[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 visited the emergency department of our hospital due to sudden paraplegia of both lower extremities caused immediately after slip down. On presentation to the department, both his lower limbs were observed to be almost paralyzed, with a motor grade of 2 or lower in both limbs. This paralysis showed a gradual aggravation. The patient had a history of renal cell carcinoma diagnosed 7 years prior, and achieved remission without any recurrence after total nephrectomy and adjuvant chemotherapy. He was also diagnosed with papillary thyroid carcinoma 5 years ago, and yet again achieved remission after surgical treatment. The patient signed an informed consent statement, and the study was approved by the Institutional Review Board of the Yeungnam University Medical Center.
The plain radiograph revealed the collapse of the T12 vertebral body. CT showed an acute burst fracture at the T12 vertebral body with an osteolytic mass-like lesion within the vertebral body and pedicle, causing severe encroachment of the spinal canal (Fig. ). Magnetic resonance imaging (MRI) revealed a bulging posterior cortex, with an acute fracture of the vertebral body and severe compression of the spinal cord (Fig. ). Considering his medical history and the MRI findings, a pathologic fracture with a tumorous condition was suspected. Therefore, the evaluation of the malignant potential and metastasis in the remote area was necessary. Hence, 18FDG PET/CT was performed, and 18FDG uptake at the T12 level was measured. A maximum standardized uptake value (maxSUV) of 1.7 was noted, with a central FDG defect on the vertebral body (Fig. ); this was interpreted as a benign fracture by a senior radiologist. Additionally, there was no positive uptake in the other body parts on PET/CT. Although there was a discrepancy between the interpretation of the spine fracture lesion on MRI and PET/CT, the patient required emergent surgical treatment owing to acute paraplegia caused by spinal cord compre

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


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

[User]
RADIOLOGY NOTE:
A 57-year-old male patient was referred to our hospital because of blood in the sputum for more than 2 months and a lung mass found on a plain CT scan in a local hospital. The patient had a small amount of white mucous sputum with bright red blood filaments, without chest pain or abnormal body temperature.
The patient's laboratory examination in our hospital showed that the white blood cell count increased to 13.59 × 109/L in the blood routine, and neutrophils accounted for 90.6%. In the male tumor markers combination (14 items), carcinoembryonic antigen (CEA) serum level increased to 19.76 ng/mL (normal range, 0–5 ng/mL), and the other markers were within the normal range.
Chest contrast-enhanced CT revealed a 53 × 46 mm mass in the posterior segment of the right upper lobe with heterogeneous enhancement, extensive central liquefaction, a few striped shadows around the tumor, and multiple enlarged mediastinal lymph nodes (Fig. A to C). Lung cancer with a small amount of peripheral obstructive inflammation is considered and further examination is recommended to assist in the diagnosis.
Whole-body PET/CT showed a round cystic-solid mass in the posterior segment of the right upper lobe, with irregular margins. The thickness of the cyst walls was not uniform. The cystic wall showed significantly increased fluorodeoxyglucose (FDG) uptake (maximum standardized uptake value was approximately 8.70), but the central cystic component was not accompanied by FDG uptake. Several enlarged lymph nodes with increased FDG uptake were observed in the right hilum and mediastinum, and the maximum standardized uptake value was approximately 4.82 (Fig. ).
The doctors considered the possibility of a malignant tumor in the right upper lobe with multiple lymph node metastases in the right hilum and mediastinum, and suggested a needle biopsy at the site with a high metabolism and more solid components at the upper edge of the tumor. Chronic mucosal inflammation with interstitial fibrous hyp

[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 female patient was referred to a dentist for evaluation of a painful expansion in her mandible []. Intraoral examination revealed a diffuse swelling in the posterior area of the left mandible. The overlying mucosa was erythematous, ulcerated and necrotic []. The panoramic radiograph showed a radiolucent lesion with ill-defined borders extending from the second premolar to second molar []. The incisional biopsy was performed, and the general pathologist's diagnosis was ameloblastoma. Other consulting reports from other General Pathology Departments were ameloblastic fibroma (AF), osteosarcoma and mesenchymal chondrosarcoma. Due to the first microscopic diagnosis (ameloblastoma), en bloc resection from the second premolar to the third molar was done and reconstruction was performed after 6 months using autogenous iliac bone graft stabilized using titanium mesh and plate. Two years later, she came back with a huge recurrent lesion and obvious facial asymmetry. Therefore, she was referred to an oral and maxillofacial pathology center for more investigation, and her primary biopsy specimens and previous histopathological slides were reviewed. Two slides (number 1, 2) of the primary lesion were present. Careful evaluation of slide number 1 showed scattered benign ameloblastic islands and dental papilla-like stroma with tumoral giant cells [Figures and ]. Hyalinization was seen around these benign islands []. Dentinoid material was also found near some odontogenic epithelial nests []. Slide number 2 revealed a highly cellular mesenchymal tissue with hyperchromatic and bizarre pleomorphic cells without any epithelial islands. The malignant counterpart was similar to a poorly differentiated round-cell sarcoma. Some eosinophilic materials, most likely dysplastic dentin, were also found in this malignant counterpart [Figures and ]. The eosinophilic material was osteoid-like, and in these areas, the histopathologic feature was very similar to fibroblastic osteosar

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


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

[User]
RADIOLOGY NOTE:
A 48-year-old Caucasian man with past medical history of asthma, diverticulitis, benign prostatic hyperplasia, presbyopia, and obesity presented with a tender palpable left forearm mass. The pain started five years after the patient sustained a deep knife wound in this area that required stitches. Initially, without significant discomfort, the mass progressively grew for years. The pain worsened significantly in the last eight months prior to presentation as he began experiencing dysesthesias that radiated distally to his thumb, index, and middle fingers when the mass was lightly touched. The pain had become so bothersome to the patient that even the wind blowing across his forearm caused extreme discomfort. It affected his livelihood as a truck driver and was deterring him from playing golf.
Plain radiograph revealed a 1.6 cm ovoid density within the lateral soft tissues of the left forearm (Figure ). Subsequently, a MRI of the left forearm was taken, which showed a 1.6 x 1.3 x 1.8 cm subcutaneous mass with low T1-weighted signal intensity that avidly enhanced with contrast and high-intensity signal on T2-weighted imaging (Figure ). The mass was closely associated with the neurovascular bundle following the course of the superficial branch of the radial nerve (Figure ). This led to the initial conclusion of the mass resembling an intrinsic nerve tumor such as schwannoma, neurofibroma, or a traumatic neuroma.
On physical examination, light touch of the mass elicited significant discomfort and dysesthesias in the distribution of superficial branch of radial nerve, but sensation to both light touch and pinprick was intact as well as the motor function of the entire hand. No atrophy of the hand muscles was observed. Considering the patient’s prior trauma to the forearm at the same location as the tumor and the imaging features, the presumptive diagnosis became neuroma, a reactive neoplasm that can arise from an injured nerve [

[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 75-year-old man known to have a locally advanced tumor in the transverse colon was readmitted to our department because of generalized weakness, nausea, vomiting, and increasing abdominal pain. Three months earlier, he had undergone SEMS insertion owing to tumor obstruction. Subsequent computed tomography (CT) of the chest, abdomen, and pelvis showed a tumor in the transverse colon, with involvement of the jejunum and the greater curvature of the stomach, together with local carcinomatosis. Biopsies showed colonic adenocarcinoma. Owing to the clinical condition of the patient and the advanced state of cancer, he was not deemed suitable for curative resection or palliative chemotherapy; instead, he underwent only stent placement and received regular blood transfusions.
When the patient was readmitted, he presented with feculent and bloody vomiting. A CT scan of the abdomen showed a cologastric fistula from the anal side of the tumor. A repeat colonoscopy was performed. The stented tumor area could easily be identified on both fluoroscopy and endoscopy. It was possible to pass the colonoscope through the previously stented segment. A guidewire was introduced with the tip of the colonoscope at the oral side of the tumor to ensure that the guidewire was positioned intraluminally along the entire length of the previous stent. The endoscope was then retracted to the anal end of the primary stent, and the guidewire was safely positioned. A covered COMVI enteral colonic stent (22×80 mm, CCT2208BA; Taewoong Medical Co. Ltd., Seoul, Korea) was introduced through the instrument channel of the colonoscope and passed over the guidewire through the previously stented segment. The COMVI enteral colonic stent has a biocompatible polytetrafluoroethylene membrane tube, which is held between an inner and outer unfixed cell structure mesh. It has three radiographic markers at the proximal, central, and distal parts of the stent, respectively. The stent was positioned such that the mi

