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

[User]
RADIOLOGY NOTE:
A 24-year-old male patient whose medical history included neuroblastoma gets readmitted to the First Affiliated Hospital Bengbu Medical College with chief complaint of discomfort in his chest for 12 months. He was diagnosed with posterior mediastinal tumor in the Department of Thoracic Surgery, the First Affiliated Hospital of Bengbu Medical College 4 years ago. On December 28, 2013, the thoracotomy was performed, and the tumor was completely removed. Postoperative pathology proved to be a posterior mediastinal neuroblastoma. He did not receive postoperative radiotherapy and chemotherapy, and he did not take examination regularly for 4 years after surgery. The chest-enhanced CT scan during this hospital stay demonstrated that a 7-cm, moderately enhanced space-occupying lesions arised from the right posterior mediastinum and retroperitoneum, which was at the rear of the inferior vena cava (Fig. ). Based on his medical history, the provisional diagnosis was adult recurrent neuroblastoma.
The suitable pathway for the tumor adhering to inferior vena cava in the right posterior mediastinum and posterior mediastinum is thoracoabdominal incision. He was placed at lithotomy position, and upper abdominal median incision combined with right thoracic fifth intercostal incision was made under general anesthesia (Fig. A). Subsequently, the abdominal and thoracic cavity was entered layer by layer with right arcus costarum being cut off. The liver round ligament, the falciform ligament, the left and right coronary ligaments and the left and right triangular ligaments were cut to fully dissociate the liver. At the same time, the right diaphragm was disconnected to completely expose the mass measuring approximately 7cm × 3cm × 2 cm, which originated from the right posterior mediastinum and extended into the retroperitoneum (Fig. B). The tumor was located behind the inferior vena cava, from the right posterior mediastinum to the right renal vein, which was hard, and slightly sticky w

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


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

[User]
RADIOLOGY NOTE:
A 28-year-old woman, gravida 3 para 1, had a medical termination of a miscarriage at seven weeks, with no dilation and curettage, in 2008. In 2015, a baby was delivered by caesarean section in the breech position, weighing 3900 g. She had no significant past medical history, and her antenatal care had been uneventful. On August 9, 2018, at 19:15, she was admitted to our hospital due to a pregnancy of 9+ months and irregular contractions for 4+ hours. Periodic uterine contractions occurred every 6–8 min. The patient was not accompanied by abdominal pain or vaginal bleeding and had intermittent term after contractions. Clinical examination showed that her body temperature was 36.7 °C, blood pressure was 102/65 mmHg, pulse rate was 100 bpm, and oxygen saturation was 100%. Blood tests showed mild leucocytosis (16.61 × 109/L), normal platelet count, normal coagulation test, and haemoglobin of 102 g/L. Vaginal examination showed the cervix was tightly closed; no vaginal bleeding or fluid was found. The ultrasonography indicated that the foetal head was located above the uterine cavity, the foetal size was consistent with the gestational age, the placental position was normal, and the scar thickness of the previous caesarean section was approximately 0.2 cm. Uterine contractions declined after admission. During admission, the patient was clinically and biochemically stable, and daily cardiotocograms showed a reassuring foetal heart rate pattern. Because of the patient’s progressive anaemia (blood tests revealed a slow decline in haemoglobin to 93 g/L, 87 g/L) and sudden increasing abdominal pain, ultrasound was used but did not show ruptured abdominal fluid. An urgent laparotomy was performed and revealed a massive haemoperitoneum caused by the rupture of the uterine posterior wall. A haemoperitoneum with approximately 1 liter of blood was recovered. The lower uterine segment was intact and not ruptured. A boy with a body weight of 2900 g was delivered. Apgar scores

[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 male with a medical history of HBV-associated PAN presented with acute abdomen and septic shock. He was diagnosed with PAN 6 months earlier and was under treatment with prednisolone (32 mg daily) and cyclophosphamide (150 mg every other day). The patient was also prescribed the antiviral agent Tenofovir, but stopped taking it 2 months prior to the incident, against medical advice. The patient's medical history also included chronic renal failure and diabetes mellitus Type II. On work up, a standing chest radiograph revealed free sub diaphragmatic air.
During laparotomy, peritonitis was found due to three perforations of the small intestine. Segmental enterectomy with anastomosis was performed at two sites, the first at 10 cm from the ligament of Treitz, and the second at about 1 m from the ileocecal valve.
The patient was then transferred to the Intensive Care Unit on mechanical ventilation and circulatory support, in acute-on-chronic renal failure. On the third postoperative day he was weaned off the ventilator and remained haemodynamically stable. After consultation with the rheumatologist, the patient started treatment with tenofovir orally and IV methylprednisolone 1 gr daily for 3 days.
On the seventh postoperative day the patient's abdominal drain catheter presented enteric content, so he underwent a second explorative laparotomy. Two new perforations and multiple areas of patchy necrosis along the whole length of the small intestine were found (Fig. ). All the lesions were suture repaired after debridement, and the patient was left with an open abdomen using a vacuum device, with a plan for re-laparotomy in 48 h (Fig. ). After the second operation the patient started plasma exchanges for the treatment of PAN, along with IV cyclophosphamide 500 mg stat and IV methylprednisolone 1 gr daily for 3 days and then IV prednisone 60 mg daily.
On the third laparotomy, three new necrotic lesions, two on the small intestine and one on the cecum, were found

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


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

[User]
RADIOLOGY NOTE:
The first case is of a 57-year-old man who has undergone elective coronary artery bypass grafting for triple-vessel coronary artery disease and required sternal resuturing for sternal wound infection after 1 month of surgery. After 2 months of surgery, an angioplasty was performed to mid-LAD for 95% stenosis in the segment. Later, after 1 month, he was readmitted with repeated episodes of bleeding from the sternal wound and a small pulsating membrane at the upper part of the sternal wound. He was in congestive cardiac failure at the time of presentation, with bilateral pedal edema and crepitations in the chest. A transthoracic echo was done that showed a 40 mm × 44 mm pseudoaneurysm [] arising from the ascending aorta. A CT angiogram of the chest showed a large trilobed and partially thrombosed pseudoaneurysm from the ascending aorta [] with a narrow neck (9.0 mm), which was abutting the sternum and extending into the left parasternal region and compressing the right ventricular outflow tract and main pulmonary artery. The distance of origin of the neck measured 36 mm from the right coronary origin. After assessing the comorbid condition and the risks of redosternotomy for surgical management, the interventional management by occlusion of pseudoaneurysm opening with ASD Occluder was planned. The left femoral artery (6 F) and left femoral vein (7 F) accesses were obtained. Aortic angiogram was performed with a pigtail catheter (6F, merit), which demonstrated the trilobed pseudoaneurysm with a narrow origin from the ascending aorta, as shown by CT angiography. A right coronary angiographic catheter (Judkins Right Coronary, JR2) was used to engage the orifice of the pseudoaneurysm and selective hand injection was carried out to delineate the pseudoaneurysm anatomy. An exchange length 0.035” J tip Terumo wire (Terumo™) was then positioned into its middle lobe using a catheter. A 9 F ASD Occluder delivery sheath (Sear

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


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

[User]
RADIOLOGY NOTE:
A 58-year-old Hispanic female with a history of hypertension and hyperlipidemia was brought to the emergency department for an altered mental status. On admission, the patient was hemodynamically stable. She had a nonfocal initial neurologic exam. Her laboratory findings were consistent with hypoxemia, acidosis, and mildly elevated leukocytosis. A 12-lead ECG revealed sinus tachycardia with lateral ST segment elevation; due to these findings, the patient underwent emergent cardiac catheterization, which revealed normal coronaries.
A noncontrast CT scan of the head demonstrated a right subacute temporal lobe infarct and multiple scattered infarcts in all vascular territories raising the possibility of embolic phenomenon. Further clinical course was complicated by right popliteal and superficial femoral vein thrombosis and bilateral segmental pulmonary embolism. The patient also had a transient right radial artery occlusion.
Her initial contrast-enhanced transthoracic echocardiography (performed after the cardiac catheterization) and subsequent transesophageal echocardiography (TEE) revealed a large left ventricular mass with a wide base, attached to the anterolateral free wall. The mass had poorly defined edges and several mobile components. There were no other significant structural and functional cardiac abnormalities noted. Detailed TEE analysis (, Supplementary video in Supplementary Material available online at ) confirmed a presence of a 42 × 10 mm thrombus arising from the lateral wall and extending into the left ventricular outflow tract.
Evidence of multiple arterial and venous clots in addition to the large cardiac thrombus raised the suspicion for inherited thrombophilia. The coagulability workup was performed and came back positive for protein C and S deficiency, with activity of 26% (normal range: 84–171) and 18% (normal range: 54–132% for females) for proteins C and S, respectively. At that time, the patient had normal liver function and vitamin K 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.


