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

[User]
RADIOLOGY NOTE:
A 65-year-old man was diagnosed with pulmonary adenocarcinoma, then treated with chemotherapy. The cancer metastasized, and the patient was diagnosed with end-stage lung cancer. Cancer pain was treated with oral opioid therapy. Metastasis of the cancer caused obstructive jaundice and cholangitis, and the patient experienced septic shock. The attending physician performed emergent endoscopic biliary stent placement, in order to treat obstructive jaundice. The patient was medicated with continuous infusion of noradrenaline (0.2 μg/kg/min) through a peripheral vein, in order to maintain blood pressure. He underwent repeated placement of peripheral venous catheters, such that it became difficult to identify adequate peripheral veins for placement and maintenance of indwelling catheters. In the context of this treatment, the patient's congestive heart failure continued, which caused ascites and edema of the lower extremities.
The patient experienced orthopnea and could not sleep at night. The attending physician requested that the anesthesiologists secure a reliable venous line. The anesthesiologists checked the patient's groin and thighs; they excluded the femoral vein as a candidate for central venous access due to massive edema of the thighs. The anesthesiologists attempted to allow the patient to assume the supine or reverse Trendelenburg position; however, these positions caused worsening of the patient's dyspnea. The patient could solely tolerate the sitting position. The anesthesiologists then discontinued attempts to catheterize via the internal jugular and subclavian veins, because of the risk of air embolism during central venous catheterization of the patient in the sitting position.
The right subclavian vein was suspected to exhibit narrowing, based on computed tomography scan images (Fig. ). Thus, the anesthesiologists chose the left arm for insertion of a PICC, and found that the medial brachial vein exhibited sufficient size (diameter 4 mm) to place a PICC

[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 Caucasian 60-day-old male newborn baby came to our observation. His parents complained that he had bleeding gums in his lower and upper jaws, pain in sucking and consequent difficulties in feeding. He was full-term born and his weight at birth was 2900g. His past medical history was not significant.No noticeable findings were recorded during an extraoral examination. The intraoral examination revealed multiple whitish small masses localized on the alveolar ridge of his maxilla and mandible. His mandibular alveolar ridge showed small nodular lesions in the region of the right deciduous canine and left deciduous canine and first molar (Figure
). The size of these masses varied from 3 to 4mm in diameter.
A surgical removal of the lesions was planned in order to solve feeding problems and bleeding.
The excisions were performed in different sessions in order to limit the postoperative discomfort to the baby. All oral surgeries were performed under local anesthesia (mepivacaine 3% without adrenalin) with a 15C scalpel blade. After excision of the cysts a sponge of fibrin was used and the wounds were sutured with resorbable polyglactin suture (Vicryl 4-0; Ethicon, Johnson & Johnson, New Brunswick, New Jersey, USA) that was removed after 10 days.The first surgery involved the excision of two lesions on his left mandibular gum (Figure
).The second surgical session was made after 15 days. The excision of his right mandibular lesions revealed a neonatal tooth. In this step the surgeon decided not to remove it because the tooth incisal margin was below the gingival level and it would not create feeding problems (Figure
). A follow-up visit 30 days after the surgery showed the neonatal tooth eruption and a new maxillary lesion in the deciduous first molar region. A new surgical cyst excision was necessary and, in the same session, the neonatal tooth extraction was performed in order to allow

[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 boy was referred to our hospital for the evaluation of mental retardation due to poor performance at school. The parents gave a history of delayed milestones as compared to siblings and multiple respiratory tract infections. There was no history of visual disturbances, trauma, or central venous catheterization. The patient had two elder sisters, both of whom had no known medical issues. There was no history of mental retardation or sudden cardiac death in the first degree relatives of the mother or father. Physical examination revealed a weight for age and height for age below 3rd centile with a high arched palate, slender extremities, and long thin fingers. “Thumb sign” was positive. No kyphosis or scoliosis was present. Ophthalmological examination revealed bilateral ectopia lentis. Chest examination revealed bilateral basal crepts. Chest radiograph showed a calcified mass in the right hilar region and prominent bilateral bronchovascular markings. The patient underwent contrast-enhanced computed tomography for the evaluation of the hilar mass which was found to be a densely calcified mass in the right atrium with a calcified tail extending into superior vena cava (SVC) and the right subclavian vein. Bronchiectasis was seen in both lungs [Figures and ]. Echocardiography performed subsequently showed a nonmobile right atrial mass adherent to the endocardium with dense posterior acoustic shadowing. The lack of mobility, the absence of myocardial continuity, no relation to foramen ovale, and morphology of the mass, especially the extension into the SVC suggested that the mass represented a calcified thrombus. Coagulation studies showed prolongation of PT and aPTT with elevation of fasting plasma homocysteine (235 μmol/l) and elevated methionine (139.3 μmol/l). Radiographs of his hands showed diffuse osteopenia with long fingers []. Elevated levels of homocysteine may be found in deficiencies of vitamin B12 or folic acid and in other disorders of methioni

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


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

[User]
RADIOLOGY NOTE:
A 35-year-old female presented with an eight-week history of a severe, unrelenting pain in the left palm and radial four fingers, medial forearm, and in the shoulder pain waking her from sleep. The pain was described as dull, crushing, and deep pressure-like and of an extreme severity (8-9/10 on NRS). The pain made the patient sit on the table constantly holding her arm close to her body, keeping it immobile.
Eight weeks ago, she woke up in the morning with a severe pain in her left shoulder and hand and this pain was unlikely any pain she experienced before. The pain worsened at this day and become constant and unrelenting since then and it was heavier at night. A weakness in her left hand progressively developed 2 weeks after the onset of pain. The pain did not respond to medications and physical therapy. A magnetic resonance imaging (MRI) of the cervical spine showed no abnormalities. The electromyography study suggested an incomplete brachial plexopathy.
On examination, a moderate tenderness in the left shoulder with a moderate weakness [manual muscle testing (MMT) grade 3] of the left hand grasping and finger movement was observed. The sensory examination showed patch areas of hypesthesia, paresthesia, and mechanical allodynia to light touch and pressure in her left shoulder, medial forearm, thenar side of the palm and in four fingers which corresponded to the pain sites (). Her NRS at examination was (8/10, NRS) and the pain was more severe at night (9/10, NRS). The MRI of the left brachial plexus showed a diffuse swelling, increased signal intensity, and an enhancement of whole trunks of the left brachial plexus and its divisions suggesting a brachial plexopathy (). There was a marked asymmetrical uptake in the blood pool phase of the three-phase bone scintigraphy () and skin temperature asymmetry on digital infrared thermal imaging ().
After admission for pain control

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


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

[User]
RADIOLOGY NOTE:
A 54-year-old man with a clinical diagnosis of herpetic keratitis had undergone penetrating keratoplasty in the left eye 6 years previously for recurrent keratouveitis, which resolved after periodic treatment with ACV ointment and a topical steroid. The patient had ocular pain and redness in his left eye and periodically received topical antibiotics and a steroid for 1 month; however, the symptoms gradually worsened despite treatment, and he was referred to our clinic. The best-corrected visual acuity in the affected eye was 20/2,000 and the intraocular pressure was 10 mm Hg. Slit-lamp examination showed a small abscess with corneal erosion in the peripheral donor cornea that manifested as a suture abscess with corneal infiltrates, mild ciliary injection, and no anterior chamber inflammation (day 0; fig. ). The sensitivity of the left cornea decreased to 20 mm compared with 60 mm in the right eye. The right eye was normal. The suture at the focus was removed and wide corneal scraping was performed for cytopathologic examination and culturing to detect pathogenic microorganisms such as bacteria, fungus, or Acanthamoeba. Real-time PCR analysis was performed to detect human herpes viruses (HHVs; HSV type 1 or 2, varicella zoster virus, Epstein-Barr virus, cytomegalovirus, and HHV-6, −7, and −8) [, ]. Only Candida albicans was identified by culturing.
The patient was diagnosed with fungal keratitis and treated with topical 0.2% fluconazole hourly and 1.5% topical levofloxacin 3 times/day for 2 weeks. The ocular pain gradually decreased and the lesions slowly improved (day 14; fig. ). However, the lesion recurred and increased, showing a similar clinical appearance despite the same antifungal treatment (day 21; fig. ). Because of the unresponsiveness to the antifungal agent, a second corneal scraping was obtained to repeat the same microbiologic examinations. Light microscopy and the cultures were negative for pathogens including C. albicans. The PCR results were positiv

