[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 male presented to the emergency department with hematemesis and epigastric pain. On the evening of presentation, the patient reported difficulty in swallowing a piece of meat during dinner, which led to several episodes of retching followed by bloody emesis. His medical history was significant for extensive cardiovascular diseases including hypertension, stroke and pulmonary embolism for which an inferior vena cava filter had been in place. He had also undergone a carotid endarterectomy and taking daily aspirin. On initial presentation, the patient was afebrile, in sinus rhythm and normotensive. He had several episodes of hematemesis in the emergency department, and a nasogastric tube was placed with 500 ml of sanguineous output. Chest examination did not reveal any subcutaneous air, and lungs were clear bilaterally. On abdominal exam, however, the patient had tenderness to deep palpation of the epigastrium without any signs of peritonitis. Laboratories were significant for leukocytosis to 16.5 × 109/l and hemoglobin of 11.6 × 109/l. A computed tomography (CT) scan of the abdomen and pelvis with oral contrast was performed, which showed extraluminal contrast extending around the esophagus and around the left crus of the diaphragm that was compatible with esophageal perforation (Fig. A). The patient was resuscitated with fluids, started on broad spectrum antibiotics and after reviewing the CT scan was taken to the operating room for endoscopy, which revealed a 7-cm long esophageal perforation, starting at 29 cm and covered with blood clot. The gastroesophageal junction was identified at 42 cm from the incisors. About 1 l of blood was suctioned from the stomach and the GE junction was again visualized in retrograde view for possible involvement. There was no evidence of a tear in the gastric wall and no active bleeding was visualized. A partially covered self-expanding metal WallFlex stent (Boston Scientific) was introduced over a wire into the esophagu

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


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

[User]
RADIOLOGY NOTE:
A 51-year-old male with a history of nonischemic cardiomyopathy with a left ventricular assist device was admitted for expedited heart transplant evaluation. The evaluation included an elective colonoscopy in light of a family history of colorectal cancer in his mother who died at age 61 from the disease. The patient had his first screening colonoscopy at age 45 and was diagnosed with benign polyps, which were removed, and left-sided diverticulosis. The procedure was uncomplicated and he was advised to repeat a colonoscopy in five years.
The patient was without GI symptoms at the time of his colonoscopy. He denied tobacco, alcohol, or illicit drug use. His medications included amiodarone, aspirin, famotidine, levothyroxine, lisinopril, metoprolol, sildenafil, and intravenous heparin as well as torsemide, acetaminophen, docusate sodium, and melatonin as needed. On examination, he had a left ventricular assist device port entering at the upper abdomen, but otherwise the abdomen was soft and nontender to palpation with normal bowel sounds and no appreciable masses or ascites.
The patient underwent a standard bowel preparation which included a clear liquid diet the day prior to the procedure and 20mg of Dulcolax with 4 liters of polyethylene glycol the night prior to the procedure. Monitored anesthesia care sedation was administered with propofol. The colonoscopy was performed at night without difficulty with good bowel preparation. Abdominal pressure was briefly required to maneuver around the splenic flexure. The colonoscope was advanced to the cecum with identification of the appendiceal orifice and ileocecal valve. Findings included multiple sigmoid and descending colon diverticula and two, small (<5mm) sessile polyps that were removed using cold forceps.
The night of the procedure the patient had no pain or nausea and ate dinner and breakfast the following morning without incident. He then developed epigastric abdominal pain in the midmorning approximately 12-14 ho

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


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

[User]
RADIOLOGY NOTE:
We present a case of a 69-year-old female with a past medical history of multiple myeloma followed by autologous peripheral stem cell transplant who was hospitalized after presenting with worsening dyspnea. Prior to her stem cell transplantation, she was found to have pulmonary Cryptococcus neoformans infection and was placed on oral flucytosine and intravenous liposomal amphotericin B. Subsequent studies revealed no central nervous system (CNS) involvement, and flucytosine was discontinued. She was discharged from the hospital to complete two weeks of intravenous liposomal amphotericin B and a year of oral fluconazole. She was readmitted after two weeks due to constitutional symptoms of fever, loss of appetite, and fatigue in addition to dry cough. Cryptococcus serum titers were 1 : 640 during this time as compared to 1 : 2560 at diagnosis. Bacterial and fungal cultures taken from peripheral and central access sites revealed no growth and Aspergillus serum antigen was negative. Chest CT revealed worsening pulmonary infiltrates in both the lingula and right upper lobe with a strong suggestion of fungal source (). In this setting, a bronchoscopy with bronchoalveolar lavage was recommended. Concurrently, due to the expected low likelihood of dual infection with Cryptococcus and Aspergillus, empiric treatment of immune reconstitution syndrome was considered but held until invasive fungal infection was definitively ruled out. Subsequently, bronchoalveolar lavage was performed which showed an Aspergillus galactomannan antigen level of 3.258, confirming pulmonary aspergillosis, while cultures revealed no growth. Oral fluconazole was switched to oral voriconazole to provide additional coverage. Upon initiation of oral voriconazole, the patient defervesced and remained afebrile for the remainder of her nine-day hospital stay. She was subsequently discharged from the hospital after experiencing improvement in her condition and was diagnosed with pulmonary aspergillosis coinf

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


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

[User]
RADIOLOGY NOTE:
A 23-year-old male presented with a persistent moderate headache and blurred vision on the right side following the sudden onset of a severe headache 2 weeks previously. Computed tomography (CT) revealed a 4 cm-diameter hyperdense intracerebral hematoma in the left occipital lobe and a hypodense, thin chronic subdural hemorrhage along the left cerebral convexity (). Magnetic resonance imaging (MRI) showed no enhanced lesions besides the hemorrhage (), and cerebral angiography revealed no abnormal findings. Left occipital craniotomy and hematoma removal were performed for exploration. Intraoperative findings revealed the presence of mixed hematomas (liquid and dense hematomas) and small-sized abnormal vessels. Biopsy specimens of both hematomas and vessels were obtained. A histopathological examination revealed no tumor cells besides the hematomas and abnormal vessels. The patient underwent annual follow-up MRI evaluations, and no new lesions were detected for over 4 years ().
Five years later, a MRI revealed that a 7.5×4×5 cm-sized mass in the same location as the previous hematoma. The mass was visualized as mixed intensity on T1- and T2-weighted MR images and as a region of strong enhancement after intravenous gadolinium injection. There was no calcification and little cerebral edema was observed surrounding the mass (). Based on these findings, a brain tumor with intratumoral hemorrhage was suspected. The patient underwent a left occipital craniotomy and gross total resection of the tumor. Intraoperative findings confirmed that the tumor showed no continuity with the ventricular system (). Histopathological examination revealed clear cells with a sheet-like, papillary, or columnar to tubular arrangement. In addition, perivascular pseudorosettes were observed in the tumor. Immunohistochemical staining was focally positive for glial fibrillary acidic protein (GFAP) and epithelial membrane antigen, suggestive an ependymoma. Moreover, the tumor cells had diffuse nucl

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


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

[User]
RADIOLOGY NOTE:
The patient was a 66-year-old Caucasian female with a history of HS since 2010 with Hurley stage III lesions in the groins with six nodules and six sinus tracts. She had a HSS score of 63, DLQI score of 13, and visual analogue scale (VAS) for overall disease-related distress of 5.5 and VAS for boil-associated pain from boils in the past month was 0. The patient also had hypertension, smoked 20 cigarettes per day for 54 years and had a BMI of 26.4 kg/m2. She had no family history of HS. The patient was first seen in our clinic in 2016, where treatment with topical clindamycin twice daily and oral tetracycline 500 mg twice daily was initiated along with topical corticosteroids for local eczema. At 3-month follow-up, the skin was characterized by fibrotic and thickened cicatricial areas with purulent drainage and inflamed nodules. Topical metronidazole and oral lymecycline 300 mg twice daily were administered and the patient was referred to wide excisional plastic surgery of the groins, provided she stopped smoking 2 months prior to surgery.
Surgery was canceled due to continued smoking, and no further surgery was planned. She failed to seek further help for her HS until she was admitted 3 years later after severe worsening of HS, with multiple severe fistulae and a large foul-smelling tumor with drainage in the left groin and necrosis of lymph nodes (Figure ). A PET-CT showed ingrowth and destruction of the left ramus inferior of the pelvis and gland metastasis under the diaphragm. Biopsy demonstrated invasive poorly differentiated SCC, transformed from several years of chronic HS. The clinical picture was compatible with ulcerating vulvar cancer, and the patient received radiation therapy as a palliative measure. However, she was shortly thereafter deemed terminal and died 1 month after the initial metastatic SCC diagnosis.
A paper in 2016 by Jourabchi et al and in 2018 by Chapman et al described 80