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


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

[User]
RADIOLOGY NOTE:
A 55-year-old female patient of Greek origin was admitted in our hospital due to a recurring febrile syndrome up to 39oC during the week before the admission for which the family physician had prescribed ciprofloxacin for presumptive urinary tract infection in the context of intermittent bladder catheterizations without resolution of the symptoms.
The patient was diagnosed with probable MSA with onset 2 years before presentation. Initially, urinary incontinence was attributed to genitourinary syndrome of menopause and due to failure to manage with medical treatment the patient resorted to intermittent bladder catheterization. Symptoms progressed with frequent falls and documentation of orthostatic hypotension and finally, parkinsonism. The disease was not responsive to levodopa treatment and a DaT scan was not consistent with Parkinson's disease.
Patient history was also notable for asthma, hypothyroidism, depression, placental abruption, and endoscopic resection of multiple benign colon polyps.
At presentation the patient was unwell without any specific complaints and febrile with marked orthostatic hypotension and normal oxygen saturation. Clinical examination was unremarkable except for the neurological status where no modifications with respect to the patient's baseline were noted. The complete blood cell count on admission was notable for normocytic anemia with low reticulocyte count (Hemoglobin 9.8 g/dl). Renal function was normal and hypokalemia (K 2.9 mEq/l) as well as hyponatremia (Na 128 mEq/l) with low specific gravity as a surrogate for urine osmolality and low urine sodium (21 mEq/l) were documented. Serum lactate was normal. A chest X-ray demonstrated limited infiltrations in the left lower pulmonary field.
The patient was admitted and due to the overall clinical status hydration with isotonic fluids and treatment with piperacillin/tazobactam was initiated in the absence of positive inflammatory biomarkers (erythrocyte-sedimentation rate, C-reactive pr

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


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

[User]
RADIOLOGY NOTE:
The patient was an 8-month-old female infant with left DDH. She had been diagnosed with dislocation of the left hip at another hospital at the age of 3 months, and she was treated with a Pavlik harness for 4 weeks. However, her left hip was not reduced, and she was admitted to our institution at the age of 8 months. The anteroposterior radiograph showed that the left femoral head was completely dislocated and had shifted to the lateral and proximal side (). She did not have the abnormality at the time of birth; in addition, no past illness, allergy, or family history of DDH were noted. At our institution, she underwent closed reduction under general anesthesia. Her hip joint was reduced; however, it was unstable, and the femoral head was easily dislocated when we decreased the hip abduction angle down to 60°.
Subsequently, arthrography was performed to verify the reduction and to analyze the obstructive factors and afferent nature of the femoral head. First, the legs were maintained in the frog-leg position, and then, a 23-gauge Cathelin needle was inserted in the central part of the femoral proximal epiphyseal line using the anterior approach. After confirming that blood was not aspirated, 1 mL of air was injected to confirm that the Cathelin needle was accurately sited in the joint; subsequently, we injected 1 mL of the contrast medium.
Two minutes after air injection, the endtidal carbon dioxide (ETCO2) concentration decreased suddenly from 37 mmHg to 19 mmHg, and the blood oxygen concentration decreased from 99% to 97% (). The anesthesiologist noticed the change, and he increased oxygenation from 33% oxygen to 100% under observation. The blood oxygen concentration and ETCO2 concentration gradually improved and returned to normal values after 2 min and 12 min, respectively. Other vital signs such as blood pressure and pulse rate remained unchanged. An arthrogram showed good reduction of the femoral head. Plaster cast fixation was

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


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

[User]
RADIOLOGY NOTE:
A 60-year-old gentleman was referred to the vascular surgery service, from the orthopedics department, with a ‘pulsating mass’ behind the left knee. He had a background medical history of hypertension and hypothyroidism. He was taking candesartan and levothyroxine sodium regularly.
He hit his left knee while getting out of a lorry, 2 months before this presentation. An MRI at that stage confirmed lateral meniscal tear, and there was no other injury to surrounding structures. He had a left knee arthroscopy and repair of meniscal tear after a few weeks. He developed a swollen leg soon after the surgery. With significant swelling of his calf, and pain out of proportion and intracompartmental pressure of 40 mmHg, a clinical diagnosis of compartment syndrome was made and fasciotomy was performed to relieve the pressure in fascial compartments in the leg.
However, he had persistent pain in calf and knee, and after a few weeks, when his calf swelling reduced, a pulsating mass was felt behind the same knee. An ultrasound performed, showing a 7 × 4 cm thick walled cystic mass in the popliteal fossa filled with irregular blood, suggestive of a popliteal aneurysm.
On examination, he was hemodynamically stable. His left calf was swollen with a circumference of 3 cm greater than his right. There was a large pulsating mass palpable in his left popliteal fossa. Distal neurovascular status of the leg was intact. He had an unremarkable cardiovascular, respiratory, abdominal and neurological examination.
His laboratory reports for full blood count, urea and electrolytes were normal. In view of the ultrasound findings, a CT angiogram of lower limbs was performed. It confirmed 6 × 5 × 4 cm pseudoaneurysm, compressing and displacing his left popliteal artery. However, three-vessel run-off below the knee was satisfactory (Figs
).
A diagnosis of iatrogenic popliteal pseudoaneurysm secondary to arthroscopy was made. The absence of this on his MRI after

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


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

[User]
RADIOLOGY NOTE:
A 39-year-old man was admitted to our hospital because of a sudden onset of hemiparesis on his left side with dysarthria. He had a history of a SVA rupture that was surgically treated at the age of 24 (fig. ). During the surgery, there were no specific findings of cystic medial necrosis or crystalline lens subluxation due to the Marfan syndrome. In his infancy, there were no developmental abnormalities. In his school records, the subject had poor grades during childhood and adolescence. His family history over 3 generations was unremarkable in terms of neurological, psychological, and cardiac diseases. During the patient's examination, his body temperature was 37.0°C, blood pressure was 184/104 mm Hg, pulse was 83 beats per minute, respiratory rate was 20 breaths per minute, and oxygen saturation was 97% (while he was breathing ambient air). At the time of hospitalization, the patient presented with an acute stroke and the symptoms included left-sided weakness and dysarthria; these neurological symptoms lasted for a week after admission. We assessed the risk of juvenile ischemic stroke in a laboratory study, but high-risk factors that are linked to juvenile cerebral ischemia, such as collagen diseases and vasculitides, were not found. An electrocardiogram revealed a sinus rhythm within the normal range. Although we performed magnetic resonance imaging (MRI) with a 1.5-tesla unit on the first day and with a 3-tesla unit 2 weeks later, acute cerebral infarction was not detected (fig. ). Routine sonographic evaluation of the carotid arteries demonstrated a diffuse narrowing of the left ICA and a low-lying carotid bifurcation. Thereby, cerebral angiography was conducted, and it showed hypoplasty of the left ICA and a low-lying carotid bifurcation at the level of the C6 vertebra (fig. ). The A1 segment of the bilateral anterior cerebral arteries (ACAs) was united and formed an azygos type (fig. ). The common ACA duct and left posterior

[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 Bangladeshi male patient was discovered to have experienced a sudden episode of loss of consciousness while talking with his friends. Emergency medical services arrived 20 min later and found the patient to be in cardiac arrest with ongoing bystander cardiopulmonary resuscitation (CPR). His initial cardiac rhythm was ventricular fibrillation (VF) as the initial rhythm following which CPR was started and delivery of direct current (DC) shock as per the advanced life support guidelines. Following the first DC shock, the cardiac rhythm changed to pulseless electrical activity arrest for which CPR was continued for 22 min until the return of spontaneous circulation. He was intubated during resuscitation and then transferred to the heart hospital emergency department. On physical examination, the patient had a blood pressure of 107/73 mmHg, heart rate of 120 bpm, regular rhythm, and was receiving mechanical ventilatory support. Notably, he had equal bilaterally reactive pupils with a normal respiratory and abdominal examination. Initial laboratory investigations were significant for white blood cells 18/uL, hemoglobin 16.6 g/dL, platelet count 282/uL, alanine transaminase 129 U/L, aspartate aminotransferase 102 U/L, troponin T 700 > 1100 > 500 ng/L, and a lactic acid of 3.9 mmol/L, all of which returned back to the normal limits within 2 days of receiving the supportive care. His renal function tests and electrolytes were within normal limits. A chest X-ray, computed tomography (CT) scan of his brain and CT pulmonary angiography were all unremarkable. His 12-lead ECG was significant for Brugada pattern type 1, with typical coved ST elevation of ≥2 mm in at least one right precordial lead []. The patient was admitted to the cardiology intensive care unit, and a hypothermia protocol was initiated following which the patient was extubated after 5 days without any permanent neurological deficit. Upon reviewing the patient’s medical records, it was noted that he