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


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

[User]
RADIOLOGY NOTE:
A 28-year-old man presented to our clinic three days after his first episode of vertigo. The patient was suffering from frequent episodes of severe spinning vertigo with mild nausea; each episode lasted for a few minutes. The patient complained of a severe whirling sensation with a clockwise direction during the ictus, and experienced a dull headache after the ictus. The patient reported that he did not suffer from agoraphobia, panic symptoms, or any recent stressful conditions. Nor was the ictus accompanied by ear symptoms, such as tinnitus, hearing loss, or aural fullness, and there were no other symptoms, such as paresthesia, motor deficit, or visual disturbances, including field defect, metamorphopsia, or color change. His symptom was not predictable and occurred without any position change. The patient did not lose consciousness during the onset of the symptom, and his family members had not witnessed any eyeball deviation or head turning during the episodes. The patient had no history of motion sickness or migraine. However, he had undergone an operation in the left cerebral hemisphere for the treatment of Moyamoya disease (encephaloduroarteriosynangiosis, EDAS) 3 years ago. Brain MRI revealed the presence of an osteoplastic craniotomy scar in the left lateral convexity (). No nystagmus was observed and his symptoms were not evoked by the hyperventilation maneuver. The patient showed bilaterally symmetrical saccade and smooth pursuit. A cerebellar function test was normal and a caloric test and audiometry showed normal responses. We assumed that the ictus was a manifestation of vestibular epilepsy. Therefore, the patient was admitted to the Epilepsy Monitoring Unit (EMU). He was monitored continuously for 24 hours a day with video and computerized EEG equipment. However, the episodes of vertigo were not accompanied by any significant EEG changes, such as sharp waves and spikes. Therefore, we suspected that the episodes might be psychogenic dizziness. The patie

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


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

[User]
RADIOLOGY NOTE:
A 55-year-old Asian man presented with increasing neck pain and numbness of the upper extremities over the previous three months. These symptoms were exacerbated by coughing and over stretching. Six years before admission to our hospital, he had suffered a traffic accident and had sustained a spinal injury with complete paraplegia. Magnetic resonance imaging (MRI) studies at that time demonstrated a burst fracture of the L1 vertebral body with severe contusion of the spinal cord. The patient underwent a posterior fusion followed by six months of rehabilitation. He reported a definite improvement in pain sensation but remained wheelchair dependent.
Five years later, he presented with chest tightness. An MRI study revealed the presence of a syringomyelic cavity of the cord extending to the thoracic level. A T4-5 laminectomy and syringo-pleural shunt were performed in another hospital and our patient experienced a brief and intermittent improvement in chest discomfort.
On admission to our hospital one year later, neurological examinations elicited grade III muscle strength in both upper extremities. Deep tendon reflexes were pathologically brisk in all four limbs. MRI studies of the whole spine revealed the presence of a large syrinx extending to the medulla (Figure ).
It is likely that syrinx recurrence after the previous shunt procedure was related to shunt malfunction; moreover, it was difficult to identify any unscarred subarachnoid space. Thus, we designed a syringo-fourth ventricle shunt for this case. This procedure facilitated re-establishment of cerebrospinal fluid (CSF) flow dynamics by avoiding cord injury and damage to spinal bony structures. To the best of our knowledge, there are no previously published accounts of this procedure.
Our patient was placed in the prone position with a rigid pin-type head-holder. Suboccipital craniectomy and a partial laminectomy of C1 were performed. A Y-shaped incision was used to open the dura, and the arachnoid membrane w

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


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

[User]
RADIOLOGY NOTE:
The patient, a 58-year-old man, was referred for evaluation and management of the left jaw joint during hospitalization in the Division of Otolaryngology due to an outbreak of malignant external otitis on November 6, 2012. He began treatment in otolaryngology mainly due to running ears. However, since his condition did not improve, incision and drainage of the left jaw joint were performed after hospitalization. Later, as the patient’s condition threatened to deteriorate after pharmacological treatment at another ENT hospital, he was sent to our tertiary care hospital for treatment. His medical history included diabetes that had resulted in diabetic neuropathy.
Clinical examination of the patient revealed pain in the left jaw and mouth-opening deflection to the left. The maximum active mouth opening was measured to about 27 mm, which limitation was due to continuous pain. Tender points in the left temporalis muscle and left jaw joint were noted.
Panoramic radiographs revealed bone resorption patterns in the left condyle (Fig. ). CT scans and cone beam computed tomography (CBCT) of the temporal bone showed the same patterns (Figs. and ). MRI findings revealed the left temporomandibular joint to be surrounded by thickened soft tissue (Fig. ); T2-weighted imaging, meanwhile, showed effusion in the left mastoid air cell (Fig. ). Based on the thickening of the external auditory canal epithelium (Fig. , ), contrast-media imaging of diffusion with increased patterns around the thickening region, as well as discharge in the mastoid process, the patient was provisionally diagnosed with malignant external otitis, mastoiditis, and arthritis of the left temporomandibular joint. After treatment of the lesion by incision and drainage of the left jaw joint in the Department of Otorhinolaryngology, arthrocentesis and occlusal stabilization appliance therapy were carried out. Due to severe inflammation in the joint space, the arthrocentesis with lavage was performed twice. According

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


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

[User]
RADIOLOGY NOTE:
A 55-year-old Caucasian woman presented to our hospital with a new onset dyspnea on exertion, lower extremity swelling, and orthopnea. Her electrocardiogram (ECG) showed sinus rhythm and a complete LBBB. She underwent a transthoracic echocardiogram (TTE) that revealed left ventricular (LV) enlargement and severe LV systolic dysfunction. She had no history of hypertension or alcohol abuse, and the results of her serology evaluation were negative for Chagas. A multislice computed tomography scan showed no lesions in the coronary arteries. She was diagnosed with idiopathic dilated cardiomyopathy.
Pharmaceutical treatment was initiated and optimized to reach the target doses of carvedilol, enalapril, spironolactone, digoxin, and furosemide. While the patient showed clinical improvement, she remained symptomatic after several months of optimized doses of these treatments. She subsequently experienced clinical worsening, remaining in New York Heart Association (NYHA) functional class III to IV. She was then admitted for implantation of a biventricular pacemaker.
During hospitalization, she showed rapid clinical improvement after reversal of the LBBB. An ECG showed sinus rhythm and a QRS complex interval of 110 ms. The medical team opted for not implanting the pacemaker at that time.
However, the patient returned 10 days later, presenting with clinical deterioration in NYHA functional class III. The ECG showed LBBB once more. She also brought the TTE performed on the day of discharge revealing LV enlargement with LV end-diastolic dimension of 67 mm, LV end-systolic dimension of 61 mm, LV end-systolic volume of 155 ml, an ejection fraction (EF) of 19% (by Simpson’s method), and Grade III diastolic dysfunction. We also noted a wide QRS complex in the ECG signal obtained during the TTE. Implantation of a biventricular pacemaker was scheduled.
The implantation of the biventricular pacing was performed uneventfully, with the LV lead positioned through the coronary sinus in 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 31-year-old man experienced sudden onset of abdominal pain and tenderness in the right hypochondrium. There was no history of trauma, and no history of significant disease in the past. He underwent laparotomy at a primary health care centre, owing to a misdiagnosis of ruptured liver abscess with peritonitis. On exploration, hemoperitoneum with active bleeding from the liver surface was found. Due to lack of diagnosis of the possible cause of bleeding, perihepatic packing was done with sponges, and the patient was referred to our tertiary care institute. The patient received three units of packed cells prior to shifting to our center. On arrival, patient was pale and in hemorrhagic shock. The blood pressure was 76/50 mmHg, pulse was 124 beats per min and feeble. Abdomen was distended and diffusely tender. Laboratory investigation revealed hemoglobin of 6.8 g/dl, hematocrit 26%, and high transaminase levels. After initial resuscitation with intravenous fluids and packed red blood cells (RBC), the patient underwent a contrast enhanced computerized tomography (CECT) scan on a spiral computerized tomography (CT) scanner. CT scan demonstrated a peripherally enhancing lesion in right lobe of liver, located in segments VI and VII []. The largest dimension of the lesion was 11 cm in the craniocaudal direction, and transverse and antero-posterior measurements were 9.7 and 7.3 cm respectively. The site of rupture was clearly seen as a rent in the enhancing margin of the lesion at the postero-superior aspect [ – arrows]. On delayed scans, the lesion showed characteristic centripetal filling-in of contrast, typical of a hepatic hemangioma, with a small central non-enhancing fibrous scar []. Delayed images also revealed hyperdensity tracking along the liver surface and settling in the dependent part [], indicating the presence of active contrast extravasation. There were associated hemoperitoneum and mild bilateral pleural effusions. Remnant liver parenchyma was normal with no

