[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 Han Chinese woman was admitted to the Department of Thoracic Surgery of Beijing Friendship Hospital on 20 November 2017 after multiple nodules were detected in the right lung. The patient had a five-year history of hypertension, denied any history of smoking and drinking, and had a family history of lung disease. On 2 November 2017, she had undergone reserved mastectomy for right breast cancer followed by axillary lymph node dissection at the Department of General Surgery of Beijing Friendship Hospital. Postoperative pathology showed infiltrating ductal carcinoma in the right breast and metastases in 1–20 right axillary lymph nodes. The chest computed tomography (CT) examination showed multiple nodules in both lungs; metastasis was not excluded. The nodule in the apical segment of the upper lobe of the right lung was larger but was not confirmed as malignant. Whole-body positron emission tomography (PET)-CT examination further showed that the nodule in the apical segment of the upper lobe of the right lung was larger; the lesion was considered to be malignant, thus indicating a strong possibility of peripheral lung cancer. No abnormal increase in F18 fluorodeoxyglucose (FDG) metabolism was found in the other pulmonary nodules and mediastinal and hilar lymph nodes. Follow-up observation was recommended. It was difficult to preoperatively diagnose whether the multiple nodules of both lungs were primary lung cancer with intrapulmonary metastasis, or lung metastasis of breast cancer. The following two surgical programs were recommended after general discussion among the whole department:
Program 1: Video-assisted thoracoscopic wedge resection of the nodule in the upper lobe of the right lung and wedge-shaped resection of the nodule in the lower lobe of the right lung, followed by resection of the nodule in the upper lobe of the right lung and lymph node dissection, depending on the results of the intraoperative frozen section.
Program 2: Thoracoscopic exci

[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 Chinese man experienced severe generalized headache over a couple of days. The headache was throbbing in nature and maximum in the posterior parietal regions. In addition, he also complained of double vision, neck pain and dizziness; however, denied having nausea or vomiting. The headaches were aggravated when he assumed an upright posture (sitting or standing) and alleviated when lying down. He did not have preceding history of strenuous physical activities such as heavy weight lifting, trauma or a lumbar puncture procedure. Neurological examination revealed bilateral mild restriction of lateral gaze (likely due to VI nerve involvement), which resulted in binocular diplopia on extreme horizontal gaze. His brain computed tomography with contrast was normal. MRI brain showed prominence of cortical veins and significant distension of dural venous sinuses raising the possibility of pachymeningitis without venous sinus thrombosis [Figure ,]. In addition, cervical spine MRI revealed engorged anterior epidural venous plexus at cranio cervical junction and upper cervical spine, with mild effacement of the subarachnoid space, raising the possibility of spontaneous intracranial hypotension secondary to cerebrospinal fluid (CSF) leak; however, no nerve root diverticula was noted. Repeated lumbar puncture (LP) failed to extract any CSF. Subsequently, LP under fluoroscopic guidance confirmed a low CSF pressure (5 cm of water). The routine CSF investigations for infective and inflammatory markers were all negative.
He was treated conservatively with strict bed rest, adequate hydration and analgesia. A radionuclide cisternography showed CSF leak at the junction of cervical 5 and cervical 6 (C6/ C7) vertebrae []. Treatment options including targeted epidural blood patch (EBP) were discussed; however, the patient opted for conservative management. He was discharged after a week. We had advised him to rest at home for another 2 weeks; however, he resumed normal activit

[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 56-year-old female presented to the hospital with the complaint of fatigue, chest pain, shortness of breath, and dyspnea on exertion. On further review of symptoms she admitted to diffuse left upper quadrant tenderness and unintentional weight loss of 15 pounds. Her past medical history was significant for anemia, hypothyroidism, and a 40-pack-year history of smoking. The patient was suffering from longstanding symptomatic normocytic anemia and was followed up by gastroenterology for a potential etiology. However she underwent several endoscopies and colonoscopies with unsuccessful attempts to diagnose her anemia. The patient received multiple packed red blood cell transfusion therapies for symptomatic relief.
Pertinent laboratory findings included white blood cell count of 15.3 × 109/L, hemoglobin count of 7.1 g/dL, hematocrit of 23.4%, platelet count of 153 × 109/L, MCV of 83.4, and red cell distribution width of 19.7%. A computed tomography with contrast of the abdomen and pelvis demonstrated marked splenomegaly that is heterogeneous with multiple low attenuation masses (). In addition the patient underwent a positron emission tomography scan which showed splenic hypermetabolism ().
With no resolution of her symptomology and radiographical evidence of an enlarged hypermetabolic spleen, the patient decided to undergo an elective splenectomy. Prior to the operation interventional radiology performed a splenic artery embolization to reduce blood flow to the spleen. The patient was taken to the operating room for a laparotomy. Upon entering the abdominal cavity the spleen was easily identified and had multiple omental adhesions. Due to the size, increased vascularity, and proximity to surrounding organs the splenic vein completely adhered to the distal pancreas and was unable to be safely dissected away. This resulted in a distal pancreatectomy. Once the spleen was removed the total weight measured 1,124 grams ().
The organ was sent for pathological analysis, with

[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 Saudi female presented in July 2014 complaining of bilateral nasal obstruction for 10 years, for which she sought medical attention and underwent septoplasty and functional endoscopic sinus surgery 7 years ago at a different institute. Postoperatively, the patient noticed minimal improvement in her symptoms with persistence of right nasal obstruction. She also noticed right nasolabial fold fullness for a year, which increased in size over time associated with right facial pain. Clinical examination revealed a swelling in the right nasolabial fold measuring 2 × 1 cm. It was tender to palpation, hard in consistency, but with normal overlying skin. Anterior rhinoscopic examination of the right nasal cavity revealed lateral nasal wall swelling obliterating 90% of the nasal vestibule with normal overlying mucosa and skin colour externally. Computed tomography (CT) and magnetic resonance imaging (MRI) revealed a well-defined subcutaneous soft tissue density measuring 1.6 × 1.6 cm located in the right nasolabial fold. The lesion demonstrated isointensity with no drop in fat saturation T1 but showed hypointensity on T2 and homogeneous enhancement postcontrast ().
In August 2014, the patient underwent surgical excision of the mass through a sublabial approach, and the mass was found to be encapsulated with no infiltration to surrounding tissues and was excised completely with its capsule with uncomplicated postoperative period. Histopathological examination of the mass revealed spindle cells proliferation, forming fascicles and whorls on a background of collagen fibres. The fascicles were associated with foci of mixed inflammatory cells infiltrate composed mainly of lymphocytes and plasma cells, along with scattered eosinophils and neutrophils. The lesion infiltrates the surrounding striated muscles and fatty tissue with no infiltration to cutaneous and subcutaneous tissue. Moreover, immunohistochemical studies on the spindle cells revealed they are diffusely 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 30-year-old woman visited the hospital due to right lower quadrant pain over the period of 1 week. A laparoscopic myomectomy was performed 4 years ago because of a broad ligament leiomyoma, which was about 10 cm in size. Laboratory findings included a routine blood examination, and a C-Reactive Protein (CRP) test, with tumor markers all found to be within normal ranges. The pelvic Magnetic Resonance Imaging (MRI) scan showed some nodules at the posterior margin of the bladder that were considered to be endometriosis, and some pelvic effusion that was significant on the right side. It was also noted that there was a mass shadow at the lower right ureter (medial to the iliopsoas muscle), with distention of the lower right ureter (Fig. ). The patient also underwent computed tomography (CT) scans to enable the practitioners to observe the size of the abdominal mass and its surroundings. The CT images revealed a region occupying the middle right ureter that was considered to be a retroperitoneal aggressive fibroma, which led to severe hydronephrosis on the right kidney and upper ureter, and a right pelvic effusion (Fig. ). After more detailed examinations were conducted, there were no obvious abnormalities detected in the brain, heart, liver, gallbladder, spleen, pancreas or blood. The color Doppler ultrasound demonstrated that there was a hypoechoic mass next to the right iliac vessels that was closely related to the adjacent ureter. This resulted in severe hydronephrosis of the right kidney and a right upper ureteral dilatation (Fig. ). Ndzengue et al. [] reported a case of a pelvic desmoid tumor simulating a uterine leiomyoma recurrence. The patient that presented at our hospital had a history of uterine leiomyoma. We subsequently organized a multidisciplinary consultation to determine the next stage of her treatment plan. According to the patient’s surgical history, the next step would be determined after reviewing the results of the last surgical pathological wax,

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


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

[User]
RADIOLOGY NOTE:
A 63-year-old woman presented with a firm 7 cm multilobular tender mass located in the region of the right sternocleidomastoid directly above the clavicle. She had multiple comorbidities including renal failure, systemic lupus erythematosus, and protein S deficiency, a history of transient ischemic attack, deep vein thrombosis, and pulmonary embolism, and longstanding malnourishment requiring jejunostomy tube placement. The firm mass was identified 1 month after an unsuccessful attempt at placing a right internal jugular vein central line. When the central line was originally placed, she developed pain and swelling of her neck. The swelling was pulsatile at that time and enlarging. She was offered surgery as the standard of care for her condition which she refused because she did not want to undergo an invasive procedure and was aware of the risks involved with holding her anticoagulant medication. She had two thrombin injections in the mass since without success. She complained of right neck pain. She was not having any difficulty breathing and denied shortness of breath.
Soft tissue ultrasound after the two thrombin injections showed pseudoaneurysm and a 7 × 3.3 × 4 cm multilobular hematoma at the base of the right neck. CTA of the neck showed a corresponding heterogeneous mass. The pseudoaneurysm was seen measuring 1.5 cm at the internal margin of the hematoma. Serial imaging with CTA demonstrated enlargement over a 2-week interval ().
Angiogram showed blush of contrast coming off of the sternocleidomastoid branch of the superior thyroid artery identifying the location of the pseudoaneurysm (). This branch was embolized using glue. Repeat angiogram showed successful embolization and no contrast blush.
On follow-up one month later, the mass was no longer pulsatile but still present on physical exam. CTA of the neck showed a decrease in size from the previous CTA ().
On follow-up 8 months later, she was found to have a soft neck with no mass on physical exam.

