[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:
History and physical
A 67-year-old male former smoker with a history of prior occupational asbestos exposure and recurrent bronchitis presented with progressive dyspnea and thoracic pain to the point that he could not lie down in bed. A computed tomography (CT) scan of the chest was performed, which was interpreted as right-sided pneumonia with right parapneumonic effusion. He was sent to his local emergency department, where he was admitted for antibiotics and thoracentesis, the latter which demonstrated the presence of atypical mesothelial cells with inflammatory cells. He was readmitted two weeks later for progressive thoracic pain, was found to have a recurrent right-sided pleural effusion, and was managed with partial right pleurectomy with pleural biopsy, and talc pleurodesis. Right pleural pathology demonstrated atypical mesothelial proliferation at the pleural surface, without true invasion or definitive pathologic evidence of malignancy. Following surgery, he felt substantially better, such that he could sleep in the bed again, and he was able to return to his baseline activity levels. He underwent repeat chest CT five months later, which showed right pleural thickening and a small loculated pleural effusion, favored to represent a combination of calcification, pleurodesis, and atelectasis. He remained clinically well for another five months until he presented with cough and sinus congestion unrelieved by guaifenesin, dextromethorphan, and antibiotics. He underwent repeat chest CT that showed extensive mass-like pleural thickening completely encasing the right lung, with prominent involvement of the mediastinal pleura, and probable mediastinal extension into the right paratracheal and precarinal space, with pericardial effusion and probable pericardial metastases. There was no definite invasion into the right chest wall and no evidence of disease outside of the thorax.
He then established care at our institution’s mesothelioma and pleural disease multi-disc

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


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

[User]
RADIOLOGY NOTE:
A 32 year-old African-American female had previously presented to Children’s of Alabama at age 15 in Birmingham, Alabama with a cavitary pneumonia and was treated with clindamycin and cefuroxime intravenously for 10 days. Due to the severity of the infection, an immunologic workup was performed, and although the patient was mildly lymphopenic (absolute lymphocyte count 900 μl−1), the lymphocyte subset distributions were normal. Immunoglobulin levels were all below the normal ranges for age, and she was diagnosed with CVID. The patient received 2 monthly doses of intravenous IgG replacement therapy (IVIG) and recovered from her pneumonia but was subsequently lost to follow-up for 16 years.
At the time of her diagnosis with septic arthritis during hospital admission at 32 years of age, the patient had a history of weight loss, malaise, nausea and vomiting, diarrhoea and swelling in left knee and right wrist dating from a knee injury as detailed below. During the intervening years she had suffered chronic ear infections, chronic sinusitis, and axillary skin abscesses and had experienced several dental abscesses requiring tooth extraction and antibiotics over the preceding 2 years. She also suffered from occasional episodes of oral candidiasis/thrush. Eighteen months prior to admission, the patient had suffered trauma to the left knee and 9 months later received treatment by an orthopedist that included arthroscopy and arthrocentesis that yielded no fluid for diagnostic testing. At that time she was also beginning to have intermittent left ankle swelling and low-grade fevers. About a year after her knee injury she began experiencing pain and swelling intermittently in her left thumb and wrist. Two months prior to admission the pain and swelling in the right wrist increased significantly with the appearance of nodules around the joint. At time of admission, radiographs revealed severe destructive changes in the wrist and knee, as well as left ankle (). Initial aspiration

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


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

[User]
RADIOLOGY NOTE:
A 26-year-old woman using soft contact lens for the correction of mild myopia presents to emergency department for evaluation of a foreign body sensation of her right eye. On history, she reports standing in close proximity to a construction worker breaking a tile wall, when she felt a sudden onset of foreign body sensation. On initial examination, the patient's visual acuity was 6/6-OD and 6/6 OS. The intraocular pressure was 13 on the right eye and 15 on the left. A slit-lamp examination of her left eye was within normal limits. Her right eye examination was notable for mild conjunctival injection, a thin self-sealing corneal wound. This wound was initially estimated as a linear erosion of 2.5 millimeters in length located in the upper nasal quadrant and was Seidel negative. The anterior chamber depth was normal with few cells and no glair. The iris showed no disruption. The lens was clear, and examination of the posterior segment was unremarkable. Due to a high degree of clinical suspicion, a gonioscopic examination was performed showing a small dark foreign body embedded in the inferior chamber angle at 7 o'clock. An entry point was visible on the soft contact lens used at the time of injury confirming that the entrance wound was at the cornea.
A noncontrast CT scan (NC-CT) of head and orbits revealed a regular border radiopaque foreign body in the chamber angle, anterior to the lens. The patient was taken for surgical intervention. Removal of the foreign body via limbal incision entering on the superior aspect was complicated by disappearance of the object from the surgeons view. The procedure was stopped, and the patient was taken immediately for another NC-CT with concern for passage of the IOFB into the posterior segment. The CT demonstrated the IOFB resting in the zonules area adjacent to the lens (). 24 hours later using a slit lamp with gonioscopy, the location of the IOFB was marked by

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


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

[User]
RADIOLOGY NOTE:
A 65-year-old Chinese male resident of Guatemala presented with a 5-month history of distal symmetric arthritis and generalized fatigue. The patient described an insidious onset of pain, persistent stiffness, and joint swelling affecting the metacarpophalangeal and proximal interphalangeal joints, shoulders, knees, ankles, and feet in a symmetric fashion. This was associated with night sweats and chills but no fever. He endorsed weight loss yet denied any loss of appetite or change in diet. The patient initially self-administered oral acetaminophen and nonsteroidal anti-inflammatories with minimal improvement. Laboratory investigations of his constitutional symptoms were largely unremarkable. There was no anemia or leukocytosis on complete blood count with serum creatinine, serum electrolytes, and serum lactate dehydrogenase being within reference range. No bacterial growth was detected from blood cultures drawn. Further workup including colonoscopy and CT abdomen did not identify any other underlying etiology for his symptoms. He was evaluated by several rheumatologists with serology being negative for rheumatoid factor (RF). He was subsequently treated with low-dose prednisone with no improvement. The patient was maintained on oral hydroxychloroquine with no improvement as well.
Around two months prior to presentation in Guatemala, the patient had a fever up to 39°C associated with headache and neck and back pain which resolved spontaneously. This occurred soon after a mosquito bite. He had a concurrent transient skin rash over the medial thigh that resolved (around) three days after the mosquito bite. He was evaluated and investigated by an infectious disease physician and was found to be positive for chikungunya IgM.
On evaluation at our institution the patient had bilateral symmetric synovial swelling of the metacarpophalangeal and proximal interphalangeal joints together with mild wrist and ankle swelling with overlying warmth but no erythema. Joint pain was r

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


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

[User]
RADIOLOGY NOTE:
A 32-year-old female reported with complaints of pain and swelling in the maxillary anterior region for 3 years. There was no history of trauma and pus discharge with the swelling. Swelling was slow in growth and associated with pain. The patient had taken unknown medications for the same with no reduction in the size of the swelling. Personal history, family history and medical history was noncontributory, and history of tobacco habit was not present. Upon extraoral examination, the overlying skin was found to be normal in color with the smooth surface without any gross facial asymmetry. Intraoral examination revealed the swelling to be round to ovoid, firm to hard in consistency [], nontender, noncompressible and located on the labial gingival margin in the region of right maxillary central and lateral incisors. The overlying mucosa was normal in color. Intraoral periapical radiographs showed a well-defined pear-shaped radiolucent lesion in the interdental region of right maxillary central and lateral incisors, extending from the mid root level to the periapical region []. On the basis of clinical and radiographic features, differential diagnosis of radicular cyst, lateral periodontal cyst and benign odontogenic tumor such as adenomatoid odontogenic tumor (AOT) were postulated.
The patient was conventionally managed by surgical debridement of the lesion followed by regenerative therapy. The involved tooth was nonvital, and endodontic therapy was carried out. The lesional tissue specimen was sent for the histopathological examination.
Gross examination revealed multiple tissue fragments with the largest measuring 1.0 cm × 0.5 cm × 0.4 cm, being yellowish-white in color and soft in consistency []. Histopathologically, the sections exhibited stratified squamous surface epithelium at the one end of the section with the lesional tissue in the rest of the area. The lesional tissue was composed of nests, islands and anastomosing strands of varying size and shape consisti