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

[User]
RADIOLOGY NOTE:
A 49-year-old man was referred to our hospital with a four-month history of severe neck pain during posture changes, as well as mild paresthesia in his left arm. Because of his severe neck pain, he could not walk or remain standing or sitting. He had undergone surgery, and chemotherapy for gastric cancer 19 months previously. Metastases to the left adrenal gland and diaphysis of the right femur were diagnosed after he received chemotherapy. Physical examination was normal except for exaggerated deep tendon reflexes in his upper and lower extremities.
Radiography and computed tomography (CT) of his cervical spine showed irregular osteolysis at C2, and magnetic resonance (MR) imaging revealed a mass lesion with an apparent intensity change occupying the entire anterior part of C2. The mass had marked and homogeneous enhancement after intravenous injection of gadolinium-DTPA (). Further investigations, including technetium scintigraphy and MR imaging of the whole spine, revealed no evidence of other spinal involvement. The metastatic tumor of C2 was thought to be a candidate for his severe neck pain during posture changes, and surgical stabilization for the lesion was planned.
The patient received radiotherapy to the neck with a total dose of 30 Gy. Because his severe neck pain during posture changes had been taken worse in spite of the radiation therapy, he required surgical intervention despite his refusal at first. The preoperative anaesthetic assessment was not suggestive of any risk for airway obstruction. 2 weeks after the radiation therapy, occipitocervical fusion (C0-5) following removal of the posterior arch of C1 and laminectomy of C2 via the single posterior approach was performed.
During the procedure for decompression and pedicle screw insertion, the upper cervical spine was fixed with a Mayfield clamp in a flexed position to obtain a wide view of the C1 posterior arch. Before fixation, the flexed position of the cervical spine was changed to obtain an ade

[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 patient in her late seventies was incidentally found to have a large infrarenal abdominal aortic aneurysm in 2013 for which she had undergone an uneventful percutaneous endovascular aortic repair with left chimney. She lived alone, remained independent in her activities of daily living, and was community ambulant without aid.
She was electively admitted in September 2019 for embolization of a type 2 endoleak by the interventional radiologist. Super selective cannulation of the distal aspect of the iliolumbar branch supplying the nidus with a micro catheter was performed. Embolization was carried out using Onyx® until complete exclusion of the nidus. This was followed by repeat aortogram, which showed complete exclusion of the nidus from right-sided branches. However, there was continued filling of the nidus from the left lumbar branches. It was therefore decided to embolize the left side. After embolization, angiogram showed complete exclusion of the endoleak and the left-sided branches supplying the endo leak.
Five hours after the procedure the patient complained of bilateral lower limb weakness and numbness, right more than left. Physical examination revealed lower motor neurone pattern of weakness over bilateral lower limbs, right worse than left (Table ). Sensation testing revealed normal sensation over left, impaired sensation for right L2 to S1. Proprioception at bilateral big toes was intact. Reflexes were absent in bilateral lower limbs.
Lumbar spinal drain was inserted to decompress the spinal cord to allow more arterial flow as there was concern with spinal cord ischemia. The patient was started on fluid replacement to maintain the mean arterial pressure above 80 mm Hg. Urgent CT aortogram followed by MRI thoracolumbar spine was performed. Aortogram showed postinterval embolization of bilateral feeding arteries. Onyx material was seen within a branch of the embolized right iliolumbar artery, which extends into the spinal canal at the level of L3 and appe

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


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

[User]
RADIOLOGY NOTE:
A 70-year-old man presented to the emergency department at our institution, with angina-like chest pain, palpitations, and sweating.
One year prior to his current admission, he underwent endocrine evaluation following an incidental adrenal finding on imaging measuring 25 × 34 mm2. A 24-hour urine collection for catecholamines revealed a urine epinephrine level of 150 μg (normal limit: <27 μg/day). A 1-mg overnight dexamethasone suppression test was abnormal, with serum cortisol level of 188 nmol/l (normal limit < 50 nmol/l). He then underwent an ambulatory high dose dexamethasone suppression test. That day he was referred to the emergency department due to angina-like chest pain, palpitations, and sweating. He underwent cardiac catheterization, which demonstrated no significant pathology in the coronary arteries, and was discharged the next day. Past medical history was significant for hypertension, type II diabetes mellitus, and dyslipidemia.
A year later, on current admission, the patient's electrocardiogram showed sinus rhythm, new T wave inversion in lateral and posterior leads, with no conduction abnormalities. Bedside echocardiography demonstrated hypokinesis in the distribution of the left anterior descending coronary artery. The patient underwent urgent catheterization which once again demonstrated no pathology in the coronary arteries. A subsequent echocardiogram demonstrated normal ventricular function with moderate mitral and tricuspid regurgitation.
During his stay in the coronary care unit, the patient experienced several episodes of hypertension and tachycardia, refractory to treatment with calcium channel blockers, beta and alpha adrenergic blockade, angiotensin receptor blockers, and furosemide. As part of resistant hypertension evaluation, abdominal computed tomography was performed and a 36 × 34 × 22 mm3 right adrenal mass was identified. The adrenal mass had a density of 39 Hounsfield units (HU) prior to intravenous contrast injection, increasing

[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 Caucasian woman was referred to our level I trauma unit by the in-house dermatology department with a suspected right hip fracture after a fall at her home 3 days earlier. This previously healthy patient initially presented at the hospital and was admitted in a poor physical condition with painful ulcerating skin lesions, which covered the right axilla, lateral chest, and inner upper arm and discharged a purulent secretion. The patient described that the lesions had developed and worsened over the past few days, and she was initially referred to the dermatology department, where she was diagnosed with PG after clinical and histologic examination of the skin lesions. There were no systemic signs of infection at the time of presentation at the hospital. She was treated with local applications of octenidine dihydrochloride, paraffin gauze, and alginate dressings. Methylprednisolone treatment was initiated on the day of admission at a dose of 40 mg daily. Due to the reduced physical condition of the patient, who was in considerable pain at the site of the skin lesions, and preexisting general feebleness combined with underweight status, she was bedridden at the dermatology department. She did not report pain from her right hip until 3 days after admission to our hospital. The patient was then referred to our trauma department, where anamnesis, physical examination, and x-rays revealed a femoral neck fracture, Garden IV, Pauwels III (Fig. a, b). Due to the concurrent active PG lesions, the patient underwent temporary tibial traction. The patient’s lesions improved under care of the dermatology department (Fig. a), and there was no pathergy at the tibial traction site. Ten days after diagnosis of the femoral neck fracture and 13 days after the injury was sustained, surgery was performed with prophylactic moxifloxacin, which was continued at 400 mg daily. Hemiarthroplasty was performed according to the standard orthopedic technique with an anterolateral appro

[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 6-year-old boy presented to our hospital with a hard neck mass. He did not complain of pain or discomfort in the neck. His parents stated that the mass was observed immediately after he was born and it had grown gradually with age, especially in the past 2 years. He had never been treated before for the mass. He had no history of trauma or persistent fever. His mother's pregnancy and delivery history were normal and the boy exhibited normal growth and development at 6 years of age, with no relevant family history. Physical examination revealed a hard, immobile mass posterior to the cervical spine (Fig. ). There was no swelling or tenderness of the mass. The mass was oval, measuring 3 × 1 cm. The skin temperature was normal and the skin was not attached to the mass. There was no sign of local compression of nerves, arteries, or veins. The patient had full cervical range of motion and the mass was more evident with flexion. No masses were detected elsewhere in his body. His neurological examination was unremarkable. No pain was evoked during the physical examination. All laboratory findings were normal.
Plain radiographs (Fig. ) showed an anomalous bone attached to the left side of the C5 (the fifth cervical) vertebra. Magnetic resonance imaging of the cervical spine showed a normal spinal cord and intervertebral discs (Fig. ). It also revealed a well-circumscribed cortical bone within the dorsal cervical muscles (Fig. ). Two- and 3-dimensional computed tomography revealed a finger-like bone with a pseudoarticulation attached to the hypoplastic spinous process of the left side of the C5 vertebra (Figs. and ). The anomalous bone had an obvious cortex and medulla osseous structure (Fig. ).
The patient was diagnosed with a “cervical digit.” Because of its gradually increasing size and esthetic complaints, the patient underwent surgical excision of the anomalous bone trough a posterior midline approach. Intraoperatively, the bony mass was