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


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

[User]
RADIOLOGY NOTE:
A 73-year-old female patient visited the hospital due to left-sided hemiparesis. She did not have a family history of stroke and had been taking antihypertensive medication for the past 10 years and angina medication for the past 6 years. She had a chronic headache for past few years. She had frequent headache with nausea or vomiting on 15 days per month. A neurological examination was conducted, and left hemiparesis, paresthesia, and dysarthria were found (Fig. ). The muscle power of the left upper and lower limbs was Medical Research Council (MRC) grade III and the brain diffusion-weighted MRI (diffusion weighted image [DWI]) showed a right lenticulostriate artery territorial infarction. Obstruction and stenosis of the main vessel were not observed. Multiple CMBs were found in the bilateral deep gray matter and pons on GRE MRI (Fig. A). Transthoracic echocardiography was normal. Cilostazol 50 mg twice daily was administered for secondary prevention of stroke in consideration of the multiple CMBs. The muscle power of the patient's left upper and lower limbs improved to MRC grade IV on the 7th day of hospitalization so she was discharged. Outpatient follow-up examination found that the muscle power of patient's left upper and lower limbs improved to MRC grade V 1 month after discharge. However, her hypertension was not controlled. Therefore, the dose of existing hypertension medication was increased and the follow-up examination found that her blood pressure was well controlled afterward.
The patient presented with numbness in the left upper limb 6 months after discharge, and DWI and GRE brain MRI were performed. The newly taken DWI and GRE brain MRI were not different from previous images (Fig. B). Eight months after discharge, the patient experienced acute left hemiparesis and paresthesia with headache and she visited the emergency room within 1 hour of its onset. Neurological examination revealed that the muscle strength of the left upper and lower limbs

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


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

[User]
RADIOLOGY NOTE:
A 70-year-old male had a rapidly growing mass on his right thigh, with no pain, redness, and swelling observed on the surface of the mass.
The patient had underlying chronic hepatitis B virus infection, and was diagnosed with HCC. He had received a liver transplant for primary liver cancer 6 years prior. He was admitted to the hospital after finding a rapidly growing mass on his right thigh.
The patient underwent a liver transplant for primary liver cancer 6 years prior.
The patient was retired, living with his son, and had no family history of hereditary disease.
The patient was hospitalized and his physical parameters were examined. The vital signs were as follows: Body temperature 36 °C, heart rate 85 beats/min, respiratory rate 16 breaths/min, blood pressure 130/85 mmHg, and oxygen saturation in room air 95%. There were no apparent signs of cranial nerve dysfunction. Muscle tone, strength, and deep tendon reflexes were normal in the upper extremities, while low in the inferior extremities with more on the right side. Abdominal cutaneous reflexes were normal. The remaining physical examination was unremarkable.
After re-sectioning the right lateral femoral soft tissue mass, the patient was examined intraoperatively (right thigh mass) with a circumscribed mass of 5 cm × 3 cm × 2 cm. The findings revealed that small muscle tissue was attached to the surrounding mass, and a section of the mass was light brown, solid, and multinodular.
During admission, physical examination showed an oval-shaped mass with a diameter of about 5 cm on the anterolateral part of the right thigh. It was hard to touch, had poor mobility, and was attached to the surrounding soft tissue. He had normal blood flow from the right lower limb with adequate movement; the skin temperature was normal, no abnormality was found in the sensory nerve examination, the physiological reflex was normal, and no abnormality was found in the rest of the review. The ultrasound examination revealed a mixed echo

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


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

[User]
RADIOLOGY NOTE:
An 8-year-old girl with insulin-dependent diabetes mellitus was referred to the Pediatric Neurology Department for gait problems. She had been asymptomatic till 7 years of age when she developed polyuria, polydipsia, and acute onset vomiting along with high blood sugars, increased urine and blood ketones, and metabolic acidosis. A diagnosis of diabetic ketoacidosis with underlying diabetes mellitus was made, and she was started on insulin along with dietary and lifestyle modifications. The child responded well and was on regular follow-up with well-controlled sugars and normalization of hemoglobin A1c levels. Around a year later, she complained of gait problems. She had developed gradual onset progressive imbalance for 3 months, had frequent falls, and could not climb stairs without support. She could use her upper limbs well and did not have problems with handwriting. There was a history of slipping of slippers but no sensory loss. Examination revealed an ataxic gait with an inability to tandem walk or stand on one leg. There was no vision, hearing, speech, or cognitive issues. Deep tendon reflexes were absent in the lower limbs and power was 4/5 in distal lower limb muscles and normal elsewhere. Plantar reflexes were normal. She had loss of vibration sense in the lower limbs, but other sensations were preserved.
Nerve conduction velocity studies revealed an axonal type of generalized sensory neuropathy []. The presence of diabetes mellitus along with early-onset sensory neuropathy raised the suspicion of FA, and a two-dimensional echocardiogram was ordered. There was left ventricular (LV) concentric hypertrophy with infiltration (LV mass – 76.1 g) with impairment of LV function (ejection fraction – 52.5%). Trinucleotide repeat study for FA showed abnormally expanded GAA repeats on both alleles (>200), thus confirming the diagnosis. The patient was started on idebenone and enalapril along with continued management for diabetes. Ophthalmological and orthopedic scree

[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 man presented to our emergency department (ED) in January 2020 complaining of weight loss and asthenia for a few months. In anamnesis, there was a recent history of mononucleosis infection and the blood-test is shown above (). Physical examination revealed palpable spleen and protruding liver 4 cm below the costal arch, together with swollen latero-cervical and axillary lymph nodes bilaterally.
The patient underwent routine blood tests, chest X-ray, and abdominal ultrasound. Blood tests are reported as follows.
A chest x-ray showed no pathological changes, while an abdominal ultrasound detected an increased liver size (cranio-caudal diameter of about 18 cm), with regular margins and no focal lesions, and the spleen increased in size with biparietal diameter > 20 cm, free from focal lesions. The ultrasound also showed that the lymph nodes increased in size in the periportal area and at the level of the hepatic hilum and celiac tripod, with a maximum size of about 30 × 13 mm. Given the examinations and the clinical history, the patient was admitted to the Hematology Unit with suspected lymphoproliferative disease. A few days later, the diagnosis of visceral leishmaniasis was made based on the microscopic examination of bone marrow needle aspiration that described "intra and extracellular images consistent with Leishmania amastigotes". Treatment with Amphotericin B was started, and the patient was transferred to the Infectious Diseases department from which he was discharged after a week.
From the retrospective analysis of the clinical case, it can be concluded that the signs, symptoms, laboratory, and ultrasound were all suggestive of Leishmaniasis. Nonetheless, since the clinical presentation was very suspicious for a lymphoproliferative disease, the young patient was first admitted to the Hematology department, which in the end did not prove to be the most appropriate department. Thus, it is mandatory to take into account Leishmaniasis whenever a patie

[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:
Mrs. M.C., 72-year-old female, received a prescription for Tab Zolpidem 10 mg per day as a treatment for insomnia. She gradually increased the number of tablets and would take Zolpidem even during the day as it increased her efficiency to carry out work done earlier. Over an 8 month period, the use escalated to 300 mg per day following which she was noted to be sleeping most of the time during the day, and would not attend to her routine household chores. If she was denied the tablets, she would become irritable on minimal provocation, would complain of feeling weak, along with decreased energy and ability to carry out work done earlier and would also develop tremulousness of hands and feet along with craving for Tab. Zolpidem. In view of the above symptoms, patient was taken to a private psychiatrist. She was initiated on 6 mg of Tab Clonazepam per day and the dose of Zolpidem was reduced to 150 mg per day over a period of 28 days. However, the craving persisted and hence she was referred to this hospital.
On mental status examination at admission, patient was found to be anxious with increased psychomotor activity, ill-sustained concentration, and dysphoric mood along with tremors of outstretched hands.
On physical examination, no gross abnormality was noted except for pallor and blood pressure of 180/110 mm Hg. Routine blood investigations and chest X-ray were within normal limits. ECG showed evidence of right bundle branch block.
She was started on a daily dose of Cap Gabapentin which was initiated at 300 mg one in the morning and two tablets at night, and gradually increased by 100 mg every fifth day to the dose of 1200 mg per day and Tab Zolpidem was reduced by 15 mg every third day. Patient was successfully detoxified over a period of 30 days. At discharge, the dose of Gabapentin was reduced

[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 (height 140 cm, weight 20 kg) was referred to our hospital for dental treatment under general anesthesia with a chief complaint of an inability to open his mouth wide for dental treatment. The patient was diagnosed with spinal muscular atrophy (SMA) at one year of age through muscle biopsy. While he has clear consciousness, he has never walked, as he was unable to move his arms or legs. Since the age of 8, when he suffered aspiration pneumonia, he been completely bedridden and has been using continuous positive airway pressure (CPAP) during sleep. The patient usually has his neck turned to the left because he has difficulty breathing and sometimes experiences signs of dyspnea when he turns his neck to the right. He underwent two rounds of general anesthesia for scoliosis surgery in 2008 and 2010, and had a history of tracheostomy for dyspnea that occurred in the intensive care unit (ICU) after undergoing general anesthesia for the second time. In a limited manner, the patient was able to voluntarily open his mouth and was able to eat regular food. The patient has been complaining of pain in his TMJ and temporal area during mouth opening for 10 years, which hindered him from receiving treatment for long-term molar pain.
Therefore, he was referred to undergo general anesthesia for treatment of the molar area. However, we decided to defer general anesthesia due to a high risk of respiratory complications based on his medical history and physical examination, and instead performed local anesthesia of his TMJ area. We determined that the patient had severe pain in the bilateral temporal and TMJ area due to hyperextension of the mouth closing muscle while opening his mouth, and perform local anesthesia to alleviate tension in the TMJ and mouth closing muscle area during dental treatment. At the dental clinic, 1 mL 0.5% levobupivacaine was injected on each side of the TMJ and temporalis fascia before performing oral and maxillofacial surgery ().

