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

[User]
RADIOLOGY NOTE:
An 18-month-old boy presented with abdominal pain and distension for the past 2 days and bilious vomiting for 1 day. On examination, the child was lethargic and mildly dehydrated with a heart rate of 130/min. His abdomen was distended and tender. A vague mass was felt over the umbilical and epigastric regions. The abdominal radiographs revealed a ground-glass appearance along with a prominent bowel loop with an air-fluid level. An ultrasound (US) showed free fluid within the peritoneal cavity and an elongated, dilated, thick-walled loop of bowel in the epigastric region with inflamed mesentery. A presumptive diagnosis of small bowel volvulus with gangrene was made.
At laparotomy, approximately 200 ml of dark-red fluid was sucked out and a 25 × 9 cm tensely cystic, shiny, edematous, tubular mass with necrotic walls was found. The mass had a separate mesenteric pedicle arising from the base of the ileal mesentery, approximately 20 cm from the ileocecal junction. The pedicle had undergone torsion of three turns with resultant gangrene and perforation of the wall of the cyst. A loop of the ileum was adherent at the site of the perforation. A second cyst (8 cm in length) was present between the leaves of the ileal mesentery in the adjacent ileum, sharing a common wall with the ileum, suggesting an enteric duplication cyst. The straight arteries from the vasa recta traversed on both sides of the cyst to the adjacent bowel. The pedicle of the isolated cyst was divided between ligatures and the cyst excised. The enteric duplication cyst was excised along with the adjacent ileum and an ileoileal anastomosis performed. On sectioning the wall of the enteric duplication cyst, gastric-type mucosal folds were seen, whereas the CIDC showed a flattened inner lining. The postoperative period was uneventful. Histopathology of the CIDC revealed intestinal-type mucosa along with areas of necrosis and gangrene, while 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 64-year-old male presented with a two month history of difficulty urinating and was found to have a fungating penile mass involving 50% of his penis. The mass was hard and fixed and extended from the glans proximally up the shaft. He also had bilateral palpable inguinal lymphadenopathy. There were no associated constitutional symptoms. Given there was a high suspicion for malignancy, the patient underwent partial penectomy within a month of presentation. Biopsy results confirmed a pT2 tumor with invasive keratinizing squamous cell carcinoma, poorly differentiated, and tumor size of 5 × 4 × 2.5 cm, with corpus spongiosum and lymphovascular involvements.
Following the procedure, the patient had PET-CT for staging, and imaging revealed enlarged hypermetabolic bilateral axillary lymph nodes concerning for metastatic disease. In addition, there was a large centrally necrotic lymph node conglomerate in his left groin that had increased FDG avidity. The patient had left inguinal and bilateral pelvic lymph node dissections revealing metastatic squamous cell carcinoma in multiple lymph nodes. The left inguinal mass was also found to be metastatic well-differentiated SCC. His diagnosis was staged at T2N3M0.
After his surgical procedures, patient was started on adjuvant chemotherapy. He began first line chemotherapy with paclitaxel, ifosfamide, and cisplatin (TIP). He underwent 4 cycles of TIP but eventually developed disease progression on repeat imaging. At this point, the patient was started on cetuximab given EGFR amplification on tumor analysis with the FoundationOne testing platform. However, the patient had an allergic reaction to cetuximab, so his treatment was changed to panitumumab. The patient had stable disease and a progression-free survival of 6 months with anti-EGFR treatment, which is clinically significant given that this treatment was given in the second-line setting for an aggressive tumor type that other than chemotherapy there is no other approved drug t

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


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

[User]
RADIOLOGY NOTE:
A 40-year-old Caucasian man was referred to our unit in November 2004 with a nodule measuring 15 mm in the inferior lobe of the right lung and multiple enlarged right mediastinal lymph nodes measuring up to 45 mm, identified by performing a periodic surveillance contrast-enhanced computerized tomography (CECT) scan 6 years after a radical left nephrectomy for ccRCC (Table ).
In December 1998, because of the appearance of sudden macroscopic hematuria with pain, the patient was diagnosed with renal neoplasm without distant metastases. An open left radical nephrectomy was performed and the patient was discharged 6 d later, after an uneventful postoperative course. Pathological examination revealed an infiltrating ccRCC measuring 95 mm × 55 mm × 50 mm, Fuhrman grade 3, without the involvement of the lymph nodes and the perirenal adipose tissue, with negative surgical margins. Adjuvant systemic therapy was not indicated and the patient was followed up regularly. The complete medical history of the patient is summarized in Figure and Table .
The patient had a free previous medical history.
The patient was in excellent physical conditions and asymptomatic.
The laboratory data on admission, including renal function tests, were normal. The International Metastatic RCC Database Consortium (IMDC) Risk Score was 0.
The CECT scan suggested the occurrence of a lung metastasis (LuM) with metastatic right mediastinal lymph nodes. A positron emission tomography with 18F-labeled fluoro-2-deoxyglucose associated with computed tomography (18F-FDG-PET/CT) documented slight FDG uptake within the mediastinal lymph nodes, without evidence of further distant metastases. A computed tomography guided biopsy of an enlarged mediastinal lymph node confirmed the recurrence of the ccRCC.
In December 2004 the patient underwent right thoracotomy; intraoperative palpation of the right lung parenchyma revealed multiple nodules, which were removed with multiple wedge resections, along with radical ipsi

[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 woman was referred to our neurosurgical outpatient service with abnormal sensation in her trunk, arms and legs. The patient had a past medical history of a gastric ulcer, a right ankle plating after fracture 20 years ago and a headlice infection 6 months before first presentation. She was a smoker, social drinker of alcohol and was not taking any regular medication. She lived alone and had been struggling to manage independently.
Since her symptoms commenced 3 years previously, the patient had presented to emergency department (ED) on 11 occasions. Her primary complaint was of dysaesthetic sensory symptoms including a feeling of water retention and a gel infiltrating the skin of her face, trunk, arms and legs, feeling there was something stuck on her skin and feeling her hair was stuck down. In the weeks before the onset of her symptoms, the patient started using an olive oil moisturising cream, to which she attributed her symptoms.
While dermatological examination was conducted, comprehensive neurological examinations were not documented during the first presentations to the ED, which focused on the patient’s facial dysaesthesia.
The patient was frustrated that her symptoms were repeatedly dismissed as delusional by the ED staff. She refused assessment by liaison psychiatry and mental health review by her general practitioner. The patient was felt to have capacity throughout all consultations. The patient was not taking any psychiatric medications.
Over time her symptoms progressed. She started to complain of back pain, multiple falls and episodes of her right leg giving way which had progressed to severely compromised walking and coordination. The patient also complained of episodes of urinary and faecal incontinence. This led to a lumbar MRI which ruled out cauda equina syndrome. In her final presentation before referral, she also complained of stiff legs, difficulty walking, difficulty passing urine, reduced manual dexterity and neck pain. A neurol

[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:
Our patient was a 47-year-old male who suffered a moderate TBI as a result of an accident of falling down the stairs in 2014. He was brought to the emergency department at a local university hospital with a Glasgow Coma Scale (GCS) score of 12. An initial neurological examination revealed a moderate aphasia, right-sided hemiparesis, and a positive Babinski sign on the right. Urgent head CT showed a left-sided frontotemporal ICH with a midline shift of 9 mm (Figures , ). The patient underwent an emergency pterional craniotomy and hematoma evacuation. There was no evidence of tumor during the intraoperative period. Next day, postoperative CT scan showed a diminished midline shift to 4 mm and the remnants of hematoma (Figures , ). The postoperative period was uneventful. The patient gradually improved and was discharged for further rehabilitation after 12 days with a GCS score of 15, mild motor aphasia, and slight right-sided hemiparesis. The patient showed up for the follow-up after two years in 2016. The clinical condition was satisfactory, no focal neurological signs were observed, and the patient complained only of easy fatigability and mild intermittent head pains in the region of craniotomy. No need for an additional neuroimaging was indicated at that moment as the patient did not show any signs of neurological deficits.
In 2018, the patient was brought to the emergency department at the same institution due to a sudden onset of severe headache, right-sided weakness, and altered mental status. The patient had a GCS score of 12. Neurological examination was significant for severe aphasia, right-sided hemiplegia, and a positive Babinski sign on the right. An urgent CT scan was performed, revealing a vague spontaneous ICH in the left temporoparietal region (Figures , ). Due to atypical radiological appearance, the patient underwent a contrast-enhanced MRI scan to evaluate a potential secondary cause of the hemorrhage. A heterogeneous, contrast-enhancing frontotempor

