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

[User]
RADIOLOGY NOTE:
A 37-year-old woman presented with multiple masses on the scalp. She underwent an excisional biopsy of the scalp mass at a local clinic and visited our hospital for further work up. Computed tomography of the neck revealed a poorly enhancing mass lesion in the left lobe of the thyroid measuring about 1 cm with ipsilateral cervical lymph node metastasis (). An ultrasonographic examination of the thyroid revealed a 0.9 cm hypoechoic mass without increased vascularity (). Ultrasound-guided fine-needle aspiration (FNA) was done to rule out the possibility of primary thyroid cancer. Unlike a typical thyroid malignancy, the aspirated material was sticky and difficult to aspirate.
The alcohol-fixed smears were stained with hematoxylin and eosin and Papanicolau for the cytologic examination. The cytological smears were hypercellular and displayed spindle cell clusters in hemorrhagic background. No necrotic material was observed. The spindle cells were arranged in a fascicular pattern and showed an indistinct cell border. The cells had eosinophilic and fibrillary cytoplasm. Individual cells showed variation in nuclear size and shape. However, the nuclei of most of the cells were hyperchromatic and large, and they demonstrated an elongated shape with blunt ends (). Normal follicular cells were admixed with pleomorphic tumor cells, and were also observed around tumor cell clusters (). These features raised the suspicion for a malignant tumor of mesenchymal origin.
Histological slides from the resection specimen of the scalp mass revealed a small nodular mass measuring 0.8 × 0.6 cm. The tumor cells were arranged in bundles or fascicles of smooth muscle fibers (). They were highly pleomorphic and had a centrally located, blunted, cigar-shaped nucleus adjacent to perinuclear cytoplasmic vacuoles. The mitotic rate was high (7 mitosis per 10 high-power field), but there was no area of necrosis. Immunohistochemical staining showed a positive result for smooth muscle actin (SMA) and

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


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

[User]
RADIOLOGY NOTE:
A 65-year-old African American male presented with a 4-month history of dysphagia and 30-pound unintentional weight loss in an outpatient clinic. The patient underwent an endoscopy, which showed a friable, nodular, and circumferential, near obstructing mass extending from the distal esophagus into the gastric fundus. The biopsy was interpreted as well-differentiated adenocarcinoma. Staging CT scans of chest, abdomen, and pelvis confirmed a large mass near the GE junction measuring 6 cm in size accompanied by enlarged pancreaticoduodenal lymph nodes in the vicinity of the gastric cardia. There were no distant metastases noted. The patient underwent a Positron emission tomography scan (PET) which showed a hypermetabolic gastric mass. There was focal uptake in the dome of the liver and probable avascular necrosis of the hips, but follow-up MRI of the liver showed no liver metastases.
After declining surgery and percutaneous endoscopic gastrostomy tube (PEG) placement, the patient received two cycles of chemotherapy with Cisplatin and 5-Fluorouracil and then began concurrent chemotherapy and radiation therapy. The therapeutic regimen was complicated by severe anemia with hemoglobin of 6.5 g/dL and hematocrit of 24%, which required transfusion. The patient also developed increased dysphagia, dehydration, and malnutrition resulting in another 30-pound weight loss over 4 weeks. Therefore, the patient left in the middle of chemotherapy treatment. Two months later, the patient relocated to a different city and was seen by a new oncologist.
In the new cancer center, a following up PET scan was obtained which showed neoplasm in the gastric cardia and possible liver metastasis but no brain metastasis. A repeat CT scan of the abdomen with and without contrast confirmed again no focal liver lesion. The patient initially declined chemotherapy but agreed to complete radiation therapy. The 6 cm gastric tumor was radiated again palliatively at this point with hope to improve his oral

[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 37-year-old Taiwanese male patient presented to our medical attention with acute onset postural headache over right temporal area associating with occasional dizziness. He was well-being prior to this attack and led a normal living as a logistic bus driver for more than nine year. He claimed to carry heavy object day to day but experienced no particular physical discomfort. The characteristic of headache was worsen while he was standing up shifty and the pain could be partially relieved when he lied down on the back. On reviewing his medical history, he denies any trauma history, fever, neck pain, double vision, blurred vision, weakness or numbness of limbs, fecal or urine incontinence, loss of consciousness before, during or after the attack.
He was therefore admitted to our neurological ward for advanced study. On detailed neurological examination, it revealed he suffered from aggravating dizziness, accompanying with nausea and vomiting several times and unsteady gait leaning to right side upon standing up. Though his vital signs were stable that was checked in the emergency room along with laboratory survey showing insignificant findings, Physical examination demonstrated right facial and tongue paresthesia, mild right central facial palsy, deviation of tongue toward right side on protrusion and left deviation of uvula with dysarthria without dysphagia on the second day of admission. In addition, his muscle strength (muscle power) and deep tendon reflex tests were both normal; Nevertheless, patient showed significant right-sided dysmetria with abnormal finger-nose test and heelshin test. Right side mild dysdiadochokinesia was also founded. Additionally, rebound phenomenon of right arm and Romberg’s sign were also observed.
Initial evaluation with non-contrast cerebral computed tomography showed no intracranial hemorrhage or mass lesions. Brain magnetic resonance imaging showed presence of small focal area of high signal intensity over diffusion weighted seque