[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 previously healthy female got admitted to hospital with a progressively worsening skin rash involving lower limbs for two-week duration. The skin rash has begun as a painful small vesicle on the left foot which enlarged in size, with crops of new vesicles appearing on bilateral lower limbs. Some vesicles enlarged to bullae and then ruptured and healed with scarring.
She also complained of progressive pain and numbness on bilateral lower limbs up to knees, with numbness over left fingers that had progressed over two-week duration. She denied muscle weakness or difficulty in walking. She also had progressive bilateral ankle edema and frothyuria. She denied hematuria or reduced urine output. She had constitutional symptoms with a low-grade fever and generalized malaise. She also gave a history of recent onset wheezing controlled with inhalers but denied cough, sinusitis, or epistaxis. She had no joint symptoms, digital ulcers or gangrene, or gastrointestinal symptoms.
Lower limb examination revealed an erythematous rash with small blisters and bullae of sizes varying between 2 and 4 cm with hypopigmented healed lesions with marked involvement around the ankle (). She also had few small hyperpigmented lesions on the palmar surface of the left hand. She had no lesions in the trunk, face, or mucosa. Neurological examination revealed reduced bilateral lower limb reflexes and sensory impairment up to knee level but had no motor weakness. Joint position sense and vibration sense was intact. Upper limbs did not reveal a demonstrable neurological deficit. All peripheral pulses were felt. She had bilateral pitting ankle edema and had elevated blood pressure 160/100 mmHg. Other system examination revealed normal findings.
Her blood counts revealed a white cell count of 27,000/mm3 with a marked eosinophilia of 57% with an absolute count of 15,500/µl. Hemoglobin and platelet count was normal. The blood picture revealed marked eosinophilia without evidence of atypical

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


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

[User]
RADIOLOGY NOTE:
An 84-year-old female with a known history of congestive cardiac failure, hypertension, and stable angina was initially seen in the Emergency Department at Horton General Hospital, Banbury. She presented with an acute onset of rapidly worsening exertional dyspnoea and reduced exercise tolerance. She was subsequently diagnosed with critical aortic valve stenosis following transthoracic echocardiography and underwent an urgent aortic valve replacement. The immediate postoperative course was uneventful except for the development of a pericardial effusion requiring drainage on the 10th day. Microbiological analysis of the pericardial fluid yielded cultures of the gram-negative pathogen, Proteus mirabillis. The patient completed a full course of intravenous gentamicin for 3 weeks with serial negative blood cultures. The wound site appeared to be healing well throughout this time. Further transesophageal echocardiography revealed no significant pericardial effusion and the patient subsequently made a good recovery and was discharged. Further cross-sectional imaging was not performed at this time.
Four weeks following discharge from hospital (two months postoperatively), the patient represented with fever, worsening dyspnoea at rest, and light headedness. She was clinically in septic shock and physical examination revealed an erythematous, warm anterior chest wall alongside a fluctuant swelling overlying the sternotomy scar with some purulent discharge. Laboratory data included a severe normocytic anaemia, neutrophilic leukocytosis, and significantly raised inflammatory markers. Subsequent blood cultures grew meropenem sensitive Proteus mirabillis.
Initial treatment against the bacteraemia consisted of intravenous gentamicin and meropenem based on a working diagnosis of mediastinitis with or without bacterial endocarditis. The chest radiograph was unremarkable. Subsequent chest CT revealed osteomyelitis of the sternum, contiguous with a large anterior mediastinal abscess m

[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 came with complaint of pain and swelling over the left hip for 30 days. The patient had a history of fall in the bathroom 30 days back sustaining a trivial trauma to the left hip. The patient was weight-bearing for 1 week, after which pain was increased on walking. The patient was a known case of hypertension and diabetic on regular medications. On examination, tenderness was present at left hip region, left lower limb was externally rotated, shortened with no wound and distal neurovascular deficit.
Plain radiographs of the left hip with femur anteroposterior and lateral views revealed left subtrochanteric fracture with diffuse irregular cortical and trabecular bone thickening from the femoral head to lower third of the left femur (, ). The fracture was a complete transverse through both cortices without comminution at the subtrochanteric area of the femur. Right-sided femur appeared normal. Blood investigations showed increased ALP.
Magnetic resonance imaging of pelvis with femur showed pathological fracture secondary to Paget’s disease with significantly distorted bone matrix, profound hypertrophy and thickening of the bony trabeculae with significant obliteration of intervening medullary canal ().
As the patient was elderly, needed early mobilization and had displaced pathological subtrochanteric fracture, we planned for surgical management with intramedullary nailing. The patient was operated under spinal anaesthesia, using traction table in the supine position. Incision of around 5 cm was taken from the greater trochanter extending proximally. The entry point was made over the tip of greater trochanter after dissecting the soft tissues. The guide was passed in the center of the medullary canal till the distal femur, gradual progressive reaming was done using flexible reamers. Long proximal femoral nail (PFN) was inserted (size 11 mm × 38 cm) with proximal and distal locking (). The intraoperative sample was taken from the medullary ca

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


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

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

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


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

[User]
RADIOLOGY NOTE:
A 52-year-old woman came in our emergency room for consult due to sudden painful loss of vision of the right eye. The History of the present illness started 1 week prior to consult, the patient noted a sudden blurring of vision of the right eye described as curtain loss of vision. No history of trauma, pain, flashes, and floaters was noted, and neither consult done nor medication taken. Three days prior to consult, the patient noted a total loss of vision of the right eye associated with intractable pain, eye redness, headache, nausea, and vomiting, which prompted consult.
The patient had no known systemic diseases except for well-controlled bronchial asthma and hypertension. The patient was maintained on losartan 50 mg twice a day with poor compliance and control. The patient came in with no light perception for the right eye and 20/20 for the left eye. The blood pressure at the time of consult was at 240/100. Gross examination and extraocular muscles were normal. The right pupil was 6 mm non-reactive to light, and the left pupil was 3 mm brisk reactive to light with positive reverse relative afferent pupillary defect. Slit lamp examination of the right eye revealed shallow chambers with moderate corneal edema with microcyst and an intraocular pressure (IOP) of 60. On gonioscopy of the right eye, the angles on all quadrants were closed. Indirect ophthalmoscopy of the right eye revealed total retinal detachment with large subretinal hemorrhage. The examination of the left eye showed a formed chamber with an IOP of 12 and a cup-to-disc ratio (CDR) of 0.4 with arteriovenous crossing changes. On gonioscopy of the left eye, the angles on all quadrants were open to ciliary body band. The right eye had poor streak on refraction, while the left eye’s refraction was –0.50 D sphere. Ocular ultrasound of the right eye (Figure 1 ) revealed massive hemorrhagic

[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 51-year-old woman presented with left upper abdominal pain that had persisted for the past 6 months. The results of a physical examination were unremarkable. The results of a complete blood cell count, electrolyte count, eosinophil count, serum biochemistry, and urinalysis were within normal limits. The chest x-ray was normal and ultrasound examination revealed a heterogeneous cystic mass between the upper pole of the left kidney and the spleen. Computed tomography (CT) scan demonstrated the presence of a solitary cystic mass within the left adrenal gland with no enhancement suggestive of adrenal echinococcosis. No other intra-abdominal or intrathoracic masses were found (). Urinary catecholamines and metanephrine levels were within normal limits. The serology for E. granulosus was positive. On further enquiry, the patient confirmed a history of animal contact. On the basis of these findings, the patient was started on albendazole for 4 weeks and a plan for surgical excision was formulated.
The diagnosis was confirmed during the surgery. The cyst was approached laparoscopically by the transperitoneal route. The rest of the peritoneal cavity did not reveal any other lesions. The area around the cyst was carefully packed with gauzes soaked in betadine solution. The cyst was aspirated during the procedure and 10% betadine solution was filled inside the cyst and maintained for 10 minutes. An appropriate dissection plane between the cyst and the adrenal gland could not be found. Hence, a 10-mm trocar was introduced inside the cyst and the cyst contents were sucked out, including the germinal layer (). Partial excision of the cyst wall was done because the cyst was adherent to the renal vessels. Pathological examination of the specimen confirmed the diagnosis. The wall of the adrenal gland showed cells in clusters and also singly with necrosis in the background. The hooklet of the parasite was also demonstrated as an acid-fast structure on the pathology slide (). The pa