[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 21-year-old healthy nulliparous female presented to a regional hospital in Australia in spontaneous labour at 39 weeks and 4 days of gestation. Her pregnancy was otherwise uncomplicated and she had no medical and surgical history of note.
The patient presented to the hospital with a cervical dilation of 4 cm. Her first stage of labour lasted 1 hr and 45 minutes and her second stage lasted 1 hr and 16 minutes, respectively. Analgesic treatment in the first stage included nitrogen oxide as required and 10 mg of intramuscular morphine. Analgesic used in the second stage was only nitrous oxide as required. An episiotomy was performed at delivery. She delivered a live born infant weighing 3690 g with APGAR scores of 9 and 10. The 3rd stage lasted 15 minutes with delivery of an intact placenta.
After delivery, she further requested nitrous oxide and had 10 mls of 1.0% lignocaine infiltrated into the perineum for an episiotomy repair.
Approximately 2 hours postpartum, the patient started complaining of sudden onset dyspnea and lower chest tightness. Her GCS was 15 at this time and her vital signs were oxygen saturation >95% on room air with a respiratory rate of 18 breaths per minute, pulse of 85 beats per minute, BP 130/78, and a temperature 37.2°C.
Physical examination at the time revealed swelling in the neck and jaw line and palpable crepitus in the anterior chest wall, neck, and jaw, consistent with subcutaneous emphysema.
Initial management included observation and pulse oximetry, as she was clinically stable and able to have a conversation without increase in chest pain or decrease in oxygen saturation.
Subsequently a chest X-ray (CXR) was obtained which demonstrated pneumomediastinum with air tracking superiorly into the pericardiac spaces (). Following telephone consultation with a cardiothoracic team at our major tertiary referral center, a computed tomography (CT) contrast study was ordered as recommended. CT

[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:
Our patient was a 31-year-old African American female with a 2-3-week history of acute behavioral changes, personality breakdown, sexual inappropriateness, and religious grandiosity. Her past medical history was significant for asthma, genital HSV, and polycystic ovarian syndrome. She was admitted to the psychiatry service for evaluation of her acute behavioral changes and cognitive decline. During her admission, she developed new onset grand-mal seizures and was transferred to the neurologic intensive care unit. She continued to have frequent seizures and began to develop worsening catatonia. The neurological workup included multimodal imaging and CSF studies that were positive for GluN1 antibodies, supporting a diagnosis of anti-NMDARE. Subsequent workup including CT scans of the chest, abdomen, and pelvis, ultrasound of the pelvis, and a PET scan was negative for a tumor etiology. Our patient did not have a tumor etiology.
As the frequency of seizures increased, her mental status deteriorated and she was intubated for airway protection on hospital day 18. She had escalating episodes of autonomic instability, manifested by episodes ranging from narrow complex tachycardia with heart rates in the 140–160 bpm to severe bradycardia induced by vasovagal maneuvers such as coughing, suctioning of the endotracheal tube, and defecation. These episodes were initially self-limited but over subsequent days necessitated active pharmacologic intervention including combination of multiple rounds of glycopyrrolate and/or atropine and low doses of epinephrine during the episodes.
The initial treatment of the bradycardic episodes was targeted at reduction of vagal stimuli and triggers for bradycardia. This included suppression of coughing episodes with intravenous fentanyl and premedication with inhaled lidocaine before endotracheal suctioning. Intermittent propofol and ketamine sedation were also attempted to decrease vasovagal triggers but no clinical efficacy was appreciated. 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 67-year-old woman with a history of hypertension was admitted to our hospital with acute chest pain. Under the diagnosis of unstable angina, anticoagulant and dual antiplatelet therapy was initiated with intravenous heparin (25000/IU), aspirin (75 mg/day), and clopidogrel (75 mg/day). Laboratory tests showed a partial thrombin time of 58.3 seconds and a prothrombin time of 11.6 seconds with an international normalized ratio of 13.24. One day after commencing anticoagulant therapy, she developed sudden severe back pain and paraplegia (Grade I/V).
Although she also had hypoesthesia below the T2 dermatome, her consciousness was completely normal. Thoracic T2-weighted MRI showed intradural extramedullary low signal intensity at the T2-3, which was consistent with spinal subarachnoid hematomas. High signal intensity was also observed from C5 toT4 in the spinal cord (). Surgical exploration was then undertaken to decompress the spinal cord. Prior to the operation, heparinization was reversed and antiplatelet administration was discontinued. With total laminectomy at T1-4, we could not find any hematoma in the subdural space. However, thick hematoma compressing the spinal cord was found beneath the arachnoid membrane (). The hematoma extended into the anterior, upper and lower subarachnoid space around the spinal cord. Much of the hematoma was removed sufficiently and the spinal cord became soft. Postoperative MRI demonstrated reduced spinal cord edema. The next day, the patient complained of a severe headache and brain CT revealed SAH on both parietal lobes (). For prevention of vasospasm, nimodipine was administered to prevent cerebral vasospasm intravenously. Hypervolemic and hypertensive treatments were not started because of her poor heart function. Nevertheless, her consciousness decreased over time and blurred vision developed with hemiplegia seven days after surgery. Brain CT and MRI revealed multiple cerebral infarctions in the right posterior cerebral artery te

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


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

[User]
RADIOLOGY NOTE:
A 26-year old woman presented with traumatic complete T5 paralysis for 2 years after suffering a T5 burst fracture caused by falling from a tree while hunting. T5 posterior fusion and decompression was performed to stabilize her, but the injury was complete with no return of function after 2 years. A baclofen pump was inserted into the L3 level for spasticity after few months of the injury. The severity of the injury was classified as grade A using the American Spinal Injury Association (ASIA) grading, which is defined as complete loss of motor and sensory functions below the level of the injury ().
The stimulator that was used in this study is approved by FDA for chronic pain treatment (). After obtaining informed consent from the patient, a total of 8 leads with 8 electrodes each were implanted at L2, L3, L4, and S1 bilaterally. Four leads for a total of 16 electrodes on each nerve root with two leads each were implanted at L5 bilaterally. The procedure was performed under general anesthetic with a small laminotomy at T12 to facilitate retrograde advancement and insertion of percutaneous leads to each level (). The procedure was done and guided under fluoroscopy and the total surgical time was ~120 min. A total of 2 batteries, with four ports each, were utilized connecting in the following configuration: 8 electrodes to D port for S1, 16 electrodes with a splitter to C port, 8 electrodes from L4 and 8 electrodes to L3 with a splitter to B port, and 8 electrodes to A port from L2. This allowed activating every other contact on each lead that is plugged in the splitter. Electrodes were then anchored into the interspinous ligament and tunneled to two separate gluteal pockets on either side. All electrodes from the left were sent to the left battery and right electrodes to the right battery. This procedure allowed for a total of 64 contact points, 32 per battery, on 12 leads with implantation of 96 electrodes that covered L2 to S

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


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

[User]
RADIOLOGY NOTE:
A 61-year-old female patient without any medical history presented at our clinic with a palpable mass associated with pain in the right breast. She discovered a small mass in her right breast just after completing the breast feeding period, which increased in size gradually for 25 years. There was no nipple discharge, fever, history of breast trauma, hormone replacement therapy or family history of breast or ovarian cancer. She did have close contact with sheep and dogs.
Upon physical examination, a large palpable mass with regular borders was identified within the right breast. The nipple, areola and skin were normal. There was no palpable lymph node in the right axilla. The left breast and axilla were normal, and systemic examination did not show any abnormality.
Her mammograms showed two (large and small) oval and dense masses within the upper outer quadrant of the right breast (Figs and ). The largest mass was about 4 × 3 cm and multilobulated, and the small mass was about 1 × 1 cm well circumscribed in its contours.
There were associated calcifications at the periphery of the large lesion and diffuse linear microcalcifications at other areas of the breast. The left breast was within normal limits. The ultrasound revealed a large heterogeneous and lobulated mass that contained mixed hypo- and hyper-echoic degenerative contents with a small internal anechoic cyst at the periphery of the lesion in the upper outer quadrant of the right breast. There were no associated enlarged axillary lymph nodes.
Investigation revealed that the complete blood count, chemistry and liver function test were within normal limits with the exception of the echinococcal hemagglutination test, which was positive. The chest x-ray and abdominopelvic ultrasound were normal.
We suspected a hydatid cyst because the patient came to our clinic from an epidemic area. We decided on mass excision. The risks and benefits of the procedure were clearly explained to the patient, and consent was obtain

