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

[User]
RADIOLOGY NOTE:
A 53-year-old female was admitted to our department of general surgery because of dyspepsia and vomiting during the previous month. For her past history, she was diagnosed with diabetes and hypertension 10 years prior under medical treatment. There was no significant family history. On abdominal physical examination, there was no significant finding. Laboratory findings were nonspecific. Contrast-enhanced abdominal computed tomography (CT) and F-18 fluorodeoxyglucose positron emission tomography (FDG-PET) CT showed an approximately 12 cm sized heterogeneous mass located from fundus to mid body of stomach, which seemed to invade pancreas, spleen and left adrenal gland (). Endoscopic biopsy performed in our institution and pathologic report revealed a spindle cell tumor consistent with GIST (, ). Results of immunohistochemical stain: the tumor cell was positive for CD34 and c-kit (CD117), weak positive for smooth muscle actin; whereas S-100 was negative ().
Two weeks later, we performed laparotomy, but the mass was huge and invaded the pancreas and retroperitoneum very tightly so that it couldn't be resected. Ten days after the operation, the patient was started on imatinib therapy, a daily dose of 400 mg, maintained for 4 months. No adverse event occured during imatinib treatment. A follow-up CT, 2 months after the start of imatinib, showed a dramatic reduction in the size of the tumor. And 4 months after follow-up CT, there was no evidence of mass lesion in the stomach (); on the gastroduodenoscopy, the mass lesion was invisible with only an ulcerative lesion observed in the same location (). Although the mass lesion was not revealed clearly at the follow-up imaging study (), we planned operation to achieve curative resection of the tumor. 5 months after the treatment with imatinib, the patient underwent total gastrectomy and splenectomy. The stomach was adhered to the spleen, tightly, and the lesion was found between stomach and spleen, firm and white, having irreg

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


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

[User]
RADIOLOGY NOTE:
A 25-year-old obese Asian Indian woman with no known past psychiatric history or family history was brought to the ED for the assessment due to her suicidal ideation. According to her family, the patient had never had suicidal ideation or attempts in the past. Her vital signs were within the normal range. The patient's body mass index (BMI) was 31, height was measured to be 162.5 cm, and she weighed 182 pounds (lb).
During the interview, it was found that the patient felt low, with no interest in any activities in the past year. Apart from her work-related commute, she stayed at home. Upon further interviewing, she admitted to having sleep disturbance and binge eating. She suffered from hirsutism since the age of 17 years, which has worsened over the years. The patient complained of "bear-like" hair growth all over her body, her urge to keep pulling her body and scalp hair. The patient said she sometimes would pull her perianal hair so hard that it would bleed. The patient also complained of oligomenorrhea and dysmenorrhea. The patient said she was tired of having to keep checking her facial hair several times daily since she was worried her beard would have grown towards the end of the day. Based on the patient's evaluation and presence of bald spots on the scalp and folliculitis on the stomach from hair-pulling, she was also diagnosed with trichotillomania, a hair-pulling disorder. The patient also suffered from adult acne.
She was admitted to an inpatient facility due to suicidal ideation and the management of major depressive disorder (MDD). Laboratory workup of complete blood count, comprehensive metabolic panel, and urine analysis found no abnormalities. Also, toxicological tests were negative. An endocrinology consult was recommended, and further laboratory tests for PCOS were ordered due to the presence of hirsutism. The patient was diagnosed with PCOS, 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 59-year-old man with hypertension and diabetes presented with progressively worsening back pain radiating down the right leg, right flank pain, nausea, and vomiting. He denied hematuria, dysuria, or any problems with urination. He also had an unintentional weight loss of 5 kg during the past 6 months.
Based on systemic symptoms, CT scan was ordered to rule out malignancy. Radiographic findings were remarkable for hypodense liver lesions, pulmonary nodules, retroperitoneal lymphadenopathy, and increased bone density in L1 and L3 vertebral bodies as well as the right iliac bone. The patient also had moderate right hydroureteronephrosis of both renal moieties with delayed nephrogram and transition point within the proximal common right ureter ( and ). Lumbosacral MRI revealed right L5 nerve root impingement by a lumbar mass. Brain MRI showed abnormal signaling within right temporal lobe concerning for metastasis.
To further characterize the ureteral mass as well as to confirm the extent of collecting system duplication, the patient underwent a right ureteroscopy. Cystoscopy revealed bilateral orthotopic ureteral orifices with no ectopic orifice. Right retrograde pyelogram showed a filling defect at the proximal ureter with reduced amount of contrast moving in two levels more proximally, corresponding to a partially duplicated system (). A wire was placed into the upper pole of the kidney. A flexible ureteroscope was advanced alongside the wire confirming a bifurcation of a bifid collecting system at the level of the filling defect. The ureteroscope was advanced into the lower pole ureter, with multiple papillary tumors noted in this segment distally by the bifurcation. Selective barbotage cytology and tissue samples using a Piranha™ grasper (Boston Scientific, Marlborough, MA) were obtained. Narrowing of the proximal right lower pole ureter precluded advancement to the lower pole kidney. Attention was then turned to the upper pole ureter where multiple papillary tumo

[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 authors have obtained the patients' parent's informed written consent to publish this case report.
A 10-year-old boy (Case 3) presented with back pain after performing a handstand without a fall during a physical education session. He had no significant past medical history. At the initial visit, there was tenderness on his back, especially on the spinous process at T11. Neurologic findings were normal. Plain radiographs were unremarkable. MRI scans indicated low signal on T1WI, relatively high signal on T2WI, and high signal on short tau inversion recovery (STIR) images in the upper part of the vertebral body at T11 without deformation of the cortical endplate (). There was no high signal in the posterior elements of the spine, such as the interspinous ligament. A diagnosis of VBB was made. The patient was treated conservatively with a soft thoracolumbar brace and instructed not to participate in physical activity for a month. At follow-up 1 month later, the patient had no back pain, the tenderness on the spinous process had diminished, and the signal changes in the vertebral body seen on T1WI, T2WI, and STIR images had disappeared (). There was no residual deformation of the cortical endplate.
The other 5 children had similar clinical manifestations (). The onset of back pain in all 6 children coincided with mild physical activity, such as performing a handstand, jumping rope, or Japanese box vaulting. None of the children reported a fall. We did not check any blood test for all 6 patients because they had no past medical history. There was tenderness on the corresponding spinous process at the initial visit in all cases. Imaging findings were similar; plain radiographs were unremarkable, and MRI scans showed low signal on T1WI and high signal on T2WI and STIR. In all cases, the back pain and signal changes seen on MRI resolved after conservative treatment 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:
This 14-year-old girl was referred to our hospital from a peripheral gynecologic unit. She was mentally dull and noncommunicative. The mother stated that for the past 18 months the patient used to cry every month for a few days with abdominal pain. She was found to hit her abdomen with the pain in the recent months. Initially, the pain was relieved with oral analgesics, but later she required parenteral analgesics for pain relief. Prior to her referral to the hospital, she was reviewed by a urologist in another hospital who found a right-sided hydronephrosis and hydroureter and treated her with a double J-stent which relieved her loin pain.
The mother noticed gradual abdominal enlargement in her daughter who had never menstruated.
On abdominal examination in our unit, a pelviabdominal mass reaching the xiphisternum was found which was tense and tender with a smooth contour.
An ultrasound scan of the pelvis and abdomen revealed a blind upper vagina and bicornuate uterus with the right horn containing the hematometra and fundus reaching the epigastrium. The left horn was rudimentary and noncommunicating with the endometrial cavity. There was a right hemorrhagic tuboovarian mass 7 cm × 7 cm with multiple cysts in the ovary. The left ovary appeared normal.
Both the kidneys and ureters were normal. Pelviabdominal magnetic resonance imaging (MRI) confirmed the above findings. Intravenous pyelography was within normal limits.
A decision to undertake a laparotomy was taken to relieve her pain caused by the hematometra. This was explained to the parents, and written consent was obtained for possible hysterectomy.
Examination under anesthesia revealed a blind lower vagina that measured 1.3 cm. On rectal examination the pelvis was tense and filled with the lower end of the hematometra. As vaginal drainage of the hematometra was impossible, the abdomen was opened by a vertical midline incision reaching up to 3 cm above the umbilicus

