventricle. The presence of bruit in the posterior abdomen prompted an ultrasound (USG) that revealed a peripherally calcified large anechoic structure within in the right kidney with the color flow on color Doppler imaging concerning for a large renal artery aneurysm and/or a vascular malformation. Computed tomography (CT) angiogram done for further evaluation showed aneurysmally dilated renal artery and vein (Figure and C). The distal renal artery had a peripherally calcified focal aneurysm (Figure ) with early enhancement of renal vein suggesting an AV fistula. Besides severe dilatation of IVC, hepatic veins, and gonadal veins were seen due to compen

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

[User]
RADIOLOGY NOTE:
A 24-year-old male was admitted to the clinic due to recurrent episodes of bilateral lower limb weakness over 8 years, which had been aggravated during the past month. Eight years previously, he began experiencing bilateral lower limb weakness and gait instability, without pain or other symptoms, which were relieved by the oral or intravenous daily administration of 4–10 g of potassium supplementation. He experienced similar episodes approximately every 2 years.
One month before presenting to our clinic, the patient had rebound weakness upon the discontinuation of potassium. He was admitted to the hospital for further diagnosis. On admission, he was alert and oriented, with no sign of anemia. His vital signs were a temperature of 36.2°C, a pulse rate of 93 beats per min, 20 breaths per min, and a blood pressure of 127/87 mmHg. His waist circumference was 95 cm, and his body mass index was 26.12 kg/m2. His past medical history was positive for hepatitis B virus infection. No similar findings were present in his mother, elder sister, or his daughter. Family members had no history of consanguineous marriage, use of laxatives or diuretics, or alcohol abuse. This study conformed to human research guidelines stated in the Declaration of Helsinki, and all subjects gave their written informed consent.
Laboratory tests. All the laboratory parameters were determined by Laboratory Medicine Department of West China Hospital, Sichuan University. Serum and urine electrolytes were tested by Cobas8000 automatic biochemical analyzer (Roche, Switzerland). Arterial blood gas was analyzed by GEM3000 blood gas analyzer (Instrument Laboratory, American). Thyroid hormones were measured by electrochemiluminescence immunoassay. Plasma renin activity and aldosterone levels were detected with radioimmunoassay.
Gene analysis. The proband's father died several years before and we were unable to reach his wife, so we could not collect samples of their DNA. Other family members provided periphera

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


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

[User]
RADIOLOGY NOTE:
A 69 years-old fit male with an active life was admitted to our institution. He suffered from cervico-brachialgia, arisen 3 weeks before, and fever. He affirmed lack of appetite and weight losses during the last month, together with mild–moderate dyspnea on the previous 4 days.
His clinical history briefed hepatic steatosis and surgery 30 years before due to left colon cancer.
The transthoracic echocardiogram (TTE) diagnosed a severe mitral regurgitation (MR) due to IE; it was confirmed by transesophageal echocardiogram (TEE), which showed two vegetations on the atrial face of mitral valve, sized 11 × 10 mm on the posterior leaflet and 7 × 5 mm on the anterior leaflet (). The blood culture was positive for Streptococcus alactolyticus, and consequently, the following intravenous antibiotic therapy was prescribed: Gentamicin (80 mg × 3 every day for 2 weeks) and Ceftriaxone (2 g × 2 every day for 4 weeks).
The cervical magnetic resonance imaging (MRI) confirmed the presence of non-specific inflammation of vertebral soma C5 and C6, endorsing spondylodiscitis.
The total body computed tomography (CT) was remarkable for a hypodense area of 13 mm in the spleen and a lumbar lymph node of extended size. This was probably related to infarction derived from a septic embolism.
To assess the possible sites of infection, the patient underwent odontoiatric evaluation. The result was negative for dental foci, but the musculoskeletal and joint ultrasound of his right ankle and foot showed a synovitis of phalangeal metatarsal joint.
A colonoscopy did not show any pathological lesions beside the left hemicolectomy. The second TTE showed a size reduction of the valve vegetations. Nevertheless, owing to the presence of severe MR and the high risk of embolism, cardiac surgery was scheduled.
The patient underwent surgery 16 days after the beginning of the antibiotic therapy, started and later confirmed with blood cultures results, the day

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


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

[User]
RADIOLOGY NOTE:
A 65-year-old man was diagnosed with pulmonary adenocarcinoma, then treated with chemotherapy. The cancer metastasized, and the patient was diagnosed with end-stage lung cancer. Cancer pain was treated with oral opioid therapy. Metastasis of the cancer caused obstructive jaundice and cholangitis, and the patient experienced septic shock. The attending physician performed emergent endoscopic biliary stent placement, in order to treat obstructive jaundice. The patient was medicated with continuous infusion of noradrenaline (0.2 μg/kg/min) through a peripheral vein, in order to maintain blood pressure. He underwent repeated placement of peripheral venous catheters, such that it became difficult to identify adequate peripheral veins for placement and maintenance of indwelling catheters. In the context of this treatment, the patient's congestive heart failure continued, which caused ascites and edema of the lower extremities.
The patient experienced orthopnea and could not sleep at night. The attending physician requested that the anesthesiologists secure a reliable venous line. The anesthesiologists checked the patient's groin and thighs; they excluded the femoral vein as a candidate for central venous access due to massive edema of the thighs. The anesthesiologists attempted to allow the patient to assume the supine or reverse Trendelenburg position; however, these positions caused worsening of the patient's dyspnea. The patient could solely tolerate the sitting position. The anesthesiologists then discontinued attempts to catheterize via the internal jugular and subclavian veins, because of the risk of air embolism during central venous catheterization of the patient in the sitting position.
The right subclavian vein was suspected to exhibit narrowing, based on computed tomography scan images (Fig. ). Thus, the anesthesiologists chose the left arm for insertion of a PICC, and found that the medial brachial vein exhibited sufficient size (diameter 4 mm) to place a PICC

[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 36-year-old Brazilian male patient was admitted to the hospital with a palpable lump in his right breast, located at the junction of the upper quadrants of the right breast (Fig. ). On physical examination, the lesion appeared firm with irregular margins. Axillary lymphadenopathy was negative and there were no palpable supraclavicular nodes. On breast imaging, ultrasonography showed a hypoechoic mass with partially defined contours measuring 4.0 × 3.0 cm, located at the upper region of the right pectoralis major muscle at the 12 o’clock position with muscle infiltration (Fig. ). Histological examination of core biopsy samples revealed a malignant tumor. Preoperative exams, such as X-rays and chest CT scan, abdominal US did not show any signs of disease. Radical mastectomy was then performed, due to pectoralis major muscle infiltration, consisting in removal of the breast along with the major and minor pectoralis muscles. Biopsy of the sentinel lymph node was performed. Gross examination revealed a solid tumor measuring 3.7 × 3.5 cm with a yellowish-tan cut surface and local foci of hemorrhage. Histopathology showed intravascular papillary proliferation of endothelial cells, spindle cell areas and necrosis, atypia and prominent mitotic figures, consistent with the diagnosis of high-grade angiosarcoma with areas of infiltration of the pectoralis major muscle (HE staining, magnification of 400×) (Fig. ). Histopathology also demonstrated a surgical specimen with clear margins, absence of angiolymphatic and perineural invasion, in addition to sentinel lymph node free of metastasis. Immunohistochemical study revealed a tumor positive for CD31 marker (Fig. ), confirming the vascular nature of the tumor. At the two-week follow-up of the surgical procedure, adequate wound healing was observed, without any evidence of the disease. The patient was transferred to the clinical oncology department, where he presented with severe headache and seizures after the second cycle of a