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


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

[User]
RADIOLOGY NOTE:
A 42 year old male presented to his primary care physician with a 20 pound unintentional weight loss over a 3 month period and new left axillary lymphadenopathy. A core biopsy of his axillary mass revealed metastatic malignant melanoma. He had no prior history of a primary melanoma. A staging PET/CT revealed abnormal FDG uptake in his left axilla and small bowel. A left axillary lymph node dissection was performed and revealed 2 of 19 lymph nodes involved with metastatic melanoma, BRAF wild type, the largest of which measured 10.1 cm. His medical history was significant for oligodendroglioma, which was surgically resected eight years prior to presentation, followed by radiation therapy for recurrence five years prior to presentation. He received four doses of systemic ipilimumab for his metastatic melanoma without incident. Post-treatment imaging revealed disease progression with new diffuse subcutaneous, lung, liver and bilateral axillary lymph node metastases.
He subsequently enrolled on a genetically engineered T-cell trial, targeting tyrosinase. He received fludarabine and cyclophosphamide as a conditioning regimen, then his engineered T-cells were infused, followed by one week of low dose IL-2, (72,000 U/kg IV q8 hours). Per the treatment protocol, unfractionated creatinine kinase (CK) levels were obtained just prior to and for two weeks after infusion of the genetically engineered T-cells. The CK levels were within normal limits during the course of this treatment. He initially experienced disease response, however, four months after his T-cell therapy, he again developed diffuse progression with new hilar lymphadenopathy and progression of his lung and axillary lymph node metastases.
He was next treated with three doses of pembrolizumab but post-treatment imaging again revealed disease progression in his lungs. CK levels were not checked during treatment with either ipilumumab or pembrolizumab. Despite multiple lines of therapy, the patient continued to have

[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 Japanese man with no significant prior medical history and unknown smoking habits was referred to a urologist for investigation of hematuria, and was diagnosed as having urinary bladder cancer after further examination. He underwent three sessions of transurethral resection of the bladder tumor and intra-vesical instillation therapy (doxorubicin and cacillus Calmette-Guerin) and was then placed under observation. During the follow-up period no abdominal symptoms were observed, and an abdominal computed tomography (CT) scan revealed the incidental finding of dissection of the superior mesenteric artery (SMA). Our patient was then referred to our hospital.
His physical examination findings on admission were height of 176cm, weight of 64.5kg, blood pressure of 111/69mmHg, and pulse rate of 70bpm. Our patient had no fever and no other abnormal physical findings such as abdominal symptoms. His blood biochemistry test results were also normal. A contrast-enhanced abdominal CT scan revealed an arterial aneurysm and a dissection located approximately 1.5 and 5cm distal to the ostium of the SMA (Figure ). A false lumen of the artery was partially occluded by a thrombus. Distal to this occlusion, the arterial wall was irregularly shaped with both narrow and wide sections. The inferior mesenteric artery was also observed to have an irregular arterial wall. The renal artery also showed dissection, with an occluded false lumen; an ipsilateral renal infarction was observed as well.
On the basis of good CT contrast enhancement of the artery distal to the dissected portion and the absence of increased inflammatory parameters or clinical symptoms, our patient was prescribed oral aspirin and placed under observation. After two months, a follow-up CT scan revealed an enlargement of the pancreatic tail adjacent to the splenic artery (Figure ). In view of the absence of clinical symptoms or elevated levels of pancreatic enzymes, our patient was again placed under observati

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


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

[User]
RADIOLOGY NOTE:
A 64-year-old male, with a history of poorly controlled Type II diabetes mellitus (HbA1c = 16), presented with right arm weakness, visual disturbance, expressive aphasia, and confusion. Magnetic resonance imaging (MRI) of the brain revealed multifocal brain abscesses (right frontal lobe, right occipital lobe, and left parietal lobe) []. The patient was started on IV vancomycin, ceftriaxone, and metronidazole on the day of admission. The right occipital abscess was needle-tapped the next day, which grew Streptococcus intermedius; unfortunately, antibiotic susceptibilities could not be extracted due to inadequate growth. Despite treatment with systemic, broad-spectrum antibiotics for more than a month, the patient deteriorated into a comatose state, requiring intubation for airway protection. A repeat MRI of the brain showed IVROBA and associated ventriculitis []. An external ventricular drain was placed []. The patient underwent further needle drainage of the right frontal and left parietal abscesses. Daily CSF Gram-stain remained positive for Gram-positive cocci despite prolonged treatment with IV antibiotics. Due to continual clinical decline, intraventricular vancomycin therapy was initiated. The patient was given 10–20 mg of intraventricular vancomycin daily, through the external ventricular drain; dosages were adjusted to achieve the CSF vancomycin therapeutic trough level of 20–25 mg/L.[] A week later, IV rifampin was added to the antibiotic regimen and ceftriaxone was switched to cefotaxime 2 g every 4 h. The CSF Gram-stain turned negative after 11 days of intraventricular therapy, and 5 days after the CSF, vancomycin level became therapeutic. On the same day, the patient gradually became more alert. The patient received intraventricular vancomycin for a total of 30 days. He was discharged on 2 months after his initial presentation. At discharge, the patient could follow simple commands, exhibit a steady gait, and demonstrate full strength in all extremities;

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


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

[User]
RADIOLOGY NOTE:
A 16-year-old male patient who was previously fit and healthy presented initially with sudden onset of lower abdominal pain. He had not suffered from similar pain in the past. He had not suffered from any significant medical diseases. He smoked up to 16 cigarettes a day, his bowel and bladder habits were regular. There was no family history of inflammatory bowel disease. Physical examination revealed his heart rate was 111 beats per minute and he was apyrexial. On abdominal examination he was tender over both iliac fossae, more on the right side. Blood tests showed white cell count was 12 and C-reactive protein was <6. Urinalysis was positive for nitrates and protein. Based on his clinical presentation and elevated white cell count he was diagnosed to have appendicitis. He went on to have open appendectomy; later we found the histology did not reveal any inflammation.
Three months later the teenager presented again with right iliac fossa pain and signs of local peritonitis. Laboratory tests revealed white cell count was 18.1 and C-reactive protein was 51. A laparoscopy was performed which showed postoperative adhesions which were released. This was followed by recovery and discharge from the hospital. Following his discharge he re-presented within a period of two months with right iliac fossa pain and an elevated white cell count of 13 and C-reactive protein of 248. The clinical presentation was investigated with a computed tomography (CT) scan of the abdomen and pelvis which did not reveal any abnormality in the right iliac fossa; the rest of the abdomen was unremarkable.
Persisting pain and escalating inflammatory markers prompted a laparotomy which revealed thickened ileocaecal area suggestive of inflammatory bowel disease. Following recovery, the provisional diagnosis of inflammatory bowel disease was investigated with colonoscopy with terminal ileal biopsies, oesophagogastroduodenoscopy and barium-follow-through all of which were in the normal range. However th

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


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

[User]
RADIOLOGY NOTE:
A 79-year-old gentleman resident of Delhi, known case of diabetes mellitus with well controlled sugar on oral hypoglycemic medication presented with complaints of progressive painless diminished vision in right eye for last 4 years. There was no history of fever, swelling, redness, or watering from eye, headache, altered behavior, vomiting, facial deviation, seizures, or any other neurological deficits. He consulted ophthalmologist for decreasing vision at outside hospital who initially attributed it to diabetes retinopathy but due to progressive unexplained vision loss to the level of loss of perception of light in right eye and 6/6 in left eye (with refractive error correction) a computed tomography (CT) scan of head was done which showed poorly defined soft tissue mass in posterior part of the orbit along with involvement of right paranasal sinuses. He was started on oral steroids and referred to a higher center. Patient presented to our center with loss of perception of light in his right eye. He complained of easy fatigability and generalized tiredness. His glycemic control on steroids was very poor. Because of unilateral eye involvement, with a soft tissue mass in CT scan orbit, magnetic resonance imaging (MRI) head along with brain was done. The MRI showed the involvement of maxillary sinus, ethmoid sinus, sphenoid sinus, and orbit at right side []. The patient was referred to Department of ENT and transnasal maxillary and ethmoid sinus biopsy was taken. The biopsy revealed in KOH mounts hyaline thin septate hyphae. A multidisciplinary approach by ophthalmologist, ENT specialist, radiologist, microbiologist, and infectious disease specialist worked up further. Routine laboratory examination was normal. There was no history of trauma, travel, drowning, or near drowning or swimming or religious water dips. Steroids were tapered and stopped. Based upon the finding of thin septate hyphae in KOH mount, he was empirically started on itraconazole. Patient did not sh