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


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

[User]
RADIOLOGY NOTE:
A 44-year-old man without notable previous medical history presented with severe headache, nausea, and vomiting that had persisted for a few days. He was admitted to a local hospital, and computed tomography (CT) and magnetic resonance imaging revealed a large tumor with intratumoral hemorrhage in the right frontal lobe. For the management of intracranial hypertension, osmotic diuretics were administrated, leading to dehydration. The third day after admission, he was transferred to our hospital due to neurological deterioration including progressive disturbance of consciousness and left hemiparesis.
Magnetic resonance imaging performed at our hospital showed a rapid increase in mass effect, resulting in subfalcial and transtentorial herniation (). The commonly measured coagulation parameters, including prothrombin time, activated partial thromboplastin time, international normalized ratio, and thrombocyte count, were within the normal range. The patient underwent an emergency right frontal craniotomy performed in the supine position without excessive head rotation. The tumor was removed en bloc using the navigation-guided fence-post procedure without opening the ventricle or cistern. Accordingly, excessive CSF leakage did not occur during the operation. In addition, postoperative CSF loss through closed subgaleal drain did not occur.
Postoperatively, the level of consciousness remained unchanged from the preoperative level and no new neurological deficits were detected. A routine postoperative CT scan on the day after surgery revealed a bilateral cerebellar hemorrhage along with the cerebellar sulci facing the tentorium (). Magnetic resonance imaging showed bilateral anterior cerebral artery infarction due to subfalcial herniation and right posterior cerebral artery infarction due to transtentorial herniation that reflected the preoperative intracranial hypertension, and no evidence of residual tumor at the surgical site was found (Figures –). The cerebellar hemorrh

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


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

[User]
RADIOLOGY NOTE:
A 9-month old boy presented at a hospital in a south western state of Nigeria, with a swollen left upper arm adjoining the chest, low-grade continuous fever (38.1 °C), frequent passage of loose watery stool and persistent cries for more than 3 h. Child had been immunized about 24 h earlier. The mother reported that the symptoms were observed 2 h after the child was vaccinated with the measles vaccine at a private hospital. The child was one of three children reported to have been vaccinated with measles vaccine at a private hospital during the immunization clinic session.
On examination, he was mildly pale, febrile and anicteric. He was moderately dehydrated; mildly dyspnoeic with normal heart sound, heart rate of 148 beats/ min, breath sound was vesicular and respiratory rate of 54 cycles per minute. He was well nourished as the weight was appropriate for age. There was extensive swelling with skin discolouration (hyperemia) involving the entire left upper arm, sparing the distal third of the forearm and hand. There was also swelling of the upper part of the anterior chest wall. The swelling was firm and mildly tender. There was no history of adverse reaction to immunization or any form allergic reaction.
A day after admitting the child, extensive erythema of the left upper arm and anterior area of the chest was observed with extensive scalded skin lesion involving the deltoid area, the upper chest wall and arm (Fig. ). Desquamation of the affected areas was observed presenting like severely burned skin from a hot liquid. There was darkening and hardening of the skin over the affected area on the arm with eventual severe necrosis up to a depth of about 5 mm thereafter (Figs. and ). A diagnosis of severe necrotizing fasciitis was made.
Radical debridement of necrotic tissues was carried out under general anaesthesia. Child was also transfused with blood. Daily dressing of the wound was done and antibiotics administered were intravenous metronidazole (20 mg

[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 61-year-old male with a past medical history of hypertension presented to our ED with a chief complaint of fatigue. The patient had been visiting friends and relatives in the DRC and had returned to the US two days prior to presentation. History was obtained primarily from the patient’s son as his father was delirious, which limited his ability to provide a comprehensive history. The son stated that the patient’s symptoms began one week prior to presentation while still in the DRC. The patient returned to the US in a feeble state per the son. He had very little oral intake over the prior week and would wake up confused and disoriented during the three days prior, including not recognizing his own house or shower on the day of presentation. The patient’s confusion would wax and wane but seemed worse upon wakening in the morning and after napping, and would improve throughout the day. He reported night sweats and chills but no known fevers. He had multiple episodes of dark diarrhea, but no bright red blood or black stools. He had a mild cough but no dyspnea or chest pain. He also reported nausea without vomiting.
A review of systems was otherwise negative including absence of headache, vision changes, numbness, focal weakness, or skin eruptions. The patient did endorse multiple mosquito bites but had been on malaria prophylaxis with doxycycline, which he had continued to take upon his return to the US. The patient’s compliance with medication along with other precautions and malaria preventative measures such as mosquito nets and permethrin spray was not determined in the ED due to the patient’s critical illness and need for resuscitation. He visited the international travel clinic prior to his trip and had been vaccinated for both yellow fever and typhoid. He was unaware of any sick contacts.
On arrival, his vital signs were significant for hypotension with a blood pressure of 103/62 millimeters mercury,

[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 52-year-old male patient was admitted to our interventional radiology unit with pain, swelling and color change in the left inguinal region following therapeutic angiography. Laboratory tests showed progressive reduction in hemoglobin levels. In the diagnostic angiography that was performed two days earlier, partial occlusion in the left anterior descending artery was observed and 1 day before the patient was referred to us, he had undergone percutaneous transluminal coronary angioplasty with stent placement. The patient was under thrombolytic-anticoagulant therapy at the time of angioplasty. He had been smoking one-pack-cigarette/day for the last 40 years and he had high blood pressure. No additional important information was detected in his medical history.
In the gray scale ultrasonographic examination, a 43×26 mm pulsatile cystic lesion was observed in the left groin. Doppler ultrasound (US) examination showed “to and fro blood flow” inside the lesion. Based on these findings, the patient was diagnosed as IPA, but IPA and the morphology of its neck could not be demonstrated clearly with US. To detect the morphology, the origin, and the neck of IPA, multidetector computed tomographic angiography (MDCTA) was recommended. US-guided compression was done for 20 minutes, as well. Following compression treatment, a thrombus that formed one third of the size of the IPA was detected. The patient was recommended to sleep and bed rest in the supine position, and pressure was applied on his left groin and he was observed for one day.
In 64-MDCTA (Aquilion, Toshiba Medical Systems, Tokyo, Japan) and control Doppler US examination, IPA was originated from SEPA and the common femoral artery was normal (). In addition, an inguinal hernia containing small intestinal loops was detected in the right inguinal region (). Iatrogenic pseudoaneurysm was 36×23 mm in size and there was a 10 mm thrombus inside it. US-guided compression treatment was applied for the second time for the p

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


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

[User]
RADIOLOGY NOTE:
A 33-year-old, gravida 1, para 0, at 21 weeks’ gestation, was referred to for evaluation of an abnormal twin gestation with a facial tumour in one of the fetuses. 2-D, 3-D and 4-D ultrasound showed a bicorionic, biamniotic twin pregnancy with a normal female twin A, and a female twin B with a large asymmetric anterior mass protruding from mouth and nose not affecting the neck area, occluding completely fetal airway and compromising perinatal transition to pulmonary breath at birth. Prenatal diagnosis of epignatus was established. MRI confirmed an epignatus not invading CNS. Once diagnose was established, our Fetal Medicine and Therapy Program multidisciplinary team proposed the parents to perform an ex utero intrapartum treatment procedure to secure the airway through tracheostomy and intubation before delivery. Implications, benefits and risk of the procedure as well as posterior neonatal treatment were discussed in detail. The parents decided to continue the pregnancy and accepted EXIT. Regular ultrasound assessments showed growth of the tumour to a maximum of 93 x 62 x 56 mm. Polyhydramnios developed in the affected twin as soon as 26 weeks’s gestation, resulting in uterine irritability, and requiring 3 amnioreduction procedures (at 27 and 30 weeks’ gestation and preoperative), tocolytic agents and bed rest. Dexamethasone injections were given at 27 weeks of gestation. The mother developed anaemia from 27 weeks’ gestation that reduced haemoglobin levels to 83 g/L and was treated with ferrous sulphate, 300 mg/day. The woman was admitted at 33 + 4 weeks of gestation for a planned delivery due to the high risk of early spontaneous onset of labour and premature rupture of membranes. At 34th week, the patient underwent the EXIT procedure. Twin A was delivered and passed to the neonatal resuscitation team. Due to the breech fetal position, twin B was completely delivered and positioned approximately at placental level. According to prenatal diagnosis, a large asymmetri

[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 5-year old boy presented to the clinic with a congenital anterior right chest wall defect. The delivery was by normal vaginal delivery after a full-term pregnancy. There was no breathing difficulty at birth, and no history of paradoxical breathing. There were no other congenital abnormalities, and development was normal. Medical advice was taken from his local town and this child was referred to our center at age of 5 years. Examination showed an otherwise healthy child with an anterior right chest wall defect. There was no paradoxical breathing and oxygen saturation at rest was 99%. There was no history of breathing problems even with exercise. The clavicle was absent but the sternum was intact. The anterior rib defect extended from the first to the fifth rib. The defect was felt upon inspiration (A) and the right lung protruded through the bony defect upon expiration; and the bulge became more prominent and tense when crying (B). A CT scan showed the defect with the skin adherent to the pleura. There were no pectoral muscles across the defect (both the pectoralis major and minor were absent) (). Surgery was done by a team of plastic and thoracic surgeons. The patient was put in the semi-lateral position. A longitudinal skin incision was made anteriorly over the chest wall defect and care is given not to injure the pleura while dissecting off the skin (A). Another longitudinal skin incision was made over the latissimus dorsi muscle. The muscle was dissected off based on the neurovascular bundle. The thoraco-lumbar fascia was incorporated with the lower part of the muscle. The composite flap was then tunneled to the anterior chest wall defect as a pedicled flap (B). Drill holes were made in the sternum and remaining ribs at the edges of the chest wall defect. The muscle-fascia composite flap was then sutured over the defect using polypropylene sutures anchored to these drill holes. Two drains were inserted (one anterior drain and