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


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

[User]
RADIOLOGY NOTE:
A 44-year-old Caucasian man was working under a car when the vehicle’s transmission system fell on his chest, squeezing his torso between the heavy item and the ground. After an unknown time, he was found in an unconscious state by a relative, who called for medical aid. It was estimated that at least one hour elapsed before our patient received medical care.
On arrival to our emergency department, our patient had a gasping breath without foreign bodies in his oronasal cavities, palpable regular pulses with a rate of 130 beats per minute and an arterial pressure of 80/40mmHg. On pulse oxymetry he had a saturation of 80% on room air. His Glasgow Coma Scale score was 8 (absent eye opening, unintelligible voice responses and limp withdrawal to painful stimuli), his papillae were isochoric and light reflexes were bilaterally present. Because of his altered consciousness and impending respiratory failure, our patient was urgently intubated and put under controlled mechanical ventilation.
The rest of the physical examination revealed that his face, the front part of his neck and the upper part of his chest were congested, edematous and covered with numerous petechiae, especially on the conjunctivae and the periorbital skin. In a later bedside ophthalmologic examination, mild bilateral periorbital swelling, severe bilateral subconjunctival hemorrhages, chemosis, mild exophthalmos and mild optic disc edema were observed. Ecchymotic bruises were also noted on the back part of his neck and the upper part of both shoulders. His tympanic membranes were clear and there were no mucosal hemorrhages of his upper airways.
Absence of breathing sounds over both lung apices in combination with palpable subcutaneous emphysema over his neck pointed towards the existence of bilateral pneumothorax. Moreover, bloody fluid was drained through the endotracheal tube, indicating possible lung contusions. The physical examination of his heart and abdomen was unremarkable and electrocardiogram wa

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


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

[User]
RADIOLOGY NOTE:
A 40-year old female with history of breast cancer was referred from an out-side clinic. She had received a lumpectomy of her right breast with an axillary lymph node dissection 34 months before she first visited our institute. The pathology report obtained at the time of surgery documented infiltrating ductal carcinoma, and the resection margins were confirmed to be clear of carcinoma invasion. Three regional lymph nodes out of 16 were found to possess adenocarcinoma cells. Lymphovascular invasion was reported negative. Routine staging workup showed no evidence of distant metastasis, staging her as T2N1M0 based on an American Joint Committee on Cancer staging system at the time of surgery. As a surgical procedure, a catheter draining from the lumpectomy site was placed, which was later removed. She had completed 6 cycles of chemotherapy with cyclophosphamide, methotrexate, 5-fluoruracil regimen, and radiotherapy of the whole breast with 50.4 Gray plus a boost of 9 Gray was performed. She denied receiving any other type of surgery. No evidence of recur were observed by thorough imaging studies; regular checkups were done at the out side clinic.
On her visit, she complained of a recently noticed palpable lump on her right chest wall. Physical exam revealed an approximately 2 cm sized moveable subcutaneous nodule with rubber consistency located on the middle axillary line at the level of nipple. A small scar was noticed on the skin lying directly superficial to the nodule, which the patient claimed to be the wound site of drain catheter insertion during the lumpectomy she previously received. Ultrasonography of breast and chest wall revealed a well demarcated subcutaneous mass measuring 1.8 cm in length (). No other abnormalities were demonstrated in the remaining breast. A sonographically guided 14-gauge core needle biopsy yielded infiltrating ductal carcinoma.
A whole body bone scan and whole body positron emission tomography scan failed to demonstrate any suspected

[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 89-year-old man presented with a history of episodes of a paroxysmal headache on the right occipital region, superior and posterior to the ear, over the past 40 years. He complained of abrupt onset, sharp, electric-like pain in the right occiput radiating toward the vertex accompanied by an intense and stabbing pain localized in the depth of the auditory canal. Palpation of the right greater occipital nerve elicited the pain. A single pain episode usually lasted for a few weeks. The pain in the depth of the right auditory canal did not appear during every episode but only when the occipital pain was severe. The pain attacks usually occurred at the time the patient felt fatigued or when he was afflicted by a cold with or without fever. During the latest episode, the occipital pain was accompanied by symptoms of a herpes zoster and/or herpes simplex reactivation in the territories of the right maxillary and auriculotemporal nerves. Specifically, the skin was erythematous and small vesicles appeared on the right side of the face, around the right mouth angle and the right external auditory canal. The viral smear was not obtained and the vesicles resolved spontaneously in weeks. The frequency of the pain attacks was increasing from once in every 1 or 2 years in the antecedent decade to two or three times per year in recent years. Neurological examination revealed normal findings with no hypesthesia in the affected area, no cranial autonomic features, and no occipital skin lesions. Pain was eased temporarily by local anesthetic nerve block with lidocaine. Magnetic resonance image (MRI) examination of the cervical spine and brain was normal. A diagnosis of ON in combination with NIN was established based on symptoms which fulfilled the International Headache Society (ICHD-II) criteria []. In the antecedent decade, the patient did not take any pain killer. In recent years, carbamazepine was used at a dosage of 0.3 g daily (divided into three times) during the pain attac

[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 was referred to the Outpatient Breast Clinic due to having a huge mass on the right breast for >2 years. On examination, a firm lobulated huge mass was observed with superficial veins on the breast being significantly bulging and a skin ulcer in the lower outer quadrant (). Neither clinically positive lymph nodes nor nipple discharge were found on clinical examination.
The most recent chest computed tomography indicated a swollen anterior chest wall with areas of low density, interpreted by radiologist as possible invasion of pectoralis major muscle. Preoperative examination tests did not prove any distant metastases. The patient underwent fine needle aspiration that revealed stromal cells, often accompanied by large, folded sheets of epithelium suggesting fibroepithelial lesion.
Two years ago, the patient had undergone a mammogram (), which had shown breast asymmetry due to a large lobulated mass with smooth and circumscribed margins.
Surgery was scheduled after discussion with the patient who was explained that breast reconstruction might not be feasible due to the possible involvement of pectoralis major muscle. Informed consent was obtained from the patient. Wide mastectomy was performed. At this point, it has to be underlined that dissection was performed carefully since there were multiple bulging vessels. Trying to conserve pectoralis major muscle for reconstruction only a superficial layer of muscle fibers was resected.
Macroscopically, surgical margins were free. Reconstruction with tissue expander was decided and it was inserted beneath pectoralis major. Skin flaps were closed under some degree of tension after the placement of surgical drains. Postoperatively, the patient recovered with no complications ().
Histology revealed phyllodes tumor of 26 cm in maximum diameter with moderate cellularity and atypia, without invasive growth pattern. Heterogeneity was observed with regard to mitotic activity but not <5–7 mitoses/10 hpf were foun

[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 30-year-old unemployed Japanese male. He was diagnosed with schizophrenia at the age of 23 and had been treated at a psychiatric hospital on an outpatient basis. He exhibited water intake behaviors, and he had been drinking approx. 10 L/day for the past several years. At 29 years of age, the patient showed mild disorientation and was hospitalized for water intoxication; the details are unclear. From 6 days before he was admitted to our hospital, he became aware of nausea that gradually worsened. Two days before his admission, in the morning, he showed mild disorientation and a speech disturbance, and an ambulance was requested for transportation to a regional emergency hospital. There was no history of illnesses or accidents, such as head injury, epileptic seizures, or severe infections. No obvious hereditary diseases were observed.
During the patient’s transfer the regional emergency hospital, his Glasgow Come Scale (GCS) was E4V1M5, but there were no obvious abnormal findings in the head and neck, chest, or abdomen. Physical findings did not suggest either overhydration or dehydration. Moreover, no obvious neurological abnormality was observed such as the deep tendon reflex abnormalities or presence of pathological reflexes. A chest X-ray at the time of admission showed no pleural effusions, cardiomegaly, or pulmonary congestion.
The patient had been treated for schizophrenia with more than 10 different types of oral medication (Table ). Since these drugs are known to cause drug-induced syndrome of inappropriate secretion of ADH (SIADH), they were discontinued at the time of admission to the emergency hospital. Table shows the results of the blood and urine tests performed at the time of admission to the emergency hospital. The patient was treated for severe hyponatremia (96 mEq/L) and hypokalemia (1.9 mEq/L), and was transferred to our hospital on day 3 of his stay in the emergency hospital, so that he could receive further specialized treatment