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


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

[User]
RADIOLOGY NOTE:
A 29-year-old gravida 4, para 3 female with a past medical history notable for type 2 diabetes and elevated HgbA1c at 7.5% was first noted to have a fetal abnormality by nuchal translucency ultrasound (US) at an outside institution, with nuchal translucency measuring 3.8 mm. She underwent genetic counseling but declined further invasive testing. Cell-free DNA screening was performed and results were low risk for Down syndrome, trisomy 13 or 18. Given these abnormalities, however, she underwent further fetal ultrasound at 16 weeks and was noted to have ventriculomegaly with a suspected posterior fossa mass. She presented to our institution at 20 weeks 6 days gestation, and fetal US and brain MRI were performed. Obstetric ultrasound demonstrated symmetric bilateral enlargement of echogenic choroid plexus with associated ventriculomegaly and enlarged extra-axial fluid-filled spaces (Figure ), with differential diagnosis including intraventricular hemorrhage, choroid plexus hyperplasia or choroid plexus papilloma. Head size was larger than expected for gestational age (GA). Biparietal diameter measured 6.7 cm (corresponding with 27 weeks 2 days GA) and head circumference measured 24.2 cm (corresponding with 26 weeks 1 day GA).
An MRI scan of the fetal brain performed on the same day demonstrated bilateral ventriculomegaly (Figure ). The lateral ventricles measured up to 14 mm in atrial diameter, with normal morphology of the third and fourth ventricles. There was also marked enlargement of the supratentorial and infratentorial extra-axial subarachnoid spaces. The choroid plexus appeared enlarged bilaterally without definite hemorrhage on echo-planar imaging. Additionally, there was no susceptibility or T2 hypointensity outlining the ventricles or brainstem, suggesting that there was no prior intracranial hemorrhage.
Based on these MRI findings, targeted Doppler US was performed and demonstrated increased flow within the choroid plexus bilaterally. Thus, the US findings

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


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

[User]
RADIOLOGY NOTE:
A 40-year-old female, with 3-month history of nasal obstruction and tinnitus was admitted in August 2012. Nasopharyngeal endoscopy and biopsy already had been performed in another hospital, showing nonkeratinizing undifferentiated NPC. This histopathologic diagnosis was confirmed in our center. Magnetic resonance imaging (MRI) of the nasopharynx and neck revealed the tumor was confined to the nasopharynx and the bilateral locoregional cervical lymph nodes enlarged with its greatest dimension of 2 cm. Chest computed tomography (CT) scan, ultrasound of abdomen, and whole-body bone scan ruled out distant metastases. So clinical staging was determined to be T1N2M0, IIIA according to American Joint Committee on Cancer TNM Staging System for NPC (7th ed, 2010).
The patient was treated with definitive IMRT to 7050 cGy for primary tumor and 6600 cGy for infiltrated regional lymph nodes. Concurrent chemotherapy based on cisplatin and 5-flurorouracil was administrated for 2 cycles and then 2-cycle chemotherapy was given subsequently to consolidate the efficiency with the same regimen. At the end of therapy, she obtained clinical complete response by nasopharynx and neck MRI.
In the initial therapy, the patient had undergone abdominal ultrasonography for 4 times, and no hepatic lesions were noted during this period. Nevertheless, when she came to our hospital for 3-month conventional follow-up in April 2013, abdominal sonogram revealed a liver cystic lesion with thin wall and smooth margin of 18 × 16 mm in the right liver lobe, and the lesion was interpreted as a simple liver cyst (Fig. ). Therefore, intense follow-up was suggested. Five months later, the cystic lesion enlarged to be 59 × 46 mm, with thick wall, but no signal of blood flow. Further CT presented a low density and heterogeneous lesion taking irregular wall and incomplete septa with strong contrast enhancement, indicating liver abscess (Fig. ). However, the patient was asymptomatic, with no fever, no right up abd

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


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

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

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


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

[User]
RADIOLOGY NOTE:
In September 2011 a 52-year-old woman accessed our emergency department due to a progressive decreased level of consciousness, convulsion and sphincter’s release. Her pathological history reported an NSCLC treated seven months previously with neoadjuvant cisplatin (CDDP) based chemotherapy and upper left lobectomy. A computed tomography (CT) scan revealed one heterogeneous lesion measuring 1 cm in diameter at the right frontal lobe. Brain magnetic resonance imaging (MRI) detected two solid lesions, the first at the right frontal lobe of 1.9 cm in diameter and the second at the left occipital of 1 cm with surrounding edema and mass effect suggestive of metastasis. The woman received immediately dexamethasone 8 mg two times a day to relieve the symptoms and in October 2011 accessed our radiation therapy department for evaluation. To complete her staging she underwent a total body CT that revealed no other disease location. Thereafter, she received a single-fraction SRS on the two brain lesions. SRS was delivered by Hi-Art helical tomotherapy (HT) and planned using the 1 cm field width on a CT scan with a 2.5 mm slice thickness from the vertex to the second cervical vertebra. Dose prescription was hard constrained so that planning target volume’s (PTV) median dose equals the prescription dose. The patient was immobilized using the InterFix Radiosurgery Kit which fixes the patient’s skull to tomotherapy treatment couch. CT images were fused with MRI with 1 mm slice thickness, performed the day before on a GE SIGNA 3T scanner, to allow a better identification of the target and organs at risk (OAR). The clinical tumor volume (CTV) was expanded with an isotropic margin of 3 mm to obtain the PTV. Prescription dose was 21 Gy in a single fraction for each lesion (Figure -).
The patient well tolerated SRS and had no acute toxicity from the treatment. Approximately three months later, the first re-evaluation MRI showed stability of the two treated lesions,

[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 report the case of a healthy 19-year old male with no significant past medical or surgical history who injured his right foot his right foot in a road traffic accident and reported to our hospital within two hours of the injury. On examination, there was significant swelling of the foot with a 1.5 cm x 1 cm wound on the plantar aspect through which a bony prominence that appeared to be the head of the first metatarsal was visible. Sensation and vascularity of the foot were normal. Radiographs of the injured foot showed dorsal dislocation of the first and second MTP joints with dorsal displacement of the sesamoid complex ().
After thorough irrigation and debridement of the wound under local anesthesia, reduction was attempted within four hours of the injury using longitudinal traction and dorsally directed pressure over head of metatarsal through the wound and simultaneous plantar directed force on base of proximal phalanx in hyperextension as well as neutral position of the MTP joint, but reduction was not achieved. Patient was then investigated further and in the emergency OT under spinal anesthesia around 12 hours after the injury, reduction was again attempted but failed. The plantar wound (approx 2cm x 1.5 cm in size) which was already located in a nearly transverse direction over the 1st and 2nd metatarsal heads was extended 1.5 cm distally and medially for adequate exposure.
The head of the first metatarsal was found to be protruding plantarwards through a rent in the plantar fascia with intact collateral ligaments. The lateral collateral ligament was divided, a lever placed dorsal to the proximal phalanx, longitudinal traction and dorsal push was applied to the head of the metatarsal to achieve reduction of the 1st MTP joint. The sesamoid complex followed the proximal phalanx but the 2nd MTP joint remained unreduced after an attempt at closed reduction. A lever was applied dorsal to the head of 2nd metatarsal along with longitudinal traction through the sa

