[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 female underwent a phase III Oxford UKA [Biomet UK Ltd, Bridgend, United Kingdom] in 2006 for antero-medial osteoarthritis. A minimally invasive medial para-patellar approach was used and medium sized femur, 44 X 28mm tibia and 3mm meniscal bearing insert were implanted. She had an uneventful post-operative recovery. She was completely asymptomatic and was discharged from the follow-up at two years following the surgery with no symptoms and a range of motion of 0 to 130 degrees.
She presented to the Accident and Emergency (A&E) department in April, 2013 with history of a sudden onset of pain and swelling in the same knee. She heard a ‘pop’ in the knee while standing and did not report any obvious injury to the knee. On clinical examination, she was haemodynamically stable and afebrile and there was moderate effusion in the knee. The range of motion was from 30 to 60 degrees and she was unable to weight bear through the knee due to pain. The radiographs of her knee in the A&E department raised a suspicion of posterior dislocation of the polyethylene insert (). There was no evidence of loosening of femoral or tibial components.
The white cell count and CRP were normal, excluding an acute infection. She was admitted to the ward and surgical exploration was planned for the following day, with the view of changing the polyethylene insert or to revise the components if they were loose or damaged. The knee was opened through the previous scar of medial para-patellar approach. Intraoperatively, both the femoral and the tibial components were found to be well fixed with no scratches and rest of the knee did not show any evidence of osteoarthritis. The polyethylene insert was found to be fractured through the middle (). The anterior half was sitting on the tibial component and the posterior half was dislodged into the posterior compartment of the knee, stuck to the posterior capsule.

[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 female presented to the emergency department with the complaint of left side pain. Sensitivity in the left costovertebral region was detected during physical examination. No kind of operation or chronic disease was recorded in the medical history and family history of the patient. Creatinine value was found to be 1.37 ng/dL in the blood biochemistry examination. In the urinary system ultrasonography (USG), it was observed that the right kidney was atrophic, that the left ureter was dilated as far as the ureterovesical junction, that there was grade III hydronephrosis in the left kidney, and that there was a massive lesion of 3 × 4 cm extending into the bladder on the left side wall of the bladder (). In each abdominal contrast Computed Tomography (CT) scan of the patient, it was seen that the left ureter and renal pelvis were severely dilated and that there was a massive lesion of 3 × 4 cm extending into the bladder on the left ureter orifice on the left side wall of the bladder (). In the medical history of the patient, it was recorded that the patient had complaints of hematuria and severe pelvic pain which had been ongoing for 4-5 menstrual cycles. On transvaginal USG, a mass of 4 × 4 cm of cystic appearance was detected in simple form in the left ovary. In cystoscopy, the left orifice could not be seen although the right orifice was monitored. A red-colored solid lesion in the papillary structure was observed in the left area conforming to the symmetry of the right orifice. The lesion was partially resected by resectoscope. The resected material was sent to the pathology laboratory for histological examination. Percutaneous nephrostomy was attached to the left kidney under USG guidance. Contrast material was administered to the patient through the nephrostomy catheter, and anterograde pyelography was taken. It was observed that the contrast material was not transmitted to the bladder in the ureterovesical junction (). At follow-up examinations, wit

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


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

[User]
RADIOLOGY NOTE:
A 45-year-old man presented to our hospital in Belarus with the following history. He had been born in Belarus after an uncomplicated pregnancy. His family history was negative for congenital defects and the patient had no siblings. After birth, a systolic murmur was heard along the left sternal border leading to a referral to a pediatric cardiology centre in Ukraine where the diagnosis of tetralogy of Fallot was given based on physical examination, chest radiographs, and an electrocardiogram. Surgery was declined at that time. At no time in the patient's life were chromosomal studies undertaken. The patient had no children.
As a child, the patient had normal growth and mental development, but marked cyanosis, weakness, clubbing, and intolerance of moderate physical activity. The patient was referred to a medical institute in Moscow at age 18, after several episodes of syncope. A diagnosis of severe pulmonary stenosis with ventricular septal defect was considered at that time. A right Blalock-Taussig shunt was performed. The postoperative diagnosis was single ventricle type BIII with severe pulmonary artery stenosis and hypoplasia. After surgery, the patient was treated with digoxin, pentoxifylline, and spironolactone. The patient's condition improved significantly and he was able to walk several blocks without significant dyspnea.
The patient's condition remained stable for the next five years. He had shortness of breath with moderate exertion, but he was asymptomatic at rest. At 27 years of age, the patient reported an increase in dyspnea with minimal exertion. He was diagnosed with thrombosis of the Blalock-Taussig anastomosis and was treated with heparin for 4 weeks. He never returned to his improved, postoperative condition. He complained of palpitations, dull chest pain at rest, episodes of shortness of breath at rest, and abdominal pain. The patient had several documented episodes of ventricular tachycardia at age 35 years and was successfully treated with pr

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


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

[User]
RADIOLOGY NOTE:
On June 2016, a Caucasian 48-year-old man consulted his general practitioner for diarrhea, vomiting and epigastric pain, which increased while coughing or leaning forward. He had had a blunt abdominal trauma at work 1 month prior to his presentation. The clinical examination revealed a huge palpable abdominal mass occupying most of the epigastric and right hypochondriac region. The blood tests were almost normal except of a mild increase in gamma-glutamyl transferase. The abdominal US showed a voluminous (18 × 10 cm) heterogeneous mass located in the epigastric region in front of the pancreas and pushing the left liver lobe anteriorly and laterally. There were also multiple (5–6) intrahepatic lesions evoking hepatic hemangiomas. The abdominopelvic contrast-enhanced CT scan showed a voluminous prepancreatic tissue tumor with heterogeneous predominantly peripheral enhancement, measuring about 20 × 9 × 16 cm (Fig. ), associated with multiple hypodense hepatic nodules evoking hemangiomas, although two of them might also evoke metastatic lesions. The patient was referred to our institution for a suspected diagnosis of gastric submucosal tumor with likely hepatic metastases. The thoracic contrast-enhanced CT scan was normal.
He had no specific familial and medical personal history, except allergic asthma and active smoking. His performance status was zero. The digestive symptoms persisted and clinical examination confirmed this voluminous palpable abdominal mass. The case was discussed in the Sarcoma Multidisciplinary Board, and the diagnosis of giant pedunculated liver hemangioma was suspected. It was decided to perform a liver MRI which showed several typical hemangiomas disseminated throughout the liver, with classical enhancement after contrast injection. The largest one was a pedunculated hemangioma originating from the third hepatic segment, with exophytic development, descending in the epi- and mesogastric region, pushing the pancreas backwards. Its dimensions were