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


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

[User]
RADIOLOGY NOTE:
A 77-year-old Middle-Eastern female with a medical history of hypertension and hyperlipidemia presented to the emergency department (ED) from a day care facility apartment where 2 people at the facility have tested positive for COVID-19 but she did not have any direct contact with these individuals. About 5 days before admission the patient developed a fever with a temperature of 102°F at home, and went to her primary medical doctor who sent her to the ED. In the ED she was found to have bilateral opacities on chest X-ray and had continued intermittent fevers with generalized weakness, cough, lethargy, and dyspnea and was sent for testing for COVID-19 then transferred to our facility for further management. In our facility, her temperature was 101.7°F, blood pressure 148/76 mm Hg, heart rate of 99 beats per minute, respiratory rate of 18 per minute, and oxygen saturation of 93% on room air. Physical exam was significant for a dry cough and bilateral rales on auscultation of the lung fields bilaterally but was unremarkable otherwise. A chest X-ray (Fig. ) was performed showing bilateral opacities throughout the lung fields with predominance of the lower lung lobes she was admitted for possible pneumonia with isolation precautions for suspected COVID-19 and was started on oxygen via nasal cannula and on 1-gram ceftazidime intravenously every 8 hours and 500 mg azithromycin orally daily. CT scan of the chest (Fig. ) was performed showing bilateral ground glass appearance throughout the lung with predominance in the peripheral lower lobes. Respiratory viral panel was sent including a repeat COVID-19 test (Table ). All results came back negative however the patient's condition deteriorated 2 days after admission to our facility, and she became hypoxic to 85% oxygen saturation while on nasal cannula and remained spiking fevers up to 103.4°F. She was intubated and transferred to the intensive care unit (ICU) for further management

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


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

[User]
RADIOLOGY NOTE:
A 5-year-old boy presented to our institution with a complaint of pain, swelling, and redness in both legs. His parents stated that they had taken him to another health institution 40 days earlier because he had a fever and that a 10-day course of oral antibiotic therapy was prescribed. During a physical examination at our institution, swelling, erythema, and warmth were detected in both legs, and a purulent discharge was observed exuding from the proximal end of each tibia. He did not have a chronic illness or a history of a trauma. His laboratory tests revealed a white blood cell count of 15,640/mm3, C-reactive protein of 5.29μg/mL, and erythrocyte sedimentation rate of 63mm/h. The results of a Brucella tube agglutination test, Gruber Widal test (for Salmonella), and purified protein derivative test for tuberculosis (TB) (the TB test was previously done twice and was negative each time). The patient did not complain of a cough or fever, and his chest X-ray was normal. X-rays of his legs revealed cortical destruction and an increase in periosteal tissue in the proximal aspect of each tibia and the distal aspect of the left tibia (Figure ). Additionally, magnetic resonance imaging revealed bone marrow edema throughout both tibias, an accumulation of purulent debris in the bone marrow and metaphysis, and pyomyositis contiguous with the site of osteomyelitis. On radionuclide imaging studies, we found an increased uptake of technetium at the site of infection (that is, in the metaphysis of each tibia).
After diagnosing his condition, we carried out open irrigation and surgical drainage in his legs. After opening cortical fenestrations in the metaphysis of each tibia, we performed curettage of the medullary canal, carefully avoiding the growth plate. Approximately 150cc of purulent fluid was drained from the left tibia and approximately 200cc from the right tibia. Microbiological and pathological samples were taken during surgery for Gram staining, blood and

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


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

[User]
RADIOLOGY NOTE:
A 90-year-old Japanese woman diagnosed with a metastatic tumor in the left cheek was referred to our department of radiation oncology from the department of urology for the purpose of palliative irradiation on March 1 of 20XX. She was followed up by the department of urology for nine years for a tumor in the right kidney (1.7 cm in size). The follow-up consisted of computed tomography (CT) without biopsy because of the stable nature of the tumor. She also received hemodialysis for six years because of chronic renal dysfunction.
In the summer of 20XX-1, the patient noticed a tiny tumor in her left cheek. After January of 20XX, the tumor showed rapid growth. On February 21 of 20XX, the tumor was 2 cm in diameter with a violaceous appearance, and a biopsy of the tumor was performed. The immunohistochemical (IHC) analysis showed that the biopsy specimen was positive for chromogranin, synaptophysin, and CD56 and negative for thyroid transcription factor-1 (TTF-1), S-100, and human melanin black-45 (HMB-45). The pathologist reported it as a metastatic neuroendocrine tumor of unknown origin. Based on the pathology report, the urologist diagnosed the tumor as a metastatic tumor derived from the right kidney. The patient was referred to the departments of dermatology and plastic surgery. The dermatologist and the plastic surgeon agreed with the diagnosis made by the pathologist and the urologist and considered the tumor inoperable because of its extremely rapid-growing nature. The patient was referred for palliative radiation therapy.
At the time of presentation to our department of radiation oncology, the tumor was 3 cm in diameter. CT images showed that the tumor was almost completely spherical (Figure ). The CT examination showed no lesions indicative of lymph node- or distant-metastases in the regions from the head through the pelvis; the patient’s tumor in the right kidney had remained stable for nine years. The characteristics of the patient