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


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

[User]
RADIOLOGY NOTE:
This patient is a 14-year-old male, who felt a popping sensation and significant right knee pain while jumping and colliding with another player during a basketball game the previous day. Following the injury, he was evaluated in an outside emergency department, where anterior, posterior, and lateral radiographs obtained in the emergency department demonstrated a tibial fracture consisting of two primary components (). He was placed in a cast and sought a second opinion regarding findings and management.
Upon presentation to the clinic the following day, he reported mild pain (3/10) and noted no normal function of his leg. A physical exam was performed but was limited due to pain. Following the review of radiographic imaging, an MRI was performed, which demonstrated a type IIIB tibial tubercle avulsion fracture and complete tear of the patellar tendon from its distal attachment site, as well as a hematoma at the fracture site (). After discussing the findings with the family, the patient was scheduled to undergo open reduction internal fixation of a type IIIB fracture and repair of the patellar tendon three days following the initial injury.
An 8-centimeter anterior incision was made at the superior aspect of the tibial tubercle and extended distally. At the patellar tendon insertion site on the tibia, the tendon was noted to be completely avulsed from the bone cortex distally, while proximally, the tendon remained attached to the displaced tubercle. The tendon remained attached to the inferior pole of the patella. The anterior tibial plateau fragment was anatomically reduced using two fully threaded noncannulated screws (Arthrex, Naples, FL), while the tibial tubercle fragment was reduced via bicortical fixation with a 50 mm fully threaded 3.5 mm cortical screw (Arthrex, Naples, FL).
The distal patellar tendon was completely avulsed through two-thirds of its length. To restore the native footprint of the patellar tendon, a 4.5 mm PEEK (polyethere

[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 female was referred to our surgical oncology clinic for evaluation of cystic lesions of the pancreas found on CT scan at an outside hospital after she presented with a history of approximately nine months of vague epigastric pain, nausea and vomiting. She had a 50-year history of daily tobacco use (0.5 pack per day) and nightly alcohol use that had reportedly stopped around the same time as the onset of her symptoms, but she was otherwise healthy.
She had also undergone an MRI/MRCP at the outside hospital that revealed multiple cystic loculations of the pancreas that appeared to be possibly in communication with the main pancreatic duct (). There were calcifications in the head of the pancreas consistent with chronic pancreatitis. Her Carbohydrate Antigen 19-9 (CA 19-9) was <1. A three-phase pancreas protocol CT scan was performed at our institution that showed dilation of the main pancreatic duct with innumerable saccular cystic dilations, thought to be likely dilated side branches arising from the pancreatic duct (). The working diagnosis was the presence of pancreatic pseudocysts in relation to chronic pancreatitis. Her local gastroenterologist proposed endoscopic transgastric cystic drainage of her dominant cyst. After evaluation at our institution, the differential diagnosis included pseudocysts secondary to chronic pancreatitis as well as diffuse, multiple intraductal papillary mucinous neoplasms (IPMN).
The patient underwent an endoscopic ultrasound with fine needle aspiration and cyst fluid analysis, demonstrating a Carcinoembryonic Antigen (CEA) level of over 600 ng/mL, an amylase level of over 75,000 U/L, and rare clusters of mucinous epithelium, consistent with a mucinous tumor communicating with the pancreatic ductal system. Her case was discussed at our institution’s Pancreaticobiliary Disease Center Tumor Board and total pancreatectomy was recommended given the extent of these mucinous tumors and high suspicion for multifocal branched duc

[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 filled in an informed consent for participating to the study.
The study presents the case of a 43-year-old female patient, who was first hospitalized in 2011 in the Cardiology Clinic of Emergency County Hospital of Craiova for palpitations. We noted a positive familial history for restrictive cardiomyopathy in her mother’s sister, deceased at the age of 60 years old, who was diagnosed only by echocardiography. However, there were no genetic tests performed in her case. Moreover, our patient related a history of cardiovascular disease in her mother and maternal grandfather. However, they are no longer alive, and we have no medical documents concerning their pathology. Furthermore, we decided to perform echocardiography to patient’s 20-years-old asymptomatic son and there were no pathological changes found. Even though we recommended genetic testing in his case, it has not been performed yet.
She could not mention any other medical history. The ECG revealed atrial fibrillation, with QRS axis at 90 degrees, Q wave in DIII, negative T wave in DI, DII, DIII, aVF, V1-V6. Echocardiography revealed normal dimensions of aortic root and ascending aorta, normal diameter of left ventricle, left ventricular volume slightly reduced, normal LVEF (55%), mild mitral regurgitation, severe left atrial enlargement, normal right ventricular diameter and slight right ventricular longitudinal systolic dysfunction, severe right atrial enlargement, mild tricuspid regurgitation, moderate pulmonary hypertension (). We started oral anticoagulation and we decided to attempt electric conversion to sinus rhythm, which was successful.
At that point, the diagnosis of restrictive cardiomyopathy has already been put in discussion and the next investigation that we recommended was a cardiac MRI, which showed reduced left ventricular volume, normal systolic function (LVEF=62%), normal left ventricular wall thickness, without any pathological changes of regional contractility. Certain trabec

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


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

[User]
RADIOLOGY NOTE:
A 30-year-old female with a past medical history including bipolar disorder, major depressive disorder, severe alcohol use disorder, alcoholic hepatitis, chronic pancreatitis, and gastric ulcers presented to an outside hospital with hematemesis and malaise. She was found to have acute alcoholic hepatitis, and treatment was started with supportive therapy, prednisone, and pentoxifylline. After failing to show signs of improvement, the patient was transferred to our hospital for extracorporeal liver assist device evaluation. Her Model for End-Stage Liver Disease score was 26. She had significant comorbidities including pancreatic insufficiency, candida esophagitis, and positive blood cultures for Klebsiella. Her condition continued to deteriorate until she developed acute respiratory failure with encephalopathy requiring endotracheal intubation and intensive care unit admission. A computed tomography scan was performed emergently, and it showed subarachnoid hemorrhage secondary to coagulopathy associated with her liver disease. She continued to have persistent muscular weakness and was unable to wean from the ventilator. After 2 weeks, she was scheduled for a bedside percutaneous tracheostomy.
The patient was stabilized hemodynamically but continued to have ongoing coagulopathy with thrombocytopenia, elevated INR, and PT. The initial tracheostomy placement was complicated by false passage with a left pneumothorax that required a chest tube placement. Eight days after the initial tracheostomy placement, a persistent cuff leak was noted and required emergency reintubation with an oral endotracheal tube. The patient then underwent a surgical tracheostomy revision complicated by a right-sided pneumothorax, which also required a chest tube placement.
Six days after her tracheostomy revision, she was noted to have massive bleeding from the tracheostomy site with severe occlusion of airway anatomy. Initially, bleeding was noted at her tracheostomy site. Pressure was held at

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


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

[User]
RADIOLOGY NOTE:
A 46-year-old male with a history of severe developmental delay, hydrocephalus, and seizure disorder presented to the hospital with blunt head trauma after a ground level fall. Work-up revealed bilateral acute subdural hematomas for which an external ventricular drain was placed. Despite intensive care management, the patient deteriorated to brain death. He was subsequently evaluated for organ donation. Abdominal computerized tomography (CT) scan () revealed an “elongated structure with metallic components in the upper portion of the IVC that extends into the right atrium.” There was no medical history of a prior procedure, or symptoms, to explain the incidental finding. The radiologist's interpretation and presumptive diagnosis were a retained atrial pacing wire.
He subsequently underwent procurement for organ donation after brain death. At the time of cross-clamp, the previously identified foreign body was transected when the right atrium was incised for exsanguination. During the back-table dissection, it was apparent that the foreign body had eroded into the posterior wall of the IVC, extending down the retrohepatic IVC (Figures and ). It also created a calcified reaction at the junction of the suprahepatic IVC and right atrium, adjacent to the left hepatic vein (LHV) and middle hepatic vein (MHV). We removed the foreign body () and performed a venoplasty () of the posterior wall of the IVC and of the common wall of the LHV and MVH, so that the outflow of the LHV and MHV was not compromised after transplant. We discovered that the foreign body was, most likely, a fractured CVC due to the overall appearance and interval markings.
The liver recipient was a 65-year-old woman with cirrhosis due to alcohol abuse; her Na-MELD score was 40 at the time of transplant. She underwent caval-sparing total hepatectomy and deceased donor liver transplantation via piggyback technique: the donor suprahepatic IVC was anastomosed to a common orifice of the recipient's right