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


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

[User]
RADIOLOGY NOTE:
A 49-year-old man presented with a 4-year history of low back pain and referred pain in his right leg. While standing, he felt sensory sensations from the lateral side of his right upper leg to the knee and the medial side of his lower leg and ankle. Coughing and sneezing worsened these symptoms. He complained about some weakness of his leg, but he had no pain or other symptoms of his knee. Apart from a trochanteric bursitis 5 years earlier, his medical record reported no relevant details. Physical examination showed a restricted flexion of his lumbar spine, with pain at the level of the right sacroiliac joint during lateroflexion and extension of the lumbar spine. Local tenderness was noticed at the level of the right sacroiliac joint, gluteal and trochanteric region. Neurologic examination did not reveal any abnormalities: no weakness was noticed in his right leg, and the straight leg and femoral stretch tests were negative.
Plain radiographs of the SI-joint, pelvis and hip did not reveal any abnormality. Also an MRI of the lumbar vertebrae revealed no abnormality, especially no herniated disc. Laboratory data showed no abnormal blood levels. A technetium scintigraphic scan showed no increased isotope uptake in the lower spine, but revealed a hot spot at the level of the proximal tibiofibular joint (Fig. ).
At a second physical examination, local tenderness at the level of the proximal tibiofibular joint was present. There was a normal mechanical axis of the right leg and the knee function was optimal. Radiographs of the right knee showed proliferative bone formation between the proximal tibia and fibula. There was no dislocation or subluxation of the proximal tibiofibular joint, and the proximal fibula had a normal shaft without any bowing. A CT scan showed eccentric bone growth of both the proximal tibia and fibula, causing a synostosis at the edges of the bone formations (Fig. ).
An excision of

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


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

[User]
RADIOLOGY NOTE:
A 34-year-old married woman was admitted to pulmonary department with a 4-day history of hemoptysis. Hemoptysis occurred from the 3rd day of menstruation till 6th day and the total amount of hemoptysis was about 150 mL. She had no history of previous hemoptysis event. She had medical history of an appendectomy 20 years ago and pelvic inflammatory disease 2 years ago. She gave birth by normal spontaneous vaginal delivery (gravida 1, para 1) 10 years ago and she had not had a past history of obstetric or gynecological procedures before developing hemoptysis. Her medical history was otherwise unremarkable and she did not have a significant family history. She denied using smoking, excessive alcohol and illicit drugs. She had no complaints of weight loss, fever, dyspnea, palpitations, gastrointestinal symptoms or a history of bleeding. Her physical examination was within normal limits. Chest X-ray () had no abnormal findings. Chest computed tomography (CT) scan was performed on the 2nd hospital day, which was fourth day of menstruation and the CT scan showed a focal consolidation with adjacent ground glass opacity (GGO) in the posterior basal segment of the left lower lobe (), but there's no evidence of enlarged bronchial artery or vascular abnormality. Fiberoptic bronchoscopy showed a small amount of blood clot in the bronchi of left lower lobe. No endobronchial lesion was detected during the investigation. Bronchial washing fluid showed no acid fast bacilli, bacteria or abnormal cells. Hemoptysis was spontaneously resolved with the cessation of menstruation and did not recur during the rest of admission period. We assumed the illness as catamenial hemoptysis due to pulmonary endometriosis, and she was discharged. After discharge from the first admission, follow-up chest CT scan was performed for following up the lung lesion at 26th day of menstrual cycle. Previously noted focal consolidation with adjacent GGO lesion was almost disappeared and only a noncalcified 5-mm-

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


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

[User]
RADIOLOGY NOTE:
The patient was a 29-year old pregnant woman who previously delivered through caesarean sections two healthy full term infants. Her past medical history was significant for gastroesophageal reflux disease, asthma, obesity, gallstones, and smoking. Ultrasound at 14-week gestation revealed a right ovarian cyst. At 33-week gestation, the patient presented with preterm labor. With repeat caesarean section, a healthy female infant was delivered. At the time of caesarean section, a right salpingo-oophorectomy was performed after approximately 2 liters of fluid were drained from the ovarian cyst.
We received the specimen for intraoperative consultation. Gross inspection revealed a cystic lesion measuring 14 × 11 × 9 cm. The external surface was maroon and smooth with prominent vascular markings. Sectioning showed a unilocular cyst filled with brownish mucoid fluid. The cyst wall measured from 0.5 cm to 1.0 cm in thickness and showed severe edema. The inner surface of the cyst was flat and displayed scattered patches of hemorrhage but no solid or papillary tumor was identified. Attached to the cyst was a residual normal appearing ovary measuring 3 × 2.5 × 1.5 cm and an unremarkable segment of fallopian tube measuring 3 × 0.5 cm. The gross findings indicated a benign ovarian cyst, and thus no frozen section was performed.
On microscopic examination, the cyst was lined by one to several layers of luteinized cells that exhibited abundant eosinophilic cytoplasm with focal vacuolization. Most nuclei were small and round but focal nuclei were irregular and enlarged (Figure ). No mitosis was identified. The outer cyst wall consisted of edematous fibrous tissue and scattered nests of luteinized cells that morphologically resembled the cyst lining cells (Figure ). Special stain showed reticulin fibers surrounding large nests of luteinized cells in the cyst lining (Figure ) and in the outer cyst wall. Remnant ovarian tissue showed a corpus luteum and multiple cystic follicles. The se

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


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

[User]
RADIOLOGY NOTE:
The patient was a 4-month-old boy born at gestational age of 36 weeks by elective cesarean section because of placenta previa. During the third trimester, he was found to have right hydronephrosis, with an anteroposterior diameter (APD) of 27 mm and SFU 4. His left kidney and urinary bladder were normal, as were his initial physical examination and laboratory workup at birth. A voiding cystourethrogram at 1 day of age showed a normal bladder and urethra and no evidence of vesicoureteric reflux. Ultrasound examination showed right hydronephrosis with an APD of 26 mm (). Diuretic renal scintigraphy with Tc 99m DTPA showed right renal pelvic dilatation with an obstructive pattern of radiotracer washout and a differential renal function of 40% (). Follow-up renal ultrasound at 2 months of age showed the persistence of high grade right hydronephrosis with mild thinning of the renal cortex.
Based on a preoperative working diagnosis of right pelviureteric junction obstruction, the patient was scheduled for right pyeloplasty. Routine intraoperative cystoscopy and right retrograde pyelography prior to pyeloplasty showed that the contrast was unable to pass beyond a proximal ureteric narrowing, with subsequent application of higher pressure resulting in reflux toward the urinary bladder ().
Surgery began with a transverse muscle splitting incision through the right upper abdomen. The right pelvic-ureteric junction was wide and patent (). However, right ureteric focal narrowing was observed 4 cm from the pelviureteric junction, with distal ureterotomy showing no flow of urine through the right ureter (). This short segment, about 3 mm in length, was opened longitudinally in a retrograde manner, revealing a diaphragm-like transverse valve. This ureteric segment was excised and an end-to-end ureteroureterostomy was fashioned following spatulation of the two ends over a DJ stent, which was removed uneventfully after 5 weeks. Histological examination of the excised ureteric segmen

