[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 43-year-old female patient referred to our hospital’s emergency department in August 2014 with complaints of fever and severe pain in right breast. She noticed a soft lump and mild pain in her breast a week back. The intensity of pain increased gradually and for the last 2 days and her temperature increased. The patient had a history of 5 years of RA. The patient was not pregnant or lactating. She had three children with the last one delivered 6 years back.
On physical examination, the right breast was tender and swollen. A mobile, sensitive, soft, fluctuating mass of around 4 by 5 cm located in the right lower quadrant was palpable. The mass was not fixed to the upper skin. The upper skin was warm and erythematous. There was no nipple retraction or discharge from the nipple. Axillary lymph nodes were not palpable. The patient’s respiratory, digestive, nervous system physical examinations were normal. Physical examination of the musculoskeletal system revealed swelling in 2nd and 3rd proximal interphalangeal joints of the right hand and swelling and limitation of motion in the right knee.
Ultrasonography (USG) of the right breast revealed a heterogeneously hypoechoic deep-seated irregular collection of approximately 40×38 mm size. The patient was diagnosed with a breast abscess. The abscess was drained by USG guided drainage, and oral amoxicillin clavulanic acid 625 mg bid therapy was started empirically.
The drained fluid was sent to medical microbiology laboratory in a tightly capped, sterile container. On macroscopic examination, it was observed that the material had yellowish cream colour and dense consistency. Gram staining of the material showed abundant polymorphonuclear leukocytes and gram-negative bacilli. The material was inoculated on 5 % sheep blood and eosin methylene blue (EMB) agars plates. One of the sheep blood agar plates was incubated under anaerobic conditions. After incubation at 37 ° C for 24 h smooth, straight-edged colonies without hemolysi

[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 38-year-old woman presented paroxysmal headache for 1 month. She underwent brain computed tomography (CT) scan, which showed a space-occupying lesion in the right temporal lobe. The patient underwent surgery; the histological diagnosis was glioblastoma (WHO grade IV). Chemotherapy and radiotherapy were not administered after surgical operation. No other examinations were performed for 3 months, during which she gradually developed dizziness and headaches. Brain MRI revealed local recurrence, with multiple tumors in the right temporal–occipital junction. A second surgery was performed successfully; the histological diagnosis was also glioblastoma (WHO grade IV). The patient received adjuvant radiotherapy (64 Gy in 6 weeks using LINAC) and adjuvant chemotherapy with temozolomide, first concomitantly to radiotherapy (75 mg/m2/day), and then sequentially (200 mg/m2/day for 5 days per cycle of 28 days, for 3 cycles).
On July 16, 2016, the patient, suffering from head and neck pain for 2 days, was admitted to our department for fourth cycle of adjuvant chemotherapy. Physical examination revealed a hard mass with unclear boundaries in the right posterior neck. Neck CT revealed multiple swollen lymph nodes of varying sizes fused into a 54 × 39 × 83 mm mass with irregular edges and heterogeneous enhancement by enhanced scan, which was deemed metastases (Fig. ). Head MRI revealed multiple occupations in the right temporal, apical, and occipital lobes and in the corpus callosum consistent with tumor postoperative recurrence (Fig. ). To clarify the nature of the lumps, puncture biopsy was performed on day 6 after admission. Histological and immunohistochemical investigation revealed malignant tumor with the characteristics of glioma. As nerve compression by the mass caused severe neck pain in the patient, we planned surgical treatment to alleviate the pain symptoms and to further clarify the pathology. On July 30, 2016, the patient underwent resection of the right neck mass.

[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 74-year-old African-American male with a past medical history of severe chronic obstructive pulmonary disease, coronary artery disease, hyperlipidemia, and hypertension presented to our hospital in July 2016 with complaints of abdominal pain and gross hematuria for 1 week. His abdominal pain was sharp in nature and suprapubic in location. His hematuria had been worsening for the past week, and further history revealed that he had been having transient hematuria for the past year and a half. Additionally, for the past 2 months, he reported decreased appetite, fatigue, and a 20-pound weight loss. No other pertinent positives on review of systems were noted. His family history was unremarkable for cancers in any first- or second-degree relatives, but his social history did reveal that the patient was a heavy former smoker. Physical examination was significant for mild left lower quadrant abdominal tenderness and a large left supraclavicular mass that was firm and fixed.
CT imaging of the abdomen and pelvis revealed a 14.0 × 7.0 × 16.0 cm heterogeneously enhancing retroperitoneal mass within the left renal fossa extending into the midline (Fig. ). It showed involvement of the surrounding vasculature, as well as liver and bone metastases of the L2 and L4 vertebral bodies. CT scan of the chest was positive for bilateral pleural effusions and an additional T3 lytic lesion, but no pulmonary lesion was found. A cystoscopy was performed which did not reveal any gross abnormality of the bladder; however, urine cytology showed malignant cells concerning for SCC. Biopsies of the left retroperitoneal mass and supraclavicular lymph node were performed, both of which showed immunohistochemistry positivity for synaptophysin and chromogranin and partial positivity for PanCK and CK7. They were negative for CD45, S100, CD3, CD20, and p63. These findings led to the diagnosis of SCC of the upper urinary tract with bone and liver metastases. MRI of the brain did not show any metastatic

[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 sixteen year old boy presented with one year history of pain, swelling and restriction of left knee joint. Patient's symptoms were insidious in onset, which gradually progressed in its severity. There was no history of antecedent trauma, loss of appetite and fever. Patient does not give history of any definitive treatment taken for his present complains. On examination, the left knee was kept in 15-20° flexion with obvious quadriceps wasting. There was generalized swelling of the knee with fullness in the popliteal fossa. On palpation effusion was present with normal local temperature. There was a diffuse tenderness all around the knee, medial joint line being the most tender site. There was a bony hard slightly movable swelling palpated just lateral to the patella, which was extending to the midline beneath the patellar tendon. Irregular hard swellings could be felt along the margins of medial femoral condyle. Patient had fixed flexion deformity of 15° with further flexion was up to 110°. Instability tests were negative and there was no abnormality upon examination of distal neurovascular status. Plain X-ray of the left knee joint shows a large radiodense body in front of the femoral condyle with irregularity of the posterior articular margin of the medial condyle (). MRI was showing the effusion, synovial hypertrophy and a loose calcific body in front of the femoral condyle pushing over the patellar tendon anteriorly ()
Surgical management was planned and open procedure was preffered considering the extensive involvement with a large loose body inside the knee joint. Anterior mid-line incision was given and knee joint was exposed by medial parapatellar approach. A large loose body of around 7×4 cm was removed which was lying beneath the patellar tendon and lateral ratinaculum (,). Irregular nodular outgrowths were present along the margins of medial femoral condyle from anterior to posterior, which were thoroughly removed (,). Extensive synovectomy was done in a

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


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

[User]
RADIOLOGY NOTE:
A 45yr old lady suffered from a road traffic accident and sustained a closed diaphyseal fracture of both the bones forearm on left side. She underwent Open reduction and internal fixation of both the bones after 2 days following trauma with 3.5 Small DCP(6 hole). On subsequent follow up at 6 months with her primary surgeon it was found that there was osteolysis at the radius site while the ulna showed good signs of union. She was complaining of persistent pain (VAS Score-4) and unable to do routine activities with the involved limb. We evaluated her radiographs and did routine haematological tests. The parameters suggested there is some deep tissue infection (Raised Erythrocyte Sedimentation Rate {ESR} and C-reactive protein {CRP}) but the wound was healthy with healthy scar.
The patient was planned for staged surgery. First stage for implant removal with debridement, lavage of fracture site with culture sensitivity studies. Second stage for osteosynthesis with FVFG with plate once the acute phase reactants settled down. After a period of 2 months we again admitted the patient and did the routine investigations. As it was expected there was near normalcy of the parameters of infection like ESR, CRP. We diagnosed this as a case of gap non-union of shaft radius as evident from radiological investigation () and described all the treatment alternatives to the patient. After obtaining all the necessary consent we decided to do a free vascularised fibular grafting and fixation with a locking 3.5 small DCP. (12 hole)
We approached the radius through the previous incision site and freshened the atrophic ends of radius and finally found the gap to be 8cm (). The ipsilateral fibula was harvested in its middle 2/3rd taken as a pedicle with the peroneal artery, which arises from the posterior tibial artery, 3 to 4 cm distal to its bifurcation into the anterior and posterior tibial arteries (, ). It was fixed in the recipient site with the use of a