[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 75-year-old male patient was admitted with complaint of a painful ulceroproliferative growth in the left foot for seven months, with a history of fever for 10 days. He had a history of loss of appetite and loss of weight. There was no history of trauma or intermittent claudication.
Local examination showed an ulceroproliferative irregular growth on the plantar aspect of the left foot, below the second to fifth toes. The floor of the ulcer was filled with an exuberant, unhealthy, granulation tissue, with minimal serous discharge and patchy black pigmentation. A surrounding area of oedema was present. The ulceroproliferative growth was hard in consistency and tenderness was present []. Lymph node examination showed multiple inguinal lymph nodes on the left side, which were hard in consistency and measured 2 × 2 cm, with in-transit metastasis on the left leg [Figures and ].
An edge biopsy from the ulcer showed elongated spindle-shaped cells surrounded by mature collagen bundles. The tumour displayed a fascicular growth pattern. There were scattered collections of lymphocytes and plasma cells. Small foci of neural transformation and neurotropism were present. More than 90% of desmoplasia was seen. It was associated with a lentigo epidermal component. Clark IV level depth of invasion was seen. Immunohistochemistry showed strong positivity for S-100 []. The BRAF mutation analysis was not available in our institution. The cytomorphology of the inguinal node and in-transit metastasis were similar to primary desmoplastic melanoma. Computed tomography (CT) of the thorax showed multiple nodules noted in both the lung fields in the apical segment, superobasal, posterobasal segments of the right upper lobe and right middle lobe, and anterior segment of left lower lobe. Another pleural-based nodule was seen on the right side [].
A preoperative diagnosis was made as desmoplastic malignant melanoma, with regional and systemic metastases. As the patient had extensive metastases 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 48-year-old Caucasian man presented to the Neuro-Ophthalmology Department of the Rothschild Ophthalmic Foundation in June 2016 for decreased vision, transient visual obscuration, pulsatile tinnitus, and headaches. His symptoms had been progressively worsening for the previous 7 months. The patient was a pharmacist and was not overweight. He had a history of UC in 2002 that was diagnosed during the workup of chronic diarrhea. The patient did not have any medication for UC. He did not smoke, nor did he use recreational drugs. On examination, best-corrected visual acuity was 20/40 OD and 20/20 OS. Eyelid examination was unremarkable. The pupils were equal and reactive. There was no relative afferent pupillary defect. Ocular movements were full and he was orthophoric in all gaze directions. Dilated fundus examination showed retinal folds between the macula and the optic disk and bilateral grade-2 optic disc swelling (Fig. ). Visual field testing revealed enlarged blind spots and diffusely decreased visual field sensitivity in both eyes (Fig. ). Ocular ultrasonography revealed enlarged optic nerve sheaths. Brain MRI ruled out brain tumor and venous thrombosis. There were signs of ICH including empty sella and bilateral lateral venous sinus stenosis. Lumbar puncture showed CSF opening pressure of 26 cm of water with normal CSF contents. The headaches persisted after lumbar puncture. Ancillary testing did not reveal vitamin A deficiency or anemia. Idiopathic ICH was suspected. The patient was treated with a daily dose of 1000 mg of acetazolamide that was gradually tapered. Headaches initially improved but the treatment could not be decreased under 750 mg a day without recurrence of the symptoms.
Extensive review of systems showed that patient still had chronic diarrhea. Because of the history of UC, a colonoscopy was performed in June 2017 and showed active proctitis. Fecal calprotectin level, which has been shown to be correlated to acute inflammation in intestinal infl

[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 4-year-old boy was admitted to our hospital with vomiting of pieces of paper and no history of foreign body ingestion witnessed by the family. While the physical examination was unremarkable, the abdominal x-ray showed a disc-shaped foreign body (Fig. 1 A). The family did not recognize the object, but since they had moved to a new apartment, a lot of hypotheses were raised and it was finally thought to be a disc battery. The parents were not able to define the time of the ingestion. As the battery seemed beyond the stomach and there were no evidence of serious complications, expectant treatment was planned awaiting spontaneous passage. The child received polyethylene glycol colonoscopy preparation to expedite the progression of the foreign body through the intestine. After two days, he was still asymptomatic. The foreign body was not passed in the stool and its position on radiograph did not change. Moreover, on lateral x-ray abdomen a thin separating line was seen inside the foreign body (Fig. 1 B) that raised the suspicion of two magnets ingestion with a bowel wall lying in between them. An exploratory video-assisted laparoscopy was performed and an abnormal cluster of bowel loops was seen. To avoid the risk of perforation pulling the bowel loops which adhered tightly to each other, the small bowel was exteriorized through the umbilicus. At 70 cm distal to the ligament of Treitz, two ileal loops were noted adherent to the opposite sides of the mesentery of small bowel at the same point on their antimesenteric aspects. Further exploration revealed a transmesenteric entero-enteric fistula (Fig. 2). The fistula was isolated from the mesentery and resected and the antimesenteric borders of the two ileal loops were repaired. On opening the fistula on its longitudinal axis, two small magnets were found (Fig. 2). The patient’s parents recalled that the boy had played with the cell phone and the two magnets, which used 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:
A 74-year-old man presented to the clinic with lower extremity edema and exertional dyspnea for several weeks. Past medical history was significant for five-vessel aortocoronary artery bypass graft surgery (CABG) done in 1989 and redo three-vessel CABG in 2002. He had multiple comorbidities with 37-pack-year history of smoking. Physical examination was significant for grade II/VI systolic murmur at second left intercostal space, mild pitting edema, and jugular venous distention. Initial labs were unremarkable. Electrocardiogram revealed old anterior infarct changes. Transthoracic echocardiogram revealed severe pulmonary artery stenosis with mean gradient of 44 mmHg and peak gradient of 76 mmHg secondary to extrinsic compression of pulmonary artery by a large extrinsic mass. Right ventricular hypertrophy along with reduction of systolic function was also noted. Left ventricular ejection fraction was also reduced (30–35%) with anterior wall akinesis. Computed tomography angiography (CTA) of the heart and coronary vessels revealed a 6.0 × 5.8 cm aneurysm () involving the first obtuse marginal SVG, which was compressing the pulmonary artery. Coronary angiography was performed, which revealed 100% occlusion of all the three native vessels. SVG angiography revealed a 7 × 7 cm giant aneurysmal dilatation in the SVG to the first obtuse marginal of the left circumflex artery, which appeared to contain a large organized thrombus ().
Cardiothoracic surgery service was consulted and they proposed excision of the aneurysmal vein graft and 2/3 vessel coronary artery bypass grafting using a radial artery and/or right internal mammary artery. Given his extensive comorbidities, previous cardiac surgeries, and significantly reduced left ventricular function, surgical therapy was felt to carry significantly increased risk of morbidity and mortality. Percutaneous intervention was also discussed, where exclusion of the aneurysm by insertion of a covered stent in the SVG across the neck

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


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

[User]
RADIOLOGY NOTE:
A 59-year-old Vietnamese male presented to the Atlanta Medical Center complaining of severe posterior neck pain, right-sided hemiparesis, and right sided paresthesia. This began 4 months ago when he noticed difficulty writing and using the right hand. He had rapidly deteriorated to the point of being unable to walk or move his right arm. He had a magnetic resonance imaging (MRI) done in Vietnam, which had showed an abnormal mass in the cervical spine, which is what brought him to Dr. King at the Atlanta Medical Center.
The patient's ability to speak English was limited, but his son provided translations as necessary. The patient was alert and oriented to person, place, and time, and not invisible distress. The neurological physical exam showed significantly decreased strength in the right upper and lower extremity, as well as decreased proprioception, and light touch sensation on the right. The patient was unable to walk without assistance. Palpation of the posterior neck produced pain and paresthesia. The rest of the exam, including the complete blood count and comprehensive metabolic panel were within normal limits.
A repeat MRI with and without contrast showed an exophytic homogenously enhancing mass beginning at the C2 vertebral body level, and extending to the C2–C3 disc space, with surrounding edema within the cervical spinal cord []. The mass measured 13 mm × 14 mm × 22mm in size [].
The cervical spine showed normal alignment, and the rest of the spinal cord was unaffected. The differential provided by radiology was primary cervical spinal cord glioma versus metastatic lesion versus schwannoma versus neurofibroma.
A laminectomy and resection were planned with possible stabilization. This would be a joint surgical procedure done by a neurosurgeon and orthopedic surgeon, using a microscope to better observe the relevant area. Risks and complications including quadriplegia, paraplegia, and respiratory dependence were explained to the patient and family.
The pati