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


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

[User]
RADIOLOGY NOTE:
A 37-year-old gravida 4, para 4 was referred to our gynecology clinic by her general practitioner 16 months after vaginal delivery, with symptoms of postcoital bleeding for a month. There was no history of itching or offensive smell. She was in the period of lactation without cycle of menstruation. Routine smear test and screening for high-risk HPV test were both negative 3 years ago. The general practitioner referred the patient to the gynecology clinic after finding an abnormal cervix when he intended to take a smear. The gynecological examination revealed a vegetative mass protruding from cervical canal to vagina, 4 × 3 cm in diameter (Fig. ).
In the ultrasonographic examination, uterus was retrovert in position, myometrium was homogeneous, the thickness of endometrium was normal, and intrauterine device was seen in the uterine cavity. Magnetic resonance imaging (MRI) showed a suspicious hyperintense 4 × 3 × 1 cm solid mass arising from posterior lip of the cervical canal reaching fornix. No parametrial involvement or significant retroperitoneal lymph node enlargement was detected. Clinical diagnosis of stage 1B2 (International Federation of Gynecology and Obstetrics [FIGO] 2009) was made based on the findings. Punch biopsies of the tumor were taken and sent for histopathological examination.
The diagnosis was moderately differentiated endocervical adenocarcinoma originating from the cervix. Radical hysterectomy with bilateral salpingo-oophorectomy as well as pelvic and para-aortic lymph node dissection was performed. The final pathology result was consistent with the previous report which showed moderately differentiated mucinous endocervical adenocarcinoma. The tumor size was 4 × 2.5 × 1 cm. The depth of tumor in the hysterectomy specimen was 1 cm. No parametrial invasion was detected. There was no invasion to uterine corpus or vagina. In total, 30 lymph nodes were extracted. There was no evidence of metastasis to the lymph nodes or lymphovascular invasion. 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 43-year old female patient was referred to our department with the clinical diagnosis of ovarian malignancy. Abdominal CT scan revealed a left adnexal mass, moderate perihepatic and perisplenic ascitic fluid collection, retroperitoneal and pelvic lymph node enlargement and omental cake peritoneal seedings; thorax CT identified a paravertebral pleural cystic lesion with thick wall and serous liquid content (Fig. ). Laboratory investigations showed a mildly elevated serum lactate dehydrogenase at 546 IU/L and CA 125 at 1420 IU/L. The patient's previous history was remarkable for a malignant melanoma of the left antecubital region removed surgically 9 years ago. Histopathology report at that time revealed a Breslow 2.36 mm, Clark's level IV, superficial spreading melanoma with a nodular phase growth pattern, with signs of regression and without ulceration. Elective left axillary lymph node dissection and intraoperative isolated limb perfusion of the left upper extremity with cisplatin, melphalan and dacarbazine was performed according to an investigational protocol at the time of initial presentation of the patient. Histopathologic examination showed no evidence of metastatic disease in the excised lymph nodes. After 2 years of well being the patient was lost from follow-up. In order to establish a definite diagnosis of the present clinical scenario, ultra-sound guided aspiration of the ascitic fluid and cytopathological examination was performed. Cytological morphology showed a cellular smear with a single cell population of large pleomorphic round undifferentiated pigmented malignant cells with moderate to abundant cytoplasm. The hyperchromatic nuclei showed great variation in size and contained large nucleoli. There was pigment both within the cytoplasm and in the background. Binucleate and multinucleated cells were also frequent. Immunocytochemistry studies revealed positivity for HMB-45, vimentin and S-100 (Fig. ). The findings were identical to the initial spec

[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 51-year-old female with a history of stage 1 hypertension was admitted to the hospital post cardiac arrest. She had a significant family history of premature coronary artery disease. Her father had a coronary artery disease diagnosed in his 40’s, her mother had a pacemaker inserted, and she had two first degree relatives diagnosed with an early cardiac disease. She is a nonsmoker, nonalcoholic drinker and denied recreational drug use. She was in her usual state of health and functionally active until her husband noticed her moaning and eventually unresponsive in the middle of the night. Prior to this, the patient did not complain of any chest pain, dyspnea, dizziness, lightheadedness or any other constitutional symptoms. Her husband started cardiopulmonary resuscitation and was taken over by the emergency medical staff (EMS). She was intubated and defibrillated five times by EMS for ventricular fibrillation then was given a bolus of amiodarone. She eventually had a return of spontaneous circulation and was transported to the hospital in which she was noted to have decorticate posturing with no purposeful movements. Electrocardiogram (ECG) during this time showed sinus rhythm (Figure ). She was admitted to the coronary care unit and was placed on targeted temperature management and was maintained on amiodarone drip. Transthoracic echocardiogram showed no valvular abnormalities, normal left atrium and left ventricular cavity size but with borderline concentric left ventricular hypertrophy with an ejection fraction of 56% and note of subtle regional wall motion abnormalities. About 12 hours after initiating the targeted temperature management, the patient was in severe bradycardia in the mid 30’s and a decision was made to hold the amiodarone at that point. The patient completed the targeted temperature management protocol and eventually had a full neurologic recovery thereafter.
She was extubated and subsequently transferred to the floor. She was scheduled for cardi

[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 man visited our clinic in 2010 with an asymmetric orbit, right eye set 1 cm lower than the left and a soft, movable mass of 3 cm × 1 cm in his right eyelid, which all first appeared at the age of five. He had no signs of visual disturbance, including diplopia or limitation of the motion of the extraocular muscle. We planned to resect the eyebrow and eyelid mass and correct the dystopia; however, the patient refused to undergo orbital correction, so we settled for the excision of the eyelid mass. The mass was partially resected and was pathologically confirmed as neurofibroma.
Four years later, in March 2014, he returned to our clinic complaining about the protruding recurred mass in the right eyelid and eyebrow with orbital dystopia (Fig. ). Facial computed tomography showed dysplasia of the right frontosphenoid and orbital bone, enlargement of the volume of the orbit, widening of the superior orbital fissure, and a mass located in the superior orbital space, protruding to the right temporal lobe. The mass effect of the superior orbital mass and the longitudinal widening of the orbit were presumed to be the reasons for the dystopia. Therefore, we planned to excise the mass and remodel the longitudinally widened orbit. A two-team approach with the neurosurgeons was adopted. Using a bicoronal incision, we exposed the frontal, temporal, and zygomatic bones. The neurofibroma mass in the supraorbital region was totally excised by opening the orbit roof and lateral wall by a transcranial approach and zygomatic osteotomies. After removing the mass, a 5 cm × 7 cm bone graft was harvested from the outer cortex of the bone fragment of the calvarium, which was excised when the craniectomy was performed. The bone graft was designed into an L-shape to restore the lateral wall and floor of the widened orbit (Fig. ).
The right eyeball

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


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

[User]
RADIOLOGY NOTE:
A 40-year-old male admitted to another hospital with fever for half a month and pain in lower limbs for 1 week. Ultrasound results revealed deep vein thrombosis of the lower extremity, and laboratory examination revealed a high level of troponin I.
The patient was transferred to our hospital. Electrocardiography revealed ST elevation in leads II and III, AVF and V1–3, Q wave was found in leads II and III and AVF. Troponin I level was 4.402 ng/mL. Therefore, a diagnosis of myocardial infarction was confirmed. However, the blood cell count revealed an extremely high white blood cell (WBC) count (81.9×109/L) and low platelet count (50×109/L) that indicated leukemia. The patient underwent bone marrow aspiration that confirmed the diagnosis of acute myelogenous leukemia (M4).
The patient then underwent percutaneous coronary angiography, which revealed an occlusion of the proximal right coronary artery (). After the guidewire crossing, there was still no blood flow in the right coronary artery (). Intravascular ultrasound was performed, which showed multiple thrombi in the right coronary artery from distal to proximal. The endarterium was complete without significant atherosclerosis (). After repeated thrombus aspiration, many thrombi were aspirated, but there were still many thrombi that could not be aspirated. There are still serial stenoses in the right coronary artery ( and 1d). To improve blood flow, balloon dilatation was applied in the middle of the right coronary artery, the site of most serious stenoses (). After balloon dilatation, the blood flow partially improved (). Because of the unusual appearance of the aspirated thrombi () and the history of leukemia, the thrombi were sent for histological examination. The histological examination revealed abundant blast cells in coagulative necrosis (), according to the examination of the bone marrow. It indicated that the coronary artery was occluded by a leukemic clot.
The patient then received chemotherapy with idarub

[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 13-year-old female in her permanent dentition is presented with the chief complaint of crowded anterior teeth and retruded lower jaw. As mentioned before, there were signs that growth spurt was completed. The patient had a chin deficiency with decreased anterior facial height. There was no facial asymmetry and the lips were competent with deep mentolabial fold.
In the intraoral assessment, the oral hygiene was fair but needed improvement prior to orthodontic treatment. In addition, some caries were detected that had been taken care of before starting the orthodontic treatment. Dental midlines in both arches were coincident and also coincided with the facial midline. There was a mild crowding in maxillary arch together with a mild lower anterior crowding. Angle classification was Class II division 1, and the buccal segment relationship was one-unit Class II on both sides. The overjet was 6 mm, whereas the overbite was 80% ().
The panoramic radiograph confirmed the presence of all permanent teeth including the developing third molars (). In the cephalometric assessment (), the ANB value of 4.2° suggested a mild Class II skeletal pattern. SN to mandibular plane angle had decreased. The upper incisors were proclined (U1-SN 112 degrees) and the lower incisors were of average inclination (IMPA 91.9 degrees) ().
Possible treatments are as follows.
The upper right and left posterior segments could be distalized using cervical headgear appliance to correct the molar relationship and create space to reduce the overjet and the overbite. Even though the headgear treatment has a restraining effect on the maxilla [] it has little effect on mandible []. We can also use functional appliances, fixed or removable, which have more effect on mandible and also have a good control on both upper and lower dental arches. However both treatments rely on patient's cooperation and age.
It could be argued that this case might be treated only with fixed appliances