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


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

[User]
RADIOLOGY NOTE:
A 19-year-old male patient presented to our hospital in July 2019, with complaints of abdominal pain and vomiting for the last 15 days.
The patient had a history of recurrent abdominal pain for the last two years. Each episode was characteristic of severe central abdominal pain along with vomiting. He had multiple admissions as a result of these episodes. Detailed inquiry and checking of previous records revealed that these episodes were a result of recurrent attacks of acute pancreatitis. Each episode was characterized by markedly elevated levels of serum amylase and lipase, and imaging studies in the form of ultrasound and contrast-enhanced CT of the abdomen revealed a swollen pancreas and peripancreatic fluid collection. His imaging two years back revealed gallstones as well. Last year, he underwent endoscopic retrograde cholangiopancreaticography (ERCP) which showed gallstones and common bile duct (CBD) stones. Biliary stone removal and sphincterotomy were performed during the ERCP procedure. It was followed a few weeks later by laparoscopic cholecystectomy. He remained symptom-free for a few months. However, he again suffered from two further attacks of pancreatitis and underwent ERCP again which did not reveal any bile duct stones.
Now, the patient presented to our department with complaints of severe central abdominal pain and vomiting for the last two weeks. The pain was of moderate intensity with radiation to the back. The pain was only relieved by taking narcotic painkillers. He also had multiple episodes of vomiting associated with food intake. There was no blood in his vomitus. The patient denied intake of alcohol, illicit drugs, or any type of alternative form of medicine. There was no history of trauma, insect bite, other procedures (apart from those mentioned above), headaches, altered level of consciousness, fever, cough, altered bowel habits, jaundice, skin rashes, or abdominal distension. He had lost around 10-kg weight in the last two years. Both

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


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

[User]
RADIOLOGY NOTE:
We present a 20-year-old female with athletic constitution in good health condition. She suffered trauma caused by an accident during skiing, where she jumped over a small hill border and landed in a small pit on the slope. The traumatic mechanism of the accident was a ventral-lateral (right side) collision with the solid iced slope in knee and hip flexion at intermediate speed.
According to the patient’s narrative, she was never unconscious, but immediately felt strong pain in her right upper and lower extremities after trauma. Clinical examination of the peripheral extremities showed no signs of neurological or vascular trauma.
The patient was hospitalized via flying ambulance to the closest surgical-trauma department shortly after. At admission to the hospital, clinical examination and conservative X-rays in two planes showed a posterior dislocation of the right hip (Thompson–Epstein Grade I), but no signs of fracture. Additionally, X-rays in two perpendicular planes of the right forearm were performed, showing a combined radial and ulnar fracture. The fracture was splinted with split plaster cast of the right arm. The dislocation was treated by joint reduction (Böhler’s technique) under general anaesthesia. The procedure took place around 2 hours after trauma and was performed by a trauma surgeon. A CT scan of the hip was performed afterwards (, ), indicating an acetabular fracture line without any dislocation and consequently needing no further surgical treatment. After one night of medical surveillance, our patient was discharged from hospital with treatment recommendations to use underarm crutches and to consult the nearest trauma department for surgical therapy of the forearm fracture after returning back home. Regarding pain management, the patient received a prescription for non-steroidal anti-inflammatory drugs as prn medication.
Since it was not possible for the patient to handle crutches with her fully casted right arm, she visited the nearest trauma am

[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 female with no significant past medical history presented to the emergency department in November of 2017 with complaints of arthralgias, most notably in her right knee, left shoulder, and bilateral thighs that made it difficult for her to ambulate. She was also admitted due to a headache that was triggered primarily by coughing. Vital signs on admission were as follows: a blood pressure of 202/90 mmHg, a heart rate of 137 bpm, a respiratory rate of 20, and a temperature of 36.6 Celsius. Physical exam revealed Janeway lesions. She was found to have a neutrophilic leukocytosis, with white blood cell count at 20.4 cells/mm3 and neutrophils at 17.4 bil/L. Troponin was elevated at 1.85; this was deemed to be noncardiac in nature as the patient's pain was relieved with ibuprofen and her EKG showed no acute findings. ESR and CRP were elevated at 95 mm/hr and 24.8 mg/dL, respectively. A computed tomography of the brain showed a high-density mass in the right occipital lobe, with surrounding vasogenic edema. The patient continued to deny any visual changes or symptoms other than what was discussed above. An ophthalmologist was consulted to perform a dilated fundus exam, which was positive for small intraretinal hemorrhages that were deemed to be secondary to the patient's hypertension and less likely positive for Roth's spots. There was no evidence of disc edema. A brain MRI with and without gadolinium showed multiple small punctate bilateral areas of acute or subacute infarctions indicative of embolic phenomenon. The hemorrhagic area in the right occipital lobe was again identified, with subtle surrounding enhancement; the differential diagnosis consisted of neoplasm, vascular malformation, or embolic infarction with hemorrhagic conversion. A transthoracic 2D echo was without vegetation, so a transesophageal echo was ordered, and vegetation was shown on the posterior leaflet of the mitral valve. Two blood cultures from admission then

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


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

[User]
RADIOLOGY NOTE:
A 44-year old male was referred following investigation for chest pain and dyspnoea. He had no pre-existing co-morbidities. Physical examination revealed feeble femoral pulses and he was found to be hypertensive with marked differences between the upper and lower limbs (systolic blood pressure upper limb 190mmmHg, lower limb 75 mmHg, with an ankle brachial index (ABI) of 0.39). Electrocardiogram revealed evidence of severe left ventricular hypertrophy. This was confirmed with echocardiography which also demonstrated a tricuspid aortic valve with significant aortic regurgitation in the presence of an aortic root aneurysm of approximately 9 cm. Left ventricular function was preserved. Computerised tomography angiography (CTA) was performed to evaluate the aortic pathology in further detail (Fig. ). The scan noted an aortic root aneurysm (8.8 cm), in addition to the presence of severe aortic coarctation, with subtotal occlusion and a lumen less than 6 mm in size. The coarctation was just distal to the left subclavian artery, at the aortic isthmus. There was clear evidence of collateral circulation to the descending thoracic aorta via the subclavian and intercostal arteries. Coronary angiography confirmed a right dominant coronary system with no significant coronary disease.
A multidisciplinary team meeting took place and a consensus was agreed to proceed with a two staged hybrid approach, with the first phase involving an endovascular approach to stent the coarctation, followed by a second stage to perform the surgical repair of the aortic root aneurysm. The first stage to stent the coarctation was unsuccessful via the femoral approach, as the guidewire could not cross the coarctation. Assessment through angiography via the left brachial artery showed complete obstruction at the aortic isthmus. The decision was then made to proceed to a single stage surgical approach to treat both lesions.
After induction of anaesthesia, arterial lines were placed in the left radial an

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


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

[User]
RADIOLOGY NOTE:
A 46-year-old woman of Greek ethnicity was admitted to the emergency room at our institution because of a retrosternal pain episode 90 minutes before admission that lasted approximately 10 minutes. Additionally, the patient reported two transient episodes of chest pain during the previous 24 hours. The duration of each episode was estimated to be between two and ten minutes, and spontaneous resolution was reported. During these episodes, the symptoms included chest discomfort with radiation to the back, malaise, nausea and sweating. Our patient had no prior history of cardiac disease, coagulation disorders or drug abuse, and she mentioned only one cardiovascular risk factor (smoking). From her medical history, we found that she is a heterozygous carrier of β-thalassemia. She reported having gastric sarcoma with metastatic peritoneal infiltrates. We had performed a subtotal gastrectomy on her for this reason 2 months prior to her current presentation. Treatment with oral capecitabine (1500mg twice daily) was initiated 48 hours before she was admitted to our hospital. The echocardiogram taken in the emergency room was within the normal limits, including a sinus heart rate of about 62 beats per minute (bpm) and physiological hemodynamic parameters and negative biochemical markers for myocardial necrosis (including cardiac troponin I (CTnI), creatine phosphokinase, creatine kinase isoenzyme MB, lactate dehydrogenase, and serum glutamic oxaloacetic transaminase). She was transferred to the coronary intensive care unit (ICU) for further observation. The echocardiogram, which was performed when the patient was pain-free, revealed normal ventricular volume, no segmentary wall hypokinesia with a left ventricular ejection fraction of 72%, normal diastolic heart function, normal valve flow and absence of pericardial effusion (Figure ). Taking into account the patient’s Thrombolysis in Myocardial Infarction score for unstable angina, which was very low, she continued taking cap

[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 one-year-old Thai boy was referred to Phramongkutklao Hospital due to subacute fever, abdominal distension, mucous diarrhea, and failure to thrive. He was born at term with uneventful pregnancy, and he is the first child of nonconsanguineous parents. There was no history of autoimmune or primary immunodeficiency disorders in the family. Intradermal BCG vaccination was inoculated at the left buttock without any reaction within 3 months of life, and intramuscular vitamin K was routinely given after birth. He was exclusively breastfed. At 3 months of age, he developed frequent vomiting and irritability. Physical examination revealed enlarged and tense anterior fontanelle. CT brain showed hyperdensity lesion size of 1.5 × 1.8 cm at left temporal lobe with perilesional edema () which was confirmed to be intracerebral hemorrhage. All hematologic, coagulation studies and biochemical laboratory tests () were consistent with deficiency of vitamin K dependent clotting factors. The cause of vitamin K deficiency in this patient was presumed to be caused by malabsorption mechanism. Therefore, intravenous vitamin K was given for 3 days at initial presentation, and the coagulogram data was corrected within 24 hours. One week later, the patient developed steatorrhea. Fat malabsorption was suspected as the levels of fat-soluble vitamins were evaluated (). Cystic fibrosis was excluded by the negative sweat chloride test. At 4 months of age, perianal abscess was detected and treated with amoxicillin/clavulanic acid for 7 days without surgical drainage. However, subsequent pus culture was not performed. At the age of 6 months, lymphadenopathy of 3 cm in size at the left groin was detected. Fine needle aspiration was accordingly performed, and pus culture was found to be positive for BCG and the tuberculin skin test was positive at 15 × 20 mm. Chest X-ray revealed no pulmonary infiltration. The patient was diagnosed with BCG lymphadenitis and was treated with isoniazid and rifampicin.