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


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

[User]
RADIOLOGY NOTE:
A 68-year-old man had a history of chronic systolic heart failure and dilated cardiomyopathy, with a left ventricular ejection fraction of 32% and a left ventricular internal diastolic diameter of 81 mm. His electrocardiograph had revealed a sinus rhythm with a QRS duration of 140 ms along with a left bundle branch block morphology. He underwent a cardiac resynchronization therapy-defibrillator (CRT-D) device implantation. However, 2 weeks after the procedure, he was re-admitted to our hospital with a 4-day history of pain and swelling at the CRT-D pocket site, associated with scant serous drainage. Prior to this admission, he had undergone a skin incision and drainage at another hospital, but the procedure had failed to relieve his symptoms. The patient had a history of hypertension, a myocardial bridge in the left anterior descending coronary artery and diabetes mellitus (on irregular therapy). He also had a history of pulmonary tuberculosis 40 years previously and had completed the curative treatment course successfully, at the time. His regular medications included metoprolol, perindopril, torsemide, and amiodarone.
During re-admission, the patient did not have complaints of fever, chills, or fatigue. The physical examination was unremarkable, except for a 2-cm long, open incision on the upper left side of the chest, with mild localized edema over the CRT-D pocket. The skin around the incision was erythematous, and a small amount of scant serous discharge was noted on pressing the pocket site. Considering the likelihood of CRT-D infection, we collected the patient’s blood samples to perform cultures for aerobic and anaerobic bacteria. The samples of the exudate were also tested, using microscopic examination and culture, not only for the usual causative bacteria but also for the rarer acid-fast bacilli. On initial microscopic examination, the exudate smear did not reveal any organisms. An echocardiogram showed no evidence of vegetation or thrombosis. Other labor

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


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

[User]
RADIOLOGY NOTE:
The patient is a 56-year-old male in very good health. He exercises regularly, primarily walking, running, and bicycling, and has an excellent cardiovascular profile with a body mass index of 23. He is educated at the doctoral level and is medically literate. As reported previously [], he was diagnosed with major depressive disorder at age 42 and was treated with fluoxetine, omega-3 fatty acids and psychotherapy which were eventually effective, with the depression going into a yet-continuing remission starting at age 53. The patient had discontinued the fluoxetine more than 6 months after the depression had gone into remission. Of note, he had not experienced significant anxiety symptoms until age 54, which at that time were associated with the use of EPA-enriched fish oil supplements. The patient had taken the same refined fish oil supplements for over 5 years and he partially attributes the remission of his depression to them, but they gradually began causing the anxiety and insomnia symptoms, which became noticeable by age 54 and abated when he temporarily stopped taking the fish oil supplements. A subsequent challenge with the fish oil triggered the symptoms again, so the patient stopped taking them altogether after which the anxiety and insomnia symptoms were largely eliminated []. He was prescribed lorazepam for the anxiety symptoms, which by agreement was restricted to no more than 12 1 mg tabs per 6 months to prevent dependence.
During a recent annual physical exam, his primary care practitioner suggested montelukast for his mild chronic asthma. Two to three weeks after initiating montelukast at 10 mg/day he noticed gradually worsening generalized anxiety and began waking suddenly after several hours of sleep. During his awakenings, he often experienced strong sympathetic activation, with increased heart rate, flushing and a loosening sensation in his viscera. These panic symptoms were associated with ruminative thoughts in which routine life concerns led to

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


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

[User]
RADIOLOGY NOTE:
A 47-year-old female patient was referred to our emergency department where she presented with productive cough since 11 months, weight loss for 4 months, shortness of breath, and loss of appetite since last one month. In past history, she was treated as a case of pneumonia with empirical antibiotics at a nearby private teaching hospital where CXR revealed increased opacity. A CECT chest was done which showed left hilar lymphadenopathy with minimal left effusion with focal areas of consolidation (). As a result, empirical therapy was changed to broad spectrum antibiotics. She showed relative improvement for a period of 2 months, but then developed weakness of the left upper limb and lower limb with twitching over the face. MRI scan was done at the same private setup which revealed multiple rounded enhancing lesions scattered in the B/L cerebral and cerebellar hemispheres, midbrain, pons, and vermis. A repeat CECT chest done at our hospital showed solid mass in the left hilar region involving the left lower lobe. EBUS (endobronchial ultrasound) guided biopsy from the mediastinal lymph node and endobronchial lesion showed no evidence of malignancy. In view of the high clinical suspicion deterioration of the patient, radiotherapy was given for the space occupying lesions in the brain. As per metastatic workup, a bone scan was performed which showed increased osteoblastic activity in the left 8th and 9th rib anteriorly. A percutaneous lung biopsy was done which showed features suggestive of moderately differentiated squamous cell carcinoma. Chest X-ray was performed immediately after biopsy, and it revealed bilateral diffuse consolidation and cavitation (). However, sputum sample sent for KOH mount revealed weak, acid-fast, and filamentous bacilli resembling Nocardia spp. She was immediately started on trimethoprim-sulphamethoxazole, linezolid, and imipenem/cilastatin for suspected disseminated nocardiosis. But due to the deterioration of the type II respiratory failure

[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 25 years old female patient of African ethnicity was referred to the Department of Oral and Maxillofacial Surgery, Ayder Referral hospital (Ethiopia) with the chief complaint of a mandibular gingival mass of two years duration. On general examination, the patient was apparently healthy. The medical history and family history were insignificant. No notable findings were recorded on extra-oral examination.
Intra – oral examination revealed a solitary, well defined, roughly oval shaped gingival mass arising from the attached and free labial gingival margin covering two thirds portion of the crown of teeth 33 and 34 (Fig. ). It was a slow growing swelling which gradually progressed to its present size of 2 × 2 cm. The overlying mucosa was intact and the color was similar to the adjacent mucosa. Associated signs or symptoms such as pain, bleeding, discharge, numbness or fever were absent; oral hygiene was inadequate. The swelling was non-tender on palpation with firm consistency and smooth surface texture. Intraoral periapical radiograph (IOPA) of right mandibular anterior region was recorded. A minor arc shaped bone loss in relation to teeth 33 and 34 was demonstrated.
Based on the clinico-radiographical findings, clinical diagnosis of pyogenic granulomas was established with differential diagnosis of peripheral ossifying fibroma, peripheral giant cell granuloma and fibrous epulis. The rare differential diagnosis include benign connective tissue tumors and peripheral odontogenic neoplasms.
Following the routine blood examinations, the lesion was removed in toto under local anesthesia. The excised mass was sent for histopathological examination.
Grossly, the specimen was roughly spheroidal in shape measuring 2 × 2 cm approximately and covered by a capsule with soft to firm consistency. Cut section revealed grayish - white appearance with minute hemorrhagic areas.
The haematoxylin and eosin (H&E) stained sections were examined microscopically. The tumor mass was chiefly

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


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

[User]
RADIOLOGY NOTE:
A 54-year-old Caucasian female proceeded to our institution with epigastric pain, nausea and vomiting along with pain located around the lumbar area lasting for one week. No previous surgical history or commorbidities existed. Clinical examination did not reveal any palpable abdominal masses or abdominal tenderness and the patient’s vital signs were within the normal spectrum. Blood test detected hypercalcemia (serum calcium: 10.2 mg/dL) and parathyroid hormone level of 111.8 pg/mL. All the findings in conjunction with the clinical presentation lead to the assumption that the patient had primary hyperparathyroidism (PHPT).
Then, an ultrasound was performed but it was negative for any thyroid or parathyroid abnormalities. Subsequently, the thoracic and abdominal CT revealed a soft tissue in the anterior mediastinum 7 × 1 cm. Additional Tc-99m-MIBI scintigraphy followed, which detected an ectopic adenoma located in the lower anterior mediastinum, on the left of the median line (). Following these, a mid-sternal thoracotomy was finally scheduled.
During the operation, after the thoracotomy, surgeons attempted to detect deep into the mediastinum the parathyroid adenoma according to the preoparative localization. Indeed, the mediastinal mass was detected on the left of the median line, at the anterior mediastinum, in front of the anterior surface of the pericardium and close to the left pericardiophrenic vessels and the left phrenic nerve (). The adenoma was covered by a thin fibrous capsule. When surgeons removed the capsule, a dark red mass of 7 × 2.8 × 1 cm was finally revealed (). The detailful preoperative localization of the present mediastinal adenoma which was in close relation with various anatomical structures of the thorax, reduced effectively the difficulty of the mass excision and the potentiality of accidental surgical injuries which may lead to thoracic bleeding and subsequent obstructive symptoms.
Then, the operation continued in the usual fashion and a d