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

[User]
RADIOLOGY NOTE:
The patient is a 37-year-old woman who presented with a chief complaint of six weeks of occipital headaches, persistent dizziness, and diplopia. Her medical history was notable for childbirth three months earlier via vaginal delivery without immediate complications. Epidural anesthesia was used for pain control during labor. Of note, no accidental dural puncture was suspected at the time of procedure, and cerebrospinal fluid leak was not observed at the procedure site. Six weeks following delivery, she began to experience intermittent occipital headaches. The headaches did not appear to be postural in nature, and she had no similar episodes in the past. After developing dizziness and diplopia, she was evaluated by a neuro-ophthalmologist and an MRI was obtained. She was diagnosed with a Chiari I malformation and CN VI palsy. Additionally, MRV did not demonstrate any evidence of venous sinus thrombosis. An eye patch provided temporary relief of diplopia, and she was referred to a general neurosurgery clinic for further evaluation. One week later, her neurologic exam was significant for the progression of her symptoms, a left CN VI palsy, and near-complete ptosis of the left eye which suggested a new CN III injury. She demonstrated no overt pupillary dysfunction, did not demonstrate papilledema, her remaining cranial nerves were intact, and her strength and sensory function were not affected.
Her MRI revealed a Chiari type I malformation with approximately 5-6 mm of tonsillar herniation and no upper cervical syrinx (Figure ). The post-contrast MRI sequences revealed enhancement of the convexity dura, which can signify negative intracranial pressure, but did not demonstrate evidence of pituitary hyperemia, generalized brain sag, or subdural effusions (Figure ). A CT myelogram of the lumbar spine was obtained, and it revealed extradural contrast extravasation within the interspinous soft tissue at L1-L2 with additional spread between the right L2-3 and L3-4 nerve roots

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


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

[User]
RADIOLOGY NOTE:
Our patient was a 4-year-old boy who was referred to the urology clinic because of a history of nonprogressive unilateral scrotal enlargement of a few months duration. He had no notable past medical history, and there was no history of genitourinary trauma or urinary symptoms. The child was well-appearing and physical examination revealed a left inguinal hernia. Right testis was palpable in scrotal sac and was normal. Left hemiscrotum was enlarged, and a solid nontender mass was palpable. There was no distinct border between testis and the mass.
Laboratory investigations including urinalysis, alpha-fetoprotein and human chorionic gonadotropin were normal. Ultrasonography revealed a hernial sac in the left inguinal area (31 mm × 23 mm × 12 mm) filled with bowel. Furthermore, a vascular homogenous hypoechoic mass (27 mm × 18 mm × 12 mm) was found adjacent to the superior aspect of the left testicle (11 mm × 6 mm). Although the tumor markers were negative, however, there was a real risk of a malignant growth, so we decided not to do percutaneous biopsy and proceeded directly to open surgery with a presumptive diagnosis of testicular neoplasm. The patient was explored through a left-sided inguinal incision. Intraoperatively, we found a firm dark blue fleshy mass arising from the left testis and occupying most of testis volume []. There was also a separate smaller mass with the same characteristics located in the processus vaginalis [Figures and ]. As we did not have the facility of frozen section available and our clinical diagnosis was a tumoral growth originating from the testis, complete surgical removal with a safe margin was the best option. Radical orchiectomy was performed because there was hardly any testicular parenchyma to be salvaged; and then, surgery was finished by performing a herniotomy. Pathologic examination of the testicular mass revealed benign splenic tissue attached to a primitive nonfunctional testicular parenchyma []. Furthermore, the mass found

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


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

[User]
RADIOLOGY NOTE:
A 33-year-old woman reported to the Department of Periodontology, Sri Ramachandra Dental College, Sri Ramachandra Institute of Higher Education & Research (DU), with the chief complaint of a missing tooth and the inability to masticate. She had no relevant medical history and had a history of undergoing orthodontic treatment, extraction of the lower left first molar, and endodontic treatment done three years back in relation to the left lower second molar. The patient had presented with fair oral hygiene.
On clinical examination, a gingival growth was present on the floor of the endodontically treated tooth (#37), as seen in Figure .
The tooth had no pain, probing pocket depth, and mobility associated with it. A provisional diagnosis of a gingival polyp was given. An intraoral periapical radiograph was taken, and it revealed no crestal bone loss or bone loss involving the furcation. However, radiolucency was seen on the distal surface of the tooth near the cementoenamel junction (Figure ).
To substantiate the radiographic and clinical features and to establish the pathway of the polyp, a periodontal probe was inserted horizontally from the lingual aspect of the tooth and a small perforation was noticed on the distolingual aspect of 37. Furthermore, a Gutta Percha Point was inserted from the distolingual aspect and a pathway was established from the lingual marginal gingiva to the floor of the cavity.
A final diagnosis of gingival enlargement - gingival overgrowth due to accidental perforation was established. Treatment options included the extraction of the said tooth or the preservation of the tooth with a combination of periodontal procedures and endodontic materials, though it had a questionable prognosis. Both options were explained to the patient and the patient was willing to save the natural tooth, as she had extracted the tooth mesial to it.
The treatment plan included laser-assisted excision of the polyp followed by the restoration of the perforation with 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 51-year-old Moroccan Berber man was referred to our hospital with a history of three months of intermittent painless total gross hematuria, frequency and urgency. The medical and familial histories were unremarkable. Ultrasonography revealed a grade II left hydronephrosis and circumferential thickening of the urinary bladder wall. A computed tomography (CT) scan showed a diffuse neoplasm of the urinary bladder with no lymph node enlargement or distant metastases (Figure ). Cystoscopic examinations revealed nonpapillary sessile tumors occupying almost the whole of the bladder wall (Figure ), and the left side of the trigone obstructing the left ureteral meatus. Transurethral resection of the lesion was realized incompletely because of the diffuse character of the tumor. Histopathological specimen examination found a poorly differentiated mucin-secreting adenocarcinoma of the signet-ring cell type (Figure ).
We performed a complete gastrointestinal endoscopic evaluation and analysis of tumor markers to exclude an extravesical primary tumor site, but no other primary site was found. The tumor was therefore treated as a primary signet-ring cell carcinoma of the urinary bladder.
The patient underwent radical cystectomy with an ileal conduit and bilateral pelvic lymphadenectomy. Histopathological examination of the surgical specimen reported adenocarcinoma composed of signet-ring cells with an abundant mucin pool that was invading the perivesical adipose tissue and one lymph node (<2cm) staging the tumor at pT3bN1M0. Adjuvant chemotherapy was then performed with four cycles of cisplatin, a 100mg/m2 on day 1 and gemcitabine 1000mg/m2 on days 1 and 8 combination, every 21 days. The patient was followed up every six months, and a thoracoabdominal CT scan was done every six months. He was free from metastasis, the quality of life was good without symptoms of pain or renal dysfunction, and he achieved weight recovery soon after finishing his chemotherapy. Eighteen months pos