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


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

[User]
RADIOLOGY NOTE:
A 28-year-old Caucasian woman presented to our Emergency Unit with a short history of progressive shortness of breath and a swollen right arm. She had previously been in good health with no medical history of note but was just recovering from a severe upper respiratory tract infection, which had caused her to be unwell in bed for several days. Aside from the oral contraceptive pill she took no regular medication and had no family medical history of note.
Initial investigations with a Doppler ultrasound of her right arm and axilla demonstrated a deep vein thrombosis in the right subclavian vein with extension into the proximal internal jugular vein. A computed tomography scan confirmed the presence of the right axillary vein thrombus and the pulmonary embolus and a large right pleural effusion as shown in Figure . Despite these findings, the patient was hemodynamically stable and after review by the vascular surgery team the decision was made to manage with anticoagulation rather than thrombolysis. The initial imaging also demonstrated enlarged lymph nodes, without the normal fatty hilum, in the mediastinum and right supraclavicular fossa. The imaging of the patient’s abdomen and pelvis demonstrated a mixed echogenicity 13.5cm left adnexal mass situated between the sacrum and the anterior abdominal wall shown in Figure .
The tumor markers performed at presentation demonstrated normal values for both hCG and AFP whereas the CA-125 level was moderately elevated at 368U/mL (normal range 0 to 35). The initial management centered on the treatment of the pulmonary embolus with anticoagulation and the insertion of a prophylactic inferior vena cava filter. The differential diagnoses at this stage included: epithelial ovarian cancer, an ovarian germ cell tumor, an ovarian sex cord-stromal tumor or an atypical Meigs syndrome.
After a week of anticoagulation treatment, a laparotomy was performed which demonstrated a large left ovarian mass with ascites but no other abnormal fin

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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 30-year-old female reported to Department of Oral Medicine and Radiology with a chief complaint of swelling in left lower back tooth region since 1-year. History revealed that patient had undergone extraction of mobile teeth in the same region, 1½ years back. After 5–6 months of extraction, she noticed a swelling in the same region. The swelling progressively increased in size and was associated with mild intermittent pain in left ear. There was no history of pain or any pus discharge in the associated area. Her past medical and family history was noncontributory. Extra-orally, mild facial asymmetry was noticed on the left side of face near the angle and ramus of the mandible. On palpation, a hard nontender swelling measuring approximately 2 cm × 2 cm was evident on left lower third of face extending from mid body of the mandible to 1 cm anterior to angle of the mandible. On intraoral examination, lower left molars were missing. Mucosa over the alveolar ridge was normal in color and texture. On palpation, 3 cm × 2 cm hard, nontender expansion of buccal and lingual cortices was evident extending from region distal to lower left second premolar up to the anterior border of ramus of mandible with obliteration of the lower buccal sulcus [].
Panoramic radiograph presented a multilocular radiolucency involving the left side of the mandible []. Computed tomography (CT) revealed a well-defined expansile lytic lesion involving left angle and ramus of mandible with associated thinning of the cortices and breach in the lingual cortex of left ramus of the mandible [Figures and ]. Contrast magnetic resonance imaging (MRI) showed that lesion was heterogeneously hyperintense on T2-weighted images, isointense on T1-weighted images with heterogeneous enhancement on contrast. Minimal soft tissue extension was noted along the floor of the mouth abutting the left mylohyoid muscle. The left inferior alveolar nerve (

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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 75-year-old man was referred to our hospital for abdominal fullness and nausea since 2 months. He had a medical history of hypertension and hyperlipidemia and a surgical history of the right inguinal hernia. The patient's laboratory findings were within normal limits. Abdominal computed tomography (CT) revealed a well-demarcated oval isodensity mass of 25 mm at the tip of his appendix. Contrast-enhanced CT revealed a lesion with gradual homogeneous contrast enhancement from the arterial phase to the equilibrium phase (). No abnormal findings were found in the root to the middle of the appendix. Abdominal ultrasonography (US) revealed a well-demarcated hypoechoic tumor. The tumor size was 22 mm × 18 mm × 18 mm, with some cystic area and blood flow (). Colonoscopy findings were normal. The patient's symptoms naturally alleviated during examination period.
Preoperative diagnosis indicated appendiceal neuroendocrine tumor (NET) G1 or gastrointestinal mesenchymal tumors, such as GIST. Malignancy could not be ruled out; therefore, laparoscopic ileocecal resection with D3 lymph node dissection was recommended. Intraoperative findings revealed a well-demarcated tumor at the tip of the appendix, with no invasion into the surrounding tissue. This observation was similar to the preoperative imaging findings. According to another intraoperative finding, dissecting the adhesion between the terminal ileum and the peritoneum, which was the effect of the past herniorrhaphy, was necessary. The operation time was 167 min, and the amount of blood loss was 100 ml.
Pathological findings revealed a well-demarcated tumor originating from the muscular layer at the tip of the appendix and spindle-shaped heterotypic cells proliferating in a bundle. Vascular invasion and lymph duct invasion were not detected. No tumor cells were found in the dissected lymph node. Immunohistochemical studies revealed negative values for KIT and CD34 and positive values for S-100 protein (), which confirmed t

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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:
Mr. P D, a 63-year-old male, presented to the emergency room in mid-December with chief complaints of new onset of severe pain in his neck, right chest wall (corresponding to the fifth and sixth intercostal spaces) and right arm, and weakness in both lower limbs. The intensity of pain was a constant 10/10 on the numeric rating scale, not responding to intramuscular injections of diclofenac or tramadol at home. He was a known case of locally advanced nonsquamous cell lung cancer (adenocarcinoma), despite having undergone surgical resection of the tumor, chemotherapy, and radiation earlier. Comorbid illnesses included interstitial lung disease, for which the patient was on oral prednisolone 15 mg/day. Neurological examination revealed spastic paraparesis (power grade 2/5 in both lower limbs) with a flexor response on bilateral plantar reflexes. Bilateral upper limb motor power was grade 3/5. He was admitted under the care of his primary critical care physician. Magnetic resonance imaging (MRI), done in view of the symptoms, revealed the right Pancoast's tumor infiltrating the chest wall, right brachial plexus, and T1, T2, and T3 vertebrae. There was contiguous infiltration of the vertebral body and posterior elements with enhancing circumferential soft tissue extending the foramina and epidural space resulting in cord compression with intramedullary edema. The emergency neurosurgery team was called in for an opinion, and they ruled out surgery because of the advanced disease status of the patient. He was started on an infusion of injection fentanyl at 25 mcg/h. Dexamethasone 8 mg was started twice a day after admission. Fentanyl was escalated to 50 mcg/h and to 80 mcg/h in a day's time by the primary team for his uncontrolled pain. He continued to have breakthrough pain despite this. Owing to his uncontrolled pains, the pain management team was called in, which increased his doses for breakthrough pain by starting intravenous (i.v) morphine 10 mg every

[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:
The first patient is a young woman, 20 years old at the time of diagnosis of a synovial sarcoma that originated from the soft tissue of the left hip. The neoplastic mass was surgically removed in May 2012, and the histological examination showed a synovial sarcoma with close surgical margins. Consequently, adjuvant chemotherapy with Doxorubicin and Ifosfamide was administered for a total of six cycles. During follow-up, in February 2015, the CT scan showed almost 15 nodules in the lung ranging from 5 to 10 mm (). In the same month the patient started therapy with Trabectedin at the dose of 1.5 mg/m2 every 3 weeks. The first radiological evaluation in April 2015 showed a dimensional reduction of all the lung nodules (). The patient continued the therapy, and in July and October 2015 the CT scan confirmed the partial response of the lung lesions.
In February 2016, after 16 cycles, the patient developed hematological toxicity with thrombocytopenia G2 and neutropenia G2. From the 17th cycle the dose was reduced to 1.2 mg/m2 (80% of the expected dose). In June 2016, after 20 cycles, the CT scan still showed stable disease. The patient asked for a therapeutic pause in order to complete her university studies and recover from the treatment's toxicity. Therefore, she started a follow-up program with a CT scan every 3 months.
In September 2017 (13 months after last dose) two lung nodules appeared to be increasing. After a multidisciplinary discussion with dedicated surgeons and radiotherapists it was decided to treat the two lung lesions with stereotactic radiotherapy. The treatment was well-tolerated. However, 6 months later, in March 2018 the radiologic findings showed disease progression with multiple, new lung metastases (). In April 2018, after a new multidisciplinary discussion, it was decided to restart systemic therapy with Trabectedin. The subsequent radiological evaluations in July and October 2018 showed stable disease with signs of response in some nodules (). Th