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

[User]
RADIOLOGY NOTE:
We report the case of a previously healthy 17-year-old Caucasian male with exercise-induced pain of the right foot that had deteriorated over the course of three months. During the last week prior to presentation at our emergency department, the symptoms had progressed from intermittent to constant calf pain. At clinical examination, the right foot was pale and cool with delayed capillary refill and absent pedal pulses consistent with the clinical picture of acute limb ischemia. The left foot was warm and well perfused with palpable pedal pulses.
Doppler ultrasound study of the right lower limb showed an occlusion at the proximal part of the right popliteal artery (PA). With magnetic resonance angiography the presence of a four-centimeter thrombus occluding this section of the PA was confirmed.
Furthermore, Doppler ultrasound study of the asymptomatic, contralateral (left) popliteal region revealed an occlusion of the PA with sufficient collateralization and unimpaired three-vessel runoff to the foot.
By conventional transfemoral angiography, the previously identified occlusion of the right PA and its aberrant course were demonstrated again (). An attempt of continuous intraarterial thrombolysis of the occluded right PA was undertaken by the use of actilyse and continuous heparin applied via a lysis catheter over 24 hours. The required therapeutic dose was controlled with aPTT between 60 and 80 seconds. This resulted in a significant reduction of thrombotic material within the PA, but the vessel was still considerably occluded (70-80%). After 24 hours of catheter-directed thrombolysis, low-molecular-weight heparin (LMWH) in therapeutic dosage and continuous infusion of iloprost (over 4h) were given daily. Further investigations were started to identify the already suspected extravascular cause of occlusion.
Indeed, in magnetic resonance imaging the anomalous origin of the MHGM lateral to the medial condyle of the femur was detected. The muscle's tendon and belly cro

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

[User]
RADIOLOGY NOTE:
An 83-year-old man underwent surgical excision of a malignant peripheral nerve sheath tumor (MPNST) at the right knee at another hospital and was then referred to our hospital for further chemotherapy. Three months after the start of chemotherapy, the patient complained of severe pelvic and low back pain. A PET CT was performed which showed multiple bony lesions with a variable (moderate to high) degree of metabolic activity raising suspicion that these were metastases. The lesions, however, had a very unusual appearance and evolution as seen on CT.
Initially, the lesions presented as small rounded lytic lesions with a well-defined sclerotic margin (Figure ). They exhibited a rapid growth but the initial appearance of central lysis and surrounding sclerotic margin was preserved. Follow up PET CT scan was performed after seven weeks to evaluate the response to chemotherapy. It revealed a second concentric band (halo) around some of the lesions. This band (halo) had a ground-glass appearance and was surrounded by a second sclerotic rim. This rim was thinner and less sharply demarcated than the more central rim (Figure ). The multiple lesions were in different phases of evolution and as such had a different appearance at any given time.
Presence of multiple lesions, a known primary tumor and moderate to high uptake of FDG tracer on PET scan (Figure ) suggested metastatic disease, despite the unusual appearance of the lesions.
Other bony metastases were also evident on CT. Some were entirely sclerotic and a few had an ill-defined lytic appearance. Collapse of a vertebral body and fracture of the upper endplate of another vertebra due to metastases were also present.
Bone biopsy of a lesion with the above described doughnut appearance located in the left pubic bone was performed. A biopsy was obtained in the central lytic area and another biopsy in the peripheral halo (Figure ). Histological evaluation of both the samples showed infiltration of bone marrow by malignant s

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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 71-year-old Caucasian woman was referred to our department in September 2013 because of the development of anaesthesia of the lower right lip and chin. This symptom was preceded by a sudden diffuse pain in the right mandible which lasted a few hours one month before the development of the neurological impairment. A dental extraction in the anterior region of the mandible was performed by dental practitioner due to severe periodontal disease after the onset of the first sudden mandibular pain. History taking of the patient revealed that she suffered from hypertension, chronic obstructive pulmonary disease, rheumatoid arthritis (RA), and an IgM monoclonal gammopathy of undetermined significance (IgM-MGUS). At the first clinical evaluation she was taking methotrexate (MTX) (10 mg once a week), folic acid (5 mg/daily), prednisone (7.5 mg/daily), ibuprofen (80 mg/daily), and calcium.
The intraoral clinical examination was unremarkable, but an ulcer of 1 cm wide could be seen in the lower lip. A painful hard swelling was evident on palpation in the lower right vestibular fornix in the premolar area and in homolateral submandibular space. Lymphadenopathies were detected in the right later cervical, supraclavicular, and subaxillary groups and in the left axillary group. The patient suffered from chronic periodontitis which during years determined tooth loss and prosthetic therapy with dental implants and partial removable dentures. There were no direct dental or other local causes which could explain the onset of anaesthesia of right inferior alveolar nerve.
A dental panoramic tomography (DPT), a maxillofacial CT scan, and an ultrasound (U/S) of the neck were performed to assess the morphology and the limits of the lesion. The DPT revealed a radiopaque area diffused from 4.5 to 4.8 with some microlacunae on the alveolar ridge and lower mandibular cortex. The CT scan confirmed the microlacunar reabsorptions due to bony structural rearrangement of all the mandibular cortice

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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 16-year-old Asian male was brought to the Maxillofacial Department of University Hospital of Messina. He was previously admitted at the Emergency Department of another hospital after a motorbike accident and immediately transferred to our Unit of Maxillofacial Trauma with a diagnosis of Le Fort III fracture and mandibular fracture associated with active bleeding of the right buccal mucosa. He has the pulse of 72/min and blood pressure (BP) of 112/70 mmHg with a normal FAST exam and presented 9,2 gr/dL of hemoglobin (Hb). The CT scan showed a mandibular right parasymphyseal fracture associated with complex maxillary fractures in a Le Fort III pattern (). No condylar fractures were detected. Upon the admission to our department, his Glasgow Coma Scale (GCS) was 13/15. The clinical examination revealed a mobility of the midline of the mandible and maxilla with diffuse swelling and an unusual profuse bleeding from a mucosal wound in the right upper molar region. The patient was brought to the operative room and monitored. After several attempts with local measures (packing and electrocautery), the bleeding still remained with a blood loss of approximately 500 mL. A further blood examination revealed 7,6 gr/dL Hb. The patient was then transfused with 3 units of fresh frozen plasma and 3 units of erythrocyte. Clinically no signs of neck swelling were recorded. No pulsations were detected through auscultation. Fluid therapy was done with 1,000 mL of lactated ringers solution and the patient was immediately sent to Radiology Unit. The CT scan with intravenous contrast showed a focal rounded hyperdensity in the right infratemporal region. The patient was then referred for interventional radiology to perform an angiography that represents the “gold standard” to study arterial lesions. Angiography was performed with the patient under conscious sedation. The Seldinger technique was used to catheterize the right common femoral artery with a 5F groin sheath. A 5F diagnostic

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

[User]
RADIOLOGY NOTE:
The second case was an 8-yr-old boy with normal development who presented with acute onset of left-sided hemiparesis of the face and subsequently weakness of left-side limbs following a mild head injury. He had no history of recent viral illnesses or vaccination. Physical examination revealed no loss of consciousness or fever, but he had left-sided limb paresis with hyperreflexia and central left facial nerve palsy. Other neurologic examinations were unremarkable. Brain CT scan with contrast demonstrated low attenuated subcortical areas in the right frontal lobe and right lentiform nucleus with some mass effect ().
The first brain MRI of the patient showed a couple of hypersignal lesions in T2-WIsequence. The larger one was located in the right lentiform nucleus and insular subcortical white matter with surrounding halo. The smaller one was located in the posterior limb of right internal capsule (). Lumbar puncture revealed CSF protein of 10 mg/dl, negative oligoclonal band and AQP4 antibody and no CSF pleocytosis.
Virology assessment of CSF for HSV, VZV and HIV were all-negative. The patient was treated with a 4-day course of methylprednisolone pulse with presumptive diagnosis of Balo disease. The clinical symptoms ameliorated, but due to remaining some degree of leftsided limbs weakness, physical therapy was started.
About 2 months later, he presented to the Emergency Department with an attack of a febrile seizure. After doing brain CT-scan, the second brain MRI was done that revealed very large mass like concentric or layered high signal lesion in FLAIR sequence in the right frontal lobe white matter and adjacent basal ganglia ().
A brain biopsy of the right frontal lesion was done and showed a lesion with macrophage infiltration, prominent gemistocytic gliosis and no evidence of malignancy.
These findings were compatible with a demyelinating disease and according to neuroradiologic findings, the diagnosis of Balo concentric sclerosis was considered.
Carbamazepin