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


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

[User]
RADIOLOGY NOTE:
An 18-year-old previously healthy female initially presented to the Emergency Department with a 2-day history of peri-umbilical pain which migrated to the right lower quadrant. On further questioning, she complained of anorexia and low grade fever. On examination, she had localized tenderness in the right lower quadrant with rebound tenderness over McBurney’s point. Her laboratory results revealed increased inflammatory markers, a normal urine dip and a negative pregnancy test. A clinical diagnosis of acute appendicitis was made, and she was taken to the operating theatre for an open appendectomy. The intraoperative findings confirmed a suppurating perforated appendix that was removed and sent for histology. In the first post-operative day, the patient was feeling very well with no further complaints, and a provisional plan for discharge was made (–).
Unfortunately, from Day 2, post operatively the patient started developing symptoms of nausea, vomiting and moderate abdominal pain. On examination, she had mild abdominal distension with minimal tenderness in the lower abdomen with no signs of peritonitis. Blood tests did not display any significant changes. The abdominal radiograph showed dilated small bowel loops and an appendicolith in the right iliac fossa. A computerized tomography scan was performed and demonstrated dilated small bowel loops down to the distal ileum and a 11 mm appendicolith/stone in the right side of the pelvic cavity with no pelvic collection or other positive findings. The clinical diagnosis was that of an ileus, and she was treated conservatively with analgesia, nasogastric intubation and intravenous fluids. In the next 24 hours, her symptoms did not resolve, the abdominal distension progressively worsened with increasing lower abdominal pain and peritonism.
Consequently, the clinical decision was to take the patient to the theatre for an exploratory laparotomy. At the time of exploration, there were grossly dilated small bowel loops up to a

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


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

[User]
RADIOLOGY NOTE:
A 14-day-old male presented to the ED with a 24-hour history of swelling and redness of the right cheek. He had been doing well since birth. His mother noticed that he was crying between his feeds and appeared fussier. The parents denied fever, any kind of rash, or contact with a sick person. The cheek swelling was associated with the skin redness. The baby was born at 38 weeks twin delivery, cesarean section, no complications at birth, and was gaining weight appropriately.
In the ED, the patient was afebrile with normal vitals for his age. On exam, he had right facial redness and crying with palpation of the right cheek (). The left side was normal. The right tympanic membrane could not be visualized due to edema. Oral mucosa was normal, but purulent material was seen coming out of the mouth. When parotid massage was performed more purulent material was expressed inside the mouth from the opening of the right Stensen duct. No other significant exam findings were noted. A presumptive diagnosis of acute suppurative parotitis was made.
His laboratory tests showed a normal complete blood count. His comprehensive metabolic panel was also within normal limits except for total bilirubin and direct bilirubin levels (). A respiratory panel was obtained and was negative. A point-of-care ultrasound of the soft tissue, head, and neck was performed, which showed a swollen, hypervascular right parotid gland likely representing changes of parotitis. There was no evidence of ductal dilation, obvious calcification shadowing, or changes to suggest abscess ( and ). This was the main contribution to the diagnosis. Ear nose throat (ENT) and infectious disease specialists were consulted from the ED and agreed with the diagnosis. Even though the baby was afebrile, he received a full septic work-up. Because neonatal suppurative parotitis (NSP) causes complications such as bacteremia and meningitis in many cases, it needs to be identified and recognized

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


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

[User]
RADIOLOGY NOTE:
A 47-year-old man with unknown previous conditions underwent cranial magnetic resonance imaging (MRI) after having experienced tonic–clonic seizures in November 2012. MRI revealed nodular lesions and vasogenic edema. Positron emission tomography-computed tomography revealed a 44 × 30 mm primary lesion located in the right hilar region as well as hypermetabolic lymphadenomegaly of the lymph nodes in the mediastinum of the right paratracheal region, aorticopulmonary window, and subcarinal and right hilar regions. The biopsy specimen obtained during bronchoscopy revealed adenocarcinoma. Radiotherapy was planned because of the presence of more than 20 cranial metastases. Palliative 3-dimensional conformal radiotherapy was delivered for 15 days (total of 30 Gy in 2-Gy fractions).
The cranial lesions regressed following whole-brain radiotherapy. The patient then underwent 6 cycles of docetaxel at 120 mg + cisplatin at 120 mg, followed by 8 cycles of pemetrexed and 3 cycles of cisplatin and gemcitabine.
One year following initial therapy and 3 months after the last dose of chemotherapy, the patient presented with shortness of breath and a feeling of fullness in the neck. Thoracic MRI revealed an approximately 57 × 16 × 20 mm multiloculated cystic lesion with air density located in the upper mediastinum of the right paratracheal region and a fine fistula tract at this level associated with the trachea from its right posterolateral aspect (Figure ).
During bronchoscopy, a 1-mm fistula opening was observed in the posterior wall of the right lateral aspect, approximately 6 cm distal to the cricoid cartilage. This area was coagulated using APC. Closure of the fistula opening occurred by secondary cicatricial healing.
Control thoracic CT performed 1 week after the procedure revealed substantial improvement in the mediastinal cystic lesion (Figure ), and control bronchoscopy confirmed closure of the fistula opening (Figure A and B).
The patient did not provide any consent to publ