[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:
Miss AB is a healthy 24-year-old female who developed progressively worsening right hip and buttock pain after cessation of the oral contraceptive pill. Initially, this pain occurred only during menstruation and ovulation; however, it became more constant over the next 6 months with severe exacerbation during menstruation rendering her housebound for 3 days of each month. She had no dysmenorrhea or pelvic pain to suggest endometriosis. Sitting or lying for prolonged periods exacerbated the buttock pain and was associated with paresthesia over the posterior aspect of her right thigh, calf, heel, and dorsum of her right foot in addition to right gluteal muscle atrophy. The pain persisted despite strong analgesia and recommencing the oral contraceptive pill. She trialed physiotherapy and acupuncture without success. Investigations including ultrasound of her pelvis and right hip, as well as X-rays and computed tomography scans of her right hip and lumbosacral spine failed to identify any pathology. Finally, magnetic resonance imaging (MRI) scans of her pelvis revealed a 3.5 cm endometriotic lesion over the pelvic segment of her right sciatic nerve, before exiting the great sciatic foramen. MRI also identified atrophy of the right gluteus medius and minimus muscles, indicating the involvement of superior gluteal nerve [].
Miss AB was then referred to our unit, and following detailed gynecological consultation, she was also referred for a comprehensive neurosurgical review. Other than limited right straight leg raise, the remainder of her lower limb neurological examination was normal. Electromyography nerve conduction study demonstrated evidence of L5 radiculopathy. Following a multidisciplinary discussion with a neurosurgeon, an orthopedic surgeon, and a gynecological oncologist, the patient underwent laparoscopic excision of endometriosis.
Preoperatively, the patient underwent bowel preparation, with 24 hours of clear fluid and a single dose of PicoPrep (sodium picosu

[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:
M.J. is a 59 year old woman who presented to the emergency room at a tertiary care center with a three day history of mental status changes. According to her accompanying spouse, three days prior she had eaten out and had one episode of diarrhea. Since then she had slowly become increasingly 'confused', as she described it. She had trouble finding the right words and had been using incorrect words in sentences. M.J. seemed untroubled by this change. These symptoms were accompanied by mild anorexia.
M.J. had a no significant previous medical history. She had no recent illnesses. She had experienced two vaginal births, and in true family medicine fashion, one of the medical team taking care of the patient had delivered her grandson about one year ago.
The patient emigrated from Germany thirty years ago, and English was her second language. She resided in a medium-sized northern New England town with her husband. She operated a daycare out of her home, with approximately five pre-school aged children, none of whom had recently had any serious illnesses.
On initial presentation to the Emergency Department, M.J. had no elevation in temperature. She had a mild frontal headache. Her vital signs were otherwise within normal limits. Her physical exam showed her to be alert and oriented, but with mild dysnomia on questioning. She did not have meningeal signs, but appeared mildly dehydrated. An initial computed tomography scan of the head (with and without contrast) was unremarkable for mass or bleed. However, it showed a moderate left-sided sphenoid sinusitis. Her leukocyte count, electrolytes, liver transaminases, folate, B12 and thyroid stimulating hormone were within normal limits.
She was admitted with intravenous fluids and intravenous ceftriaxone as empiric antibiotic coverage. An otolaryngology consult was obtained to determine whether the mental status changes could be attributed to the sinus findings. Throughout the next 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:
In June 2002, a 36-year-old woman presented to her primary health care doctor with a history of flushing, diarrhoea, night sweats, and a clinically detectable mass in her left medial supraclavicular fossa. Her past medical history consisted only of essential hypertension for which she did not require prescribed therapy. Her family history included a brother with a diagnosis of sarcoma and two other non-first-degree relatives with primary brain malignancies.
Fine needle aspiration confirmed the diagnosis of medullary thyroid cancer, and in July 2002, she underwent total thyroidectomy with left-sided modified radical neck dissection and central compartment clearance. At this point, concerns were raised regarding optimal cytoreduction as the appearances of the central compartment, level 4 and level 5 nodes, were that of extensive disease. In order to maximise local disease control, she received adjuvant radical radiotherapy delivering 60 Gy to the thyroid bed.
Two years after completion of treatment, in February 2004, follow-up repeat imaging reported a recurrent nodule at level 4 of her neck. Subsequent resection confirmed this to be recurrent medullary thyroid cancer with no evidence of distant spread at the time. She continued to be monitored at the oncology clinic and remained disease-free until four years later, in May 2008, when computer tomography (CT) imaging revealed new pulmonary parenchymal metastases. These were closely monitored for the next 2 years with repeat imaging and measurement of calcitonin levels. In May 2010, it was decided that the patient should embark on systemic anticancer treatment.
She was offered participation in a phase 2 clinical trial with the agent lenvatinib (E7080) and she commenced treatment with 24 mg once daily in May 2010. One week into therapy, it was noted that she was marginally hypertensive with a blood pressure of 140/100 mmHg. No proteinuria was identified at this point, but she was commenced on 5 mg of amlodipine to manage