[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 60-year-old man was presented to the medical unit in July 2020 with symptoms of respiratory problems, severe headache, cough, dizziness, and frequent vomiting. Initial physical and clinical examinations of the patient were normal and there was no underlying disease. The patient had no history of alcohol or tobacco use and was not taking any specific medications at the time. His blood pressure was 120/80 mmHg with a regular pulse rate of 112 beats/min, a respiratory rate of 22 cycles/min, and a temperature of 36 °C. While the patient had no symptoms of arrhythmia, he had mild hypoxemia with an oxygen level of 85–92% (Table ). Important laboratory findings of the patient are listed in Table . PCR on the nasopharyngeal swab sample was performed on the day of hospitalization, which confirmed the diagnosis of COVID-19. The patient was discharged from the hospital after 2 days because his symptoms were relatively mild and there were no other serious symptoms. He was admitted to the hospital 5 days later with respiratory problems, and initial examinations revealed that his oxygen saturation was then 82% on room air. The patient underwent high-resolution computed tomography (CT) scans of the lungs and CT pulmonary angiography. CT scans of the lungs (Fig. ) showed several diffuse areas of opacity in both right and left lungs, which could indicate viral pneumonia. In addition, on CT angiography of the lungs (Fig. ), several filling defects were visible in the branch of the pulmonary artery leading to the lower lobe of the right lung, which may indicate acute pulmonary embolism. The patient was started on medications including naproxen to control the muscle pain, hydroxychloroquine and famotidine with antiviral effects, zinc to boost the immune system and repair lung tissue, and neurobion to strengthen the immune system. Some anticoagulant including injected heparin and acetylsalicylic acid tablets, and high-flow oxygen were also used. The severity of COVID-19 in this patien

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


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

[User]
RADIOLOGY NOTE:
An 82-year-old woman was electively admitted for left TKR. Her medical history included acute myocardial infarction 10 years prior, as well as hypertension, left total hip replacement and a stable, 4.5 cm ascending aorta aneurysm.
She was taking the following medications: telmisartan 40 mg once a day, aspirin 100 mg once a day, metoprolol 50 mg two times per day, rosuvastatin 10 mg once a day, rabeprazole 20 mg and lercanidipine 10 mg. Her preoperative anaesthesia assessment included an ECG which showed a right bundle branch block, as well as a chest X-ray and transthoracic echocardiogram, which showed borderline left atrial diameters, normal left ventricular size and systolic function, and an estimated ejection fraction >50%. There were no overt regional wall motion abnormalities. Mild degenerative changes of the aortic and mitral valves were observed, along with mild aortic valve insufficiency. The ascending aorta was dilated (approximately 5 cm). There were no respiratory symptoms, and spirometry did not show significant abnormality.
The patient underwent TKR. On the first day after the operation, she developed dense right arm weakness and left homonymous hemianopia. There were no other obvious focal neurological deficits. CT and brain MRI showed innumerable T2 FLAIR hyperintensities, demonstrating high diffusion-weighted imaging signals that were consistent with multifocal acute infarcts. These were predominantly cortically/subcortically distributed in both the right and left cerebral hemispheres within the frontal, parietal and occipital regions; additionally, there was a small focus within the left cerebellar hemisphere, favouring a central embolic cause. The patient was managed according to an acute stroke unit pathway, moved to a bed with telemetry monitoring and clopidogrel was added to her medications.
Following surgery, the patient complained of increasing shortness of breath and was noted to be hypoxic on room air, up to 86%. A physical examination did n

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


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

[User]
RADIOLOGY NOTE:
A 47-year-old male presented with severe ophthalmalgia and vision loss in the right eye. The patient had been diagnosed with proliferative diabetic retinopathy (PDR) 1 year earlier. The patient provided written informed consent. The patient underwent pars plana vitrectomy combined with retinal photocoagulation and pan retinal photocoagulation in the right and left eyes, respectively. The individual had also undergone Ahmed glaucoma valve implantation 8 months earlier due to NVG. A general history revealed that diabetes mellitus type 2 had been diagnosed 10 years previously and that the patient was treated with subcutaneous insulin injections. The patient’s best-corrected visual acuity (BCVA) was 20 letters [Early Treatment Diabetic Retinopathy Study (ETDRS) chart] in the right eye and 80 letters in the left eye. The intraocular pressure (IOP) was 50 mmHg in the right eye and 14 mmHg in the left. A slit-lamp examination of the anterior segment revealed corneal edema, rubeosis of the iris, a dilated pupil, the loss of the light reflex, lens opacity and a vitreous hemorrhage in the right eye. A normal anterior segment was observed in the left eye. The retina of the right eye was invisible. A clinical examination of the retina of the left eye revealed a small cotton-wool patch above the disk, hemorrhagic foci at the posterior pole and a laser spot on the peripheral retina (). Optical coherence tomography (OCT) found an almost normally shaped macula in the left eye (). The patient was administered with an intravitreal injection of bevacizumab (1.25 mg; Genentech/Roche, Basel, Switzerland) in the right eye. Ten days after the injection, the patient presented with sudden visual loss in the left eye. The patient’s BCVA was now 22 letters in the right eye and 25 letters in the left eye. The IOP was 30 mmHg in the right eye and 14mm Hg in the left eye. The rubeosis of the iris had

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


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

[User]
RADIOLOGY NOTE:
An otherwise healthy 78-year-old man experienced subacute-onset back pain that radiated to both lower extremities and was worse with ambulation. Over the course of a month, the patient then experienced progressive neurological deterioration with bilateral leg weakness leading to an eventual inability to walk. Magnetic resonance imaging (MRI) study, performed one month after onset of symptoms, showed a lesion with extensive enhancement of the lesion periphery () and extension of enhancement to the distal nerve roots on sagittal fat-suppressed T1-weighted MRI (). Axial T1-weighted MRI with contrast demonstrated hyperintense lesion periphery (), and axial T2-weighted MRI demonstrated homogenous hyperintensity of the lesion (). Lastly, sagittal T2-weighted MRI demonstrated evidence of degenerative changes but no involvement of the vertebral bodies or disc spaces (). Since the patient did not have any indication of infection, our working diagnosis was that of a malignant neoplastic process with probable spread to the distal nerve roots.
Based on the symptomatology and extensive involvement of the nerve roots, the plan was to perform a biopsy of the lesion to obtain a histological diagnosis. The patient was positioned prone on a Jackson table, and neuromonitoring for somatosensory evoked potentials (SSEP) and motor evoked potentials (MEP) was established (Supplementary ). A vertical incision was made over L2 through L4, and intraoperative X-ray was used for localization of the lesion. Bilateral laminectomy of these levels was performed, and the dura was fully exposed and opened over the midline. At this point, thickened, reactive arachnoid was encountered. Opening the dura, we found that the nerve roots were plastered and very adherent to this arachnoid. In certain cases where the pathology is not immediately evident, intraoperative ultrasound is a useful adjunct to provide real-time confirmation of the location of the lesion. We have found this to be especially valuable

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


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

[User]
RADIOLOGY NOTE:
The patient is a 47-year-old man with severe opioid use disorder who presented to the Infectious Disease Elimination Act (IDEA) SSP at the University of Miami Miller School of Medicine with right arm swelling and pain progressing over 3 days. On this day, he was visiting the student-run walk-in wound care clinic, which provides free medical services to a population with substance use disorders and often experiencing homelessness []. He was assessed in the clinic by a first-year medical student and a third-year medical student who reported that his right arm had become red, hot, swollen, and painful in the area where he normally injects fentanyl. The pain started in the forearm but had crossed into the dorsum of his hand impeding flexion at the wrist. On review of systems, the medical students elicited symptoms of fevers, night sweats, and 5 kg of unintentional weight loss over the past 2 weeks.
The medical students presented the case to the two volunteer attendings staffing the clinic—an internist and a surgeon—who then assessed the patient. Using a point of care ultrasound, they identified a large fluctuant abscess of the right forearm tracking over the wrist with a contiguous collection in the right hand. Diffuse cervical and axillary lymphadenopathy was noted on physical exam. The attendings determined that the infection was too severe to be managed with on-site incision and drainage and oral antibiotics. The students escorted the patient to the emergency department (ED) of the nearby county hospital with a written note from the IDEA clinic attending.
On routine opt-out screening labs in the ED, the patient tested reactive for HIV by 4th generation screening test with an indeterminate differentiation assay for HIV-1, suggesting acute HIV infection. HIV viral load by polymerase chain reaction returned at over 1 million copies/ml. Ultrasound of his right upper extremity in the ED showed a complex subcutaneous collection measuring 1.2 by 3.6 cm