[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 9-year-old girl was presented to our hospital on referral from a peripheral hospital with a one-week history of darkish discoloration of both feet and her left hand and a six-day history of a purulent feculent discharge from an exploratory laparotomy wound. She had presented to the referring hospital eight days earlier, with a two-week history of high-grade fever and a one-week history of a generalized abdominal pain and diarrhea. She had an exploratory laparotomy at the referring hospital. Intraoperative findings include a feculent intraperitoneal collection and a single perforation on the antimesenteric border of the terminal ileum. An intraoperative diagnosis of perforated typhoid enteritis was made, and the perforation was closed in two layers. One unit of blood was transfused postoperatively. On the first day of postsurgery, the patient developed darkish discoloration of the left hand and both feet which were associated with pain. She was not a known sickle cell disease patient and had no past histories suggestive of intermittent claudication. On the second day of postoperation, a purulent discharge from the lower aspect of the laparotomy wound was noted, and there was darkening of the feet and duskiness of the distal one-third of both legs. Due to the progressive worsening of the patient's condition, she was referred to our hospital on the seventh day of postoperation.
At presentation to our unit, she was acutely ill looking, febrile with a temperature of 38.1°C, dehydrated, not pale, and anicteric. Her respiratory rate was 30/minute with reduced air entry and coarse crepitations in both lower lung fields. She had a pulse rate of 130/minute, which was regular and of moderate volume. Only first and second heart sounds were heard. Her abdomen was full, and did not move with respiration, and had a midline dressing soaked with a feculent fluid. There was a complete wound dehiscence of the abdominal wound, with both edges being necrotic

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


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

[User]
RADIOLOGY NOTE:
A 45-year-old woman with a history of open Fobi-Capella RYGBP was diagnosed with primary biliary cirrhosis and listed for LT. Bariatric surgery was carried out seven years before, followed by an emergency reintervention for obstruction of the jejunojejunostomy. Hepatopathy was diagnosed at 41 years of age. The patient presented Ig G antibodies for cytomegalovirus and a negative viral DNA detection by quantitative PCR. There were no other relevant comorbidities.
She was admitted to the emergency department with melena and hematochezia. Physical examination revealed hypotension, paleness, icterus and a pain-free abdomen without ascites. Her Model for End-Stage Liver Disease score was 33. The patient did not smoke, consume alcohol to excess or use nonsteroidal anti-inflammatory drugs, acetylsalicylic acid, or proton pump inhibitors. The Helicobacter pylori (HP) status was unknown, nor it was investigated. The patient was clinically managed with intravenous crystalloids, blood borne products transfusion, PPI and ciprofloxacin. The upper endoscopy was negative and the abdominal Doppler ultrasound showed signs of portal hypertension with patent hepatic vessels. Six days after admission, deceased donor LT was carried out without perioperative complications.
The postoperative immunosuppression regimen consisted of prednisone, tacrolimus and mycophenolate sodium. The prophylactic antibiotics consisted of amikacin and ampicillin until postoperative day (POD) 2 and ivermectin on PODs 2 and 3; sulfamethoxazole was introduced on POD 8. Acetylsalicylic acid and prophylactic low molecular weight heparin were suspended from POD 3 to POD 7 because of anemization without signs of bleeding. Low molecular weight heparin was reintroduced at therapeutic dose because of the thrombosis of a branch of the right portal vein. On POD 7 hepatic biopsy was performed due to elevation in liver enzymes. Moderate acute cellular rejection was diagnosed and treated with pulse therapy of methylpredniso

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


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

[User]
RADIOLOGY NOTE:
A 40-year-old female presented with progressive weakness of all four limbs of four months duration, bowel and bladder disturbances of two days duration. She was also complaining of pain and paresthesias in all four limbs. The patient was presently bedridden. There was decreased sensation to pain, touch, temperature and posterior column sensations below neck. There was no history of trauma and fever. On physical examination there was no dermal sinus or other stigmata. Higher mental functions and cranial nerve examination was normal. Motor examination revealed increased tone in all four limbs, muscle bulk was normal in all groups. Power was grade 4/5 in all groups. Deep tendon reflexes were exaggerated in both upper and lower limbs with bilateral Hoffmann and Babinski signs. Sensory examination revealed decreased sensation to all modalities below C5 level. Magnetic resonance imaging (MRI) revealed a well defined intramedullary lesion extending from C2-C3 level with widening of the cord. The lesion was hypointense on T1W images, hyperintense on T2W and fluid attenuation and inversion recovery images with thin rim of enhancement after contrast administration ( and ). The patient underwent laminectomy from C1 to C4. During surgery after opening the dura, pale and widened cord could be seen. A midline myelotomy was performed and a thin walled cyst with pale yellow clear contents was recognized. There was ill defined capsule, difficult to separate from the surrounding cord; only small fragment for biopsy could be taken (). Histopathological examination of the excised specimen revealed features of an epidermoid cyst (). Immediately after surgery in post-operative period the patient deteriorated in motor power but recovered to the pre-operative period over a period of one week. At the 6 month follow up she reported improvement in motor power with reduction in the spasticity, complete control in bowel and bladder functions and able to carry her activities of daily living. Fol

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


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

[User]
RADIOLOGY NOTE:
A 51 year old lady with NF-1 as she has multiple neurofibromas and seven café au lait macules larger than 5 mm. Presented to A&E with a 24 hour history of malena. She was on warfarin for aortic root and valve replacement surgery she had in the previous year. Although she remained haemodynamically stable, her haemoglobin levels gradually dropped 4 units over the next 36 hours. Along with correction of her clotting function, investigations were initiated that included an upper GI endoscopy which revealed blood in the second part of duodenum. Due to a rapid deterioration in her haemodynamic status colonoscopy was cancelled and a mesenteric angiogram was done that suggested bleeding from the region between the 4th part of duodenum and upper jejunum from intestinal mass. She was subjected to emergency laparotomy. At surgery, smooth nodular masses were found on the serosal surface of the first 50 cm of jejunum; these were 3-4 cm and projected into the lumen having eroded the mucosal surface. Resection of the affected segment and end to end anastomosis was performed. The rest of the bowel appeared free of any masses and after concluding surgery the patient was transferred to ITU postoperatively. She made an uncomplicated recovery and was discharged 7 days after operation. A subsequent CT scan did not reveal any other masses.
Histopathology revealed an 8 cm length of jejunum involved with tumour nodules, smallest 3.4 cm and largest 4.4 cm, composed of spindle and polygonal cells. The tumour involved the full thickness of the bowel wall and there was no spread of disease to lymph nodes. Immunohistochemistry demonstrated positive staining for CD117 (cKit) (Figure ), and negative staining for broad range cytokeratins; MNF 116, CD34, desmin, S-100 and chromogranin. On the basis of mitotic count (2/50 HPF) and tumour size it was classified as a GIST of intermediate malignant potential. Proliferation index detected by Ki67 was very low (less than

