[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 man was admitted to our cardiovascular surgery department with an 8-month history of dizziness and a discovery of IAFB for 4 months. He had a sudden dizziness 8 months ago and the computed tomography (CT) indicated cerebral stem infarction. Cerebral angiography was performed at the local hospital, and he was treated with aspirin and atorvastatin calcium. About 4 months ago, the symptom of dizziness reappeared with limited movement of left upper limb. CT revealed new multiple cerebral infarctions and IAFB. The patient was therefore prescribed with rivaroxaban 10 mg/d for 6 months. In order to retrieve the IAFB, the patient was transferred to our hospital.
The physical examination of the patient showed no obvious abnormalities. The neurological examination showed the left upper limb muscle strength score was level 2. Brain CT scan revealed multiple softening foci appeared in left frontal lobe, right parietal lobe and right cerebellar hemisphere (Fig. ). Echocardiography demonstrated strong echo foreign bodies in ascending aorta and aortic arch (Fig. , Supplemental video ). A further three-dimension X-ray images revealed a linear, high-density shadow within the aorta, part of which was wrapped around the aortic arch, with one end entering the right common carotid artery and the other end located in the thoracic and abdominal aorta (Fig. ). He was diagnosed as IAFB and referred for emergent open surgery.
The patient was placed in the supine position, sternotomy was performed with a mid-sternal incision and fully exposed the heart, ascending aorta and aortic arch. After systemic heparinization, an arterial perfusion tube (18Fr) was inserted via the right subclavian artery and a venous bipolar drainage tube (32/34Fr) was inserted into the right atrium to establish extracorporeal circulation. At the same time, a left heart drain was left in place via the right superior pulmonary vein, and a coronary retrograde perfusion tube was inserted through the right atr

[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:
Hip fracture in a 82-year-old woman needing hip replacement surgery. She weighs 115 kg, is affected by dementia and diabetes, and non-cooperative.
On the basis of current DRG systems that do not incorporate nursing intensity weights (NIW), hospitals obtain the same level of reimbursement for these two cases. Instead, from a nursing perspective these two cases require a completely different intensity of nursing care, and where the second case presents a higher level of nursing intensity (). One practical way to measure nursing intensity is to use a set of NIWs for each DRG and apply them at discharge to adjust routine care and intensive care per diem charges. For our scenario, we based our NIW on the North American Nursing Diagnosis Association (NANDA) Nursing Interventions Classification.
The patient in scenario 1 requires a much lower intensity of nursing care than the one in scenario 2, who will need a higher intensity of nursing care than the standard on which a healthcare organisation would plan its resources. However, according to current DRG systems the hospital will obtain the same level of reimbursement for the two patients.
Ideally speaking, if intensity of nursing care was included in the DRG system, these two scenarios would require nurses to assess and document the level of patient complexity upon admission, and then plan and provide care accordingly. This would also entail the availability of appropriate levels of reimbursement and therefore the staffing and resources needed to cover the higher intensity of nursing care.
However, this would require nurse administrators to use up-to-date knowledge and make decisions to implement nursing care models according to evidence-based staffing levels. If it is true that nurses in clinical setting must justify what they do, and how and why they are doing it, then nurse administrators/managers must justify what skill mix, and what nurse staffing level they are ensuring to determine good nursing practice without mis

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


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

[User]
RADIOLOGY NOTE:
A 64-year-old male with a history of frequent chest infections presented to the department complaining of leakage from his speech valve and coughing on oral intake. The patient had a laryngectomy 16 years ago, following laryngeal cancer. Postoperatively, the patient was advised to care for his speech valve with a Blom–Singer voice prosthesis brush (). For the past 15 years, the patient had used the insight brush to clear tracheal mucous secretions rather than clearing the speech valve, as it allowed him deeper access to the trachea (). The patient was repeatedly advised by the medical and nursing staff to use the brush only to maintain the lifespan of his speech valve. As per the manufacturing guidelines, the brush should be used once a day only to clean the speech valve, but not to clear mucous secretions inside the trachea. After 1 month’s usage, a brush should be replaced. However, the patient went against the medical advice and used the brush vigorously several times a day to clean tracheal mucous secretions. As a result, he had mislaid voice prosthesis brushes numerous times in his bronchi or carina, which had to be removed by bronchoscopy.
On examination, the patient had no obvious abnormality in the valve puncture. The stoma site was normal except for some crusting around the edges. A marked abnormality on the tracheal wall ~6 cm inferior to the stoma site was revealed, through a flexible nasal endoscopic examination. The abnormality was later confirmed to be a TOF. The patient underwent a computed tomography (CT) scan to delineate the surrounding anatomy as to facilitate the planning of the surgery (–).
Initially, direct suturing under endoscopic guidance was attempted, which was initially successful but within a day the suture line had been disrupted by use of the brush. A percutaneous endoscopic gastrostomy was inserted for nutritional support. One option was to perform a right thoracotomy to disconnect the TOF and interposition an intercostal muscle flap

[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 male patient visited the outpatient clinic of the department of plastic surgery with a swelling of the left cheek that had lasted for about 6 months. The patient reported no events that could have caused particular trauma to the left facial area. The size of the patient’s cyst had recently been increasing, prompting him to visit a tertiary hospital for examination and treatment ().
Upon physical examination, the swelling of the left cheek was not accompanied by pain and tenderness. There was no change in size or feeling of warmth during eating, and a soft movable mass was palpable. Facial nerve function was intact. We then performed contrast-enhanced facial computed tomography (CT) for further evaluation. The differential diagnosis between BLEC and vascular malformations is very important. In general, vascular malformations are hyperdense on contrast-enhanced CT scans, whereas BLECs present as hypodense, thin-walled lesions. The CT findings showed a well-defined cystic mass with peripheral rim enhancement and central poor enhancement, confined to the superficial lobe of the left parotid gland (). The mass was suggestive of a benign cystic lesion, such as sialocele or first branchial cleft cyst. The hospital protocol for HIV diagnosis was followed. An HIV rapid test, enzyme-linked immunosorbent assay test, and Western blot were negative. We considered superficial parotidectomy, since the lesion was benign. The patient underwent left superficial parotidectomy under general anesthesia for resection of the mass. During the operation, the soft tissue surrounding the mass showed severe adhesion and fibrosis. After careful dissection and identification of the five main branches of the facial nerve, en bloc mass removal was performed successfully. Sternocleidomastoid (SCM) muscle transfer was performed to prevent Frey syndrome and a depression deformity of the parotid region. The histopathologic report was suggestive of a BLEC of the parotid gland (). Seroma w

[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 91-year-old woman presented with severe abdominal pain and vomiting. She revealed a 12-h history of abdominal pain that had suddenly worsened and was associated with vomiting 1 h prior to presentation. She was otherwise healthy and denied the regular use of any medications.
A physical examination showed a blood pressure of 96/58 mmHg, heart rate of 95 beats/min, respiratory rate of 24 breaths/min, and hypothermia. An abdominal examination showed a diffusely rigid abdomen with rebound tenderness over the entire abdomen and reduced bowel sounds. Contrast-enhanced abdominal computed tomography showed a paraesophageal hernia in which part of the stomach was incarcerated (Fig. ). Free air and ascites were observed in the hernia sac and peritoneal space. The patient developed gastrointestinal perforation-induced peritonitis; however, the association between the incarcerated hernia and the perforation was unclear.
An emergency laparotomy was performed through the upper abdominal midline incision, and we observed that part of the stomach was incarcerated within the paraesophageal hernia sac, which also contained ascitic fluid that appeared like gastric fluid. After reducing the stomach, we detected a perforation measuring 7 cm on the posterior wall of the gastric fundus (Fig. ). The affected part of the stomach showed full-thickness necrosis, for which we performed total gastrectomy with Roux-en-Y reconstruction. During the operation, the patient’s hemodynamics was unstable; thus, hernia repair only involved closure of the orifice, and fundoplication was not performed. The operative time was 3 h 22 min and the amount of bleeding was limited to 104 ml. The resected specimen showed an ischemic necrosis–induced perforation measuring 7 × 4.5 cm on the posterior wall of the gastric fundus (Fig. ). Postoperatively, the patient remained hemodynamically unstable despite maximal resuscitative efforts and died on postoperative day 2.
After the operation, the patient remained hemody