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

[User]
RADIOLOGY NOTE:
An 8-year-old boy with chronic encephalopathy secondary to hypoxic ischemic syndrome, with cerebral palsy and symptomatic epilepsy, was admitted to the emergency department of the children's hospital. He had been seizure-free for the past year with an enteric-coated delayed release formulation of VPA (375 mg every 8 hours). Thirty days prior to hospital admission, he was started on LTG 25 mg/day along with VPA, since his seizures were no longer under control with VPA. Two weeks later, the dose was increased (50 mg/day). His morning trough plasma VPA level was measured before LTG was added to the therapy yielding a concentration of 85 mg/L. On admission, he presented macular lesions on the front of the thorax that extend to the back, followed by bilateral eyelid edema and ulcerated lesions at the level of lips, jugal mucosa, and pharynx. He developed erythematosus conjunctivitis with ulcers. He presented skin rash with high fever (39°C) and respiratory failure type I. History revealed that no such lesions occurred earlier and that was the first time such rashes have occurred. Other personal and family history was not relevant. From a dermatologic point of view and based on the history and clinical presentation, a diagnosis of SJS was made. Since the presumptive cause was LTG, the drug was discontinued immediately. Soon after the patient admission, periofocal and ocular involvement worsened. Intravenous immunoglobulin was administered for 48 hours. Mouth care (oral washes with sodium borate) and eye care (tobramycin ophthalmic drops) were also indicated.
From a hemodynamic point of view, four hours after admission, his condition deteriorated and he developed septic shock with peripheral circulatory failure. The patient was admitted to the intensive care unit with intravenous fluids and antibacterial therapy due to skin infection by Staphylococcus aureus. In addition to fluid resuscitation, dopamine was administered. Despite the inotropic treatment, the patient's condi

[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 January 2016, a 72-year-old man with no notable medical history presented at our emergency center for tropical diseases a few days after returning from a 2-week vacation in Cuba. He described skin lesions without pruritus, fever and diffuse myalgia. Clinical examination revealed a diffuse papular rash on his arms, legs and trunk (Fig. A) and two ulcerated lesions on the oropharynx. Considering his recent travel and no sexual risk history, the most likely diagnosis was a tropical infection. Considering the current polemic and excitement, Zika infection was considered as a likely hypothesis. The patient was screened for Zika, dengue and rickettsiosis and put on a 10-day course of empiric antibiotic treatment with doxycycline. The skin rash disappeared completely within 2 weeks, but the laboratory results did not confirm the hypothetic diagnosis.
In March 2016, he presented to the ophthalmic emergency department with a rapidly evolving, painless, bilateral loss of vision. Within a few days, his visual acuity dropped down to 0.1 in the right eye and 0.05 in the left eye. without any other accompanying symptoms (no ocular pain, neurological symptoms, headache or scalp tenderness, jaw claudication, fever, proximal myalgia, arthralgia or fatigue). He reported not having been exposed to any toxins, drugs or vaccines in the weeks preceding the loss of vision. Fundoscopic examination revealed bilateral papillary edema with thunder hemorrhages in the right eye (Fig. B). Goldmann’s visual fields showed an altitudinal superior deficit in the right eye and a large central scotoma in the left eye with a small preserved inferior temporal area. He was hospitalized and immediately started on high doses of corticosteroids and aspirin. Fluorescein angiography of the retina excluded arterial leakage or obstruction. Orbital magnetic resonance imaging (MRI) revealed an increase of the signal of the right optic nerve and the appearance of a hypersignal on the left on the STIR sequence

[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 34-year-old woman was referred to our clinic due to reoccurring cervical swelling on the left side with concomitant dysphonia and dysphagia. Computed tomography revealed extensive abscess formation. Therefore, the patient was hospitalized, and the abscess was drained and put on intravenous antibiotics.
Past medical history of the patient revealed several neck operations starting when she was ten years of age. Multiple hospitals were involved in the process. Initially, second branchial cleft cyst was suspected, and extirpation was performed. Thereafter, multiple reinfections occurred, with abscess incisions and drainages performed several times. Extensive diagnostic work-up with repetitive computer tomography, magnetic resonance imaging, and barium esophagograms was performed but failed to show the presence of a fistula and sinus tract. Due to the recurring infections, exploratory cervicotomies were performed twice, without any sign of remaining cyst duct or fistulas. In total, the patient underwent 12 interventions, including seven operations in general anesthesia and four tomographic imagings. The cumulative x-ray exposure was calculated to be 16 mSv.
After the patient was finally referred to our clinic, we began a new diagnostic work-up as we assumed the diagnosis to be erroneous, since the patient suffered so many recurrences. Careful patient history revealed that new cervical abscess formation almost always followed upper respiratory tract infections. This was a strong clinical clue for a fistula and sinus of the upper aerodigestive tract with allowing spread of the infection to the neck. Retrospective evaluation of pathological reports showed that the suspected cyst contained merely pseudoepithelium. True cysts remnants would have contained epithelium; therefore, the diagnosis recurring second branchial arch cyst infections should have been doubted earlier.
Suspecting a branchial cleft anomaly of the third or fourth arch, we performed a new barium esophagogra

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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 62-year-old woman was referred to the authors' hospital for evaluation of a corneal ulcer in her left eye. With the patient's consent, a review of the clinic record was conducted. Ten years previously she received an allogeneic hematopoetic stem cell transplant for treatment of myelodysplasia syndrome. Her course was complicated by the development of cGVHD affecting the liver, skin, esophagus, mouth, and eyes. Severe keratoconjunctivitis sicca had been treated with a PROSE lens for more than 2 years prior to developing this corneal ulcer. Her medical status was compromised by systemic steroid dependence and by steroid induced diabetes mellitus.
After presenting with a corneal ulcer in her left eye, the patient was empirically treated with topical 0.5% moxifloxacin (Vigamox, Alcon) that was applied 6 times a day (once before the PROSE lens was inserted in the morning, 4 times during the day inside of the PROSE lens reservoir, and once again at night after the PROSE lens was removed). After failure to improve on 4 days of this treatment, she was referred to Massachusetts Eye and Ear Infirmary for additional corneal ulcer evaluation, culture and modification of treatment. Upon presentation, the central cornea was opaque and neovascularized with tissue loss of approximately 60% of the corneal thickness. There was an epithelial defect that measured 2.5 mm by 1 mm, with an underlying 2 mm by 1 mm infiltrate. Microbiological smears and cultures were performed with the specimen from corneal scraping. No bacteria or fungi were evident with Gram stain or Calcofluor white stain. At the time, frequency of application of topical moxifloxacin was increased to every 2 hours while awake (approximately 8 times per day), delivered as one drop added to the PROSE reservoir after removal and cleaning reinsertion of the device and replenishment of the reservoir with preservative free saline (B).
Four days after culture and modification of antibiotic

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


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

[User]
RADIOLOGY NOTE:
A-5-year-old boy with 3-week mouth ulcers on both cheeks visited our children's dental clinic with his parents. He had been examined and treated with systemic antibiotics at another clinic for 1 week yet there had not been any recovery. A doctor at the clinic asked him for biopsy to make an initial diagnosis, which made patient's parents worried, resulting in their decision to have him transferred to our dental clinic.
At our place, patient's body was normal and showed no signs of fever. He was not aware of the habitual cheek biting during the day. The patient's face was swollen and suffered from deformity. The ulcers (Figure ) on the mucous membrane of both cheeks, with a white implant about 3 × 2 mm on each side. The lesions were strong, not sticky, but painful if being touched. The patient's saliva had normal color and glands; lower jaw nodes were portable, painful, and 5 mm in size. The patient could bite normally and had no crowded teeth.
We noticed that the child sucked his cheeks frequently while he was playing. Even when he was reminded, he continued sucking the cheeks.
Ulcers of the mucosa on both cheeks were due to unknown reason of cheek biting.
Treatments of local lesions including the reduction of pain and the risks of subsequent infections associated with drug use, the prevention of any further trauma in cheek mucosa, as well as the promotion of wound healing process being planned with the orthodontic support.
Treatment of local lesions: Oral gingivitis (2% chlorhexidine) and gingival hygiene (metronidazole 10%), three times a day after meals. Biting correction: Orthodontic support was used to remind the patient and protect him against further damages. We have used the EFStart Evolution function of Orthopedics—France in this case; it was cut and modified in the second molar area to avoid being touc