[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:
Staged bilateral total hip arthroplasties were performed on a 55-year-old man with a neglected untreated history of DDH, who gradually developed severe bilateral hip joint arthritis. The chief complains included bilateral hips and knee joints pain on walking associated with a progressive limitation in the range of hip motion and walking ability distance day after day. The history of the present problem went back to the age 45 with an incident of the low back pain repeated at the ages 50 and 52; each time relieved by conventional bed rest and other conservative measures. The progressive changes in lumbar spine (L2-L3) including discopathies and stenosis of the spinal canal were also contributed to his limitation of walking ability for last 10 years.
The patient was born as the last member of a large size family of a second degree consanguineous traditional marriage, with the maternal age 43, having 3 sisters and 4 brothers without hip disease. In the past medical history, the patient presented a history of the right nasolacrimal stenosis operated at the age of 3 and 8, right inguinal hernia operated for at 1 and 3. A suspected dentine dysplasia characterized by deciduous and permanent teeth with clinically normal appearing crowns, some hypermobility and spontaneous dental abscesses started in childhood and ended with the loss of all teeth at the age of 22 to 27. An unsuccessful closed reduction of the left hip joint at the age of 11 put in spica cast from the tip of the toe up to the chest level was performed and immobilized for 9 months. A history of night bedwetting, up to the age of 11, due to urinary reflux evolving in the left renal regression and hypoplasia, accidentally revealed upon a renal infection and diagnosed by renal angiography at the age of 22. A problem of ingrown toe nail started from the age of adolescence with multiple recurrence after a surgical correction was noticed. Two attacks of the left ear Menier’s disease reported to be experienced at 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:
The second case is a 75-year-old gentleman with a background of ulcerative colitis who underwent an elective open tube graft repair for an 8 cm inflammatory aneurysm. In retrospect, inflammatory features are seen to extend distally to the iliac bifurcation on initial imaging (). Thus, the patient may have benefited from the management of this at the initial surgery.
Fourteen months later, he presented to the emergency department with melaena and haemoglobin of 62 g/l. Following resuscitation an OGD was normal and CT angiography was unable to determine any definitive active bleed but suggested a possible AEF given the close proximity of the third part of duodenum to the aortic graft. Twenty-four hours later, the patient collapsed with a large amount of melaena and frank rectal bleeding in hemorrhagic shock. A new CT scan showed an AEF between distal right common iliac artery and ileum () not associated with the suture line of the previous open repair. Of note, this was found to be present on initial emergency imaging when reviewed by a specialist vascular radiologist.
The previous open aneurysm repair was relined with 84 × 24mm COOK® bifurcated endovascular aortic aneurysm repair (EVAR) and 13 mm COOK® limb extension into the right external iliac artery with embolisation of the internal iliac artery. Procedure completed with 24mm COOK® stent extension into contralateral common iliac artery. The patient recovered well from the initial procedure and returned to theatre the next day for laparotomy and resection of the distal ileum adhered to the inflammatory iliac aneurysm. Joint case with the emergency general surgery team at the local hospital performed with extensive washout and small bowel side to side stapled primary anastomosis.
Aside from a prolonged ileus, the patient made a good recovery with intravenous antibiotics and steroids. The patient was discharged on lifelong antibiotics according to local microbiology guidance. At 3 months and 12 months follow up, 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:
The patient, a 37-year-old woman, was admitted to our hospital on July 7, 2018, after 5 days of sudden headaches with nausea and vomiting. On July 3, 2018, with no obvious cause for symptoms, her family sent her to the local hospital for treatment. On July 3, 2018, head computed tomography (CT) showed subarachnoid hemorrhage (Fig. ). On July 4, 2018, CT angiography revealed no obvious abnormalities. After she underwent conservative treatment at a local hospital for 5 days, she achieved relief from the headaches. To obtain a diagnosis and further treatment, she visited our hospital. Physical examination revealed a positive meningeal irritation sign and a positive Kernig sign, and the 2 transverse fingers displayed positive cervical rigidity; no other obvious abnormalities were found. There was no history of hypertension, heart disease, diabetes, or other conditions. She denied a history of trauma or surgery. Head digital subtraction angiography (DSA) performed at our hospital on July 8, 2018, showed fenestration at the junction of the middle and upper portions of the basilar artery with an aneurysm; spontaneous pseudoaneurysms could not be excluded, the bilateral posterior communication was obviously open, and the posterior cerebral artery was well developed (Fig. A, B).
The patient underwent stent-assisted fenestration and channel occlusion under general anesthesia. An Enterprise stent 4.5 × 22 mm in size was placed in the normal fenestration malformation channel with the 2 ends of the stent completely covering the openings of the lesion channel. Target 360 NANO (1.5 mm × 3 cm) and helical (1.5 mm × 2 cm, 1 mm × 2 cm) spring coils were placed to fill in the fenestration malformation channel. Intraoperative routine heparin saline irrigation and continuous anticoagulation therapy were performed. After stent placement, tirofiban was administered intravenously at 10 mL/kg/h to prevent angiogenesis in the stents. Following the procedure, the stents were found to be well

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


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

[User]
RADIOLOGY NOTE:
A 32-year-old woman in her fourth pregnancy, with parity of 2, presented at 19 weeks’ gestation to the gynecologic emergency department with lower abdominal pain for the past 2 days. Her obstetric history included retained placenta in both first and second deliveries, which necessitated manual revision of the uterine cavity and curettage. She had a perforation of the left posterior uterine wall during curettage in her second delivery that was laparoscopically repaired. In her third pregnancy, she presented with an acute abdomen at 19 weeks’ gestation and underwent exploratory laparoscopy that demonstrated a 2.5 cm rupture in the posterior uterine wall at the site of the previous perforation. Laparoscopy was turned into laparotomy; the rupture was sutured and the patient recovered well. Magnetic resonance imaging (MRI) performed at 21 weeks’ gestation demonstrated placental tissue penetrating, but not perforating, the myometrium of the posterior uterine wall, which was indicative of placenta increta (). After counseling, the couple chose to terminate the pregnancy, and hysterotomy was performed at 22 weeks’ gestation.
In the current pregnancy, upon admission to the emergency department, the patient presented normal vital signs, and the gynecologic examination revealed 19 weeks’ gestation – sized uterus, a closed cervix, and no vaginal bleeding. Transabdominal ultrasound scan suggested abnormal placentation (). This suspicion raised by sonography, together with the patient’s history, prompted an MRI at 24.2 weeks that demonstrated the presence of placenta percreta at the site of the previous placenta increta (). Following counseling, the couple decided to continue the pregnancy, and the patient was hospitalized for observation. Two days later, the woman reported severe abdominal pain. Rapid bedside ultrasound examination demonstrated intraabdominal bleeding, and emergency CS was performed. During laparotomy, massive intraabdominal bleeding was observed, originating fr

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


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

[User]
RADIOLOGY NOTE:
A 24-year-old man was working on a farm loading bails of manure into the manure spreader when a coworker started the machine for “just a second” to test the motor. The patient became entangled in the spreader mechanism, which created the injury. Local emergency medical services were immediately dispatched. Our patient was treated with established protocols and air ambulance transport was requested due to the severity of the injury. He was transported to our level-1 trauma center in a stable condition.
The patient was met by our trauma team in the trauma bay and was found to have an eviscerated bowel wrapped in a moist towel extruding through a 12-cm curvilinear abdominal laceration 10 cm inferior to the costal margin extending vertically down the right midclavicular line. Additionally, the patient had an open pelvic fracture and a large curvilinear laceration extending from the right inferomedial portion of the inguinal area to the superior pubic symphysis and finally coursing to the left medial thigh resulting in degloving of the penis and bilateral testicular avulsion []. He was taken to the operating room immediately for exploration and wound care.
The trauma surgery team performed a trauma laparotomy and explored the abdominal cavity in addition to further assessment of the pelvic trauma. The urology team was able to concurrently examine the genital trauma. Both spermatic cords were completely severed. The team immediately performed testicular sperm extraction on the right testicle, collecting 21 vials of viable sperm, in an effort to retain the patient's future reproductive potential. It was determined that the left testicle was capable of revascularization.
As the trauma surgery team continued with the exploratory laparotomy, a discussion ensued regarding the priority and order in which the patient's surgery should be carried out. There was concern that revascularization of the testicle was time-sensitive and may be futile if delayed for an extended period of