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


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

[User]
RADIOLOGY NOTE:
A 37-year-old Asian woman, para five, all born by spontaneous vaginal delivery and one first trimester miscarriage treated by dilatation and evacuation six months back, presented with eight weeks missed miscarriage. Dilatation and evacuation were performed without any complications. After 45 days, she reported in an emergency, with a single episode of profuse and heavy vaginal bleeding and a history of irregular vaginal bleeding for the last 40 days. She also took tab misoprostol 800 ug prescribed by a local practitioner in suspicion of retained products of conception but the bleeding continued. There was no past history of a bleeding disorder or a family history of any gynecologic cancer. On examination, she was in a state of hemodynamic shock, with cold clammy skin, blood pressure 90/40 mmHg, and a weak, low-volume pulse of 140/min. The chest was clear, with a respiratory rate of 20/min. Pelvic examination showed a bulky uterus with closed os and normal adnexa. On investigations, her hemoglobin was 5 gms/dl while platelets were normal. Red cell indices showed iron deficiency anemia. Electrolytes, clotting profile, and renal function tests were normal. The histopathology report of the previous evacuation revealed chorionic villi with no evidence of trophoblastic disease. Her beta-human chorionic gonadotropin (HCG) was less than 25 IU/L. She was resuscitated with two liters of intravenous (IV) normal saline. Bleeding was controlled with inj. tranexamic acid 1 gm stat and then eight hourly. Four pints of packed cells were transfused. Ultrasound Doppler was done, which showed a bulky uterus with irregular and thickened endometrium with some debris and blood clots. Vascularity on color flow suspected uterine arteriovenous malformation (Figure ). She was planned for embolization but on refusal, was managed conservatively on oral progesterone 5 mg three times for 21 days. She remained asymptomatic for six months and had regular menstruation. Later, she opted for oral con

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


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

[User]
RADIOLOGY NOTE:
A previously healthy 10-year-old Hispanic male presented with a chief complaint of a rash on his left chest and back for three days. The rash began gradually, which was described as both itching and burning in sensation. Prior to the onset of the rash, the patient stated that he had felt a burning sensation to the area where the rash eventually developed. According to his parents, the patient was fully vaccinated, including the varicella vaccine, and had never contracted chicken pox. They denied any sick contacts at home. The patient had no other known risk factors such as trauma, family history of HZ, autoimmune diseases, or other malignancies that would have predisposed him to HZ. All reviews of systems were negative.
Physical examination was remarkable for grouped vesicles noted on the left anterior chest and healing vesicles with eschars noted on the left upper back (). The rash appeared along the sixth thoracic dermatome. The rash was painful, blanched with palpation, and was without induration or discharge. Vital signs and the remainder of the physical examination were unremarkable. Diagnosis of HZ was clinical, given the classic unilateral dermatomal distribution and vesicular appearance of the rash. The patient remained stable during his emergency department (ED) visit and was discharged home with a prescription for acyclovir and acetaminophen for anticipated neuropathic pain, generally associated with HZ. Patient was advised to follow up with his pediatrician in one week.
The patient’s mother was contacted approximately three weeks after his ED visit using a Spanish-speaking phone translator. The mother informed the author that the rash had lasted approximately eight days and the lesions were completely healed the following week. She reported that he no longer had any pain at the site of the rash. Of note, his younger sister, who was 10 months old, developed a rash all over her body, including back, buttocks, and legs, and was diagnosed with varicella.

[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 35-year-old, 70 kg, 180 cm, male patient with traumatic cervical spine injury was admitted to our intensive care unit with chief complaints of labored breathing and partial loss of power in all four limbs. After securing the airway with a tracheal tube, central venous cannulation was attempted using 7 F20 cm triple lumen catheter (Certofix, Braun, Germany). Under strict aseptic precautions landmarks were identified and right SCV was located infraclavicular at medial 2/3 and lateral 1/3 of the clavicle using introducer needle in single attempt. After confirming good backflow of the blood, guide wire (50 cm with j-tip), was introduced up to 15 cm mark without any resistance. After that tissue dilator was threaded over the guide wire followed by railroad of triple lumen catheter (up to 13 cm) over it, although the line was inserted in single pass but resistance was encountered during removal of guide wire. Gentle traction was applied several times to remove it but all in vain. Bed side chest roentgenogram revealed the guidewire going through right SCV towards SVC but after its entry it took sharp turn and entered IJV on the same side []. With bed side X-ray as a control we tried to remove the guide wire, pushing it caused the assembly to move inside the right atrium (arrhythmia elicitation) but attempts at removal resulted in decoiling at the site of insertion. This prevented the applied force from being transmitted to the stuck component. Further attempts at removal of the guidewire were deferred and patient was shifted to intervention radiology suite. The attempts at removal of guidewire by passing a tissue dilator to straighten the kinked portion were not met with success, so through percutaneous right transfemoral venous route a vascular snare was used to pull the guide wire out of IJV []. It was followed by successful railroad of long and large

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


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

[User]
RADIOLOGY NOTE:
A 27-year-old male presented with a 1-day history of intermittent gross painless hematuria. His past medical history included herniated lumbosacral disk with radiculopathy, otherwise unremarkable. Social history included current smoking, 6 pack/year, and occasional EtOH. The patient was single and had no children; family history was negative for genitourinary malignancies. Physical examination was unremarkable with BMI 23 and BP 120/86 and no prescribed medicines or drug use. Laboratory tests showed normal CBC, normal coagulation profile, and normal renal function.
Axial, contrast-enhanced CT demonstrated a centrally located, 4 x 4 x 4.6 cm, lobulated mass invading the renal vein and extending into the lumen of the infrahepatic inferior vena cava (). CT angiography of the chest showed no evidence of detectable pulmonary emboli and bone scan was negative for metastases.
Right radical nephrectomy, partial adrenalectomy, inferior vena cava tumor thrombectomy (infrahepatic), and extended retroperitoneal lymphadenectomy were performed; flexible cystoscopy performed during this surgery showed a bulbar urethral stricture (not clinically significant) and otherwise normal bladder. The intravascular tumor pedicle was easily removed intact from the vein lumen by pulling.
Gross examination of the nephrectomy specimen demonstrated a centrally located tumor with no gross invasion of adjacent tissue but with the pedicle extending into the inferior vena cava (). Grossly, the tumor pedicle had a smooth surface and no attachment to the renal vein. Grossly, the mass was partially cystic with variably sized cysts with a smooth lining. The intervening stroma formed grossly discernible nodules of variable thickness. No tumor necrosis was grossly apparent. The lesion appeared to be well demarcated with no invasion of adjacent kidney parenchyma.
Microscopically, the tumor was well demarcated with an elongated pedicle bulging into the renal pelvis and renal vein and a biphasic morphology wi

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


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

[User]
RADIOLOGY NOTE:
The first patient is a 61-years-old woman with a history of migraine headaches, depression treated with paroxetine, memory loss, and paresthesia in her hands and feet for several years. This patient is an active patient at our center and continues to follow up with the neurologist at the age of 61 years. The patient's data were reviewed for the past 19 years when she was first diagnosed with MS (). The clinical data included over 30 encounters, office visits, pharmacy notes, and radiology reports among others. She was first referred to a neurologist at the age of 43 years with the complaint of sudden onset of pain in the right shoulder while lifting heavy weight at work. Her past medical history was positive for depression treated with paroxetine, intermittent blurred vision, slurred speech, and occasional episodes of imbalance. The family history included a stroke in her father at 40 years and a brother who died from a stroke at an unknown age. A living brother and son endorsed migraine headaches. Cervical spine imaging demonstrated a C1 dorsal signal abnormality contiguous with the medulla. Degenerative changes were noticed in the cervical spine at C5-6 and C6-7 with spurring and some left foraminal stenosis. Electromyography (EMG) was performed that showed subtle findings of denervation of right-hand muscles. An initial diagnosis of cervical myeloradiculopathy was considered secondary to her shoulder injury, and she was prescribed pain medication for symptom relief. Her symptoms continued to deteriorate with increasing pain in both arms and finger paresthesia. An MRI of the brain demonstrated confluent T2 hyperintensities in the temporal lobe, lenticulostriate nucleus, thalamus, and the brainstem for possible MS. A lumbar puncture was completed in an outside facility, reportedly unremarkable, though the results were unavailable for confirmation. She completed a 2-weeks course of oral prednisone and was started on glatiramer acetate for a presumed diagnosis of MS.

[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 A was a 73-year-old white male who was diagnosed with RCC in 2000 and subsequently underwent a left radical nephrectomy. He went on to have multiple locoregional recurrences in the nephrectomy bed and in the lower pole of the right kidney. By January of 2007, he had involvement of the pancreatic tail and the left adrenal gland as well. He was evaluated at our medical center in March of 2007. He was restaged at that point and it was confirmed that he had no disease outside of the abdomen, so he was offered radical resection of his disease with curative intent by surgical oncology, but the patient declined. Therefore, he was started on sunitinib 50 mg daily for 4 weeks of a 6 week cycle, and an MRI in July 2007 showed decrease in the size of the tumor in the left renal bed and the pancreatic mass and right renal pole mass remained stable. Imaging after 24 weeks of sunitinib showed stable disease in known sites. His disease remained stable until imaging performed in April of 2008, after 36 weeks of treatment, showed clear enlargement of the renal fossa mass. The patient was then started on temsirolimus 25 mg IV weekly for second-line therapy. The patient had thrombocytopenia, worsening of lipid profile, and elevated blood glucose levels on temsirolimus that required a 20% dose reduction. After 12 weeks, CT scan showed pneumonitis consistent with mTOR inhibitor induced pneumonitis, a possible new lung metastasis, and progression of disease in the liver and renal fossa. Single agent bevacizumab 10 mg/m2 given every 2 weeks was started for third-line therapy and restaging every 3 months showed continued stable disease. The patient enjoyed 12 months of stable disease on single agent bevacizumab. It was stopped despite stable disease due to development of osteonecrosis of the jaw and patient request. The patient subsequently progressed rapidly and expired while off therapy.