[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 51-year-old right-handed male patient diagnosed with signet ring adenocarcinoma of the gastroesophageal junction. He had surgical resection followed by chemotherapy and radiation therapy. Follow-up showed no evidence of disease recurrence.
Nine months later, he complained of left hip pain followed by mild left leg weakness. Subsequently, the patient was admitted with intestinal obstruction. During admission, he had gradual worsening of the left leg weakness and the development of right leg weakness. It associated with lower limb numbness and saddle area numbness. Initial spine magnetic resonance imaging (MRI) was normal. Nerve conduction study revealed mild motor axonal neuropathy. The patient was discharged from hospital after conservative treatment of the bowel obstruction.
Eight days following discharge, he presented to the emergency department with fecal incontinence and urinary retention requiring Foley catheter insertion and worsening of his lower limb weakness. Repeat spine MRI with contrast was normal. Two days later, he developed progressive bilateral facial weakness, slurring of speech, and swallowing difficulties. He had no headache, double vision, and no alteration of mental status. His review of systems revealed significant weight loss.
Examination of the patient during admission to neurology revealed dysarthric speech. His cranial nerve examination revealed facial diplegia, bilateral sensorineural hearing loss, and weak gag reflex. He had mild asymmetrical upper limb weakness and normal upper limb reflexes. He showed hypotonia of lower limbs, severe asymmetrical weakness, and absent lower limb reflexes. He had length-dependent sensory loss pinprick and normal vibratory and proprioceptive sensation. Furthermore, the patient had absent rectal tone. General examination was unremarkable.
The patient had repeat spine MRI with contrast (fig. ) which showed diffuse leptomeningeal enhancement surrounding the spinal cord and cauda equin

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


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

[User]
RADIOLOGY NOTE:
A 55-year-old man presented to our university hospital complaining of general fatigue for the past several months. 13 years earlier, he had undergone aorta valve replacement at our hospital for severe aortic regurgitation caused by infective endocarditis with aortic valve vegetations and had been receiving oral warfarin as an anticoagulant since that time. He was 167 cm tall, weighed 60 kg, and had a body mass index of 21.7. Laboratory investigations revealed severe anemia with hemoglobin of 4.4 g/dL, so he was admitted to the internal medicine department of our hospital for blood transfusion. He also reported a 5-year history of untreated right ankle pain that had worsened in the previous month. During this hospitalization, he was referred to our department for the assessment of the right ankle pain. On physical examination, there were tenderness, local warmth, and redness over the right ankle, especially on the anterior aspect, and range of motion at the ankle joint was limited to 0°of dorsiflexion and 5° of plantarflexion. Laboratory investigations revealed evidence of inflammation(white blood cell count 8600 cells/µL and C-reactiveprotein 8.44 mg/dL). Clinical examination showed no feature ssuggestive of congenital connective tissue disorder. Radiography and computed tomography images revealed osseous destruction and diffuse narrowing of the right ankle joint space ( and and , ). Synovial fluid culture from the right ankle was negative. After 18 days of hospitalization, when the anemia had improved (hemoglobin 10.7 g/dL), we performed anterior ankle arthroscopic surgery with heparin cover. The procedure included irrigation, extensive debridement, synovectomy with the removal of loose fragments, and curettage using standard anteromedial and anterolateral portals. Intraoperatively, dense fibrous tissue, aggressive hypertrophic synovitis, extensive severe chondral fibrillation, and subchondral erosion were seen in then arrowed ankle joint space ( and ). A sample 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 90-year-old man was admitted to our hospital to receive a permanent implanted pacemaker (VVI mode) to treat completed atrioventricular block. The patient had a medical history of percutaneous coronary intervention to the right coronary artery 10 years ago. He had a normal serum hemoglobin, platelets, red blood cell count, prothrombin time, and partial thromboplastin time. He was not taking any anticoagulant or antiplatelet medications.
A decision to implant a pacemaker was made, and we used left subclavian vein puncture, which is our preferred technique for venous access. The operator had almost 20 years of experience in cardiac pacing. The infraclavicular approach based on anatomic landmarks was used without the use of ultrasonographic guidance. Left subclavian vein access was attempted with an 18-gauge needle, a tear-away introducer 9 Fr sheath, and a guidewire with a J-shaped soft tip. The fluoroscopic guidance for guidewire navigation was used. Venous access was hard, and multiple puncture trajectories and sites were attempted. With venous access, there was blood return. A guidewire was inserted, the needle was removed, and the dilator was advanced. However, the pacemaker leads were then inserted with considerable difficulty and were removed. Venous access was reattempted. Finally, access to the left subclavian vein and implantation of the pacemaker succeeded. There was no established evidence of arterial puncture or needle-air reflux suggesting parenchymal puncture. The patient was sedated and had no complaints. During the procedure, he had normal oximetry, perioperative electrical parameters were adequate, and the pacing system was implanted. The procedure ended without incident. However, in the hour after the procedure, the patient's blood pressure steadily decreased while his heart rate steadily increased. Hemodynamic deterioration did not respond to fluid resuscitation. A chest radiograph showed a left hemothorax (). A left hemothorax and pseudoaneurysm o

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


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

[User]
RADIOLOGY NOTE:
Case 2 was a 75-year-old Japanese man who presented at our hospital with acute abdominal pain, nausea, and cold sweat. His CT scan showed retroperitoneal bleeding (around the pancreas and the dorsal side of the ascending colon). His general condition was stable, but he was admitted to our hospital as a conservative measure. His angiography (6 days after admission) showed an aneurysm of the pancreaticoduodenal artery without active bleeding.
Our experience treating MAL syndrome in case 1 enabled us to diagnose the disease accurately in case 2. MAL syndrome was the cause of the aneurysm in this patient too (). We selected laparoscopic surgery based on the MAL syndrome and the benefits of this surgery. The patient's posture for the surgery was the lithotomy position. Intra-abdominal pressure of 12 mmHg was maintained. The points of the trocars were as follows: a 12 mm trocar at the navel for the camera, two 12 mm trocars at the right upper abdomen, and a 12 mm trocar and a 5 mm trocar at the left upper abdomen ().
First, we lifted the liver umbilical ligament by surgical sutures and put in an organ retractor to the crus of the diaphragm in order to improve the field of vision. After opening the omental bursa, we lifted the stomach with a snake retractor and observed the dorsal side of the stomach. We confirmed the left gastric artery and tied it with tape. The tape was taken out from the right outside trocar, and an assistant pulled it to provide traction of the surgical field. Following the celiac artery to the root, the artery was fastened by the MAL. We cut the MAL away little by little with a vessel-sealing system until the running direction of the celiac artery was clearly confirmed. Using a blood flow meter, we confirmed the improvement of blood flow of the left gastric artery (from 5 mm/min to 69 mm/min). A drainage tube was placed in the left sub

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


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

[User]
RADIOLOGY NOTE:
A 36-year old woman was admitted acutely to our institution with a four week history of increasingly intrusive palpitations associated with pre-syncope. She was 31 weeks into her second pregnancy having experienced no problems during the first or second trimester or at all during her previous pregnancy 6 years earlier. Ambulatory monitoring organised prior to her admission had demonstrated frequent unifocal premature ventricular contractions (PVC) including couplets and triplets, and short salvos of non-sustained ventricular tachycardia (VT) corresponding with symptoms. The initial physical examination, electrolytes and laboratory investigations were unremarkable. Obstetric assessment revealed a healthy fetus consistent with 31 weeks of gestation.
Her electrocardiogram during a typical episode revealed a monomorphic wide-complex tachycardia of left bundle branch block morphology consistent with an origin from the right ventricular outflow tract (). Echocardiography demonstrated a mildly dilated left ventricle with normal function and an ejection fraction of 63%. Initial attempts to control her arrhythmia medically with oral and intravenous metoprolol were unsuccessful. The patient was subsequently treated with oral verapamil therapy but, despite initial benefit, suffered with recurrent and increasingly sustained episodes of VT associated with hypotension and pre-syncope. Following obstetric consultation, the option of catheter ablation was offered as a therapeutic option. After discussion of the potential risks to the mother and foetus, both of the procedure and of potential radiation exposure, informed consent was obtained.
The patient was brought to the electrophysiology laboratory in the postabsorptive state and placed in the left lateral position using a wedge to decompress the inferior vena cava. A midwife was present to monitor the foetal heart rate. Lead shielding of the abdomen and pelvis was used to shield the fetus as much as possible if any fluoroscopic 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 49-year-old male smoker with a history of squamous cell carcinoma was found to have a 4 cm left hilar mass on CT scan. An EBUS FNA performed of the mass demonstrated abundant mucinous material with clusters of pleomorphic cells []. The nuclei were enlarged and hyperchromatic, with coarse chromatin and dense basophilic cytoplasm. The background showed abundant mucinous material with entrapped inflammatory cells and bronchial cells []. The ROSE was malignant, favoring a nonsmall cell carcinoma; however, it was uncertain if the mucin was associated with the neoplastic cells or simply a contaminant. The immunohistochemical stains performed on sections of the cell block revealed that the tumor cells were positive for p63, CK5/6, and negative for TTF1. In addition, the tumor was similar in morphology to the patient’s prior lung biopsy with a diagnosis of squamous cell carcinoma. The final diagnosis was metastatic squamous cell carcinoma with the mucin attributed to bronchial contamination.
This case illustrates the discrepancy or mismatch that may exist between background material and the cells of interest in EBUS FNA. For example, a mucinous background usually leads us to infer that there is a mucin-producing adenocarcinoma []; however, similar to pancreatic EUS-guided FNAs, mucin can be a contaminant from the needle path and is not necessarily produced by the tumor cells present. This is an important aspect of EBUS FNA to be aware of, particularly because cytopathologists often rely on the background material to aid in making a diagnosis and for subtyping tumors.
When looking at an EBUS FNA with a mucinous background, there are two cytomorphologic clues that can help to determine if the mucin is truly indicative of a mucin-producing adenocarcinoma. The first clue is the presence of columnar cells, or cells with voluminous mucinous cytoplasm or targetoid vacuoles with a central mucin droplet. A second clue is the presence of “dirty” mucin with entrapped inflammatory ce