[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 17-year-old male, presented to the emergency department of our institute, following road traffic accident. He was unable to stand after the accident and was complaining pain around left hip, left thigh, and leg. Patient was managed as per advance trauma life support protocol. On secondary survey, pelvic compression test was positive and tenderness was elicited over left thigh and leg. There was no distal neurovascular deficit. Radiological evaluation showed left transverse mid shaft femur fracture, spiral fracture distal third tibia, and transverse acetabulum fracture with complete disruption of sacroiliac (SI) joint (). Fracture of transverse process of L5 vertebra and left superior and inferior pubic rami was also present. Computerized tomography (CT) was done to further appreciate the fracture geometry. CT showed superior and medial displacement of ileum which was completely separated from sacrum and also ischium and pubis through transverse fracture through ileum ().
Patient developed acute respiratory distress syndrome (ARDS) the same day and was intubated and shifted to critical care unit. As a measure of damage control orthopedics, tibia and femur were temporarily stabilized with external fixator. Patient was kept on ventilatory support for 2 weeks. One week after weaning off from ventilator, intramedullary nailing was done for both tibia and femur. Five days; thereafter, patient was planned for open reduction anterior and internal fixation of pelvis and acetabulum. SI joint dislocation was addressed first from lateral window of ilioinguinal approach along with anterior superior iliac spine osteotomy for enhanced exposure. As already it was about a month post-injury, reduction of ileum to its anatomic position was a sizable challenge, which was accomplished using following maneuvers in synergism. Axial traction was applied by an assistant. A Schanz Pin was inserted through the lateral aspect of ileum percutaneously, in a manner similar to iliosacral screw u

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


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

[User]
RADIOLOGY NOTE:
In 1994, a 34-year-old woman suffered from a left arm caput humeri fracture that led to open reduction and internal fixation by a plate osteosynthesis. During the next 4 years, she developed a severe posttraumatic omarthrosis that necessitated the implantation of a total shoulder joint arthroplasty. Eight years later, she again injured her shoulder and now suffered from a rotator cuff lesion and a slight loosening of the humeral stem. The rotator cuff lesion was treated by open surgery, and the humeral part of the arthroplasty was changed. In 2006, the patient injured her shoulder once more and this time the TJR was luxated and a major rotator cuff lesion was diagnosed. Once again surgery was proceeded. The TJR was restored and the rotator cuff lesion was fixated. Five days after this procedure, signs of a severe infection occurred. With further surgical revisions and antibiotic treatment, the situation could be solved. But due to these revisions, the rotator cuff was destabilized because of the loss of soft tissue, and during the following months, the arthroplasty luxated frequently. In September 2006, a reversed shoulder arthroplasty (Grammont prosthesis) [] was implanted. All these procedures were performed in external institutions. We do not have more detailed information about the patient’s history before the lady was sent to our department of septic and reconstructive surgery in July 2007. We could not obtain precise information why the primary osteosynthesis led so rapidly to a severe omarthrosis, about the implantation of the TJR and finally why a reversed endoprosthesis was implanted in such a young lady.
When she came to our department, she showed signs of an acute exacerbation of the already known infection of the left shoulder joint (white blood cell count (WBC): 9.3 × 109/l, C-reactive protein (CRP): 37 mg/l). First goal was to get in control of the infected articulation and preserve shoulder function.
The patient was taken into the

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


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

[User]
RADIOLOGY NOTE:
A 42-year-old male was referred to his ophthalmologist regarding the complaint of sudden blurriness of vision in his right eye. He was diagnosed five months ago with a case of ENKTCL, nasal type, stage IV-B with testicular and central nervous system involvement with 23% natural killer (NK) cells on cerebrospinal fluid (CSF) flow cytometry. He was on an active therapeutic plan consisting of cycles of chemotherapy (i.e., SMILE protocol: dexamethasone, methotrexate, ifosfamide, L-asparaginase, etoposide), to which there was a complete response in the form of negative flow cytometry and computed tomography (CT) of the chest, abdomen, and pelvis. Five months after the initial diagnosis, prior to the fourth cycle of treatment, a complaint of blurriness of right eye vision was made. Brain CT was done aiming to rule out ocular involvement, which turned out to be unremarkable. At the time of the complaint, visual acuity was 20/30 -2 in the right eye as opposed to 20/20 in the left eye. The right eye showed relative afferent pupillary defect. Extraocular muscle movements were competent in both eyes. On examination of the anterior chamber, +1 cells were visualized in the right eye only. On dilated fundus examination, there was vitritis in the right eye which obscured the vision. Left eye examination was insignificant. B scan ocular ultrasonography revealed retinal detachment in the right eye. An optic CT revealed vitritis in the right eye; an impression of disease infiltration of the eye was made. The therapeutic plan was a diagnostic vitrectomy followed by systemic therapy. A pars plana vitrectomy was made and the vitreous specimen was sampled revealing the presence of 10% viable lymphoid cells expressing CD2 and CD56 on immunohistochemistry stain. An orbital magnetic resonance imaging (MRI) was ordered revealing evidence of an enhancing retinal lesion centered on the optic disc with diffuse restriction consistent with lymphomatous infiltration; minimal proptosis 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 68-year-old man presented with computerized tomography (CT) scan results showing a 5-cm solid cystic mass in the tail of the pancreas (Figures and ), with no signs of vascular or visceral invasion. There was no evidence of metastatic disease. The patient was completely asymptomatic; the CT scan was performed as part of a routine follow-up of angiographic aortic endoprosthesis placement 3 years prior for treatment of an abdominal aortic aneurysm. In addition, the patient's history included well-compensated pulmonary emphysema and a pulmonary lobectomy for a pT2N0M0 adenocarcinoma of the lung (lower left lobe) 5 years prior. There was no history of abdominal trauma or previous abdominal surgery and no family history to suggest genetic disease.
No clinical signs were found on physical examination. Magnetic resonance imaging failed, owing to the generation of artifacts associated with the aortic prosthesis. Levels of serum tumor markers (carcinoembryonic antigen [CEA] and CA 19.9) were in the normal range. Surgery was performed on the suspicion of cystadenocarcinoma. During the surgical exploration, the mass appeared to be localized completely to the tail of the pancreas, with no invasion of adjacent structures. There were no enlarged nodes surrounding the tumor. A left pancreatectomy was performed with spleen preservation and lymphadenectomy of the celiac axis and peripancreatic nodes. The transection margin was tumor-free. The gross appearance of the mass was of a dense grayish tumor containing a cystic cavity, with no signs of a capsule and no evidence of necrosis.
Histologic sections showed proliferation of spindle-shaped or stellate cells, with a fasciculate and storiform growth pattern within a background of myxoid intercellular matrix (). Glassy, hyalinized, and keloid-like collagen fibers were also present focally. The cystic area was the result of dilatation of entrapped excretory pancreatic ducts. Immunohistochemical staining showed cytoplasmic positivity fo

[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 past medical history of hypertension presents to our facility with complaints of worsening abdominal pain for the last week. The patient reported that he had been experiencing abdominal discomfort that he initially attributed to gastric reflux, for which he was prescribed anti-reflux medications by his primary care physician, without improvement of symptoms. He stated that the abdominal pain was initially intermittent but subsequently progressed to persistent and constant abdominal pain. He also reported associated abdominal distension during the past week, with nausea and vomiting that began one day prior to presentation. The patient additionally reported not having a bowel movement for the past three weeks. The patient denies previous abdominal operations as well as ever undergoing a colonoscopy or upper endoscopy. He denies any family history of cancer. He reported denied a history of tobacco, alcohol or illicit substance use. He reported his occupation as a mechanic.
The patient’s vitals were stable on first encounter, apart from mild tachycardia of 103 beats per minute that normalized with intravenous crystalloid resuscitation. A complete blood count as well as chemistry panel were within normal limits. Lactic acid level was 1.2 mmol/Liter.
The patient’s physical exam was significant for abdominal distension that was tympanic to percussion in all four quadrants. The patient’s abdomen was diffusely tender to palpation, with increased tenderness in the epigastrium, but without peritonitis. No hernia was palpated in the bilateral inguinal regions. There were no prior surgical scars on the abdomen or pelvis.
Computed tomography (CT) of the abdomen and pelvis with intravenous contrast only demonstrated a high-grade obstruction with dilated, fluid-filled loops of small bowel and a transition point in the right lower quadrant (Figure ). The transition point demonstrated a segment of circumferential wall thickening without fat stranding (Figur

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

[User]
RADIOLOGY NOTE:
A 32-year-old male, addicted to heroin for 3 years, was found in a semiconscious, unresponsive state in his room and brought in a state of shock with gasping respiration by family members to the emergency room. He was hypothermic, hypotensive with blood pressure 70/45 mmHg, a heart rate of 128 per min, shallow respiration with a rate of 12/min, and hypoxemic with oxygen saturation 88% on 10 liter per min oxygen. Initial evaluation was suggestive of an acute opioid overdose as the patient was a known heroin addict; there were pinpoint pupils with hypoventilation and hypothermia. A blood sample was sent to the toxicology laboratory. After 0.4 mg of intravenous naloxone in increments of 0.1 mg boluses, patient's sensorium level improved and respiration became more normal with an improvement in oxygen saturation, but he remained hypotensive. Fluid resuscitation was continued, vasopressor (noradrenaline infusion) added, and an infusion of naloxone was started. The patient was shifted to the ICU for further observation and treatment. Blood gas analysis showed persistent metabolic acidosis. Hematological parameters were normal but biochemistry revealed signs of acute rhabdomyolysis with a marked rise in the creatinine kinase level, hyperkalemia, and high blood urea nitrogen (BUN) and creatinine. Aggressive hydration with alkalinazation and forced diuresis was started. Despite the aggressive therapy for about 3 h, the patient went into anuria with a marked rise in creatinine. The patient started to agitate, and become restless with a complaint of generalized body and joint pain and his respiration became labored; auscultation revealed bilateral diffuse crepitation. The patient was intubated and connected to a mechanical ventilator with propofol and remifentanil infusion as sedative-analgesic. An urgent chest X ray confirmed acute pulmonary edema. Nephrology consultation was sought for urgent dialysis; naloxone infusion was stopped. Although the metabolic parameters improved