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


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

[User]
RADIOLOGY NOTE:
A 10-year-old, 36.4-kg male intact Labrador retriever presented to The Ohio State University Veterinary Medical Center for evaluation of a slowly growing cutaneous mass. The owners reported a flat, cutaneous mass caudal to the left elbow that slowly increased in thickness and alopecia over a period of 1.5 years prior to evaluation. Prior to presentation, the mass was aspirated by another veterinarian and was diagnosed as a carcinoma based on cytology. Physical examination identified a semi-fixed, 6 cm, raised cutaneous mass (). Additionally, the left prescapular and axillary lymph nodes were firm and enlarged on palpation, measuring 4.4 and 2.9 cm in diameter, respectively (). A complete blood count and serum chemistry panel revealed no values outside the laboratory reference intervals. Thoracic radiographs revealed no evidence of pulmonary metastatic disease or other clinically relevant abnormalities.
FNA samples from the elbow mass and left superficial cervical lymph node were collected and submitted for cytologic evaluation. Cytology from the primary elbow lesion was suggestive of a carcinoma with moderate, mixed inflammation, evidence of previous hemorrhage, and reactive fibroplasia, although initial report noted that carcinosarcoma or mixed-type carcinoma could not be excluded. Multiple clusters of epithelial cells frequently containing intracellular, eosinophilic secretory material were found in acinar formations, which was suggestive of a glandular neoplasm (). A similar neoplastic cell population was seen in the lymph node sample.
One week following initial presentation, the dog was presented to The Ohio State University Veterinary Medical Center for further staging. The owners reported that the dog did not exhibit any signs of discomfort, lameness, or signs of systemic disease. On physical examination, a firm, flat, mobile, subcutaneous, alopecic, 4.7 × 5.0 cm subcutaneous mass was palpable caudal to the left elbow, with firm subcutaneous extensions coursin

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


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

[User]
RADIOLOGY NOTE:
A 65-year-old male positive for hepatitis C virus antibody had been treated for HCCs in the liver segments 5, 6, 7, 8 in our hospital since October 2014. The patient was initially treated for the ruptured HCC in the segment 5 with TACE, while subsequent examinations detected other HCCs in segments 6, 7 and 8 which were similarly treated by 2nd line TACE, following the Japanese HCC therapeutic guidelines. After the treatment, the tumors in segments 6 and 7 were well controlled, while the pre-ruptured tumor in segment 5 and the lesion in segment 8 still remained viable. Hence, a 3rd line TACE was performed after 6 months: while the segment 8 tumor were well embolized after the treatment, the segment 5 tumor could not be embolized completely. Subsequently, it continued to gradually develop, as the caudal side of this tumor was perfused by the gastroepiploic artery, due to the ruptured tumor progression into the greater omentum. The collateral vessels from the omental branch into the tumor disturbed further TACE, as we suspected it could induce ischemia in the GI tract. Hence, the chemotherapeutical sorafenib was selected and administered repeatedly ().
Since this pre-ruptured tumor began and continued to involve the duodenum in the next six months, causing anemia and malnutrition, even further administration of sorafenib became difficult. At this point, the patient was referred to our surgical department for the first time. His critical situation compelled us to consider a surgical intervention.
A pre-operative examination by CT revealed a massive HCC in segment 5 of 6.5 cm in diameter, protruding from the liver and penetrating the duodenal wall (a), while other small HCC lesions appeared to be controlled. A gastroendoscopy revealed an ulcerative mass lesion in the posterior wall of the duodenal bulb (b), which was revealed to be HCC following histology analysis of a biopsy sample. Laboratory analysis revealed anemia (hemoglobin 9.2 mg/dl) and low albumin 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.


[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 female patient, 34 years old at the time of the first visit, was referred to us to correct her gingival esthetic problem caused by the formation of gingival/mucosal overgrowths. Gingival outgrowths localized in the second, third, and fourth quadrants, corresponding to the position of premolars and canine roots, were identified during an oral examination. Their consistency appeared hard and unmovable, and they presented a normal gingival color. The lesions were asymptomatic, and the morphology did not change over time ().
The anamnestic investigation revealed a history of FGG surgery in 2004 (8 years before our first examination) in each site that was treated for gingival recessions; allergic reactions to nonsteroidal anti-inflammatory drugs, paracetamol, cephalosporin, penicillin and its derivatives, and macrolide antibiotics; absence of any systemic conditions affecting metabolism; and altered wound healing (cutaneous keloids and hypertrophic scars).
The hypothesis of exostosis formation was suggested by the following clinical observations: benign aspect, nodular and hyperplastic tissue, hard and stable on palpation, not symptomatic, and localized in canine and premolar areas involved in a surgical procedure that could have acted as a promoter event.
We decided to perform an excisional surgery, followed by a histologic and molecular evaluation. The Review Board of the Research Center in Oral Implantology of the Università degli Studi di Milano in Milan, Italy, approved the treatment and research protocol before the first surgery.
All procedures were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. The patient was informed about the formulated medical hypothesis and the need for surgical intervention to remove the lesions and analyze the specimen. The patient agreed to the surgery and signed a written informed consent for

[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 woman was referred to our center after identification of multiple masses in her left breast on screening mammography and subsequent left mastectomy. She was diagnosed with NF1 during childhood and displayed neurofibromas on her face, chest, trunk, and upper limbs (Figure ). The patient had previous right-sided breast cancer at 34 years of age with positive lymph node involvement, positive estrogen receptor (ER) status, and negative progesterone receptor (PR) status. She was subsequently treated with right mastectomy, adjuvant chemotherapy, and adjuvant tamoxifen at that time. She had her first menstrual period at 14 years of age and reached menopause at 50 years of age. No history of hormone replacement or oral contraceptives was reported. She denied smoking in the past and only occasionally drank alcohol. The only family history of breast cancer that was noted was in a cousin and a niece on her mother’s side, and there was no documented family history of NF1.
The patient underwent bilateral screening mammographs after experiencing a rupture of her already present right breast implant, which found three to four masses in her left breast, with the largest being 2.9 cm. Subsequent ultrasound-guided core needle biopsies were procured, which suggested multiple masses of distinct pathologies. The patient then underwent left mastectomy and sentinel lymph node biopsy. Further workup with chest and abdominal computed tomography (CT) as well as bone scan detected no distant metastasis. Pathology confirmed the diagnosis of left breast invasive ductal carcinoma with two separate foci, the larger being a 44 mm tumour at stage pT2, pN1a (grade III) and with positive ER and PR statuses, and the smaller tumour measuring 7 mm at stage pT1b, pN0 (grade II) with triple-negative status. Her case was reviewed at the weekly Breast Multidisciplinary Team Tumour Board meeting and it was proposed that she be initially started on adjuvant chemotherapy - three cycles of fluorou

[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:
Altered mental status and severe headache developed in a 54 year old female, previously diagnosed with acute myeloid leukemia, four weeks after admission for high dose chemotherapy followed by matched unrelated donor stem cell transplant. Following her conditioning chemotherapy, which consisted of busulfan and fludarabine and subsequent bone marrow transplant, she developed a nodular pneumonia thought to be fungal in nature but culture negative by bronchoscopy specimens. During this time, the patient was on tacrolimus for graft versus host disease prophylaxis. This was started 25 days prior to the onset of mental status changes. Tacrolimus levels were maintained in a therapeutic target range of 10–15ng/ml during this time frame. On day 27 of the admission, she complained of severe headache which was followed by confusion. Also of note, the patient developed accelerated hypertension in the 48 hours surrounding the episode of confusion. Neither visual disturbance nor seizure activity was noted. Prior to this event, the patient was fairly normotensive with a systolic blood pressure range of 120–130 mmHg. At the peak of confusion, she was noted to have blood pressure of 188/90 mmHg. Calcium channel blocker therapy was then started and normotension was achieved.
Cranial T2-weighted MRI showed increased FLAIR and signal in the left and right cerebellar hemispheres that did not enhance or show restricted diffusion. There was also increased flair signal in the left and right posterior parietal occipital cortex consistent with posterior reversible leukoencephalopathy. Tacrolimus was discontinued and mycophenaolate mofetil was initiated. Within 24 hours of discontinuation of the tacrolimus, the neurologic symptoms began to resolve and the patient was again normotensive. Subsequent to this, she did develop grade II graft versus host disease of skin requiring high dose steroids and sirolimus was then added to the regimen. Because of the concern for potential worsening of the no