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


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

[User]
RADIOLOGY NOTE:
A 24-year-old married Arab woman had been admitted to a local health center 2 months prior to referral to our urology department. She had been hospitalized there four times in 1 year for acute pyelonephritis. The fourth episode raised the suspicion for an underlying problem and justified her referral to our urology department after management of the acute pyelonephritis.
On admission, she complained of ascending left-sided flank pain during micturition but did not have dysuria or hematuria. She also had a history of frequent urinary tract infections (UTIs) as a young adult.
She was perfectly asymptomatic on the right side. A physical examination was normal. Her temperature was 37.4 °C, her blood pressure was 128/84 mmHg, and her pulse rate was regular at 76 beats per minute. Laboratory tests were normal; in particular, a urine examination showed no leukocyturia or bacteriuria.
She underwent an abdominal ultrasound which showed an asymmetric size of the kidneys and a bilateral chronic pyelonephritis aspect. Her right kidney measured 10 cm while the left measured 12 cm.
A voiding cystourethrography (VCUG) was performed and showed grade IV VUR on the left side and grade I VUR on the right (Figs. and ).
An abdominal and pelvic computed tomography (CT) scan detected a left completely duplicated collecting system with hydroureteronephrosis and poor opacification of the upper pole moiety. In addition, the parenchyma of the upper pole moiety was atrophied with secretory and excretory delay. In association with VCUG findings, it appeared that the refluxing ureter was the one that drains the upper pole moiety and inserts lower into the bladder. On the right, a duplex collecting system was detected with hypotonic calyces, pelvis, and ureter of the upper pole moiety. An atrophic parenchyma and poor opacification of the upper pole moiety was also detected (Figs. and ). Renal scintigraphy was not available.
We carried out a left hem

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


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

[User]
RADIOLOGY NOTE:
This study presents a 55-year-old male admitted in our center with a 1 × 1 centimeter laceration on the sacral area skin, 12 cm above the anus. He had fallen from a mulberry tree and had removed the sunken tree branch. He presented no neurological deficit or fever and had a normal sphincter function. The laceration was dirty with slow CSF leakage. The pelvic X-ray showed an area of defect in the sacral region (). The computed tomography (CT) of the spine revealed a hypodense penetrating object that was introduced from the posterior aspect of the sacrum into the dural space and then stopped in the S1 vertebral body, and the object did not penetrate the anterior cortex of the vertebral body (Figures and ).Because of the possibility of pelvic organ injury in cases of penetrating sacral injury, we consulted with an expert general surgeon. Based on normal findings on physical exam and pelvic CT scanning, our consultant surgeon assured us. Thereafter, the patient was transferred to the operating room. Under general anesthesia, the patient was operated in prone position. Muscle dissection revealed a wooden foreign body on the sacral lamina that passed into the S1 body (). First, a laminectomy of an intact superior portion of the S1 lamina was performed and the wood was released from the surrounding bone, and finally, it was pulled out. Before the wood was removed, the dural sac was mildly compressed above the level continuously, to prevent CSF from filling our surgical field. Also, a portion of the patient's clothes was removed from the vertebral body (). The bone defect was massively irrigated, and the defect of the dura was repaired with Prolene suture separately in a watertight manner. Thereafter, the Valsalva maneuver was performed and no CSF leakage was observed. Finally, the surgical wound was closed in a layer-by-layer manner. The patient was under close observation for 3 days and then discharged without any deficit

[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 86-year-old female patient with a history of hepatic hydatid cyst since 2012 presented in November 2016 with a history of productive cough, yellowish-green sputum with mild shortness of breath, and loss of appetite. She had no complaints of chest pain, fever, palpitations, nausea, or vomiting and did not report any change in bowel habits or urinary symptoms. The patient was from a rural area. She had a history of long-term antiparasitic medication; however, details about the indication for and type and course of therapy were not available in the medical records. On respiratory examination, the lungs were found to be clear with good air entry bilaterally; fine crepitation was noted. The patient was admitted for investigation. Sputum culture showed scanty growth of normal respiratory flora, and rhino virus was detected in nasal swab culture. Chest X-ray showed a mass-like opacity in the right lower zone, in the right paracardial area. A nonhomogenous airspace opacity was observed in the left lower lung zone associated with a small left pleural effusion that indicated atelectasis or infection as differential diagnosis. Thoracic computed tomography (CT) was performed to investigate the mass-like opacity in the right lower zone. The CT showed multiple intraluminal cystic filling defects in the right main pulmonary artery and right lobar branches, mostly pulmonary artery hydatid cysts (see Figures and ). There was one large cyst in the right lower lung lobe representing a parenchymal hydatid cyst and another large cyst existed with air in the left lower lobe representing hydatid cyst in the left lung (see ). There was minimal bilateral pleural effusion, more on the left side. We conducted magnetic resonance imaging (MRI) of the thorax, which confirmed the presence of the cystic lesion within the right pulmonary trunk extending to the right lower lobe, showing low signal intensity on T1 and high intensity on T2 images with septation (see Figures and ). Parenchymal hydat

[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 85-year-old Caucasian woman presented to our hospital with right flank pain 10 years ago. She had a past medical history of type 2 diabetes mellitus and essential hypertension. She denied any history of thyroid disease and neck irradiation. She had no family history of any cancer. She was a housewife and had no history of tobacco smoking or consuming alcohol. A physical examination at the time of presentation was not significant except for right costovertebral angle tenderness. Her heart rate was 96 beats per minute and blood pressure was 155/90 mmHg. The findings of laboratory tests, which were complete blood count, liver and renal function tests, and urine analysis, were within normal range and they did not help us find the etiology of her right flank pain. Abdominal screening with computed tomography (CT) revealed a mass on her right kidney, which was considered a primary renal cell carcinoma and she underwent a right nephrectomy. Unexpectedly, PTC metastasis was diagnosed from demonstrative histopathological findings, such as positive immunoperoxidase staining for thyroglobulin (Tg). After further examinations of her thyroid and neck with ultrasonography (USG), a total thyroidectomy was performed. Pathological examination of thyroid tissue revealed a 5 cm tumor with capsular invasion and a strong positive immunoperoxidase staining of cytokeratin-19, HBME-1, and galectin-3. She was diagnosed as having metastatic PTC. Orally administered levothyroxine 75 mcg daily was initiated in addition to the metformin 1000 mg twice daily and amlodipine 10 mg daily treatments she received prior to PTC diagnosis. Postoperative serum Tg was above 300 ng/ml and anti-Tg was negative. Afterward, she was screened with unenhanced thoracic CT and skeletal scintigraphy. They revealed bilateral multiple nodules in her lungs and bone metastasis on T10 vertebra and right sacroiliac joint. Initially, 30 Gy radiotherapy was implemented to her T9–10 vertebrae for 12 days. We also started

[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 fifty-year-old male presented with a one-month history of left shoulder pain unresponsive to conservative management. The patient was a nonsmoker with a BMI of 27, a history of dyslipidemia, and no prior history of shoulder problems. Upon physical exam the patient had decreased ROM of the left arm as well as a positive Jobe sign, Hawkins sign, and Speed test. An MRI was consistent with a large, full thickness rotator cuff tear with fatty infiltration of the supraspinatus and infraspinatus. The patient was diagnosed with a full thickness rotator cuff tear and opted for surgical management. On the day of surgery, the patient was given a preoperative, ultrasound-guided, interscalene nerve block with 25 mL of 0.5% ropivacaine administered with a 21 gauge, 90 mm, echogenic short bevel needle. Next the patient underwent induction of general endotracheal anesthesia. The patient was placed in the lateral decubitus position with the head in a neutral position, and a boom was used to apply 15 pounds of traction throughout the arthroscopic procedure. Glenohumeral debridement and subacromial bursectomy were performed arthroscopically, followed by repair of the supraspinatus and infraspinatus rotator cuff tendons. Inspection of the biceps tendons revealed extensive synovitis. Traction was released and an open subpectoral long head biceps tenodesis was performed. The total case time was three hours and twenty-eight minutes.
The patient presented seven weeks postoperatively with the inability to flex the left thumb interphalangeal joint or the index DIP joint; he was diagnosed with AIN palsy. The patient also had mildly decreased sensation to light touch along the median nerve distribution in the hand and mildly decreased sensation to light touch and subjective paresthesias along the ulnar nerve distribution. However, according the patient, the findings along the ulnar nerve distribution existed prior to the surgery. He was observed clinically and at twenty-two weeks postoperati