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


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

[User]
RADIOLOGY NOTE:
A 39-year-old male was referred to a hand surgeon at our hospital with history of swelling in the right thumb of 2 years duration. It was noticed following a trivial trauma and it had been gradually increasing in size with no associated constitutional symptoms. On clinical examination, there was grade 4 clubbing of right thumb []. A plain radiograph of the hand showed an expansile lytic lesion involving the distal phalanx of the thumb with marked cortical thinning and focal defects in the cortex. Subperiosteal bone resorption was seen in the phalanges, particularly along the radial aspects of the middle phalanges of the middle and index finger and also along the phalangeal tufts []. In view of elevated serum alkaline phosphatase and with a suspicion of solitary bone metastasis, Tc 99m methylene diphosphonate bone scintigraphy was performed. Bone scintigraphy revealed generalized intense tracer uptake in the axial and appendicular skeleton including the costal cartilages []. Increased tracer uptake was noted in the distal phalanx of right thumb [] and both scapulae. There was stasis of tracer in both kidneys. Based on these findings, the possibility of hyperparathyroidism was suggested. Further evaluation revealed elevated serum calcium, 12.5 g% and serum PTH levels, 1,821 pg/ml.
Radiograph of the lumbar spine showed diffuse osteopenia. Bilateral stag horn renal calculi were also noted []. Lateral radiograph of the skull showed granular deossification giving the classical “salt and pepper” appearance and loss of sharp definition of the inner and outer tables []. Tc 99m sestamibi parathyroid scintigraphy [] demonstrated a functioning parathyroid adenoma in the region of the inferior pole of left lobe of thyroid, which was confirmed by single-photon emission computed tomography [Figure and ] with associated tracer uptake in the distal phalanx of the right thumb [] confirming the diagnosis of primary hyperparathyroidism due to left inferior parathyroid adenoma and brown

[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 53-year-old male underwent living-donor LT for hepatitis B virus-associated liver cirrhosis and HCC (). Before LT, he did not receive any HCC treatment. The resected liver had a single 1.5 cm-sized HCC without microvascular invasion, and therefore met the Milan criteria. The pretransplant serum AFP level was 16 ng/ml.
At the age of 65 years (12 years after LT), the patient showed very slow elevation of AFP levels, albeit within the normal range, over 3 months of outpatient clinic follow-ups (). A CT scan of the abdomen was taken 6 months prior to the observed increase in AFP levels, but no abnormalities were detected (). The pelvis was not examined at that time. A subsequent CT scan of the abdomen-pelvis was performed after detection of the slow rise in the AFP level and identified a 4 cm-sized mass at the pelvis (). A PET scan using [18F]-fluorodeoxyglucose revealed that the mass showed hypermetabolic uptake (). At this time, the AFP level was gradually elevated but was still within the normal range (). These findings suggested that the mass was likely to be metastatic HCC.
Open laparotomy was performed, and two masses were excised with equivocal tumor-negative resection margins (). A pathological analysis confirmed that the masses were metastatic HCCs. After excision, the patient's AFP level dropped rapidly (); however, 6 months later, it increased again, although it was still within the normal range. Follow-up CT and PET scans revealed multiple seeding nodules at the pelvis (). The patient underwent treatment with low-dose calcineurin inhibitor, sirolimus, and full-dose sorafenib, and displayed no serious adverse side-effects. Growth of the peritoneal seeding nodules was visualized on follow-up CT scans, and sorafenib therapy was stopped after 2 years of administration. The patient changed to receive everolimus monotherapy because its Korean National Health Insurance coverage for LT recipients. During the 6 years since HCC recurrence was diagnosed, the patient

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

[User]
RADIOLOGY NOTE:
A 31-year-old right hand dominant, African American female presented to the University of Chicago Emergency Department with swelling and progressive pain of her right thumb (first digit) that worsened with activity. She first encountered pain in her previously healthy thumb 2 weeks prior to presentation. She denied trauma and surgery to the affected digit. On physical examination, the digit was erythematous and moderately tender to palpation. Motor function was grossly intact but range of motion (ROM) at the metacarpophalangeal (MP) and interphalangeal joints was reduced because of pain. No neurovascular deficits were noted. There were no palpable masses. The patient was afebrile and a complete blood count and basic metabolic panel were within normal limits. X-rays of the digit revealed radio-opaque masses around the volar aspect of MP joint consistent with synovial chondromatosis without evidence of acute fracture (Fig ). The digit was managed conservatively and placed in a spica splint. The patient was admitted for empiric antibiotic therapy for suspected cellulitis or abscess in the setting of underlying synovial chondromatosis.
After 24 hours, physical examination revealed moderately decreased erythema and swelling and improvement of thumb ROM. Severe thumb pain persisted. A hand surgery consult was requested, and CT scan of the hand was obtained. Consistent with the initial x-rays, foci of mineralization adjacent to the thumb MP joint were noted (Fig ). This was again suggestive of synovial chondromatosis. The thumb was placed in a spica splint and the patient was seen in hand clinic the following week. After 1 week of immobilization, swelling of the thumb had subsided but pain and tenderness at the first MP joint persisted. Total active motion of the thumb was 36°. Surgical excision of the masses identified by radiography was subsequently recommended.
During surgery, access to the masses was achieved by making an L-shaped incision transversely along the digita

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

[User]
RADIOLOGY NOTE:
The patient, a 53-year-old female, was admitted to the hospital on April 05, 2019 in a car accident resulting in a fracture of the distal left tibiofibula, and was given routine heel traction and symptomatic treatment to reduce swelling after admission. On April 18, 2019, we performed “tibiofibular fracture incision and internal fixation + bone grafting,” after which we were given symptomatic treatment for swelling and pain relief. He was discharged from the hospital on May 16, 2019, and at the time of discharge there was still about 3 cm of poorly healed skin and localized redness and swelling in the lower and middle sections of the left ankle incision, and then continued to have the left ankle dressing changed at the local community hospital, and the wound never healed. One year after the operation, he was readmitted to the hospital for rehabilitation.
A follow-up X-ray showed that the metal internal fixation of the left inferior tibiofibular fracture was in place, no loosening was seen, the alignment of the severed end was acceptable, and the left inferior tibial segment was mildly osseointegrated (Fig. ).
On examination: the left ankle incision was interrupted for about 3 cm with poor healing, a small amount of muscle necrosis, fat liquefaction, a large amount of yellow purulent secretion overflow and necrotic material was seen in the local wound. The wound did not improve after routine dressing changes.
PRF gel preparation and application the preparation process was strictly aseptic: - A disposable screw-in 20 mL syringe with an 18G needle was used to draw 20 mL of autologous blood under strict aseptic conditions, and the screw-in syringe was tightened with a disposable plug, and the posterior projection and tail were cut off. Weigh, level, and centrifuge at 3000 r/min for 10 minutes. After resting, the blood sample was divided into 3 layers, the upper layer of yellowish clarified liquid was platelet plasma,

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

[User]
RADIOLOGY NOTE:
An 18-year-old male patient from Greece was admitted to our department due to chronic nonspecific knee pain (for the last 3 months) for a plain X-ray and an MRI examination.
Clinical examination two weeks prior to MRI revealed pain at the medial compartment and a meniscal tear was considered the most probable diagnosis, as the patient was also a semi-professional footballer. Physical examination revealed no skin stigmata, orbital pathology or other pathologic conditions. There was no history of previous trauma and his medical history was unremarkable. Laboratory findings were also unremarkable. No medication at the time of the examination except occasionally anti-inflammatory agents. The patients did not smoke or drink. From family history, and according to information from patient’s father, his mother died 3 years ago (at the age of 42) from an ovarian cancer and his little brother at the age of 3 from a brain tumour (no more data were available).
Plain X-ray () revealed a geographic lytic lesion at the medial aspect of the proximal tibia with no evidence of soft tissue mass or internal calcifications. Small periosteal reaction demonstrated at the lower aspect of the lesion. CT examination () confirmed the findings of plain X-ray and showed a lytic geographic lesion with wide zone of transition at its lateral aspect causing slight expansion and thinning of the cortical bone, scalloping of the endosteum, no soft tissue extraosseous mass. Internal amorphous calcifications were demonstrated inside the lesion. MRI contrast enhanced examination () revealed a lesion of fairly homogenous low signal intensity at T1-weighted sequences, mainly cystic lesion with fluid-fluid levels at T2-weighted images. After contrast agent administration () enhancing viable tissue was detected mainly at the periphery of the lesion. CT of the lungs, MRI examination of the rest of the tibia and bone scintigraphy was negative. Biopsy of the lesion showed telangiectatic osteosarcoma. The patien