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


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

[User]
RADIOLOGY NOTE:
A 29-year-old man received a living-unrelated kidney transplant abroad for end-stage kidney disease secondary to neurogenic bladder. The patient had an uneventful postoperative clinical course with good early graft function. The data of HLA matching and induction protocol are lacking. He was maintained on prednisone, cyclosporine, and myocophenolate mofetil. The patient was discharged on postoperative day 5, with an adequate urine output and serum creatinine 110 μmol/L. In addition, he was kept on intermittent self-catherization four times per day. Forty-eight months after transplantation, the patient was diagnosed in another institution to have chronic allograft failure based on slow rising serum creatinine. No renal allograft biopsy was obtained as the patient refused. His immunosuppression was modified, whereby tacrolimus was substituted for cyclosporine A, when his serum creatinine had increased to 400 μmol/L.
Sixty-three months after renal transplantation, the patient was first seen in our hospital, when he presented with hypoxic respiratory failure secondary to pneumonia, pulmonary oedema, and deteriorating kidney allograft function. His blood urea and nitrogen (BUN) was 44 mmol/L and serum creatinine 700 μmol/L. He was admitted to the intensive care unit and started on ventilatory support. Appropriate antimicrobial coverage was started for pneumonia and haemodialysis was initiated. During the hospital admission for about a month, the patient was diagnosed to have advanced graft failure based on his clinical progression. The patient refused the renal allograft biopsy. He was maintained on haemodialysis and discharged on prednisone 5 mg daily. Tacrolimus and mycophenolate mofetil were discontinued.
Two months later (65 months post renal transplant), the patient was admitted because of abdominal pain, graft tenderness, and gross haematuria. There was no history of abdominal trauma or recent renal allograft biopsy. Upon admission, the patient was pale, tachycardi

[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 39-year-old African American male presented to the emergency department with shortness of breath and chest tightness of one day duration after missing hemodialysis (HD) two days prior. His past medical history was significant for hypertension, heart failure with an ejection fraction of 23% with diffuse hypokinesis, pulmonary embolism (PE), end stage renal disease (ESRD), and sarcoidosis with cardiac, hepatic, renal, and central nervous system (CNS) involvement (, ).
The patient reported that he was diagnosed with sarcoidosis nine years before by undergoing liver and kidney biopsies at another Institution. At the time of diagnosis, imaging revealed an inoperable 2-millimeter left frontal lobe brain aneurysm. The patient was started on prednisone, methotrexate, and adalimumab. Over the next several years his disease was complicated by worsening hypertension, chronic kidney disease (CKD), and heart failure with a reduced ejection fraction (HFrEF).
The patient suffered from three cerebrovascular accidents (CVA) which occurred 5–8 years after the confirmed diagnosis, resulting in left lower extremity weakness and a tonic-clonic seizure disorder. He had also undergone biliary duct stent placement due to obstruction likely provoked by granuloma expansion. The year prior to presentation, the patient developed Staphylococcus aureus bacteremia complicated by sepsis and endocarditis requiring cardiothoracic intervention with the placement of a bioprosthetic heart valve in mitral position. His immunosuppressant medications were stopped at that time. Four months before the current presentation, the patient was admitted for management of hypertensive emergency, a computed tomography (CT) and magnetic resonance angiography (MRA) of the head revealed high T2 and prominent brainstem signaling, suspicious for neuro-sarcoidosis (). Additionally, the imaging noted a partially empty sella and left ophthalmic artery aneurysm (). During the following months, the patient commenced regula

[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 19-year-old Chinese woman was admitted to our institution for the treatment of monostotic FD of her femoral neck. She presented in June 2015 with non-traumatic, nonspecific left hip pain that occurred during university basketball training. She first noticed the pain a month before and visited an out-patient clinic in another hospital when the pain did not improve. She denied any injury to the area or loss of range of motion (ROM), and her condition was not improved by analgesia. X-rays of the region demonstrated a fairly extensive ground glass lesion (Fig. ) in her left femoral neck, which is a classic sign of FD. Computed tomography (CT) and magnetic resonance imaging (MRI) revealed the lesion to be 10 cm in length (Fig. ). She was managed conservatively for 6 months; however, because the pain did not improve she was referred to Keio University Hospital for management. She opted for surgical treatment of the lesion for pain relief and to prevent future fractures and to return to her active lifestyle. She has no other significant past medical history.
In July 2016, she underwent surgery to augment her left femoral neck with an autologous cortical, free fibula bone graft. A minimal curettage and lavage of the femoral neck was done to remove fibrous dysplastic tissue to make room for the graft. The free fibula graft was then harvested from her left fibula. The graft was 10 cm long and hammered into the femoral defect to act as an intramedullary pin. No screws or plates were used and the defect in the fibula was filled with β-tricalcium phosphate (Superpore®; HOYA Technosurgical Inc., Japan) (Fig. and Table ). Samples of the tissue were sent to our pathology department for histological analysis, which confirmed the diagnosis of FD. There were no intraoperative complications and her postoperative course was uncomplicated; a short course of prophylactic cefazolin and adequate analgesia were prescribed. She discharged with non-

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


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

[User]
RADIOLOGY NOTE:
A 58-year-old woman was admitted to the hospital with severe back pain accompanied with nausea and vomiting. Because of the back pain, she underwent a selective nerve root block in the lumbar spine at another hospital. After the spinal procedure, the patient felt more severe back pain, newly developed pain, and weakness in her right leg. She had intact voiding sensation and no difficulty voiding at the time of admission. The paraparesis was checked during a neurologic examination. In the right lower extremity, ankle dorsiflexion (Gr III/IV+) and toe flexion and extension (IV-/IV+) weaknesses were prominent compared with those of the left lower extremity. Deep tendon reflex was absent on the right knee, and the "extensor toe sign" was negative bilaterally, without clonus. Sensory impairment to the pain was noted on the L5 dermatome of the right calf.
An MRI revealed a ventrally located intradural mass extending from T10 to L2; the mass was iso- to hypointense on T1-, and the hyperintense portion on the T2-weighted images was compatible to the bleeding inside the tumor. The lesion was heterogeneously enhanced with contrast administration ().
One day after her admission, the patient experienced worsening of her neurological status with weakness of the lower extremities and the loss of anal tone and voiding sensation. She underwent an emergency operation with high-dose methylprednisolone therapy.
A laminectomy from the T10 to L2 levels was performed using a posterior midline approach. After the dura was opened, the mass was exposed to be dark and oil-colored, and a chocolate-colored subdural hematoma was observed above and below the mass (). The mass was not connected to the nerve roots. However the mass was adhered to the ventral dura. Therefore, the mass was removed en bloc under an operating microscope, with coagulation of the dural attachment. A frozen section biopsy of the mass was performed, and under microscopic examination, it