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


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

[User]
RADIOLOGY NOTE:
A 63-year-old female patient, 168 cm height and 53 kg weight on referral, suffered the following (chronical) diseases. She was diagnosed with a papillary thyroid carcinoma in 1989, which was treated by resection and radiotherapy. In the following years, she developed a stenosis of the esophagus. Because of this disease, repeated aspiration led to several episodes of respiratory insufficiency due to pneumonia and purulent pleurisy, which was treated by pleurectomy. Furthermore, she developed a restrictive ventilation pattern and a recurrent nerve palsy. Consequently, the patient was treated by percutaneous endoscopic gastrostomy and tracheostoma two decades before referral. She was put on home ventilation although not completely dependent on the ventilator. Her mobility decreased a lot and from 10 years before referral she never left the bed or nursing chair due to a secondary depression, and over this time, she nearly stopped talking. As a consequence, her mandible was nearly fixed, and she could not open her mouth over a maximum of 20 degrees at referral. Six years before referral, the left axis vertebralis was stented and developed furthermore stenosis of the internal axis carotis on both sides. In the meantime, arterial hypertension and secondary lactase deficiency were diagnosed. With the intention to alleviate the swallowing of saliva, the esophageal stenosis was dilated in a secondary hospital. On October 11, the patient was referred to the University of Erlangen due to a decreasing general condition. Unfortunately, a fistula between the esophagus and tracheal membrane had occurred in the upper third of the trachea which corresponded to the former field of radiotherapy. The patient was examined by several chiefs and consultants of Ear, Nose and Throat, Thoracic Surgery, Pulmonology and Medical intensive care unit at the University of Erlangen and she was deemed too unstable for open surgery. The inability to open the mouth and the recurrent nerve palsy gave ri

[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 male presented to us in the outpatient department with complaints pain on lifting weight with the right arm, deformity and limited range of motion of the right elbow for five months. The patient had fallen down and sustained the injury to his right elbow while hanging from the rootlets of a Banyan tree, following which, he had pain, swelling, and deformity of the right elbow. He had sought treatment from a local bone setter for four weeks following which pain and swelling decreased, but the deformity and elbow stiffness had persisted, for which he attended our hospital.
On examination, the Beighton hyperlaxity score of the patient was 5/9. There was flexion deformity of the elbow joint and wasting of muscles of the arm and forearm. The olecranon process was displaced from the olecranon fossa of the right humerus and an abnormal bone mass was palpable on the anterior aspect of the distal humerus. There was a flexion deformity of 40 degrees of the elbow joint with further flexion of 70 degrees. Pronation and supination were normal. There was a valgus laxity of the right elbow joint. The differential diagnoses were neglected dislocation of the elbow joint (posterior/anterior) and mal-united supracondylar fracture.
Antero-posterior and lateral radiographs of right elbow demonstrated an anterior dislocation of the elbow joint with an anterior bone mass at the distal humerus. The bony anatomy of the elbow appeared unclear on radiography, and a Computed Tomogram (CT) with 3D reconstruction () confirmed an anterior dislocation of the right elbow joint with a bony projection from the anterior border of the distal humerus. We hypothesised that because of hyperlaxity the patient had sustained anterior dislocation of the elbow joint without associated fracture. Massage and attempts to reduce the elbow joint by the bone setter had led to the formation of a heterotopic bone mass on the volar aspect of the humerus.
We performed an open reduction of the elbow by combi

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


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

[User]
RADIOLOGY NOTE:
A 50-year-old woman had a hard navel mass. She regularly visited the Department of Internal Medicine at our hospital for the treatment of diabetes. In August 2011, she presented to the Department of Dermatology with a main complaint of an umbilical mass; however, she was sent to the Surgical Department because of the diagnosis of an umbilical lesion located deep in the abdomen. The hard mass, which was the size of a thumb, was palpable at her navel. She did not feel any pain.
An abdominal computed tomography (CT) scan showed the enhanced tumor; it was 2 cm in diameter and located in the pancreatic tail (Figure ). The contrasting effect was poor compared to normal tissue, which was a finding suggestive of pancreatic cancer. The para-aortic lymph node was not swollen; however, low, enhanced foci were scattered in the spleen, which was a finding suggestive of metastasis.
The fluorodeoxyglucose-positron emission tomography (FDG-PET) scan showed swelling in the pancreatic tail with abnormal accumulation (Figure ). This contrasting pattern along with the CT findings suggested pancreatic cancer. Accumulation in the spleen was noted, so we were unable to rule out the possibility of invasion. There was a small granular shadow with slight accumulation suggestive of lymph node metastases.
Skin thickening and abnormal accumulation in the umbilical region were also noted. Consecutive accumulation was not observed in the peritoneum, which was suggestive of local inflammation, not dissemination. No other abnormality was found.
The patient was placed in a supine position for the operation. First, we used Kocher mobilization at the front part of the inferior vena cava, moving toward the anterior surface of left renal vein to back side of the superior mesenteric artery. We confirmed no para-aortic lymph node swelling. The greater omentum was resected from the spleen to the pancreas, transverse colon, and splenic flexure. The inferior mesenteric vein was set aside. The adhesion betwee

[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 male was referred to the Department of Oral and Maxillofacial Surgery five months after a severe motor vehicle accident for treatment of pain and inability in closing the mouth. The patient had sustained severe head injury for which he had been hospitalized in the trauma department for 45 days. Craniotomy had been carried out and a cerebral shunt inserted to reduce intracranial pressure. In extra-oral examination, a deviation was present in the orbital axis, which was a sequel of the head injury. The mouth was found open and the mandible was anteriorly displaced (). Depressions anterior to the tragus were visible bilaterally and the condyles were fixed and palpable in front of the ears. Intraoral findings included loss of several teeth; anterior displacement of the lower jaw, and anterior open bite with an inter-incisal distance of 40 mm. Anterior displacement of both condyles was seen on the panoramic radiograph () and confirmed by CT views. According to the findings from the history and physical examination, a diagnosis of irreducible long-standing condylar dislocation was established and the patient was scheduled for treatment under general anesthesia. The occlusal models were prepared to check the postoperative occlusion. The procedures were explained to the patient and a detailed consent form was obtained. General anesthesia was administered via naso-endotracheal tube using intravenous midazolam, phentanyl, muscle relaxants, and propofol. Under general anesthesia, noninvasive methods such as different modalities of jaw manipulation and controlled tractions failed to reduce the jaw. Subsequently, the angles of mandible on either side\were exposed via bilateral Risdon approaches to apply traction using bone hooks in the sigmoid notch and heavy traction wires passed through bur holes at the angle (). These procedures also failed to bring the condyles into their appropriate position. Therefore, bilateral vertical osteotomies were carried out and the m

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


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

[User]
RADIOLOGY NOTE:
A ten-year-old girl was admitted to our general hospital with numbness of her left palm and fingers in the last 5 months before admission. At that time, she was hit by a car while she was riding a bicycle. The car was coming from opposite side, and she fell with her left forearm was sliced by licensed plate of the car. There was a semicircular open wound with active bleeding on the left forearm, and she was in pain. She was brought to a nearby clinic and had her left forearm sutured. After the pain subsided, she felt numbness of her left hand and fingers. In addition, she could not extend her fingers. Finally, the patient decided to seek medical attention and get further treatment at our general hospital.
From physical examination, there were claw hand deformity with thenar and hypothenar atrophy as well as a scar on the anterior side of distal forearm (). Sensorium loss of the palm and third, fourth, and fifth fingers was impaired. No tenderness was found. Capillary refill of the fingers was normal. Range of motion of the fingers was altered with limitation of finger abduction and thumb apposition (). Moreover, range of motion of the wrist was within normal limit.
Routine laboratory examination was within normal limit. The patient was taken for wrist and forearm radiographs and, similarly, there was no abnormality depicted on either bones or soft tissue.
The patient also underwent electromyography examination which showed median and ulnar nerve lesion at the left forearm with total axonal degeneration. No signs of reinnervation of both peripheral nerves were detected.
The patient was diagnosed as ulnar and median nerve palsy of left forearm, and then we planned to perform surgical exploration of the nerves and to repair with sural nerve graft, Zancolli procedure and sural nerve graft.
Intraoperatively, skin incision was made on the previous surgical scar. Injury site was explored, and complete rupture of both ulnar and median nerves was

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


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

[User]
RADIOLOGY NOTE:
A 30-years old woman visited at our hospital, complaining of pain in her lower back, left inguinal area, and left leg. Two months before this visit, she was found to have a mass growing in her left thigh, which was causing her pain (). The tumor in her thigh was removed surgically. Her excisional biopsy revealed fibromatosis of the rectus femoris muscle. Following the procedure, she continued to experience pain at the operated site, as well as pain in her left inguinal region. Starting from day 3 after the surgery, the previously mentioned pains were accompanied by pain in her lower back and in the medial side of her left knee. She was asked to rate her pain using a visual analogue scale (VAS) and her rating, on average, was 100/100. She was admitted to the hospital due to the high severity of her pain. She complained of more severe pain when sitting or lying down on her back.
Physical examination found hyperesthesia and static allodynia in the left medial side of her affected leg. Both her left hip flexion (G 4/5) and left knee flexion (G 4/5) were diminished. The results of her straight leg raise test and trendelenburg test were normal. Her blood test results revealed an elevated erythrocyte sedimentation rate and C-reactive protein concentration of 56 and 4.49, respectively.
On her first day at the hospital, motor nerve conduction studies were performed. The results showed that the compound motor action potential amplitudes in her left femoral nerve were within the normal range but were reduced as compared with her right femoral nerve. Sensory nerve conduction tests revealed that sensory nerve action potentials were not obtained in her left saphenous nerve or in her medial femoral cutaneous nerve. Electromyography (EMG) results showed increased insertional activity in the left vastus lateralis, fibrillation, positive sharp waves (2+), and diminished recruitment. Based on the results, femoral neuropathy was suspected and pregabalin 150 mg and duloxetine 60