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


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

[User]
RADIOLOGY NOTE:
We present a case of a 36 year old male who was admitted with recent onset of shortness of breath. CT pulmonary angiogram demonstrated large right sided pulmonary emboli (Figure ). Moreover, a filling defect was noticed in the right atrium (Figure ). The defect appeared to be lobulated, irregular, of low attenuation and arising from the free atrial wall. On transthoracic echocardiography (Figure ) the mass was demonstrated to be extending through the tricuspid valve. A presumptive diagnosis of right atrial myxoma with complicating pulmonary embolism was made. Urgent surgery was arranged. At the time of surgery the right atrial appendage was noted to be very congested and "angry looking". Total cardiopulmonary bypass was established using aortic and bi-caval cannulation. The right atrial cavity was found to be replaced by a friable tumor which had "fronds like" appearance (Figure ). The mass was extending through the tricuspid valve to the right ventricle. A sample of the tumor was subjected to frozen section examination which suggested the diagnosis of Leiomyosarcoma. The entire free wall of right atrium was excised extending from and to the origin of vena cavae. Anteriorly the incision was carried forward up to the atrioventricular groove, taking care to preserve the right coronary artery while ensuring macroscopic clearance of tumor. The resection margins were submitted for histological examination and were subsequently proven to be tumor free. The right atrium was reconstructed using autologous pericardium (Figure ). Bilateral pulmonary embolectomy was also performed. Histological examination of tumor confirmed the frozen section findings. On the cut surface, the tumor had a whirled white appearance, with focal brown areas. The microscopic examination revealed the presence of a spindle cell tumor, forming fascicles orientated at right angles. The study revealed the morphological aspect characteristic to leiomyosarcoma.
Although resection margins were clear the ma

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


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

[User]
RADIOLOGY NOTE:
This is a 30-year-old man who sustained an open, segmental right femoral shaft fracture and an ipsilateral femoral neck fracture after being hit by a vehicle while riding a scooter. He initially underwent irrigation and débridement of the open fracture, retrograde intramedullary nail fixation of the right femur, and dynamic hip screw fixation of the ipsilateral femoral neck (Figure ). The patient was instructed to be nonweight bearing on the right leg postoperatively; however, 3 weeks later, he sustained a fall, which resulted in failure of the intramedullary nail at the level of distal extent of the dynamic hip screw construct. The patient then underwent revision of the intramedullary fixation and stage 1 of the induced membrane technique after the segment of devitalized diaphysis was removed. The segmental defect of the femur diaphysis measured 9.3 cm medially and 4.8 cm laterally. During this period, the patient remained nonweight bearing on the right leg. One month after stage 1, the patient underwent stage 2 with the removal of the antibiotic spacer and placement of autograft bone from the iliac crest and proximal tibia. The patient was made nonweight bearing on the right leg for 12 weeks, advanced to toe-touch weight bearing for three more weeks, and finally progressive weight bearing. However, the patient continued to have pain at the fracture site. Nine months later, he was diagnosed with a right femur nonunion. He was referred to the author and underwent a repeat autograft bone grafting of the right femur defect with RIA (Depuy Synthes). At that time, placement of a fibular strut allograft was performed as described above. The patient was made toe-touch weight bearing after surgery and advanced to partial weight bearing of 25% to 50% body weight 6 weeks after. Ten weeks after surgery, he was advanced to partial weight bearing of 50% to 75% body weight. The patient was finally advanced to full weight bearing 5 months after the last surgery. At the last visit

[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:
Here, we report a 57-year-old Caucasian female, with an unremarkable past medical history, who was referred to our neurosurgical department after she presented with an incidentally found lesion on magnetic resonance imaging (MRI) of her lower spine. On physical examination the patient did complain about discomfort in her pelvic area when sitting, left greater than right. However, she did not have any related neurologic complains such as back pain or leg pain, nor did she display any weakness, numbness or tingling sensation or other signs of radiculopathy. The mass was incidentally discovered on lumbar MRI, which was obtained for evaluation of her atypical pelvic pain.
Routine MRI was obtained demonstrating a right-sided sharply demarcated, poorly and heterogeneously contrast enhancing paraspinal lesion at the junction of the lumbar and sacral spine. The mass was localized immediately adjacent to the posterior elements (lamina and spinous process) and was deeply seeded in the right multifidus muscle adjacent to the L5 inferior articular process. It measured approximately 3.0 × 3.0 × 3.5 cm in size on T1 postcontrast images
[]. Based on radiographic criteria alone, the differential diagnosis included: Schwannoma, lipoma or liposarcoma, fibroma, myoma, sarcoma or metastatic disease among rare other entities. A full systemic work up was performed and included a contrast enhanced computed tomography (CT) of the chest, abdomen, and pelvis as well as a mammogram and were negative for any other focus of systemic disease. As the lesion was concerning for a neoplasm, the patient was counseled and advised to pursue a histopathological diagnosis to direct further treatment options. She opted for an open surgical approach aiming for an excisional biopsy and she was consented and taken electively to surgery.
Preoperative repeat MRI was performed within a 4 week window after initial presentation and revealed an unchanged right-sided paraspinal lesion at the level of the lower pos

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


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

[User]
RADIOLOGY NOTE:
A six-month-old female infant was referred to cardiology due to progressively increasing oxygen requirements and cardiomegaly on chest X-ray. She was born at 25 weeks of gestation and had multiple medical problems in the early neonatal period including retinopathy of prematurity, hyaline membrane disease, gastroesophageal reflux, severe liver dysfunction, and suspected necrotizing enterocolitis. She had a history of ligation of her patent arterial duct on the 16th day of life. On physical exam her respiratory rate was 65, her heart rate was 153, and blood pressure was 130/80 mmHg. Her oxygen saturation was in the low 90s on 30% FiO2 (fraction of inspired oxygen). Her lung sounds were coarse. Her heart had regular rate and rhythm, with no murmurs. Her abdomen showed a liver edge that was palpable three centimeters below the right subcostal margin. She had a palpable bruit at the left antecubital fossa. Pulses were normal and equal on all extremities, and there were no obvious discrepancies in limb lengths. An echocardiogram showed severe pulmonary artery hypertension with mild right ventricular and atrial dilatation, with a patent foramen ovale shunting right to left. Biventricular systolic function was normal, with no evidence of left ventricular hypertrophy or dilatation. A duplex ultrasound of the left upper extremity showed presence of an AVF between the left brachial artery and vein as evidenced by increased flow obtained from the left brachial artery with dilated, tortuous brachial veins demonstrating arterialized flow along the length of the veins. Velocity measurements of up to 692 cm/second were obtained at the level of the AVF (Figures and ).
The calculated blood flow in the fistula was estimated to be about 450–500 mL/min, which is equivalent to up to twice the estimated total cardiac output for this patient. The fistula was not ligated because its location was high risk for limb-loss. She was managed with diuresis and blood pressure control. One month lat

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


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

[User]
RADIOLOGY NOTE:
The present case is about a 48-year-old, female patient had presented fullness of abdomen, right flank pain and on and off hematuria for last 1 month. Computed tomography (CT) imaging revealed a large localized tumor of the left kidney with features not suggesting of any metastasis []. Right radical nephrectomy was done and grossly it was a 18 cm × 15 cm × 6 cm tumor replacing upper pole of kidney. Histopathology came out as clear cell RCC with Furhman's grade III with no capsular invasion and adrenal and hilar vessels were free of tumor. In the routine follow-up at 3 months, she had no complaints and CT scan was unremarkable. After 9 months of surgery, she complained of pain in the right hypochondrium radiating to shoulder. Ultrasonography followed by CT chest and abdomen was performed which delineated multiple liver metastasis, few lung metastasis and small ovarian mass (3 cm × 4 cm) [Figure and ]. Fine-needle aspiration cytology of the liver lesion confirmed it as metastasis from RCC []. Bone scan of the whole body did not show any evidence suggestive of skeletal metastasis.
The patient received sunitinib via an expanded access program at standard dose of 50 mg orally continued for 28 days followed by 14 days off. She was kept under strict follow-up for complications and objective response of the tyrosine kinase inhibitor (TKI). After two 6-week cycles side-effects experienced by the patient included grade 1 mucositis, grade 1 skin changes, grade 2 taste and grade 1 fatigue. Due to this, the patient was converted to dosage of 37.5 mg orally once daily (for 28 days followed by 14 days off). The patient tolerated this regimen well with no further adverse events. After eight 6-week cycles of sunitinib she complained of lower abdomen discomfort. A reassessment CT scan of the patient's chest, abdomen and pelvis showed an excellent partial response with the almost complete disappearance (90%) of liver and lung metastasis []. However