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


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

[User]
RADIOLOGY NOTE:
A 4-h-old male newborn weighing 3,400 g was referred to our hospital with an imperforate anus. There was no orifice in the perineal region. A white median raphe cyst, 4 mm in diameter, was present on the ventral side of the penis. Auscultation of the heart and lungs was normal. The patient’s family history was unremarkable. After 24 h, the color of the middle raphe cyst turned dark green. The cyst was incised at bedside, and meconium passed from it. Insertion of a soft catheter showed a deep fistula running parallel to the urethra (Fig. ). Urination was normal, with no urine passed from the fistula. Urethrography and fistulography, performed 3 and 4 days after birth, respectively, showed a long fistula running parallel to the urethra from the rectal pouch to the penis (Fig. ). The distance between the rectal pouch and the anal dimple was 1 cm. During urethrography, a small amount of contrast retrograde had flowed into the rectal pouch (Fig. ), suggesting a communication between the fistula and the urethra. X-rays and ultrasound did not show any anomalies in the sacrum and spinal cord. No other anomalies could be identified.
One-stage limited posterior sagittal anorectoplasty (PSARP) was performed on the fourth day after birth. With the urethral catheter indwelling, the patient was placed in the prone position, and a sagittal incision was made. The posterior rectal wall was opened in the midline and extended distally, ending directly at the fistula, which was 2 mm in diameter. The dissection continued between the rectum and the urethra until the two structures were completely separated from each other. The distal end of the fistula was ligated to the remaining part of the corpus spongiosum penis (Fig. ). The muscles were repaired and anorectoplasty was performed. The urethral catheter was removed on the seventh postoperative day and there was no difficulty 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 47-year-old Caucasian male with a past medical history of schizophrenia, alcohol and drug abuse presented to an outside facility with symptoms of recurrent emesis and epigastric pain. Abdominal CT scan and chest X-ray in the emergency room revealed right pneumothorax and a chest tube was placed. Soon after, the patients went into septic shock and required vasopressors, IV antibiotics and mechanical ventilation.
Esophagogastroscopy was deferred because of his instability. His blood cultures were positive for staphylococcus hominis. The following day a transesophageal echocardiogram to rule out valve endocarditis was negative. The patient appeared to improve on antibiotics but two days later his condition worsened again, and he was transferred to our facility. Upon arrival it was noted that there was copious thick mucinous output from the chest tube. A gastrografin study of the esophagus confirmed a sizable perforation at the lower esophagus (fig. A, ). Because of the appearance of a large esophageal defect with extensive pleural contamination, we did not consider stenting [–]. The patient was stabilized and taken to the operating room. A right posterolateral thoracotomy was done through the seventh intercostal space. The pleural space contained copious amounts of purulent fluid and gastric content which exuded from an exceptionally large esophageal defect in the lower third of the esophagus. The defect initially appeared to measure 5 × 3 cm in diameter, however after debridement of its necrotic edges it measured 9 × 4 cm (fig. A, ). Faced with the large defect, sepsis and delayed treatment, we entertained the idea of performing an esophageal exclusion surgery, however because of concern with his behavioral difficulties and the potential lack of compliance, we decided that a one stage attempt for definitive esophageal repair would be best for him. Because of his compromised status, we felt that he would not tolerate an esophagectomy and that an attempt to patch the

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


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

[User]
RADIOLOGY NOTE:
An 82-year-old Caucasian woman was referred for evaluation and treatment to our department (a tertiary Orthopaedic and Sarcoma Referral Centre) by a consultant oncologist. Following staging, the patient had undergone open excision of her right kidney 10 months before her referral, due to renal cell carcinoma (RCC), followed by adjuvant chemotherapy. Approximately one month following her operation, the patient reported pain at her left proximal tibia. The gradually increasing severity of the pain had forced her to minimize her everyday-life activities. Being unable to bear weight, she was only capable of household walking with the use of a walker for a period of approximately 7 months before her referral. Eventually, she became bedridden.
The patient's medical history was significant for coronary disease (had undergone cardiac by-pass 32 months before her referral) and impaired renal function, which severely deteriorated following her renal operation. Her physical examination revealed local tenderness at palpation at the proximal part of the right tibia. The patient underwent further examination with plain radiographs (), a CT- and a MRI-scan (), which showed the existence of a lytic lesion at the proximal tibia, extending into the popliteal cavity, due to the complete destruction of the posterior tibial cortex. Despite this extension of the lesion into the popliteal fossa, the lesion was abutting on the neurovascular structures and it did not encircle them. The diagnosis of a RCC metastasis was confirmed by CT-guided core needle biopsy. The patient subsequently underwent a bone-scan with Tc99 which showed evidence of multiple skeletal metastases (pelvis, lumbar and thoracic spine, and thoracic cage), even though she reported no pain at all other affected areas. Following a Multi-Disciplinary Meeting, the patient was offered two surgical options, either an above-knee amputation or a palliative limb salvage option. The latter involved extended curettage of the lesion,

[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.T.P, male, 69 years old, in June 2018, reported a tumor associated with pain in the soft-tissue region of the left forearm. Imaging examinations and a biopsy of the lesion were performed, and a high-grade malignant ESFT was identified. The patient was then submitted to neoadjuvant chemotherapy associated with local radiotherapy and later to marginal resection of the lesion with free margins in the pathological examination.
Six months later, during routine follow-up with his urologist, the patient presented a prostate-specific antigen value of 9.04 ng/mL. He underwent a multiparametric magnetic resonance imaging of the prostate, which demonstrated a highly suspected peripheral prostatic abnormality for clinically significant neoplasia (Prostate Imaging-Reporting and Data System 4). A biopsy of the prostate was then performed by transrectal ultrasound, and the anatomopathological study was compatible with prostate adenocarcinoma, Gleason 9 (4 + 5) in one fragment in the left apex and in two fragments in the left middle third and Gleason 7 (3 + 4) in a fragment at the apex on the right.
In order to complete the PC staging, a PET/CT using a 68Ga-PSMA study was requested. The study demonstrated multiple focal areas of abnormal uptake in the prostate with standard uptake value maximum (SUVmax) up to 5.0 and also a single diffuse intramedullary lesion in the right humerus with SUVmax = 10.8 [Figures -]. No signs of lesions were identified in the pelvic lymph nodes or in the other bones.
By the fact that the bone lesion presents in an uncommon site of PC metastasis, because it does not have common anatomical features of PC, and because the patient had already been treated for a high-grade solitary fibrous tumor (SFT), a biopsy of the humeral lesion was performed to identify its etiology.
Finally, the histopathological and immunohistochemical studies confirmed that the humerus lesion was a metastasis of the SFT and the patient received specific treatment for SFT

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


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

[User]
RADIOLOGY NOTE:
A 21-year-old woman with a massive mediastinal–left chest wall VM, atresia of the left subclavian vein, and CTEPH was referred for evaluation primarily for PTE and secondarily for heart–lung transplantation. The patient was born with a compressible mass extending from the left neck, left chest, and left axillary areas. Six months prior to referral, she was diagnosed with an acute PE and treated with warfarin. She had not had an acute venous thromboembolic event prior to this and therefore was not previously on anticoagulation. She then reported progressive exercise intolerance progressing to severe dyspnea on exertion, ultimately becoming wheelchair-bound. Her pulmonary artery pressure was elevated and oral tadalafil therapy was started. Contrast-enhanced chest computed tomography (CT) revealed an extensive VM in the left anterior mediastinum immediately behind the sternum, extending across the midline anterior to the ascending thoracic aorta and through the thoracic outlet into left axilla and left chest wall. The vascular mass abutted the right ventricular outflow tract and the main pulmonary artery ().
Left upper extremity venography demonstrated complete interruption in the continuity between the left axillary vein and innominate vein due to congenital absence of the left subclavian vein. The left chest VM was directly opacified from the left axillary vein on the contrast injection. The only venous egress from the massive left chest VM was through the left innominate vein stump, which connected into the superior vena cava (SVC), then to the right atrium. Thus, spontaneous thrombi in the left chest VM intermittently detached and caused recurrent PE. Lifelong anticoagulation alone was not considered to be a viable solution given it would have to be interrupted perioperatively for the PTE leaving her at high-risk for recurrent PE postoperatively. Additionally, should she develop any type of bleeding complication, there was no mechanical method (an “IVC filter equiv