[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 white, 23-year-old female, with no history of coagulation disorders or other diseases, was referred to our hospital with a history of neck pain that commenced 1 year ago, and about 6 months ago evolved with a loss of power and multiple falling episodes.
The general physical examination was normal. In the neurological examination, the patient was completely lucid, tetraparetic, 4/5 on the right and 3/5 on the left and hyperreflexia in the 4 members.
Magnetic resonance imaging (MRI) demonstrated the existence of a large lesion, suggestive of ependymoma, which extended from the floor of the fourth ventricle, emerged from the foramen of Magendie and descended to the C2 level []. No other alteration was observed in the complementary preoperative examinations.
The patient was submitted to median suboccipital craniotomy and C1 laminectomy in the park bench position with the left side down []. The procedure was performed with continual electrophysiological monitoring, which showed no evidence of abnormalities over the whole surgery. During resection of the lesion, adhering to the floor of the fourth ventricle, near the vagal trigone, the patient presented great pressure lability, with rapid pressure elevation, blood pressure 230/120 mmHg. After intensive anesthetic management, the lability was corrected and the tumor completely removed without other complications.
As a routine in our department, in the immediate postoperative period, we tried to wake up the patient and extubate. However, the patient did not have a level of consciousness sufficient to tolerate extubation, and was maintained under mechanical ventilation. Therefore a brain computed tomography (CT) was carried out immediately after surgery [], which showed multiple supratentorial hemorrhages. The patient evolved with good neurological response, opening her eyes when called and obeying commands. Considering the progressive clinical recovery, the absence of lesions of significant mass and the presence of multip

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


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

[User]
RADIOLOGY NOTE:
We present the case of a 68-year-old male with a background of psoriatic arthritis for which he was medicated with regular leflunomide and intermittent courses of steroids for symptomatic flares. He had also taken alendronic acid for 10 years before it being discontinued 6 months before his fracture, as his dual-energy X-ray absorptiometry scan confirmed normal bone density.
Following a fall from standing height, the patient had initially been asymptomatic but gradually developed pain in the right hip on weight-bearing over the subsequent 2 weeks, leading to his delayed presentation. On assessment, he had pain over the lateral aspect of his right hip in the subtrochanteric region, with radiographs demonstrating an impending fracture (). At this stage, the patient was advised that a prophylactic nail was indicated but declined surgical intervention at that stage to travel abroad on business matters.
While abroad, the patient suffered another fall which completed the subtrochanteric fracture and was treated locally with a dynamic condylar screw (DCS) (). On his return to the UK at 2 weeks from the index procedure, it was apparent that the metalwork had failed, albeit with no clinical sign of infection. Revision fixation was undertaken 2 weeks later with the DCS being exchanged for a 95° blade plate (). All microbiology cultures sent at the first revision surgery were negative, including for tuberculosis and fungi.
One month following revision, the patient presented with wound erythema and discharge. Radiographs were unremarkable but an ultrasound scan demonstrated a large collection along the length of the plate (). This was washed out and antibiotics were commenced, however, samples from this surgery grew no organisms. A second washout a month later for a similar presentation grew Staphylococcus epidermidis on enrichment culture only. Despite 3 months of antibiotics, the patient suffered ongoing issues with his wound and a third washout was performed which grew Staph

[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 76-year-old man with a past medical history of coronary artery disease, hypertension, and severe septal hypertrophy suspicious for hypertrophic cardiomyopathy, presented to the hospital with progressive symptoms of heart failure. He had been suffering from worsening dyspnea and lower extremity edema for several months. Lab work over the preceding months had shown deranged liver function tests, concerning for right heart failure. He was admitted for intravenous diuretic and inotrope therapy. At his cardiology clinic appointment prior to this hospital admission, an ECG showed typical atrial flutter and diffuse low voltage []. A right heart catheterization showed moderately elevated right greater than left filling pressures with a right atrial pressure 18 mmHg, pulmonary capillary wedge pressure 21 mmHg and a Fick cardiac index 1.6 liters/min/m2. The ScvO2 was 48%.
Of note, a year prior to this admission, a transthoracic echocardiogram (TEE) had shown severe asymmetric septal hypertrophy (2.6 cm), suspicious for hypertrophic cardiomyopathy, but had not been further evaluated. A repeat TEE at the present admission showed a left ventricular ejection fraction (LVEF) of 35% as well as the aforementioned septal hypertrophy []. However, due to the significant low voltage on ECG, despite the significant LVH on echocardiogram and history of hypertension, a cardiac MRI was ordered to rule out infiltrative cardiomyopathy as opposed to hypertrophic cardiomyopathy.
The images showed normal left ventricular chamber size with severe, asymmetric left ventricular hypertrophy, primarily involving the septal wall with a maximum septal thickness of 27 mm []. The LVEF was measured at 40%. Also noted was diffuse, global late gadolinium enhancement of the left ventricular myocardium, consistent with a diagnosis of cardiac amyloidosis []. The only extracardiac clinical finding suggestive of systemic amyloidosis was carpal tunnel syndrome. Serum and urine electrophoresis did not detect a mo

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


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

[User]
RADIOLOGY NOTE:
We saw this 34-year-old Indian lady in late February 2017. She had been in her usual state of health till 20 years of age when she had an episode of facial weakness (? side) which resolved over 1 ½ months. She was then asymptomatic, got married and she went to the USA at the age of 25. For the next 7 years, she did not have any symptoms. 3 years before presentation (in March 2014), she had a transient episode of slurring of speech, which resolved in less than 24 hours. In September 2015, she developed bilateral lower limb swelling and erythema with a maculopapular rash which resolved in a few days. In November 2015, when she visited India, she had tingling and numbness of both lower limbs, bilateral painful swollen legs, maculopapular rash below knees (treated by a local practitioner with oral corticosteroids). Rash and swelling resolved in 2 days but paresthesias persisted. She was continued on oral steroids for the next few weeks before she left back to USA and steroids were stopped.
In March 2016, she developed high grade fever of 104°F, accompanied with right lower limb weakness and worsening of lower limb paresthesias. She was admitted and evaluated in a teaching hospital overseas. The following data were extracted from the documents from the treating hospital. Clinically she was alert, oriented and her speech, language and cranial nerves were normal. She had right foot drop with bilateral ankle hyporeflexia with normal upper limb and knee reflexes. At this point of time she was investigated extensively. MRI of the brain was done which showed multifocal lesions in both supratentorial and infratentorial compartments; predominantly in deep and subcortical white matter. These lesions were predominantly hyperintense on T2 and FLAIR images; some of the lesions contained foci of hypointensities on susceptibility-weighted images suggesting hemorrhages and some had a peripheral rim of diffusion restriction. Minimal perilesional edema was seen [].

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


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

[User]
RADIOLOGY NOTE:
A 9 years old, previously healthy boy presented with sudden onset of colicky abdominal pain of 4 h duration. The pain was mainly infra-umbilical. Associated with this he had gross abdominal distension and 2 episodes of non-bilious vomiting. Parents reported that the child had bowel movements daily before he joined school since when bowel movement became every 2–3 days. The parents do not remember when the child passed the first meconium. The child had had similar attack a month before presentation to our hospital and rectal tube deflation was done at a nearby hospital. Otherwise there was no other complaints. His growth and development is similar compared to his peers. He was not on any medications. There was no family history of similar illnesses.
On physical examination except for tachycardia other vital signs were all in normal range. All anthropometric measurements were in normal range. He was in pain while holding his abdomen. He had gross abdominal distension. There was no direct or rebound tenderness. Abdomen was hyper tympanic to percussion. Bowel sounds were increased. There was no organomegally or palpable masses on deep palpation. Per-rectum examination showed empty rectum. No stool or blood on examining finger. A Plain abdominal radiographs showed single hugely dilated bowel loops in the left lower quadrant with single air fluid level (Fig. ). Abdominal ultrasound was unremarkable except for gas filled abdomen. Complete blood count and organ function test was done and all were in normal range.
We put the patient in knee-chest position and gently introduced fully lubricated rectal tube into the rectum and slowed advanced upward. Gush of air and scanty stool came out. The abdomen became soft and the cramp subsided. We left the tube in the rectum for 24 h. We took full thickness rectal biopsy the next day. It showed aganglionated rectum with absent ganglion cell in both submucosal and muscles layers. We also obtained diagnostic barium enema and it showed re