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


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

[User]
RADIOLOGY NOTE:
A 29-year-old woman was found unresponsive near a snowy mountain trail in winter. On that day, the outside air temperature ranged from − 2.0 to 1.0 °C. When emergency medical services arrived on the scene, they found that the patient was in cardiac arrest and in asystole. It was noticed that she also had mandibular rigidity. On the way to the hospital, emergency medical service staff were unable to insert an oral airway device for ventilation because the mandibular rigidity prevented sufficient mouth opening. The chest was compressible. CPR was performed with manual chest compression and bag valve mask ventilation ratio of 30:2 during transportation. When she was admitted to the hospital, 52 min had passed since she was discovered. She remained in cardiac arrest with an asystolic cardiac rhythm. Her initial core temperature was 22 °C measured by bladder thermistor. Her mandibular rigidity remained, and neck mobility was also restricted. Both elbows and knees could be passively bent with resistance and the chest wall was not stiff. We were concerned that postmortem changes (i.e., rigor mortis) had begun. We tried to force open her mouth for intubation and found that it could be slightly opened. Although this was insufficient to visualize the vocal cords with a conventional laryngoscope because of the impossibility of controlling it, we were able to insert an “Airway scope™” video laryngoscope, which allowed successful intubation. Although the patient was in cardiac arrest due to severe accidental hypothermia, which indicated an enhanced possibility of successful resuscitation, the mandibular rigidity connected, along with the supposition of rigor mortis initiation made us believe that it would be difficult to resuscitate successfully. However, her initial blood gas analysis revealed that her serum potassium level was 5.4 mmol/L (Table ). We decided to use veno-arterial ECMO to generate effective systemic perfusion and to rewarm the patient. After ECMO initiated, her

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


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

[User]
RADIOLOGY NOTE:
The patient was a 66-year-old man who presented with dyspnea and cough and was referred to the Second Hospital of Jilin University 5 years ago. The patient was a retired worker with a 40 pack-year history of smoking and no history of other diseases. HRCT scan of the chest revealed that the patient had masses in both lungs, with fibrous stripes and diffuse subpleural reticular pattern, which were indicative of IPF (Fig. a, b). Lung function tests showed a substantial decrease in the diffusing capacity of the lungs for carbon monoxide (DLCO; < 60%), while blood gas analysis showed reduced levels of partial pressure of oxygen (PaO2). Treatment with glucocorticoids and pirfenidone led to improvement of the symptoms. With regular treatment, the patient’s condition continued to remain stable, as confirmed by a follow-up chest HRCT performed 5 years later. However, the follow-up scan revealed a newly developed, irregular mass in the right upper lobe and enlargement of the anterior trachea and posterior vena caval groups of lymph nodes; the lower lobes did not show any changes on either side (Fig. c, d). The patient then underwent fiberoptic bronchoscopy for retrieval of a tissue sample. Pathological examination of the sample revealed SCLC in the superior lobe of the right lung (Fig. e, f).
A chemotherapeutic regimen comprising nedaplatin (80 mg/m2) and etoposide (100 mg for 5 days) was then initiated. However, during the chemotherapy, the administration of antifibrotic agents was continued. After 4 courses of treatment, marked reduction of the tumor was observed. A repeat thoracic CT scan revealed reduction in the size of the shadow in the upper right lung and significant decrease in the size of the metastatic lymph nodes in the anterior tracheal and posterior vena caval groups of lymph nodes; however, there was no visible decrease in the severity of IPF (Fig. g, h). Thus, we concluded

[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 describe a healthy and active 58-year-old man, who four months prior to presentation noticed that he was gaining weight, in spite of participating in aerobic exercise daily and having no change in diet. Three months prior to presentation the patient began noticing an increase in abdominal girth, stating that it, ‘felt like a large ball in my belly. The patient began to develop occasional abdominal discomfort, which slowly increased in pain and frequency. The patient also developed symptoms of constipation and severe gastroesophageal reflux, for control of which, he began taking laxatives and a proton pump inhibitor. He eventually saw his primary care physician and had a computer tomography (CT) scan done, showing a large spherical cystic mass in the abdomen measuring 32 cm by 25 cm (Figure ). The CT scan findings in short were of a massive uniloculated retroperitoneal cyst seen non- communicating to the pleura, or any other abdominal viscera and occupying nearly the entire abdominal space, displacing his entire bowel to the patient’s left, with the cecum and ascending colon located anterior and left of the midline. The mass spanned from the pelvis inferiorly to the liver hilum superiorly. The liver and stomach were compressed. The patient was referred to a surgeon and the recommendation was made to proceed with surgery after complete evaluation. He has no risk factors related to the mesothelioma (exposure to asbestos or any virus) or any malignancy. We checked other risk factors including occupational (exposure to silica or cadmium), family history, social (alcohol intake and smoking) or history of trauma.
In the operating room, after a midline laparotomy, a massive retroperitoneal cyst was discovered to span nearly the entire abdominal width, displacing his entire bowel to the patient’s left, with the cecum and ascending colon located anterior and left of the midline. The mass spanned from the pelvis inferiorly to the liver hilum superiorly. The colon was dissec

[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 present case report is about a 33-year-old female patient who was referred to our department for evaluation of recurrent renal stones. She had recurrent episodes of flank pain since 2002, with one session of extracorporeal shock wave lithotripsy (ESWL) done 8 years back. She continued to experience flank pain after ESWL with history of passing stones. On examination, she had overgrowth of the entire right half of the body. The upper limbs measured 57 cm on the right and 54 cm on the left; lower limb measured 90 cm on right and 85 cm on the left; right foot was larger than the left by 3 cm []. The right half of the trunk was also larger than left; the discrepancy in the length of lower limb resulted in scoliosis with pelvic tilt. Patient recalled of having limping gait from early child hood.
On evaluation, she was found to have a glomerular filtration rate of 114 ml/min/1.73 m2 of body surface area, urine sediment was non-remarkable except for pyuria; urine cultures did not grow any organisms. Her serum sodium, potassium, calcium and phosphorus were normal and intact. Parathyroid hormone was also in the normal range. A 24 h urine collection showed hypercalciuria (560 mg in 24 h), citrate excretion in the low normal range (265 mg in 24 h) and potassium wasting (20 meq in 24 h). Urinary excretion of uric acid, oxalate and phosphorus were in the normal range. Arterial blood gas analysis was normal with corresponding urine pH of 6.5. A furosemide and overnight fludrocortisone test (1 mg fludrocortisone 10 h pre-test/40 mg furosemide on day of test) was done for confirmation of incomplete distal renal tubular acidosis (RTA); urine pH remained at 6.5 confirming a distal acidification defect. There was no evidence of proximal tubular dysfunction. Plain radiograph and non-enhanced computed tomography (CT) of the abdomen showed left sided medullary

[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 67-year-old man presented to our ENT department with complaints of shortness of breath and dysphonia that had been ongoing for 2 months. This patient was referred to the ENT outpatient department with a growing tumor on the right side of the larynx. Histology of a biopsy sample verified a benign tumor. Because the biological behavior of the tumor was described as aggressive growth, a new biopsy was performed. The sample was analyzed, and histology showed a suspicious fibrosarcoma. He had not been smoking and denied alcohol consumption. Respiration was difficult.
A laryngeal examination revealed an exophytic mass in the right vocal cord and anterior commissure. The mobility of the right vocal cord was maintained, and there was a tumor of approximately 12 mm × 15 mm × 17 mm arising from the commissure and ventral part of the vocal cord.
Direct microlaryngoscopy was performed under general anesthesia with a representative biopsy taken from the lesion. The result of the histopathological examination was myofibroblastic sarcoma of the larynx. The laryngoscopy showed the tumor of the vocal cord, the mobility of the right vocal fold was with reduced excursion of the vocal cord by the tumor mass, but the mobility was more than 2 mm in the lateromedial direction. The vocal cord on the left had complete function.
Given the respiratory distress, an urgent tracheostomy with general anesthesia was performed.
CT scans showed the transglottic location of the tumor mass being 40 mm × 22 mm × 16 mm into the base of the epiglottic cartilage. No infiltration to the cartilage was evident. No lymph nodes were described, as the largest lymph node was not over 5 mm. See .
We performed a total laryngectomy. The tumor in the larynx was completely obstructed by the laryngeal lumen. Revision of the lymph nodes on both sides was performed, and no evidence of enlargement was detected. A histopathological diagnosis of myofibroblastic sarcoma of the larynx (MFS / LGMS) was performed.
The next s

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


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

[User]
RADIOLOGY NOTE:
A 54-year-old previously healthy man was admitted from another hospital for subarachnoid hemorrhage with left hemiparesis and hemihypesthesia.
During the previous two weeks, he had complained of a progressive headache and neck pain associated with dizziness. The headache was oppressive and holocranial, but particularly intense in the occipital region. It had strong postural variation, appearing only in the upright position and disappearing within seconds after lying down. He had no history of trauma. He developed numbness of the left limbs and fell, resulting in head injury and admission to the other hospital.
Physical examination detected a contused wound in the left temporal area. Neurological examination showed left hemiparesis with hemihypesthesia and left hemianopsia.
CT scan revealed right frontoparietal subarachnoid hemorrhage and a right parietal hematoma measuring 8 mm in diameter (reported as a probable venous malformation) (). The patient was treated with nimodipine and transferred to our hospital for further tests.
Cranial CT angiography showed hypoplasia of the A1 segment of the right anterior cerebral artery. The carotid artery, vertebral artery, and other branches of the circle of Willis were of normal size and patency.
Digital subtraction angiography to investigate the cause of intracerebral hemorrhage () found no aneurysms or arteriovenous malformations but revealed a tubular filling defect within the right frontoparietal superficial cortical vein (vein of Trolard) and signs of congestion of the other deep and superficial veins of the brain. Contrast material was slow to empty from the left transverse sinus, suggesting moderate intracranial hypertension.
After treatment with subcutaneous heparin and subsequently with oral anticoagulants, the patient's neurological deficits resolved but his headaches persisted. The headache worsened when standing and improved shortly after lying down.
Brain MRI () to investigate this headache showed diffuse pachymeni