[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 23-year-old male was brought to our hospital following a motor vehicle accident. He was conscious and obeying commands. His oxygen saturation was 100%, with 4L of oxygen by mask. He was normotensive and had a respiratory rate of 24/min. His abdomen was soft with no external injuries. Primary survey revealed injury to the right shoulder and both lower limbs. An initial computed tomography (CT) scan revealed a large retroperitoneal hematoma, and active contrast extravasation was noted in the retroperitoneum adjacent to the bare area of the liver and right adrenal gland. Hemoglobin significantly dropped (from 9 g/dL to 5.8 g/dL) after 48 h, along with severe tachycardia (135–140 beats/min). There was a mild drop in blood pressure to 90/60 mmHg and an increasing requirement of oxygen. However, during this period, his sensorium was normal, urine output was adequate, and the abdomen was soft with audible bowel sounds. A repeat CT scan of the abdomen revealed an increasing retroperitoneal hematoma with persistent active arterial contrast extravasation into the retroperitoneum. As there was coexistent liver injury, the bleed was initially attributed to laceration of the bare area of the liver; however, the exact injured vessel could not be identified. Careful analysis of CT images revealed the site of origin of bleed to be below the liver with no contrast extravasation from any of the hepatic arterial branches. As the patient was becoming unstable with further drop in hemoglobin, an urgent multidisciplinary team discussion involving surgeons, interventional radiologists, and emergency physicians was convened. As per the decision, the patient was taken for digital subtraction angiography to identify the source of active contrast extravasation in the retroperitoneum. Angiography of the hepatic, lumbar, intercostal, and renal arteries was done. Right renal angiogram revealed aberrant origin of the right inferior phrenic artery []. A posttraumatic aneurysm was seen in the adr

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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 66-year-old female presented to The Affiliated Tumor Hospital of Zhengzhou University (Henan, China) with a firm, immobile, painless and slow-growing mass of the right medial thigh that had been apparent for seven years. One week prior to treatment, the mass became intermittently painful and the movement of the right knee joint was limited. A physical examination revealed a 10-cm firm, immobile and tender mass in the right medial thigh. The temperature and color of the local skin of the mass were normal. The right knee joint was restricted to a 90° flexion, but the muscle strength and sensation of the lower limbs was normal. X-rays revealed a high-density lesion of 10 cm in diameter in the medullary cavity and around the cortical bone of the inferior femur (). Computed tomography (CT) revealed an inhomogeneous soft-tissue mass in the posterolateral and deep layer of the hamstrings in the right inferior femur. Calcifications were apparent as multiple small flecks; however, there was no definite boundary of the calcifications. The lesion invaded the medullary cavity and the cortical bone (). Emission-CT (ECT) revealed an abnormal radioactive distribution as a mass in the right inferior femur (). MRI revealed an irregularly-shaped, expanding lesion in the right inferior femur. The lesion had a low signal intensity on T1-weighted images, which was similar to the muscle tissue, and an inhomogeneous hybrid signal area on T2-weighted images, including a small area of high signal intensity in the area of low signal intensity (). Bone cortex dissolution and a periosteal reaction due to new bone formation were detected locally. A 92×99×96-mm mass was identified in the posterolateral section of the lesion. The mass adhered to the biceps femoris and was adjacent to the popliteal artery and vein, but no invasion to the knee joint cavity was observed. Following an open biopsy, the mass was confirmed to be a desmoplastic fibroma

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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 20-year-old woman was admitted to the ophthalmology department with progressive bilateral upper eyelid swelling for 6 months. She had no other symptoms related to her eyes. A physical examination revealed dry mouth and nasal congestion. She had a history of triamcinolone (Nasacort) nasal spray usage for nasal congestion for nine months. Her family history was unremarkable. Her best corrected visual acuity was 10/10 in both eyes. The only pathologic finding identified through slit-lamp biomicroscopy was the presence of bilateral, symmetrical, solid, lobular masses in the lateral upper eyelids at the location of the lacrimal glands (). There was no proptosis. The patient’s dilated fundus examination was unremarkable. Intraocular pressure was measured as 16 mmHg in both eyes. Pupillary response to light and eye movements was normal. The result of a Schirmer test without anaesthesia was 1 mm/5 minutes in both eyes.
Skin examination revealed subcutaneous nodules in the scalp. Upon systemic examination, the bilateral parotid and submandibular glands appeared swollen (). Magnetic resonance imaging (MRI) of the orbit revealed involvement of the superior eyelids and the anterior orbit and bilateral symmetrical diffuse enlargement of the lacrimal glands with an isointense signal intensity relative to muscle on T1-weighted images and a hypointense signal intensity on T2-weighted images (). On MRI, the maximum and minimum thicknesses of the lacrimal glands were 11 mm and 7 mm, respectively. Parotid and submandibular glands were evaluated with ultrasound and MRI. Neck ultrasonography showed heterogeneous and hypoechoic areas in the parotid and submandibular glands bilaterally. MRI of the neck showed bilateral cervical lymph nodes of pathological size and bilateral enlargement of the parotid and submandibular glands with a heterogeneous appearance. For definitive diagnosis, a lacrimal gland biopsy was taken from the orbital lobe using an upper lid crease incision. Microscopic e

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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 35-year-old woman with no past medical and surgical history presented to the emergency department with severe colicky right flank pain radiating to right lower quadrant. The patient reported that the pain started two weeks previously and had been worsening since the last few days.
A complete history was taken and physical exam performed, along with comprehensive laboratory and radiological evaluation. Elevated white blood cell (WBC) count with borderline renal function was noted, and an abdominal computed tomography (CT) was done without intravenous contrast (Figure ). This demonstrated a calcified 1.5 cm mass next to anterior aspect of right psoas muscle, which was misdiagnosed as possible ureteral calculus, and a presumed diagnosis of obstructive uropathy was established.
After the diagnosis was made, the patient was admitted to the urology service, actively resuscitated with fluids, given pain medication, and observed. She deteriorated during the course of admission with increasing fever, chills, and worsening pain. We obtained repeat blood work along with the cultures from blood and urine, and the patient was immediately taken to the operating room for cystoscopy, retrograde ureterography, and ureteral stenting as a temporary measure of managing obstructive uropathy. The patient was taken to the operating room where cystoscopy revealed orthotopic ureteral orifices with unremarkable bladder architecture. An intraoperative stent was placed, and fluoroscopic examination revealed the presence of extra-ureteral lesion with calcification and the absence of any filling defect. The ureter ran medial to the calcification, and the J stent was left in situ. She was informed of her findings and was advised to have further investigation and management by excisional biopsy. However, the patient left the hospital against medical advice.
She returned to the emergency room after three months, complaining of persisting right flank pain that was on and off, and was subsequently

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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 66-year-old otherwise healthy female, presented to the emergency department with 2-week duration of neck pain. The patient experienced sudden onset of neck pain since her head was forcibly jolted during a religious ritual. Her examination by the emergency department revealed a head tilt to the left side with no neck tenderness. She was neurologically intact.
A computed tomography (CT) scan of the cervical spine was conducted to rule out a fracture which was preliminarily reported to have widening of the atlantodens interval (ADI) measuring approximately 6 mm (normal less than 3 mm) (). No fracture was noted and overall alignment was normal. As examination findings (ADI excluded) were found to be normal, the patient was discharged with advice to return if any worsening symptoms.
The following morning, the CT scan was reviewed by the radiologist attending who found significant rotation of C1 on C2 with almost complete loss of articular contact involving the right side (). These findings are compatible with a type II AARS as per the Fielding and Hawking classification requiring prompt spine consultation. In addition to this, there was gapping on the left C1–C2 articulation and compression on the right side (). The image impressions were relayed to the emergency department and the patient was contacted to present herself to the emergency department for reassessment as soon as possible.
After the patient’s arrival to the emergency department, she was promptly referred to the orthopedic spine service. The spine team physical examination showed that the patient had torticollis with her neck tilted to the right side and rotated toward the left side. She had mid line tenderness on palpation of the posterior cervical spine. Her active and passive range of motion was restricted secondary to pain. The patient’s motor and sensory examination was unremarkable and she did not have upper motor neuron lesion signs. The patient was admitted for conservative management with head hal