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


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

[User]
RADIOLOGY NOTE:
A 37-year-old man who complained of paroxysmal abdominal pain for 4 months, diarrhea for 15 days and weight loss of 4 kg was admitted to our hospital in April 2019.
In December 2018, he was admitted to another hospital with abdominal pain and hematemesis. Gastroscopy revealed a duodenal mass with bleeding, and pathological analysis of a biopsy showed inflammation and the presence of an ulcer. A computed tomography (CT) scan revealed thickening of the gastric antrum and duodenal bulb walls, with slightly enlarged perigastric and omental lymph nodes. Hematemesis stopped after 5 days of treatment, and a second endoscopy was performed. The second gastroscopy revealed a duodenal bulb ulcer (Forrest IIb) and chronic superficial gastritis. Pathological analysis of a biopsy showed chronic inflammation caused by Helicobacter pylori (HP) (+++) infection and no evidence of a tumor. A contrast CT scan showed diffuse wall thickening of the gastric lesser curvature and antrum. Based on the presence of neoplastic lesions with the enlargement of multiple lymph nodes, lymphoma was suspected. He was then given quadruple therapy (unknown drugs) to eradicate HP for 2 weeks and continuous omeprazole treatment.
In 2013, he was found to be infected with HIV, then diagnosed with AIDS in 2016. He had been on combination antiretroviral therapy (cART) since July 2018. His latent syphilis was also cured by Penicillin injection in November 2016.
Physical examination showed normal vital signs but a slightly elevated heart rate of 102 beats per minute. His superficial lymph nodes were not palpable and the size of a palm, and the tough mass was touchable in the middle of the epigastric region with tenderness but no rebound pain.
Laboratory tests revealed a c-reactive protein level of 18.02 mg/L, erythrocyte sedimentation rate of 32 mm/hour and albumin level of 40.8 g/L. His Epstein–Barr DNA level was <4 × 102 copies/mL, and the patient was negative for cytomegalovirus (CMV

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


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

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

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


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

[User]
RADIOLOGY NOTE:
A 23-year-old man with BRAF mutant melanoma received four doses of ipilimumab. The patient had an initial response to treatment however by approximately month 5 after starting ipilimumab, he developed disease progression. Thereafter, the patient initiated vemurafenib. The dose of vemurafenib was reduced from 960 mg daily to 720 mg daily secondary to multiple episodes of uveitis (treated with relief by intraocular steroids).
At approximately month 7 after initiating ipilimumab and 2 months after initiating vemurafenib, the patient developed severe chest pain and cough. Diagnosis of cardiogenic shock was made based on vital sign changes as well as electrocardiogram showing ST segment elevation and elevated cardiac enzymes including creatine kinase and troponin-T. The patient was started on both cardiac inotropic and vasopressor agents and anti-coagulated in the setting of intermittent atrial fibrillation. Transthoracic echocardiogram was performed revealing normal left ventricular size but severe global hypokinesis, left ventricular EF of 20 %, and right ventricular systolic pressure of 33 mm Hg. Diuresis was attempted with intravenous furosemide and cardiac rate and pressure control were obtained. Cardiac MRI was performed and deemed suggestive of myocarditis.
After stabilization, right heart catheterization to assess hemodynamics and right ventricular endomyocardial biopsy were performed. Pathology revealed lymphocytic myocarditis manifesting with lymphohistiocytic infiltrates and cardiomyocyte damage without identification of eosinophils (Fig. ). Electron microscopy confirmed ultrastructural findings consistent with lymphohistiocytic myocarditis. A diagnosis of immune-mediated myocarditis was made and high dose intravenous corticosteroids were initiated until vasopressive agents could be withdrawn. Oral steroids were then tapered over approximately six weeks.
Vemurafenib had been held since admission however this was restarted five days after admission to the hospi

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


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

[User]
RADIOLOGY NOTE:
A 17 year-old girl was admitted in our institution in August 1994 with a metaphyso-epiphyseal bone tumor of the proximal humerus. An incisional biopsy made the diagnosis of telangiectasic osteosarcoma (), in conformity with clinical and radiological features. The patient received pre operative chemotherapy in respect to french protocol at this time (4 cures of Holoxan/cis platinium). Then a limb-salvage procedure consisting of an extra articular resection of proximal humerus with gleno-humeral articulation was performed. The reconstruction consisted of an arthrodesis with a vascularised scapular crest bone graft. The histopathologic examination of the specimen concluded of clear wide margins and no viable cells have been found out (good response, Huvos grade 4). The patient received two more cures of the same chemotherapeutic protocol. She has been continuously follow-up every 6 months for 5 years then every year [Magnetic Resonance Imaging (MRI) and chest X ray] until now.
In 2005, because of the unsightly appearance of her left arm due to resection of soft tissue and mainly deltoid muscle (), she was referred to a reconstructive surgeon of our institution and received three autologous fat grafts harvested from her abdominal wall and injected circularly around the bone graft in soft tissues (March 2005, June 2005 and January 2006). The patient reported a good cosmetic result with a lasting increased volume of the arm.
In August 2007, she consulted her oncologist because of pain, inflammation and swelling at the lipofilling site (). The Magnetic Resonance Imaging (MRI) showed an extensive soft tissue tumor (). Histological analysis of the biopsy revealed an osteosarcoma with neoplastic cells and thin osteoïd formation (). No lipid droplets have been observed after Oil Red O staining of the biopsy. No distant relapses have been found out. The patient received again 4 cures of chemotherapy (API-AI French protocol) and a trans scapula amputation was performed (). Tumor

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


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

[User]
RADIOLOGY NOTE:
The patient is a 63-year-old man who initially presented to an outside hospital for workup of hematuria. The patient was found to have a mass in his left kidney and radiological workup had shown lesions within his liver. The patient came to our hospital seeking treatment from one of our urologists. In order to rule out a urinary bladder carcinoma, a urinary cytology was performed and showed no malignant cells. As part of his preoperative workup, the patient had CT scans of his thorax, abdomen and pelvis. The scans once again showed a large lesion on his kidney (Figure ) and also defined multiple lesions within his liver. All but one appeared to be small simple cysts. A lesion found in segment 4a of the liver showed a circumscribed 1.1 × 1.6 cm hyperattenuating lesion pre-contrast (Figure ) that did not enhance post-contrast. The report indicated suspicion for metastasis or hepatocellular carcinoma. Because of the concern for metastatic disease, the lesion was removed and frozen section was performed intraoperatively. A 1.5 × 1.5 × 0.5 cm tan-pink cyst was examined and diagnosed as an epithelium lined cyst. Surgery was then continued and left nephrectomy was performed for removal of the renal mass. The surgery was without complications and postoperative hospital course was uneventful. On permanent sections, the cyst was microscopically described as composed of ciliated pseudostratified columnar epithelium, subepithelial connective tissue, smooth muscle layer and outer fibrous capsule (Figure and ). A diagnosis of CHFC was given. Grossly, the renal mass consisted of a well-circumscribed nodule with a solid, golden yellow cut surface. Histologically, it was composed of malignant clear cells with a rounded to polygonal shape and abundant clear cytoplasm forming a trabecular and nesting pattern with a prominent delicate vascular network. The final diagnosis was renal cell carcinoma (RCC), clear cell type. Two years after the surgery the patient is free of disease.