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


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

[User]
RADIOLOGY NOTE:
A 63-year-old female patient was admitted to our hospital with intermittent epigastric abdominal pain for the past three months. Results of the physical examination on admission indicated no icteric sclera. The abdomen was soft with no palpable abdominal mass. The patient had experienced a weight loss of about five kg in the past two months and had no history of hepatitis B or C. She had been exposed to dogs and sheep and denied any history of exposure to infected cases from the epidemic area. After admission, CA19-9 was measured and was 796.20 U/mL. No serological examination for echinococcosis was performed because of the limited conditions of our hospital. Test results from pelvic ultrasound indicated menopausal uterus and uterine fibroids. Test results from gastroscopy showed chronic non atrophic gastritis. Colonoscopy revealed multiple polyps in the large intestine (basically removed); intestinal histopathology (cecum, biopsy) showed severe chronic inflammation of the mucosa and adenomatous hyperplasia of the individual glands. Contrast-enhanced computed tomography of the upper abdomen (Fig. A) revealed a more homogeneous thickening of the gastric wall in the antrum. Round unenhanced low-density foci with a diameter of 4.6 cm was seen in the S7 segment of the liver. Nodular calcifications were also observed. No significant dilatation was noted in the intrahepatic and extrahepatic bile ducts. The size and shape of the gallbladder were normal, the wall was not thick, and no significant abnormal density was observed in the cavity. The pancreas, spleen, and adrenal glands showed no significant abnormalities. Test results from computed tomography indicated liver cyst and intrahepatic calcifications. Contrast-enhanced magnetic resonance imaging of the liver and gallbladder (Fig. B, ) revealed a normal size and shape of the liver and proportion of each lobe, and the intrahepatic and extrahepatic bile ducts and flow vessels ran naturally. A long T1 and long T2 cystic s

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


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

[User]
RADIOLOGY NOTE:
A 29-year-old woman known to have SLE for 6 years presented to the emergency department with a 5-day history of upper abdominal pain. She described the abdominal pain as dull and crampy, mild to moderate in intensity and localized to the epigastric and right upper quadrant regions. Two days before admission, the abdominal pain became constant and severe, and associated with nausea and vomiting but not associated with positional changes, eating, bowel movements or other factors. There had been no fever, chills, diarrhea, heartburn, hematemesis, melena or hematochezia. There was no history of herbal use, taking any new drugs or ingestion of unusual or undercooked foods and no recent travel or contact with ill persons. She was not known to have drug allergies and had no history of cigarette use, alcohol drinking or drug abuse.
She had been discharged from the hospital 2 weeks previously due the intrauterine death of her fetus at 30 weeks gestational age. She had been treated for SLE with low-dose prednisolone, with the addition of azathioprine and hydroxychloroquine and was maintained on pantaprazole as gastric prophylaxis. Her family history was notable for her mother who also had SLE.
On physical examination, the patient was afebrile. Her blood pressure was 158/90 mm Hg, pulse rate was 117 beats per minute, respiratory rate was 22 breaths per minute and oxygen saturation was 97% while breathing room air. The patient appeared to be in severe pain, with a pain score 8/10, and there were no jaundice, pallor, skin rash or mouth ulcers. The lungs and heart sounds were normal. Abdominal examination yielded right upper quadrant tenderness with no guarding or rebound tenderness, normal bowel sounds and no palpable organomegaly or masses. Results of the remainder of the complete multisystem examination were unremarkable.
Laboratory studies revealed the following: serum sodium 132 mmol/L, potassium 4 mmol/L, and creatinine 54 μmol

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


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

[User]
RADIOLOGY NOTE:
Patient is an otherwise healthy 50-year-old female adult, without any past medical history. She presented to the emergency room with fever and epigastric pain, having experienced 3 months of an intermittent pain in the right upper quadrant that was related to fatty food intake. Abdominal examination showed upper abdominal tenderness and a positive Murphy sign.
Laboratory data found elevated white blood cell count and a positive C-reactive protein. Bilirubin, liver function tests and amylase were normal. Due to pain, an abdominal ultrasound was requested that revealed two gallbladders. Two piriform images, with anechoic content, were detected. The left one had gallstones and right one had biliary sludge, also the right gallbladder had a thickened echogenic 4.5 mm wall (Fig. A). A magnetic resonance cholangiopancreatography confirmed this diagnosis. It revealed a normal liver and a gallbladder duplication with inflammation signs in one of them (Fig. B), they both had independent cysts ducts that joined in a common cystic duct before entering a normal diameter common bile duct (Fig. C).
Gallbladder duplication with cholecystitis in one of them was suspected. Due to clinical, laboratory and images findings, surgery was decided.
At laparoscopy, multiple adhesions from omentum to the gallbladder fossa were seen and released, revealing the Calot’s triangle structures. After achieving critical view of safety, a gallbladder duplication was identified, the right gallbladder had purulent bile with thickening of its walls, the second gallbladder appeared normal. Both of them had independent cystic ducts, but only one cystic artery was detected (Fig. A and ). From there surgery was straightforward, clips were applied to the common cystic duct and cystic artery respectively and they were divided between the clips without any complications. After that, the gallbladders were dissected off the gallbladder fossa using electrocautery and retrieved in a latex bag via the umbilical port

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


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

[User]
RADIOLOGY NOTE:
A 34 year old male patient, a worker in the salt mines, presented to us complaining of diminished vision in both eyes since the past 10 years. He also complained of diminished night vision which was stationary and non-progressive. His vital parameters and general physical examination was noted to be within normal limits.
Ocular examination revealed a visual acuity of 6/36 (OD) and FCCF (OS). The pupillary reactions were sluggish in both eyes. The remainder of the anterior segment examination was noted to be normal. Fundus examination (Fig. a, b) showed presence of widespread outer retinal atrophy with visible choroidal vessels and peripheral sub-retinal scarring. The left eye shows evidence of foveal atrophy. A small peripheral rim of normal retina, around 1 disc diameter in size, was noted on indirect ophthalmoscopy.
We initially considered a diagnosis of choroideremia, retinitis pigmentosa and scarred posterior uveitis. There was no family history of nyctalopia and an evaluation of his siblings revealed a normal retina. The blood-work on uveitis also came out to be negative.
We once again reviewed the past medical history and upon detailed inquisition the patient divulged a history of a suicide attempt 10 years ago. He stated that he had consumed the chemical used in the iodination of salt after which he noted the diminished vision in both eyes.
We carried out an OCT evaluation (Fig. c, d) of the patient which showed evidence of outer retinal atrophy with associated sub-foveal scarring which was more pronounced in the left eye. A thinning of the choriocapillaris was evident in the OCT scans along with disruption in the continuity of the retinal pigment epithelium (RPE) in the left eye at the fovea. An examination of the medical records revealed an old fundus fluorescein angiogram, from 10 years ago, which showed prominent areas of choroidal hyperfluoresence due to extensive window defects, indicative of RPE damage (Fig.