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


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

[User]
RADIOLOGY NOTE:
A 27-year-old gravida 2 para 1 live birth 1 North Indian woman with one previous lower segment caesarean section (LSCS) presented to our outpatient department (OPD) at 35 weeks with complaints of intermittent pain in the lower abdomen that was radiating to her back for the last 5 hours. There was no associated complaint of leaking or bleeding per vaginum. Her antenatal period was uneventful. However, she was diagnosed as having a fibroid on the left side of the uterus but reported no complications that could be attributed to it. Her general and systemic examination was unremarkable. All the antenatal investigations were normal. Her recent ultrasound (USG) report suggested a single live intrauterine pregnancy with an intramural fibroid measuring 8.6 × 6.5 cm located in the left anterolateral wall of the lower uterine segment.
On admission, her heart rate was 96 beats per minute, blood pressure was 110/70 mmHg, and mild pallor was present. Abdominal examination revealed a term size uterus with longitudinal lie. Mild uterine contractions were present with positive scar tenderness. On auscultation, fetal heart rate was 142 beats/minute. Vaginal examination depicted a 2 cm dilated cervix, which was 20–30% effaced, presenting part at −3 station with intact membranes. She was taken up for emergency LSCS given previous cesarean section with preterm labor and scar tenderness. Her preoperative hemoglobin was 12.1 gm%, hematocrit was 34.5%, and blood group was O positive. Adequate blood products were arranged and informed written consent was obtained from the patient and her relatives after explaining to them about the risk of excessive bleeding, need for blood transfusion, and peripartum hysterectomy. During surgery, the abdomen was opened by an infra-umbilical vertical incision for adequate access. There was a single large intramural fibroid occupying most of the lower uterine segment. The previous scar was intact but thinned out, possibly because of the stretching effect of

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


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

[User]
RADIOLOGY NOTE:
A 35-year-old female patient who had lived in the United Kingdom all her life was referred with pain in the right side of pelvis in 1997. She was investigated for back and hip problems. All her blood results including inflammatory markers were normal.
Radiographs and bone scan were normal. She was thought to have hip dysplasia and a MRI revealed abnormal signal changes in the right ilium suggestive of neoplasia or infection. She was referred to the Oncology team for further opinion and management in May1998. She was afebrile and there was no history of infections and exposure to Tuberculosis. She did not have any pets and there was no history of contact with farm animals. Biopsy of the pelvic bone was carried out on 11/6/98 and the histology showed necrotic bone with microsequestra surrounded by a foreign body reaction of histiocytes and giant cells with a thin fibrous wall. Special stains for mycobacterium and fungi were negative. Propionibacterium was grown in culture sensitive to penicillin, amoxicillin, erythromycin and ciprofloxacin. She was advised to take of Penicillin-V 500 mg four times a day for six weeks. Nevertheless Propionibacterium bone infection was thought to be the unlikely cause of her hip pain. She was reviewed on 14/12/98 with worsening right hip pain. Examination showed limitation of right hip movements. Radiographs now showed abnormality in the right ilium with narrowing of the joint space. She was advised to have repeat blood tests including a FBC, ESR and Myeloma screen (all the blood tests were normal). MRI scan on 7/1/99 showed altered marrow signal change from inferior part of right sacro-iliac region to acetabulum and lobulated cyst in the soft tissue around the right hip region. Hydatid disease was considered as a diagnosis and Core biopsy of the abnormal region and aspiration of the cysts lateral to the ilium were performed on 28/1/99 and samples were sent for histology, microbiology and hydatid immunotests

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


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

[User]
RADIOLOGY NOTE:
A 58-year-old male with hypertension without regular medical control was presented to our emergency department for the complaint of left side chest pain that lasted for an hour with concomitant hypotension. He had no cold sweating, radiating pain, or claudication. The 12-lead electrocardiogram suggested inferior wall and right ventricle STEMI, including ST elevation in leads III, and aVF, lead I with reciprocal ST depression, and right side V4R elevation (Fig. A). Under the impression of an inferior wall STEMI, antiplatelet medications and inotropic agent were administrated, and the patient was sent promptly for a primary PCI.
Emergent primary PCI was approached through right radial access. After the insertion of radial sheath, the radial systolic blood pressure was 82 mm Hg. When the diagnostic catheter was advanced to the ascending aorta, the systolic aorta pressure became 20 mm Hg higher (ie, 102 mm Hg). Due to the abnormally large pressure differential between the peripheral radial artery and central ascending aorta, TAAD was suspected. After a short trial that failed to locate ostium of the right coronary artery, we withdrew the diagnostic catheter from the ascending aorta back to the innominate artery and there, we found the maximal pressure damping site around the junction of aorta arch and innominate artery (Fig. B). Through the diagnostic catheter, the injection of contrast medium was performed and subsequent imaging results showed a stenosis near the injection site and irregularly narrowing of the ascending aorta (Fig. C and D, Video 1). TAAD was finally diagnosed. The bedside echocardiography also conducted to visualize a dissection flap located over the ascending aorta together with a moderate aortic valve regurgitation. Computer tomography of the aorta further verified the TAAD with extensive dissection involving innominate artery, left carotid artery, and bilateral iliac arteries. Imaging results provided evidence of a false lumen compromising the inno

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


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

[User]
RADIOLOGY NOTE:
A 27-year-old male patient without significant past medical or surgical history presented to the outpatient clinic department with incidental finding of splenic cyst on ultrasonography which he had undergone few days back for vague pain abdomen. He could not recall any abdominal trauma in the past. Physical examination was unremarkable except for a non-tender splenomegaly up to 3 cm from the left subcoastal margin. A CT scan [] was done which showed splenomegaly with non-enhancing cystic lesion of size 14 cm × 11 cm. Haematological including ELISA for hydatid serology and biochemical tests was normal. Laparoscopic splenectomy was planned for the patient because of the large size and possibility of pressure symptoms. He was given a course of antihelminthics and vaccinated against Streptococcus pneumoniae, Haemophilus influenzae and Neisseria meningitidis was given 2 weeks before surgery.
On the operating table, the patient was placed in the right lateral decubitus position, left side up at a 45°–60° angle in reverse Trendelenburg position with the left arm positioned as for a left lateral thoracotomy. Operating table was flexed 30° at the flank to increase the distance between the lower rib and the iliac crest. 5 ports were used, with one 10 mm camera port at supra-umbilical area and rest being 5 mm ports. Intraoperatively, the cyst was causing pressure atrophy of the residual splenic parenchyma and also had multiple perisplenic and pericystic adhesions. The cyst fluid was aspirated which was clear in colour and around 1.5 L in volume. Dissection was started from inferior pole and Splenocolic along with lienorenal was divided. Further medial mobilisation was done by dissecting the gastrosplenic ligament. Splenic vein and artery were ligated at hilum as shown in . Finally, splenophrenic ligament was divided which lead to completely mobilised spleen. Spleen along with cyst was removed in to in endobag by dilating 10 mm right hand working port.

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


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

[User]
RADIOLOGY NOTE:
A 65-year-old man arrived at the emergency room because of acute consciousness disturbance. TC of the brain showed a hemorrhage in the mesencephalic region. His conditions were very critical (GCS = 3), even if the breathing function was normal. Family members were informed of a probable bad outcome over the course of hours. The patient was admitted to intensive care unit and then, after a few days, to a normal care unit. He remained stable for several days. After 20 days he recovered a waking state and he was transferred to a rehabilitation department for post-comatose patients. At that time the neurological examination showed a clinical picture of “acinetic mutism”: the patient was alert but he was’nt able to make any movement either spontaneous or on request and the verbal expression was impossible. Occasionally he was able to follow the examiner‘s movements with his eyes. Considering the location of the lesion, it was decided to start transdermal rotigotine 2 mg/24 h, a dosage to be increased to 4 mg/24 h in the following week. In the following days the patient began making spontaneous movements and progressively improved his interaction with the environment; he was then transferred to a neuromotor non-intensive rehabilitation unit and after about 4 months he came back to our outpatient clinic with a normal mental state and left-sided mild hemiparesis which however allowed him to walk independently. Up to now he remained stable in follow-up visits. The second case regard a 50-year-old woman, after a bereavement in the family, spent many days locked in home refusing visits and food. After a couple of weeks she was found at home in a serious confusional state with delusions. A diagnosis of psychotic episode was made and she was treated with neuroleptics drugs for a long time. Delusions improved but two months after neuroleptic withdrawal she developed a total inability to move and to talk as for a severe auto-