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


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

[User]
RADIOLOGY NOTE:
A 49-year-old man with advanced AIDS (CD4 8 cells µl−1) and overall poor performance status on antiretroviral therapy was admitted in November 2016 with 10 days of nausea with vomiting and reported retching, chest pain, odynophagia and persistent diarrhoea. He had been admitted to the hospital at least five times in the previous 2 years and had a history of azole-resistant oral and esophageal candidiasis. Over the preceding months he was on suppressive therapy with fluconazole as an outpatient. His examination on admission was noteworthy for cachexia and oral thrush. He was started on micafungin 100 mg daily with delayed improvement in his upper gastrointestinal symptoms by day 5. He was awaiting discharge with a planned three-week course of micafungin. However, on day 7, aerobic blood culture collected on admission showed growth and Gram stain was reported as budding yeast. Given his clinical improvement, lack of fever and no new complaints, he was continued on micafungin with further diagnostics ordered. Ophthalmologic exam, echocardiogram, computerized axial tomography imaging of his head, lumbar puncture and cryptococcal antigen were all negative. Upper endoscopy was not done as his symptoms improved. Repeat fungal blood cultures were collected on day 7, which later showed no growth. The budding yeast were not identified as a possible dematiaceous fungus until hospital day 11 (). Multiple colonies were seen on the initial growth media, notably black in color by this time; however, complete identification could not be made by morphology alone and the isolate was sent to the Department of Health. Given the patient’s improvement in his presenting symptoms, he was discharged home to complete a final week of micafungin with planned follow up as an outpatient.
The isolate was eventually identified as A. pullulans by ribosomal RNA sequencing, and results were released 1 month after the patient’s admission date. Based on the report from the Department of Health using th

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


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

[User]
RADIOLOGY NOTE:
The patient was a 74-year-old woman who had undergone colectomy for adenocarcinoma of the sigmoid colon at the age of 72 years. Before the colectomy, she had been found to have a tumor measuring approximately 25 mm in the left lobe of the thyroid that was diagnosed as an adenomatous goiter by fine-needle aspiration. Two years after her surgery, a 6-month follow-up computed tomography (CT) scan revealed enlargement of the thyroid tumor, but she remained asymptomatic. Blood tests revealed a small increase in CA 19-9 (from 3.5 ng/ml 6 months earlier to 8.9 ng/ml) and in carcinoembryonic antigen (CEA) (from 1.7 ng/ml to 4.6 ng/ml). Her thyroid function tests were normal. Physical examination and laryngoscopy revealed a firm elastic nodule in the thyroid gland and left vocal fold paralyzed in the midline position. The maximum phonation time (MPT) was 10 seconds. There was no cervical lymphadenopathy. Ultrasonographic examination of the neck revealed a solid tumor in the left thyroid lobe with a diameter of 35 × 25 × 20 mm. CT showed spread of this mass to the tracheoesophageal groove, suggesting invasion of the left recurrent laryngeal nerve (RLN; ). Fine-needle aspiration cytology of the thyroid tumor showed a few clusters of elongated tumor cells with hyperchromatic dark nuclei on a background of benign hepatocytes, and the mass was reported as metastatic adenocarcinoma. Positron emission tomography-CT showed focal uptake in the left thyroid lobe with no evidence of distant metastasis (). Therefore, the diagnosis was metastasis of adenocarcinoma to the left thyroid gland. We then performed a hemithyroidectomy with resection of the left RLN and immediate reconstruction using the ansa cervicalis nerve (). The tumor was observed to be adherent to the adjacent structures, i.e., the trachea and external muscle of the esophagus as well as the left RLN. The surgical margin was confirmed to be adequate, and the decision was made not to

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


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

[User]
RADIOLOGY NOTE:
The patient was a 41-year-old female with past medical history of appendectomy and dysmenorrhea. She presented to the emergency department with nausea, severe vomiting, and acute pain in the lower abdomen. She reported having experienced asthenia and weight loss for one month. On clinical examination, abdominal distension and tenderness were discovered. Blood tests revealed leukocytosis with neutrophilia, and a contrast-enhanced abdominal computed tomography (CT) showed a 7 × 7 × 4 cm hyperenhanced mass in the cecum that caused complete bowel obstruction (). Also, a 5 × 3 × 3 cm right adnexal mass that compromised the ovary with intimate contact with the uterus was found (). Furthermore, the CT showed dilated loops in the small bowel (>4 cm), some of which had an enlarged wall thickness and presence of intraluminal fluid stasis ().
With these findings, particularly the observation of a mass through the CT scan, and due to the evident weight loss that the patient had undergone, neoplasia could not be ruled out. Surgery was decided, and at laparotomy, a volume of 200 ml of inflammatory fluid was found in the cavity. Most of the loops of the distal ileum were dilated, and a 7 × 7 × 3 cm cecum mass was discovered, which compromised the ileocecal valve and caused complete bowel obstruction. Surgical decision was straightforward, the cecum mass was completely resected, and a right hemicolectomy was executed. An ileocolic anastomosis was also performed during the procedure. Furthermore, the right adnexal mass that was previously identified through the CT scan (measuring 4 × 3 × 2 cm) was observed to be firmly attached to the ovary and the fimbriae and displayed a pale external capsule surrounded by a cystic component. Gynecology consultation was required, and due to the size of the mass and its characteristics, surgical removal of the right adnexal mass was performed. After completion, closure of the abdominal wall was performed, and the remainder of the procedure continue

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


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

[User]
RADIOLOGY NOTE:
A 16-year-old Hispanic male with a past medical history of bronchial asthma presented with his caretaker to our institution with complaints of intermittent abdominal pain, wet cough, and poor weight gain since infancy. The patient also had associated foul-smelling, floating stool with inability to gain weight despite a good appetite. He had no history of gastrointestinal disease, multiple respiratory infections, or severe asthma attacks. He also complained of a recent development of symmetric wrinkling with fissures and swelling of his hands’ palmar skin. His caretaker explained noticing the wrinkling during infancy; however, it was not until the start of his new job at a carwash when it became more prominent. Symptoms occurred within 3-5 minutes of water exposure and resolved within minutes after terminating water contact with no residual side effects. He could not associate worsening of wrinkling with water temperature or various bodies of water. There was never itchiness, pain, or burning sensation present with wrinkling. The patient mentioned having dry skin and increased sweating in his palms since infancy but had never been diagnosed with a dermatological condition. He also denied any family member experiencing similar symptoms.
On the physical examination, the patient’s height and weight were below the third percentile based on age, with his body mass index (BMI) at the 23rd percentile. He also presented with neurodevelopmental delay closer to the age of 11-12 years. Upon mouth inspection, oral mucosa was dry with gingival inflammation and halitosis present. Breath sounds on bilateral lung fields were clear; yet, clubbing was appreciated bilaterally in his upper extremities. The abdomen was mildly distended with normal bowel sounds and non-tender to palpation on all quadrants. The patient was asked to wet his hands on the examination room sink for 5 minutes. Increased thickness and wrinkling with associated blanching and edema was seen on bilateral palms 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 61-year-old African American male with past medical history of hypertension and schizophrenia presented to the emergency room following 2 episodes of syncope.
He reported 3 month history of progressive neck mass. Physical examination revealed a temperature of 37.7 degrees, blood pressure of 130/87 mmHg, pulse of 92 bpm, and respiratory rate of 17 bpm. There was extremely large left sided neck mass extending into the left axilla and multiple palpable left and right cervical lymph nodes. The lungs were clear to auscultation, and there was a 2/6 systolic ejection murmur heard best at the bases. The abdomen was soft and nontender, without palpable organomegaly. There was a 5x2 cm right gluteal non-tender, non-mobile mass with central ulceration and also a 2x2 cm spherical mass at the left upper back with small central ulceration. There was 2+ pitting edema of the lower extremities bilaterally. There was differential swelling of left upper extremity. Electrocardiogram showed normal sinus rhythm, left axis deviation, low voltage and mild t wave inversion in V2–V4 ().
Initial CT scan of the abdomen and pelvis showed diffuse metastatic disease of the visualized lower chest, abdomen and pelvis including superficial soft tissues, left kidney, and probable right kidney. There was diffuse confluent adenopathy and massive right inguinal lymphadenopathy, along with pronounced diffuse anasarca. There are multiple renal masses. There are solid masses arising off of the lateral aspect of the left kidney involving the upper, middle and lower lobe (). The left kidney mass was described as an exophytic lesion. There was a mass along the anterior aspect of the heart that measures approximately 5 cm but incompletely visualized. CT head was negative.
Transthoracic echocardiogram revealed a large mass measuring 4.8 cm x 3.0 cm extending from the apex to the mid RV cavity, and extending into the RV outflow tract stopping just short of the pulmonic valve (). There