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


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

[User]
RADIOLOGY NOTE:
The patient is an 85-year-old male with a remote history of prostate cancer treated with an open radical prostatectomy and adjuvant radiation therapy who subsequently developed recurrent gross hematuria and clot retention secondary to radiation cystitis. He completed approximately forty sessions of hyperbaric oxygen therapies but continued to experience recurrent gross hematuria requiring multiple inpatient hospitalizations for continuous bladder irrigations and requiring transfusion of blood products. He was discharged from the hospital two weeks prior to his most recent admission with a urinary catheter after a prolonged hospital course during which he was treated for gross hematuria. His hospital course was also complicated by a small bowel obstruction managed nonoperatively and a C. difficile infection. On the night prior to this admission, he noticed poor drainage from his urinary catheter prompting his presentation to an outside Emergency Department where he was initiated on continuous bladder irrigation and transferred to our institution.
The following morning, the patient endorsed diffuse lower abdominal pain, had a marked increase in his leukocytosis, and had a poorly draining catheter with worsening gross hematuria. The patient was brought to the operating room emergently for a cystoscopy and clot evacuation. After clot was removed from the bladder and better visualization was obtained, a perforation was visualized at the dome of the bladder that extended towards the base of the bladder. In order to differentiate between an extraperitoneal and intraperitoneal bladder perforation, a fluoroscopic retrograde cystogram limited to the anterior-posterior view in lithotomy position was performed () using approximately 50 milliliters of iohexol (Omnipaque™) contrast dye; however, the image findings were equivocal.
A portable cone-beam CT scanner (O-arm™, Medtronic, Minneapolis, MN) was brought into the operating room and positioned around the surgical table. An ad

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


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

[User]
RADIOLOGY NOTE:
A 47-year-old man was brought to a nearby hospital presenting with: sudden vertigo; vomiting; and gradual right-sided hemiparesis that eventually evolved to quadriparesis, without any previous medical illness, which began a few hours earlier in the day. Computed tomography of his brain revealed no abnormal densities at the brainstem, and a computed tomography angiogram (CTA) of his brain revealed a proximal basilar artery occlusion. He was referred to our institution 11 hours after initial onset under the basis of being treated with mechanical thrombectomy. Upon arrival, he was intubated but was alert and keenly responsive. Neuroexamination showed left horizontal opthalmoplegia, a motor power grade of 2/5 on the left side, and hemiplegia on the right side that ultimately correlated to a National Institute of Health Stroke Scale score of 21. A brain MRI shortly after the examination demonstrated restricted diffusion at bilateral pons, with greater restriction on the left side, including a restricted diffusion at bilateral cerebellar hemispheres (Figure ). Magnetic resonance angiography (MRA) of his brain demonstrated the same findings that were seen in the CTA. Following a discussion with his wife, we agreed to continue with endovascular treatment. After two attempts of stent retriever thrombectomy, complete recanalization was achieved (Figure ). Antiplatelet therapy was applied for 24 hours after the procedure. The following day, an MRI and brain MRA follow-up revealed hypersignal intensity at bilateral pons and cerebellar hemispheres that both appeared more distinctive than the initial MRI however remained limited to the same region (Figure ). Electrocardiography monitoring and transthoracic echocardiogram were unremarkable. He was fed via nasogastric tube, received daily physical therapy, and was admitted in the stroke unit for 12 days before being referred for further rehabilitation at his previous hospital. He was discharged with an evaluated NIHSS score of 18.

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

[User]
RADIOLOGY NOTE:
A 39-year-old woman was referred to our clinic for persistent elevated β-hCG after surgical evacuation of a blighted ovum. She complained of amenorrhea combined with intermittent vaginal spotting and lower abdominal discomfort. She had an obstetric history of 2 full-term vaginal deliveries and one induced abortion. Fourteen weeks earlier, she had undergone surgical curettage for a blighted ovum at 7 weeks of gestation at a local clinic. Physical examination was normal except mild low abdominal tenderness, and vital signs were normal. Her serum β-hCG was 95 mIU/mL. A review of her previous sonography, performed before curettage, revealed a gestational sac with a yolk sac in the endometrial cavity, a diagnosis compatible with a blighted ovum. We telephoned the obstetrician who had performed the curettage and confirmed that the previous procedure was uneventful with no suspicious uterine perforation. Transvaginal sonography revealed an empty uterus and a 2-cm mixed echoic mass in the uterine fundus (). Color Doppler evaluation demonstrated abundant arterial and venous flow on the mass (). Magnetic resonance imaging (MRI) showed a 2.3×1.3 cm mass lesion of heterogeneous signal intensity with many tortuous tubular signal voids in the uterine fundus. The endometrial-myometrial junction was intact (); the mass was heterogeneously well enhanced after contrast material infusion. Also, multiple small cysts in left ovary were noted with MRI.
After conservative care including analgesics for 2 weeks, her β-hCG level had slightly decreased to 73 mIU/mL but her abdominal discomfort was persistent, and the mass on ultrasonography had increased to 2.7×2.0 cm. At this time, the possible differential diagnosis included placenta site trophoblastic tumor (PSTT), heterotopic pregnancy, and remnant placenta. Diagnostic laparoscopy was planned in order to acquire samples for histology. We suggested resection of the mass, but the patient opted for total hysterectomy due to fear of malignanc

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

[User]
RADIOLOGY NOTE:
A 39-year-old man visited the emergency room with a dizziness and balance impairment that occurred 6 hours before. At the time of admission, the patient showed alert consciousness, but neurological examinations showed the signs of cerebellar dysfunction. Finger to nose, heel to shin and rapid alternating movement test showed that cerebellar function was impaired on the left side, with intact function of the right side. Blood pressure was 150/80 mmHg, and pulse rate was 88 beats/min with normal sinus rhythm of electrocardiography. He had no underlying disease and no medication use. Routine laboratory tests of blood and electrolytes, were within normal ranges. He initially denied any trauma, but remembered severe pain when he underwent a cervical chiropractic manipulation about two weeks prior. Upon imaging, skull and cervical spine radiographs were normal. Brain computed tomography (CT) showed normal cerebellar parenchyma (). But magnetic resonance (MR) imaging (MRI) revealed acute infarction in the left PICA territory (). Gradient echo image suggested blood clot in left PICA (). MR angiography revealed complete occlusion of left VA with retrograde blood flow ().
Transfemoral cerebral angiography revealed the occlusion of left VA at V1/2 junction. And it showed the retrograde blood flow to the left VA to the V2 segment (C1 level) and also showed the occlusion of left PICA (). After angiography, the patient was admitted to a neurological intensive care unit, and he received antiplatelet therapy with the use of Aspirin® 100 mg/day (Bayer AG, Leverkusen, Germany). There was no embolic source in the heart transthoracic echocardiogram and heart CT. And doppler ultrasonography did not reveal atherosclerosis of both internal, external carotid arteries. So it is unlikely that the infarction was caused by cardiac thrombosis or other vascular abnormalities.
At 1 month later, axial CT imaging showed the change to the chronic phase of left PICA infarction (). And in neck CT subt