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

[User]
RADIOLOGY NOTE:
A 33-year-old male, otherwise healthy, presented to the emergency room with right iliac fossa pain. It was sudden in onset and lasted for about 15 minutes. The pain was severe in intensity and associated with nausea. There was no associated fever, vomiting, or constipation.
The patient had a history of an uneventful appendectomy 15 years back for acute appendicitis. He remained asymptomatic for several years following the procedure. However, four years ago, he presented with ureteric colic, and a CT scan abdomen confirmed a left ureteric stone. The CT scan also incidentally demonstrated a fecalith in the right iliac fossa. He subsequently underwent DJ stenting at that time with complete resolution of symptoms.
During the current visit, abdominal examination showed tenderness in the right iliac fossa with guarding but no abdominal distention, rebound tenderness, or rigidity. A small mass was also palpable in the right lower abdomen. The patient was otherwise vitally stable.
Lab workup showed a total leukocyte count of 10,770/µL and C-reactive peptide levels of 62.7 mg/L. CT scan performed in the emergency room revealed a fecalith in the appendicular stump measuring approximately 17 mm in the maximum transverse diameter (Figure ). CT scan did not show any inflammatory changes, fat stranding, or fluid collection. The patient got admitted to the hospital for further workup and management.
The gastroenterology team was taken on board. Colonoscopy was advised to delineate the exact location of the fecalith and to determine whether it was safe to remove the stone endoscopically. Colonoscopy showed a large impacted and deeply embedded stone in the appendicular stump, covered by normal colonic mucosa and projecting into the cecum (Figure ).
The ileocecal valve was normal in appearance, and deep terminal ileal intubation showed normal small bowel mucosa. It was not considered safe to remove the stone endoscopically due to the high risk of cecal perforation. As a result, the p

[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 18-year-old male patient having indwelling catheter in situ reported with the complaint of inability to move his legs and no sensation below his navel []. He also told that his legs seemed to be cold. He was having loss of appetite. He could not hold the urge of defecation.
On asking about the history of the same, he stated that he was alright till evening of 8 April 2010 and then he felt feverish and developed pain all over the body. He took some medicine for the same from his family doctor. He woke up late in the morning and was unable to stand up by himself. He stood with support and tried to walk. During the walk, he felt that his legs were not in his full control. He had not voided any urine since morning. In the evening, along with his relatives, he again consulted the other doctor who then referred him to higher center.
He got admitted to the hospital on the next day with the complaint of no sensation in lower half of the body as well as insensitivity to touch from lower part of neck to toe. He was also having the feeling of tightness around the abdomen.
Lumbar puncture was done on the same day, which showed increased polymorphs. On 15 April 2010, CT-head was done and it was normal. He also faced some respiratory problems and so was on intermittent oxygen inhalation therapy from 12 to 18 April 2010. On 17 April 2010, MRI cervico-dorsal spine with MRI brain was done, findings of which were as follows.
Long segment T2 hyper intensity of the cervicodorsal spinal cord from the C3 level onward. Suggestive of myelitis.
Therefore, the present case had been diagnosed as that of transverse myelitis and came to us after two months of acute attack. At that time, he was having total paraplegia, no sensation below umbilicus, and other typical features of transverse myelitis such

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

[User]
RADIOLOGY NOTE:
A 17-year-old male patient attended the oral and maxillofacial surgery clinic in King Saud University requesting extraction of all third molars. The patient’s medical history was unremarkable; he was a non-smoker and revealed no history of previous facial trauma or surgery. There was neither pain nor swelling of the buccal and lingual sulci of the mandible and no cervical lymphadenopathy. Initial dental examination revealed a minimally restored permanent dentition with good oral hygiene. A panoramic radiograph showed that all third molars were present and impacted except on the upper right side where the tooth was missing, with the lower third molars in close proximity to the inferior alveolar canals (Figure ). The radiograph was otherwise unremarkable with no signs of pathology or abnormality.
A CBCT of the mandible was requested for further assessment of the relation and proximity of the roots to the inferior alveolar canal. A survey of the CBCT sections of the mandibular body revealed bilateral sublingual depressions inferior to the premolars and first molars extending to the inferior border of the mandible that was not seen on the panoramic radiograph.
To assess the depth and width of these depressions, the CBCT images were reconstructed in planes aligned with the axes of the right and left mandibular second premolars in the mesiodistal dimension, buccolingual dimension, and the coronoapical dimension. Then, linear measurements representing the width of the depressions were made along a line drawn a tangent to the heights of contours (crest of curvatures) of the lingual surfaces of the mandible superior and inferior to the bilateral depression. The superoinferior width of the depressions was found to be 2.1 cm on the right side and 2.9 cm on the left side. Linear measurements representing the buccolingual depth of the depressions were made along a line drawn perpendicular to the above-mentioned width line to the deepest point of the depression; it measured 0.59

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

[User]
RADIOLOGY NOTE:
A 75 year old lady was referred to the Orthopaedic Outpatients Department with a painless, slowly growing mass on the dorsum of the right wrist. She first noticed the swelling a year previously and attended her local doctor who felt it was a ganglion. Past medical history included hypertension, osteoarthritis, polymyalgia rheumatica and malunion of a right distal radius following a distal radius fracture sustained 5 months prior for which she declined surgical intervention (,). Clinical examination revealed a radially deviated wrist with a classic dinner fork deformity. There was a 6 X 9 cm round painless mass on the dorsum of the distal radius adherent to both the underlying structures and skin which did not transilluminate and with necrotic area of overlying skin (,). General physical e x a m i n a t i o n w a s u n r e m a r k a b l e w i t h n o o b v i o u s lymphadenopathy, no breast masses, no organomegaly and clear lung fields. Her right hand had capillary refill of under 2 seconds, palpable radial and ulnar pulses and normal sensory and motor exams. Mantoux test was negative making TB an unlikely cause. Blood count, renal and liver function were within normal range, ESR 74 (elevated), haemoglobin 11 g/dl. On ultrasound scan there was a large vascularised soft tissue mass infiltrating the tendinous structures on the dorsum of the right wrist. MRI of the wrist showed a large mass causing extensive osteolysis of the distal radius and extending proximally with abnormal replacement of the marrow in the distal one third of the radius. The soft tissue component of the mass involved the entire extensor tendon groups and infiltrated through the subcutaneous tissues to the dermis (,,). CT thorax abdomen and pelvis and whole body bone scan confirmed that this was an isolated lesion with no evidence of dissemination. The patient was brought to theatre for biopsy following consultation from the National Musculoskeletal Tumour Centre. Subsequent histopathological

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

[User]
RADIOLOGY NOTE:
We present the case of 32-year-old female patient who presented to the urologist with fever lasting for the previous two months, usually 37°C to 38°C, with occasional temperature leaps to 40°. Laboratory blood tests showed leukocytosis with cell counts up to 19,000. The patient did not complain of lumbar pain. Urinalysis showed leukocyturia, erythrocyturia, and slight positivity for protein. The patient was treated with a combination of amoxicillin, clavulonic acid, and cefuroxime. Abdominal ultrasound and multiphase CT depicted a large, expansive, heterogenous mass in the lower pole of the left kidney measuring 92 × 59 × 76 mm. CT scans showed a renal neoplastic mass with increased peripheral inhibition and poor central inhibition, possibly due to central necrosis. The tumor was unsharply demarcated from the surrounding parenchyma and pelvic system (). Regional lymphadenopathy was present, but there were no signs of propagation in the main renal vein or perinephric fat tissue, and there were no signs of liver or bone metastasis. Chest CT showed no signs of lungs metastasis or mediastinal lymphadenopathy. In order to determine the final histopathological diagnosis, histopathological and immunohistochemical analyses were performed, complemented by reverse transcryptase-polymerase change reaction (RT-PCR). Gross examination of the slitted specimen showed a sharply circumscribed tumor measuring 9 × 6 × 6 cm and replacing a large part of the kidney. The renal tumor displayed infiltrated parenchyma but no expansion into the pelvic system and ureter or signs of spreading into the main renal vein. Gross appearance of the tumor was white-yellow with large necrotic areas. The microscopic analysis of perinephric fat tissue, regional lymph nodes, and the left adrenal gland revealed no signs of metastasis. Microscopic analysis showed that the tumor was composed of solid nests and stripes of tumor cells with small oval and round nuclei, and some of the nuclei contained small nuc