[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 23-year-old female attended the OPD, Faculty of Dental Science, with the chief complaint of swelling in the floor of the mouth, difficulty in chewing, and inability to move the tongue and open her mouth fully. She also complained of malaise, pain in the floor of the mouth loss of appetite and loss of weight. She had observed the swelling about 6 months ago with the subsequent difficulty in moving her tongue. There was no history of trauma or illness preceding the swelling. No alteration in the taste or paraesthesia was complained. No relevant medical history was present. On examination, the patient appeared ill looking. Extraoral scarring was not present. A diffused smooth swelling extending from right cheek to the floor of the mouth, obliterating the angle of the mandible, was noted. Asymmetry of the face was very conspicuous (). Enlarged lymph nodes were palpated in the submandibular region. On examination of the mouth cavity, the diffused swelling occupied the floor of the mouth on the right side; the oedema of the lower right gingiva and vestibule of the lower jaw were also observed. The tongue was coated, and constant fibrillation of the right side of the tongue was observed. She felt extreme difficulty in protruding her tongue, and on extreme effort to protrude the tongue, it showed deviation to the right side, almost to a right angle (). Examination of other cranial nerves was found to be normal and intact. Routine examination of the total count, differential leucocytic count, and immunological and serological examination showed no viral infection or autoimmune disease. Blood glucose and the liver function test were normal. The chest X-ray was clear with no lung pathology. An oral pantogram and CT scan of head and neck were advised to evaluate the possible cause of the hypoglossal nerve palsy. The radiograph and the CT scan revealed the right third molar tooth impacted lying horizontally, deep within the mandibular bone (). A diffused swelling confined to 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 32-year-old Sistani-Persian White man presented to a hematologist for the recent appearance of petechial lesions and epistaxis. He mentioned a history of ITP 13 years prior to his visit which had not responded well to standard corticosteroid therapy, was managed with splenectomy after 3 months of resistance to steroids and had remitted since that time until the recent reappearance of symptoms. He also reported having had pharyngitis 2 weeks before his current symptoms onset that had not been improved by amoxicillin-clavulanate administration. He also reported a history of recent meningococcal vaccination and stated that his symptoms had started within 24 hours after meningococcal vaccination. The laboratory results showed a platelet level of 25,000 per microliter. With a diagnosis of relapsing ITP, he was started on standard prednisolone regimen for 1 month which did not improve his condition. After 2 months he was seen by another hematologist for further evaluation and persistence of thrombocytopenia. A bone marrow biopsy was performed which confirmed the diagnosis of ITP (Figure ). He also underwent a scan for accessory spleen which was negative. Following this visit, he was given 40mg/day of pulsed dexamethasone for 4 days every 2 weeks for 8 weeks in addition to pulsed rituximab (800U/week) for 4 cycles neither of which was sufficiently effective to reduce his symptoms. Detailed information regarding his medication history following this visit is presented in Table .
Twenty months after relapse of ITP, when our patient was taking sirolimus, he presented to our hematology clinic again with sudden onset of new symptoms including hypersomnia, abnormal behavioral changes, clumsiness, and compulsive hyperphagia. His wife reported that her husband slept approximately 20 hours a day during his symptomatic period, did not wake up spontaneously except for voiding and could not be awakened upon calling on him. She also recounted that her husband had drunk coffee the nig

[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:
History
A 27-year-old Caucasian male presented to the emergency department with an open right tibia and fibula shaft fractures following a high-speed motorcycle crash. The patient was helmeted at the time of the crash and there was no reported loss of consciousness. He reported isolated right lower extremity pain without neurologic complaints.
Exam and diagnostics
This was an isolated injury with no clinical or radiographic evidence of intracranial, -thoracic, -abdominal, or -pelvic injury. A FAST exam (Focused Assessment with Sonography in Trauma) was performed prior to our orthopaedic exam, which demonstrated no signs of hemorrhage.
Inspection of the right lower extremity revealed two large wounds to the anterolateral and anteromedial tibial diaphysis. The anterolateral and anteromedial wounds measured approximately 20 cm and 12 cm in length, respectively. Both wounds exhibited gross contamination with road debris as well as exposed muscle and fracture fragments (Figure ). There was no clinical evidence of compartment syndrome. There were no sensory or motor deficits involving the superficial peroneal, deep peroneal, or tibial nerves. A strong dorsalis pedis pulse was palpable, however the posterior tibial pulse was unidentifiable on palpation or Doppler ultrasound. A computed tomography (CT) angiogram was obtained which demonstrated vascular stenosis of the posterior tibial artery at the level of the fracture. All hematologic and metabolic labs were within normal ranges.
Time from the emergency department to the initial operative encounter
Dual antibiotic prophylaxis, consisting of cefazolin and gentamycin, was administered promptly upon arrival to the emergency department. Antibiotic administration was estimated to be within three hours from the time of injury. A brief bedside irrigation with 3 L of sterile saline was performed and the wounds were dressed with moist gauze. The patient was then provisionally stabilized with a moldable long leg fiberglass splint a

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


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

[User]
RADIOLOGY NOTE:
We present the case of a 51-year-old woman with a history of Guillain-Barré syndrome as a teenager, probable neuroborreliosis in the 1980s, and a malignant melanoma in situ in the 1990s. She has given informed consent to this report. The patient had repeat rectal surgeries for sphincter damage after childbirth, and in 2011, she was diagnosed with a T4 rectal cancer causing haemorrhage. No distant metastases were found and treatment with curative intent was decided at a multidisciplinary team conference. She had neoadjuvant chemotherapy with fluorouracil and leucovorin followed by radiation with 50.4 Gy to the rectum. The tumour was resected half a year after the diagnosis. The postoperative course was uneventful except for a superficial wound infection and she was discharged after 3 weeks of hospitalization. After 2 weeks, she was readmitted because of a Takotsubo cardiomyopathy and intestinal obstruction requiring more surgery with resection of a short segment of small bowel. After 1 year, the first lung metastases were diagnosed with a 2-cm metastasis in the right lower lobe and a 5-mm. tumour in the lower left lobe. After 3 pulmonary resective procedures, further lung metastases were seen during follow-up. A second line of chemotherapy was started with oxaliplatin, resulting in shrinkage of the noted lesions. Then, local treatment was done with SBRT, 17 Gy ×3 for 2 right-sided metastases and a resection of the left lung, 3 years after the resection of the primary tumour. Three months later a new lung metastasis was diagnosed and treated with SBRT, 7 Gy ×8. Six months later, 2 more lung lesions were found and a third line of chemotherapy based on irinotecan was started, but as tumour progression was observed, treatment was discontinued after 3 months.
Without having the final test result on microsatellite instability in the tumour, it was decided to start PD-1 treatment (this was not within a clinical trial, since the only available trial in Sweden had not opened

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


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

[User]
RADIOLOGY NOTE:
A 22-month-old boy with Down syndrome was admitted to our department for elective adenotonsillectomy because of sleep apnea due to adenoidal and tonsillar hypertrophy. Despite conservative treatment for the previous five months with nasal rinsing and intranasal steroid spray, his symptoms had deteriorated and he was indicated for surgery with post-operative observation overnight. Except for the presence of habitual belching, his medical history revealed no other abnormalities.
After a nontraumatic and uneventful orotracheal intubation, guillotine adenotonsillectomy was performed under general anesthesia. Hemostasis was achieved by dry gauze compress on both sides, no bipolar cautery was necessary. Both tonsils were easily removed without remarkable adhesions and there was no excessive bleeding during or after the procedure. Our patient was monitored in the recovery room and discharged to the ward after 40 min.
The next morning during visitation rounds, the patient’s dismissal home was postponed due to inadequate fluid intake. The physical examination and vital signs showed no aberrant findings. In the afternoon the patient was reassessed because of a swelling on the right side of his face. His vital signs were normal and there was no fever or difficulty breathing. Further physical examination showed facial swelling on the right side and crepitus was felt during palpation. There were no signs of cellulitis. Oral examination of the tonsil bed revealed normal wound healing without obvious mucosal tears. Ultrasound confirmed the presence of subcutaneous emphysema.
The progression of the emphysema quickly resulted in signs of an obstructed airway with a saturation of 81% SpO2 and the use of accessory muscles of respiration. The patient was quickly transferred to the pediatric intensive care unit where he was intubated. Shortly after successful intubation, the patient went in cardiac arrest and 2 min of cardiopulmonary resuscitation was performed. Bedside evaluation arres

[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 Hispanic woman presented to our medical center with cutaneous and mucosal bleeding. The patient was in her usual state of health on the morning of admission day. In the evening she noticed raised purple lesions on her tongue and a diffuse rash consisting of regularly shaped, flat, purple spots on her legs. The patient sought out an urgent care where she was found to have critically low platelets with a platelet count of 1,000 platelets per microliter and was transferred to the Emergency Department. The patient noted the rash must have developed between 12:45 pm–5:30 pm on the day of her admission. The rash was not associated with pain or pruritis. A full review of systems was performed which was negative other than presence of increased menstrual bleeding on the day of admission.
Past medical history is remarkable for dysfunctional uterine bleeding secondary to her Etonogestrel implant, mild asthma controlled with as needed albuterol inhaler, and vitamin D deficiency. The patient reported allergies to shellfish and penicillin, both of which give her hives. In addition, she reported a history of local reaction to a vaccine after receiving influenza vaccine and pneumonia vaccine in same arm on same day in October 2019. She denied family history of bleeding disorders, hematologic conditions, and autoimmune conditions. She endorsed social drinking but denied use of tobacco products (including vape devices, cigarettes, smokeless tobacco) and other illicit drugs. There were no recent changes to her home environment. The patient denied recent allergic exposures, sick contact, or recent viral illness. However, she reported receiving her first dose of the Pfizer SARS-2-Coronavirus ten days prior. On physical examination, the patient was afebrile, hemodynamically stable, and showing no signs of active bleeding. On examination of the skin and mucous membranes, she had hemorrhagic bullae of the oral mucosa and tongue and a diffuse petechial rash of the bilateral l