[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 20-year-old primigravida female was referred to our tertiary center at 21 weeks of gestation for the management of fetal hydrops which was characterized by generalized edema, massive pericardial effusion, mild cardiomegaly, and ventricular hypertrophy. Doppler studies showed a high peak systolic velocity in the middle cerebral artery (MCA) of 61.41 cm/s (2.28 MoM) suggestive of fetal anemia. Doppler investigations showed reverse flows in the MCA and ductus venosus (DV) with umbilical venous pulsation. Fetal echocardiography showed cardiomegaly (cardiothoracic area ratio; CTAR 45%) resulting in severe regurgitation of all valves and impaired ventricular function without structural cardiac defects. The endocardium was echo-dense, suggesting the presence of fibroelastosis ().
The maternal blood was analyzed for toxoplasma, cytomegalovirus, herpes simplex virus, coxsackie virus, and parvovirus B19 and showed evidence of parvovirus B19 seroconversion. All other infection screening tests were negative for recent infections. The mother did not recall any symptoms of viral infection at the beginning of her pregnancy. The maternal blood groupwas A positive and the maternal red cell antibody screening was negative.
The options for pericardial effusion aspiration and umbilical blood sampling for anemia were discussed. In view of the fetal circulatory disorder and lung decompression, it was decided to perform pericardial centesis and draining of the pericardial effusion. The procedure was performed at 22 weeks of gestation without any complications. However, the fetus died one day later. Fetal pericardial fluid and ascites, as well as the amniotic fluid, tested positive for parvovirus B19 DNA and revealed a normal female karyotype 46, XX.
A postmortem examination revealed a hydropic stillborn fetus, weighing 486 g without any gross anomalies. Autopsy of the heart revealed severe hypertrophy and dilatation of the right and left ventricles. The dilated wall of the ventricle 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:
An 11-year-old female patient visited the ophthalmology clinic with a four-month history of diplopia, especially when concentrating on a distant target such as letters on the whiteboard in school. She denied any headache during those periods. The patient had no remarkable past medical history. She had already visited another ophthalmology clinic with the same symptoms and underwent brain magnetic resonance imaging (MRI), which she was told was normal.
At the first visit, her visual acuity was 20 / 20 in both eyes. Slit lamp examination was done and there were no specific indications. Extraocular movement testing revealed 20 prism diopters (PD) comitant esotropia at distance, and straight at nearer proximity. Cycloplegic refraction was also done and the refractive error was -3.25 sph -0.50 cyl Ax180° in both eyes.
On fundus examination, mild optic disc edema was found in both eyes (). Optical coherence tomography also demonstrated a mild thickening of the nerve fiber layer. A visual field test using the Swedish interactive thresholding algorithm standard 30-2 revealed a bilateral enlargement of the blind spot ().
A systemic examination revealed no significant abnormality. At the time of initial presentation, the patient was obese with a body mass index of 29.7 kg/m2 (body weight 66 kg, height 149 cm). We asked the patient to bring the previous brain MRI for verify the findings, but she was lost to follow-up over the next four months. After four months, she returned to the clinic with an increased deviation angle of esotropia to 25 PD at the primary position, and still straight at nearer proximity. Optic disc edema, and bilateral enlargement of the blind spot in the visual field remained the same.
At six months after initial presentation, the deviation angle increased to 35 PD at distance without an abduction deficit. We suspected IIH, although there was no headache, normally typical and the most common symptom of pediatric

[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 62-year-old African American female presented to her primary care physician with intermittent abdominal pain and discomfort for a few months. On review of systems, she denied any recent illnesses, nausea, vomiting, diarrhea, fever, chills or weight loss. Besides very faint bilateral wheezing on lung auscultation, her physical examination was quite unremarkable. Her past medical and surgical history consists of asthma, type 2 diabetes mellitus, dyslipidemia, hypertension, previous tobacco user, cholecystectomy in 1988 and tubal ligation in 1986. The patient’s family history was negative for any malignancies except for her mother passing away from endometrial cancer and one brother who died from prostate cancer. An initial computed tomography (CT) scan of the abdomen and pelvis showed a 2.1-cm soft tissue mass within the omentum (). There was no hepatomegaly or splenomegaly, no lymphadenopathy or any abdominal effusions described. The differential diagnosis was quite wide and included mainly malignant mass, especially after a repeat CT scan of the abdomen and pelvis 6 months after the initial presentation that showed the mild growth to a 2.4-cm soft tissue mass within the omentum. Therefore, a CT-guided biopsy of the omental mass was persued and showed mature adipose tissue and omentum EMH ( and ). Per all the imaging done and biopsy of the omental mass, no concern or possibility of an accessory spleen was described. At that point, a secondary cause for her EMH was considered with a wide differential diagnosis including myelofibrosis, chronic hemolytic anemia or hemoglobinopathies, inflammation/infection and bone marrow irradiation, which were all excluded with the following investigations: a peripheral smear that did not show any hemolysis and only showed hypochromic red blood cells with mild leukocytosis; routine biochemical tests, including liver, pancreatic and renal function tests, serum immunoglobulins, blood and urinary protein electrophoresis and other tumor

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


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

[User]
RADIOLOGY NOTE:
The patient is a 46-year-old male who presented to the neurosurgery clinic with a one-year history of progressive right eye blurry vision, which he first noticed while serving as an umpire in a little league baseball game. He denied any headaches, although he had recently developed a painless pressure sensation behind the right eye. He had no contributory medical history (e.g. endocrinologic, vascular) to explain an optic mononeuritis, and there was no personal or family history of neurofibromatosis. An evaluation by neuro-ophthalmology showed severe degradation of the right eye visual fields with sparing only of the inferior medial field. Right optic atrophy was also appreciated on examination. Physical examination in the neurosurgery clinic was unremarkable for any focal neurological findings, and both of his pupils were equal, round, and reactive to light and accommodation. A T1-weighted MRI with contrast demonstrated a 4 x 5 mm homogeneously enhancing mass at the right orbital apex within the bony canal and along the medial aspect of the right optic nerve sheath with resultant mass effect on the right optic nerve (Figure ).
The differential diagnosis at this point was optic nerve meningioma versus optic nerve glioma. Optic nerve signal was also consistent with neuritis on the right. After discussion of the operative plan in the clinic, the patient agreed to undergo endoscopic endonasal surgery for bony and dural decompression with resection of the tumor if it was felt to be amenable intraoperatively. Informed patient consent was obtained prior to treatment.
The neurosurgery team worked with otorhinolaryngology (ENT) for the skull base approach. The right-sided ethmoid air cells were opened to expose the medial orbital wall. A posterior septostomy was performed on the right, and the face of the sella was widely opened to expose the tuberculum sellae and planum sphenoidale superiorly. We removed the most distal portions of the lamina papyracea on the right. The ri

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


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

[User]
RADIOLOGY NOTE:
A 48 year old Irish Caucasian female presented to our Emergency department with a history of central chest pain radiating to her back in an interscapular region. The pain was of sudden onset, with the chest pain resolving spontaneously but the back pain remaining. Of note the pain was associated with shortness of breath, nausea and sweating. Her background history included being a current chronic smoker (30 pack year history), epilepsy (since 16 years old), hypercholesterolemia, depression (post partners death from ischemic heart disease 18 months previous) and a strong family history of cardiac disease. Mediactions at presentation included: Dalamne 30 mg nocté, Efexor XL 150 mg PO BD and Tegretol 200 mg PO BD.
On examination she was noted to have a systolic blood pressure differential of 50 mmHg between her right and left upper limbs and had a weak radial pulse on the left side. The remainder of her examination was normal. All Cardiac bloods were within normal range.
A CT thorax and abdomen were carried out to investigate the principle differential diagnosis of a dissecting aortic aneurysm. This was ruled out and a stenosis in the left subclavian artery was noted. No bruit was audible over the subclavian artery. A differential diagnosis of TA recorded.
Coronary angiography, MRI angiography (Figure ), along with angiography of the great vessels/aorta (Figures ) were carried out and these confirmed the diagnosis of TA. The coronary angiogram showed an occluded PV branch of the left circumflex artery. The ateriogram showed a long segmental left subclavian artery stenosis and a significant stenosis in the origin of the celiac artery Figure .
A treatment regime of intravenous Methylprednisolone 1 g OD for three days followed by Prednisolone 60 mg PO OD for four weeks was commenced, along with Mycophenolate Mofetil 500 mg PO BD, Aspirin 75 mg PO OD, Clopidogrel 75 mg PO OD, Ator

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


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

[User]
RADIOLOGY NOTE:
A 31-year-old male patient presented to our clinic with symptoms of neck pain, back pain (pain in the lower cervical and upper thoracic region), and numbness in both arms for the last 3 months. His physical examination revealed hypoesthesia at the C4 and C5 dermatomes in both arms with no loss of strength. Cervical computed tomography (CT) showed a destructive and compressive lesion in the C4 vertebra corpus (Fig. ). The retropulsion caused by compression had narrowed the canal. The lesion was also seen to be completely wrapped around the vertebral foramen at the right C4 level and to extend to the lateral mass posteriorly in the axial sections on CT (Fig. ). Weinstein, Boriani, Biagini (WBB) classification was used for the classification of the tumor (Fig. ) []. In this case, the tumor was located at the regions 5, 6, 7, 8, and 9 and invaded all the layers except the dura mater. Corpectomy was performed to the C4 vertebra with an anterior approach together with discectomy to the upper and lower disc spaces during surgery. The lesion was seen to extend to the right C4 vertebral foramen in the surgical observation after corpectomy, and the tumor was carefully dissected 360° around the vertebral artery at this level. Once the vertebral artery was revealed, we entered between the mass extending posteriorly to the lateral mass, the spinal cord, and the vertebral artery and performed meticulous intracavitary curettage. In order to ensure stability after tumor excision, the upper and lower corpus endplates were decorticated with the curette. A corpectomy cage was placed into the C4 space, and the system was fixed by placing a plate screw on the upper and lower vertebra from the anterior (Fig. ). There was no additional neurological deficit postoperatively. The patient’s neurological complaints improved during the postoperative period. There was no residual or remaining tumor after resection.