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


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

[User]
RADIOLOGY NOTE:
The patient, a 36-year-old woman with a known case of exstrophy of the bladder had undergone repair of the defect 17 years previously. However, dehiscence of the repair had occurred and the patient continued to leak urine from the lower abdominal wall. Six months following this, an ileal conduit urinary diversion was done to prevent the continuous leakage of urine. Six month prior to presentation, the patient had noticed an irregular mass arising from the exposed bladder mucosa that was rapidly increasing in size. On examination, a hemispherical growth with an irregular surface was seen in the region of the exposed bladder mucosa (). The computed tomography scan showed a mildly enhancing nodular lesion on the right side of the lower abdomen superficially. The lesion was confined to the urinary bladder. A wedge biopsy was taken from the growth, and the results were suggestive of squamous cell carcinoma. The results of a routine hematological evaluation, liver function tests, and a chest radiograph were normal. The patient thus underwent removal of the urinary bladder along with a cuff of the surrounding abdominal wall and pelvic lymph node dissection (radical cystectomy). After resection, there was a full thickness defect of the lower abdomen about 8 cm×9 cm in size. To cover this defect, the peritoneum was mobilized on both sides and was sutured in the midline. Both recti were also mobilized and sutured in the midline. The skin defect was resurfaced with an extended groin flap from the left side and the secondary defect thus created was covered by a split thickness skin graft (, ). Histopathological examination of the resected specimen was suggestive of well-differentiated squamous cell carcinoma infiltrating the underlying muscle (stage pT2a) with dense lymphocytic infiltration of the stroma. All the resected margins and deeper plane of resection were free of tumor (). In the postoperative period, the patient developed a small collection beneath the flap that was d

[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 34 year-old pregnant woman G3P2A0L2 from Syria, who was referred to our department at 14 weeks gestational age (02/2017) for evaluation of an abnormal first trimester nuchal translucency ultrasound scan including an abnormal spine (fused and underdeveloped vertebra) and a gastroschisis. The rest of her blood exams from her first antenatal visit were normal. From her past obstetrical history, she mentioned two term vaginal deliveries 9 and 11 years ago. From the maternal or the paternal past medical history there were no predisposing risk factors such as smoking or alcohol consumption. There was no family history of dwarfism and the patient and her partner, who was from Livanos, were non-consanguineous. During the detailed scan, we confirmed the abovementioned ultrasound findings. So we consult the couple to proceed with Chorionic villus sampling (CVS). The first results from the molecular karyotype came back negative for any of the 512 examined genetic diseases. Due to the specific ultrasound findings, we proceed to a more specific examination in order to reveal any mutation in the DLL3, MESP2, LFNG and HES7 gene. The result was positive for a mutation in the DLL3 gene. After careful and detailed consultation with the couple, they decided to proceed to induced abortion which was successfully completed one week later without any complications (). The fetus and the placenta were sent for histopathological examination. The final autopsy report confirmed the presence of various congenital malformations of the spine and ribs, which are characteristic phenotypic findings of the SCD.
After the abortion the couple received a specific genetic counseling regarding the recurrence risk. The risk of having an affected offspring is 50%. Ten months later the same couple came to our department for a scheduled first trimester scan which revealed a foreshortened spine with fused and undergrowth vertebrae and multiple fused ribs (, , ).
So we proceed

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

[User]
RADIOLOGY NOTE:
A 67-year-old woman, in good health other than systemic hypertension, lost consciousness soon after complaining of severe epigastric pain at her workplace. The ambulance crew found the patient in cardiopulmonary arrest and paramedics immediately started CPR by manual chest compressions; return of spontaneous circulation and recovery of consciousness occurred 4 min later. On arrival at the emergency room, the patient’s level of consciousness was 14 on the Glasgow Coma Scale, blood pressure was 102/74 mmHg, and pulse rate was 103/min. No cardiac murmur was detected, but vesicular breath sounds were moderately diminished in the left lung field. Cardiac enzyme studies were not consistent with a diagnosis of myocardial infarction. An ECG showed a normal sinus rhythm, and no arrhythmias or signs of myocardial ischemia were observed. A chest X-ray revealed massive left pleural effusion with no right pleural effusion, while cardiomegaly and pneumothorax were not identified. Transthoracic echocardiography demonstrated normally functioning ventricles and valves, and mild pericardial effusion. Computed tomography (CT) showed a type A acute aortic dissection (AAD) with thrombotic occlusion of the false lumen and an ulcer-like projection in the proximal arch, along with mild pericardial effusion and massive left pleural effusion (Fig. ). Occlusion of the branch vessels of the aortic arch and pulmonary emboli were not detected. Immediately after the CT, the patient fell into circulatory collapse. After drainage of bloody effusion from the left pleural space, an emergency operation was begun through a median sternotomy. No sternal fracture and bleeding in the mediastinum were found. When the pericardium was opened, a small amount of bloody effusion was present, but cardiac injury was not observed. In addition, a large laceration (10 cm) was found in the left posterolateral pericardium at the phrenico-pleural junction, through which the pericardial cavity communicated to the left p

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

[User]
RADIOLOGY NOTE:
A 50-year-old woman positive for hepatitis B virus underwent a right hemihepatectomy extended to a medial part of Couinaud segment IV for HCC in May 2000. The initial tumor was mainly located in Couinaud segment V and was 10 cm in diameter with capsule invasion. Histologically, it was moderately differentiated HCC with thick trabecular pattern with microscopic vascular invasion. In January 2001, partial resection of the medial segment was performed due to recurrence in the form of intrahepatic metastasis. During a period of 8 years after second surgery, no recurrence sign was detected by 5-year regular imaging follow-up at our hospital. In December 2008, the patient consulted a home doctor for chest discomfort and then was recommended to our hospital again for the purpose of general examination. The serum value of alpha-phetoprotein (AFP) increased to 248369 ng/mL (normal rage; <20 ng/mL). Computed tomography (CT) revealed a heterogenous mass, 9 × 7 cm in diameter, in the remnant liver (). The mass had expanded to the adjacent organs, inferior vena cava (IVC) () and the pericardium (), indicating a diagnosis of intrahepatic recurrence from HCC. Angiography revealed that the remnant liver was supplied by left hepatic artery with no tumor stain (). Because selective angiograms showed a hypervascular tumor supplied from the descending branch of the inferior phrenic artery (IPA) () and the phrenic branch of the internal mammary artery (IMA) (), transcatheter arterial embolization (TAE) was selected first. However, TAE could not relieve her chief complaint, and after evaluation that there were no other distant metastases, complete surgical resection was planned on January 2009. Because it was difficult to identify the whole aspect of the tumor from just the abdominal upper midline incision, an additional median sternotomy was carried out (Figures and ). Pericardial fluid was found to have no malignancy after cytological examination. At the superior border of the tumor,

[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 59-year-old female with a medical history of chronic hepatitis C was referred for management of a right nonhealing neurotrophic ulcer due to Bell's palsy. One-year prior, she reported experiencing “lightning bolt” pains across the right side of her face. She was referred to a neurologist who did not note any abnormality of facial sensation or motor function at that time; a brain MRI was obtained and was unremarkable (this study was not dedicated to the fifth nerve, and no comment was made on structures inferior to the skull base in this report). She was diagnosed with trigeminal neuralgia and treated with carbamazepine. Subsequently, she noted a decrease in visual acuity and was evaluated by optometry where a serological workup for temporal arteritis was ordered and returned negative. She went on to develop right hearing loss and noticed right temporal wasting. She developed a right-sided facial paralysis and returned to her neurologist who now documented right fifth and seventh nerve palsies. As a result, she underwent a lumbar puncture with normal protein and cell counts as well as negative results for HSV, West Nile, and tuberculosis. At this time, her ophthalmologist independently documented right facial weakness, decreased facial sensation, and neurotrophic keratitis consistent with fifth and seventh nerve palsies. The patient was told her symptoms were a result of Bell's palsy. No repeat neuroimaging was obtained after the onset of her facial weakness. She was treated with pressure patching of the affected eye but, due to a lack of resolution, was ultimately referred for management of the neurotrophic ulcer.
On presentation to the oculoplastic service, visual acuity was count fingers and she demonstrated 6 mm of lagophthalmos, a poor Bell's reflex, and a large central corneal epithelial defect (Figure ) Incomplete facial and trigeminal nerve palsies were diagnosed on the basis of lagophthalmos and reduced corneal sensation, and additional workup with neuroim