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

[User]
RADIOLOGY NOTE:
A 54-year-old Caucasian male presented to our emergency department with severe epigastric pain with intractable nausea and vomiting over 48–72 hrs. The patient reported early satiety, a 30 lb. weight loss over 3 weeks and was unable to tolerate anything by mouth. Additionally, the patient had developed a left lateral neck mass which progressively increased in size over the past 9 months. Patient denied tenderness to palpation of the mass and dysphagia. His past medical history was significant for papillary carcinoma of the thyroid, GERD, chronic hepatitis C, polycystic kidney disease (PKD) and chronic kidney disease (CKD). His past surgical history was remarkable for thyroid malignancy treatment with radioactive iodine and total thyroidectomy in addition to a gunshot wound. Family and social history were not significant. On physical exam, a left supraclavicular soft tissue mass 6 cm in diameter was appreciated, it was non-tender with no submandibular lymphadenopathy. A soft tissue mass was also palpable on the anterior abdominal wall in the epigastric region.
Given the patient's malignant history, significant weight loss in the past 3 weeks with increasing left mass size, nausea, vomiting and abdominal pain, the patient was admitted for further evaluation. Initial studies included ultrasound of the abdomen for workup of acute pancreatitis with findings unremarkable for the body of the pancreas and the head and tail not being visualized. CT of the abdomen and pelvis revealed pulmonary nodules in the posterior segment of the right lower lobe of the lung and bronchiectasis of the left lower lobe, PKD and bilateral hepatic cysts. Oncology was consulted, and a CT of the chest and neck were ordered in addition to a chest X-ray that was remarkable for two pulmonary nodules with an enlarged paratracheal node. Pulmonology was consulted, and the patient was recommended to follow-up in 6 months for surveillance of the pulmonary nodules. ENT and Surgery were consulted, and an e

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


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

[User]
RADIOLOGY NOTE:
A 64-year-old woman was referred to our hospital for the treatment of chest wall necrosis. She had undergone Halsted surgery and postoperative radiation therapy with cobalt-60 (30 Gray) and megavoltage X-rays (30 Gray) 25 years earlier. Following the treatment, her left upper limb became completely paralyzed.
Six years earlier, she had sustained a left clavicle fracture due to osteonecrosis, and she had subsequently developed a chronic cutaneous fistula measuring 1 cm in diameter. The fracture and cutaneous fistula failed to heal, and she experienced bleeding from the fistula since 1 year. Two months before visiting our hospital, she was hospitalized in the Department of Breast Surgery at another hospital for massive bleeding and local infection. She was treated with antibiotics and cleansing of the fistula and the infection subsided 2 months thereafter. She visited our hospital after discharge.
At initial examination, her height was 153 cm and weight was 34 kg. Necrosed clavicle was exposed through the 6-cm-wide skin defect in the left clavicular region, and air entered and exited the opening from deep within the chest while breathing (Fig. ). Computed tomography (CT) revealed the part of the first to third left ribs, part of the left clavicle, the subclavian artery, and the brachial plexus to be missing. Her upper left limb was nourished by retrograde blood flow from the thoracodorsal artery; however, blood flow was weak to the skin of the arm, the surface of which was cold, resulting in complete paralysis of the upper extremity. Several rounds of debridement eliminated the necrotic tissue, and the local infection was completely resolved. Debridement revealed a tissue defect measuring 4 cm × 8 cm and 4 cm deep at the base and approximately 10 bronchial stumps on the surface of the collapsed lung covered in granulation tissue, from which exhaled air and sputum were effusing (Fig. ). She presented with severe emaciation and malnutrition, but no

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


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

[User]
RADIOLOGY NOTE:
A 31-year-old man was admitted to our hospital, complaining of hematochezia which had lasted for 1 month. His past history involved a high anterior resection of the rectum in our hospital due to intussusception caused by Peutz-Jeghers polyposis (Fig. ). He was hospitalized for 1 month after the procedure. Unfortunately, details of the surgical procedure that had been performed and the reason for his extended postoperative hospitalization were unknown, because clinical records from his previous admission were not available. He was followed up for 3 years after the procedure, during which he had no abdominal symptoms. He remained symptom-free until the month prior to readmission when he began to suffer from hematochezia. On this admission, hematochezia was his only symptom and there were no abnormal abdominal findings on physical examination. Blood test results, including levels of tumor markers, were all within normal limits. Colonoscopy revealed a hemorrhagic tumor with a smooth surface protruding from the anastomosis of the previous high anterior resection, at a distance of 10 cm from the anal verge; a second examination 4 days later revealed that the tumor had disappeared (Fig. ). The biopsied tumor and other small polyps were histologically diagnosed as adenocarcinoma and hamartomatous polyps, respectively (data not shown). We performed a low anterior resection of the rectum, including the anastomotic site with the adenocarcinoma, combined with a resection of the ileum for strong adhesion. The patient was discharged from our hospital 42 days after the operation.
Gross appearance of the resected rectum showed a defect of the rectal mucosa with a smooth edge and a mucosal bulge located at the anastomotic site (Fig. ). Cut surfaces demonstrated a submucosal tumor mainly occupying the proper muscle layer under the defect (Fig. ). Microscopically, the submucosal tumor comprised an adenocarcinoma and a bone lesion at the anastomotic site (Fig. ). The surface of the tum