[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 woman with a known history of giant cell tumor of the left first metatarsal was evaluated for worsening left medial midfoot pain. She had previously undergone curettage and polymethylmethacrylate (PMMA) cementation of a biopsy-proven giant cell tumor of the first metatarsal two and a half years prior at a different institution. Six months following the index surgery, she had a recurrence treated with repeat curettage, liquid nitrogen local adjuvant, and placement of bone substitute graft. After the second procedure, she was ambulatory, but occasionally used a boot for comfort and avoided high-impact activities. Physical examination demonstrated a prominent first metatarsal base and a well-healed dorsal incision. She exhibited tenderness to palpation throughout the area of the scar.
Radiographs of the left foot showed an expansile, radiolucent lesion of the first metatarsal base surrounding the known cement implantation of the first metatarsal (). Magnetic resonance imaging showed a large soft-tissue mass surrounding the first metatarsal circumferentially and abutting the second metatarsal (). There was high T2 signal with no T1 signal changes at the base of the second metatarsal. Computed tomography (CT) scan demonstrated an expansile lucency at the proximal aspect of the first metatarsal base toward the dorsal lateral side (). There were some areas of cortical breach, and the bone was expanded and abutting the base of the second metatarsal. There was no evidence of direct extension into the second metatarsal or areas of osteolysis within the second metatarsal base. She was diagnosed with a second recurrence of giant cell tumor of bone of the first metatarsal base. As the tumor was recurrent, with destruction of the articular surface and little residual bone of the first metatarsal base, a wide resection of the tumor was recommended.
The procedure began by harvesting iliac crest bone graft (5 cm in length, 2 cm in depth). The prior dorsal incision was

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

[User]
RADIOLOGY NOTE:
A 41 years old male presented with chief complaint of gradual onset breathlessness on exertion New York Heart Association (NYHA) II and pain in right lower chest. There was no history of haemoptysis, orthopnea or paroxysmal nocturnal dyspnea. Pain in chest was dull in nature, non-radiating and relieved by taking medication. There was no history of hypertension, diabetes mellitus or any other prolonged illness.
There was no history of significant loss of weight and appetite.
On examination patient was conscious, cooperative and average built. His pulse rate was 78 per minute and blood pressure was 120/70 mmHg.
There was no significant respiratory distress at that time. Systemic examination revealed decreased air entry on auscultation at the lung bases.
Other systems were within normal limits. Routine blood investigations including complete blood count (CBC), renal and liver function tests were within normal limits. His coagulation profile including platelet count, prothrombin and activated partial thromboplastin time were also within normal limits.
Chest radiograph revealed bilateral pleural effusion that was later confirmed by ultrasonography of the chest.
Echocardiography revealed localized pericardial effusion adjacent to right atrium (RA) with multiple echodense nodular masses seen within pericardial cavity with constriction pathology.
There were significant respiratory variations across mitral and tricuspid valve. Inferior venacava (IVC) was dilated and collapsing less than 50% with inspiration. There was mild dilation of RA with no regional wall motion abnormality (RWMA). Computerized tomography (CT) scan thorax revealed large eccentric sarcomatous mass lesion, aneurysmal dilatation of RA and bilateral pleural effusion. Based on these results pleural tapping was done which revealed haemorrhagic fluid. Fibreoptic bronchoscopy was also done. Fine needle aspiration cytology (FNAC) and pleural cytology revealed no active malignant or inflammatory cells.
A provision

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

[User]
RADIOLOGY NOTE:
We present the case of a healthy 31-year-old woman with an obstetric history of 1 pregnancy, 1 live birth, no abortions (G1P1A0), and a urinary tract infection in the first and second trimesters, without complications. At 21 weeks of gestation, the patient had gross hematuria. We performed cystoscopy and observed a lesion of 3–4 cm in the right wall not identifying the right ureteral orifice (Fig. ). Pelvic magnetic resonance imaging (MRI) without contrast was performed and showed a bladder tumor along the right wall that was 6.3 × 3.5 × 6 cm lateral to the right ureter and lymph nodes, 13 × 9 mm in the right external iliac vessels and 10 × 7 mm in the right internal iliac vessels (Fig. ). The patient had no predisposing factors for bladder cancer.
From an obstetric perspective, the pregnancy was normal without complications.
At 26 weeks of gestation, we performed transurethral resection (TUR) of the bladder lesion. The biopsy showed well-differentiated, invasive bladder squamous cell carcinoma (pT2). Abdominal MRI and chest computed tomography (CT) did not reveal metastatic disease. A staging study was performed after TUR to evaluate possible tumor dissemination and the need for systemic therapy.
The case was presented to a uro-oncology committee meeting and a maternal fetal medicine unit: the patient was offered the alternative of immediately terminating the pregnancy or waiting until 30 weeks for delivery and subsequently performing the surgery. The patient opted for the latter.
The patient underwent C-section at 30 weeks. The newborn was healthy, with no complications.
As recommended by the multidisciplinary committee, the patient did not receive neoadjuvant chemotherapy based on the histology of pure squamous cell carcinoma. One month after delivery, we performed open radical cystectomy with extended bilateral lymphadenectomy through the common iliac vessels and presacrum, a hysterectomy and a right oophorectomy. Blood loss was 1100 cc. There were no other comp

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

[User]
RADIOLOGY NOTE:
A 55-year-old postmenopausal woman presented in our outpatient department because of increasingly serious vaginal bleeding in the previous 2 years. She had experienced a caesarean delivery at 28 years old and underwent natural menopause at 53 years old. The bleeding, which followed a severe cough, was less than normal menses at first but later was heavy and left her clothes soaking wet. The patient reported that the bleeding was fresh blood, which could be stanched by compression in a sitting position. At the time of admission, a vaginal speculum examination showed that the vaginal wall had many varicosities and some bleeding spots. To exclude malignant diseases, the patient underwent colposcopy, and the varicosities and bleeding spots were further confirmed in the vaginal mucosa (Fig. a). However, iodine staining showed no lesions on the mucosae (Fig. b). In addition, the endometrial thickness was less than 4 mm according to transvaginal ultrasonography.
Simultaneously, we noticed that the patient had obvious venous varicosities in her left leg and that the diameter of the left leg was significantly larger than that of the right leg (Fig. a). She stated that the venous varicosities were found when she was 10 years old but not treated because of poor medical conditions. To exclude vascular malformation, we advised the patient to visit the vascular surgery department. On contrast-enhanced computed tomography (CT) scanning of the legs, several varicosities and hyperplastic soft tissue and muscle were found in the left leg but not in the right leg (Fig. b). To determine whether multiple arteriovenous malformations were present, the patient underwent a CT scan of the pelvis, which showed some venous varicosities in the left internal pudendal vein but not in the right vein (Fig. a). However, pelvic arteriovenous shunts and pelvic congestion syndrome were not found on the 3-D reconstructed image (Fig. b).
Then, deep arteriovenous shunts in the left leg were found by arter

[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 56-year-old woman presented to our hospital with acute congestive heart failure. She needed dobutamine support and bilevel positive airway pressure for NYHA class IV dyspnea. Chest radiography revealed congestive heart failure. Echocardiography revealed severe aortic stenosis with heavily calcific bicuspid valve; the LVEF was significantly reduced at 15%. The aortic valve area measured 0.52 cm2. Mean pressure gradient was 49 mmHg. A peak aortic jet velocity was 4.4 m/s. Right-heart catheterization revealed a cardiac index of 1.6 L/min/m2 and pulmonary hypertension with the mean pulmonary artery pressure of 55 mmHg. Coronary angiography showed normal coronary vasculature without signs of significant stenosis. The pulmonary capillary wedge pressure was 37 mmHg. Computed tomography demonstrated a mildly dilated ascending aorta with a diameter of 42 mm. She was diagnosed as heart failure reduced ejection fraction (HFrEF) due to severe aortic stenosis. The society of Thoracic Surgeons predicted mortality score was 12.4%.
Our heart team discussed her treatment. Our patient was a younger AS patient with severe LV contractile dysfunction and with bicuspid valve. Considering the severe LV contractile dysfunction, the patient seemed suitable for TAVI as the lack of ischemic cardiac arrest and extracorporeal circulation helps avoid ischemia, as well as ischemic reperfusion injury, inflammatory reaction, and oxidative stress. However, we hesitated to perform TAVI for this patient because extension of TAVI to such a younger patient with longer life-expectancy raises the issue of durability. Leaflet asymmetry of the implanted transcatheter heart valve which might occur after deployment into bicuspid valve may have an impact on long-term valve durability. While, conventional SAVR is possible while the heart is arrested with cardioplegic arrest, which is effective in majority of AS patients with acceptable morbidity and mortality. However, in some cases, especially in patients wi