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


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

[User]
RADIOLOGY NOTE:
A 16-year old female presented to the orthopedics outpatient department with complain of inability to squat, sit cross-legged and painless awkward gait for about last six years. Detailed birth history could only reveal that she was delivered through normal vaginal route at home and cried immediately after birth. She was normal at birth but when she started walking at the age of 15 months, there was a waddle. She had difficulty in walking and running since early childhood because of the need to abduct and externally rotate the limb in every step. The patient could not sit comfortably except in a high chair position. No history of repeated intramuscular injections in the buttocks was forthcoming. There was no history or signs suggestive of post-polio residual paralysis.
On examination she had an abnormal gait with lower limb kept in the attitude of external rotation and abduction while taking each step. Inspection showed a depressed groove over the skin of the buttock running along the course of the gluteus maximus muscle bilaterally, and no skin puckering was observed There was a typical restriction of movement, so that both hips could not be flexed or extended in the usual saggital plane (between 30° to 90°) with the hip in neutral position, adduction was limited and squatting was possible in typical frog leg position (). In 0-30° both hips could be flexed in saggital plane but while attempting more flexion there was external rotation and abduction. On flexion of the hip the knee was going to the ipsilateral axilla. However the hip joint could be flexed to 110° in wide abduction (Video 1). Hip rotations were full and free. According to GMC (Gluteal muscle contracture) classification [] the patient belonged to severe/level III type. Radiographic findings were within normal limit no iliac hyperdense line was seen and fibrosis of postero-inferior fibers of gluteal maximus was seen in MRI.

[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 11-year-old African female patient presented to paediatric surgery department with a 4 months' history of lump on the left side of the neck. She gave a history of a painless and slow-growing lump on the left side of the neck that was treated with antibiotics by several general practitioners with no improvement. She did not have any comorbidities; however, her mother has a thyroidectomy for nodular goiter. She appeared chronically ill without pallor, jaundice, or proptosis. Her vital signs were within normal limits. She had a lateral neck mass that measured 50 mm × 40 mm which was mobile, nontender, and hard with attachment to the skin. Other systemic examinations were unremarkable. Blood investigation was within normal limits including thyroid function tests. A neck ultrasound showed an enlarged left cervical lymph node with a normal blood flow in the right and left thyroid lobes. There was a macrolobulated lesion (TIRADS 5) with increased flow and mass effect to the internal jugular vein (). A lymph node biopsy was done and confirmed a metastatic papillary thyroid carcinoma. A subsequent staging computed tomography (CT) scan showed a distinct focal peripheral mass lesion on the inferior pole of the left thyroid lobe with calcifications, mass effect on the left internal jugular vein (), and bilateral upper lung lobe nodules. An uneventful total thyroidectomy with a modified neck dissection was done and sent for histopathological assessment.
Gross pathology showed a thyroid tumour that measured 55 × 35 × 10 mm and matted lymph nodes. The tumour was unencapsulated, hemorrhagic, and firm without necrosis.
Microscopic examination confirmed papillary variant of PTC evidenced by tumour arranged in papillae, nests, and follicles (Figures and ). These structures were lined by follicular cells with nuclei exhibiting grooves, clearing, pseudoinclusions, overlapping, and crowding. In addition, five lymph nodes that were sampled showed metastatic disease.
An iodine-123 singl

[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 83-year-old woman with advanced frontal lobe dementia, hypertension, and dyslipidemia presented to the emergency department from home due to increased somnolence reported by the patient’s daughter. Given the patient’s general malaise and decreased responsiveness with unknown baseline behavior, the patient was admitted for further evaluation. Her family reported that other than the lack of responsiveness, she was at her baseline level of function. Upon admission, the patient was found to be mostly non-verbal and had a decreased appetite. The daughter, who stayed with the patient at her bedside for the entire duration of the hospitalization, reported that the patient was having a productive cough with increased shortness of breath. On clinical examination, the patient was a thin, elderly woman with muscle wasting of the extremities. She was in a constant lethargic state, non-verbal, arousable to pain, but did not respond to verbal commands. Her vital signs were within normal limits, including oxygen saturation of 95% on room air. Laboratory values revealed hypokalemia and pancytopenia. An incidental 1.6 cm nodular lesion in her thoracic wall and multiple nodules in the thyroid were revealed by chest CT. Saliva specimens were tested for infection and she was found to have a mycoplasma infection. She was treated with antibiotics and inhaled steroid treatment following a pulmonology consultation. Her medical history was otherwise unremarkable. The conclusion by the initial medical team attributed her altered mental status to late-stage dementia.
A second medical team reviewed the case after a Monday 0630 hrs handoff, three days post-admission. Upon clinical evaluation by the new medical team, the patient was noted to have upper respiratory stridor. A closer re-examination of the previously obtained radiographic images, which included a CT of the brain and chest and chest radiographs, revealed what appeared to be a large foreign body in the hypopharynx-upper esophagus

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


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

[User]
RADIOLOGY NOTE:
A 46 year-old female with metastasis of breast cancer at T4-6 was referred to our hospital. Five years before, she had received a mastectomy based on the diagnosis of right breast cancer (T2N1M0 stage IIIB). After surgery she underwent postoperative chemotherapy. Three years after the mastectomy (2 years ago) multiple bone metastases and liver metastasis were detected, and chemotherapy and radiation were performed. Six months ago, a new lesion of liver metastasis and axillary lymph node metastasis were detected and hormone therapy was started. When she was admitted to our hospital, she had multiple liver metastases, multiple bone metastases (rib, lumbar spine, sacrum, and pubis), and axillary lymph node metastasis. Metastasis of T5 had invaded into adjacent vertebrae above and below (T4 and T6) and the spinal cord was severely compressed (). She had upper back pain with paralysis of her bilateral lower limbs. Her Frankel grade was C and she could not stand without supports. TES of T4 to T6 was performed (). The excised en bloc laminae and en bloc vertebral bodies of T4 to T6 were placed into liquid nitrogen for 20 minutes. Then, the frozen laminae and vertebral bodies () were crushed and packed into a titanium cage. The cage was placed between T3 and T7 for spinal anterior reconstruction (). At the end of surgery, a small amount of the tumor tissue from the resected vertebrae (T4 to T6) was also placed into liquid nitrogen for 20 minutes. The frozen tumor tissue was then implanted under the skin of right axilla.
At one month after surgery, the axillary lymph node metastasis decreased in size without any other treatments (). Her muscle strength of the bilateral lower extremities gradually improved after TES. Her Frankel grade became D and she could walk with a cane at follow-up (18 months after TES). The lymph node metastasis was stable at follow-up. Some 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 gentleman was first referred to orthopaedic services with a history of persistent knee pain, located over the right femoral condyle near the origin of the lateral collateral ligament. Eleven years prior to presentation, the patient was involved in a road traffic accident where he sustained a fracture of the right femoral neck and ipsilateral shaft. Initial management consisted of open reduction, fixation of the femoral neck fracture with cannulated screws and the ipsilateral shaft fracture with plating. The patient later had a revision of the plate to a femoral nail. Union was subsequently achieved with the femoral shaft fracture; however, a significant external rotation deformity was noted, and discomfort to the knee.
The patient was referred on to our tertiary referral orthopaedic centre for femoral de-rotation surgery. An initial CT scan performed revealed an external rotation deformity of 45 degrees. The patient procedure included removal of femoral nail, osteotomy with de-rotation surgery, and subsequent exchange nail. The femoral nail was fixed proximally and locked into place distally, following the corrective 45 degrees of internal rotation achieved to the distal femur during osteotomy, performed under intraoperative radiographic guidance. The post-operative rehabilitation regime consisted of initial touch weight bearing only, with gradual increments in weight bearing status. At six months follow-up, the patient complained of distal lateral femur pain. A repeat CT scan was performed, revealing a delayed femoral union. This was initially thought to be the cause of the patient’s symptoms. The patient was admitted for dynamization of the femoral nail with an injection of bone graft substitute, and iliac crest graft. Despite eventual union, the patient continued to complain of pain at the distal lateral femur, with a cracking sensation on movement now noted.
Repeat clinical examination revealed a palpable crepitus over the distal iliotibial band wi