[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 report the case of a 42-year-old woman who underwent orthotopic renal transplantation for the first time, using a kidney from her sister. The patient had developed end-stage renal disease secondary to lupus nephritis. She had a medical history of bilateral thrombosis of both common and external iliac arteries due to lupus anticoagulant and antiphospholipid antibodies that had required bilateral percutaneous angioplasty with wall stenting. The medical workup had documented thrombosis of both iliac veins and of the lower portion of the lower part of the inferior vena cava as well as extensive atherosclerotic lesions of the abdominal aorta. In addition, she had a history of mitral valve replacement with a St. Jude prosthetic valve and received anticoagulation therapy with acenocoumarol.
The patient had an HLA semi-identical sister who was willing to donate a kidney. The donor workup had documented a slightly lower tubular mass of the right kidney which was chosen for procurement. The “classic” extraperitoneal pelvic transplantation of a kidney graft was contraindicated because of stented iliac arteries and extended atheromatosis of the aorta (). An alternative surgical technique with the transplantation of the graft into the location of a native kidney was proposed to the recipient and her sister who both consented to the procedure. Mapping CT-angiography of the recipient showed that the left renal artery was appropriated for anastomosis with the graft artery. At the same time the anatomical variant of the left recipient renal vein was found with low implantation to vein cava inferior (VCI; ).
The graft was procured by laparoscopic right donor transperitoneal nephrectomy with utilization of linear stapler Endo-GIA as previously described []. The warm ischemic time was 3 minutes measured from the first clip applied to the renal artery until the kidney was perfused with preservation solution. The graft was cold flushed with HTK solution and preserved on ice during the

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


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

[User]
RADIOLOGY NOTE:
A 57-year-old woman presented to a private practitioner with a swelling in the left labial region in last three years, which was now associated with bleeding, foul smelling discharge, and pruritus since last one month. There were no enlarged inguinal nodes at the time of presentation. She underwent wide local excision alone and was diagnosed with SCACP. Postoperative margin status was negative. Three months postoperatively, she presented to our institutional Oncology OPD with an ulcerative lesion in the left labial region along with right inguinal lymphadenopathy.
Histopathological examination of the ulcerative lesion in the left labia showed epidermis comprising of keratinized squamous epithelium and dermis showing a tumor extending from lower epidermis into deep dermis. The tumor was made up of multiple nodules comprising of duct-like structures, some appearing to be cystically dilated, papillary structures having central fibrovascular cores, solid nests, and islands (). Dense infiltrate of lymphocytes was seen inside the ducts and papillae and in the surrounding stroma (). These ductal and papillary structures were made up of multilayered round to oval to columnar cells having scanty eosinophilic cytoplasm exhibiting moderate nuclear atypia with vesicular chromatin and some showed prominent nucleoli (). Histopathological findings favoured the diagnosis of SCACP, residual disease. Fine needle aspiration (FNA) was done from the enlarged firm right inguinal lymph node. The aspirate cytosmears showed abundant cellularity comprising of clusters, nests, papillary structures, and discretely scattered malignant epithelial cells characterized by round to oval cells having scanty eosinophilic cytoplasm exhibiting hyperchromatic or vesicular nuclei with high nuclear-cytoplasmic ratio and some showed prominent nucleoli. Background showed numerous mature and transformed lymphocytes and eosinophilic proteinaceous material (). Based on the cytomorphology, a diagnosis of metasta

[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 1-year-old-male baby was presented to the hospital with a history of an abdominal mass. A local pediatrician in the outpatient clinic incidentally discovered it when he was examining the child for a complaint of distention and chronic diarrhea.
The child was referred to the hospital and was admitted to the Pediatric Surgery Department. Physical examination indicated the mass was painless and mobile. The palpable mass was nontender and extended from the upper left quadrant to the umbilicus. Vital signs were normal, and the child was asymptomatic with a good appetite. He did not complain of vomiting, constipation or abdominal pain. His weight at admission was 9 kg. Laboratory tests were normal. Abdominal ultrasound showed a hyperechoic soft tissue lesion with a maximum diameter of ~10 cm, pushing the intestine to the right without obstruction of the intestinal lumen.
Computed tomography (CT) of the abdomen revealed a homogeneous, well vascularized mass measuring 9.4 × 10.6 cm and encapsulated with thin septation in its medial part. The mass was located in the upper left quadrant and extended to the pelvis with an oval appearance (). Other abdominal findings were normal. Under general anesthesia, an incision was made in the midline above the umbilical region. The findings were a soft, yellow mass with defined margins, originating from the small intestine’s mesentery, 30 cm from Treitz ligament ( and ). Complete excision of the mass was performed without intestinal resection ( and ). Histopathology showed a normal adipose tissue composed of mature adipocytes with no evidence of mitosis or nuclear atypia, which confirmed the presence of the mesenteric lipoma (). Oral feeding was started 2 days after the operation, and the patient stayed in hospital for 5 days. He was discharged in a good condition with normal bowel movement. The child was evaluated 4 months after the procedure. He had no complains, and abdominal ultrasound revealed normal findings.