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


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

[User]
RADIOLOGY NOTE:
A 67-year-old female was admitted to the hospital due to chest pain for three hours. She had a history of arterial hypertension for 30 years and diabetes mellitus (DM) for 3 years. ECG showed acute inferior and right ventricular myocardial infarction. After administration of 300 mg aspirin, 180 mg ticagrelor and 5000 U heparin, CAG was carried out emergently via the right TRA. The results showed that there was 60–70% stenosis in the middle of the right coronary artery, and the distal segment was completely occluded. Then, a 2.5 × 28 mm drug-eluting stent was implanted into the distal segment of the right coronary artery. The 6Fr sheath (Terumo Radifocus) was removed from the radial artery after 25.5 h, and the puncture site was bandaged with gauze for ten hours. On the third day post operation, we found that the pulsation of the artery near the puncture site could not be appreciated during palpation, whereas a weak pulse existed in the distal radial artery in the AS region. We suspected that the radial artery might be occluded. Vascular ultrasonography showed that there was no blood flow near the puncture site. Because the patient had recently undergone right RAO, we decided to recanalize the occlusion via the right dTRA. Therefore, after successful puncture of the distal radial artery in the AS, the radial artery was confirmed to be completely occluded by cannula angiography (Fig. ). Then, a 6Fr sheath (Terumo Radifocus) was inserted into the distal radial artery, and the tip of the sheath was near the distal segment of the occlusion. After failing to absorb the thrombosis, a Runthrough guidewire was sent through the occluded segment, then we injected 2000 U heparin and 200 ug nitroglycerin through the sheath, and a BRAUN 2.0 × 20 mm balloon was used to dilate the occluded segment with 8–10 atm × 1 min of pressure for several rounds. Repeated angiography showed

[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 five-year-old male began experiencing a popping sensation followed immediately by the sensation of heat and pressure starting medially at the base of the skull which radiated two centimeters bilaterally. He was a product of a nonconsanguineous union, whose birth history did not involve instrumentation and whose past medical, surgical, and developmental histories were all noncontributory. This sensation was experienced simultaneously with bilateral numbness of the posterior tongue and difficulty in speaking, both of which lasted fifteen seconds with gradual attenuation. The above would occur upon abrupt lateral rotation (either direction) of the head approximately five to ten times a year unrelated to trauma, diminishing in frequency as the patient aged.
Between the ages of eleven and fifteen, as a competitive fencer, the patient would experience the same symptomology when performing actions involving extreme, abrupt lateral rotation of the head, translating to a frequency of approximately once to twice weekly.
At the age of nineteen, during military training and combat, the same symptomology was experienced approximately fifteen times when abrupt lateral rotation of the head prompted by various forms of minor external head trauma was experienced. After discharge from the military, frequency of these episodes was sustained with simple lateral rotation of the head outside the context of trauma for six months with spontaneous abatement.
At the age of twenty-one, the first time the patient came to medical attention for the above complaint, the patient's physical and neurologic examinations were completely normal, including cranial nerve exam. Of note, the patient was not hyperelastic, nor was there a family history of the same. Magnetic resonance imaging (MRI) of the cervical spine (Figures –) was performed revealing slight dysplastic enlargement of the anterior arch of C1 vertebrate, mild degenerative changes of the atlantoaxial junction, and spinal canal caliber on

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


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

[User]
RADIOLOGY NOTE:
A 24-year-old office worker male presented to outpatient orthopedics department of our hospital with nonresolution of his symptoms despite a previous surgical intervention. His complaints dated 6 months back when he sustained trivial trauma following which he was unable to bear weight on his right lower extremity. There was no history of fever or constitutional symptoms. An X-ray right hip and pelvis were performed which revealed a subtrochanteric fracture of the right femur with displaced fracture fragments []. There was no evidence of osteoporosis, lytic/blastic lesion suggestive of bone tumor. Subsequently, he underwent open reduction with intramedullary nail fixation for fracture stabilization.
After 6 months postsurgery, he presented to our outpatient with complaints of persistent local pain and swelling. He was unable to bear weight on the right lower limb. Fresh radiographs revealed lysis around the implant with resorption of the fracture ends []. Notably, there was no evidence of callus formation. Computed tomography scan or magnetic resonance imaging could not be performed due to financial constraints. Suspecting persistent low-grade chronic pyogenic infection, he was planned for surgical debridement with external fixation. Intraoperatively, the muscles and soft tissues were found to be indurated. Pearly white structures and granulation tissue were identified at lesional site. A through betadine wash was performed, excised tissue sent for histopathology, and external fixator applied.
The excised specimen consisted of multiple fragments including pearly white-flattened structure measuring 2.8 cm × 2 cm × 1 cm. Microscopy revealed fragments of thick eosinophilic acellular lamellated membrane corresponding to parasite exocyst []. Degenerating bits of thin endocyst/inner nucleated germinal layer were seen occasionally. High magnification showed characteristic refractile dagger-shaped hooklets []. Hence, diagnosis of hydatid disease of the right femur was render

[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 41-year-old African-American man was admitted to the hospital after 2 days of acute onset of non-exertional shortness of breath and a non-productive cough. His medical history included chronic back pain and seizure disorder. He was involved in a motor vehicle accident about 2 months prior to admission, after which he started having the chronic back pain. He has an extensive history of alcohol use for at least 5 years, a seven pack-year history of tobacco use and marijuana use daily for the last 5 years. Vital sign was only remarkable for tachycardia with a heart rate 130 bpm and tachypnoea. His blood pressure was 112/85 mm Hg, and he was breathing without supplemental oxygen with 97% O2 saturation. Physical examination on admission was significant for decreased breath sounds on the right compared with the left, diffuse wheezes, and rales on the right lower and mid lung fields. His cardiac examination was unremarkable, and his abdomen was soft and non-tender, with no costovertebral tenderness.
On admission, a chest X-ray was taken of the patient that showed a right pleural effusion extending through two-thirds of the patient’s right hemithorax (). The patient also had a CT thorax with contrast that showed a right pleural effusion which appeared to communicate with right retroperitoneal fluid via a Bochdalek hernia as well as a 1.5 cm hypodensity in the posterior pancreatic body with dilation of the main pancreatic duct. CT of abdomen without contrast confirmed fluid in the right pararenal retroperitoneal space communicating with the large right pleural effusion via a right-sided Bochdalek hernia (). A cystic lesion in the posterior pancreatic body was also seen that appeared to communicate with the dilated main pancreatic duct with associated main pancreatic ductal dilatation.
A diagnostic and therapeutic thoracentesis was performed, removing a total of about 1.5 L of serosanguineous fluid. The pleural fluid was consistent with exudative

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


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

[User]
RADIOLOGY NOTE:
A 68-year-old woman was admitted to the emergency department for abdominal pain and lower leg swelling that had begun about 2 months prior and worsened a day ago. She underwent cholecystectomy and appendectomy 5 years previously and had a medical history of hypercholesterolemia and hypertension. A colonoscopy was performed approximately a year ago, and there was no abnormality except for mild colitis. Physical examination revealed mild swelling of the lower extremities and no abdominal tenderness.
A computed tomography (CT) scan revealed a large thrombus from just below the intrahepatic IVC to the common iliac vein (CIV), which seemed to be acute-on-chronic DVT (). There were no lesions causing external compression to the IVC. Only D-dimer was increased to 0.95 mg/L fibrinogen equivalent units, and laboratory tests including protein C, protein S, antithrombin, IgG anticardiolipin, lupus anticoagulant, and homocysteine levels were all normal.
After puncture of the right internal jugular vein, venography was performed. Venography showed the thrombus from just below the intrahepatic IVC to the right CIV, over a length of approximately 16 cm (). A 14-mm×10-cm Niti-S stent (Taewoong Medical, Seoul, Korea) was inserted via the right internal jugular vein to remove the IVC thrombus. The stent was woven from a single thread of nitinol wire in a tubular configuration and could be retrieved after partial deployment by advancing the outer sheath. After positioning of the stent at the top of the thrombus, the stent was partially deployed and gently advanced to cover the thrombus. Subsequently, the 12-F outer vascular sheath was advanced to capture the thrombus, and the stent was retracted through the vascular sheath capturing the thrombus. This procedure was repeated until the entire thrombus was removed (). On final venography, most of the IVC thrombus was removed; however, a small amount of the thrombus remained firmly attached to the lower IVC and the right CIV wall (). Bloo