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


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

[User]
RADIOLOGY NOTE:
A 7-year-old male child was presented to the Pediatric Department in Shatbi University Hospital with recurrent chest infections since 1 year. Repeated chest X-ray showed left pleural effusion. The child was managed conservatively and discharged from the pediatric department. During the course of follow-up for the respiratory condition an abdominal ultrasound was ordered to investigate a new onset minor abdominal discomfort. An abdominal cyst was found which, otherwise, was not clinically palpable during abdominal examination. Subsequent computed tomography (CT) scanning of the abdomen and pelvis with intravenous contrast revealed a retroperitoneal thick-walled fluid filled mass, measuring approximately 11.5 × 13 cm in close relation to the main pancreatic duct with inflammation of the adjacent pancreatic tissue. Provisional reports indicated a pseudo-pancreatic cyst with further extension into the posterior mediastinum through one of the diaphragmatic hiatus (
). Serum amylase and lipase were markedly elevated (amylase: 45,630 U/I and lipase: 180,000 U/I).
The decision after surgical consultation was to perform laparotomy. The child was prepared for the operation. Through an upper midline incision, the abdomen was explored. This revealed a large, smooth, and fluctuant mass behind the stomach extending up to the posterior mediastinum through the esophageal hiatus, mostly arising from the pancreas. Aspiration of the coffee ground contents was done followed by a drainage procedure by anastomosing the posterior wall of the stomach to the anterior wall of the cyst wall (cystogastrostomy) using running 4/0 vicryl sutures. A Penrose drain was inserted in the left upper quadrant followed by a layered closure. The postoperative course was uneventful. Nasogastric suction and intravenous fluids were continued for 5 days, after which oral feedings were gradually given. The drain was removed after 5 days and the child was discharged from the hospital on the 9th postoperative day

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


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

[User]
RADIOLOGY NOTE:
A 45-year-old Thai male presented with a six-month history of right buttock and hip pain. The patient could not recall any injuries or incidents that may have caused the pain. He had no medical problems nor was he taking any medication. The MRI of the lumbosacral spine from the initial consultation at another hospital was unremarkable. He was treated unsuccessfully with a non-steroid anti-inflammatory drug and acetaminophen. He was referred to our institution for consultation. Physical examination revealed a healthy-appearing adult with an ill-defined 12 cm × 20 cm nontender firm mass at frank and groin area. There was no overlying skin change. Both hips had a full range of movement. The neurovascular function in the field of lower extremity was found to be intact, except the power of extensor hallucis longus on the right side was grade 4/5. He had no palpable lymphadenopathy. Laboratory studies were within normal limits.
A plain radiograph of the pelvis revealed a well-defined mineralized mass extending from the right pubic and periacetabular area that also extended to the left pubic bone. The right obturator foramen was obliterated by the tumor mass. There was a popcorn-like chondroid matrix at the soft-tissue part of the tumor, which also extended into the pelvic cavity (Figure ). Bone scintigraphy and computed tomography (CT) of the chest showed no distant metastasis except the abnormal uptake of the right pelvic and hip area. The CT scan of the pelvis showed a huge tumor mass in the pelvic cavity that involved the right sacroiliac joint and anterior border of the sacrum (Figure ). The initial diagnosis was a chondrosarcoma involving both pubic areas, the right periacetabulum and ilium.
Incisional biopsy was performed over the right pubic area. Microscopic examination revealed small chondrocytes with dark nuclei and scant cytoplasm. They were arranged in clones and binucleated cells were present. No mitotic figures were

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


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

[User]
RADIOLOGY NOTE:
The patient was a 40-year-old male shop keeper with complaint of pain and a mass in right side of chest cage. The symptoms started 20 days ago in right lower part of back of chest which had increase in size gradually, with cough, sputum, fever and chills, pleuritic chest pain, and dyspnea. The patient indicated loss of appetite and loss of weight of approximately 7 kg in recent 20 days.
Past Medical History. There was no history of diabetes mellitus, hypertension, surgery, or blood infusion and there was also no history of respiratory problems.
Familial History. The patient was married and his family relations had no recent infectious disease.
Social History. The patient has been smoking 3-4 cigarettes per day for 15 years. He has been addicted to opium for 14 years, both orally and by inhalation, and he had a history of 2 years in jail.
Physical Examination. Vital signs were stable. No specific disorders were found in physical examination of head and neck, ear, nose, and lymphatic system. Heart sounds were normal. There was elliptical bulge of 8∗4 cm in lower part of back of right hemithorax (). There was no fluctuating in palpation but there was mild tenderness. There was wheezing heard in lower part of right chest cage. But no rale and decrease in sound were found.
In chest X-ray, a soft tissue thickness was detected. The right costophrenic angle was blunt but with or without significant fluid. Left diaphragm became flat which could be possibly because of an old problem and there was no subpulmonic effusion. Fibrosis was seen in the apexes especially in the right one ().
In CT scan with and without contrast, fibrosis was seen in apexes especially the right lung which leads to parenchymal deformity and bullous emphysema. Reticular densities were seen in upper part of right lung. Free fluid did not exist. Skin and under

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


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

[User]
RADIOLOGY NOTE:
This is a case of a 38-year-old man who presented to psychiatry as a referral for depression by neurology. He had been followed by the neurology department for intractable migraine resistant to all treatment for the last year. His past medical history was also significant for obstructive sleep apnea and obesity. The patient arrived at our clinic with dark sunglasses and was accompanied by his mother. He reported that he had had headaches for the last year with no relief. He denied any history of prior headaches. Imaging was performed to look for an organic cause of the headache and rule out structural deformities. A CT of the head without contrast revealed a nonspecific deep subcutaneous soft tissue mass overlying the left occipital bone, measuring approximately 2 cm at the basal diameter. An MRI of the brain without contrast showed small vessel changes. Under the care of neurology, the patient tried sumatriptan, rizatriptan, topiramate, propranolol, nortriptyline, trazodone, and valproic acid and had recently undergone Botox treatment with minimal relief. He rated the pain an eight out of ten in the moment and a ten out of ten at its worst. The pain was frontal and located over his left eye. This was debilitating him to an extent where he had to resign from his job last year as a truck driver; since then he had been homebound. He preferred to stay in his darkened room all day. He stated that people talking, bright lights, and outside noise made his pain worse; therefore, he had no interest in going out and seeing people. He reported sleep lasted only three to four hours a night, but since he received his sleep apnea machine a couple of weeks ago, his sleep increased to four to seven hours a night. However, his sleep continued to be disturbed, with ongoing headaches, and he lacked energy when he woke up from sleep. He also developed poor appetite, hopelessness, depressed mood, and passive suicidal ideation

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


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

[User]
RADIOLOGY NOTE:
A 53-year-old woman complaining of sudden onset of abdominal pain was transported to our hospital by ambulance at midnight. She had a history of two normal vaginal deliveries and small-bowel obstruction associated with BLH 10 years ago. In the latter, the patient underwent urgent surgery and ischemic bowel was excised in a local hospital.
Abdominal X-ray examination revealed no niveau formation (Fig. ) although the patient mentioned that the symptoms were similar to those observed at the time of the previous surgery. There were no signs of bowel obstruction or peritonitis in physical examination. Hematological and biochemical examinations also yielded no abnormal findings. The patient was hospitalized and carefully observed overnight as an acute abdomen patient.
Because of no relief of abdominal pain, the patient underwent contrast-enhanced computed tomography (CT) the next morning. Abdominal CT showed that the mesentery of the dilated small bowels converged at the right side of the uterus where an intervening band was found (Fig. ). From these findings, we decided urgent surgery because of closed-loop obstruction associated with bowel herniation in the right broad ligament of the uterus.
Laparotomy revealed that the ileum entered a small opening in the right broad ligament of the uterus, by which the ileal loop approximately 70 cm in length was strangulated. The right broad ligament was partially incised and the hernia orifice was widened to release the strangulated ileal loop. The incarcerated ileum was preserved because ischemia was reversible.
The opening in the broad ligament measured 2.5 cm in diameter. The shape was oval and the margin was smooth (Fig. ). To reinforce the mesometrium, the defect was repaired with “vest over pants” type sutures [] using 3-0 silk strings.
The patient had a favorable postoperative course and was discharged on postoperative day 9. We obtained the surgical records from the hospital where the patient underwent the previous surgery

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


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

[User]
RADIOLOGY NOTE:
A 73-year-old Japanese man on PD presented with progressive worsening of abdominal pain and cloudy peritoneal fluid. He had high blood pressure, and he started continuous ambulatory peritoneal dialysis (CAPD) because of hypertensive nephrosclerosis 8 years previously. A PD catheter was primarily inserted at the right abdomen, but it was removed and inserted at the left abdomen because of exit site and tunnel infection 5 years previously. He had no past medical history of diabetes mellitus and major abdominal surgery. In the peritoneal equilibration test, his result was high. Bloody ascites was not evident. One year previously, he had been hospitalized for PD-associated peritonitis caused by touch contamination that was treated with intraperitoneal cephazoline and cephtazidime. Bowel adhesion was not noted 5 years previously; however, local bowel adhesions and agglomeration of the intestine were detected by computed tomography (CT) after the identification of PD-associated peritonitis (Fig. , ). The major findings of EPS, such as peritoneal thickening and calcification, were not noted on CT.
On physical examination, his blood pressure was 134/74 mmHg, pulse rate was 76 beats/min, and temperature was 99.7 ° F. He complained of severe pain in the right upper quadrant of the abdomen, and this area was tender on palpation. The exit site was clear. Laboratory tests revealed mild inflammation, with a white blood cell count of 10,100 /μL and C-reactive protein level of 0.9 mg/dL. The peritoneal fluid cell count was increased at 980 /mL. Based on these findings, PD-associated peritonitis was diagnosed. CT showed localized dilation of the intestine, which suggested adhesive small bowel obstruction (Fig. ). As we suspected that the peritonitis might be associated with bacterial translocation from the dilated intestine, he was advised to stop eating and was switched from CAPD to hemodialysis. Additionally, he was treated with intravenous vancomycin and cephtazidime. The PD cath