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


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

[User]
RADIOLOGY NOTE:
An 83-year-old man presented with a complaint of chest pain. He had undergone a right pulmonary lower lobectomy for lung cancer 3 years previously, and he was taking several drugs daily to treat hypertension and diabetes. Upon arrival at the emergency room in Ise Red Cross Hospital, the patient had a high fever reaching 39.6°C and hypoxia with saturation of percutaneous oxygen of 89% that necessitated oxygen inhalation. His blood pressure was 140/80 mmHg at the time of presentation but gradually deteriorated thereafter. Computed tomography (CT) showed a ruptured aortic aneurysm located at the proximal descending aorta with extensive mediastinal hematoma (). Laboratory testing revealed an increased peripheral leukocyte count of 11,500 cells/mm3 and an elevated C-reactive protein level of 7.7 mg/dL. A sustained high-grade fever and elevated inflammatory response in his laboratory testing pointed to underlying aortic infection. Because the patient’s condition was too severe to undergo surgical debridement and reconstruction of the diseased aorta, we performed emergency TEVAR to salvage the patient upon arrival. Under general anesthesia, the left common femoral artery, exposed through an inguinal incision, was used as the remote access vessel. Preoperative CT showed that the aneurysm was present as a pseudoaneurysm with a 12 mm orifice and 62 mm maximal diameter. The proximal landing zone, i.e., the distance between the left subclavian artery and the orifice of the pseudoaneurysm, was estimated to be 27 mm, and the diameter of the proximal neck was 30 mm. Initial aortography confirmed the orifice of the aneurysm to be distal to the left subclavian artery, in agreement with the preoperative CT finding. Of the c-TAG (W. L. Gore & Assoc., Flagstaff, AZ, USA), 34×150 mm was carefully advanced over the stiff wire and deployed with the proximal edge of the stent-graft positioned just distal to the left subclavian artery. Consequently, the distal edge of the stent-graft was lo

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


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

[User]
RADIOLOGY NOTE:
Case 1: Ms. K, a 70-year-old woman who immigrated to the US at the age of 53, began complaining of watery eyes, chest pain, lower back and joint pain, leg cramps, and weakness. She harbored delusions of being afflicted with high blood pressure, uterine cancer, blood cancer with bone metastasis, brain cancer with extensive metastasis, and believed that her brain was "shrinking."
She first visited a cardiologist in 2013, complaining of intermittent episodes of chest pain over six months. An electrocardiogram (EKG) at the time showed bradycardia, a first-degree atrioventricular (AV) block and a left bundle branch block. At her sixth visit with the cardiologist, she mentioned non-specific somatic complaints, which she said were because of a "hematological problem." Five months later, she was evaluated for “renal hypertension” and imaging studies showed a renal cyst. While she did not follow up with the nephrologist, she continued to make hospital visits for persistent chest pain. A full medical workup was completed and found to be normal at every ER visit. Medical records from a prior ER visit revealed that she had made claims that the Russian military entered her residence and stole her urine, resulting in the disappearance of her kidneys.
Ms. K was brought to the ER by the police after she showed up with a can of gasoline and matches at her primary doctor's office and threatened to burn it down. She was irate and claimed that all of her doctors, in the US and in her home country, were concealing the fact that she had oncological issues. She vehemently denied any psychiatric illness, stating that these diagnoses appeared on her records as a result of a rumor started by an envious former colleague. She explained that because she had been a former practicing neurologist in her home country, she was confident that she had cancer. Upon repeated

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


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

[User]
RADIOLOGY NOTE:
A 46-year-old man presented with unremitting low back pain and right leg weakness that had persisted for 1 month. He had previously received partial liver transplant under a diagnosis of liver cirrhosis in March 2005 but fever with an unknown origin persisted after the transplant. Suspecting sepsis, the patient was treated with multiple antibiotics, but a fungal colony was found in the left lower lung field during the antibiotics treatment. Aspergillus was confirmed in the sputum culture test. Accordingly, 60 mg of Amphotericin B was injected intravenously for two weeks but with no significant improvement. Consequently, 50 mg of a different antifungal agent, candidas (caspofungin acetate), was injected over a 2-week period, and a lobectomy was performed on the left lower lung. The patient was under immunosuppression (cyclosporine 250 mg orally), which was continued under antifungal treatment after the lobectomy. After the lobectomy, he complained of mild low back pain and consulted our department. Mild tenderness was found over the low back but there was no abnormality on the plain radiograms except for the degenerative changes in the lumbar spine. Low back pain was not significant enough to recommend a MRI, so we just recommended limited activity, non-steroidal anti-inflammatory drugs and close observation. However, the low back pain did not subside, and he again consulted our department. A physical examination revealed severe tenderness and rigidity over the lower lumbar area. Straight leg raising on the right lower extremity was restricted to 50°, and extension of the right great toe and dorsiflexion of right ankle were poor. The sensory performance of his right leg had decreased, a limited range of motion of the right hip was noted, and the Patrick test was positive. A laboratory examination showed an erythrocyte sedimentation rate (ESR) of 100 mm/hour (reference range, 0 to 15 mm/ hour), C-reactive protein (CRP) of 2.14 mg/dL (reference range, 0 to 0.3 mg/dL

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


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

[User]
RADIOLOGY NOTE:
A 58-year-old man was referred to the ER of our hospital in March 2019, having a cerebral vascular accident. His medical history reported high blood pressure and hypercholesterolemia. He had quit smoking in 2018 (40 pack-years).
Despite initiation of anticoagulants, he suffered from recurrent strokes, and in May 2019, a cardiology work-up CT scan revealed a lobular mass located in the left atrium of the heart. The tumour rather resembled a cardiac myxoma than a thrombus and was best visible on a contrast CT scan and ultrasound (Fig. ).
Cardiac surgery was performed, and a mucinous tumour, attached to the wall of the left atrium and left lower pulmonary vein, was removed. The tumour could easily be excised, and frozen sections were not conclusive. The resection was macroscopically complete.
Definitive histology showed a lesion at the transition of the left lower pulmonary vein to the left atrium consisting of a proliferation of mesenchymal cells with moderate cytonuclear atypia and varying cellularity. Part of the lesion protruded into the lumen, and part of the lesion showed an invasive growth pattern. CDK4+ and MDM2+ amplification, as determined by multiplex ligation-dependent probe amplification, was positive, which is characteristic of an intimal sarcoma, a very rare tumour belonging to the class of malignant soft tissue sarcomas. Microscopically, the resection margins contained tumour tissue, so the resection was considered incomplete.
A PET-CT scan for staging did not show any metastases. No adjuvant systemic treatment was given, and the patient remained symptom free until November 2019, when he had another stroke. On the CT scan, a small lesion at the base of the resection area was seen, suspicious for local recurrence (Fig. ). As re-surgery was not an option, after multidisciplinary board discussions, the patient was referred to the radiotherapy department. It was decided to irradiate the tumour with stereotactic MR-guided online adaptive radiation therapy (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 23-year-old Asian man was referred to the ER of Xiamen Chang Gung Memorial Hospital with a 1-day history of right-sided chest pain that had been aggravated for 1 hour. He had no known medical illnesses and was well until the evening prior to presentation, at which time he developed obvious right-sided chest pain radiating to his ipsilateral shoulder with persistent chest tightness. This tightness was described as sticking in nature, significantly worse on deep inspiration and with movement, and relieved by leaning forward or lying down. There was an associated dry cough but no hemoptysis. There was no history of trauma, injury, difficulty in breathing, or palpitations. He was tall and thin and described himself as otherwise quite healthy. He had never previously been admitted to a hospital. He reported no significant chronic medical history, such as primary hypertension, any type of heart disease, disturbed microcirculation, peripheral neuropathy, diabetes mellitus, an impaired immune system, malignancies, leukemia, the long-term administration of corticosteroids, liver cirrhosis, renal failure, urinary tract infection, or hemodialysis. He also reported no history of infection, such as tuberculosis, any type of hepatitis, or acquired immunodeficiency syndrome (AIDS). There was no prior history of traumas, blood transfusions, surgical procedures, or other serious events in his medical history. He had not lived in an epidemic area and had no history of toxin or radioactive exposure. He denied a personal or family history of bleeding diathesis but reported a 10-year history of smoking 8–10 cigarettes per day. He was an office worker by occupation. He had experienced similar symptoms on one occasion 4 years previously. No abnormalities were detected at that time, and his symptoms resolved.
A physical examination (PE) revealed a young man who was awake and alert but in mild to moderate painful distress. His respiratory rate was 22–26 breaths/minute with an oxygen satur