[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 seventy-six years old lady presented to our Emergency Department with complaints of progressive worsening of headache eleven days in duration and acute onset of several episodes of vomiting since the past two days. She was referred from another center where she was treated symptomatically with no relief of either pain or vomiting. She reported no weakness or numbness of upper and lower limbs. There was no history of fever, abnormal body movements and loss of consciousness. She reported decreased appetite and alteration of sleep habit. She did not give any history of recent trauma or falls. She however gave a history of head surgery 20 years back for a subdural hematoma that she had due to a fall and a leg fracture 7 years ago which was fixed with plates. An interesting revelation was that the patient had remained unconscious for three months following her previous surgery for SDH evacuation.
On examination, she was ill-looking. Her vitals were normal. Cardiovascular, respiratory and abdominal examination were normal with a blood pressure of 140/80 mm Hg , pulse rate of 80 beats per minute, a respiratory rate of 20 breaths per minute and oxygen saturation (Sp02) of 98%. She was afebrile, conscious with a Glasgow Coma Scale of 15 and normal neurologic exam, including that of cranial nerves. Tone, power and reflexes were normal in both upper as well as lower limbs. Sensations to all four limbs were also preserved. Palpation of spine revealed no tenderness or steps.
Initial laboratory investigations including random blood glucose, hematological profile including that of clotting, liver and renal function tests and other basic tests were normal. A non-contrast CT scan of the head was ordered in the ER which revealed a small hyperdense area surrounded by hypodense areas indicating acute on chronic, right subdural hematoma with a small acute bleed around the temporal lobe and a chronic bleed around the temporoparietal region. The CT also showed a massive hypodense area i

[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 79-year-old male was referred to the surgical outpatient department with a 2-month history of altered bowel habit. Abdominal examination and digital rectal examination in the outpatient clinic were unremarkable.
The laboratory studies, full blood count and biochemistry were normal. A colonoscopy study identified four abnormal lesions, two of which were colonic subcentimetre polyps. More distally in the mid-rectum, at 15 cm from the anal verge, there was a sizeable, villous polypoidal lesion, which was proved on biopsy to be a tubulovillous adenoma (TVA) showing low-grade dysplasia. More proximally in the distal sigmoid colon at 25 cm there was a segment of a malignant-looking lesion associated with a stricture (). However, biopsy samples from this region showed hyperplastic colonic mucosa showing lamina propria fibrosis and mild chronic active inflammation with separate pieces of granulation tissue and ulcer slough but no evidence of malignancy.
As per local protocol for malignant-appearing lesions on endoscopy, a staging CT scan was arranged on the basis of the colonoscopy appearances to facilitate the cancer pathway. This demonstrated, at the site of the presumed malignancy in the distal sigmoid colon, a 7 cm segment of circumferential thickening on a background of diverticulosis (). This was associated with a few subcentimetre locoregional and inferior mesenteric lymph nodes. There was no suggestion of malignancy elsewhere; so the proposed CT staging was T2/3 N1 M0.
Although the 5 cm rectal TVA could explain the patient’s symptoms it was felt at the multidisciplinary team discussion that either lesion could be responsible for the patient’s symptoms. Despite the lack of malignant cells from the biopsy samples the surgical team were still concerned about a potential sigmoid colon malignancy from the endoscopy and CT appearances. It was felt that the colonoscopy sampling was not truly representative of the malignant appearing sigmoid colon lesion seen at colonosco

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


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

[User]
RADIOLOGY NOTE:
A 58-year-old male with a past medical history of atopic dermatitis and severe psoriasis on Risankizumab (Skyrizi) presented with a chief complaint of progressive left leg swelling for a week associated with erythema and pain. The patient had a chronic history of skin breakdown on his bilateral legs due to psoriasis. He was vacationing in Belize and was walking barefoot on the ocean beaches. Initially, he noticed a burning sensation and increased redness of the left lower limb when he was still in Belize. The swelling, pain, and erythema progressed. The blisters developed a week after initial symptoms (see Figure ) and two days before the arrival in the emergency room. He did not report any fever and chills.
On physical examination, he was afebrile with a temperature of 36.8 degree celsius. He was hypotensive with a blood pressure of 88/61 mmHg and had tachycardia with a pulse rate of 114 beats per minute. He had bilateral lower limb erythema, with swollen and tender left leg, and blisters on the lateral aspect of the left leg. He had mild leukocytosis with a white blood cell count of 12,300 cells/microliters with an absolute neutrophil of 8.17(*10^3 cells/microliter). His blood culture showed many Gram-negative rods. The point of care lactate was 2.8 and the sepsis protocol was initiated with IV fluid resuscitation and broad-spectrum antibiotics. The ultrasound Doppler of the bilateral lower limbs ruled out deep vein thrombosis (DVT). He was admitted to the medical ICU for further evaluation and management. The Infectious Disease team was consulted for antibiotics management.
The General Surgery was consulted for the clinical concern of necrotizing infection. The CT scan showed no obvious abscess or gas in the subcutaneous tissue. The patient complained of the disproportionate pain in comparison to the erythema and then developed hemorrhagic bullae in the interim. His clinical condition did not

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


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

[User]
RADIOLOGY NOTE:
This is a 51-year-old male who presented acutely after he sustained a mutilating injury to his dominant right hand while using a large tire saw at work. He had a complete avulsion of the thumb and near-complete amputation of the index finger at the metacarpophalangeal joint. The zone of injury extended proximally to the radius, and severe damage was sustained by the trapezium and scaphoid bones. There was significant soft tissue injury of the radial and dorsoradial aspect of the hand, but his third, fourth and fifth digits were not involved. He had intact sensory and motor function to the ulnar three digits. The amputated thumb was placed on ice and transported with the patient to the hospital.
The patient was taken emergently to the operating room for possible replantation. Careful examination revealed bony amputation of the entire thumb, through the first metacarpal and trapezium. There was multilevel soft tissue injury of the thumb, and hence, it was not suitable for replantation. The second finger had multilevel injuries, with no appreciable blood supply. The index proximal phalanx and the second metacarpal had severely comminuted fractures rendering it nonsalvageable (Figure ). A revision amputation of the second finger was performed, and a temporary negative pressure therapy was applied to the damaged radial aspect of the hand.
Multiple reconstructive options were discussed with the patient, including simple soft tissue coverage with a skin graft, osteoplastic reconstruction with a toe-to-thumb transplant, and a single-stage pollicization of the middle finger to reconstruct the thumb. The patient had a significant medical and social history including his active tobacco and cocaine use, in combination with poor glycemic control, which put him at increased risk of wound complications with any surgical intervention. We discussed the utility of a great toe-to-hand transplant for thumb reconstruction, but being a laborer, the patient declined to sacrifice his foot

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


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

[User]
RADIOLOGY NOTE:
A 69-year-old White European woman consulted with suspected chronic adult hydrocephalus. She had a history of subarachnoid haemorrhage from a ruptured aneurysm in the terminal region of her basilar artery and an unruptured aneurysm of her anterior communicating artery. She had undergone cerebral embolization 6 months earlier. On clinical examination she presented with gait disorders associated with cognitive impairment. Computed tomography found hydrocephalus. She was admitted to our neurosurgery unit for a depletive lumbar puncture (50cc). Twelve hours after the procedure, she experienced complete and proportional right hemiplegia, confusion, deviation of her head and eyes to the right, and cortical blindness. She also had a generalized tonic-clonic seizure which ceased with a dose of clonazepam. Her blood pressure at that time was normal. Emergency cerebral magnetic resonance imaging (MRI) showed bioccipital and left-side basal ganglia hyperintensities in the fluid attenuated inversion recovery and the diffusion-weighted images (Figures , and ). We observed a high apparent diffusion coefficient (ADC) suggesting vasogenic oedema. The above MRI image findings are consistent with a radiological diagnosis of PRES. We implemented antiepileptic therapy, calcium channel blockers to prevent vasospasm and antiplatelet therapy to prevent ischemia.
We noticed a pronounced improvement concerning her neurological deficit in the first 2 days and almost complete recovery of motor disorders after 5 days. Her vision problems persisted with minimal recovery of central vision. She also had massive amnesia.
After a positive progression for 5 days, she had perseverations and automatism with difficulty to make contact.
Electroencephalography showed posterior slow waves without any spikes.
Her evolution was successful with appropriate antiepileptic therapy. She left the unit to go to a rehabilitation centre. Four months later, her clinical state worsened and she went into a coma. A cere