[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 77-year-old man with hypertension and hyperlipidemia underwent an outpatient nuclear stress test which demonstrated a reversible inferior wall defect. He subsequently underwent cardiac catheterization diagnosing severe multivessel atherosclerotic disease. A referral was placed to a cardio-thoracic surgeon for coronary artery bypass graft (CABG) surgery. A chest CT scan obtained during pre-CABG evaluation demonstrated a mild ascending aortic root dilation measuring 4.1 x 4 cm, without any evidence of dissection. The patient subsequently underwent CABG without any intra-procedural or immediate post-procedural complications. He was discharged home in a hemodynamically stable condition on the fifth postoperative day.
Three weeks later, the patient presented to the emergency department complaining of a productive cough, nausea, vomiting, and fever. Based on physical examination, laboratory and imaging studies, he was diagnosed with sepsis secondary to pneumonia. A CT chest performed during initial evaluation for pneumonia in the ER redemonstrated the ascending thoracic aortic root dilation, as well as a new 3.9 cm long segment of dissection of the ascending thoracic aorta, originating 3 cm distal to the aortic root (Figures , ). The dissection did not involve recently grafted vessels. The new dissection was felt to be iatrogenic secondary to the recent CABG surgery. Treatment options along with their benefits and risks were discussed in detail with the patient. Medical management of the new dissection was agreed upon between the patient and the team of multidisciplinary physicians. This was a deviation from standard practice, albeit the most pragmatic approach, and this was communicated to the patient clearly.
The patient was started on metoprolol and losartan, with a blood pressure goal of less than 130 mmHg systolic. The patient remained hemodynamically stable throughout this hospitalization. A repeat CT scan was performed nine days after presentation, which demonstr

[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 gentleman, ex-smoker, presented to our hospital complaining of mild epigastric pain, regurgitation, and heartburn. On top of that, he has a long-standing history of gastroesophageal reflux disease (GERD), which was managed by proton pump inhibitors. His past medical history was significant for hypertension. He was previously diagnosed with a liver hemangioma based on abdominal ultrasound two years before the presentation. He had no relevant family history. Physical examination revealed mild epigastric tenderness with no palpable abdominal mass. Laboratory data showed no anemia but positive stool occult blood test. Tumor markers including AFP, CEA, and CA 19-9 were all within normal range. Upper GI endoscopy revealed mild esophagitis, Los Angles grade A along with Barrett's esophagus without dysplasia and a 1 cm polyp at the GEJ. A sample was sent for histopathology; the rest of the stomach and duodenum were normal. The patient did not have a previous endoscopy prior to this one.
Infused computed tomography (CT) of the abdomen and chest showed mild GEJ thickness with no evidence of mediastinal or celiac lymphadenopathy and no signs of metastasis. It also demonstrated a large heterogeneously enhancing mass about 6 × 9.5 cm with central necrosis in the upper abdomen that appears to be originating from the gastric antrum (greater curve). The mass was highly suggestive of GIST based on CT; it was the same mass that was previously misdiagnosed as a liver hemangioma (). Endoscopic ultrasound confirmed the previous findings. However, no biopsy was attempted due to the risk of bleeding.
Histopathological examination of the GEJ polyp revealed tubulovillous adenoma with elements of adenocarcinoma in situ. The patient was admitted with a provisional diagnosis of early-stage adenocarcinoma of GEJ along with the incidental finding of enlarging gastric GIST. A trial of endoscopic mucosal resection of GEJ polyp was attempted but failed because of the polyp location th

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


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

[User]
RADIOLOGY NOTE:
A 15-year-old Caucasian boy with no relevant medical history went to the emergency department after suffering trauma in his right hand caused by a fall forward while playing football. He presented a deformity at the base of the second finger, swelling, and painfully restricted motion. Rotational deformity of the second finger associated with radial deviation and hyperextension was found during physical examination, but neurovascular structures were intact.
The X-ray () showed fracture of the proximal phalanx diaphysis of the second finger of the right hand with deviation. Closed reduction under sedation was performed applying traction and ulnar deviation followed by syndactyly and immobilization with Zimmer splint. The control X-ray () revealed acceptable reduction, and the patient was referred to follow-up at the outpatient consultation. The conservative treatment was kept for 25 days, with apparent fracture healing on the X-ray (), but the patient presented limitation on active flexion of the finger which was interpreted as a sequel of the immobilization. Thus, he was referred for physical therapy rehabilitation. Six weeks after the initial trauma, the patient was observed at the emergency department for new right-hand trauma. On examination, no active flexion of the third phalanx of the second finger of the right hand was noticed. The X-ray didnot show any new fracture (). Then, the patient underwent an ultrasound that revealed deep flexor tendon entrapment at the previous fracture focus. A surgery was proposed and accepted by the legal guardians. The patient was prepared to surgery. After the Bruner incision in the palm face of the affected finger, the entrapment of the deep flexor tendon within the proximal phalanx was observed (). Then, tenolysis of the entrapped tendon was made () enabling the visualization of the bone space created by the fracture and where the tendon was trapped (). After that, a reconstruction of the pulleys was performed using a portion o

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


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

[User]
RADIOLOGY NOTE:
A 71 year old Caucasian female with a remote history of PTC presented with a 2-month history of palpable left-sided neck mass. Physical examination revealed a non-tender mass in the left lateral neck. There were no other abnormalities identified in a full head and neck examination. There was no palpable mass in the thyroid bed. Ultrasonography of the neck revealed an absence of normal thyroid tissue, consistent with patient’s history of distant thyroidectomy, and a solid mass in the left side of the neck superolateral to the expected location of the thyroid, in level III. This inhomogeneous mass appeared vascular and measured 2.8 cm in length by 1.7 cm in diameter. It was not felt to resemble a normal lymph node in ultrasonographic features. Nonetheless, from its appearance and anatomical location, this new mass was initially suspected to represent a lymph node or a carotid body tumour.
Computed Tomography (CT) ruled out non-nodal neck pathology, and identified the mass as being consistent with an enlarged lymph node (Figs. , ). Again, this study revealed no evidence of recurrence in the thyroid bed, nor other evidence of neoplastic disease.
Two fine needle aspiration biopsies (FNAs) were performed. The specimens were cellular and consisted of groups of epithelial cells in flat sheets and papillary-like clusters. The cells showed enlarged nuclei with nuclear grooves and a few intranuclear inclusions. Immunohistochemistry on the cell block was positive for TTF-1 (thyroid transcription factor 1), consistent with cells of thyroid origin.
A positron emission tomography (PET) study was performed to rule out distant metastatic disease. Apart from the known mass in the left neck, the PET study showed no other Fluorodeoxyglucose (FDG) avid lesions (Fig. ). Given these diagnostic findings, the patient was scheduled for a left lateral neck dissection after obtaining informed consent. The patient subsequently underwent an uncomplicated left level II-III neck dissection under g

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


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

[User]
RADIOLOGY NOTE:
A 37-year-old African-American woman, who was 20 weeks pregnant, presented to our emergency room (ER) with complaints of chest pain and shortness of breath. These symptoms started two months previously and had progressively worsened. Approximately two years prior to this presentation she had had an evaluation for chest pain that included cardiac testing and a chest X-ray. Eventually she was diagnosed with dystonia and started on trigger point injections at multiple different sites including the left sternoclavicular joint. She developed a left-sided pneumothorax as the result of these injections and underwent video-assisted thoracoscopic pleurodesis for a refractory pneumothorax. She was symptom free for about 20 months. She subsequently had recurrence of her left-sided chest pain which was treated with episodic sternoclavicular joint trigger point injections. Our patient was not able to recall any of the medications used in the injection. Her chest pain progressively got worse and she developed shortness of breath one week prior to her current presentation. The chest pain was substernal, sharp, with 5/10 intensity, aggravated by breathing and had no relieving factors. She denied fever, chills, smoking or drug use. A review of systems was otherwise negative. Her vital signs in the ER were normal except for resting tachycardia, with a pulse of 100 beats per minutes. A physical examination revealed swelling and tenderness of the sternal notch with tenderness to palpation over her left sternoclavicular joint. The rest of her physical examination was normal.
Laboratory data was significant for a white blood cell count of 13.3 × 109/L with 82% granulocytes. A chest radiograph revealed possible upper mediastinal widening and left basilar scarring with blunting of the left costophrenic angle. A computed tomography (CT) angiogram of her chest was performed, and revealed a 4.7 cm gas-containing abscess in the retrosternal region behind the manubrium, with associated sclerosi