[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 16-year-old boy presented with anterior open bite and infra-occlusion of the maxillary left incisor. His anterior teeth had been injured in a fall when he was 8 years old. He had no dental treatment before attending the orthodontic department. According to the patient, his open bite had developed gradually. His facial profile was straight with a slightly retruded mental region. Facial analysis showed symmetry and a good balance between the facial thirds. The patient did not like to smile as he was ashamed of his teeth (Figure ). He also had a compensatory tongue thrust habit caused by the anterior open bite.An intraoral examination (Figure ) showed that the patient had a severe anterior open bite extending from the left maxillary canine to the right lateral incisor. The molar relationship was Class I, and there was a small space between the maxillary right lateral incisor and the canine. The maxillary midline had shifted to the left. The maxillary left central incisor was severely infra-occluded and the adjacent teeth were inclined. The crown of the maxillary right central incisor had been fractured, and the endodontist found that the pulp of the right central incisor was necrosed, although the other incisors were vital.
A panoramic radiograph showed that the maxillary left central incisor was infra-occluded and the alveolar process in this region was deficient in vertical development. Cephalometric analysis showed a normal skeletal relationship with an ANB angle of 3.7° and a high mandibular plane angle of 39.11°. The maxillary and mandibular incisors were protruded: U1 to PP, 127.90°; and IMPA, 99.62°. The overbite was -8.87 mm (Figure , Table ).
This case was diagnosed as a skeletal Class I malocclusion with severe open bite and high mandibular plane angle. The maxillary left central incisor was diagnosed as potentially ankylosed because of the trauma history, infra-occlusion, inadequate alveolar bone in the maxillary anterior

[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 male with a 4-month history of sexual dysfunction was referred to the endocrinological department. His past medical history was negative and he was not taking any medication. Psychogenic impotence was ruled out by a psychiatric examination. He had a serum prolactin (PRL) value of 240 ng/ml. Laboratory examinations, including other pituitary hormones, did not reveal other abnormalities. Magnetic resonance imaging (MRI) showed a space-occupying mass within the SS, which partially enhanced by gadolinium. MRI did not reveal any sellar floor defect and an empty sella was detected [Figures and ]. These findings suggested the presence of an ectopic prolactinoma within the SS. The patient was put on bromocriptine at a dose of 1.25 mg once a day for 1 week, which was then increased to 1.25 mg twice a day for 2 months. However, he continued to present sexual dysfunction and his serum PRL level did not decrease sufficiently. Thus, bromocriptine was changed to cabergoline administered at a dose of 0.25 mg twice a week and then it was increased gradually until reaching a dose of 1.5 mg three times a week. Three months later, the patient still had sexual dysfunction and his serum PRL value was 195 ng/ml. Thereupon, he was referred to the neurosurgical department. Surgical treatment was proposed because of three reasons. First, dopamine agonist treatment administered thus far had failed in lowering the serum PRL level. Second, clinical manifestations due to hyperprolactinemia persisted in spite of medical treatment; and third, he told the physicians that he wanted to get his wife pregnant, as they had been planning for a long time. So, he underwent surgical treatment. A transsphenoidal approach without opening the sellar floor was performed using an operating microscope and the lesion within the SS was completely removed. An intact sellar floor was confirmed during surgery. The postoperative course was uneventful. Histological examination including immunohistochemica

[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 7-year-old male patient who presented at the Neurology service for a headache in his right temporal region that had evolved during one week, of intermittent nature, mild to moderate intensity, each episode between 3-4 seconds; and with subsequent, complete recovery. No history of trauma; he denies presenting fever or other systemic manifestations. There was no distal coldness, crying, or pallor, no feeling of dizziness, nausea, emesis, photophobia, phonophobia, or autonomic symptoms, no relationship with valsalva, or associated with exercise. Neither the patient nor his parents identified any triggering factors.
The patient reports four episodes of PSH in the week prior to the consultation, without interfering with his sleep hours. There is no history of other neurological symptoms, epileptic seizures or changes in personality. The interrogation did not recognize alterations in neurodevelopment, he presents a good school performance and an adequate sleep pattern. No personal background of relevance. No headaches or other related pathologies are reported in the family history.
On physical examination, he presented normal vital signs, a weight of 22 kg and 1.22 m of height. In the neurological examination, neither alterations nor skin stigmas indicative of neuro-cutaneous syndromes were identified.
The intervention was started with a one-month observation period, in which the child's caregiver was asked to prepare a headache diary that would allow characterizing and quantifying the episodes (date and time, laterality, associated activity, duration and need for medication).
The following month, he was cited for a control, where 21 episodes were quantified with the clinical characteristics described above but without a predominant laterality; no triggering or attenuating factors were identified. A simple and contrasted cerebral magnetic resonance imaging was performed, which showed no alterations of any kind. Based on the characteristics of the episodes, the clinical

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


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

[User]
RADIOLOGY NOTE:
An 88-year-old female presented to the emergency department with abdominal pain and vomiting. She was mildly tender in her right upper quadrant but was focally more tender in her right lower quadrant. Her blood results showed an elevated white cell count of 12.9 × 109 l–1 and a neutrophil count of 10.4 × 109 l–1. Furthermore her C-reactive protein level was 34 mg/L. An abdominal ultrasound showed multiple calculi within the gallbladder. Gallbladder wall thickness was not assessed. A non-contrast CT scan, due to the patients impaired renal function, was then ordered as the patient’s physical exam findings were not in keeping with a diagnosis of cholecystitis.
The CT showed abnormal dilatation of the proximal small bowel with a possible transition point in the left iliac fossa. Pneumobilia was also noted due to prominence of the hepatic biliary tree (). No evidence of a ductal calculus was observed. The CT scan was reported as showing features of a bowel obstruction with a transition point in the left iliac fossa. The pneumobilia was reported as being possibly an indicator of previous sphincterotomy. There was no evidence of appendicitis or another inflammatory process in the right iliac fossa.
The following day, while proceeding with conservative management, the treating team requested a small bowel follow through to investigate the obstruction. After further review and discussion with the treating team it was revealed that there was no history of an endoscopic retrograde cholangio-pancreatography or cholecystectomy. An addendum was added to the CT report, suggesting that the appearances were indicative of a gallstone ileus from a choledochoduodenal fistula () with a non-calcified gallstone possibly being present at the transition point in the left iliac fossa ().
The patient underwent a laparotomy and a gallstone was found obstructing the distal jejunum. A 41 mm gallstone was removed by vertical enterotomy, later confirmed on histological diagnosis. The patient had

[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:
62 year old female was diagnosed seropositive RA in 1987. At this time, radiological erosive joint damage was already present. Therapy with oral and later parenteral gold was provided for more than five years with very little clinical benefit. Following this, the patient was successfully treated with methotrexate for four years. MTX had to be terminated in 1999 due to MTX pneumonitis and leflunomide was started. Because of high disease activity and radiological progress (also with involvement of the atlantodental joint) treatment with etanercept was initiated in February 2000 with initially good response. At the end of 2001 an increase in RA activity could be observed and rituximab was applied within the framework of a local pilot study in the use of rituximab for RA February 2002. Altogether 4 infusions of rituximab were administered at weekly intervals in dosages of 375 mg/m2 under premedication with paracetamol (1000 mg) and clemastin (1 mg) without significant acute side effects. The preceding antirheumatic therapy with etanercept 25 mg twice weekly, leflunomide 20 mg and prednisolone 2.5 mg daily was continued. After rituximab therapy a measurable decrease of disease activity (decline of DAS28 from 5.7 to 4.4 after three months) was observed lasting up to 2007 with a DAS28 < 3 (Table ). In addition the radiological assessment showed no progression between 2002 and 2006. 25 months after rituximab therapy and 13 months after completed B-cell regeneration, pneumonia was diagnosed and treated successfully with antibiotics. In november 2004 (34 months after rituximab), october 2005 (45 months after rituximab) and january 2006 (48 months after rituximab), acute bronchitides as infective exacerbations of the patients known chronic bronchitis occurred and were successfully treated. No opportunistic infection occurred at all. The patient was retreated with rituximab in 2008 due to increasing disease activity with radiological progress compared to 2006. Etanercept was st

[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 previously healthy 8-year-old male with reported history of fever for 2 days prior to hospitalization. He was admitted after recurrent generalized tonic–clonic seizures progressed over the course of hours to refractory status epilepticus. On the suspicion that he was having viral encephalitis, a lumbar puncture was performed on the day of admission, which showed slightly elevated cerebrospinal fluid protein of 48.3 mg/dL (normal 15-45 mg/dL) without pleocytosis. A meningoencephalitis panel was positive only for recent or current infection with influenza A/B by antibody enzyme immunoassay. Other routine laboratory testing on admission was normal other than elevations in aspartate transaminase of 406 IU/L (normal 10-40 IU/L) and alanine transaminase of 324 IU/L (normal 7-56 IU/L). The patient was intubated at the time of admission, and pentobarbital and midazolam drips were used to induce electroencephalography suppression, leading to hypotension requiring pressor support. A brain magnetic resonance imaging (MRI) done at this stage of his illness was read as normal, other than gadolinium enhancement of the meninges, consistent with meningoencephalitis. Despite being on high doses of several antiepileptic drugs, his status epilepticus remained refractory to medical treatment. His hemodynamic instability progressively worsened to the point of cardiovascular collapse, and he was placed on extracorporeal membrane oxygenation. He was being treated with broad-spectrum antibiotics for intermittent fevers, a positive sputum culture for Pseudomonas, and a posterior scalp ulceration, and there was clinical suspicion for sepsis. When the patient developed dilated pupils and hypertension, computed tomography (CT) and MRI scans of the head were performed, and extensive bilateral brain lesions were seen. Given the refractory nature of his seizures and the severity of his brain damage, the family and medical care team agreed on a decision to withdraw care. The pati