[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 patient with a BMI of 25 was referred to our tertiary center (Cerrahpasa Medical Faculty, Gynecological Oncology Unit) in August 2016 with the diagnosis of platinum-resistant ovarian cancer. She had undergone primary cytoreductive surgery 6 months ago. Her medical history was unremarkable except for treatment for epithelial ovarian carcinoma. Positron emission tomography and computed tomography (CT) revealed implants on the right diaphragmatic surface after first-line adjuvant chemotherapy. She has never had any thoracic or abdominal symptoms and no history of major trauma. Initial preoperative evaluation of the patient revealed no significant sign of diaphragmatic hernia. Her physical examination was normal, including chest auscultation sounds and chest X-ray. Thoracic CT did not reveal any abnormal image that could be evaluated as a diaphragmatic hernia. Secondary cytoreductive surgery and HIPEC were planned. She was placed in flank position, and, under general anesthesia, laparotomy was performed. An oval defect with the dimensions of 3 × 4 cm was seen in the left posterolateral site of the diaphragm (Fig. ). The most distal portion of the inferior lobe of the left lung was visible through the defect during inspiration and expiration movements. There was no herniation or strangulation of abdominal components. In addition, the right diaphragm was completely stripped because of a tumor implant. Meanwhile, a 6 × 3 cm iatrogenic diaphragmatic defect was detected (Fig. ). Drainage chest tubes were inserted bilaterally via the 6th intercostal spaces to avoid leakage of the chemotherapeutic agents across repaired diaphragm and postoperative massive pleural effusion. The tissue around the congenital left-sided defect was excised circularly and the defect itself was repaired with interrupted nonabsorbable monofilament sutures. The iatrogenic defect was also repaired with interrupted nonabsorbable monofilament sutures. After complete cytoreduction 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:
A 50-year-old female patient was referred to the Department of Oral and Maxillofacial Surgery of the VU University Medical Center in Amsterdam with complaints of a long ongoing unpleasant altered nasal airflow after the placement of eight dental implants in the maxilla. Four months prior to implant surgery, a bony augmentation of the atrophic edentulous alveolar crest and a bilateral maxillary sinus floor elevation using autogenous bone harvested from the anterior iliac crest had been performed. Shortly after implant placement, one of the implants placed in the area of the left first incisor had to be removed due to an oronasal fistula and subsequent lack of osseointegration. No further complications such as rhino-sinusitis, nasal discharge, pain, recurrent epistaxis, or headaches were reported.
However, anterior rhinoscopic examination revealed that the apical part of the dental implant placed in the upper right first incisor region had perforated the nasal floor close to the nasal septum and partially extended into the right nasal cavity (Fig. ). The mucosa of the left nasal cavity was intact and demonstrated no signs of inflammation. Radiological examination (dental and panoramic radiographs and computer tomography) confirmed that the implant placed in the right first incisor region had perforated the cortical bone of the nasal floor (Fig. ).
After a discussion with the patient regarding the risks and benefits of surgery, transnasal resection of the apical part of the titanium dental implant in general anesthesia was opted for. During surgery, the floor of the nasal cavity was locally anesthetized and the nasal mucosa surrounding the dental implant was incised and meticulously elevated exposing the nasal floor and the apical part of the perforating dental implant. Under direct vision and adequate sterile saline cooling, the perforating implant was resected to the level of the nasal bone initially using a hard steel fissure burr. The titanium surface was further 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 68-year-old Japanese man presented with weight loss of 6 kg over a 4-month period. His other medical problems included hypertension and hyperuricemia. The patient's family history was unremarkable. Physical examination revealed conjunctival pallor. Computed tomography (CT) revealed a 7-cm left renal mass, and renal biopsy confirmed a diagnosis of renal cell carcinoma (RCC), although no apparent adrenal metastasis was detected during the CT. Nevertheless, the patient underwent unilateral nephrectomy with ipsilateral adrenalectomy based on the current guidelines for RCC. The guidelines recommend ipsilateral adrenalectomy with radical nephrectomy for tumors that are >6 cm, based on their high risk of adrenal metastasis, even in the absence of radiographic evidence of metastasis.[
The surgery was uneventful, although the patient lost consciousness when he stood up for the first time on postoperative day (POD) 1. The patient's blood pressure could not be measured, and electrocardiography revealed ventricular fibrillation. The patient received 4 injections of epinephrine and 2 defibrillator shocks, which led to the return of spontaneous circulation at approximately 20 minutes after the ventricular fibrillation was detected. Pulmonary embolism was initially suspected, although CT failed to detect any emboli. The workup included coronary angiography, which revealed 90% luminal narrowing of the #6 branch of the lateral ascending artery, and the narrowing was attributed to vasospastic angina. The patient underwent percutaneous coronary intervention, which successfully stabilized his cardiopulmonary condition. Laboratory testing revealed marked increases in potassium levels and eosinophil counts from POD 1 to POD 2 (Table ), when the patient experienced the cardiopulmonary disturbance.
Two weeks after the percutaneous coronary intervention, the patient developed a retroperitoneal cystic infection, which induced fever and hypotension, and Pseudomonas aeruginosa was identified

[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:
Having the first intervention done at another health center, a 38-year-old male patient engaged in mining, presented to our emergency department (ED) with an isolated crush injury of the left leg 18 hours after lateral and medial sides of his left knee was temporarily squeezed at a high speed between a tree and an operative machine. The patient’s history revealed that he presented to the hospital 5 hours after the injury as the skin did not have a laceration. Investigation of the epicrisis reports and hospital records revealed that the patient underwent Doppler ultrasonography at the sixth hour. The Doppler examination revealed the presence of a probable thrombus\in the popliteal area. An embolectomy was attempted with a Fogarty catheter, but was unsuccessful as the catheter did not pass through the distal area. The patient presented to our ED at the 18th hour of the injury. In the immediate physical examination of the patient, the left knee level showed signs of paleness, coldness, anesthesia, hemorrhagic bullae, and ecchymosis posterior to the knee (). Tibialis posterior, dorsalis pedis, and popliteal arterial pulses were not felt. There was no motor function of the ankle and the toes. Successive tendon examination did not show any signs indicating a possible tendon injury. Radiographs of the leg did not show any bone pathology. The previously performed angiography revealed that the popliteal artery was totally occluded and there was no pathway to distal flow (). The patient was transfused 2 units of blood for hematocrit <27%, and as his general condition deteriorated an above-knee amputation was undertaken.
Under spinal anesthesia, the patient was placed in the supine position in a sterile field. Knee tendon examinations did not reveal any pathological finding under anesthesia.
A fish-mouth incision was performed over the skin and the fascia. The bone was shortened 10 cm proximal to the femoral condyle. The popliteal artery and the vein were identified, tied, 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 39-year-old male farmer was referred to our emergency department with generalized pain on the right leg with loss of the skin throughout the lower leg leaving the soft and hard tissue exposed to the environment shown in . He could not move his right leg and feel no sensation at some part of the limb. No history of loss of consciousness, amnesia, and headache was reported. He was a smoker and occasional drinker but did not have allergic and vascular risk factors such as hypertension, diabetes, or dyslipidemia. There was no history of medication use.
Two weeks earlier, he had a motorcycle accident and crashed into a truck with the right leg as the focus of impact. He was immediately brought to the hospital, where he was taken plain X-Ray on the right leg with suspicion of open fracture of the right lower limb. Clinically, the patient was alert and complained that he had intense pain and unable to move the right leg. The doctor explained the urgent need for operation as there was an open fracture observed, but the patient decided to discharge against medical advice and sought home treatment with a TBS. During the treatment, the leg was directly manipulated by holding the patient down, while the TBS performed the manipulation without using analgesics. The traditional herbs were used in the mixture and blended into a cream that was applied to the lower leg right after the manipulation. Afterward, the splint was applied over the herbal cream, and a bandage was put around tightly to hold the splint in place.
After 24 h, he started to feel intense pain, swollen and numbness throughout the right leg. He had a fever that developed in the following days with limb exuding foul-smelling discharge. Progressive darkening of the limb was noticed, and the leg was swollen. He was subsequently brought to the hospital and treated for five days. Before referred to our hospital, his vital signs were reported as blood pressure 90/60 mm Hg, pulse

[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 81-year-old Japanese woman with a 2-week history of abdominal distension presented to our hospital for assessment. The patient did not have a past history of malignancy, with only a cesarean section as a relevant feature in her history. Endoscopic examination at a previous hospital revealed the presence of early carcinomas in the stomach and distal esophagus. The patient was referred to our hospital for endoscopic resection.
Laboratory data, as well as serum carcinoembryonic antigen, squamous cell carcinoma antigen, and cytokeratin-19 fragment levels, were close to normal limits. Endoscopic examination revealed mild granular elevated lesions, with slightly depressed irregular mucosa, extending from the anterior wall to the right wall of the distal esophagus (Fig. ). This irregular mucosa further extended from the anterior wall to the left wall, with the boundary on the oral side being unclear (Fig. ). A superficial elevated tumor-like lesion was also observed in the lower body of the stomach, with a diameter of about 10 mm (Fig. ). Based on the endoscopic biopsy specimen, this gastric lesion was diagnosed as a well-differentiated tubular adenocarcinoma. On the other hand, the preoperative biopsy specimens of the esophageal tumor showed intraepithelial tumor cells, which were isolated or in clusters, and consisted of large clear cells with atypical nuclei and prominent nucleoli. No glandular structures and no obvious intracytoplasmic mucin were observed. These histological findings were consistent with a malignant melanoma, with a pagetoid spread of invasive adenocarcinoma or squamous cell carcinoma, and Paget’s disease as a differential diagnosis. Immunohistochemically, the tumor cells diffusely stained positive for CK7 and partially for CK20, with negative staining for S100 protein and HMB-47. On the basis of these results, a diagnosis of malignant melanoma was excluded. All human mucin core proteins examined (MUC2, MUC5AC, and HIK1083) were also negative. Furth