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


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

[User]
RADIOLOGY NOTE:
A 60-year-old male presented with slowly progressive drowsiness was admitted to our hospital. Magnetic resonance imaging (MRI) revealed an obstructive hydrocephalus caused by midbrain tumors [Figure and ]. He had past history of a malignant lymphoma of the stomach, which had occurred 10 years earlier. ETV and an endoscopic biopsy were performed to treat the hydrocephalus and to confirm the histology of the tumor.
The operating sheath was inserted into the right lateral ventricle through a right-sided coronal burr hole. The endoscope was advanced into the third ventricle through the sheath and the foramen of Monro. The floor of the third ventricle was thin and translucent. Under continuous visual control, the biopsy forceps and a 4-French Fogarty balloon catheter were used to perforate and widen the stoma. The basilar tip and bilateral posterior cerebral artery were visible below the stoma, but there was no injury to these arteries. A biopsy was not performed because the tumor did not appear on the surface of the ventricle, but cerebrospinal fluid (CSF) cytology revealed malignant lymphoma cells. After some minutes of irrigation, no bleeding was confirmed, and external ventricular drainage was then inserted into the right lateral ventricle.
The patient was in our intensive care unit with continuous monitoring of heart rate and blood pressure. His systolic blood pressure was stable in the range of 130–110 mmHg. He was drowsy, but did not exhibit confusion or other signs of significant pain. After the procedure, the initial level of ventricular drainage was 10 cm H2O. About 220 ml of CSF was drained in the first day after surgery. The patient remained drowsy, but a computed tomography (CT) scan the day after the operation showed no abnormal findings except dilated lateral ventricles. The CSF continued to drain. Two days after the operation, we set the level of ventricular drainage to be the same as that on the first day. About 300 ml of CSF was gradually drained with a

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


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

[User]
RADIOLOGY NOTE:
A 66-year-old man, who complained of upper abdominal pain, was found to have EGJ tumor by endoscopy (Fig. ). He was diagnosed as having Siewert type II adenocarcinoma (E=G, cT1b, cN0, cM0, cStage I) []. We planned to perform lower esophagectomy and proximal gastrectomy with double tract reconstruction.
In the computed tomography (CT) scan before surgery, a 10-mm aneurysm in the middle third of the splenic artery was found (Fig. ). Due to the anatomical location of the aneurysm, endovascular treatment was not considered due to recanalization and coil migration. The size of the aneurysm was not a high risk of rupture [], but we concerned about the possibility of SAA rupture due to postoperative pancreatic fistula (PF) associated with suprapancreatic lymph node dissection such as station 11p and 11d. We thought that spleen blood flow could be preserved even after SAA resection by preoperative CT scan and unnecessary invasive procedures could be avoided by simultaneous surgery. However, during simultaneous proximal gastrectomy and SAA resections, it was not clear whether there was sufficient blood supply to the spleen. Thus, we performed the surgery with a minimally invasive abdominal and left thoracic approach (MALTA) while continuously examining for the presence of blood supply to the spleen using fluorescence imaging.
The patient was placed under general anesthesia and was positioned in reverse Trendelenburg with the left side of the upper body lifted and the legs spread. Laparo- and thoracoscopic proximal gastrectomy and lower esophagectomy with D1+ lymph node dissection and double tract reconstruction were performed. First, we resected the SAA. Next, laparoscopic proximal gastrectomy was performed using five ports. Four ports were inserted into the thoracic cavity through the 9th, 10th (× 2), and 11th intercostal spaces, with the patient in the same body position. Lower thoracoscopic esophagectomy and lymph node dissection of the lower mediastinum was performed und

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


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

[User]
RADIOLOGY NOTE:
A 36-year-old woman presented in 2006 at the department of surgery, Maria Pia Hospital, Turin, for important chronic constipation and abdominal pain. She had a long history of constipation with an average of one evacuation every four days despite continual use of laxatives and had been hospitalized several times before for intestinal partial obstruction. Furthermore, the patient suffered of left hemiparesis with difficulty speaking because of a subarachnoid hemorrhage at one year of age. She was implanted a neurostimulator in the third sacral nerve root, but the device was removed two years later due to its inefficacy. In 2010, she was hospitalized again after another partial obstruction, and loop ileostomy was performed. Despite this, the symptomatology did not improve, and the obstructive episodes continued. Colonic manometry and abdominal X-ray revealed a picture of inertia coli.
On November 2015, during the programmed closing operation of ileostomy, the ileum appeared distended with brownish serosa. Therefore, a decision was taken not to close the ileostomy, and a diagnostic surgical biopsy of the ileum was made. Histologic examination showed an abnormal accumulation of eosinophilic granules in the cytoplasm of smooth muscle cells with disruption of muscular fibers (). The mucosa was normal. The pigment was interpreted as lipofuscin, and a suspicion of BBS was raised.
Blood levels of vitamins A, D, E, and K were dosed, and vitamins D and E were found to be low (0.3 mg/dl and 6 ng/ml, respectively). Antibodies against transglutaminase were negative, and there was no clinical or laboratory suspicion of coeliac disease.
After 8 months of nutritional supplementation, the vitamin values were at the lower limit of the normal range (0.8 mg/dl and 10 ng/ml, respectively), but the patient still suffered of recurrent intestinal functional obstruction. Abdominal X-ray and CT evidenced severe intestinal dilatation (), indicating the persistence of a severe impairment of col

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


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

[User]
RADIOLOGY NOTE:
A 50-year-old male, farmer by occupation presented with a history of high grade fever for 8 days with pain in the calf and thigh muscle region for 4 days, pedal edema, and decreased urine output for 1 day. There was no history of rash, cough, jaundice or history suggestive of urinary tract infection. Patient presented to a rural tertiary care institute with a history of treatment for 2 days at a local health center and the details of treatment were not available at the time of presentation to our institute. Later the details of treatment given at local health center revealed that, patient had received a course of antimalarial (Chloroquine), analgesics and intravenous fluids. Patient was referred to our institute in view of persisting fever and hematuria. At the time of presentation, patient had myoglobinuria []. On examination, pulse was 90 beats/min, blood pressure was 130/80 mm Hg and there were no signs of pallor, icterus, clubbing or lymphadenopathy. The eschar was seen in the right medial aspect of the shoulder [] and there was bilateral pitting pedal edema. The systemic examination was within the normal limits.
The details of laboratory examination are shown in .
The renal parameters were deranged and the muscle enzyme creatine phosphokinase total was elevated. The liver function tests were normal. The complete hemogram showed a normal total leukocyte and platelet count and no malarial parasites. Electrocardiogram revealed tall-tented T waves with a rate of 88 beats/min. The chest X-ray and ultrasonography of the abdomen were normal. The blood and urine culture were sterile. The Widal test leptospira, and dengue serology were negative.
In view of rhabdomyolysis and ARF, urgent hemodialysis was planned. Meanwhile, patient was started on doxycycline 100 mg and received treatment for hyperkalemia. The repeat sample for potassium after correction revealed a value of 7 mE/l. In view of persistent hyperkalemia patient was immediately taken to hemodialysis.

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


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

[User]
RADIOLOGY NOTE:
A 19-year-old Caucasian female patient without significant medical history presented to the emergency room with symptoms of dizziness, headache and emesis. She denied any smoking or alcohol history. She denied any history of head trauma or bleeding diathesis. Family history was positive for breast cancer and lymphoma in maternal grandmother, but no reported history of thyroid malignancy. Her Glasgow coma scale score was 15. On neurological examination, motor strength was five over five in all extremities. Cranial nerves II to XII were intact. Sensations to touch and pain were intact. Finger to nose test was normal and there was no ataxia. Complete blood count and liver function tests were within a normal range.
CT head [] revealed acute intraparenchymal hematoma in the right cingulate gyrus and the splenium of the corpus callosum measuring 4.1 × 3.4 cm in size, with extension of hemorrhage into the ventricular system resulting in mild dilatation of the temporal horn of the right lateral ventricle. Carotid and cerebral angiogram were unremarkable. MRI of brain [ and ] demonstrated a non-enhancing and non-hemorrhagic component of the lesion along the lateral margin of the hemorrhage that was suspicious for a tumor. Subsequently, the patient developed hydrocephalus and she underwent sub-temporal craniotomy with the placement of a ventricular drain into the right temporal horn. Cerebrospinal fluid analysis was negative for flow cytometry and cytology.
CT chest, abdomen, and pelvis revealed a 11 mm hypodense lesion in the left lobe of the thyroid []. The patient has not been symptomatic with respect to thyroid. Ultrasonogram of thyroid [] confirmed the presence of a hypoechoic nodule in the superior aspect of the left lobe of the thyroid measuring 14 × 11 × 11 mm in size. No blood flow was observed within the nodule. MRI of brain performed four days after admission [] showed a heterogenous, hemorrhagic parasagittal right parieto-occipital brain lesion of 39 × 31 mm with