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


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

[User]
RADIOLOGY NOTE:
A 27-year-old female (46,XX) patient with normal cognition visited the Endocrinology Clinic of 1st affiliated hospital of China Medical University (Shenyang) for amenorrhea with an unknown etiology. The patient had labial fusion when she was born and underwent plastic surgery afterward. During puberty, the patient underwent another surgery for an ovarian cyst. The patient was treated in another hospital as PCOS for several times resulting with mild remission of amenorrhea and recurrence of ovarian cysts. The patient was suspected of having 21-OHD due to increased 17OHP levels and came to our hospital for a genetic test for CYP21A2 mutations. The patient did not have fatigue, loss of appetite or other symptoms and was the only child in the family. Her parents appeared to be normal. She was born by vaginal delivery, and the mother had no complaints of abnormal manifestations during the perinatal period or history of reproductive system diseases. Her parents are nonconsanguineous. Physical examination of the patient revealed the following characteristics: a height of 165 cm and weight of 55 kg; no hyperandrogenism symptoms like hirsutism or acne; and no purple stripes. The patient complained of difficulty of bending the metacarpophalangeal joints from childhood (Fig. ). There were no obvious abnormalities in the genitals.
The ultrasound showed the presence of a 1.2 × 1.4 cm fluid area in the left ovary, and there was a 9.5 × 6.3 × 4.3 cm cyst in the right ovary behind the uterus. Digital radiography (DR) suggested there were no bone abnormalities (Fig. ). The adrenal CT scan showed there were no obvious hyperplasia changes (Fig. ). The laboratory test results of the patient and her parents are shown in Table . The levels of progesterone and 17-hydroxy progesterone of the patient were significantly increased. Androgen levels were not increased, and the basal level of cortisol in the morning was within

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


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

[User]
RADIOLOGY NOTE:
A 33-year-old Caucasian woman was referred to our facility for primary infertility resulting from her partner, who had secretory azoospermia. Our patient had regular menstrual cycles. Her body mass index was estimated to be 21. Previous hormonal and ultrasonographic evaluations confirmed ovulatory cycles. Obstructed tubes were seen on X-ray hysterosalpingography. During the hysterosalpingography, there was no free spillage of contrast material into the peritoneal cavity. Laparoscopy showed tubal patency. Our patient did not have any post-surgical complications. Six intracervical inseminations with donor sperm failed. Four intrauterine inseminations with donor sperm also failed. Finally an in vitro fertilization with donor sperm was performed. A first transvaginal oocyte puncture had been performed eight months previously without any complications. Induction of ovulation was initiated by using pure follicle-stimulating hormone administrated intramuscularly.
When more than three follicles ≥17mm in diameter were present, 5000IU human gonadotropin was administrated intramuscularly. Our patient had not taken any other medication before the oocyte puncture. Transvaginal ultrasonography-guided oocyte retrieval was performed 35 hours after the human chorionic gonadotropin injection had been given. The follicles were retrieved by sequential puncture without reinsertion of the needle through the vaginal wall, so only one puncture was made on each side. A total of 13 oocytes were retrieved without using solutions for flushing. At the end of the procedure there were no ultrasonographic signs of bleeding and our patient was kept in the department for observation.
Three hours after the procedure our patient stated she had abdominal pain. Her blood pressure was normal, and her pulse rate was 70 beats per minute. There was no fever. An abdomen rebound defense appeared. Her hemoglobin level was 99g/L and hematocrit was 29 percent. A transvaginal sonography revealed a blood collectio

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


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

[User]
RADIOLOGY NOTE:
A 15-year-old Caucasian female presented with an intra-articular fracture and adjacent laceration at the distal portion of the proximal phalanx of the thumb resulting in near complete loss of the interphalangeal joint (Figures and ). The injury was incurred from a table saw accident. The patient had an initial pain level of 4/10 and was unable to flex her thumb. The patient and her family were offered a joint arthrodesis for joint stability, but they did not desire a fusion. The patient felt a fusion would limit activities important to her such as texting, playing video games, and applying cosmetics. Joint replacement was offered to the patient as an alternative treatment. In the present case, an HUD was utilized in an off-label manner and inserted into the interphalangeal joint of the patient's thumb. The patient and family were counseled that this was not a standard treatment option and that if fusion was needed in the future, it could be more complicated and require bone grafting compared to using fusion as the initial alternative.
The patient was followed for 22 months postoperatively and has remained happy with her choice of procedure. The patient's motion in the thumb IP joint is currently a 40 degree arc which is very reasonable given the repair of the flexor pollicis longus tendon and collateral ligament as well. There was excellent range of motion (ROM) in the metacarpophalangeal joint (MCP) which is comparable to the contralateral side. Radiographs demonstrated good seating of the joint implant with no evidence of loosening or periprosthetic fracture (Figures and ). The collateral ligaments were all stable at the IP joint, and the scar on the left volar thumb was well-healed. The patient reported pain of 0/10 at her most recent follow-up and recorded a DASH score of 6.82. No known complications have arisen as a result of the surgical reconstruction to this point in time.

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


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

[User]
RADIOLOGY NOTE:
A 65-year-old woman presented with abdominal pain and hypophagia for 2 weeks. She had a medical history of alcoholic pancreatitis. A computed tomography (CT) scan of her abdomen and pelvis revealed thickening of the transverse colon wall. Colonoscopy showed an ulcerated tumor in the transverse colon, and histological analysis indicated moderately differentiated adenocarcinoma. Serum carcinoembryonic antigen (CEA) levels were normal, and no sites of distant metastasis were reported on preoperative examination. She underwent a laparoscopic extended right hemicolectomy using the non-touch isolation technique. Histopathological examination of the specimen revealed a moderately differentiated adenocarcinoma invading the subserosal layer with low venous invasion (v1) and no lymphatic invasion (ly0). The surgical margins were negative. A total of 92 lymph nodes were removed, of which none showed metastases. The tumor was diagnosed as stage IIA (T3, N0, M0) according to the International Union Against Cancer tumor, node, and metastasis (TNM) classification (7th edition) []. The patient had an uneventful recovery and was on regular follow-up every 3 months without adjuvant chemotherapy.
Fifteen months after her colectomy, a CT scan demonstrated a tumor in the antero-lateral rectal wall that was 20 mm in diameter, and a right ovarian tumor that was 25 mm in diameter (Fig. ). The ovarian tumor was a cystic mass with a solid component on magnetic resonance imaging (Fig. ). Colonoscopy revealed a superficial elevated lesion in the middle rectum that was shown by histological examination to be moderately differentiated adenocarcinoma (Fig. ). Serum CEA levels were normal. These findings were indicative of rectal cancer with ovarian metastasis, or double primary cancer of the rectum and ovary. A diagnostic and therapeutic laparoscopy detected no disseminated peritoneal metastases or liver metastases. Intraoperative cytological examination of the peritoneal lavage was negative for