[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 57-year old male presented to the emergency room with high grade fever and chills.
The patient was known to suffer from metastatic colon cancer. Following positive occult blood in his stool he was diagnosed in 2010 with colonic adenocarcinoma, involving the cecum, without any evidence of distant metastasis. A laparoscopic right hemicolectomy was performed. His final pathology revealed a T3N1 tumor. He received a FOLFOX adjuvant systemic chemotherapy.
The patient recovered well and proceeded with standard regular oncologic follow up including interval abdominal CT and PET scans as required.
About 3.5 years after the index operation several new lesions, suspicious of secondary spread were revealed. A lesion in the upper lobe of his right lung was resected thoracoscopically. Another lesion caused a significant obstruction of the right kidney that resulted in nephrostomy tube insertion.
The patient was offered a cytoreductive surgery with heated chemotherapy (HIPEC) with curative intent. At surgery HIPEC was performed as planned after resection and excision of all the abdominal load of metastases except for a solid lesion involving the IVC and the 3rd part of the duodenum, deemed unresectable. Due to its presumed irresectability the site was marked with metallic clips for later irradiation.
After surgery the patient underwent a targeted irradiation to the marked site and received additional course of systemic chemotherapy. He underwent further follow up with PET scans, revealing three main lesions with a high uptake on PET, at the previous anastomosis of the transverse colon with small bowel, in the omentum next to the anastomtic site and the metastsasis revealed at previous surgery involving the inferior vena cava, near the entrance of the right renal vein and the third part of the duodenum. There was no evidence of neither liver nor other distant metastasis.
The patient remained in a good general condition and performance status up to his presentation with fever and

[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 24-year-old female patient was referred to the Department of Periodontics, K.S.R Institute of Dental Sciences with the chief complaint of growth in the gums of right upper front teeth for the past 2 months. She was 10 days old of post-partum phase when she visited the Department of Periodontics. Past dental history revealed of similar growth in the same region which was excised in a private clinic during the 7th month of pregnancy. No history of radiographs taken in the same region. Within a week, same type of growth reappeared and gradually started increasing in size. As the lesion re-appeared, patient was apprehensive that it could be a carcinogenic tumor which was interfering with speech and mastication. She wanted immediate attention toward the lesion and treatment for the same.
On extra oral examination, no gross abnormalities were detected. On intra oral examination, diffused gingival growth was noticed between the 12 and 13 region. On the labial aspect, it measures l cm × 2 cm in diameter, red, sessile, smooth and shiny, soft in consistency and bled on slight provocation []. On the palatal aspect, the lesion was similar, but the size is somewhat more pronounced when compared with labial aspect [] Due to the increase in size of the tumor, subgingival local irritants were found more around the involved teeth due to the improper plaque control measures. On periodontal examination, periodontal pocket depths of 7 mm, clinical attachment loss of 5 mm, with Millers Class I gingival recession was associated with the involved 12 and 13 teeth region. Based on the clinical findings, the lesion was provisionally diagnosed as a pregnancy tumor with localized periodontitis and the differential diagnosis was made as peripheral giant cell granuloma, peripheral ossifying fibroma with localized periodontitis.
Routine blood investigation was advised and values were found to be within normal limits. Full mouth intraoral radiographic investigations revealed horizontal type of b

[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:
Woman 52 year old with severe grade III APLD came in consultation. She was also aware of her familiar condition. Liver transplantation was offered to her in another center but she refused. Previous MRI from another center showed multiple giants cysts compromising the whole abdominal cavity. Cysts reached hypogastric area and both inferior quadrants. Higher segments of the liver seemed to be respected. Globulous deformation of the abdomen was clearly observed. Despite aesthetic and mild abdominal pain symptoms were not as significant as they were in her two sister so she did not want to underwent liver resection too. However she kept coming to consultation every six months.
Two years later she came back presenting jaundice with serum levels of FAL>1700 mg/dl. Bilirrubin 9,8/7,9 mg/dl. New MRI showed cyst compression of the hepatic pedicle including common bile duct and portal vein ( A and 3B)
Surgery was soon programed and approach was discussed. We decided laparoscopic approach but being aware room will be very reduced even after pneumoperitoneum. We decided to start by performing aspiration and evacuation of the big lower and anterior cysts to intend reducing the mass and make new space for the laparoscopic procedure. By performing this gesture followed by several fenestration and partial cysts resections space was increased within the abdominal cavity so laparoscopic liver resection could be then performed. Once gallbladder was located, we then identified two cysts that seemed to be responsible for hepatic pedicle compression. Fenestration was done and, then, intra-operative cholangiogram showed no further compression of the common bile duct with adequate passage of contrast to duodenum. Standard cholecystectomy was completed and later laparoscopic left lateral sectionectomy was done in association with several more cyst fenestration. Post-operative course was un-eventful and patient was discharged at 6th day with decreasing levels of FAL and bilirubin. Late follo

[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 87-year-old man presented with episodic macroscopic hematuria for 1-week. He had a similar episode around 4 months back. There was no associated dysuria or any past history of urological problems. Physical examination, vitals, and basic laboratory workup were unremarkable.
Urine cytology revealed the presence of hematuria, pyuria, and cells with atypical morphology and the cytology was reported as suspicious for malignancy. Cystoscopy was performed which showed the presence of a 5 cm ×4 cm × 3 cm, solid looking tumor in the posterolateral surface of the bladder along with multiple small cauliflower like papillary tumor in the dome and the posterior wall. Computerized tomography (CT) of the lower abdomen revealed the growth [] along with the presence of multiple enlarged inguinal lymph nodes. No evidence of distant metastasis was observed. Transurethral resection of the bladder tumor (TURBT) was done using 1.5% glycine irrigation and monopolar cautery and the sample obtained was sent for histopathological examination, with a clinical working diagnosis of lymphoma, owing to the unusual solid appearance of the tumor and presence of the regional lymph node enlargement. On histopathological examination, the tumor was predominantly composed of the lymphoepithelioma-like component which comprised more than 90% of the tumor []. The tumor showed the presence of a large pleomorphic cell with prominent nucleoli and ill-defined cytoplasmic outline, imparting a syncytial appearance []. These cells were seen infiltrating into the muscularis propria and was staged pT2b. There was heavy infiltration of lymphoid cell within the tumor. The papillary area seen on cystoscopy was consistent with urothelial carcinoma, but this component comprised no more than 5% of the tumor, and this component was not seen to infiltrate the muscle layer. Immunohistochemistry (IHC) showed the expression of CK7 in the tumor cells [] and the cells were negative for CK20 []. Special stains performed for

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


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

[User]
RADIOLOGY NOTE:
A 14-year-old female had a bony defect on her head that was discovered by X-ray Photograph (xp) and computed tomography (CT) imaging, which were performed to investigate a head injury. The lesion was associated with scalp sutures she had received for a head injury she sustained at the age of 6. Immediately below the injury, a gradually enlarging bone-like tumor mass was observed. Upon admission, a subcutaneous mass with the same hardness as bone was found, which was palpable on the left occipital bone, and head xp showed a corresponding bone transmission image at the same lesion (Figure ). CT demonstrated a corresponding image of a bony defect and swelling of the outer table of the skull (). MRI revealed a corresponding bony defect and swelling at the subcutaneous tumor mass with cystic changes in the cavity of the bony defect, and a contrast study showed a partial enhancement around the cystic change (). 99mTc-HMDP bone scintigraphy demonstrated strong accumulation at a part of the cystic lesion (), and head DSA study revealed no tumor stain or feeder ().
Based on clinical symptoms, history, and image observations, the differential diagnoses included aneurysmal bone cyst, simple bone cyst, eosinophilic granuloma with cystic change, growing skull fracture, and cystic FD. Therefore, a biopsy and tumorectomy under general anesthesia were performed to diagnose and radically cure the patient.
Intraoperative Observations. A cutaneous scar due to past injury was observed at the surface of skin immediately above the skull mass (, arrowheads). The outer table of the skull beneath the skin of the scar was smooth without fracture but swollen (). After removing the outer table of the skull, the cystic cavity and bloody liquid component were observed. After aspiration of the liquid component, only bony tissue was grossly observed inside the cavity without macroscopic tumorous change, and the inner table of the skull was maintained with mild thinning (s). Finally, the cystic bon

[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:
The patient was a 41-year-old woman, gravida 0. She had notable medical history. Laparoscopic right salpingo-oophorectomy and left cystectomy were performed for bilateral ovarian endometriomas, which were both pathologically diagnosed as benign. After surgery, she underwent regular outpatient treatment with dienogest. Six months later, she presented with left lower abdominal pain and expressive aphasia. A 7 cm diameter cyst had formed in the left ovary, with a solid ingredient and surrounding ascites. Contrast-enhanced computed tomography (CECT) revealed peritoneal dissemination, multiple lymph node metastases, liver metastasis, pulmonary embolism, and deep venous thrombosis of the lower limbs. Brain magnetic resonance imaging (MRI) revealed that infarctions occurred at multiple locations in the bilateral cerebral hemisphere centered on the left frontal lobe and in the right cerebellar hemisphere. She was diagnosed with advanced ovarian cancer, accompanied by Trousseau's syndrome. She was hospitalized (Day 0) and received 10,000 units of heparin per day intravenously. On Day 11, she developed a left visual field deficit due to occlusion of the left retinal arterial bifurcation. On Day 17, she had vertigo and vomiting. Brain MRI showed new infarctions of the cerebellar vermis, left caudate nucleus head, and cerebral subcortex. On Day 26, the first chemotherapy was administered (paclitaxel 175 mg/m2 and carboplatin AUC5). On Day 29, a blood transfusion was performed for anemia due to digestive tract bleeding. On Day 30, she had chest pain. Myocardial infarction was suspected from ST elevation on electrocardiogram and hypokinesis from the anterior wall to the apex on echocardiography. Stent treatment must be combined with antiplatelet therapy, which could not be performed with the administration of heparin in the presence of gastrointestinal bleeding. Instead, she was administered an increased dose of heparin (20000 units per day) and isosorbide dinitrate. On Day 35, p