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


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

[User]
RADIOLOGY NOTE:
The patient is a 37-year-old Hispanic female who initially presented for a firm mass on her right breast that had enlarged and became painful over one year. Her medical history is significant for Sjogren’s syndrome with no systemic treatment, hypothyroidism, parity, a right breast benign adenoma, and bilateral breast augmentation with subsequent removal of the implants due to infection. A fine-needle aspiration (FNA) biopsy showed GM (Figure ). Right axillary lymph node contained lymphoid tissue with sinus histiocytosis. There was no evidence of cancer, fungus, or tuberculosis. A diagnosis of idiopathic GM was made. However, no treatment was given as she was lost to follow-up.
Three months after the FNA, her incision site did not fully heal while the mass continued to grow. There was worsening erythema, induration, and pain associated with the mass. Ultrasound (US) of the mass showed complex partially fluid-filled parenchymal changes directly under the indurated area with extension into the biopsied GM lesion suspicious for fistularization with possible abscess or phlegmon formation (Figure ). US findings did not indicate that the mass was drainable. Although her labs did not indicate an active infection, the patient was placed on oral linezolid 400 mg twice daily for 14 days and asked to follow-up in the outpatient surgical clinic.
Prior to the completion of her antibiotic course, she presented with thick drainage from the site of the mass. This presentation was consistent with a breast abscess, for which the patient underwent an incision and drainage (I&D) with packing. During the post-op evaluation, the site of I&D showed granulation and sanguineous drainage without any signs of infection which was supported by her labs and vital signs. Post-I&D US showed resolution of parenchymal fluid and confirmation of a persistent path between the I&D site and the biopsied GM lesion (Figure ). Differential diagnoses from US included progression of GM with fist

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


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

[User]
RADIOLOGY NOTE:
In December of 2006, a 57-year-old man presented with severe right upper posterior chest and back pain. A chest X-ray revealed a mass in the right upper chest. A subsequent CT scan confirmed an 8 cm mass in the posterolateral right upper lobe (RUL) with destruction of the adjacent ribs and invasion into the chest wall. Moreover, there was a separate spiculated mass in the contralateral left upper lobe (LUL) measuring 11 mm. A PET/CT showed the large RUL mass with a standardized uptake value (SUV) of 14, and the LUL lesion had an SUV of 3.4. There was no significant hypermetabolism in the mediastinum and there was no evidence of distant disease.
In January 2007, he underwent a cervical mediastinoscopy and left video-assisted thoracoscopy with wedge resection of the left upper lobe lesion. The LUL pathology showed a moderately to poorly differentiated adenocarcinoma measuring 1.0 cm. All of the mediastinal lymph nodes were negative. It was unclear whether or not the LUL nodule was a separate primary or a metastatic lesion from the RUL primary mass. A brain MRI showed a 6 × 6 mm lesion in the midline pons with minimal hemorrhage and mild surrounding edema that was strongly consistent with a single metastatic lesion (see ). Therefore staging was determined to be T3N0M1, Stage IV, and it was felt that his primary disease should be treated aggressively secondary to chest wall invasion and pain and limited metastatic disease. He was started on chemoradiotherapy to the RUL primary, and Gamma Knife radiosurgery was performed the next month to target the lesion in the pons. A prescription dose of 14 Gy to the 50% isodose line was used, which resulted in 100% of the tumor receiving 15.1 Gy (see for an example of the treatment planning process). The conformality index was excellent at 1.2.
He completed 60 Gy in 30 fractions via a 3D conformal

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


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

[User]
RADIOLOGY NOTE:
We assess a 59-year-old woman in a gynecological oncology center. The CA125 level is 153 U/ml. On transvaginal ultrasound, we describe a solid ovarian mass with a maximal lesion diameter of 59 mm, a maximal diameter of the largest solid component of 59 mm as well, and without acoustic shadowing. There is presence of fluid outside the pouch of Douglas (ascites). If we introduce these parameters in the ADNEX model (in this case, application for smartphone), we obtain the results and column charts as illustrated in . First we add the risk predictions for the four malignant subgroups to obtain the total risk of malignancy, which is 95.3% for this patient. Thus the tumor is likely to be malignant. Then, we look at the differentiation between four malignant subgroups and observe a predicted risk for secondary metastatic cancer of 21.2% (compared to a baseline risk of 4.0%) and a risk for stage II-IV ovarian cancer of 67.9% (compared to a baseline risk of 14.1%). The predicted risks for the other subgroups are lower (4.6% for stage I cancer and 1.6% for borderline) and are also smaller than the baseline risks.
The corresponding relative risks (i.e. ratio of predicted risk and baseline risk) for secondary metastatic cancer and stage II-IV ovarian cancer are 5.3 and 4.8, respectively. The relative risks for borderline or stage I ovarian cancer are below 1. With the knowledge of the increased risk for advanced stage ovarian cancer and more importantly secondary metastatic cancer, clinicians may adjust their preoperative diagnostics by excluding a tumor of other primary origin, such as gastric cancer or breast cancer. In case of a solid tumor these investigations may include PET-CT, MRI whole body diffusion, gastroscopy, colonoscopy, or mammography. This is important as appropriate therapy depends on the origin of the primary tumor. This patient was eventually diagnosed with metastatic gastric cancer (Kruk

[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 33-year-old male with a previously diagnosed Spetzler-Martin Grade 5 AVM in the left parietal lobe that had been treated conservatively. On the night prior to presentation he developed a sudden-onset, diffuse, severe headache that radiated to the suboccipital region. There was no nausea, vomiting, or loss of consciousness.
On the initial assessment the patient was awake, alert, and fully oriented. There were no cranial nerve, motor, or sensory deficits. A fundoscopic examination revealed no papilledema or retinal hemorrhage. A CT scan at admission revealed IVH within the left frontal horn, both occipital horns, both temporal horns, and the third ventricle. There was no ventriculomegaly (). Comparison of this scan with previous CT scans did not suggest the early hydrocephalus. We were concerned about the possibility of recurrent hemorrhage or the development of hydrocephalus, and hence the patient was admitted to the neurosurgical intensive care unit (ICU) for close observation. A catheter angiogram and MRI scan obtained on the following morning revealed no change in the AVM (). A repeat head CT scan on the second day of hospitalization demonstrated stable IVH without ventriculomegaly. The patient was then transferred from the ICU to the neurosurgical ward for observation.
Approximately 40 hours after initial presentation, the patient experienced severe headache with associated nausea. An urgent CT scan revealed the interval development of hydrocephalus, with the suggestion that a portion of the intraventricular thrombus had migrated from the left lateral ventricle to the junction of the third ventricle and the cerebral aqueduct (). There was no recurrence of IVH or subarachnoid hemorrhage. The patient was immediately transferred back to the ICU with anticipation of a need for ventriculostomy placement.
Shortly thereafter his headache began to improve. On examination the patient appeared more comfortable and was not lethargic. He remained without fo

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


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

[User]
RADIOLOGY NOTE:
An 18-year-old female (45 kg, 152 cm), a known case of Stage IV metastatic sigmoid colon cancer, post 4 cycles of chemotherapy (CAPOX regimen), was admitted in the palliative care unit with complaints of pain abdomen for 10 days, multiple episodes of vomiting, inability to pass stools, and flatus for 3 days. There was no history of fever, cough, and difficulty in breathing at the time of presentation. She resided in the containment zone of the national capital which was the hotspot for coronavirus. X-ray erect abdomen was done which revealed multiple air–fluid levels []. Initially patient was managed conservatively and kept nil per oral. Nasogastric tube was inserted. Injection paractemaol alongwith injection fentanyl infusion was given for managing her pain. After 24 h of conservative management, there was no improvement in signs and symptoms; it was decided to go for contrast-enhanced computed tomography (CECT) abdomen, which revealed single-level obstruction at the level of sigmoid colon with the proximal bowel dilated and the distal segment collapsed []. Keeping in mind the ESMO and ACS guidelines for cancer care prioritization during the COVID pandemic, it was decided to take the case for surgical intervention.[] However, at the same time, the patient developed fever, so, along with infection control department, it was decided to test for severe acute respiratory syndrome (SARS)-coronavirus before taking up for surgery as the patient came from a COVID-19 hotspot area and fell into the category of immunocompromised patient as well as developed fever despite giving round-the-clock paracetamol. The patient and the family members were explained about the pros and cons of the surgery, and written informed consent was taken. Once the reports of SARS coronavirus came out to be negative, then, the surgical oncologists proceeded with palliative diversion transverse loop colostomy with both the anesthesiologists and the surgeons using full precautions and personal protec