[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 homeless male presented four weeks after his left ankle was twisted in an altercation. At that time, he experienced immediate deformity and the inability to bear weight. The patient decided to delay treatment until he was able to place weight on his leg and seek medical attention.
Upon presentation to the emergency room four weeks later, the following clinical and radiographic appearance was documented (Figures and ). Ankle imaging demonstrated a chronic dislocation, with typical posterior translation of the talus with respect to the tibia, along with concomitant posterior translation of the distal fibular segment (). He maintained approximately 10 degrees of motion through his tibiotalar joint. Due to the deformity, the patient stated that his lower extremity was not functional for simple activities of daily living, such as prolonged standing or walking any distance less than a block. Although he would comply with postoperative nonweight-bearing restrictions, the patient stated he would not participate in any care plan which required more than one surgery. Based upon prior behavior, the care team judged the patient would be unable to maintain or adjust a multiplanar corrective frame, nor return for periodic office visits and radiographs. As such, a single-stage procedure was planned.
The patient was brought to the operating theater with general anesthesia, pharmacologic paralysis, and supine positioning. Two approaches were used. The first was a lateral longitudinal incision along the anticipated position of the posterolateral fibular border once reduced. Following fibular exposure, osteoclasis of the developing fracture callus was performed. As the distal segment was mobilized, it became apparent that the syndesmosis was grossly incompetent. The distal fibular segment was externally rotated, and the syndesmotic incisura was debrided of reactive tissue. Through this interval, the posterior capsule was released off its pathologic attachments to the pos

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


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

[User]
RADIOLOGY NOTE:
In this report, a case of hospital-acquired pulmonary legionellosis in an immunocompromised patient - a 70-year-old Caucasian man - is described. Sixteen years before he presented to us, he had a condition that was diagnosed as low-grade non-Hodgkin lymphoma of the B-cell small lymphocytic type (stage IV with mediastinal, abdominal, bone marrow, and superficial node site involvement), and nine courses of combined polychemotherapy were administered with cyclophosphamide, doxorubicin, vincristine, and prednisone. Four years before he presented to us, lymphoma chemotherapy was started again with cyclophosphamide and fludarabine because of a progression of mesenteric involvement of the disease. This regimen was interrupted four months later because of toxicity, and 11 courses of alemtuzumab were administered thereafter in the Oncology and Hematology Clinic of our division.
Three years before he presented to us, he was discharged from our ward after a two-week hospitalization for fever and pancytopenia (first hospital admission of this report). After seven days, he was hospitalized again, in another ward of the same hospital, because of fever, dyspnea, and bowel movements with loose stools (second admission). A chest X-ray showed an inflammatory infiltrate at the base of his right lung, and another slight infiltration seemed to be spreading in the upper field of his left lung. The results of laboratory tests were unremarkable except for significant increases of erythrocyte sedimentation rate and C-reactive protein, minimal increases of aspartate aminotransferase and alanine aminotransferase, and mild anemia. The results of blood cultures, a cytomegalovirus antigen test in serum, and a Clostridium difficile toxin stool test were negative. A course of empirical antibiotic therapy with piperacillin/tazobactam plus ciprofloxacin was started. A rapid defervescence ensued, and our patient was discharged after an eight-day course of antibiotics. However, two days after discharg

[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 healthy 53 year-old male presented with a 6-month history of non-productive cough. He had no significant past medical or surgical history and was a nonsmoker. Computed tomography (CT) demonstrated 7.4 × 5.2-cm right posterior mediastinal mass, abutting the trachea, superior vena cava, ascending aorta, and esophagus, as well as an incidentally noted retroesophageal SCA with a separate right carotid artery originating from the aortic arch (, ). CT-guided percutaneous biopsy revealed high-grade leiomyosaroma. Esophagoscopy did not demonstrate esophageal mucosal involvement. Metastatic workup was negative. After multidisciplinary discussion, four cycles of neoadjuvant chemotherapy with doxorubicin and dacarbazine were given in the hope that the tumor would decrease in size, permitting wider resection margins; however, there was no objective radiographic response.
He was subsequently taken to the operating room for resection and possible esophagectomy with planned substernal reconstruction and possible ligation of the right subclavian artery. Through a fourth intercostal muscle-sparing posterolateral thoracotomy, the large mediastinal mass was noted. Because the tumor was abutting the superior vena cava, ascending aorta, retroesophageal SCA, and trachea, it was not feasible to achieve wide margins without disrupting the vital structures. However, the mass encapsulated and was able to be dissected away from the surrounding vital structures. Extra care was taken not to injure the right subclavian artery, which was skeletonized away from the tumor. The mass was arising from the proximal esophageal muscular layer. Because there was no direct invasion of surrounding tissues, the mass was resected with partial resection of the esophageal muscular layer without violation of the mucosa or tumor capsule. A previously harvested intercostal muscle flap reinforced the exposed but intact mucosal layer of the esophagus.
The postoperative course was complicated by low-volume chyle le

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


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

[User]
RADIOLOGY NOTE:
A 63-year-old woman, with arterial hypertension as the only relevant medical history, presented with a sudden binocular diplopia. Right 6th nerve palsy was evidenced on physical examination at admission. AngioCT revealed a right ICCA aneurysm with signs of partial thrombosis without evidence of rupture []. Patient’s symptoms worsened to complete cavernous syndrome 5-days later, and a new AngioCT showed progression of the thrombosis with discrete mass effect [], so steroids and antiplatelet therapy were initiated. Angiography on admission confirmed the presence of a giant aneurysm of the anterior portion of the right ICCA [-]. Since endovascular techniques seemed inappropriate due to the partially intraluminal thrombosis and very wide neck, PAO was considered as the optimal treatment choice. A balloon test occlusion (BTO) was performed to evaluate the preoperative risk of ischemia without relevant findings and no evidence of retrograde filling of the aneurysm by anterior or posterior communicating arteries [ and ]. Then, the patient underwent surgical ligation of the cervical CCA at the level of C6 with a 3/0-silk, and anticoagulation was started 3 days after surgery. Symptoms of cavernous sinus syndrome resolved with the exception of 6th nerve palsy during postoperative recovery. A cerebral magnetic resonance angiography (MRA) revealed decrease of the size of the aneurysm lumen and no ischemic lesions were detected [].
Nine months later, and without new neurological symptoms, signs of aneurysm growth were detected in a serial MRA [], and a new angiography was planned. Right CCA angiogram showed the therapeutic occlusion of the right ICA, but the right vertebral angiogram demonstrated proximal partial recanalization of the ICCA aneurysm. Collateral supply was explained from the external carotid artery (ECA) through the occipital artery with an inverse flow to the ICA []. Therefore, surgical occlusion of the cervical ICA at the level of the ansa cervicalis of the hypo