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


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

[User]
RADIOLOGY NOTE:
A 60-year-old male patient reported with the chief complaint of swelling in the lower right side of the face since 1 month. History revealed that the swelling was small 1 month back which rapidly grew to attain the present size.
Extra-oral examination revealed a diffused swelling on the right side of the face measuring approximately 6 × 7 cms in size, extending from the temporal region to inferior border of the mandible superior-inferiorly and from the nose to the ear anteroposteriorly. The skin over the swelling was slightly stretched with no secondary changes []. On palpation the swelling was non-tender, varied in consistency from soft in the center to hard at the periphery. The right sub-mandibular lymph nodes were palpable, non-tender, hard and fixed to underlying structure.
Intraoral examination showed an oval swelling present on the right side of the jaw in the retromolar area measuring approximately 4 × 3 cms in size. The swelling had diffuse margins with smooth surface [].
Radiological examination revealed a diffused radiolucency involving the lower body and angle of the mandible extending from right second premolar to angle of the mandible [].
Considering the size and aggressive nature of the lesion, surgical resection with wide margins of the lesion was carried out. The gross soft tissue specimen received for histopathological examination measured approximately 12 × 5 mms in size, was soft to firm in consistency, irregular in shape and whitish brown in color. The surgical material was fixed in buffered formalin and subjected to histopathological analysis.
On histopathological examination, the Hematoxylin and Eosin (H and E) stained section showed sheets of tumor cells interspersed by cartilage area showing calcification [Figures and ]. Higher magnification showed pleomorphic cells with large basophilic ovoid nuclei and small darkly stained nuclei with little cytoplasm [Figures and ]. High degree of vascularity was seen in some areas. Scattered, small, poor

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


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

[User]
RADIOLOGY NOTE:
A 6-year-old male who presented with complaints of tremors in right upper limb for two months which did not increase in frequency or severity over this period. He had history of occasional holocranial headache for two months. There was no memory or behavioral changes or compromise of school performance. Systemic examination was normal and neurological examination revealed no gross deficit except blurred margins of optic disc. Contrast enhanced CT scan showed large defined isodense mass lesion involving the bithalamic region with continuity in midline. Lateral ventricles were enlarged anteriorly and posteriorly to the mass. There was no enhancement on contrast.
MR of head showed huge bithalamic lesion, of size about 7 cm × 7 cm × 5 cm interconnected with massa intermedia without any gap in between, occupying whole of the third ventricle, except a part anteriorly. It was uniformly isointense on T1 weighted and, hyperintense on T2 and FLAIR weighted images, with no contrast enhancement.
There was no restriction to diffusion weighted images. Extent of lesion was up to midbrain, infiltrating bilateral cerebral peduncles reaching to left medial and posterior temporal and medial occipital lobes. Lateral ventricles were dilated with periventricular lucency and no perilesional edema was present [Figures –]. MR spectroscopy (water suppressed proton MRS) of the tumor revealed choline and creatinine peaks with creatinine peak greater than choline peak. The N acetylaspartate signal was decreased. Small lactate peak was also noticed [].
As the mass was very bulky and ventricles were also obstructed, a decision to debulk (and not only biopsy) was taken in order to reduce the mass effect in supratentorial compartment. He was planned for surgery with interhemispheric and transcallosal approach. Lateral ventricles were distorted. A possible tumor decompression was done and a decompression of about 30% was acheived. Intraoperatively tumor was very firm, moderately vascular which was n

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


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

[User]
RADIOLOGY NOTE:
A 37-year-old male patient went to the ophthalmic emergency room complaining of pain in the left eye, lasting for two months, with high intensity shooting and progressive ipsilateral eyelid swelling, followed by diplopia and decreased visual acuity. An external eye examination showed hard and cold edema of the lower eyelid, ocular motility with limitation in adduction, and discreet ipsilateral proptosis. Hertel exophthalmometry was used to measure the degree of ocular protrusion and the value obtained was 18,2 mm for the right eye and 25 mm for the left eye ().
The best corrected visual acuity was full (20/20) in the right eye and 0.8 (20/25) in the left eye. No refractive error was detected in any of the eyes. Biomicroscopic examination of the right anterior segment did not reveal any abnormal findings, although the left eye showed conjunctival hyperemia, chemosis, and keratitis.
Intraocular pressure was measured using an applanation tonometer and it was found to be 11 mmHg in the right eye and 16 mmHg in the left eye. No pathological findings were detected during fundoscopy. The optical coherence tomography (OCT) of the left eye revealed no abnormalities. The cause for low vision in the left eye was found to be eyelid edema and keratitis. The cause for left eye motility reduction was the extraocular muscles (EOM) affected by the lesion. The affected EOM were the lateral rectus, inferior rectus, and inferior oblique. Magnetic resonance of the orbit showed left eye proptosis and thickening and increase of soft tissues associated with heterogeneous impregnation of contrast in the infralateral region of the left eyelid (Figures and ). A biopsy was performed in the lower left eyelid on the second day of hospitalization using the Posterior Inferior Orbitotomy to access the lesion.
Histology showed a chronic inflammatory process, well-formed, tightly packed, with nonnecrotizing granulomas surrounded by lamellar hyaline collagen, and negative immune

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


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

[User]
RADIOLOGY NOTE:
A 58-year-old woman was diagnosed with poorly differentiated squamous cell carcinoma of the right base of the tongue with lymph node metastases. She underwent partial glossectomy and right modified neck dissection in 2016. She was treated with five cycles of adjuvant radiation as well as 5-fluorouracil and cisplatin chemotherapy with weekly cetuximab postoperatively. Five months after surgery, she was found to have osseous metastatic lesions in T12 and L3 vertebral bodies with extension into the left pedicles and surrounding soft tissue extension into the left paraspinal muscles. Therefore, she was treated with palliative radiation therapy. Despite the extensive treatment, she was later found to have metastatic lesions in the liver. She then received two doses of immunotherapy with pembrolizumab.
Her initial hemoglobin level prior to treatment with pembrolizumab was 9.8 g/dL. Three weeks after receiving one dose of pembrolizumab, her hemoglobin dropped to 7.8 g/dL. She was subsequently transfused with one unit of packed red blood cells and received a second dose of pembrolizumab on the same day. She was noted to have isolated anemia with a hemoglobin of 6.7 g/dL three weeks after receiving the second dose. There was no known source of bleeding despite extensive medical workup. Direct antiglobulin test was negative, and total bilirubin was not elevated (1.1 mg/dL) with a direct bilirubin of 0.2 mg/dL. The differential diagnoses at that time included acquired drug-related PRCA, B19 parvovirus-associated aplastic crisis, a marrow infiltrative process such as squamous cell carcinoma metastasis to the bone marrow, or a lymphoproliferative disorder. To further evaluate the cause of anemia, she underwent a bone marrow biopsy and aspiration with a review of her peripheral blood smears. The bone marrow findings are consistent with those of PRCA, likely related to immunotherapy. Following the bone marrow biopsy, the patient was noted to have declining performance status and 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:
A 30-year-old male patient presented to the outpatient clinic of the Endocrinology Department with chief complaints of a 6 kg weight loss over the last four months and bilateral prominent and bulging eyes. In addition he gave a history of palpitations and tremors. He also had complaints of frequent loose motions and heat intolerance. He was a known case of rheumatic heart disease with mitral stenosis under treatment with salt restriction, digoxin, and β blockers. In the last four months he was admitted thrice, with episodes of atrial fibrillation and congestive heart failure. He had no history of liver disease. He was neither a smoker nor an alcohol consumer.
On physical examination, he had fine tremors of both hands. His weight was 49 kg. Pulse rate was 120 beats / minute, regular, and blood pressure was 150 / 70 mmHg in the right arm supine position. Eye examination showed bilateral exophthalmos, with conjunctivitis and periorbital edema. There was diplopia on looking to both sides, indicating ophthalmoplegia amounting to stage IV NOSPECS classification. Hands were warm and moist. Thyroid was soft and diffusely enlarged with grade 3 goiter and audible bruit. The liver and spleen were not palpable. Cardiovascular system examination revealed loud first heart sound and mid-diastolic murmur, with delayed peaking at the mitral area. There was no evidence of pulmonary arterial hypertension or congestive heart failure at presentation. The other systemic examination, including per abdomen examination, was unremarkable.
His initial T4 was 22.4 μg / dl and TSH < 0.01 uIU / ml. He was diagnosed with Graves’ disease and started on propranolol with prednisolone for Graves’ ophthalmopathy. Carbimazole was also initiated at a dose of 30 mg per day, in two divided doses. He neither did a thyroid scan nor took I131 because of concern with iodine allergy and exacerbation of the eye manifestations. Three weeks later, FT4 was normal