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


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

[User]
RADIOLOGY NOTE:
A 25-year-old man was admitted to the emergency department after falling off his bicycle. He was hit by the bicycle's handle bar into the left side of the abdomen. The clinical examination revealed a fit young man who had only a scratch (abrasion) on the abdominal wall left of the umbilicus. Hemodynamically he was normal and alert and referred to intense pain at the abrasion site. The abdomen was soft, without signs of peritoneal irritation while sensitivity was only at the point of the abrasion. Laboratory tests, including white blood cells, liver enzymes, and amylase, were normal. The abdominal X-ray in upright (standing) position did not reveal the presence of free intraperitoneal air. Abdominal ultrasound did not reveal any solid abdominal organ injury nor the presence of free intraperitoneal fluid. The pain was attributed to hematoma of the rectus abdominis muscle pricey below the abrasion which was revealed by ultrasound.
The pain of the young man was gradually worsening and was mostly described diffusely throughout the whole abdomen. The abdomen remained soft and tender without signs of peritoneal irritation. We proceeded to the administration of per os contrast material and CT abdomen. The CT scan revealed the presence of sufficient amount of free intraperitoneal contrast but did not allow the clarification of the exact point of escape. The free contrast material was detected at the left side of the abdomen, at the area of the descending colon but mainly in the pelvis (). The intraluminal contrast had even reached up the level of the transverse colon.
The patient was taken to the operating room for exploratory laparotomy immediately after the CT scan (4 hours after the arrival at the emergency department and about 4.5 hours after the time of injury). Intraoperatively, fecal peritonitis due to isolated rupture of jejunum 30 cm from the ligament of Treitz was revealed. The rupture was at the center of an extensive jejunum serous layer fissure giving the pictur

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


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

[User]
RADIOLOGY NOTE:
A 22-year-old man presented with a swelling in the left ramus of the jaw 2 years ago. Examination revealed a unilocular radiolucent lesion, with a scalloped inferior border []. The CT scan revealed a well defined hyperdense soft tissue seen in the region of and below the left coronoid process of mandible, with suspicion of sclerosis. A partial mandibulectomy was performed and a reconstruction plate with a mini plate at the anterior region along with a fibular graft in the jaw was inserted to repair the defect []. Microscopy of the biopsied specimen revealed a diagnosis of central giant cell granuloma.
After one year, the patient, now 23 years old, complained of a recurrent swelling in the same region. Intraorally, the patient presented with a growth in the left buccal mucosa at the level of the occlusal plane, which was excised and microscopically reviewed. Histopathological examination revealed it as a granuloma []. The first molar along with the premolars were removed, the region was curetted and a new reconstruction plate was given.
A year later, the patient now 24 years old, was referred to the Department of Oral Surgery with the complaint of pain and recurrent swelling of the left jaw []. The patient had difficulty in opening the mouth. There was no paresthesia and both medical and familial histories were non contributory.
Clinically the lesion extended from the corner of the mouth to the anterior part of tragus on the left side, which was 4 × 4 cm in size, irregular in shape with a rough texture. The swelling was hard in consistency, showed no secondary changes and was non tender on palpation.
Intraoral examination revealed an exophytic growth present posteriorly near the junction of the buccal mucosa and pterygomandibular fossa region, at the level of the occlusal plane, sized 1 × 1.5 cm and soft in consistency. It had a smooth surface with no fluctuation on palpation []. Presently the CT scan revealed an evidence of an expansile destructive

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


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

[User]
RADIOLOGY NOTE:
This is a 62-year-old woman who presented with progressive weakness and gait abnormalities which began in her early fifties. As the symptoms progressed, she developed frequent urinary tract infections and was referred to an infectious disease physician. The multiple urinary infections prompted the infectious disease doctor to recommend a neurological consultation.
Her neurological examination revealed a normal mental status and cranial nerve examination. Tests of her sensation and cerebellar system disclosed no abnormalities. Her stretch reflexes were symmetrical and 4+ at the ankles with sustained clonus, 3+ at the patellae with crossed adductor responses. Her extensor responses were plantar. In her arms, testing the brachioradialis, biceps, and triceps reflexes showed normoactive responses (2+). The muscle tone was increased in her legs and she had a spastic gait with scissoring. Her muscle bulk was normal and she had normal power except for mild weakness of hip flexion bilaterally (Medical Research Council Grade 4/5). Prior investigations that had been performed and the following were negative or normal: MRI of the brain, cervical, and thoracic spine with and with contrast, routine serum chemistries and cell blood counts, and an electromyogram which showed no evidence of neuropathy, myopathy, or motor neuron disease.
A family history revealed many individuals affected with a neurological disorder including a brother with ‘neuropathy’ and father with ‘amyotrophic lateral sclerosis’. She also has a paternal uncle and a male cousin diagnosed with difficulty walking due to a neurological disorder. The presence of these multiple members of her family diagnosed with a neurological disorder suggests a genetic disorder with an autosomal dominant pattern of inheritance. Her neurological examination was highly suspicious for SPG and genetic testing was performed focusing on genes that cause this disorder.
The patient underwent Whole Exome Sequencing (WES) through a commerc

[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 with a body weight of 67 kg was admitted in our day care centre for bunion surgery. Her medical history included hypertension, hypercholesterolemia, a surgical history of appendicectomy and she smoked 5 cigarettes a day. She was compliant with her medication intake (amlodipine, simvastatin, prazosin, acetylsalicylic acid) and in a healthy condition. The patient had fixed dentures. Anaesthetic care was provided by an anaesthetist with a broad clinical experience of over 30 years. Anaesthesia was induced with 120 mg propolipid, 20 mcg sufentanyl and maintained with sevoflurane 2% in an oxygen-air mixture via spontaneous ventilation. A single use LMA size 3 (Solus®, intersurgical, Wokingham, Berkshire, United Kingdom) was successfully inserted after one attempt and the cuff was inflated with 20 ml of air. There was no documentation of difficult insertion, no complications during surgery and the duration of the procedure was 80 min.
The LMA was removed on recovery from general anaesthesia with the cuff deflated with evidence of a little blood on the LMA cuff. At discharge from day care centre the patient complained of a sore throat and a small amount of bloodstained sputum. This was not investigated any further and she was discharged with simple analgesics. The following day the pain in her throat became progressively worse and she presented to her general practitioner with fever, dysphagia and throat pain. Amoxicillin (500 mg (mg) 4x/day) and analgesics were prescribed as treatment for laryngitis. After three days symptoms persisted and the patient started to experience respiratory difficulty and worsening pain. The skin from the sternum bilaterally to both ears was swollen, red and warm and she was admitted to the emergency department.
A contrast-enhanced computer tomography (CECT) scan of the neck and upper chest showed a large collection in the visceral space, with a mass effect leading to a deviation of the trachea to the left.
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 patient is a 75-year-old female with a past medical history of chronic obstructive pulmonary disease, type 2 diabetes mellitus, atrial fibrillation not on anticoagulation. She had multiple hospital admission due to urinary tract infection and left hip pain due to fracture status post open reduction and internal fixation three months before that presented to the emergency department with acute on chronic left hip pain. Patient’s pain started two weeks ago, and she described it as severe, sharp, constant, radiated to the left thigh, that has been progressively worse to the point that she has been unable to walk; nothing had made the pain better. On exam, she had an externally rotated left lower extremity, tender, cold to palpation, along with a 3-cm decubitus ulcer around the heel.
Initial laboratory workup showed elevated potassium of 7.2, creatinine at 13.34 mg/dL, blood urea nitrogen of 103, initial white blood cell counts 51,200/mcl, platelet 585, lactic acid 7.2, erythrocyte sedimentation rate 97 and C-reactive protein 23. Her electrocardiogram was significant for generalized hyperacute T wave. Given electrolytes abnormalities, a non-tunneled central line catheter was placed for urgent hemodialysis. Before this was able to be done the patient became hypotensive and tachycardic, not responsive to aggressive intravenous fluids resuscitation, requiring initiation of vasopressors. She was taken to the intensive care unit and started on vancomycin and piperacillin-tazobactam for empiric coverage. Additional tests result included a positive urine culture for Escherichia coli along with blood cultures showing Gram-positive rods.
At the time of admission, the primary diagnosis was septic shock secondary to urinary tract infection with suspected blood culture contamination. Further workup included left hip arthroscopy to identify another source of infection due to severe persistent left hip pain and lack of improvement in her overall clinical status, but it was unable