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


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

[User]
RADIOLOGY NOTE:
A 48-year-old woman presented to the gastroenterologist at a local hospital with a 1-year history of dysphagia, which had been progressively worsening over the preceding two months. During endoscopy, a bulging tumor 70 mm in length with an intact overlying mucosa was observed in the esophagus 30 cm away from the incisor (Fig. ). Endoscopic ultrasonography (EUS) demonstrated a hypoechoic and homogeneous mass in the submucosal layer. Subsequently, a chest computed tomography (CT) scan revealed a homogeneous irregular mass arising from the posterior wall of the distal esophageal wall that was 69 × 36 mm in size and compressed the esophagus and trachea (Fig. ). Physical examinations, biochemical tests and cardiopulmonary function were normal. This patient had no medical or family history and was referred to our department for further treatment. Surgical evaluations were discussed preoperatively. Based on the current imaging data, a diagnosis of esophageal SMT was made, most likely leiomyoma. The patient was not recommended further preoperative endoscopic biopsy, which could probably result in mucosal adhesion to the tumor and a subsequently increased risk of mucosal injury during surgery. Taking into consideration the precarious location and large size of the tumor, a decision of robot-assisted resection surgery via the right transthoracic approach was made. The plan was to completely excise the tumor and maintain the integrity of the esophageal mucosa with a low threshold for conversion. Additionally, an esophagectomy with intrathoracic gastroesophagostomy was prepared if the tumor could not be removed.
The surgical procedure was performed using a da Vinci Surgical System (Model S; Intuitive Surgical, Inc., Sunnyvale, CA, USA). After induction of general anesthesia and placement of a double-lumen endotracheal tube, the patient was placed in the left lateral decubitus position. A 12-mm camera port was inserted at the 10th intercostal space (ICS) at the midaxillary line.

[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 75-year-old woman with paraparesis was referred to our hospital for diagnostic studies based on tentative diagnoses of low spinal vascular malformation or secondary spinal bleeding. She had a history of hypertension treated with enalapril 5 mg/daily and atrial fibrillation treated with NOACs. Ten days before admission to the hospital, she presented to the emergency room of a regional hospital with abdominal pain. On physical examination, a spontaneous hematoma 3 × 4 cm in diameter in the left iliac muscle was found. The patient was taking dabigatran at the dose of 150 mg twice a day. Change of dabigatran to apixaban (2.5 mg twice a day) was recommended because of the high cardioembolic risk associated with underlying atrial fibrillation. The dose of apixaban was reduced because of bleeding risk. No other risk factors such as hemostatic or spinal disorders were present. Results of laboratory tests including coagulation tests and renal function tests were unrevealing. Ten days after discharge from the emergency room, she developed multiple cutaneous hematomas in the upper extremities and a sudden onset of predominantly distal bilateral crural motor deficit. She was admitted to the hospital where a predominantly left paraparesis was confirmed. A spinal magnetic resonance imaging (MRI) revealed a hemorrhagic focus suggestive of spinal vascular malformation, which was not confirmed at operation.
On admission to the Department of Neurology of our hospital, neurological examination showed paraparesis, predominantly distal and of the left side, with discrete hyperreflexia, hypoesthesia of the low dorsal deep sensitivity, indifferent left plantar reflex, and normal response on the right side. MRI of the spine revealed a large subdural hemorrhage with discontinuous cervical-dorsal-lumbar-sacral involvement with secondary spinal cord compression but without signs of associated vascular malformation (Figures and ). The patient was treated surgically, and D1

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


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

[User]
RADIOLOGY NOTE:
A 3-year old girl presented with swelling over the root of the nose. Her parents had noticed swelling 7 months previously, which was gradually progressive and was the size of a small lemon at the time of presentation. The swelling was not associated with fever, nasal obstruction, bleeding or any other nasal complaints. The patient was prescribed antibiotics and anti-inflammatory drugs by the general practitioner, following which the swelling decreased slightly. The patient had recurrent episodes in which the swelling increased in size. The size of the swelling decreased on medication, but never completed resolved. There was no history of tubercular contact or any other family history of tuberculosis. On examination, the root of the nose was broadened by the ill-defined 2.5×2.0 cm swelling, but the overlying skin was normal ().
On palpation, the swelling was soft and non-tender with a normal temperature. Anterior rhinoscopy revealed no abnormality. Blood analysis showed raised erythrocyte sedimentation rate (ESR; 38mm). The patient had a positive Monteux test, and a chest X- ray showed no abnormality. Contrast enhanced computed tomography (CT) of the nose revealed an enhancing soft tissue mass lesion in the superior aspect of both of the nasal cavities, measuring 2.0 ×1.8 × 2.8 cm (AP × TR × CC), eroding the intervening nasal septum, frontal and nasal bones at the glabella and reaching to the subcutaneous tissue ().
The base of the skull was eroded with a small intracranial extension. Magnetic resonance imaging (MRI) of the brain and paranasal sinus revealed enhancing soft tissue mass in the basifrontal extra-axial region with dural enhancement extending inferiorly into the superior parts of the nasal cavities with osseous destruction ().
The patient underwent endoscopic examination and biopsy under general anesthesia. On endoscopy, a smooth reddish mass was seen in the left nasal cavity. The mass was friable and found to be eroding the nasal septum, reaching the opp

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


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

[User]
RADIOLOGY NOTE:
Our patient is a 42-year-old male who initially presented to our clinic with a 5-year history of intermittent right knee pain.His medical history was significant for gout, managed with allopurinol, and he had previously undergone a nephrectomy to treat chronic renal disease. He denied any prior trauma to his knee but has worked in an oil field for his entire adult life. He reported a 2-month history of acute worsening of his pain as well as catching and locking symptoms that preceded his initial orthopedic assessment. He presented to our emergency room before orthopedic assessment due to sudden onset of right knee pain; blood tests revealed a uric acid level of 7.4 (normal) and a knee aspiration by the emergency room physician showed the presence of negative birefringent crystals. Pre-operative clinical examination of his right knee examination was significant for an effusion with medial greater than lateral joint line tenderness to palpation. His active and passive range of motion was 20—°, limited by pain. He had pain medially with McMurray testing and was ligamentously stable. He had no palpable gouty tophi within the knee and there was no evidence to suggest gouty tophi present anywhere else on his body. Weight-bearing knee radiographs showed mild tricompartmental degenerative changes with osteophyte formation. Magnetic resonance imaging (MRI) of the right knee displayed tears along the posterior horn of both menisci and mild thinning of the articular cartilage of the medial and lateral femoral condyles and mild osteophytoses. Given the patient’s presentation and new onset of mechanical symptoms, a diagnosis of symptomatic meniscal tearing in the setting of chronic degenerative osteoarthritis was made. The possibility of a gout flare was also discussed but thought unlikely due to the combination of his new mechanical symptoms with a negative prior history of knee involvement. After counseling of management options was completed, a trial of conservative care 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 64-year-old male was admitted to the orthopaedic ward with fever. He had a past medical history of smoking, nephrolithiasis and paraplegia following a motor accident 30 years ago. The patient suffered a mid-shaft fracture of his left femur 12 months earlier, without dislocations, treated conservatively with no operation. There were no recent gastrointestinal events, skin diseases or pressure sores.
A computed tomography (CT) scan on admission demonstrated avascular necrosis of the left hip joint with joint destruction and many fluid collections in the soft tissue around the joint. Blood tests showed a white blood cell (WBC) count of 20 210 µl−
1, and a C-reactive protein level of 29.5 mg dl−
1. Synovial fluid tapping revealed a WBC count of 80 000 µl−
1. Synovial fluid cultures and blood cultures were sent for analysis.
Septic arthritis of the left hip joint was diagnosed and the patient was treated with antibiotics including metronidazole and underwent surgical drainages of the hip. After initial surgical drainage, the patient developed multiple organ failure including cardiovascular instability, decreased urine output and acute respiratory failure due to septic shock and was admitted to our general intensive care unit (GICU). During the next 4 days in the intensive care unit, the patient continued to be septic with elevated temperatures (39.2 °C) and continuous leukocytosis (20 000 µl−
1). During this period, intensive supportive management included the administration of vasopressors and broad-spectrum antibiotics.
On a detailed workup of sepsis, multiple bloods, sputum, wound and stool cultures were obtained. Diagnosis of septic arthritis was confirmed by a positive synovial fluid for . A repeated CT scan of the left hip, pelvis and lower abdomen with contrast media demonstrated multiple, inoculated abscesses around the left hip joint area spreading to the left flank and anterior abdominal wall (). No evidence of colitis or other potential intra-abdominal sourc