[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 female with a past medical history of Stage IB breast cancer s/p right-sided mastectomy ten years prior to presentation, hypertension, diabetes mellitus type 2, GBS (two months ago) on treatment with monthly outpatient intravenous immunoglobulin (IVIG) was presented to the emergency department from her nursing home with a chief complaint of inflammation in her left breast. While at the nursing home, erythema of the left breast along with axilla was noticed for which she was treated with a course of cephalexin and clindamycin for possible cellulitis. However, symptoms worsened, and she presented to the hospital. On examination vital signs were stable and breast examination was remarkable for erythema and swelling of the left breast and axilla along with palpable left axillary lymph nodes. Oncology service was consulted for inflammatory changes of the left breast and draining axillary lymph nodes. Her oncological history was reviewed for breast cancer s/p right-sided mastectomy (ten years prior) with pathology revealing infiltrating ductal carcinoma, moderately differentiated. The patient did not receive radiation or chemotherapy. Three years after mastectomy, the patient stopped following up with her oncologist. Her last mammogram was four years ago. Patient reports being negative for the BReast CAncer (BRCA) gene. She has a strong family history of breast cancer. Breast cancer in her mother was diagnosed at the age of 48 years, her sister was diagnosed at the age of 70 years, and her paternal aunt was diagnosed at the age of 60 years (Figure ). Punch biopsy of the left 4 mm peri areolar mass was obtained for the new breast lesion. Metastatic workup with computerized tomography (CT) scan of chest/abdomen/pelvis showed left axillary lymphadenopathy with largest one measuring 1.7 cm, left internal mammary lymph node (LN) 6 mm, shoddy paratracheal and subcarinal lymph nodes. Bone scan and CT scan of the brain did not show evidence of metastasis. 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:
A 33-year-old man was involved in an automobile accident and was brought to our hospital by ambulance. He had been in the front passenger seat and had been wearing a three-point seatbelt. He reported severe back pain, but showed no neurological deficit.
Anteroposterior and lateral radiographs of the spine showed an increased gap between the 1st and 2nd lumbar spinous processes and 2nd lumbar vertebral fracture (figures not shown). Magnetic resonance imaging (MRI) of the spine also demonstrated an L2 vertebral fracture and disruptions of the posterior ligamentous complex between L1 and L2, in combination with extensive subcutaneous hematoma ().
Computed tomography (CT) of the spine in the sagittal orientation and 3-dimensional (3D) CT further revealed the involvement of the superior end plate of the L2 vertebra, comprising horizontal splitting from the left pedicle, through the left transverse process, and reaching the center of the neural arch (). The right-sided L2 pedicle was intact.
After checking the general condition of the patient and excluding intra-abdominal injury by enhanced CT and ultrasonography, the patient underwent L1-L2 single-level instrumented fusion using a posterior approach. Initially, monoaxial pedicle screws with conventional trajectory were placed at L1 and L2 pedicles on the right side (intact pedicle side). A rod slightly bent in lordosis was then introduced and connected with these pedicle screws with a compression force applied between screws. This procedure achieved reduction and the fracture gap at the left L2 pedicle and lamina was completely closed. Polyaxial pedicle screws were used on the left side. A pedicle screw with a conventional trajectory was placed at the left L1 pedicle. A CBT pedicle screw was then inserted through the fractured L2 pedicle under fluoroscopy. This CBT screw was used as an alternative to an osteosynthesis screw. A rod was introduced on the left side, bilateral facet fusion with local bones obtained from the

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


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

[User]
RADIOLOGY NOTE:
A 54-year-old man with a past medical history significant only for hypertension presented to our clinic with a large soft tissue growth on hislower back which had been present for the past 20 years. Over the past three years it had been rapidly enlarging, nearly doubling in size over that time frame. He had recently re-established medical care after having not seen a physician since childhood. At the time of presentation, he denied any pain or tenderness over the mass and denied any systemic symptoms such as fever, night sweats, and weight loss. The patient had an unremarkable physical exam except for the large soft tissue mass over the lower back, with the maxiumum dimension measured to be 38cm () .
After evaluation by the surgical oncology and radiation oncology services, an abdominal CT scan was obtained and thisdemonstrated a large (35 cm, x 38 cm x 17 cm), heterogeneous soft tissue mass. A differential diagnosis consisting of teratoma versus liposarcoma was established based on the radiologic imaging. Subsequently, several core biopsies of the mass were performed, all of which revealed fat necrosis with calcifications.Surprisingly, given the size and rapid growth of the mass, a diagnosis of benign giant lipoma was made.
Four weeks after presentation, several surrgical teams performed a six hour operation to remove the 14 kilogram mass. After the patient was widely prepped and draped, the skin overlying the central portion of the tumor was shaved and harvested as multiple split thickess skin grafts (). Subsequently, an incision was made in the skin overlying the tumor in an area outside the skin graft donor sites, preserving significant flaps in all dimensions to permit primary closure (). Numerous, large variceal vessels feeding the tumor were ligated as the tumor was dissected off of the paraspinous muscles, which constituted the deep margin.
The specimen was sent for frozen section analysis,which was consistent with a lipoma, and was confirmed on final the pa

[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 female presented to us with history of recent onset right flank pain. It was sudden in onset and moderate in intensity and associated with nausea. There was no history of fever, hematuria or trauma. On examination, temperature was normal and her blood pressures were persistently high. There was mild tenderness in the right flank. There was no organomegaly. Genital and pelvic examinations were normal. Laboratory examination revealed hemoglobin of 12.2 g/dl. Total counts, renal function, coagulation profile and urine routine microscopy were normal. X-ray of KUB region did not reveal any abnormal radiopaque shadow. On abdominal ultrasonography, both the kidneys were of normal size, shape and position. There was a subcapsular collection of size 9.5Χ6 cm anteriorly extending from upper to lower pole in the right kidney []. Renal parenchyma was compressed by the collection. Doppler study ruled out any arteriovenous fistulae as a cause for the collection. Left kidney, urinary bladder and rest of the abdominal organs were within normal limit. Computed tomography with urography (CT IVU) was done. It revealed well-defined subcapsular pocket of fluid collection of size 10Χ6Χ2 cm on the anterior aspect compressing the right kidney. The Hounsfield unit of the collection was 50, which was suggestive of clotted blood. There was no solid component or abnormal contrast uptake in the collection. Both the kidneys showed prompt excretion. Both the ureters and urinary bladder were normal. She was advised complete bed rest. Proper analgesia and antibiotic was given. She responded well to conservative treatment. Her symptoms decreased within 2 days. Her blood pressure was brought under control with two drugs – beta blocker and calcium channel blocker. On serial sonography, the size of the hematoma decreased. She was discharged on fourth day in stable condition. She was followed up at 6 weeks. Repeat CT scan was done at that time. Collection at that time regressed to 3.6�

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


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

[User]
RADIOLOGY NOTE:
We have observed a delayed large local skin reaction to the first dose of Vaxzevria in a 62-year-old, white female. Except for cat allergy, no history of allergy was reported. Previous vaccinations had been well tolerated without remarkable skin or systemic reactions. Following the resolution of initial local and systemic symptoms after vaccination, the delayed reaction had an onset on day 10 that appeared near the injection site. The appearance of the reaction was an erythema with a maximum diameter of 10 cm on day 14 after vaccination (Fig. ). Considerable induration and pain near the injection site was reported. Besides the local erythema, no further cutaneous symptoms in other localizations were observed. The symptoms cleared up after 15 days and fully resolved over the following 3 days. No systemic symptoms occurred with delayed local reaction. The patient did not require treatment for reaction. A biopsy was not performed.
The complete post-vaccination course was as follows: On day 0, the vaccination with Vaxzevria took place and no immediate reaction to the vaccine was observed. On day 1 after vaccination, the patient reported elevated temperature, malaise, and fatigue. The symptoms of systemic reaction resolved on day 2, but a slight soreness near the injection site was reported. On day 3, an erythema with a 5-cm diameter, warmth, and swelling was observed near the injection site. On days 4–6, local symptoms remitted and completely resolved on day 7–9 except for a palpable nodule in the deep soft tissue. On day 10, a new erythema recurred near the injection site and spread to a maximum diameter of 10 cm on days 11–14, accompanied by large, localized swelling and induration. From day 15, the erythema was regressive and had completely resolved by day 18. Photographs show the skin reaction over time, with varied size and severity of the local findings between day 10 and 15 (Fig. ).
In the light of changing data on

[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 78-year-old Japanese woman (gravida 10, para 2, abortion 8) had a 10-year history of uterine prolapse but she had no gynecological examination. She had no smoking history and her body mass index was 19.7. She visited our hospital because of a 1-month history of bleeding from an ulcerated lesion on the surface of the prolapsed uterus. Upon examination, the uterine prolapse appeared as complete eversion of the posterior vaginal fornix and was manually irreducible and classified as stage IV according to the Pelvic Organ Prolapse Quantification System []. On the surface of the completely prolapsed uterus, an ulcerated lesion of 3 cm in diameter was observed and a deep-seated induration was felt. A histological biopsy of a mass in the vaginal wall led to a diagnosis of keratinizing squamous cell carcinoma. Magnetic resonance imaging revealed the mass with a depth of 1.6 cm, but the endometrial cavity was not depicted (Fig. ). The mass was located approximately 3 cm from the cervical os with no sign of invasion to adjacent tissue. According to the International Federation of Gynecology and Obstetrics (FIGO) staging system, the tumor was vaginal cancer staged as I, and a fluorodeoxyglucose positron emission tomography/CT revealed no metastases to the lymph nodes or other organs. Although the diagnosis of this case was vaginal cancer, the main tumor was located in the uterine cervix because of the completely prolapsed uterus. Therefore, we considered that it is practical to develop the treatment plan according to the uterine cervical cancer. Because of the patient’s advanced age and the presence of arrhythmia (paroxysmal supraventricular tachycardia and paroxysmal atrial fibrillation), she was ineligible for a combination of surgery under general anesthesia and chemotherapy; therefore, RT alone was planned. If EBRT had been administered, radiation dermatitis of the genitalia would have been a concern because the prolapsed uterus would be irradiated. Neither a probe nor a