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


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

[User]
RADIOLOGY NOTE:
A 44-year-old woman with a history of metastatic triple negative breast cancer and lung metastases presented with a six-month history of recurrent haemoptysis. She had no other significant medical history. She was initially managed for her right breast cancer with a wide local incision and adjuvant chemoradiotherapy in 2014; however, her malignancy recurred two years later. She had positive margins on subsequent right mastectomy and proceeded to excision of the right pectoralis major and overlying dermis. Six months later she was found to have bilateral pulmonary metastases and underwent initial diagnostic bronchoscopy identifying a bleeding mass in the medial segment of the right middle lobe (RB5), which was subsequently treated with topical adrenaline and biopsied – confirming metastatic disease. Her malignancy progressed despite palliative chemotherapy with epirubicin and cyclophosphamide, during which time she developed worsening haemoptysis of ~1/2 cup (~120 mL) daily. A multidisciplinary decision was then made to perform therapeutic bronchoscopy due to excessive distress caused to the patient because of haemoptysis. She underwent bronchoscopy using a therapeutic video bronchoscope (Olympus BF-TH190, Olympus Corporation, Tokyo, Japan) introduced via a rigid bronchoscope, which provided secure airway access. Endobronchial survey revealed the source of bleeding in the distal right middle lobe, although the actual bleeding source was not directly visible. A volume of 2 mL of TISSEEL was injected into the right middle lobe bronchus via a catheter followed by deployment of a size 6 Spiration (Redmond, WA, USA) IBV to add stability and prevent expectoration (Fig. ). A further 1 mL of TISSEEL was then applied over the valve (Fig. ). The procedure abolished the patient's haemoptysis instantly.
Two weeks later the patient developed recurrent haemoptysis; however, repeat bronchoscopy showed a different source of bleeding in the right lower lobe, with the existing combina

[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 34-year-old male patient with no prior medical history presented at the Emergency Department reporting ingestion of several metallic objects one hour before. The clinical examination was unremarkable, and the patient was in overall excellent condition. X-ray studies revealed at least 4 metallic objects in various parts of the GI tract ().
Considering the timing of ingestion and the type of the ingested materials, endoscopic extraction was decided. Esophagogastroduodenoscopy (EGD) was performed approximately 2 hours after the ingestion. Four objects were visualized at the time of endoscopy (one screw in the first part of the duodenum, one elongated pin impacted in the antrum wall, one coin, and one small metal scrap in the stomach). The coin was easily removed from the stomach using a Roth Net. An overtube was then introduced in order to safely retrieve the remaining 2 larger sharp objects. None of the remaining objects could fit in the overtube, and the patient's tolerance to the procedure was poor despite maximal sedation. No other protective devices such as rubber hoods were available at the time of endoscopy. Therefore, any further efforts to extract the objects were abandoned, and the patient was returned to the surgical ward for monitoring. Recognizing that complication rates could be high in this patient and that referral to another better equipped facility would require time, such that it would expose the patient to the risks of delayed intervention, we improvised a handmade rubber hood, constructed from a plastic transfusion pressure infusor (). This material was chosen because it was flexible enough to invert back on itself in the cardia upon withdrawal of the scope, yet thick enough to withstand puncturing. The hood was fastened with silk tape to the distal end of a 9.8 mm gastroscope (GIF-Q165 Olympus Corporation, Tokyo, Japan), in a coned fashion (to facilitate the entrance of the foreign body into

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


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

[User]
RADIOLOGY NOTE:
A 26-yr-old man, with no other medical history, complained of progressive headache and vomiting for 3 months. A neurological and physical examination revealed no abnormal findings. Laboratory findings including karyotyping were normal.
Computed tomographic (CT) scans demonstrated only asymmetry of the lateral ventricles, with enlargement of the right lateral ventricle (). Subsequent magnetic resonance imaging revealed a large, cystic, nonenhancing lesion with a thin wall in the right lateral ventricle. The cyst contents had the same signal intensity as cerebrospinal fluid (CSF) on MRI ().
The patient underwent endoscopic transventricular cyst resection. The patient was positioned supine with head in neutral position and the thorax elevated 15 degree. A linear incision on the right frontal scalp, parallel to the sagittal suture, was applied to the pericranium. A 15-mm burr hole was placed 3 cm from the midline and just behind the hair line. The dura was incised in cruciate fashion. A 12-French introducer sheath was inserted into the frontal horn of the right lateral ventricle under freehand-guidance. A 2.7 mm rigid telescope was introduced, and the cyst wall obstructing the right foramen of Monro was identified (). An avascular area in the midportion of the cyst wall above the foramen of Monro was chosen for fenestration. The cyst wall was punctured by gentle pushing the tip of the probe. With microscissors and forceps, the cyst wall was opened as widely as possible (). CSF in the cyst was expelled and the foramen of Monro was opened. The shrunken cyst was separated from the ventricle around the foramen of Monro. We drew the margin of opening with forcep carefully. The cyst was removed totally with no resistance (). At that time, subsequent intraventricular hemorrhage was identified, so continuous irrigation of lactated Ringer's solution was done because the bleeding focus could not be found. After identifying no active bleeding, the neuroendoscope was then withdrawn

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


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

[User]
RADIOLOGY NOTE:
A 24 year old man presented with on and off fever and diffuse abdominal pain since one week. He also had constipation, vomiting and abdominal distention since two days.
He was apparently normal a week ago when he developed abdominal pain for which he visited a peripheral hospital. An Ultrasonography (USG) abdomen was done, which revealed the possibility of a mild appendicular inflammation. He was treated with oral antibiotics and analgesics following which his abdominal pain subsided. Few days later he developed abdominal distention and vomiting.
On examination he was afebrile and vitals were stable. Abdomen was soft, distended and non tender. Free fluid was present in peritoneal cavity and bowel sounds were absent. Routine blood investigations were normal except for leucocytosis of 30,400 with neutrophilia. Plain X-ray of abdomen showed dilated jejunal and ileal loops with multiple air-fluid levels. Paracentesis yielded hemorrhagic ascetic fluid. USG abdomen revealed gross ascites and thickened bowel wall with absent peristalsis. Contrast enhanced CT abdomen showed small bowel obstruction and massive ascites.
Meanwhile patient was kept nil per oral with nasogastric aspiration. He was started on prophylactic intravenous antibiotics and analgesics. On reassessment patient's condition remained unaltered. A diagnosis of mechanical intestinal obstruction of unknown etiology was made and he was scheduled for emergency laparotomy.
Abdomen was opened with a midline vertical incision. Three litres of hemorrhagic fluid was drained. Dilated jejunal loops were seen. These loops were traced up to a segment of ischemic ileum. The ileal segment was strangulated by a band composed of inflamed appendix and omentum (Fig &). The band was running from caecum to ileum producing a window underneath. Through this window the intestine had protruded (Fig ).
The attachment of the band was released from the ileum and omentum, following which appendicectomy was done. The bowel was found viabl

[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 man with a 13-year history of coronary heart disease and 7-year history of hypertension was admitted to our hospital for acute onset dizziness and unsteady gait for one week. He reported acute onset of dizziness and difficulty in walking, and these symptoms would become worsened when he got up from the bed or sofa. On admission, his blood pressure was 135/85 mmHg and heart rate was 66 beats/min; and neurological examination revealed nystagmus on horizontal gaze. His pupillary reflexes and extraocular movements were intact, no limb weakness and sensory deficits were found; and bilateral finger--to-nose and heel-to-shin tests were normal. Additionally, bilateral Babinski signs were absent. However, Romberg sign was impossible to evaluate as the patient could not be able to cooperate with further examination.
Similarly, laboratory tests were within normal limits. Brain MRI performed 10 h after admission demonstrated two areas of restricted diffusion on diffusion-weighted imaging (DWI) in the left hemisphere (Fig. b). However, no acute infarction was seen in the posterior cerebral artery territories. Considering the location of infarction area could not well explain his clinical symptoms, a digital subtraction angiography (DSA) was done which revealed that the left ICA was occluded (Fig. a). Meanwhile, it showed that the left middle cerebral artery and bilateral anterior cerebral artery were supplied by the basilar artery via a PTA (Fig. b + c). Based on that we presumed that in the setting of acute left ICA occlusion, a cerebral blood flow steal phenomena occurred from posterior circulation to anterior circulation which caused the patient to have acute onset of dizziness and difficulty in walking. We also speculated that the PTA may play a protective role in preventing the patient from having severe anterior circulation ischemic stroke. Furthermore, CT perfusion showed no remarkable difference between the two hemispheres (Fig. a), which was consistent wit

[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.