[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 59-year old male patient was referred to our hospital after suffering a VF attack and was successfully treated with defibrillation. At his initial evaluation, the patient's mind was clear and his hemodynamic parameters and other physical examination findings were normal. His electrocardiogram results indicated a sinus rhythm with a rate of 60 bpm, there was no significant ischemic finding, the QT interval was normal and there was no suggestion of Brugada syndrome or arrhythmogenic right ventricular dysplasia (). Biochemical tests including cardiac troponin, serum potassium and magnesium levels were all normal. His previous medical history indicated that there had been two syncopal episodes within the last 2 months. There were no specific triggers for these episodes, but the patient described anginal chest pain immediately before the syncopal attacks. He had experienced no exercise-induced angina, and there were no instances in his family history of sudden death of unknown origin. His echocardiogram results showed that the cardiac chambers were of a normal size, there was normal systolic function of both left and right ventricles, and the wall thickness was also normal. Coronary angiography was administered and a moderate lesion was detected in the middle portion of the right coronary artery (RCA) (). This lesion was evaluated with fractional flow reserve (FFR) using 200 µg and then 300 µg intravenous adenosine injections. The FFR ratio was found to be 0.86. Amiodarone perfusion was administered at the time of his first medical contact, and this treatment was continued for 24 h. The day after hospitalization he experienced another VF episode and was successfully treated with defibrillation. His monitor records detected an ST elevation in inferior leads a few seconds before the VF (). Vasodilator treatment including nitrate and calcium channel blockers (nifedipine, isosorbide mononitrate) was added to his therapy. Despite vasodilator therapy being applied, he experi

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


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

[User]
RADIOLOGY NOTE:
A 33-year-old Caucasian male presented to our surgical unit after 3 days of progressively worsening abdominal pain. The patient also reported the onset of constipation for some days, but he denied any associated nausea or vomiting.
His past medical history included a right-sided Wilms' tumor treated with unilateral nephrectomy when he was 2 years old. Moreover, during the follow-up for this pediatric tumor, some progressively growing intra-abdominal cystic formations, localized at the level of the mesentery, have been incidentally identified.
Physical examination revealed a hypogastric mass and diffuse abdominal tenderness without abdominal distension.
The patient underwent an abdominal CT scan () which showed the presence of 3 contiguous and communicating cystic formations located at the level of the mesentery that altogether had a major axis equal to 115 mm. Among these, the mass with larger dimensions (major axis equal to 87 mm) was the most ventral one and it was localized in contiguity with the abdominal wall, in the subumbilical region. Moreover, further intra-abdominal lesions similar to the previous ones, but significantly smaller in size, were described.
Due to worsening symptoms, an exploratory laparotomy was performed and a voluminous cystic mass, composed of 3 confluent formations, with a major axis equal to about 10 cm, and incorporated in the mesentery of the last ileal loops, was observed (). Some other similar but significantly smaller lesions were found, in particular in the pelvic cavity and in correspondence of the cecal appendix. Thus, an en bloc resection of the voluminous mesenteric formation together with the corresponding intestinal loops with ileoileal anastomosis, an appendicectomy, and some peritoneal biopsies were performed. The whole procedure was hampered by the presence of scar adhesions due to the previous nephrectomy.
The postoperative period was complicated, on the 8th postoperative day, by a circumscribed peritonitis due to dehisce

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


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

[User]
RADIOLOGY NOTE:
A 73-year-old Chinese man was found a cervical mass for 1 month. He had a history of coronary heart disease for 2 years, but no relevant personal or family history of malignancy. Physical examination showed bilateral neck asymmetry, the trachea was deflected to the left, the carotid pulse was normal, approximately 6 × 5 cm solid masses were felt in the right lobe of the thyroid gland. The tumor mass border was unclear with smooth surface, and the tumor moved up and down with swallowing. The left lobe of the thyroid gland had no palpable mass and the neck had no palpable swollen lymph nodes. Accessory examination of neck color Doppler ultrasound at our hospital showed increase in size of the right lobe of the thyroid gland, which had abnormal shape. The upper right pole of the thyroid gland had an approximately 5.6 × 6.0 × 4.2 cm sized mass, with unclear margin, and multiple cystic nodules in the thyroid. The CT of thyroid showed increase in size of the right lobe of the thyroid gland, and an approximately 5.6 × 6.0 × 4.2 cm sized mass, the trachea was compressed and deflected to the left, the thyroid cartilage was compressed, deformed and reached the right subglottic region. The right thyroid lump had multiple calcifications, indicative of a tumor (Fig. ). Electronic laryngoscope examination showed ventricular bands thickening, the right ventricular bands compartment showed a rice-like projection, arytenoid region movement was poor (Fig. ). Thyroid function test was 5.07 mIU/L. The patient underwent subtotal thyroidectomy and excisional biopsy of neck mass under general anesthesia. Intraoperative findings indicated a hard mass in the thyroid gland area, the lateral border and the lower bound were closely related to the surrounding soft tissues, but there was an extremely close relationship between the medial border, the thyroid cartilage, and cricoid cartilage, with no gap between them. An ENT doctor was invited for intraoperative consultation, who suggested that so

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


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

[User]
RADIOLOGY NOTE:
A 73-year-old woman was admitted to our hospital in coma after having an acute thunder clap headache. Her vitals were stable apart from high blood pressure and other signs of increased intracranial pressure (ICP). Her CT showed extensive SAH with acute hydrocephalus and signs of elevated ICP. An anterior communicating artery aneurysm was identified on CT angiogram. Patient underwent urgent surgery including insertion of external ventricular drain (EVD), right-sided craniectomy and clipping of the aneurysm at the same time. She had a fair good outcome after the surgery immediately with improvement in consciousness and good control of her ICP. An intensivist with bedside ultrasound experience followed the patient with daily TCS using a hand-held pocket ultrasound device (GE Vingmed Ultrasound AS, Horten, Norway) (Fig. a). Image acquisition was facilitated by the absence of bone on the site of the craniectomy which allows close contact with the brain structure through the skin. The technique is usually straight forward. In contrast to CT scan no preparation is required except for good head position. The head is cleaned with saline where the probe is applied if necessary. The TCS probe is applied directly on the skin where the craniotomy defect (in the temporal region) is and images in coronal plane are obtained. To visualize the brain images, as described by Seidel et al. [] and by Couture et al. []: we positioned the ultrasound probe over the temporal area in an axial orientation with the marker pointing toward the occiput. Then using 2D imaging, we adjusted the display depth to see the opposite skull border. Following these initial steps, we scanned in a cranial to caudal direction to identify the intracranial bone artifacts: contralateral skull, foramen lacerum, petrous ridge, and sphenoid bone. Then we tilted at about 10° cranially to identify the 3rd ventricle. Color Doppler using a low-velocity scale is then used to visualize the main cerebral arteries along 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 77-year-old man with a past medical history of type 2 diabetes, hypertension, and ESRD underwent deceased donor renal transplantation. Two months following his renal transplant, the patient was admitted for an acute kidney injury discovered on routine follow-up laboratory testing. From a baseline creatinine of 1.3 mg/dl after the transplant, he was noted to have a creatinine of 2.7 mg/dl and a renal biopsy was obtained. Histopathology was suggestive of mildly active cellular rejection and acute tubular injury but with no concerns for antibody-mediated rejection. The patient received three days of methyl-prednisolone 250 mg daily intravenously and was subsequently transitioned to high-dose oral prednisone with a taper.
The patient was readmitted within three weeks of his renal biopsy with worsening renal functions, now with a creatinine level of 3.8 mg/dl. At this time, he was on prednisone five mg daily, tacrolimus four mg twice daily, and mycophenolate 500 mg twice daily. His family reported poor oral intake and that he had been taking furosemide at home. He received intravenous (IV) normal saline and diuretics were held. However, as his renal functions did not improve beyond a creatinine level of 2.1 mg/dl, the decision was made to perform a repeat renal biopsy. During ultrasonography for the renal biopsy, concerns were raised for a possible renal artery aneurysm. An ultrasound of the right lower quadrant and transplant kidney subsequently showed a 3 cm x 3.4 cm x 4 cm aneurysm proximal to the renal artery anastomosis to the right external iliac artery (Figure ). The right external iliac artery to renal artery anastomosis was patent and the renal vein was noted to be patent as well. No peri-transplant kidney fluid collections were noted and no hydronephrosis was seen.
Subsequently, a pelvic arteriogram was performed, which showed patent pelvic and iliac arterial flow. However, a large pseudoaneurysm arising directly off the right external iliac artery was re-not