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


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

[User]
RADIOLOGY NOTE:
A 73-year-old female with a past medical history of chronic pancreatitis, type 2 diabetes mellitus, gastroesophageal reflux disease, lower gastrointestinal (GI) bleed, hypertension, paroxysmal atrial fibrillation, cerebrovascular accident, seizure disorder, and pulmonary embolism (PE) presented to an outside hospital after a reported seizure at her nursing home. Emergency medical services were called at the nursing home and the patient was reportedly hypoxic with oxygen saturation in the 70s on room air with subsequent development of agitation and lethargy after the seizure. The patient was transferred to an outside hospital's emergency department (ED), where additional tonic-clonic activity was noted. She subsequently developed hypotension with a blood pressure of 52/36 mmHg that was refractory to crystalloid intravenous fluid resuscitation. Central venous catheter (CVC) was placed and norepinephrine was started for persistent hypotension. Labs were notable for leukocytosis, troponin elevation, and low mixed venous saturation on CVC venous blood gas. The patient was subsequently transferred to a tertiary care facility cardiac intensive care unit for evaluation of cardiogenic shock.
Upon arrival, the patient was alert and following commands, but disoriented. She was still requiring supplemental oxygen and norepinephrine for hypotension. Given the concern for cardiogenic shock, a stat bedside transthoracic echocardiogram was obtained, which demonstrated a large pericardial effusion with tamponade physiology. The patient was urgently taken to the cardiac catheterization lab for pericardiocentesis with a drain placement. This yielded 580 ml of hemorrhagic fluid with rapid improvement in hemodynamics following drainage. During the pericardiocentesis, fluoroscopy demonstrated two embolized fragments of the IVC filter within the right ventricle (RV). Review of past imaging revealed that the embolized fragment was visualized on computer tomography (CT) of the chest one yea

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


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

[User]
RADIOLOGY NOTE:
The patient was a 67-year-old man with a history of angina pectoris and placement of two SESs in the left anterior descending (LAD) artery in 2003. He had had no complications and had been taking aspirin until 2018, when he experienced transient urticaria on the trunk and extremities without any known underlying triggers. The allergic reaction subsided spontaneously within 24 h, but a similar reaction occurred 3 days later. A few hours after the onset of the recurrent urticaria, the patient experienced acute chest pain.
He was transferred to a cardiac centre. Physical examination findings demonstrated erythematous, pruritic, and oedematous skin lesions on the trunk and extremities (). The electrocardiography showed ST-segment elevation in leads V1 through V5 with reciprocal changes (). Steroids were administered for his allergic reaction, and he underwent emergent coronary angiography (CAG).
The imaging test revealed in-stent thrombi in the LAD artery (). Thrombectomy and drug-coated balloon dilation were performed, which resulted in coronary artery flow of TIMI III, but in-stent thrombosis occurred immediately after the procedure. Afterward, catheter-directed urokinase thrombolysis was performed. Owing to the underlying thrombosis, coronary evaginations were not visualized on the optical coherence tomography (OCT). The subsequent CAG performed on the next day revealed in-stent thrombosis that had diminished. Three months later, we performed a follow-up CAG and confirmed contrast staining outside the stent contour. This is referred to as peri-stent contrast staining (PSS; ). OCT images confirmed that the PSS were in fact coronary evaginations around the two SESs ().
The decision was taken to initiate lifelong dual-antiplatelet therapy, as patients with coronary evaginations are at increased risk for subsequent ST. The systemic allergic reaction was thought to be an element that promoted platelet activation and thrombus formation, but antihistamine medications were n

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


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

[User]
RADIOLOGY NOTE:
A 53-year-old Egyptian female with past medical history of hypertension with nephropathy leading to end stage renal disease, one month after the start of hemodialysis, presented with fever and shortness of breath at an Egyptian hospital. Blood cultures grew Staphylococcus aureus and the sepsis was treated aggressively with piperacillin with tazobactam and Imipenem. She was transported from Egypt for further treatment in the United States.
On presentation at the referral center the patient was found to be in septic shock.
Her blood pressure on admission was 73/41 mm of mercury, with a heart rate of 120 beats per minute and a respiratory rate of 22 breaths per minute. Her white cell count on admission was 9,400 cells/μL; the differential count included 97.9% neutrophils with 2% lymphocytes. C-reactive protein on admission was 4.7 mg/dL. She was hypotensive and tachycardic. She had vesiculobullous lesions on the nose (), forearms, and the feet (). Some of the lesions desquamated to leave ulcers. She had a previously placed left sided internal jugular central line for hemodialysis. This central line was immediately removed on presentation and a fresh dialysis catheter was placed. Blood cultures grew Candida albicans on day 1 and continued to grow in all blood culture bottles consistently, during her stay. Appropriate investigations for infective endocarditis were performed.
A transthoracic echocardiogram revealed bulky leaflets of the mitral valve with a highly mobile vegetation about 2.3 cm long attached to the anterior leaflet (). This vegetation was prolapsing into the left atrium and was causing moderate mitral regurgitation. Computed tomogram (CT) scan of the chest, abdomen, and pelvis was also performed. It showed bilateral pleural effusions in the chest, with triangular opacities in the lungs suggestive of infarcts (). There was mild splenomegaly with triangular hypodensities consistent with splenic infarcts (). A CT scan of the abdomen and pelvis was found to ap

[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 male presented at the Department of Orthopedic Surgery, Southwest Hospital, complaining of a dull intermittent pain, for three months, along the anterolateral aspect of the right knee. The pain was relieved by taking Celebrex®, however, it was exacerbated by activity. The patient had identified a slow-growing mass on the outside of the right lower thigh and, a month prior to admission, the patient had noted a moderate sensation of warmth in this region. There was no history of accident, injury, fever, weakness or weight-loss. The patient visited another hospital in April 2012 and radiographs demonstrated a tumorous lesion in the right distal femur. The patient was referred to the Southwest Hospital in May 2012 with an unremarkable medical history. However, the physical examination was notable due to swelling, a decreased range of motion of the right knee and a palpable mass (size, ~5×4×3 cm). The laboratory assessments of the patient’s alkaline phosphatase levels were unremarkable. The radiographs revealed an expansile and osteolytic lesion of the right distal femur with a periosteal reaction (). Magnetic resonance imaging demonstrated an expansile, intramedullary, poorly defined neoplasm with a moderately high signal intensity area on T1- and T2-weighted images in the distal part of the femur, with diffuse erosion of the cortex and involvement of the surrounding soft tissue (). The intraosseous central location and uniform cortical destruction indicated that the lesion was not a soft-tissue sarcoma, which are associated with bone invasion. An emission computed tomography (CT) bone scan demonstrated an abnormal isolated concentration of radioactive agent (used for bone imaging) at the femoral site, which revealed that no distant metastases had occurred (). Chest CT did not demonstrate any thoracic abnormality and the CT-guided biopsy results showed blood clots as well as a small quantity of heterogeneous cells (). Therefore, the clinical diagnosis 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 55-year-old male patient complained of dysphasia for 4 weeks and continuous deterioration for 5 days. The patient had a history of ischemic stroke (Fig. , ), which manifested as right limb numbness and amaurosis 1 year ago. He had a history of hypertension for 10 years, a myocardial infarction 3 years ago, and cigarette smoking for 40 years, but no history of diabetes, hyperlipidemia, and alcohol consumption. The patient exhibited a disorder of linguistic expression and long-term memory impairment without a limb motor disorder. Cranial MRI confirmed an ischemic stroke at a local hospital (Fig. , ). The symptoms were relieved after medical treatment. The dysphasia relapsed 5 days before admission. Cranial computed tomography (CT) showed a hypodense lesion in the left temporal and occipital lobes (Fig. ). Cerebral infarction was considered based on serial cranial MRI, which showed hyperintensity at the internal border zone and the border zone between the left temporal and occipital lobes, and Doppler ultrasound revealed severe left carotid artery stenosis. The patient was transferred to our stroke center for further treatment. At the time of admission, the vital signs were normal. A neurologic examination showed mild dysphasia, normal cranial nerves, normal limb motor function, and negative Babinski signs bilaterally. CT perfusion imaging showed mild ischemic in the territory of the left middle cerebral artery (Fig. ). Cervical computed tomography angiography (CTA) confirmed the first segment of the carotid artery with severe stenosis (Fig. ). An electrocardiogram revealed an abnormal Q-wave involving the inferior wall, which was consistent with an inferior myocardial infarction. Homocysteine (35.3 μmol/L) and the following laboratory investigations were normal: triglycerides, total cholesterol, low-density lipoprotein cholesterol, antinuclear antibodies, anti-neutrophil cytoplasmic antibodies, prothrombin time, and tumor markers. The patient was given medical treat

[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.