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


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

[User]
RADIOLOGY NOTE:
A 50-year-old Hispanic man with known history of obesity and hypertension presented with a 3-month history of abrupt episodes of weakness and altered mental status. He referred severe psychomotor symptoms as well as anxiety, aggressiveness, agitation, weakness, diaphoresis, and decreased visual acuity occurring at any time of the day and improved by eating. Upon further questioning, our patient, who worked as a truck driver and whose symptoms had reflected poorly in his workplace, also expressed overall discomfort with life and wishes of death due to the intensity of his symptoms. He had no history of tobacco smoking or excessive alcohol consumption. Medications taken prior to admission included candesartan 16 mg and hydrochlorothiazide (HCTZ) 12.5 mg once a day for hypertension.
During the following weeks, the symptoms increased in severity and frequency, with continued unremitting anxiety and weakness accompanied by loss of consciousness and extreme burning sensation in his entire body. After this acute episode, he was evaluated by a primary care physician in a local hospital and hospitalized for 4 days, where he continued to present recurrent episodes of irritability and aggression to self and others. He was discharged and referred for psychologic evaluation by mental health services at another institution. No specific diagnoses were given.
Upon release from mental evaluation, he was evaluated by a third physician, who performed a 3-hour postprandial blood glucose test which revealed a blood glucose level of 58 mg/dL. Suspecting an insulinoma, our patient was admitted to a third-level hospital, and upon arrival his vital signs were: afebrile (37 °C), heart rate of 93 beats per minute, blood pressure of 161/84 mmHg, respiratory rate of 19 breaths per minute, and oxygen saturation of 98% on room air. A physical examination revealed an oriented, well-nourished, and hydrated patient, without any stigmata on skin, a normocephalic and atraumatic head, and no masses or

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


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

[User]
RADIOLOGY NOTE:
A 12-year-old girl unrestrained rear seat passenger was involved in a motor vehicle accident (MVA) as a head on collision. There was no history of ejection. She was received in the emergency room unconscious with glasgow coma scale 8/15, and her initial vital signs were as follows: Blood pressure 110/67 mm Hg, pulse rate 141, saturation 96%, and she was breathing with difficulty. Her chest exam revealed reduced air entry on the left hemithorax. She was intubated and ventilated. Her abdominal exam revealed a soft and laxed abdomen. Her initial CXR showed lung contusion and raised left hemidiaphragm []. The suspicion of left diaphragmatic rupture was raised for which a nasogastric tube was inserted and CXR was taken again confirming the intrathoracic herniation of the stomach []. The patient was sent for pan CT scan. It confirmed the presence of left diaphragmatic rupture, left pneumothorax, right lung contusion, and right hemothorax with no evidence of intra-abdominal injuries []. The patient underwent an emergency exploratory laparotomy. Exploration revealed ruptured left diaphragm extending medially from the left edge of the liver laterally with herniation of the left lobe of the liver, stomach, and spleen. They were reduced, and closure of the diaphragmatic tear was done in a double-breast fashion using 1 Prolene suture. Formal laparotomy at the time was negative for other injuries. Bilateral intercostal tubes were inserted, and the patient was shifted to intensive care unit. Her postoperative CXR showed persistent elevation of the right hemidiaphragm []. A second urgent CT scan was done which pointed out to the possibility of right diaphragmatic rupture []. The patient underwent right exploratory posteriolateral thoracotomy on the second day postoperatively. It revealed a missed tear of the diaphragm's dome with limited herniation of the right posteriosuperior surface of liver. Repair was done successfully and the patient had an uneventful postoperative course an

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


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

[User]
RADIOLOGY NOTE:
A 22-year old woman presented to our clinic with a palpable mass for 6 months. The mass was painless. Her medical history was not remarkable for any disorder. On physical examination she had a palpable mass filling the left upper quadrant and epigastrium. On laboratory examination she had normal levels of total protein, albumin, globulin, alanine aminotransferase, aspartate aminotransferase, blood urea nitrogen, serum creatinine, carbohydrate antigen 19–9 (Ca19-9), carcinoembryonic antigen (CEA) and alpha-fetoprotein (AFP). She also had negative serology for hepatitis B and C viruses. On ultrasonography there was a hypoechoic, solid mass with sharp contours and heterogenous pattern which had a size of 16 x 10 cm and diffuse cystic-degenerative areas and which appears hypervascular on Doppler USG (A). The described mass was considered to reside exophytically in the left lobe of the liver. An urgent abdominal tomography showed a giant solid mass that originated from the inferior part of the medial segment of the left lobe of liver and that extended inferiorly. Its size was approximately 17 × 15 x 11 cm. It had smooth contours and marked hypervascularity. It contained diffuse cystic-degenerative areas. A giant hepatic adenoma was primarily considered in the differential diagnosis, which also included liver tumors of mesenchymal origin or hepatocellular carcinoma on a non-cirrhotic basis (B).
The patient’s abdominal cavity was explored with a subcostal incision. There was a mass with smooth contours, measuring 15 x 12 cm in the left lobe of the liver, which grew exophytically. Other parts of the liver were normal. The mass’s portion out of the liver was of hypervascular appearance that compressed adjacent tissues but was easily separable from them. The mass was excised with liver tissue and gall bladder, with a negative surgical margin, with the help of an ultrasonic dissector and cautery. There was no additional lesion in the abdominal cavity ().
The macroscopic examin

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


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

[User]
RADIOLOGY NOTE:
A 48-year-old woman with hypertension, rheumatoid arthritis, seasonal allergies, and long-standing solid food dysphagia presented to our gastroenterology clinic with progressively worsening dysphagia and transient food impaction. The patient reported approximately 7 years of solid food dysphagia, but prior to this, has had no upper gastrointestinal symptoms, trouble swallowing, or dietary modification. She had sought prior gastrointestinal evaluation, and an endoscopy 2 years after symptom onset showed rings and furrows, but biopsies were not obtained and dilation was not performed. Though no specific treatments were initiated, the patient did note an improvement in her ability to swallow following the procedure.
One year prior to her presentation, she developed recurrent solid dysphagia which progressively worsened. Solid foods, particularly bread and meat, would get stuck in the upper chest and resulted in transient impactions 2–3 times per week. In most instances, if she waited, the food would ultimately pass; however, in some cases, she would have to regurgitate the food. She reported eating slowly, taking small bites, chewing thoroughly, and drinking a lot of liquids during meals. Because of suspicion of eosinophilic esophagitis (EoE), she was placed on a proton pump inhibitor (omeprazole 20 mg twice daily), and repeat endoscopy was performed. She was given propofol for sedation, and the endoscopy went smoothly, but it was noted that she was yawning multiple times during the procedure.
Immediately after the procedure, the patient experienced severe left-sided facial pain. On examination, there was a spasm over the left masseter muscle, and she was unable to close her mouth. In an attempt to control her pain and relax her muscle spasm, the patient was given 25 μg of fentanyl and a 30-mg dose of propofol, but these were not successful. Given the severity of her pain and her inability to close her mouth, she was referred to the emergency department for suspicion o