[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 18-year-old male presented to clinic with a 1-year history of the left-sided shoulder pain and symptomatic instability. The patient also described an occasional popping sensation in the anterior aspect of the shoulder. The symptoms began after the patient was pushed into a wall while playing hockey which resulted in an anteromedial directed force to the left arm and shoulder. He further described this traumatic episode as a forceful adduction and internal rotation of the left arm. He denied any other trauma or surgeries to the shoulder and had no other relevant past medical history.
On exam, the patient’s pain was localized to the bicipital groove and the posterior glenohumeral joint line. Speed’s and O’Brien’s tests were positive. The load and shift test demonstrated posterior laxity with translation of the humeral head to the posterior glenoid rim without frank dislocation; which was markedly different when compared to the contralateral shoulder. A passive range of motion (ROM) demonstrated 160of forward flexion overhead bilaterally. The patient’s active internal rotation of the left arm behind the back reached the level of the T10 vertebrae and he had a negative liftoff and belly press tests. With the elbows flexed and arms at the patient’s sides, active external rotation was measured at 65 on the left. The patient demonstrated 5/5 strength in all directions of movement of the left shoulder. Magnetic resonance (MR) arthrogram and MR imaging (MRI) of the left shoulder joint were indicated medial dislocation of the LHBT with intact subscapularis and supraspinatus tendons (). No abnormalities were noted in the osseous structures of the shoulder and the posterior labrum was intact. However, the posterior capsule appeared to be enlarged on MRI studies. The treatment options were discussed with the patient, and the plan was made for open biceps tenodesis and arthroscopic posterior capsulorrhaphy with a possible labral repair if indicated

[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 54-year-old female presented with worsening left leg pain and swelling for one day. On presentation, her oral temperature was 36.7 degrees Celsius, heart rate of 76/minute, blood pressure of 129/88 mmHg, and respiratory rate of 18/minute with oxygen saturation of 99% on room air. She was in moderate discomfort due to pain and a physical exam was remarkable for erythematous swelling in the left leg extending from the ankle up to the pelvis. The entire left limb was tender to palpation with feeble distal pulses.
The patient’s medical history was significant for similar complaints about 30 years ago when she was on oral contraceptives. She stopped them on medical advice and remained well. Eight months prior to the current presentation, she was diagnosed with DVT. There were no risk factors identified at the time. Laboratory workup for procoagulant disorders was negative. She was initiated on warfarin while being bridged with low molecular weight heparin (LMWH). Her International Normalized ratio (INR) remained therapeutic through this time. About three months prior to the current presentation she was diagnosed with endometrial cancer and within a month of diagnosis, she underwent a total abdominal hysterectomy. The perioperative anticoagulation was managed with LMWH and warfarin was resumed on discharge with bridging. The current presentation was 90 days after her surgery.
In the current admission, hemoglobin was 9.8 g/dl, white blood cell count was 8670, and platelet count of 188,000 cells per microliter respectively. Her INR was 2.4. All these values were close to her baseline values. Her electrolytes were within normal limits and creatinine was 1.1 mg per deciliter. A venous duplex showed an acute occlusive DVT in the left lower extremity with a superficial thrombosis in the greater saphenous vein. A computed tomography (CT) with contrast of the abdomen and pelvis showed a persistent clot in the left femoral vein which had extended proximally as well as distally (

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


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

[User]
RADIOLOGY NOTE:
An 82-year-old male was admitted to the emergency department for worsening shortness of breath and hypoxia. He was admitted a week after he was diagnosed with a left ninth rib fracture secondary to a fall. He had long-standing history of chronic obstructive pulmonary disease, coronary artery disease, and peripheral vascular disease. Chest radiographs revealed a left pleural effusion and possible infiltrate. The patient was initially treated with a nebulizer, prednisone, and empiric antibiotic coverage with ceftriaxone and azithromycin. The patient failed to improve with the medical interventions and a therapeutic thoracentesis was performed. The thoracentesis was completed with ultrasound guidance, with the puncture made above the 11th rib at mid chest on the left. The pleural effusion was found to be frank blood. No immediate complications were noted, and the patient was taken to recovery. The next day the patient was found to be in respiratory distress. A chest x-ray revealed an opaque left hemithorax that was likely rapid accumulation of pleural fluid (Fig. ). A follow-up contrast-enhanced computed tomography (CT) of the chest performed during the arterial phase revealed a left intercostal pseudoaneurysm with hemothorax and adjacent compressive atelectasis (Fig. ). Ultrasound of the left chest wall was performed (Fig. ) directly over the thoracentesis site and doppler flow revealed bidirectional fluid flow, indicating the presence of a large pseudoaneurysm (Fig. ).
Following identification of the left intercostal pseudoaneurysm, the patient underwent a thoracic aortogram and multiple-level left intercostal angiogram (Fig. ) under IV conscious sedation. Selective catheterization of the T5, T6, and T7 intercostal arteries was unsuccessful in identifying the pseudoaneurysm. Selective catheterization of T10 and T11 intercostal arteries was performed with a C2 Cobra catheter, following multiple catheter exchanges due to the patient’s atherosclerotic vessels. The pseud

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


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

[User]
RADIOLOGY NOTE:
A 19-year-old boy presented to us for evaluation with the complaints of easy fatigability. He was a known case of congenital heart disease with patent ductus arteriosus and had undergone device closure for the same at 4 years of age. He was a diagnosed as a case of CEPS at the age of 13 years, when he underwent preanesthetic workup, to repair an accidental tibial fracture, which revealed transaminitis and subsequent ultrasound abdomen revealed the presence of CEPS. Echocardiography done revealed no residual patent ductus arteriosus with device in situ. There was significant right atrial and ventricular dilatation with estimated high pulmonary arterial pressure (estimated right ventricular systolic pressure of 90 mmHg) with preserved right ventricular function. Presence of high pulmonary arterial pressures which was initially attributed to late closure of patent ductus arteriosus could be contributed by the presence of high-flow extrahepatic portosystemic shunt, so he underwent CT of the abdomen to determine the type of shunt. CT demonstrated the presence of Type 2 Abernethy malformation with large window type communication between the portal vein and IVC []. He was subsequently planned for angiography to assess hemodynamics as well as possible closure of communication. Hemodynamics data revealed pulmonary arterial pressure of 75/43 with the mean of 50 mmHg against systemic pressures of 111/64 with the mean of 80 mmHg. Before attempting to close the extrahepatic portosystemic communication, the mean portal venous pressure was documented to be 13 mmHg with no significant increase postballoon occlusion. Angiography revealed large window type communication with IVC [], so it was decided to use covered stent in the IVC to close the communication. A self-expandable aortic stent graft (Endurant II 36 mm × 36 mm × 49 mm – Medtronic) was used to close the communication. Poststent implantation, there was complete closure of the communication. Within 24 h of stent graft placem

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


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

[User]
RADIOLOGY NOTE:
A 37 years old woman was admitted to the outpatient clinic due to a swelling on her neck, left upper eyelid ptosis and miosis for two years (). There was no palpitation, sweating and nervousness. On physical examination, there was a mass with a diameter of approximately 5 x 5 cm located at the left thyroid lobe and ptosis of the left eyelid. The thyroid functions tests in terms of free T3, free T4, TSH were normal.
Thyroid ultrasonography displayed that there was a solitary heterogeneous nodule which is 55 x 51 mm in size located at the left upper posterior of the gland. In addition, there were two nodules at the left thyroid lobe. The larger one is hypo-echogenous and has a dimension of 15 x 8 mm. The other nodule has a dimension of 7 x 5 mm, located at the posterior section of the right lobe (). Similar images were also observed in a computerized tomography (). Fine needle aspiration cytology of thyroid nodule was benign in terms of the cytological investigation.
The patient had consultation the ophthalmology department in aspect of ptosis and miosis. On the ophthalmologic examination (MC), there was left upper eyelid ptosis and miosis. Under the bright conditions, the pupil sizes were measured as 4 mm in the right eye and 2 mm in the left eye. Under the dim light, they were measured as 6 mm in the right eye and 3 mm in the left eye, and there was left pupillary dilatation lag. The pupils were equally responsive to both the light and near stimuli. Extraocular motility was normal in the eyes. No relative afferent pupillary defect was detected. Bilaterally, intraocular pressure was normal. There was no abnormal finding by slit-lamp and at the fundus examinations of both eyes. Best corrected visual acuities were 20/20 in both of the eyes. After instillation of topical aproclonidine (0.5%), (Iopidine, Alcon Laboratories Inc

[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.