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


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

[User]
RADIOLOGY NOTE:
A 30-year-old female with a medical history of hypertension and smoking sustained a left mandibular angle fracture after a fall from a ladder. The patient underwent open reduction and internal fixation of her left mandibular angle through an intraoral approach without complications. The patient developed an infection at the site of the hardware and nonunion of the fracture site as a result of noncompliance—lack of smoking cessation and poor oral hygiene—with postoperative instructions. For treatment of the nonunion and infection, the patient returned to the operating room (OR) approximately 1 month after the initial surgery for debridement and removal and replacement of the hardware. Two months from the time of injury, the patient sustained a fist-to-face assault and developed an abscess at the site of the hardware. Incision and drainage of the abscess were performed at an outside hospital. However, the patient developed an extraoral fistula at the site of the infected hardware. She was scheduled for an elective fistulectomy, debridement of the previous fracture site, and removal and replacement of hardware 4 months from the time of her initial injury.
In the OR, all standard American Society of Anesthesiologists monitors were placed. The patient underwent preoxygenation for 8 minutes prior to intubation, and induction of general anesthesia was facilitated with 80 mg lidocaine, 160 mg propofol, 150 mcg fentanyl, 120 mg succinylcholine, and 10 mg rocuronium. Nasoendotracheal intubation was performed with a 7.5 mm nasal right angle endotracheal (RAE) tube, and a MacIntosh 3.5 laryngoscope was placed with direct laryngoscopy; however, 2 minutes after intubation during confirmation of tube placement, the patient was found to have a leak related to cuff rupture. An Eschmann-guided exchange was performed with a 7.0 mm nasal RAE tube and a McGrath video laryngoscope because a Cook airway exchange catheter was not available. Placement was confirmed with bilateral breath sou

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


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

[User]
RADIOLOGY NOTE:
A 55-year-old healthy Caucasian female with no history of ocular disease was observed in the emergency department with fever, myalgia, nasal congestion with 3 days of evolution, and a generalized rash for 1 day. She had contact with dogs. Physical examination revealed a cooperating and well-oriented patient with stable vital parameters and a tympanic temperature of 38.2°C. There was a maculopapular rash on the upper limbs, abdomen, and the dorsal region. A tache noir, a small crust surrounded by a violet halo, was visible in the region of the left thigh. There were no meningeal signs and no cardiorespiratory or abdominal changes. Serology for R. conorii was positive with an IgM titer of 1/320. Autoimmune and thrombophilia studies were negative. Hypercholesterolemia and systemic hypertension were excluded. The patient was admitted to our department and therapy with oral doxycycline 100 mg every 12 h was initiated. Oral doxycycline was given for 10 days.
On the first day of hospitalization, the patient reported decreased visual acuity (VA) of the right eye (RE). A CT scan was performed which was normal. No ophthalmologic examination was requested.
There was a systemic improvement and the patient was discharged after 6 days. Five days thereafter, the patient returned to the emergency room with complaints of worsening of RE VA. Observation revealed an RE VA of 20/100 and there was a superior temporal artery branch occlusion with perivascular sheathing in the ocular fundus as well as cotton wool spots and edema (fig. ). The retinal edema affected the macular region (fig. ). Campimetric examination revealed an inferior nasal scotoma, consistent with fundus lesions (fig. ).
Intravitreal injection of triamcinolone acetonide 3.2 mg/0.08 ml was given only once and showed significant improvement of the retinal edema and a recovery of RE VA to 20/25 after 1 month. The vascular sheathing and the occlusion persisted (fig. ), and

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


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

[User]
RADIOLOGY NOTE:
A 15-year-old male without any symptoms was referred to our hospital because he was noted as having an abnormal shadow on chest X-ray at a health checkup. No abnormal findings were observed on his hematological and biochemical examinations. On chest computed tomography (CT), a 40 × 33-mm wide tumor shadow with clear boundaries in the right pulmonary hilar area was found. The tumor was strongly enhanced in the early phase. Abnormal findings were not found in the lung field and mediastinum (Fig. a–c). Bronchoscopic examination was performed under topical anesthesia. The lateral segment of the lower lobe of the right bronchus was narrowed by compression of the tumor although the endobronchial mucosa was intact. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) was performed but no specific findings were obtained from the cytological and histological evaluation. However, the patient was admitted to our department for surgery because 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) showed abnormal accumulation in only the tumor; SUV (standard uptake value) max was 4.4 (Fig. d), which suggested potential malignancy. Due to the possibility of a malignant tumor, right middle and lower lobectomy was necessary due to its localization, and depending on the intraoperative findings, it was also necessary to perform right pneumonectomy. We informed the patient and his mother of this before surgery and obtained their consent. However, from the imaging morphology of the tumor and lack of evidence of malignancy in EBUS-TBNA, we also kept in mind before surgery the possibility of benign tumors including Castleman’s disease. We decided to make a final decision on the procedure based on the findings of the intraoperative macroscopic findings and the intraoperative frozen section diagnosis.
On operative findings, the tumor existed between the middle and lower lobes of the right lung with no pleural involvement. The interlobar pulmonary artery 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 58-year-old male patient reported to the college with a chief complaint of swelling and pain in gums in the right upper back tooth region for the past 1 month. Lesion initially started as a small swelling and gradually increased to the present size. Medical history was positive for epistaxis a month back and blood on coughing for 1 month. The patient also gave a history of extraction 2 months in that region after he noticed a loosening of his teeth, which was uneventful. Family history was noncontributory. Extraoral examination revealed mild swelling in the middle-third of the face on the right side [].
Intraorally, single large, noduloproliferative growth was seen on the right maxillary ridge, extending from the right second premolar region to maxillary tuberosity area and also up to mid-palate region not crossing the midline []. It was tender on palpation. There was presence of soft-tissue mass protruding from the extraction socket behind 14. The overlying mucosa was reddish pink. The swelling was sessile with ill-defined borders, reddish pink in color and was firm in consistency. Regional lymph nodes were not palpable.
Based on the history and clinical findings, a provisional diagnosis of nasopharyngeal carcinoma of maxillary antrum with a differential diagnosis carcinoma of maxillary antrum was made.
A series of radiological and routine hematological investigations were performed. Radiological investigation included orthopantomography and paranasal sinus view. The orthopantomograph revealed loss of maxillary antral bone with ragged borders on the right side. The bone loss is evident up till the floor of the right orbit. There was presence of soft-tissue shadow over the alveolar ridge with complete destruction of the alveolar bone on the right side. Coronoid and condylar processes were normal []. Para nasal sinuses view showed destruction of the superior, lateral, and facial wall of the right maxillary antrum, expansion of the malar bone on the right side later

[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 was admitted to our university hospital for polymenorrhea, weight gain and pain in the left iliac region. Before admission, a Pap smear and a diagnostic hysteroscopy were carried out; the former tested negative, while the latter showed simple endometrial hyperplasia. During the physical examination, the patient was in a good condition and without weight loss. An abdominal examination revealed a flat and painless abdomen, and no palpable mass was found. During the gynecological visit, the uterus was larger in size, while the right ovary and fallopian tube were within expected limits. On the left side, an orange-shaped mass was observed; it had irregular layers, was fixed and painless. An abdominal ultrasound revealed a hypoechoic, inhomogeneous, 9.5 × 5.2-cm mass on the left side of the pelvis and behind the ovary. Computed tomography (CT) was not performed due to the patient's allergy to the contact medium. An atypical ultrasound appearance addressed the probable malignancy of the mass.
The patient underwent surgery. After opening the abdominal cavity, a free-fluid sample was taken, and the cytological result tested positive for malignant cells. The pelvic mass was firmly anchored to the small intestine, colon, sigma and uterine body (fig. ). After removing the adhesions, double ureters were observed, which had been incorporated in the mass. The resection of the unilateral double ureters was necessary in order to remove the entire mass, after which the left ovary and tube were removed.
A histological examination showed a malignant retroperitoneal mass with clear nuclear polymorphism, whereas the right ovary and tube were unaffected. Anti-reflux termino-terminal ureteral anastomosis with two double-J stents was carried out (fig. ). Total hysterectomy with preservation of the right adenexum and regional lymphadenectomy was performed. The postoperative recovery was uneventful, and after 7 days, the patient was discharged. The final histological resu