[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 February 2014, an 11-year-old male presented with a history of recurrent respiratory tract infections and suspected tuberculosis following a case within his family. On physical examination, he appeared to be in good health. Chest auscultation did not reveal any specific pathological heart or lung sounds. Abdominal objectivity was negative. His parents did not refer any other relevant medical history about him. Tuberculin skin tests resulted positive and a chest X-ray showed a dishomogeneous parenchymal consolidation in the left lower lobe (). Suspecting active tuberculosis, a preliminary CT scan of the thorax was performed showing a heterogeneous consolidation with some cystic masses containing mixed fluid and air in the left lower lobe posterior segment, not in communication with the respiratory tract, and a probable expression of a dysplastic parenchymal area ( and ). These findings were suggestive of pulmonary sequestration, including a differential diagnosis of congenital pulmonary airway malformation, because of the presence of a cystic component within the consolidation. The injection of contrast medium showed an artery arising from the descending thoracic aorta that divided into two 1.2 cm after its exit, with both branches extending to the dysplastic area; therefore, a diagnosis of intralobar sequestration with associated aspects of bronchial atresia was made; superinfection and trapping of contiguous parenchyma coexisted. Just below the emergence of the previously anomalous vessel, another artery was detected that crossed the midline to achieve a healthy parenchyma in the right pulmonary base, configuring a pattern of aberrant systemic artery feeding a normal lung (–). Other congenital anomalies that appear to be related to pulmonary sequestration were absent; in particular, pulmonary venous drainage was regular through the pulmonary veins, there was no communication between the bronchus and the oesophagus, and no diaphragmatic defects or other gross pul

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


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

[User]
RADIOLOGY NOTE:
A 31-year-old male with Marfan syndrome and a history of recurrent pneumothorax presented with back pain, nausea, and vomiting during exercise and was diagnosed on CT with an uncomplicated type B aortic dissection from the left subclavian artery to the right common iliac artery. The proximal intimal tear was located just distal to the left subclavian artery with a maximum diameter of 15 mm, and a large false lumen (max diameter 35 mm) ( and Video 1). Physical examination revealed no abnormalities and electrocardiogram (ECG) was normal. The patient was treated medically with a betablocker and calcium antagonist and follow-up imaging were planned. An MRI was performed 5.5 weeks after the type B dissection, which was already scheduled due to an increase in aortic diameter at the outpatient clinic earlier that year. In our tertiary centre aortic aneurysm in young patients are routinely monitored using MRI, including aortic 4D flow analysis. The MRI showed a dilated root of 40 mm and known type B dissection. Aortic lumen was split just distal to the left subclavian artery into true and false lumen, which directed blood volume (3.6 L/min) mainly towards the false lumen (true lumen 0.8 L/min, 22% and false lumen 2.8 L/min, 78%). On 4D flow streamlines did not indicate helicity or vorticity in the ascending aorta or aortic arch, however, vorticity was observed in the proximal false lumen ( and Video 2). Increased WSS was observed at the sinotubular junction (STJ), inner wall of the ascending aorta, and just proximal and distal to the subclavian artery at the location of the dissection ().
Two weeks after MRI, the patient presented to the emergency department with jaw pain, visual complaints, and decreased sensibility of the right arm. On physical examination, the patient was briefly hypotensive [86/56 mmHg, after fluid challenge 117/70 mmHg (left equals right)], with good peripheral pulses and no other abnormalities.

[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 47-year-old man, sport teacher, referred to us for a persistent respiratory distress. He was taken to a city hospital 3 days before admission for severe acute respiratory distress and chest pain. A chest X-ray done in that hospital revealed a pneumothorax on the right side, and a chest tube was then inserted. Despite the presence of the indwelling chest tube, the patient continued to complain of dyspnoea and later developed subcutaneous emphysema. A chest CT scan was then requested to look for the possible cause of the pneumothorax. It revealed a massive pneumothorax with subcutaneous emphysema on the right side associated with a typical complex aspergilloma cavity well defined at the right lung apex (Figures and ). The patient was then referred to our hospital for further management.
On arrival, he was conscious, alert, and oriented in time and space but dyspnoeic, presenting with signs of respiratory distress. The vital parameters on arrival revealed the following: blood pressure: 136/93 mmHg, heart rate: 86 beats/min, respiratory rate: 28 cycles/min, temperature: 38.5°C, and oxygen saturation: 79% on 6 l/min of nasal oxygen. There was massive air in the drain. A second chest drain was inserted. As a sport teacher, he did exercises regularly. He was treated for pulmonary tuberculosis 2 years back and was declared healed. Elsewhere, his past medical and surgical history was unremarkable. He had no specific complaints for 2 years and had been fine ever since. He also complained of cough and blood-stained sputum.
The physical exam revealed an anxious patient with severe dyspnoea and massive subcutaneous emphysema (diffuse subcutaneous air with tympanic chest, all over the trunk and the cervical and scrotal regions as seen in ). Despite insertion of the second drain, there was still a persistent significant air leak with hypoxia. A preoperative workup was thus quickly done and revealed a hemoglobin count of 14 g/dl, a negative HIV serology,

[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 77-year-old male with a past medical history of NHL/SLL diagnosed almost 10 years ago, who presented to the hospital with abdominal swelling, altered mental status, and difficulty in urinating associated with hematuria. On physical examination, diffuse bulky lymphadenopathy was found in the cervical, axillary, and inguinal areas. Detailed oncologic history and treatment regimens that were taken by the patient have been well explained in Table .
Laboratory workup showed hypokalemia, hypophosphatemia, and elevated lactate dehydrogenase levels. During the hospitalization, computed tomography (CT) scan head was done that showed negative findings for any acute events. Due to altered mental status with underlying worsening of NHL and metabolic disturbances, the toxic and metabolic encephalopathy were the differentials under consideration. Metabolic derangements were corrected during hospitalization and that improved his mental status as well. Idelalisib treatment was discontinued abruptly a week prior to patient’s presentation to the hospital due to pancytopenia and a mixed response on the CT scan imaging. Upon admission, a repeat CT of the abdomen and pelvis showed diffuse bulky lymphadenopathy in the abdomen; one of the nodes in the anterior para-aortic region was measured about 5 cm × 5 cm × 8 cm (Figure ). Bilateral iliac, inguinal, and retroperitoneal lymphadenopathy was also significantly increased in size compared with prior CT scan. There was diffuse lymphadenopathy along with axillary and cervical regions as well (Figures -).
Bone marrow biopsy was done that showed a cluster of differentiation 5 (CD5) and CD23 positive B-cell population (37% of the lymphoid gate), lambda-restricted. Almost all of the B-cells showed immunophenotypic expression of CLL/SLL with lambda light chain restriction that was found in previous cases of this patient. Interestingly, a kappa light chain restricted population of monoclonal plasma cells co-expressed with CD56 (1.1% 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:
After a 75-year-old male, who pursued gardening as a hobby, noticed decreased vision in his left eye, he visited an ophthalmologist in September of 2015. He had a history of hypertension, colon cancer and metastatic hepatic tumor. As an ophthalmologic examination revealed macular edema in his left retina resulting from branch retinal vein occlusion (BRVO), he underwent a posterior STTA injection in his left eye to treat the macular edema. After routine disinfection of the lid margins and conjunctival sac with 10% and 0.625% (16-fold dilution) povidone iodine, respectively, the procedure was performed uneventfully. The patient once again visited his ophthalmologist in November due to complaints of ocular pain and hyperemia in his left eye. The symptoms did not improve even though he received oral and topical antibiotic treatment for 3 days. Computed tomography of the orbit was performed and revealed a peribulbar high density lesion of the left eyeball. Due to a suspected peribulbar infection, he was subsequently referred to our hospital in the middle of November.
At his first visit, best corrected visual acuity (BCVA) (decimal) was 1.2 in the right eye and 0.15 in the left eye. Intraocular pressures were normal. Although the upper and lower eyelids of his left eye were swollen, we observed no restrictions of his eye movement. Slit lamp examination of the left eye showed ciliary injection, cells in the anterior chamber and a subtenon abscess in the superotemporal quadrant, which corresponded to the site of the posterior STTA (Fig. ). While our fundus examination did not reveal any intravitreal involvement, it did find macular edema and BRVO, which had been reported by his previous doctor. The right eye exhibited no abnormal findings, including both the anterior and posterior segments. The patient had no fever. The orbital magnetic resonance imaging (MRI) revealed the presence of a peribulbar high intensity lesion that corresponded to