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


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

[User]
RADIOLOGY NOTE:
A 43 year old female with chronic back pain developed depression and attempted suicide with an overdose of diazepam and methadone after an argument with her husband in the evening. She intentionally consumed approximately 40 to 50 tablets of diazepam at 5 mg strength as well as an unknown quantity of methadone tablets was found the following day in an unresponsive state with a respiratory state of only 4 breaths per minute but was revived at a local hospital with the use of naloxone. Although she could awaken and answer questions appropriately, this was only transient and required a naloxone drip infusion over 24 hours; no flumazenil had been used. Her potassium was also elevated initially at 7.6 that later normalized and had a leukocytosis secondary to mild aspiration pneumonia that was successfully treated with antibiotics. She was discharged within one week in a much improved state to a psychiatric facility. After two days as in-patient for psychiatric care, she was discharged to home in a markedly improved state with a mental status that was back to her baseline and fully able to be self-sufficient without any cognitive deficits. Interview with family and friends confirmed that she was cognitively normal and fine up until 3 weeks after the event when she abruptly changed midday and seemed confused and forgetful with a rapid worsening the following day. She was first noted not be able to play cards with her family, had developed social withdrawal with a lack of personal hygiene, and became incontinent as well. She appeared very lethargic and not very interactive. After this continued for approximately 5 days without any improvement, she was evaluated at the Emergency Dept. and admitted after a CT head exam disclosed marked and diffuse hypointensity throughout the subcortical white matter (). This was later evaluated by MRI as being a confluent change throughout the entire white matter, and appeared diffusely hyperintense on both FLAIR and T2 weighted sequences ()

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


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

[User]
RADIOLOGY NOTE:
A 37-year-old woman with LAM underwent bilateral lung transplantation on cardiopulmonary bypass for progressive hypoxic respiratory failure despite medical therapy with sirolimus over the preceding 5 years. Sirolimus was held for a total of 9 weeks prior to transplant (3 weeks prior to listing). She was extubated to room air on postoperative day (POD) 3, but developed a right sided chylothorax on day 4. Conservative measures, including no enteral nutrition, total parenteral nutrition (TPN), and subcutaneous octreotide were attempted with no clinical improvement. On POD 26, she required a sub-xiphoid window for a large pericardial effusion. An attempt at lymphangiography to seal the thoracic duct was attempted 6 weeks after transplant but was unsuccessful. She developed a chylous leak from the abdominal portion of the thoracic duct, resulting in chylous ascites. On POD 55, she underwent right sided video-assisted thoracoscopy with lysis of adhesions and mass ligation of the thoracic duct, but the chylothorax persisted. Both sirolimus and everolimus were tried after transplant without success. Whereas sirolimus was reasonable well tolerated pre-transplant, she developed anasarca after transplant. Everolimus was started at 5 mg, increased to 10 mg daily, and continued for 6 weeks. However, she developed ill-defined bilateral lung infiltrates and hypoxia not attributable to acute rejection or infection. These resolved after discontinuation of the drug.
Five months after transplant she underwent thoracotomy with repeat ligation of the thoracic duct and two additional large lymphatic tributaries, as well as mechanical and chemical pleurodesis resulting in resolution of the chylothorax. A Denver shunt was placed to control chylous ascites. This shunt would require multiple revisions, manipulations, and replacements over the next 2 years and finally removed. She was referred to a second tertiary care center with a specialized lymphangiography unit for an opinion and possibl

[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 male patient was referred to the department of oral and maxillofacial surgery, with a complaint of chronic persistent dislocations for 5 years. The patient's general health was good. He had no history of previous mandibular trauma. On clinical examination, pain in the bilateral preauricular region and reciprocal click on both sides were observed. Mandibular movement was restricted on both sides. At clinical examination, it was observed that the temporal, masseter, and lateral pterygoid muscles were tender and painful bilaterally. Intraoral examination showed that he had a good oral hygiene. No occlusal disturbances were observed. Orthopantomogram revealed that the right and the left condyles being positioned anterior to the glenoid fossa [].
The patient informed that he had undergone an autologous blood injection. After the treatment, his symptoms recurred. Therefore, surgical management (bilateral eminectomy) of the mandibular dislocation was planned. A three-dimensional model from the cone beam computed tomography data was received to guide and assist in operation for providing precise cut of the articular eminence [].
Bilateral eminectomy surgery was performed under general anesthesia. Standard preauricular approach was used. A vertical incision was made into the temporal fascia over the root of the zygomatic arch in the region of the glenoid fossa. The articular tubercle was exposed by subfascial and subperiosteal dissection []. The superior joint space was opened and checked by manipulation of the mandibular movement. The articular eminence was controlled on the model and both were removed using piezosurgery during the operation [Figures and ]. The temporomandibular ligament and the joint capsule were sutured to the zygomatic arch through 3–4 drill holes, and the overlying soft tissues were closed in layers.
The patient made an uneventful recovery being discharged from hospital the following day. During the 3 weeks after surgery, the patient was i

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


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

[User]
RADIOLOGY NOTE:
A 61-year-old Caucasian male presented to the hospital with a complaint of sudden shortness of breath. CT scan of his lungs was diagnostic for pulmonary emboli and a small lung nodule of 0.5 cm, and incidentally revealed a left adrenal mass of 9 cm. The patient was treated with anticoagulation for pulmonary emboli. He did not show any symptoms of hyper or hypoadrenalism, but serum metanephrine and cortisol were done routinely to determine the secretory status of the adrenal adenoma, and both of them were within normal limits. Biopsy of the left adrenal nodule was ordered by a general practitioner and was performed one month after the discharge, and it was found to be non-diagnostic. However, a repeat biopsy done three weeks after the first one revealed adrenal cortical tissue, raising concerns related to adrenal hyperplasia, adenoma, and unrepresentative biopsy material. The patient was referred to endocrinology three months later. Evaluation by the endocrinologist did not reveal any history of weight gain, weakness, or insomnia. The patient had not observed any change in his libido or hair distribution. He had a history of hypertension for more than 10 years, which was being controlled with two medications. Physical exam showed normal vital signs, no stigmata of Cushing’s syndrome, and normal body mass index (BMI). Urine analysis for catecholamines and cortisol were within normal limits, and so were serum aldosterone-to-renin activity, electrolytes, and dehydroepiandrosterone sulfate (DHEA-S) levels. A repeat CT scan of the abdomen done four months after the first one revealed a bi-lobed heterogeneous mass in the left adrenal gland measuring 9 x 5.5 cm with a central low density likely indicating necrosis (Figure ).
The mass was suspicious for ACC. A CT scan of the patient's lungs revealed enlargement of the lung nodule to 0.8 cm. He subsequently underwent FNA of the pulmonary nodule.
The adrenal core biopsy and lung nodule fine needle aspirate were sent to a patho

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


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

[User]
RADIOLOGY NOTE:
A two-week-old female was brought in with an initial complaint of multiple masses that failed to regress since birth. She was born from a nonconsanguineous union and the mother’s pregnancy was uneventful. The baby was delivered vaginally at 37 weeks of gestation and multiples masses were found over the body. The treating physician advised follow-ups on discharge. However, the parents decided to seek more medical help for the child and she was admitted for more investigations.
On physical exam, the child was alert and active. She was not jaundiced and no pallor was noted on the extremities. Her vitals were all within the normal range and the birth weight and changes in weight corresponded properly. Two masses measuring 26 mm by 19 mm and 19 mm by 17 mm were observed on the forehead and the scalp (Figures -). One smaller mass was seen on the abdomen, measuring 11 mm by 10 mm (Figure ). All three masses were red and non-hemorrhagic. The parents reported that the size of the masses did not change since birth. No similar family history was found and both parents were healthy. Any hepatosplenomegaly was not observed on palpation nor were any other cutaneous lesions detected. She did not present with any other systemic abnormalities. An ultrasound was performed, and it revealed a normal liver, spleen, and kidneys with no masses or lesions. A Doppler examination also showed a fast-flow vascular lesion, as reported by many other articles []. The full blood count showed normal levels of white blood cells, platelets, hematocrit, and red blood cells.
The diagnosis of congenital hemangioma was confirmed and the family was properly educated about the condition as well as possible complications. A wait and watch approach was adopted and the child was scheduled for regular visits at three months. The family was asked to properly monitor the size of the masses and informed that appropriate surgical treatment would be provided if the masses fail to regress or if they continue to grow

[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.