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


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

[User]
RADIOLOGY NOTE:
A 26 year-old male student presented to a chiropractic clinic with a complaint of chronic bilateral ankle pain. Walking was not limited by pain, although he reported sharp constant pain that was located over the dorsum of the ankles. The pain intensity varied from 2/10 to 7/10. The pain was aggravated by physical activity such as running and relieved by rest and ice. There was a previous history of locking and swelling in both ankles. The locking was usually accompanied by decreased active dorsiflexion until the patient manually self-mobilized the ankle to regain the lost motion. He reported recurrent bilateral ankle sprains over the past few years. The patient was otherwise healthy and past medical history and systems review were unremarkable.
On examination, the patient weight was within normal limits with respect to his height. No lower limb alignment abnormalities or leg length inequalities were noted. There was no swelling or redness. He had difficulty heel walking due to left ankle pain. Right ankle active and passive ranges of motion were decreased by 10% in dorsi- and plantar flexion. Resisted testing was unremarkable. Neurological examination of the lower limb was unremarkable. Orthopaedic examination illustrated positive bilateral anterior drawer and synovial impingement manoeuvres. The impingement manoeuvre involved concurrent pressure applied anterior and inferior to the lateral maleolus while the ankle was moved from plantar to dorsiflexion []. One leg stance was held for 5 and 10 seconds on the right and left, respectively. Joint play illustrated restrictions in the right subtalar joint. Muscle palpation revealed tight bilateral soleus, fibularis and anterior tibialis muscles with no noted asymmetry in muscle mass.
The patient was diagnosed with bilateral synovial hypertrophy with associated ligamentous laxity. He received conservative treatment which included ultrasound, soft tissue therapy, ankle joint manipulation and exercises. After eight visits o

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

[User]
RADIOLOGY NOTE:
The patient was a 24-year-old male who experienced difficulty in walking for three months prior to our examination, and complained of dysarthria as well as diplopia. In his personal history, he had undergone laparoscopic sleeve gastrectomy surgery in the department of surgery seven months prior to our examination. At that time, he was in a state of morbid obesity, and he was 190 cm tall, weighed 170 kg, and had a 47.1 kg/cm2 body mass index (BMI). The patient had hypertension and diabetes mellitus for one year before surgery, but no medical history of alcohol addiction, hepatitis, or tuberculosis. After the initial surgery, he had to undergo additional surgery twice due to leakage of gastroesophageal anastomosis. However, the leakage was continuous, so total parenteral nutrition was given for approximately 60 days. Stent insertion was then performed to begin parenteral nutrition. Subsequently, the patient exhibited a confused mental state and symptoms of delirium. The severity of the symptoms was weak, and his general condition gradually improved even with conservative treatment. The symptoms of delirium were considered temporary symptoms that often appear after an operation. Therefore, the patient left the hospital.
In the physical examination that was performed when the patient was admitted to the hospital, he presented with alert consciousness without a sign of cognitive deficiency. At that time, his weight was 110 kg, which was 60 kg lighter than before the operation, and his BMI was 30.5 kg/cm2. Judging from these data, his morbid obesity was remarkably improved. Sensory examination was normal both for superficial and deep sensation. However, as a result of a Medical Research Council of Great Britain (MRC) examination, it was found that the muscle strength of both arms and legs appeared to be at a level of 4-4+/5, showing slight muscle weakness. Dysmetria was observed in both hands and feet, which was more serious on the left side of his body compared to the ri

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


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

[User]
RADIOLOGY NOTE:
A 23-year-old male with a history of alcohol abuse and splenomegaly of unknown etiology presented with the chief complaint of abdominal pain. The patient provided information of intranasal cocaine use on the day prior to his presentation to the hospital. His pain was associated with multiple episodes of vomiting. At the initial evaluation, the patient was awake and alert with a Glasgow Coma Scale (GCS) of 15, a heart rate of 120 bpm, and a systolic blood pressure of 130 mmHg. On physical examination, the patient was found to have signs of peritonitis. Computed tomography (CT) scan imaging revealed hemoperitoneum and a possible splenic laceration (, ). Hemoglobin was low at 11 mg/dL. A urine test was positive for cocaine use. The patient denied any recent history of trauma.
The patient presented with signs of peritonitis and free fluid in the abdominal cavity with a suspicion of splenic injury, and was taken to the operating room for exploratory laparotomy. Upon entering the abdomen through a midline incision, a large amount of blood was identified in the abdominal cavity. The blood was evacuated, and all four quadrants were packed with laparotomy pads. The spleen was palpated, and blood was found oozing from the hilum. Inspection from the diaphragm to pelvis revealed no other pathology. We proceeded with a splenectomy beginning with dissection of the lateral and posterior attachments to the spleen. Once the spleen was mobilized and brought to the abdominal incision, the short gastric arteries were ligated. The splenic artery and vein were then tied off with silk sutures. Smaller vessels entering the hilum were occluded with surgical clips and ligated. After all vessels were successfully divided, the spleen was removed.
The splenic bed was inspected, and hemostasis was secured. The liver was re-inspected, and the bowel ran from the ligament of Treitz to the ileocecal valve. The colon was inspected as well. All looked