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


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

[User]
RADIOLOGY NOTE:
A 68-year-old female with a long history of intermittent back pain had a relatively acute onset of severe low back pain radiating down the posterior left buttocks and left leg for three weeks. She denied any trauma or other possible inciting factors. The pain had been getting progressively worse, and she also had developed numbness in the left S1 and S2 dermatomal distributions. An epidural steroid injection performed at a local facility provided partial relief and lasted for approximately 24 hours. The pain was described as intense, electrical pain different from any pain she had ever felt in terms of distribution and severity. Due to the exacerbating factors including standing and walking, thus, she presented to clinic in a wheelchair and preferred to lay in the fetal position. She had presented to the emergency department two days prior to neurosurgery consultation due to continued worsening of pain and numbness.
A thorough neurological examination was negative except for a positive straight leg raise on the left.
Lumbar spine X-ray did not reveal any abnormal alignment or transitional anatomy (). Lumbar spine MRI (Figures and ) revealed a cystic mass with similar intensity to cerebrospinal fluid (T2 hyperintense/T1 hypointense) located on the dorsolateral left side of the sacral spinal canal inferior to the left S1 pedicle. It was causing significant compression on the exiting S1 and traversing S2 nerve roots. Sacral arachnoid or Tarlov cyst, cystic schwannoma, and synovial cyst were all included in the differential. She was referred to neurosurgery for urgent evaluation of her severe pain in the setting of an intraspinal sacral mass. After obtaining a clinical history from the patient and further reviewing of the MRI, the imaging diagnosis was questioned. A synovial (or juxtafacet) cyst was thought possible even though it was not in close proximity to the facet joint and was located in the sacral spinal canal. Further, the cyst contents were slightly heterogene

[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 proband, a 78-year-old woman, at age 73 began to complain of distal and proximal progressive weakness of the left leg. Two years later the weakness spread to her right leg, leading the patient to be wheelchair confined. Neurological examination at diagnosis (age 78 years), 50 months from symptom onset, showed asymmetrical (more severe in the left side) weakness and wasting of the lower limbs, sporadic fasciculations of the thighs, with absent lower limbs tendon reflexes. Muscle strength and deep tendon reflexes in upper limbs were normal. Hoffmann and Babinski signs were absent. Sensory examination in all limbs, bulbar and respiratory functions were normal. The ALS Functional Rating Scale (ALSFRSr) score was 37. Extensive motor and sensory nerve conduction studies in all limbs revealed severe decrease of compound muscle action potential amplitudes in lower limbs as only abnormal finding. Electromyography (EMG) examination confirmed acute and chronic denervation signs in lumbar-sacral bilateral multiple myotomes and normal pattern in cervical, bulbar and thoracic muscular districts. Motor evoked potential (MEP) examination showed the sparing of central motor pathways. No autonomic or cognitive impairments were present. Brain and total spine magnetic resonance imaging (MRI) were negative for degenerative signs of pyramidal tracts or compressive abnormalities of lumbar-sacral nerve roots. Blood creatine kinase levels and CSF examination were normal. Diagnosis of pure lower motor neuron disease with flail leg phenotype was made. The DeltaFS at diagnosis scored 0.2/month showing a slow progression rate of the disease [], confirmed by the subsequent clinical course. Indeed, the first respiratory dysfunction and bulbar symptoms occurred 20 and 27 months after diagnosis, respectively, whereas weakness in upper limbs appeared one year later. Non-invasive ventilation started at month 90 and death occurred 8 years and half after symptom onset, due to respiratory failure. O

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


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

[User]
RADIOLOGY NOTE:
A 47-year-old woman was admitted to the hospital due to sudden severe headache. The patient presented with drowsiness initially, but soon manifested symptoms of vomiting and convulsions. She then became stuporous, with both pupils fixed at 6 mm. Brain computed tomography (CT) demonstrated subarachnoid hemorrhages in both cerebral hemispheres, a large intracerebral hemorrhage in the left Sylvian cistern area and an intraventricular hemorrhage (). CT angiography (CTA) was attempted to locate a possible ruptured brain aneurysm; however, the contrast media was unable to penetrate the brain due to severe brain swelling, so it was impossible to evaluate the intracranial vessels. To reduce the intracranial pressure, an emergency decompressive craniectomy was performed. In addition to the severe brain swelling, a saccular aneurysm in the left middle cerebral artery was identified that was still actively bleeding. Thus, aneurysm neck clipping was performed. The surgery lasted for 3.5 hours, with norepinephrine administered because the patient's blood pressure could not be maintained. The patient's status worsened postoperatively, and she entered a coma, with pupils fixed at 7 mm. There were no notable changes other than a slightly changing pupil size, and her vital signs remained stable. However, movement, respiration, and brainstem reflexes were all completely absent.
Electroencephalography (EEG) performed on postoperative day (POD) 9 to delineate brain activity showed minimal continuous, irregular, and low-amplitude slow activity, and a neurologist confirmed the results as equivalent to brain death. Subsequently, the hospital's brain death review committee evaluated the patient's status and confirmed the diagnosis. Organ donation was recommended to the family, but they declined. Limb movements not seen before were observed on POD 15; the upper limb movements included bilateral arm flexion to the chest and shoulder adduction, similar to the Lazarus sign. The hands were not

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


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

[User]
RADIOLOGY NOTE:
We present a case of a 67-year-old man who was admitted with a 4-day history of abdominal pain. The patient had diffuse peritoneal symptoms and was septic on admission to the hospital. He had earlier been diagnosed with COPD stage 1 and is still smoking around 10 cigarettes a day. He had no other known chronic illnesses and did not use any medication. Broad-spectrum antibiotics (piperacillin–tazobactam) and intravenous fluid therapy was initiated immediately. A computerized tomography (CT) scan revealed free air in the abdominal cavity (Figure ). The patient was recently diagnosed with a suspicious lesion in the right lung and a suspected pathological fracture localized in the lumbar spine. He was then operated on utilizing a novel Graham patch for a perforated duodenal ulcer. The perforation was measured at about 1.5 cm in size. An 18 French drain with low active pressure (suction) was left in the abdominal cavity. Postoperatively, there was a persistent leakage of about 1000 mL per day. On the ninth postoperative day, he underwent an upper endoscopy. The perforation was visualized in the duodenal bulb and could easily be traversed with a 5.8 mm upper slim scope (Figure ).
The patient's clinical condition was tenuous, and it was felt that he would likely not be able to tolerate a major surgical intervention such as a Billroth II reconstruction since he was deemed to be an ASA class 4 according to the American Society of Anesthesiologists. A subsequent consultation with the endoscopic interventional team led to a decision to attempt a stent placement to rescue the failed surgical ulcer closure.
Using a therapeutic upper endoscope, we then placed a “through the scope” Hanaro Partially Covered duodenal stent (110 × 26-20-26 mm). The covered part of the stent is 74 mm (Figure ). A good position was confirmed by utilizing fluoroscopy.
The general condition of the patient was quite poor, and he had 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 42-year-old woman who had undergone twice cesarean sections presented with hematochezia and was evaluated by CT scan in August 2011. A CT only detected an enhanced abdominal wall mass near the abdominal scar, which was thought to be desmoid at the time (Fig. a and b). As the hematochezia continued, a further endoscopic workup was performed, and well-differentiated adenocarcinoma was detected at sigmoid colon. The whole body CT scan detected no other distant metastasis. She underwent elective open sigmoidectomy with D3 lymph node dissection for sigmoid colon cancer with mid-line incision in May 2012. Histology of the sigmoid colon showed well-differentiated adenocarcinoma invading to subserosa with 8 out of 20 regional lymph nodes involved. The sigmoid colon cancer was classified as pT3N2b, according to the TNM classification of the Union for International Cancer Control Eights Edition []. Molecular analysis showed KRAS mutation and microsatellite-stable. Postoperative course after sigmoidectomy was uneventful and the patient was treated with 12 cycles of FOLFOX regimen as adjuvant chemotherapy. The patient entered a scheduled clinical follow up program which included: regular physical examinations and CEA test every 3 months, and whole-body CT every 6 months. CT after adjuvant chemotherapy revealed the lesion on the abdominal wall had decreased in size and inguinal lymph nodes were all normal in size (Fig. c and d). In April 2014, a routine follow-up CT scan revealed enlarged left inguinal lymph nodes as well as a growing enhanced mass lesion on the abdominal wall at the site of cesarean section scar (Fig. e and f). 18F-fluorodeoxy glucose positron emission tomography (FDG-PET) revealed significant accumulation at both lesions (Fig. g and h). A CT showed no distant metastases were detected in other organs and laboratory data showed serum CEA level was within the normal range (1.3 ng/ml). Although metastases to both inguinal lymph nodes and the abdominal wall from

[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.