[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 male was referred following investigation for chest pain and dyspnoea. He had no pre-existing co-morbidities. Physical examination revealed feeble femoral pulses and he was found to be hypertensive with marked differences between the upper and lower limbs (systolic blood pressure upper limb 190mmmHg, lower limb 75 mmHg, with an ankle brachial index (ABI) of 0.39). Electrocardiogram revealed evidence of severe left ventricular hypertrophy. This was confirmed with echocardiography which also demonstrated a tricuspid aortic valve with significant aortic regurgitation in the presence of an aortic root aneurysm of approximately 9 cm. Left ventricular function was preserved. Computerised tomography angiography (CTA) was performed to evaluate the aortic pathology in further detail (Fig. ). The scan noted an aortic root aneurysm (8.8 cm), in addition to the presence of severe aortic coarctation, with subtotal occlusion and a lumen less than 6 mm in size. The coarctation was just distal to the left subclavian artery, at the aortic isthmus. There was clear evidence of collateral circulation to the descending thoracic aorta via the subclavian and intercostal arteries. Coronary angiography confirmed a right dominant coronary system with no significant coronary disease.
A multidisciplinary team meeting took place and a consensus was agreed to proceed with a two staged hybrid approach, with the first phase involving an endovascular approach to stent the coarctation, followed by a second stage to perform the surgical repair of the aortic root aneurysm. The first stage to stent the coarctation was unsuccessful via the femoral approach, as the guidewire could not cross the coarctation. Assessment through angiography via the left brachial artery showed complete obstruction at the aortic isthmus. The decision was then made to proceed to a single stage surgical approach to treat both lesions.
After induction of anaesthesia, arterial lines were placed in the left radial an

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


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

[User]
RADIOLOGY NOTE:
A 39-year-old non professional soccer player arrived in our Emergency Department complaining of pain in his anterior thigh near the insertion of the rectus femoris on the anterior inferior iliac spine (AIIS), which happened during a football match; he referred a feeling of snapping in the same zone.
The patient walked with the help of two crutches because he was unable to weight bear freely due to pain.
An evident hematoma in the region mentioned above was noticeable.
On physical examination there was pain due to manual pressure, a deficit of strength in hip flexion against manual resistance and a gap in the AIIS region which was clinically palpable. For this reason we suspected a lesion/avulsion of proximal rectus femoris.
An ultrasound study confirmed our suspicion and showed the presence of hematoma at the myo-tendinous junction with fascial blood layers and tendon rupture of the proximal rectus femoris ().
Furthermore, magnetic resonance imaging (MRI) performed 7 days later confirmed the diagnosis and showed a lesion of the myotendinous junction characterized by partial lesion of the direct head and total lesion of the indirect head of the tendon with retraction of 1.5 cm associated to edema and hematoma ().
In that moment the patient got better. He did not use crutches, he had less pain during his daily life and he had less pain both in manual pressure and in tests against manual resistance.
In the face of this clinical improvement we decided to not consider the surgical option and to treat the patient with ultrasound guided PRP injections and a specific rehabilitation program, which was initially based on isometric exercises and, later, on eccentric work exercises and it was always accompanied by tecartherapy.
An autologous blood sample of the patient was taken by the Transfusion Center of the University Hospital of Parma. From this sample, 3 stocks of PRP were obtained. The injections were done 10, 20 and 30 days after injury (5 ml of PRP and 1 of

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


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

[User]
RADIOLOGY NOTE:
An 11-month-old boy was referred to a tertiary center for failure to thrive, poor muscle tone, short neck, kyphosis, and unusual spacing between teeth. He was diagnosed with infantile HPP after repeated low ALP activity test results and radiographic assessment of severe rickets-like skeletal changes and tongue-like lucencies projecting into the metaphyses. He was hospitalized multiple times for pneumonia likely related to musculoskeletal manifestation of HPP, which required treatment with intravenous antibiotics. At age 9 years, he developed persistent headaches; a magnetic resonance imaging (MRI) cranial scan confirmed craniosynostosis with Chiari malformation and cerebellar tonsillar herniation. He underwent craniovertebral decompression, with removal of the posterior arch of C1; a ventriculoperitoneal shunt was inserted to relieve intracranial pressure. He subsequently underwent 2 shunt revisions.
The patient experienced multiple fractures, starting at age 17 years, when he sustained bilateral femoral fractures when jumping off a wall; this required bilateral intramedullary rod insertion. At age 18 years, he sustained a right tibial fracture while jumping. Bone healing was delayed, but the fracture eventually healed satisfactorily. At age 20 years, he sustained bilateral femoral fractures when he rolled off his bed during a seizure and required rehabilitation for approximately 8 months.
Over the first 18 years of life, the patient was hospitalized 8 times for a total of 43 days (Table ). Of these hospitalizations, 5 separate admissions required a stay of ≥5 days; the stay for insertion of a ventriculoperitoneal shunt was 14 days.
Outpatient specialist visits represented a significant proportion of the healthcare resource utilization by this patient (Fig. ). Most of the outpatient specialist visits required consultation with providers in 12 specialties, including pediatric dentist (38 visits), pediatric endocrinologist (32 visits), neurosurgeon (27 visits), and ge

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


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

[User]
RADIOLOGY NOTE:
A 30-year-old female was referred to the urology clinic for severe lower urinary tract symptoms (LUTS) in addition to suspicion of a urethral mass. Her symptoms started two years earlier after the indwelling urethral catheter was removed following her Caesarian section. She noticed that a vestibular mass protruded at the level of her urethra and she reported increasing need to strain to void. In addition, this vestibular mass was very painful, and it required manual reduction to allow for her to void. LUTS got progressively worse over the course of the two years. In addition to the dysuria, she had intermittent hematuria, frequency of every hour as well as nocturia 3 to 4 times per night. Her personal past medical history was only positive for a remote appendectomy and a caesarean section. The patient had been previously worked up by her obstetrician since the LUTS appeared after her caesarean delivery. She had repeated urine analyses and cultures that were negative. Abdominal ultrasonography demonstrated the presence of two cystic lesions in the bladder of 2.5cm and 9mm in diameter. The kidneys did not show any hydronephrosis nor hydroureter. Her blood work, including renal function, was unremarkable.
Examination in lithotomy position revealed a very sensitive erythematous mucosa protruding from the urethra. Patient had to manually reduce the vestibular mass in the sitting position so that she could undergo cystoscopic examination under local anesthesia. Otherwise, it was too painful for the patient. Once reduced, cystoscopy was performed and demonstrated the presence of two large ureteroceles. The left ureterocele, which was significantly larger than the right side, demonstrated erythematous and edematous mucosa indicating that the vestibular mass previously noted by the patient and on examination was likely the wall of the left ureterocele. To rule out duplex system, a triphasic CT-urogram was ordered and it confirmed the patient's bilateral single-system uretero

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


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

[User]
RADIOLOGY NOTE:
A 22-year-old otherwise healthy, right-hand dominant machine male technician was referred to our center one week after injuring his left wrist. His medical history revealed that the trauma was in the form of falling on the outstretched hand with the forearm in pronation. He had an operation in an external center almost three months ago and the pain and limitation of movement started due to falling on the wrist one week ago. Physical examination was significant for tenderness on the dorsoradial aspect of the scaphoid of the left wrist. His active range of motion was 30o extension, 40o flexion, 20o radial deviation, and 30o ulnar deviation. Plain X-ray and computed tomography (CT) images at the time of evaluation showed an unhealed proximal pole fracture and a broken headless screw (Figure 1). Also, it was suspected that there might be an ulnar translation of the carpus following the last trauma. Although there was no physical examination finding suggestive of wrist instability, previous radiographs of the patient were requested. Relevant information was obtained based on the previous radiological images, which were performed in another center prior to primary surgery (Figure 2). Accordingly, the carpus gradually moved to the ulna along the fracture line with the first trauma and in follow-up images. The patient was followed with a short scaphoid cast for the first eight weeks and, when the fracture was displaced, surgery was decided. The surgery was performed dorsally with the headless screw, the plaster application was continued for an additional one month. The headless screw inside the scaphoid bone, which did not heal, was broken due to a newly added trauma three months after the operation. Therefore, the patient was referred to our hospital.
The patient was placed in a removable long opponens splint and revision surgery was planned, after the informed consent form was obtained from the patient. Surgery was performed by two certified orthopedic hand surgeons and f