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


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

[User]
RADIOLOGY NOTE:
A 39-year-old female patient was admitted to our hospital with dyspnoea as the main symptom. She had had a murmur since childhood but it was never investigated, and she was not able to play as a child due to dyspnoea. Her dyspnoea had increased in the previous two weeks, as had her generalised body oedema.
On physical examination, she was found to have blood pressure of 90/60 mmHg with a regular heart rate of 66 beats per min. Her jugular vein distention was raised about 15 cm above the sternal angle with a prominent A wave. She had central and peripheral cyanosis (). The pericardial examination was significant for the visible apex beat pulsations in the fifth intercostal space in the mid-axillary line and there were also visible pulsations along the parasternal border and second intercostal space. The apex beat was palpable in the fifth intercostal space with ill-sustained heave. The second heart sound was palpable in the second intercostal space.
Auscaltation of the heart revealed S1, S2 and S4 along with a systolic murmur of grade 4/6 with maximum intensity in the left second intercostal space. Lung auscultation revealed bilateral crackles up to one-third of the chest bilaterally. The abdominal examination was significant for tender hepatomegaly, which was four fingers below the costal margins, and the total hepatic span was measured to be 19 cm. She had bilateral pedal oedema extending up to the lower abdomen and involving the external genitalia (, ). She also had grade II clubbing bilaterally.
The chest X-ray showed a large boot-shaped heart (–). The patient was admitted to the critical care unit with a diagnosis of congestive heart failure and she was started on empirical therapy. The next day an echocardiogram was done, which showed marked left ventricular hypertrophy, a dilated left and right atrium and severe tricuspird regurgitation associated with severe pulmonary artery stenosis, ventricular septal defect (VSD) and

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


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

[User]
RADIOLOGY NOTE:
A 63-year-old female was referred to the pulmonary clinic for insidious onset of dyspnea. The patient had multiple medical problems, including inflammatory bowel disease treated with prednisone varying from 10 to 60 mg/day, hypertension, hypothyroidism, peptic ulcer disease, and a distant history of lower extremity DVT. She was also using continuous positive airway pressure at night for obstructive sleep apnea with good control of her symptoms.
She had gradual onset of her dyspnea around one year prior and it had progressed to the point where she was unable to complete activities of daily living without getting short of breath. She was not hypoxic at rest with a room air oxygen saturation of 95%. Her physical examination was unremarkable. The only abnormality in her spirometry was an expiratory reserve volume of 4% predicted. The diffusion capacity was in the normal range. Arterial blood gas analysis showed a PaO2 of 66, PaCO2 of 38, and pH of 7.41. CT scanning of the chest including HRCT, inspiratory and expiratory films, and CT angiogram did not show parenchymal lung disease. Echocardiogram showed normal left atrium, right atrium, and right ventricle with a left ventricular ejection fraction of 43%. There was mild diffuse hypokinesis and a dobutamine stress echocardiogram did not show regional wall motion abnormality or valvular disease. As her symptoms were out of proportion to pulmonary abnormalities, left and right heart catheterization were done. Left heart catheterization confirmed normal coronaries and mild LV dysfunction. PA pressures were 21/7 mm Hg and PAOP was normal. Cardiac output obtained by thermodilution method was 5 liters/min. PA saturation was 69.4%.
As her symptoms worsened an echocardiogram with bubble study was done that showed early appearance of bubbles in the left atrium suggesting intracardiac shunting. Right to left shunt was confirmed on TEE. On augmentation of her heart rate by dobutamine and atropine, a significant increase in the exte

[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-years-old male presented to UiTM Primary Care Clinic, Sungai Buloh, Selangor, Malaysia with a history of persistent left hip pain. The patient had underlying bronchial asthma, present since childhood, that had been well-controlled with salbutamol use as required. The patient was not on any inhaled corticosteroids.
The patient first presented with a 2-week history of left anterior hip pain that occurred after he slipped on the stairs and landed on his left knee with no direct trauma to the hip. The pain worsened with initiation of movement and weightbearing on the affected joint, especially when exiting a car or climbing stairs. He was overweight, normotensive, with full range of movement of the bilateral hips. The patient had no history of prolonged corticosteroid use, alcoholism, and he had no systemic medical conditions. Left hip X-ray showed no obvious evidence of fracture and he was discharged with analgesia. It was difficult to attribute the fall as a cause for the hip pain since there was no direct trauma to the hip; however, the hip pain could be a referred pain from the knee.
The patient then presented a month later complaining of acute lower back pain which radiated to the left groin and had been present for 3 days. He was noted to have an antalgic gait with paravertebral muscle spasm. On examination, the straight leg raise test was negative with normal neurological examination of the lower limbs. Lumbosacral X-ray was normal and the patient was discharged with analgesia. He was reviewed 2 days later, stating improvement and no longer had an antalgic gait.
Subsequently, the patient continued to have several recurrent episodes of intermittent left hip pain. In between attacks, his pain would partially subside. He returned to the clinic with similar symptoms and this prompted the primary care team to arrange for an orthopedic assessment. On examination, the patient had limited internal rotation and external rotation of his left hip and a

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


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

[User]
RADIOLOGY NOTE:
A 58-year-old male patient reported with a complaint of growth on the left inner side of cheek for 6 months which was increasing in size with a history of difficulty in chewing and brushing. There was no history of any pain or tendency of bleeding accompanying the growth. The medical and dental history was nonsignificant and noncontributory. The patient did not give any history of trauma, tobacco chewing, or alcohol consumption.
On intraoral examination, a well-defined, solitary, sessile, round to oval, pinkish growth with distinct borders were noted on the left buccal mucosa in relation to mandibular left first and second molar. The growth was approximately 1.5 cm × 1 cm × 1.5 cm. (Anteroposterior × Mediolateral × Superoinferior). On palpation, the growth was non tender, soft in consistency, and with no tendency for bleeding []. Since the history and clinical appearance of the growth was not characteristic of a specific lesion, a provisional diagnosis of soft-tissue overgrowth was made, and the patient was advised for an excisional biopsy to reach a conclusive diagnosis. The differential diagnosis included fibroma and peripheral giant cell granuloma.
A white, nonscrapable, homogeneous patch was also noted on the left buccal mucosa posterior to the swelling extending to the buccal vestibule and gingiva in relation to the mandibular left first and second molar region. The patient was again questioned in detail for any adverse habit such as tobacco chewing in any form, but the patient denied any habits such as tobacco chewing or smoking. Based on the clinical appearance of the white patch, a provisional diagnosis of homogeneous leukoplakia on the left buccal mucosa was made. Frictional keratosis was considered as a differential diagnosis.
Preoperative hematological assessment revealed all parameters within the normal limits. After obtaining informed consent from the patient, excision of the growth was done under local anesthesia. Bleeding was controlled by applying pr

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


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

[User]
RADIOLOGY NOTE:
A 69-year-old Caucasian male with a past medical history of hypertension, oromandibular dystonia treated with Botox, and recent diagnosis of gastroesophageal reflux disease (GERD) presented to his primary care provider noting an area of his left chin that was numb. The area was small and could be covered with 1 finger. He followed up acutely three weeks later with significant dysphagia for solids, but not liquids. He was urgently referred for an upper endoscopy. Upper endoscopy revealed LA Class D esophagitis with ulceration in the distal esophagus, and biopsies showed inflamed glandular mucosa with at least high-grade dysplasia. These findings were consistent with a diagnosis of Barrett's esophagus secondary to GERD.
Three weeks after his upper endoscopy, he presented to the emergency department with right jaw pain and swelling after hitting his jaw on a work bench. A CT revealed right mandibular angle fracture and coronoid fracture (). The facial trauma team was consulted and, secondary to his oromandibular dystonia, he was discharged on a liquid diet with Augmentin, Peridex, and close follow-up. He was seen in the clinic a week later and denied trismus, malocclusion, or difficulty with his liquid diet. On examination, he was found to have an exophytic mass of the right retromolar trigone, which he noted his teeth had been hitting. This mass was present before his fracture and had gotten larger over time. This mass was biopsied in the clinic and came back as likely metastatic adenocarcinoma ().
The patient underwent a second upper endoscopy. Biopsy taken during this second endoscopy was consistent with a moderately differentiated adenocarcinoma of the distal esophagus. A PET/CT revealed a large, hypermetabolic distal esophageal mass consistent with the given diagnosis of esophageal adenocarcinoma. Hypermetabolic lesions involving the regional lymph nodes, lungs, spine, and right mandible, as shown in , were found on PET/CT. These findings were consistent with a St

[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.