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


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

[User]
RADIOLOGY NOTE:
The patient is a 79-year-old male with a past medical history of hypertension who presented to the emergency department with an ongoing history of weakness, fatigue malaise, and right upper quadrant abdominal pain. Labs showed transaminitis as well as elevated bilirubin concerning biliary obstruction. The patient was also noted to have gram-negative rod bacteremia. Computerized Tomography (CT) scan of the abdomen pelvis revealed significant intra and extrahepatic ductal dilation and intra and extrahepatic pneumobilia (). He underwent an ERCP and found to have thick sludge and stone debris from the ampullary orifice. Due to a concern for a possible filling defect in the distal common bile duct versus possible stricture, distal common bile duct brushings were performed in addition to biopsies and stenting with a 10 French 5 cm biliary stent. Pathology from the brushing and biopsies were negative for dysplasia or malignancy.
During his hospitalization, the patient was found to have elevated troponins and electrocardiogram (EKG) changes consistent with NSTEMI. He underwent a pharmacological stress test followed by coronary angiography. He was found to have chronic occlusion of his Right Coronary Artery (RCA). Given these findings and acute coronary events, surgical intervention for cholecystectomy was delayed. The patient was brought back for robotic cholecystectomy after subsequent follow-up and clearance with his cardiologist and surgery clinic. Intraoperative findings revealed dense adhesions to the gallbladder involving the omentum and colon. A dense adhesion was present between the gallbladder and the transverse colon, and a provisional diagnosis of cholecystocolonic fistula was made on further dissection. The case was continued robotically, and the diagnosis of cholecystocolonic fistula was confirmed with the finding of a fistula between the fundus of the gallbladder and the transverse colon (). The fistula was divided. The gallbladder dissected in dome down metho

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


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

[User]
RADIOLOGY NOTE:
A 12-year-old male patient reported to the Department of Pediatric and Preventive dentistry with a chief complaint of the broken upper front tooth with the broken fragment retrieved by the parent which was stored in the milk until examination. History revealed that the patient had a traumatic fall for1 day before in open ground. On intraoral examination, an oblique complicated crown-root fracture was seen extending into the cementum in the left maxillary central incisor (tooth number: 21) []. The remaining coronal fragment was found to be mobile hanging on to the tooth structure. The patient reported the pain on palpation and percussion. Further examination revealed that there were no injuries to the supporting tissues, lacerations over the lips, or any swelling in and around the region of trauma. Intraoral periapical radiograph revealed two accompanying fracture lines, one extending up to 2 mm into the alveolar crest on the mesial half and the other running from the midline 1 mm into the cementoenamel junction; with a closed apex []. In this case scenario, a regular fragment reattachment procedure would not be possible as there was extensive subgingival involvement. Traditional treatment plan would be extraction, but the patient's parents were not willing for the extraction, and hence, hence, intentional reimplantation with extracoronal fragment reattachment was adviced to the patient and the parent. After obtaining the consent from both the patient and the parents, the treatment was done as follows.
In the first visit, the mobile fragment was removed and stored in isotonic saline solution, till it was reattached. Pulp extirpation was done, and calcium hydroxide closed dressing was given (Calcicur®– VOCO, Germany) followed by the medications. The patient was advised a soft diet and to report after a week. In the second visit, the root canal treatment was done, and the patient was recalled for fiber-reinforced composite post placement after a week. Peeso reamers

[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 50-year-old Caucasian male who presented to the emergency department with complaints of lower abdominal pain, fever and sweating. On examination, the patient had tenderness to palpation in the right iliac fossa, with significant rebound tenderness and guarding. Body temperature was recorded at 38.5°C.
The patient's past medical history was significant for an incident of similar pain six months prior to presentation. He was diagnosed with sigmoid diverticular disease confirmed by computed tomography (CT) scan and managed conservatively. A subsequent colonoscopy confirmed the diagnosis, and did not reveal any other colonic pathology.
Further investigations revealed a raised white blood cell count of 16,000 per microliter. CT scan of the abdomen and pelvis disclosed evidence of extensive free gas under the right dome of the diaphragm confirming suspicion of a perforation. Fluid-filled prominent loops of small bowel were noted. However, none of them were dilated to suggest obstruction. Mild bowel thickening was also noted around the cecum. Pneumatosis coli suggestive of ischemic bowel, extending from the cecum to the proximal ascending colon was seen. A blind ending structure with calcifications was also seen (Figure ). Other significant findings on the scan included a liver cyst, consistent with the patient’s previous CT scan, and consolidation at the base of the right lung.
Subsequently, the patient underwent an emergency laparotomy and a diffuse four-quadrant peritonitis was seen. A giant perforated MD, 80 cm proximal of the ileocecal valve was identified as the cause of the peritonitis. The giant MD measured approximately 10 cm in length and 2.5 cm in width (Figure ). A small perforation at the tip of the MD was observed. No other intraabdominal pathology was identified, in particular, there was no evidence of colonic ishchaemia. Resection of the segment of small bowel bearing the MD was performed with a side-to-side stapled anastomosis.
Patho

[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 twenty-four-year-old Irish male with a background history of congenital deafness, intellectual impairment and repair of a posterior urethral valve initially presented to the paediatric nephrology services with nephrotic syndrome. A renal biopsy revealed secondary focal segmental glomerulosclerosis and significant tubuleinterstitial fibrosis. Following introduction of Renin-Angiotensin-Aldosterone system blockade, his proteinuria was controlled.
Despite this, his chronic kidney disease progressed. Ten years later, he was approaching end-stage kidney disease. A Tenckhoff catheter was inserted without complication. Six weeks later, PD training was initiated. A bicarbonate/lactate buffered solution was used to avoid infusion pain, which he would be unable to verbalise. The following months were complicated by dialysis-associated pericarditis that resolved with intensive haemodialysis for a number of weeks. His baseline PD prescription consisted of seven cycles of two litre exchanges with 1.36% dextrose solution. He was also prescribed an icodextrin-based daytime dwell.
Five months later, he was admitted with clinical and radiological evidence of a large, rightsided pleural effusion with pleural thickening. The exact duration of the effusion was unclear as he was unable to verbalise symptoms. It was thought to have developed over weeks given the apparent absence of symptoms and the degree of pleural thickening. A chest radiograph four months earlier showed normal lung fields.
He was afebrile and systemically well. His serum biochemistry and haematology were unchanged and his inflammatory markers were not raised. ECG and echo were normal. A diagnostic pleural aspirate was performed under ultrasound guidance. This yielded serous fluid and also identified numerous loculations within the collection.
The pleural fluid biochemistry was atypical for that seen with pleuroperitoneal leak (). However, as the patient was so well clinically, and numerous pleural fluid cultures wer

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


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

[User]
RADIOLOGY NOTE:
A 32-year-old female patient presented with a history of persistent right knee pain for over three months. There was and no history of any kind of trauma. Her medical history revealed no other medical conditions. Physical examination did not reveal any knee signs. The range of motion was normal although the patient had mild pain in excessive flexion (over 120°). The symptoms of the patient were mimicking blocking symptoms due to mechanical causes at excessive flexion and full extension. She also described an occasional audible clicking at the superolateral patellofemoral joint. The only remarkable finding was a palpable bony mass over the superolateral aspect of the right knee with tenderness and mild swelling in this area. This lump was hard as a bone, was immobile, and particularly sensitive to palpation.
Plain radiographs revealed a sessile bony mass located at the superolateral aspect of the knee joint without a stalk (Figures -). MRI scan was performed and showed a bony bulge arising from the superolateral aspect of the knee joint (within the joint capsule) with surrounding synovitis (Figures -). The imaging findings and the physical examination (especially the palpable bony mass) posed the diagnosis of solitary intra-articular osteochondroma. Due to the symptoms of the patient, diffuse and persistent pain for over three months, arthroscopic removal of the tumor was decided.
Under general anesthesia, standard arthroscopic portals were performed and the arthroscopic examination of ligaments, menisci, and cartilage was normal. Τhen with the aid of a needle the tumor was marked in the superolateral aspect of the knee joint, surrounded by a bursa, and superomedial and superolateral portals were performed.
The bursa was removed with the shaver and from the superolateral portal an osteotome was inserted at the base of the tumor (Figure ). With precise movements, the tumor was excised and finally removed with a hemostatic clamp through the portal. Finally, a burr shav

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

[User]
RADIOLOGY NOTE:
A 30-year-old female originally from Slovenia was first noted to have asymptomatic hypertension in 2008 during a routine check-up at a gym. She was referred initially to a general physician who performed a 24-h blood pressure monitor, which revealed a mean systolic pressure of 160 mmHg and a mean diastolic pressure of 110 mmHg. A work up for a secondary cause of hypertension included a renal ultrasound, which demonstrated a normal renal and urinary collecting system, a normal aldosterone:renin ratio and an echocardiogram which showed evidence of moderate left concentric hypertrophy. A 24-h urine collection for caetacholamines and metanephrines was carried out and found to be markedly elevated (see ).
The patient was then referred to our service for further evaluation. The patient had no past medical history and was not on regular medication. She had been living in Ireland for the past 7 years and was attending a course at a local college. There was no family history of hypertension or endocrine disease. On examination, she had no clinical features to suggest an endocrinopathy and, apart from an elevated blood pressure of 150/100, her clinical examination was entirely normal. A full biochemical profile and endocrine blood panel including neuroendocrine markers were carried out (see ). Radiological localisation with a CT adrenal protocol was carried out and showed a left sided 4.5×3.2 cm adrenal mass with Hounsfield units of 35. A MIBG scan confirmed increased and abnormal uptake by the left-sided adrenal lesion with no other uptake noted. The patient underwent a laparoscopic adrenalectomy after adequate alpha and beta blockade. The patient was re-evaluated 6 weeks after the surgery. She remained normotensive of all medication and repeated urinary caetacholamine and metanephrine collections were within the normal range. Genetic analysis was performed and confirmed a mutation in exon 8 of the RET gene.
Examination of the thyroid gland revealed no clinical abnormality a