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


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

[User]
RADIOLOGY NOTE:
A 57 year old man presented to the clinic with a chief complaint of vague left sided abdominal pain for two weeks. One year earlier he had been admitted on two separate occasions for left shoulder pain with significant tenderness over the bicipital groove, lateral border of the scapula, and sternocleidomastoid. The patient had survived a mine explosion in 1967 while serving in the Vietnam War resulting in surgical asplenia. Physical examination at the time of presentation was unchanged from previous admissions. CBC revealed a decreased RBC count (4.47 cells/L) with a borderline low hemoglobin level (14.5 gm/dL) and a slightly elevated MCV (98.1 fL). Fecal occult blood study was positive.
A colonoscopy was performed under IV sedation with 25 mg of meperidine and 2 mg of midazolam. Colonoscopy revealed a large number of diverticula in the sigmoid and descending colon. The scope was negotiated up to the splenic flexure at which point the lumen was no longer visualized. The patient was turned supine and to the right lateral decubitus position. Despite these maneuvers the colonoscope could not be advanced past the splenic flexure. The scope was withdrawn and the injected air was removed.
Within 24 hours of colonoscopy the patient presented to the emergency department with complaints of abdominal distension, epigastric pain, nausea, and dyspnea. A CT scan of the abdomen was interpreted as normal. The patient was discharged with analgesics. Two days later he returned with similar complaints. A second CT scan was read as normal. The patient was again discharged. Four days post colonoscopy the patient was admitted to the hospital due to worsening pain and dyspnea. He had not had passed flatus or stool since the colonoscopy. Physical examination now revealed a tachycardic, diaphoretic man in respiratory distress with a distended abdomen and faint bowel sounds. Laboratory analysis revealed the following at the time of admission: urine positive for protein, WBC's

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


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

[User]
RADIOLOGY NOTE:
The patient is a 37-year-old Asian male who is right hand dominant. He initially presented to an outside emergency department (ED) after a motor vehicle collision. He was restrained in the front passenger seat when his vehicle rear-ended another vehicle. He extended his right upper extremity against the dashboard just before the impact. At the first ED, the patient was noted to have right wrist tenderness as well as lacerations over the dorsal surfaces of the 2nd and 3rd digits. The degree of swelling and presence of tenderness were not noted. Plain radiographs were obtained. They were read as notable for fractures of the distal radius, scaphoid, triquetral, and capitate bones. An anterior dislocation of the lunate bone was also present. Closed reduction of the lunate dislocation was attempted unsuccessfully a total of three times. The hand lacerations were then irrigated and sutured closed. The hand was placed in a splint in the position of function (intrinsic plus). He was then discharged on Cephalexin and acetaminophen with codeine and instructed to follow up at our ED for further evaluation later that day.
The patient was seen in our ED approximately 19 hours after discharge from the first hospital ED. The history was confirmed. The right hand and forearm were noted to be swollen, tense, and very tender. Light touch and two-point discrimination were diminished but present. Capillary refill was 2 seconds in all digits. The motor exam was remarkable for marked diminution of strength secondary to pain. Radiographs obtained confirmed the presence of the fractures noted at the first hospital. Compartment pressures were measured using a Stryker Intracompartmental Pressure Monitoring System in select areas of the forearm and hand. They were significantly elevated in all compartments tested ().
The orthopedic surgery service was consulted. The patient was taken to the operating room where he underwent release of the transverse metacarpal ligament, numerous fasciotomies

[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 80-year-old man with a background of hypertension, gout, osteoarthritis and cerebrovascular disease presented following an injury to his left big toe. He developed confusion and sepsis secondary to deep infection of his left big toe. As part of the initial septic screen, he had a CT scan which did not show any evidence of hydrocephalus (Fig. a). He was started on intravenous antibiotics and the decision was made to undertake amputation of the infected toe. After extubation, he had persistently reduced level of consciousness. A CT head scan performed post-operatively showed new onset acute hydrocephalus with no evidence of haemorrhage or infarction (Fig. b).
He was urgently transferred to a tertiary neurosurgical centre with a GCS of 11 (E4, V2, M5) and underwent an emergency external ventricular drainage (EVD) insertion under local anaesthetic. Intra-operatively, his CSF was under moderate pressure and it was clear and colourless. His CSF results showed a white cell count of 28 × 106/L, red blood count of 3 × 106/L with no organisms. Post-operatively, he recovered to a GCS of 14 (E4, V4, M6). However, he still had persistent hydrocephalus on the repeat CT head scan. Apart from raised inflammatory markers and mild hyponatremia, his blood tests were unremarkable.
Due to crowding of his foramen magnum, a decision was made to have a MRI head and spine. This showed erosion of the odontoid with marked degenerative changes at the atlantodental joint. Interestingly, a large tissue mass presumed to be a pannus was also seen causing severe compression at the cervico-medullary junction and obstruction to CSF flow at this level (Fig. ). Prior to this presentation, the patient had never suffered from any neck pain or limb weakness.
On further examination, he was not myelopathic but had widespread tophi in his hands and feet. He was started on treatment for gout with Colchicine 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 63-year-old woman was admitted to the First Affiliated Hospital of China Medical University in June of 2010 for further examination of the liver tumor which was detected by ultrasonography in the annual health check. Physical examination showed no abnormalities. Hematological and chemical studies, including tumor markers such as α-fetoprotein and carcinoembrionic antigen, gave normal results. Hepatitis virus markers, such as hepatitis B surface antibody, hepatitis B surface antigen and hepatitis C antibody, were all negative. Conventional ultrasonography revealed well-demarcated isoechoic tumor with a diameter of 30 mm in the segment V of the liver. The spleen, pancreas, and kidneys were without any focal lesions. There are no pathognomonic clinical signs for tuberous sclerosis. The patient did not consent to tumor biopsy, and we could not rule out the possibility of malignancy due to the result of ultrasonography and CT scan. The patient desired to undergo tumor resection on her own initiative, and partial hepatectomy was performed. The patient was alive with no tumor recurrence or metastasis at 2 years of follow-up.
Gross examination showed an elastic hard mass with a diameter of 30 mm. The tumor did not have a capsule, but it was clearly demarcated from the normal hepatic parenchyma. The tumor was grayish-white on cut surface.
The neoplasm was demarcated from the surrounding liver tissues with relative clear boundary, presenting with a solid cellular growth pattern and abundant vascularity with frequently dilated vascular channels (Figure. A–D). The tumor was characterized by the infiltration of numerous inflammatory cells in the background, including small lymphocytes, plasma cells, and eosnophils (Figure. C–F). The proportion of tumor area with inflammatory infiltration was more than 80%. The tumor cells were spindled and histiocytoid in shape, with slightly eosinophilic cytoplasm and small central nucleoli, and arranged along the vessels or scattered among t

[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 healthy 5 years-old boy was referred to the Centre for the Study and Treatment of Dental Trauma in Primary Dentition (NETRAD- Federal University of Pelotas, Brazil), after 3 years and 5 month of follow-up in private dental clinic. Reportedly, at 21 month of age, he had experienced a fall from the proper high, while riding his scooter that caused subluxation of the primary right and left maxillary central incisors, and partial intrusive luxation of the primary maxillary right lateral incisor.
Clinical and radiographic examination revealed crown discoloration of both primary maxillary right and left central incisors and the maintenance of the intrusion of the primary maxillary right lateral incisor. Also, mobility of the primary maxillary right central incisor and pulp necrosis of the primary maxillary left central incisor was detected. Endodontic treatment was performed in the primary maxillary left central incisor. Extraction of the primary maxillary right lateral incisor was performed, because of the lack of re-eruption. The patient was oriented to regular follow-up every 6 months.
By the time the patient had eight years and 5 months of age, developmental disturbances like hypoplasia and crown dilaceration of the permanent maxillary right central incisor were confirmed, as previously observed radiographically (Fig. ). For aesthetic reasons, restorative treatment was performed with resin composite for both labial and palatal surfaces. After 2 years, in another follow-up assessment, the absence of eruption of the permanent maxillary right lateral incisor was diagnosed and cone bean computed tomography was requested. Bond between the crowns of maxillary right central and lateral incisors through enamel bridge was observed.
A multidisciplinary treatment plan, involving periodontist, orthodontist and pediatric dentists, was outlined in an attempt to expose the teeth through gingivectomy for the orthodontic traction. During the gingivectomy procedure, an attempt was pe

[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.