[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 pregnant woman (G2P1) was referred to us due to suspected bilateral ovarian cysts at 8 weeks of gestation. She had undergone ovarian cystectomy twice under open surgery: left and right ovarian cystectomy for mature cystic teratoma and mucinous cystadenoma, respectively. She had no additional medical history or familial medical history. Transvaginal ultrasound and magnetic resonance imaging (MRI) (Figures and ) revealed two pelvic cysts. The left-sided unilocular cyst was 9 cm in diameter. The right-sided multilocular cyst was 5 cm in diameter. We diagnosed this condition as bilateral ovarian cysts.
Although the serum levels of tumor markers (CA125, CA19-9, and CEA) were normal for a pregnant woman, considering the large size of the cyst, cyst resection was attempted at 14 weeks; however, it was converted to probe laparotomy. Marked adhesion around the cysts, posterior uterus, and Douglas' pouch made cyst resection impossible as extensive adhesiolysis may cause uterine damage and also uterine contractions after surgery. Gross examinations revealed no metastatic lesions or lymph node swelling. Abdominal fluid cytology revealed no malignant cells.
At 32 weeks of gestation, MRI revealed that the left-sided cyst size had increased to 27 cm in diameter (Figures and ), although she was asymptomatic. As shown in , the right-sided multilocular cyst became very close to the left monocytic cyst. At this stage, the left large monocytic cyst appeared to merge with the smaller right multilocular cyst, forming a large cyst occupying the entire pelvic cavity, which was later confirmed by laparoscopic findings.
This large cyst showed no solid-part or papillary growth. The serum levels of tumor markers remained normal. Malignant ovarian tumor could not be ruled out but was considered less likely. We weighed merits and demerits between relaparotomy for tumor resection during pregnancy and a wait-and-see approach for several weeks; the former is likely to require extensiv

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


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

[User]
RADIOLOGY NOTE:
A 67-year-old Chinese man appeared with a growing nodular, vascular tumor (enlarging from 0.5 × 0.5 cm to 4 × 3 cm in nine months) with pruritus and ulcers in the left parietal region of the scalp. The patient presented to the neurosurgery clinic of our hospital in November 2015. A computed tomography (CT) scan of the chest, abdomen, and pelvis showed no evidence of metastatic disease. The patient underwent macroscopic radical resection of the tumor and free skin graft repair. Histopathology analysis revealed diffuse distribution of tumor cells with an invasive growth pattern in the epidermis and dermis. Tumor cells were oval and spindle-shaped and showed obvious cellular atypia. Lumen-like structures and massive tumor necrosis was observed (Fig. ) as angiosarcoma of corium and subcutaneous with infiltration into the muscles and the soft tissues. Histoimmunnochemistry analysis revealed a typical vascular endothelium CD31 (+) and CD34 (+), and lymphatic endothelium D2–40 (+) with a high Ki-67 index (50%). A computed tomography (CT) scan of the chest, abdomen, and pelvis showed no evidence of metastatic disease. The patient refused to undergo adjuvant chemotherapy and/or radiotherapy as recommended. One month after surgery, 18F-FDG PET/CT scan showed evidence of metastasis to liver and bone, with local recurrence occurred two months later. The patient was hospitalized in May 2016 due to scalp angiosarcoma recurrence at six months post-surgery. The patient did not experience any systemic symptoms during the post-operative period. With respect to the patient’s medical history, the patient had a history of hypertension for five years, but denied any family history of malignancy. Physical examination showed pink nodules with ulceration in the parietal and frontal regions of the scalp, and nodular lesions anterior to the left ear. A CT scan of chest and abdomen showed multiple solid nodules in the lungs and liver. Radiotherapy was not considered necessary due to widespread

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


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

[User]
RADIOLOGY NOTE:
A 58-year-old male presented with a 2-day history of dimmed vision on his left eye. He reported having had headaches and swollenness behind his left eye during the last week. The patient had undergone heart surgery after a myocardial infarction 9 months prior to his first visit. He was taking several prescription medications because of hypertension and stent implants in his heart. These included aspirin, ticagrelor, bisoprolol, candesartan, and atorvastatin. Except for a pollen allergy, he negated other disorders.
An eye examination revealed free eye motility in all directions and slight movement-associated pain in his left eye. BCVA was 1.0 in the right eye and 0.1 in his left eye. There was no diplopia. A RAPD was present in his left eye at the same examination. Color vision was affected in the left eye. The results of a fundus examination revealed a normal optic disc in the right eye, except adjacent ectopic myelin in the lower portion. Retina and macula were without signs of disease. Examination of the left eye revealed papillary edema. Macula and retina were normal except for small hemorrhage from a vessel in the lower fundus. Blood pressure was 150/90. Initial laboratory tests that included ESR, CRP, serum calcium, ACE, anti-nuclear antibodies (ANAs), anti-neutrophil cytoplasmic antibodies (ANCA), and syphilis screen were normal, except for a slightly elevated IgA test.
An MRI of the orbita was performed a week after his first visit to the clinic and revealed a slight edema surrounding the left optical nerve, fitting with OPN. At this time, the patient reported that his vision had normalized. Steroid treatment was therefore not initiated. Since his first visit, he reported having three episodes of lost vision in his previously unaffected right eye a few days earlier. Also present was minor pain in his left eye and a few shorter episodes of blurred vision.
At a new visit, 3 weeks after his first