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


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

[User]
RADIOLOGY NOTE:
The patient is a 76-year-old woman with a two-year history of left elbow pain empirically diagnosed as gout. When her symptoms failed to improve with appropriate management, radiographs were obtained, demonstrating a lesion in the proximal radius () characterized as a mildly expansile lucent lesion with a thin zone of transition but no sclerotic rim. Internal osseous septations were present and there was cortical thinning but no visible cortical breakthrough, periosteal reaction, calcified matrix, or soft tissue mass. The initial differential diagnosis included metastasis, multiple myeloma, and other less common entities such as a primary sarcoma of bone or atypical infectious process. She was referred to our tertiary care hospital to consult with an oncologic orthopedic surgeon. Further history obtained at that clinic visit elicited that 3 years previously she had incidentally discovered lytic lesions in her skull and left clavicle that were evaluated in another medical system. Biopsy of both lesions performed at that time was inconclusive showing a mix of inflammatory and fibrous cells per report. The pathologic specimens were not available for further review. Physical exam at her clinical visit was unremarkable with no palpable lymphadenopathy and no visible abnormality at the symptomatic left elbow. SPEP and UPEP tests were negative.
Her initial imaging work-up included CT of the chest, abdomen, and pelvis; contrast-enhanced MRI of the left forearm; and nuclear medicine bone scan. Her CT scan showed no findings of primary malignancy and—pertinent to her eventual diagnosis—showed no lymphadenopathy or vital organ abnormality. Bone scan demonstrated marked radiotracer uptake at the site of the lytic lesion in the proximal left radius as well as at the previously biopsied skull and left clavicle lesions (). The MR scan of the left forearm showed a marrow replacing lesion within the proximal diaphysis of the radius (). The lesion was T1 isointense, T2 hyperintense a

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

[User]
RADIOLOGY NOTE:
The 8-year-old boy patient presented with painful red lumps, pus discharge, and alopecia on the back of the head since 2 weeks ago. In the past two weeks the patient complained of pruritus and rashes on his head which were especially severe in the afternoon and evening. The patient was not given any treatment. However, 1 week ago, the patient’s mother noticed that the patient’s alopecia in the pruritic area and the rash had increased. The patient also began to complain of pain in the head area. Therefore, the patient decided to come for treatment at a dermatology and venereology specialist clinic. History of fever is denied. Similar complaints were also found in the patient’s twin, that consist of alopecia, red lumps, and pus discharge. But we did not found other family member with the same complaints. The patient has a history of playing with stray cats in front of his house and is said by the family to have poor hygiene. Informed consent was obtained from the patient and his family for his case and images to be published in this paper. This case details of this manuscript also has been approved to be published by the Department of Dermatology and Venereology, Faculty of Medicine, Universitas Sumatera Utara.
Dermatological examination revealed multiple erythematous nodules with sinuses in the scalp of the parieto-occipital area and alopecia. There is tenderness in the area of the lesion. () On palpation, there is no palpable enlargement of the lymph nodes. There is no lesion in the other parts of the patient’s body. Based on the history and physical examination, the differential diagnosis in the patient was kerion type tinea capitis and impetigenic scabies.
We examined skin scrapings in the lesion area using KOH 10% and examined it under light microscope, which did not show any fungal elements. The culture also showed a

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


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

[User]
RADIOLOGY NOTE:
A 30-year-old primigravida booked for antenatal care at 9-week gestational age. Her booking parameters were all normal. Pelvic ultrasonography showed a single intrauterine live fetus at 9 weeks and a solitary right lateral wall myoma measuring 17.4 cm × 11.2 cm. Her antenatal period was essentially uneventful. During her visit at 36 weeks, her abdomen was asymmetrically distended with increased prominence of the right half of the abdomen. Obstetric examination revealed a live fetus in oblique lie and breech presentation. Obstetric scan done confirmed a live fetus in breech presentation and a large myoma and tortuous dilated vessels on the lower myometrium on Doppler flow study.
She was counselled and scheduled for an elective caesarean section at 38-week gestation due to breech presentation in a primigravida with coexisting leiomyoma. Her preoperative investigations were normal.
At surgery, she was diagnosed with uterine torsion (120-degree dextrorotation) due to the right position of the left round ligament, fallopian tube and ovary. The torsion was corrected and a huge (about 40 cm × 40 cm) myoma was observed to occupy the entire anterior wall of the gravid uterus (). There was no obvious uterine anomaly and the fallopian tubes and ovaries were grossly normal. The spinal anaesthesia was converted to a general anaesthesia with endotracheal intubation. The subumbilical skin incision was extended cephalad, and the gravid uterus and leiomyoma were exteriorized before a deliberate midline vertical incision was made on the posterior wall of the uterus and a healthy male baby was delivered by breech extraction. After delivery of the baby, she was given intravenous carbetocin 100 μg and tranexamic acid 1 g. The uterine incision was repaired in layers using 1–0 polyglactin suture and haemostasis was achieved as shown in . The anterior abdominal wall incision was closed in layers with Nylon 2 suture to the rectus sheath. Her post-operative vital signs

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

[User]
RADIOLOGY NOTE:
A 65-year-old man complained of left knee swelling and pain without any trauma episodes. His local physician performed knee aspiration, which revealed massive haemarthrosis of the knee, although the patient had no hereditary disease or drug usage that might be associated with a haemorrhagic tendency. However, despite the conservative treatment via aspiration, haemarthrosis of the knee persisted. Therefore, at 4 months after the onset, the physician performed arthroscopy, which revealed limited joint surface degeneration with no colouration, lateral meniscus degeneration, and a partial tear, which was suspected to be the source of bleeding. Thus, lateral meniscectomy was performed to address the tear.
Unfortunately, the haemarthrosis of the knee persisted, and the patient was referred to our institution at 3 years after the onset, due to refractory haemarthrosis and osteoarthritis progression. At the admission, left knee radiography revealed the end stage of osteoarthritis (), and we performed various examinations to investigate the cause of the chronic haemarthrosis. However, the cause remained unclear, as enhanced magnetic resonance imaging and thallium scintigraphy did not reveal the presence of any tumorous lesions, such as pigmented villonodular synovitis or hemangioma. Furthermore, blood analysis failed to identify the cause of bleeding tendency, as platelet counts, alanine transaminase levels, aspartate transaminase levels, activated partial thromboplastin time, and prothrombin time were all normal. As the patient did not have family history or medication that might explain the haemorrhagic tendency, we diagnosed him with spontaneous haemarthrosis and performed total knee replacement.
We performed the total knee replacement under general anaesthesia using a cemented mobile-bearing prosthesis (Vanguard RP, Biomet, Japan). The articular cartilage of the left knee was exposed via the medial parapatellar approach, which revealed that the entire articular cartilage

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

[User]
RADIOLOGY NOTE:
A 28-year-old nulliparous pregnant Japanese woman was referred for prenatal evaluation at 30 weeks of gestation because of abnormal ultrasound findings of fetal congenital heart defects. The family history of the parents was unremarkable. Fetal ultrasonography at 30 weeks and 5 days of gestation showed vascular ring, Ebstein's anomaly, ventricular septal defect, and single umbilical artery. The estimated fetal body weight corresponded to the Japanese standard for the gestational age. Fetal ultrasonography showed vertex presentation of the moving fetus and the fetal stomach appeared to be normally dilated (). The pregnant woman had not felt any fetal movements since 31 weeks of gestation. At 32 weeks and 5 days of gestation, fetal ultrasonography showed absence of fetal movement with breech presentation, polyhydramnios, absent filling of stomach, and fetal growth restriction (FGR) (). However, abnormal Doppler findings regarding the fetal middle cerebral artery, umbilical cord artery, and ductus venous were not observed. Clinical diagnosis of fetal akinesia was made at this point. At 32 weeks and 6 days of gestation, amniocentesis was performed to assess the possibility of chromosomal aberrations. Interphase fluorescence in situ hybridization (FISH) analysis on uncultured amniocytes for chromosome 13, 18, and 21 revealed two signals, respectively. At 34 weeks and 6 days of gestation, progression of polyhydramnios with maternal respiratory compromise occurred () and 2300 mL of amniotic fluid was removed. G-banding analysis on cultured amniocytes revealed a karyotype of 46,XY,22pstk+ (). After discussion with the parents about the prognosis of the fetus based on ultrasound findings, including fetal akinesia since 31 weeks of gestation, FGR, congenital heart defects, and left-sided pleural effusion that indicated severe phenotype with prenatal onset of genetic disorders, perinatal palliative care was chosen. At 36 weeks and 3 days of gestation, fetal ultrasonography sho