[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 Nigerian female was admitted with a large, symptomatic abdominal mass. She was para 0, gravida 0 and in 2011 underwent open myomectomy through a lower midline abdominal incision for large, symptomatic fibroids. She also had a background of pulmonary tuberculosis (TB) which was treated in 1995, iron-deficiency anemia, and a benign goiter. We received the consent of all patients. Within the first few months following her open myomectomy she began to develop abdominal ascites, which was drained percutaneously on approximately three occasions in 2011-12. Owing to some personal circumstances, she did not attend her regular outpatient appointments and was eventually lost to follow-up. However, her abdomen continued to swell, with expansion of the skin and subcutaneous tissue that surrounded the scar.
She had no other relevant gynecological history and, aside from ferrous sulfate, she took no other regular medications. She was a non-smoker, denied alcohol use, and lived independently with her extended family. In 2016, five years following her original open myomectomy, she presented with a large abdominal mass that appeared to arise from the abdominal wall. This mass began to spontaneously discharge large volumes of brown fluid on the day of her admission. She was systemically well and gave no history of change in bowel habit or obstructive symptoms. She was not sexually active and had a normal menstrual history. She was not up-to-date with smear testing but denied intermenstrual bleeding. Her last menstrual period was one day previously.
On clinical examination she was thin, weighed 48 kg, with a body mass index (BMI) of 18. She was hemodynamically stable with a normal cardiorespiratory examination. She had a soft abdomen, with evidence of shifting dullness, and a large, irregular, firm mass that arose from the lower half of the abdomen overlain by her lower abdominal midline scar (). It measured approximately 30×20×10 cm. The overlying skin was

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


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

[User]
RADIOLOGY NOTE:
A 58-year-old woman was admitted to the Cardiovascular Department on September 24, 2017 for paroxysmal palpitations, chest tightness, and dizziness of approximately 6 mo duration without a history of syncope or structural heart disease.
Fatty liver, a rough gallbladder wall, and plaque formation in the left internal carotid artery were demonstrated by ultrasonography, which suggested liver disease, cholecystitis, and carotid atherosclerosis. The left ventricle was slightly enlarged, and the pulmonary artery was widened. The cardiac examination revealed mild mitral regurgitation. The ejection fraction was normal. Chest computed tomography (CT) showed a few old lesions in the middle lobe of the right lung and small nodules in the lower lobe of the right lung. A possible “drop effect” was noted in the lower lobe of the left lung. Thickening of the pleura was present bilaterally. Mediastinal lymphadenopathy was also detected. Double-phase angiography of the left atrium pulmonary vein showed no abnormalities. The patient was not treated for any of these findings before the current hospitalization because no imaging studies had ever been performed on the patient.
The patient denied cigarette smoking and consumption of alcohol. She had a history of hypertension for 20 years, for which the highest recorded blood pressure was 220/110 mmHg; she was treated with valsartan and amlodipine. The blood pressure was well-controlled.
The patient denied family history.
A physical examination was performed once on the patient after hospitalization. The patient had shortness of breath with a respiratory rate of 30 per min. Auscultation of both lungs was significant for thick breath sounds without dry rales, wet rales, or a pleural friction rub. Percussion of the heart was normal. Palpation of the apex beat was normal with a heart rate of 179 per min, and the rhythm was irregular. No heart murmur was heard in each valve auscultation area, and there was no pericardial friction rub. There

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


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

[User]
RADIOLOGY NOTE:
An 85-year-old female with a past medical history of diabetes mellitus, hypertension, and hyperlipidemia underwent surgical consultation in October 2015 for an incidentally found right foot mass subsequent to an elective gynecologic procedure. The patient first noticed a small lesion on the dorsum of her right foot approximately 12 years ago. She never sought medical attention for this slowly growing and asymptomatic lesion. However, this lesion had been growing more rapidly and had become foul smelling over the past 3 weeks. She denied any pain, paresthesias, weight loss, or recent trauma to the foot. She also denied any history of smoking or significant sun exposure. Her only surgical history included a recent total abdominal hysterectomy and left salpingo-ophorectomy. On physical examination, she was a well-nourished Caucasian female who was found to have a large exophytic, fungating 8.0 × 8.0 × 0.6 cm malodorous mass on the dorsum of her right foot (Figure ). This mass was insensate to light touch with no surrounding erythema. She had palpable dorsalis pedis and posterior tibial pulses with full range of motion of that foot. The left lower extremity was benign in examination, with no masses or lesions. A thorough dermatologic examination did not reveal any other concerning lesions. A punch biopsy of this mass was consistent with BCC. Subsequent magnetic resonance imaging (MRI) showed a large soft tissue irregularity surrounding the second to fifth extensor tendons (Figure ). Given these findings, the patient underwent a wide local excision of this BCC with full-thickness skin graft for coverage.
The lesion was excised in its entirety with a 5-mm circumferential margin beyond the extent of visible tumor. This incision was carried down directly to the fascia overlying the extensor digitorum longus tendons. Intraoperative pathologic evaluation noted a negative deep margin; therefore, resection of extensor tendons was not required. The specimen was sent to pathology

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


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

[User]
RADIOLOGY NOTE:
The proband is a 35-year-old male with a 10-year history of sprains and muscle ruptures. He reported six left knee sprains since the age of 17 and two ruptures of the right rectus femoris muscle at the age of 29 and 30, respectively. The patient did not mention any strenuous activity that could explain the ruptures. Given the presence of weakness and discomfort in the shoulder girdle, an ultrasonography of the left superior arm was performed, showing calcifications of the tendon of the supraspinatus muscle.
At the age of 31, the patient reported a rupture of the right biceps femoris muscle that occurred in the attempt to dismount his motorcycle. These episodes were followed by a series of spontaneous muscle ruptures of the right biceps femoris and other muscles not related to any exertion.
At the age of 30, the patient started complaining about generalized muscle pain and progressive hyposthenia in his proximal lower limbs. The x-ray of the hip bones was normal. The neurological examination and the electrophysiological studies of the limbs were negative. A spinal MRI revealed several disc herniations for which the patient had undergone surgery, without pain relief. Since the muscular pain was invalidating, an opioid therapy was started leading to partial remission.
Due to the lack of an underlying diagnosis, even after a series of clinical evaluations, the patient came to our attention.
On physical examination, the proband was slender and considerably taller than his parents (185 cm vs. 160 cm of the mother and 161 cm of the father). He reported a growing spurt at the age of 16, with a gain of 22 cm in 1 year (from 160 to 182 cm of height). Other findings were pectus excavatum, arm span of 187 cm (arm span/height ratio: 1.01), flat feet, and cutaneous striae on the hips and the thighs.
On the clinical suspicion of Marfan syndrome

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


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

[User]
RADIOLOGY NOTE:
A 39-year-old Caucasian female with a history of cerebral palsy with spastic quadriplegia and congenital hydrocephalus with VP shunt presented to our institution for rapidly developing abdominal distension, pain, and coffee-ground emesis. On examination, the patient was lethargic and in obvious discomfort. Her abdomen was markedly distended with rebound tenderness and decreased bowel sounds. Abdominal ultrasound revealed severe free fluid in the abdomen which was confirmed on CT of the abdomen. Upper endoscopy was negative for active bleeding, varices, or ulcers. Diagnostic paracentesis showed serum-ascites albumin gradient (SAAG) > 1.1, total protein (TP) < 2, and clear yellow fluid. There was no evidence of cirrhosis on imaging with patent hepatic vein, splenic vein, and inferior vena cava (IVC). She had an echocardiogram that did not show any cardiomyopathy or restrictive pericarditis. Fibrosure showed F0, no hepatic fibrosis. Repeat CT later on in that admission showed large amount of intra-abdominal partially loculated fluid suspicious of CSFoma (Figure ).
Neurosurgery was consulted and did not feel that CSFoma was likely. She followed up with GI outpatient for workup of the ascites with all workup for hepatic or portal vein etiology being negative, including a transjugular liver biopsy. It was determined that the fluid collection was not hepatic in nature and that CSFoma needed to be further investigated. She continued to experience worsening distension and foot swelling and again presented to the ED one week following discharge. She was seen by neurosurgery who requested additional abdominal imaging. Upon review of imaging studies, including CT of the abdomen/pelvis (A/P), it seemed CSFoma was caused by loculations and septations around the peritoneal end of the VP catheter. She was taken to the operating room for attempted laparoscopic drainage of her intraperitoneal CSF cysts. That was followed by open conversion to repair a loop of bowel that was inadverte

[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.