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


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

[User]
RADIOLOGY NOTE:
A 56-year-old male patient sustained a total amputation at the level of the right upper arm after a cable was wrapped around it in an occupational injury. The patient had complete disruption of the muscles, vessels and nervous structures, as well as a fracture of the humerus in the distal third.
The patient had no other injuries and was otherwise fit and healthy. Immediate preparation of the stump and the amputated arm was performed by two separate teams. After debridement, bone resection of the humerus and identification of the vascular and nervous structures was performed, and a stable osteosynthesis with a 4.5-mm plate was executed. Subsequently, an anastomosis of the brachial artery was completed. Successful revascularization was achieved 4.5 h post trauma. Revascularization was followed by anastomosis of the veins, immediately after which a veno-venous hemodiafiltration was initiated. Then, an epineural suture of the radial, ulnar and median nerves was performed, and the muscles were readapted. A fasciotomy of the lower arm and carpal tunnel release were also performed. The skin was left open. The procedure took 5.5 h. Post-operatively, the patient showed good re-capillarization of the fingers and physiotherapy was initiated to mobilize the fingers. On the 4th post-operative day, a skin graft was used to close the wound. The patient developed neuropathic pain of the ulnar and median nerves with a positive Hoffmann-Tinel sign, which was treated by opioid therapy. The patient was transferred to rehab and showed good progress in elbow movement; however, bending of the thumb and fingers was not possible, although intensive therapy had been performed. This was the indication for the functional transfer of the gracilis muscle with adaption to the deep antebrachial flexor tendons and nerval anastomosis to the ulnar nerve.
Six years after the trauma, the sensitivity of the fingers was almost normal, and prehensility had been preserved. Although the patient

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


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

[User]
RADIOLOGY NOTE:
A 63-year-old lady underwent right-sided nephrectomy for renal cell carcinoma (RCC) in 1991. She required a further nephrectomy in 2003 for RCC in the contralateral side rendering her haemodialysis dependent. Following 2-year disease free survival she was considered for transplantation. An initial CT scan of the abdomen in 2005 raised the possibility of bone metastases, promoting further investigation; however, isotope bone scanning and MRI revealed degenerative changes only. Her oncologist advised yearly surveillance CT scans following transplant listing. Following the routine work-up she was activated on the UK transplant deceased donor waiting list.
A CT scan in 2007 demonstrated two hyperdense lesions within the head and body of the pancreas, and a radioisotope octreotide scan was performed to exclude a non-functional neuroendocrine tumour. Appearances on the 24 and 48 h octreotide images demonstrated intense tracer accumulation within the left gluteus medius and the right-proximal vastus medialis muscles, confirmed on single photon emission computed tomography (SPECT) (Figure ).
An ultrasound-guided muscle biopsy of the right-proximal vastus medialis muscle was performed which demonstrated a highly vascular clear cell tumour in keeping with metastatic RCC. Endoscopic ultrasound-guided fine needle aspiration (FNA) of the pancreatic lesions also demonstrated a vascular clear cell tumour. The patient remains completely asymptomatic. Given the low volume and low turnover of her metastatic disease, interferon therapy has been deferred at present.
Following the diagnosis of in situ tumours such as RCC, European Best Practice Guidelines (EBPG) recommend a waiting time of at least 2 years before consideration for transplantation []. However, case reports have documented latency periods for recurrent RCC of up to 19 years []. Surveillance CT in this case proved to be useful.
Although skeletal muscle RCC metastases have been described, it is a rare occurrence. CT scannin

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


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

[User]
RADIOLOGY NOTE:
A 56-year-old female presented with bilateral otalgia and hypoacusis gradually progressing for the past two weeks and left sided facial palsy significantly increasing within two days. She has been previously twice unsuccessfully treated with antibiotics in another hospital due to chronic otitis media. She also had a history of psoriasis and hyperthyreosis. AAV may occur with antithyroid drug therapy. However, the patient was treated only one month before the blood test; thus the possibility of drug-induced AAV is low.
Otoscopic examination revealed bilaterally thickened and reddish eardrums. There was a subtotal perforation of the right tympanic membrane and an anterior perforation of the left tympanic membrane with effusion. Left facial nerve palsy was categorized as grade IV according to House-Brackmann. Nose examination was normal. The pure tone audiometry showed severe bilateral mixed hearing loss on the level of 80–100 dB with air bone. On the right the threshold is on the level of 95–100 dB with air bone gap of 50 dB. On the left the threshold gap is 70 dB. Chest X-ray revealed signs of bronchitis. Urine analysis was normal.
High resolution computed tomography scans of the temporal bones showed bilateral sclerosing mastoiditis and opacification of the right tympanic cavity with an air-fluid level. No signs of bony destruction within the ossicular chain, the internal ear, or facial canal were present (). Magnetic resonance imaging (MRI) with the use of T2-weighted, T1-weighted, and contrast enhanced images was performed and showed normal appearance of cerebral structures and mastoid cells filled with fluid on both sides. Hypertrophic pachymeningitis sometimes shows in the GPA patients wit hear involvement. In this case there were no signs of pachymeningitis on MRI examination. The diagnosis of acute otitis media with peripheral facial nerve paralysis was made and intravenous antibiotics treatment was started. As there was no response to drug therapy, 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:
A previously healthy 10-year-old girl presented with a large swelling arising from the right little finger of 6 months duration. The swelling was initially small and painless to start with and was associated with fever and chills. She was seen at a local hospital, where a radiograph was taken which revealed a cystic and lytic lesion of the little finger proximal phalanx []. It was diagnosed as osteomyelitis, and she was treated with analgesics and antibiotics. As the swelling and pain progressed, she was referred to this institute. The swelling was 6 × 6 cm, tender, pulsatile and firm in consistency. The fresh radiograph showed a large soft tissue mass with some calcification within and complete destruction of the phalanx [Figure and ]. Magnetic resonance imaging (MRI) scan of the hand revealed an ill defined expansible lesion in the proximal phalanx with marrow signal changes that were T1 hypointense and T2/Short tau inversion recovery hyperintense with juxtacortical soft tissue mass []. Fine needle aspiration cytology (FNAC) of the lesion was performed and reported as having features of “small blue round cell tumor.” Computed tomography (CT) of the chest, abdomen, and pelvis was normal. Axillary lymph nodes were enlarged, and FNAC had features suggestive of reactive lymphadenitis. The patient underwent wide excision with fifth carpometacarpal joint disarticulation. Histopathology of excised tissue showed small round cells with high nuclear-cytoplasmic ratio and coarse chromatin with occasional pseudorosettes, suggestive of Ewing's sarcoma. The cells were periodic acid Schiff positive and immunohistochemistry was positive for CD99 [Figure and ].
The patient was discharged and advised to review after 3 weeks for chemotherapy. However, the patient was non-compliant and returned about 4 months after the surgery with pain and swelling of the dorsum of the hand with dilated veins []. There was a history of fever. Blood investigations revealed hemoglobin of 9 g% and eryt

[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.