[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 previously healthy and active 53-year-old Swede male who worked full-time in the metal industry had arthrosis of the right knee and had experienced episodes of pain in his right ear since 2011. The patient was injured when a 400-kg metal device fell on his right leg during the course of his work (13th March). The patient was wearing security shoes and clothes at the time of the accident. He presented with a superficial abrasion (15 cm × 3 cm) on the front of the right lower leg, without heavy bleeding, and swelling of the right ankle. X-rays and blood tests ruled out a fracture and organ failure (Fig. ). He was assessed by the attending surgeon at the University hospital in Linköping. Surgical intervention or revisions were not indicated and the patient was dismissed with a recommendation for local antiseptics and elevation of the leg while sitting or lying down.
A nursing assistant at the Occupational Health Center cared for the patient’s abrasion; it was covered regularly during 4 weeks every other day with an occlusive bandage (Mepilex foam dressing, Mölnlycke Health Care, Sweden), a wound dressing material that is routinely used at health centers. The patient had no fever during this period and did not change the dressing himself. There is no document about him contacting the Department of Infectious Diseases or the health center during this period. He had noticed that the ulcer was producing odorous discharge, but the attending nurse did not experience a situation that should be referred to specialist. The patient was referred to the hospital (13th April) due to visible muscle necrosis accompanied by yellow, odorous secretion at the bottom of an ulcer on the front of the right leg (Fig. ). The patient had no fever, and his vital parameters were stable, although he did have diffuse redness and pitting edema on the right leg. The laboratory analysis revealed normal white blood

[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 45-year-old Haitian American female with no significant medical history presented with a six-month history of progressive solid food dysphagia and a one-month history of odynophagia. The patient had lost 15 pounds and was only able to tolerate pureed food or liquids. She had experienced no symptomatic relief on omeprazole 40 mg twice daily for the past two months and did not use tobacco, alcohol, or illicit substances. Her initial blood count and metabolic panel were unremarkable. An esophagogastroduodenoscopy (EGD) revealed erythematous and friable mucosa with ulcerations in the proximal esophagus (). There was a stricture encountered at 15 cm from the incisors through which the gastroscope could not be traversed. Biopsies were taken from the inflamed esophageal mucosa and the proximal lumen of the stricture. Brush cytology was collected through the stricture as there was a concern for malignancy. A subsequent barium esophagram and upper GI series demonstrated 2 cm irregular narrowing in the cervical esophagus, but no abnormalities in the rest of the esophagus, the gastroesophageal junction, stomach, duodenum, or proximal jejunum. Contrast-enhanced computed tomography (CT) of the chest showed no acute esophageal, mediastinal, pulmonary, or cardiac pathology. The esophageal biopsy indicated acute and chronic inflammation with filamentous sulfur granules consistent with Actinomyces; rare fungal hyphal elements were additionally identified (Figures , , and ). The cytology was negative for malignant cells and the acid-fast bacilli (AFB) stain was negative, ruling out Nocardia as a potential pathogen. The patient was started on intravenous (IV) Penicillin for a diagnosis of esophageal actinomycosis and oral Fluconazole for a presumed Candida coinfection given concurrent fungal elements. Her human immunodeficiency virus (HIV) status was negative and her fasting blood glucose was within the normal range. She was discharged on Fluconazole 200 mg daily for 2 weeks and IV

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


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

[User]
RADIOLOGY NOTE:
A 38-year-old male was admitted to the hospital with sudden headache accompanied by nausea and vomiting for 5 days. No obvious positive nervous system signs were found at admission. On admission, CT and MRI of the head revealed lesions in the right thalamus and third ventricle and subsequent hydrocephalus (Fig. a–f). Clinical diagnosis: Right thalamic glioma, obstructive hydrocephalus.
According to the CT and MRI scans, the tumour originated from the right thalamus and grew medially and anteriorly, with the main body located in the body of the lateral ventricle. The anterior boundary of the tumour adhered to the interventricular foramen, the posterior boundary of the tumour closed the junction between the body of the lateral ventricle and the atrium and the medial part of the tumour wrapped around the midline structure. The patient also had obstructive hydrocephalus due to the tumour blocking the interventricular foramen. Therefore, the right trans-frontal lateral ventricle approach for tumour resection and third ventricle ventriculostomy were selected. First, the tumour was partially excised to separate and protect the thalamostriate vein and internal cerebral veins. After identifying all the structures, the tumour was completely removed along the approximate boundary of the tumour. Tumour resection followed the sequence of the dorsal wall, lateral wall, anterior pole, posterior pole, ventral wall and medial wall. A third ventriculostomy was performed by adjusting the microscope angle (Fig. f).
Postoperatively, there was no deterioration of the consciousness level, motor weakness or aphasia. Diabetes insipidus occurred during and after the operation and improved markedly at the time of discharge after 2 weeks. A postoperative MRI scan showed that the tumour was completely resected, and the ventricles were significantly smaller than they were in the preoperative MRI scan (Fig. g–l). The pathology was glioma blastoma. The patient received radiotherapy and chemotherap