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


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

[User]
RADIOLOGY NOTE:
Patient 3 is a 45-year-old Jordanian female with an itchy eruption of 3 months' duration. This affected the nape of the neck and the upper back. No triggers were identified and the patient was otherwise healthy.
The patients' demographics and their clinical features are outlined in . Clinically, all patients were noted to have erythematous papules that coalesced to form plaques. These were arranged in a reticular pattern that was more prominent peripherally. In addition, patient 1 had associated vesicles and minimal erosions (Figures and ). In all patients, the lesions were symmetrically distributed and had a predilection for the trunk. Other involved areas included the lateral and posterior aspects of the neck (patients 1 and 3), the lateral chest wall (patient 1), and the lumbosacral area (patient 1). Different types of lesions coexisted in all patients including papules, patches, and plaques, in addition to vesicles and erosions in patient 1. A clinical diagnosis of PP was suspected clinically in patients 1 and 2.
The main histological findings are summarized in and . The histopathological features were similar in all cases, showing features consistent with early lesions according to Boer's criteria []. The major histological differential diagnoses were impetiginized spongiotic dermatitis, pityriasis lichenoides, and viral exanthem. Periodic acid-Schiff stain was negative in all specimens. Direct immunofluorescence was performed for patients 1 and 2 only and was negative.
The clinical course varied, but all three patients had eventual complete resolution of all lesions. Patient 1 was treated with superpotent topical corticosteroids prior to presentation to our department. However, there was no improvement and new lesions continued to emerge. The patient subsequently reported gradual spontaneous resolution 10 weeks after onset of the eruption, leaving postinflammatory hyperpigmentation. Patient 2 was previously treated with moderately potent topical corticosteroid

[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 pregnant female patient presented to the antenatal clinic with a history of acute lower abdominal pain and associated vaginal bleeding, reporting passing drops of blood without passage of clots. On clinical examination, the patient was haemodynamically stable with no significant abnormalities identified. Background clinical history revealed that she was a booked patient and compliant with antenatal follow-up visits. This was her fourth pregnancy, with two previous normal vaginal deliveries at term. Records also revealed a previous termination of pregnancy, carried out 5 years prior at 16 weeks of gestational age. The termination was conducted as an inpatient procedure, likely involving invasive uterine instrumentation; however, further details were not available.
Biochemistry revealed a normal full blood count. She was known to be Human Immunodeficieny Virus (HIV) positive, with a CD4 count of 98 and a viral load of 212, as well as Rapid Plasma reagin (RPR) negative, Rhesus positive and Hepatitis B surface antigen negative. She had no other known co-morbidities. During the current pregnancy, the patient had been repeatedly treated with antibiotics for recurrent urinary tract infections with culture-proven Escherichia coli. She also had a prolonged hospital admission for more than 2 weeks after presenting with vaginal bleeding, and was assessed with a threatened miscarriage. At the time, the bleeding resolved spontaneously.
An initial abdominal ultrasound at 21 weeks of gestational age had identified a low-lying placenta. A subsequent follow-up obstetric ultrasound documented an intrauterine singleton at approximately 29 weeks of gestational age, with a vertex presentation. Placenta previa was noted, with the suspicion of morbid adherence. No evidence of abruptio placentae was found. The patient was subsequently admitted to hospital for monitoring and further workup, with a diagnosis of antepartum haemorrhage as a complication of placenta previa.
Prior

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


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

[User]
RADIOLOGY NOTE:
The patient in our study was a 35-year-old female who sustained a low voltage alternating current (110–380 V) electrical injury to her left hand. Left forearm pain, paraesthesia and bluish skin discoloration were features from initial presentation. In the 3 weeks following injury, she developed progressive patchy paraesthesia and dysaesthesia predominantly in the median nerve distribution of the affected hand. An ultrasound showed a normal appearance of the median nerve and of structures within the carpal tunnel and distal forearm. Acute carpal tunnel syndrome was suspected as being responsible for at least part of the presenting symptoms. With the possibility of secondary median nerve compression related to the injury, a carpal tunnel release procedure was undertaken at 3 weeks post injury. The median nerve appearance was macroscopically normal. Postoperatively, some paraesthesia in the territory of the median nerve improved but forearm pain persisted.
From 1 month post injury, the patient's disease continued to progress; all movements and sensory stimulants to the affected hand were grossly intolerable and a diagnosis of CRPS was made. The diagnosis was made based on the patient fulfilling the Budapest criteria, as shown in Table .
From 1 to 10 months post-injury, the patient received specialist therapy and pain management including pharmacological agents such as gabapentin, paracetamol, ibuprofen, tramadol, amitriptyline, ketamine, pamidronate infusions, lidocaine plasters, nabiximols, and capsaicin cream, which all failed to give relief. Supraclavicular catheter blocks, transcutaneous electrical nerve stimulation (TENS), and hand physiotherapy were also ineffective. At 9 months post injury, the patient was experiencing spontaneous skin breakdown with weeping, cellulitis and was hospitalized as a result of these infections. She was unable to clean her skin due to excessive pain. By the end of this period the patient had developed a functional loss of the limb. Th

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


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

[User]
RADIOLOGY NOTE:
A 3-year-old male with a history of medical treatment for cough, sputum, and rhinorrhea complained of bilateral leg weakness and severe lower back and leg pain for 1 day. He was born at 40 weeks’ gestational age by normal spontaneous vaginal delivery without any perinatal problems. He showed good growth and development and did not suffer from any particular medical illness. Routine immunization had already been administered and any vaccine-associated complications had not been developed.
On admission, the patient complained of severe pain and burning sensation on back and lower extremity as well as flaccid paralysis of the whole body that was worse in the lower extremities. On physical examination, function of all cranial nerves was intact and muscle strength of bilateral proximal upper extremities was grade 1 according to the Medical Research Council (MRC) criteria with no discernible movements elsewhere. Deep tendon reflexes, including patellar and Achilles tendon reflexes, were absent bilaterally. Upper motor neuron signs such as Hoffmann and Babinski signs were absent. There were no signs of ataxia or nystagmus or meningeal irritation signs and no bladder or bowel dysfunction was found at admission.
Laboratory studies showed a total white blood cell count of 7500 cells/mm3 and C-reactive protein level of 0.17 mg/dL; results of other biochemical blood tests were within normal ranges. Cerebrospinal fluid analysis and magnetic resonance imaging (MRI) of the whole spine were performed for differential diagnosis of acute flaccid paralysis. Cerebrospinal fluid analysis parameters were within normal ranges; however, whole spine MRI after gadolinium injection showed high signal intensity on the cervical and lower thoracic spinal cord as well as cauda equina in the T-1-weighted image (Figure ). Although albuminocytologic dissociation in cerebrospinal fluid was typical finding in GBS, elevations of protein usually occurred in the second or third week of illness in AMAN, 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.