[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:
After falling off a mountain bike down an incline into some brush, a 49-year-old male mountain biker presented to an outside ED with normal vitals, severe vertigo, nausea, intractable vomiting, profound hearing loss, and tinnitus. A CT was performed, which showed opacification of the ear canal, but did not comment on any abnormalities of the inner ear. The patient was transferred to our facility for further management. On examination, there was a spontaneous right-beating nystagmus and the facial nerve was intact. A tree twig was embedded in the left external auditory canal, obscuring visualization of the tympanic membrane.
Temporal bone CT demonstrated a linear foreign body projecting from the external auditory canal to the oval window, and an additional, separate small foreign body projecting into the vestibule. Presence of extensive intralabyrinthine air was detected radiographically (). On axial view, air bubbles were seen in the vestibule, posterior semicircular canal, and the scala vestibuli compartment of the cochlear basal turn, as well as in the lateral and superior semicircular canals (). Preoperative audiogram conducted at bedside revealed normal hearing on the right side and moderate-to-severe mixed hearing loss on the left.
The patient was diagnosed with a traumatic PLF with extensive pneumolabyrinth due to penetrating temporal bone injury and was taken urgently to the operating room less than one day after his inciting injury. A three- centimeter tree twig was lodged in the ear canal and found to be penetrating the tympanic membrane. Postauricular approach included mastoidectomy and intraoperative assessment of the middle ear ossicles and extent of injury. The long process of the incus was dislocated but still attached to the malleus, the stapes was deeply embedded into the vestibule, and the oval window was completely open but covered by blood clot. All penetrating foreign bodies were extracted. Temporalis fascia was used to seal the oval window and a

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


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

[User]
RADIOLOGY NOTE:
The patient was a healthy 25-year-old man with a one-year history of right ankle pain following trauma.
He had met a car accident while walking. One year earlier, he had undergone open reduction and internal fixation on his right ankle for fracture at another hospital. A tibia diaphysis spiral fracture was fixed by the anterograde intramedullary nail with infra-patellar approach. An ankle malleolar fracture was fixed by the locking plate and cannulated cancellous screws with direct lateral and medial approach. He had finally consulted us because of worsening ankle pain while walking. On physical examination, there was tenderness in the anteromedial joint space of the right ankle. Slight ankle swelling was noted. Dorsiflexion of the right ankle was 10°, similar to that of the left ankle, but plantarflexion was restricted to 38°, compared with 60° on the left, but the ankle instability test was negative.
The first three months, even though we performed intra-articular injections, arthroscopic synovectomy for osteoarthritis, and the fixation implant removal in order to release implant irritation, his ankle pain persisted.
The AOFAS ankle score at that point in time was 50 . Radiographs showed moderate narrowing of the ankle joint and forward displacement of the talus (-A, B). Computed tomography of the right ankle showed an osteochondral defect on the anterolateral surface of the distal tibial plafond (). This was diagnosed as progressive osteoarthritis caused by an osteochondral defect on the anterolateral surface of the distal tibial plafond, and surgical repair of the osteochondral defect was recommended. Three months later, the osteochondral graft was performed on the patient's right ankle. The patient was placed in the supine position under general anesthesia. The lower extremity was prepared and draped in the standard sterile fashion. We inserted the 2.0 mm K-wire in his right calcaneus, then skeletal traction was done in order to open his right ankle joint space

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


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

[User]
RADIOLOGY NOTE:
A 65-year-old Japanese woman was referred by her local dentist to our hospital for retrieval of a fragment of Peeso reamer that had broken during a root canal enlargement and that was embedded in the canal of her right mandibular first premolar, extending beyond the apex (tooth number 44). As it was not possible to remove the mandibular foreign body from the root canal at the referral dentist, she was admitted to get it removed using a surgical approach. During the intraoral clinical examination, there was an access cavity filled with a temporary filling material and the tooth was sensitive to pressure. There was tenderness in the apical portion of the tooth. A panoramic radiograph obtained at the initial visit after the patient referral revealed a well-defined fractured instrument lying in the mandible beyond the apical foramen of her right mandibular premolar tooth. Moreover, computed tomography (CT) images revealed that the fractured segment was located within the mandibular bone (Fig. ). A diagnosis of migration of a broken endodontic instrument beyond the apical foramen into the mandible was made, and surgery was considered necessary to eliminate the symptoms. The decision was made to proceed with the surgery because of increasing pain.
Surgical intervention was required to find the apical root cutting-edge lesion and the broken dental instrument through a small bony window and to remove it from the oral cavity by pushing up in order to reliably preserve the tooth for restorative treatment. Therefore, we decided to use three-dimensional navigation-guided surgery for its minimally invasive nature and high surgical accuracy. As it is difficult to synchronize with the preoperative imaging data during surgery due to the mobile nature of the mandible, we used a customized interocclusal splint for repeatable mandibular positioning while enabling surgical access. As part of the CT imaging preparation for navigation, a customized interocclusal splint was fabricated by

[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 12-year-old boy presented to the Pediatric Emergency Department shortly after receiving an electric shock at a nearby apartment building. As the boy, his mother, and younger brother were waiting outside the building for friends to “buzz them in” (), an individual exited the building and held the door open. The mother and younger brother entered without touching the door. As our patient entered the building, he grasped the metal door knob with his left hand while at the same time keeping his right hand on a metal stair railing that was adjacent to the entrance. This action occurred just as the door entry mechanism was activated from upstairs. As a result, the patient sustained an electrical shock inducing upper extremity tetany, prohibiting him from releasing his grip. The shock lasted approximately 5 seconds and was witnessed by the patient's mother. The patient retained consciousness throughout the event and did not fall afterwards.
Initial evaluation in the Emergency Department centered on the potential cardiac, myopathic, and renal aspects of the injury. The patient was admitted for telemetry monitoring in the Pediatric Intensive Care Unit. No arrhythmias were noted. The following morning, the patient complained of bilateral wrist pain. He had mild swelling and erythema, therefore an orthopaedic surgery consult was requested for evaluation.
The child was able to use both hands, favoring the right over the more painful left. There were no burn marks or abrasions, but mild, bilateral, distal radius volar angulation deformities were present. Anteroposterior, lateral, and oblique radiographs of both wrists revealed bilateral, buckle-type, apex-dorsal angulated fractures of the distal radial metaphyses (Figures and ). The patient was placed in bilateral volar splints to reduce wrist motion, preserve hand function, and permit examination of his skin. He was discharged home directly from the PICU on hospital day three and followed an uneventful course to clinical 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:
Our inhouse specialist palliative care service (PCS) treated a 75-year-old man suffering from lung cancer. Originally, the patient was transferred from an orthopedic clinic where a pathological lumbar fracture was diagnosed. The patient was transferred to our internal medicine unit for further tumor examination. At the time of cancer diagnosis in November 2020, adenocarcinoma of the right upper lobe of the lung with osseous and lymphogenic metastases was far advanced, as well as metastases of the adrenal gland. Due to a rapidly worsening state of health and aggravating symptoms, such as dyspnoea and weakness, the planned radiotherapy and commencement of a tumor-specific therapy could not be carried out. Therefore, PCS management was initiated. During the patient’s hospital stay, his wife was his only visitor due to COVID-19 visitation restrictions. Before beginning PCS care, the patient had already been hospitalized for approximately 3 weeks in the internal medicine unit of the hospital, and an oropharyngeal swab for a SARS-CoV-2 PCR (polymerase chain reaction) test had last been performed on the day of admission to the hospital with a negative result.
On the day of transfer to the palliative care unit, the patient’s symptoms became significantly more severe. He suffered increasingly from shortness of breath and a cough, as well as developing a fever. Visitors were required to fill out a questionnaire before every visit asking about any potential contact with COVID-19 infected individuals and symptoms of infection, but a measurement of body temperature was not obtained. On admission to our palliative care unit, the patient’s wife denied that she or her husband had contact with anyone infected with COVID-19, and according to her questionnaire answers, she was free of symptoms. The patient’s symptoms were interpreted as being due to pneumonia from pre-existing lung cancer. Wearing a mask was impossible for the patient. The nurses along with other members 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.