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

[User]
RADIOLOGY NOTE:
In October 2016, A 54-year-old male presented with bilateral crippling hip pain in the groin on both sides radiating to the front of the thigh with reduced mobility for almost 3 years and progressive worsening of symptoms. He had developed a significant limp preventing him from walking and performing routine activities independently with disturbed sleep.
On examination, he had a bilateral stiff hip, antalgic gait with a BMI of 34.1. Both hips had very limited range of motion (). He had a poor Harris Hip Score of 34.2 in the left hip and 34.3 in the right hip. Anteroposterior X-ray of the pelvis with both hip joints showed severe bone-on-bone arthritis () in both the hip joints. He elected to undergo simultaneous bilateral soft tissue sparing bikini anterior hip replacements described previously by the senior surgeon []. The left hip was operated first followed by right with a surgical time of 135 minutes total.
Post-operatively, mechanical thromboprohpylaxis was used for 24 h followed by oral aspirin 300 mg with nexium for 6 weeks. He was mobilized within few hours after surgery as part of our enhanced recovery programme. He started walking with the aid of a walking frame and even managed a dozen steps unaided the same day. He was discharged on the 2nd post-operative day. He started on his exercise bike Day 5 post op and resumed driving on the sixth day onwards as he was very mobile with a single crutch mainly for safety and not on any narcotic analgesia. He felt very confident and comfortable and had no issues driving.
On day 9 post-op, he was back at work doing light duties and clerical activities by which time he was mobile with pain free hip movements and without any mechanical dysfunction. At the 6 week mark he had a well healed surgical scar with no swelling and walked in without a limp. He was followed

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


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

[User]
RADIOLOGY NOTE:
A 46-year-old Caucasian male was referred to our neurology clinic due to sensory symptoms of lower extremities. Presence of dark urine at 8 years of age revealed that he was diagnosed with AKU (urinalysis and biochemical testing confirmed the presence of HGA at the time of diagnosis). He developed progressive lower back and shoulder pain before 25 years of age and first signs of ochronosis were evident as early as 12 years of age on pinna of ears. Family history was unremarkable (no report of osteoarthritis, AKU or consanguinity). The patient had extensive arthritic and cartilage damage on all weight bearing joints of knees, hips and vertebral column. Shoulder joints were the most severely affected showing extensive swelling, limited mobility and arthritic degeneration [Figures and ]. Clinical examination of the spine showed impaired cervical, thoracic and lumbar mobility. An MRI of spine displayed multi-level disc space narrowing, spinal cord compression and disc herniations at cervical and lumbar spine with effacement of cerebrospinal fluid space [Figures and ]. The patient experienced persistent tingling, diffuse constant pain and numbness in both of his feet and toes. Motor testing of the lower extremities showed normal muscle tone and strength, however, motor movements of the upper extremities were sluggish and painful, and muscle strength was slightly weak. Sensory testing of the extremities to pin prick, light, touch, vibration and temperature was normal. Examination of the patient's gait was also normal. Patient reported no trouble with vision, speech or swallowing. Due to extensive shoulder arthropathy and cartilage damage, the patient required bilateral shoulder replacement and underwent total right shoulder replacement surgery. The patient showed symptoms of dysthymia, although he did not meet formal criteria for depression. Limited mobility, decreased range of motion (ROM) and lost function of day-to-day basic activities initiated irritability, social is

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


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

[User]
RADIOLOGY NOTE:
A 44-year-old female was found to have an incidental FDG-avid right thyroid lesion following staging PET for colorectal carcinoma. She was asymptomatic from the thyroid lesion and biochemically euthyroid. There was no personal or family history of thyroid disease and no prior history of radiation exposure to the head and neck region. CT scan of the neck confirmed a 40mm thyroid nodule, and ultrasound guided fine needle aspiration of this nodule was suggestive of a follicular neoplasm.
A right hemithyroidectomy was performed. The gross specimen weighed 67 grams and the cut surface revealed a round solid well-circumscribe tan nodule, with scant compressed residual thyroid parenchyma at the superior pole. The entire specimen was submitted for examination. Sections showed the nodule to be entirely encapsulated by a thick fibrous band without capsular or vascular invasion. The tumour showed predominantly areas in keeping with usual follicular adenoma formed by microfollicles with scant colloid and lined by cells with bland round to ovoid nuclei ().
Present centrally and entirely within the encapsulated and conventional adenoma was an 11 mm focus showing distinct insular growth pattern with atypical cell morphology. The cells contained round to ovoid nuclei with irregular nuclear membranes, small nucleoli, and high nuclear to cytoplasmic ratio. The mitotic count was very high (8/10 high power fields), although tumour necrosis was absent, meeting criteria for PDTC (). In addition there were several regions, one of which was adjacent to the PDTC-like area, showing formation of trabeculae and high nuclear cytoplasmic ratio, without sufficient nuclear morphology or mitotic count for PDTC criteria ().
The PDTC-like focus and adjacent trabeculae region did show noticeably higher proliferation rate by MIB1 immunohistochemical (IHC) staining (). IHC staining showed retained expression of TTF1 (), with loss of thyroglobulin (which was retained in background follicular adenoma comp

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

[User]
RADIOLOGY NOTE:
A 54-year-old, Hispanic male with no known past medical history presented to the emergency room with a chief complaint of sudden-onset right-sided weakness over the past 24 hours. The patient denied any associated dizziness, visual disturbance, or reduced level of consciousness. He had not seen a physician in over 20 years. His social history was significant for chronic alcohol abuse with consumption of at least one pint of tequila or beer per day for at least 35 years. The patient was tachycardic to 101/min with a physical exam that was remarkable for right-sided facial droop as well as 1/5 strength in the right upper and lower extremities. He was noted to have a National Institutes of Health stroke scale of 17.
A stat computed tomography (CT) of the head without contrast as well as magnetic resonance imaging (MRI) without contrast were negative for acute stroke. The patient's urine drug screen and alcohol level was unremarkable. His labs were significant for an ALT of 70, AST 251, direct bilirubin 0.4, INR 1.1, platelets 79 x 10^3 (Table ). All of his other labs were normal. Further investigation with right upper quadrant ultrasound suggested possible liver cirrhosis. Computed tomography of the abdomen and pelvis revealed a micronodular appearance of the liver with numerous scattered hypodensities (Figure ). A hepatitis A, B, C panel, autoimmune panel, alpha-1 antitrypsin deficiency panel and iron panel were all negative. Our patient was suspected to have alcohol-induced cirrhosis due to his extensive alcohol history.
A lipid panel and Doppler of the neck were obtained which were found to be normal. Once an ammonia level was found to be 140 micro mol/L, the patient was started on lactulose and rifaximin. The patient opted out of physical therapy the first two days of admission; however, his neurological symptoms resolved without residual neurological deficits about 36 hours after treatment of lact

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

[User]
RADIOLOGY NOTE:
A 39-year-old male patient with the chief complaint of left-side motor weakness arrived at the emergency department. He was alert with no unusual medical history or ongoing medications. Blood pressure was normal, and results of laboratory investigation did not indicate coagulation abnormality or other specific findings. The patient began to show symptoms nine hours before arrival at hospital.
Brain computed tomography (CT) and brain CT angiography taken at our hospital showed a subarachnoid hemorrhage (SAH) in the right sylvian fissure and a right proximal middle cerebral artery occlusion (). A series of brain magnetic resonance images (MRIs) and digital subtraction angiography (DSA) showed an acute cerebral infarction in the right striatocapsular area due to proximal right middle cerebral artery (MCA) occlusion (). The patient had both ischemic stroke and SAH. No salient lesions that might be considered a cause of SAH were observed. Therefore, considering it a large-artery ischemic stroke, we established a treatment plan. Because more than nine hours had passed since the patient's symptoms developed, we decided that medical treatment through dual antiplatelet medication (aspirin 100 mg daily, clopidogrel 75 mg) would be better for the patient than any other treatments.
On the fifth day after admission, he had an episode of tonic-clonic seizure and brain CT after seizure showed increased SAH at the basal cistern and both sylvian fissures (). DSA showed a lesion, apparently a dissecting aneurysm (DA), in the right supraclinoid internal carotid artery (ICA), that had not been visible earlier (). Due to the patient's stuporous consciousness level, it was impossible to perform a balloon test occlusion. However, trapping of the lesion in the ICA was considered viable based on the “Allcock test” and “Matas test” results. Thus, internal coil trapping was performed on the right supraclinoid ICA lesion. Subsequently, lumbar drainage was performed, and his consciousness level

[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.