[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 53-year-old male was referred to the Oral Medicine Department by Dermatology in July 2008, with an 8-month history of blistering and soreness of the oral mucosa. On examination, there were small erosions and ulcers present on the soft palate and bilaterally on the buccal mucosae. The patient had been under the care of Dermatology since 2003 for an itchy rash on the legs, scalp and chest. A biopsy from a crusted lesion on the scalp (Fig. ) in 2003 revealed acantholysis of the keratinocytes in the upper part of the prickle cell layer (Fig. ), and direct immunofluorescence studies showed IgG positivity around the upper epidermal cells. These features were consistent with a diagnosis of PF. He was started on Mycophenolate Mofetil (MMF) 500 mg twice a day and Prednisolone 10 mg once a day by Dermatology in 2006, which had resulted in excellent control of his cutaneous lesions. Prior to this, Azathioprine alone had been introduced on two occasions by Dermatology, however the patient failed to tolerate it due to nausea and vomiting. Oral involvement only began in January 2008 which required hospital admission for a short period.
His only other relevant medical history was hypertension, for which he took Nifedipine. At initial presentation, he was also taking Ranitidine and Alendronic Acid for protection against osteoporosis with prolonged systemic corticosteroid use. He was a non-smoker and had low alcohol intake.
At initial appointment, MMF dose was increased to 1 g in the morning and 500 mg in the evening for 2 weeks, and thereafter 1 g twice a day. Full blood count, urea and electrolytes and liver function tests were normal, and regular blood monitoring was carried out appropriately. In light of good response to systemic therapy and as only very small erosions/ulcers were present at this point, oral biopsy was not arranged. He was seen regularly on the joint Oral Medicine/Dermatology clinic and complete resolution

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


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

[User]
RADIOLOGY NOTE:
Our patient is a 55-year-old gentleman with a clinical stage T2N2A moderate to poorly differentiated squamous cell carcinoma of the left tonsil. He received concurrent chemotherapy delivered during the first and fourth weeks of radiation treatment. The chemotherapy consisted of cisplatin at 100 mg/m2 and fluorouracil (5FU) at 1000 mg/m2 on days one through four. We used intensity-modulated radiotherapy with primary intent to spare the right parotid gland. A total dose of 7000 cGy was delivered to our expanded tumor target using 6 MV photons over 35 fractions of 200 cGy each. In treatment planning, the spinal cord was contoured. The maximum spinal cord point dose was 4478 cGy and the mean spinal cord dose was 2692 cGy. displays radiation dose distribution through isodose lines in the axial, sagittal, and coronal planes as well as the dose volume histogram (DVH) for treatment targets, the brainstem and the spinal cord. Image guidance with orthogonal pair radiographs, AP and lateral, was performed prior to each daily treatment. The patient tolerated the treatment course fairly well with expected confluent mucositis and temporary need of a feeding tube for nutrition. The patient lost 3.4 kg (4.9% of initial body weight) throughout the treatment, going from 69.2 kg to 65.9 kg at the completion of treatment on May 19, 2006; the patient showed no evidence of disease.
Four months after completion of treatment, in September 2006, the patient first developed electric-shock sensations with neck flexion causing severe right arm pain with the feeling that the extremity was swollen and numb. The severity of the pain prompted an ER visit. On the patient's followup in October, the patient had persistent difficulty with these electric-shock sensations radiating down his back into his arms with neck flexion. The patient experienced another episode in November to the left forearm requiring oxycodone to alleviate the pain. When the patient came for followup in December, he reported no

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


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

[User]
RADIOLOGY NOTE:
A 6-year-old boy with no pathological history accidentally fell from the top of an approximately 3 m climbing pole and injured his right extended elbow and wrist joint. Due to pain and deformity in the right elbow and wrist joints, he visited our hospital. Swelling and a dinner fork deformity of the right wrist joint and pronounced swelling of the right elbow joint were observed. No skin damage was observed. No findings of nerve injury or arterial injury were obtained in the right upper limb. Radiography revealed lateral dislocation of the radial head, a fracture of the proximal ulnar metaphysis, and mild bending deformation at the fracture site. In addition, fractures of the distal radius and ulna, as well as dorsal displacement of the distal fragment, were seen (). Thus, the patient was diagnosed with Bado type III Monteggia injury with ipsilateral fracture of the distal radius and ulna.
Manual reduction under nerve block was attempted on the day of injury. However, because it was difficult to maintain the reduction of the radial head, as shown in , open reduction and percutaneous procedures were performed under general anesthesia. A Kirschner wire was inserted, percutaneously, from the olecranon into the ulnar diaphysis. When the Kirschner wire was in place, the dislocation of the radial head immediately showed good reduction. Further, open reduction and fixation of the fractured distal radius and ulna were performed with Kirschner wires (). A long-arm cast was used for external fixation with the elbow in 90° flexion and the forearm in an intermediate position.
Two weeks after surgery, callus formation at the fractured bone was observed. Therefore, the cast was removed, and range of motion (ROM) exercises of the elbow and wrist joints were initiated. Since bone union was achieved at 6 weeks postsurgery, the Kirschner wires were removed. Pain, ROM limitation, and lateral instability were not observed in the elbow or wrist joints at 3 months after surgery. Addition

[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 72-year-old female patient, who was hospitalized in the internal medicine department, was evaluated by the on call Orthopaedic Surgeon, because of pain and swelling of her left hand after a CT scan with IV contrast, which was performed in order to exclude pulmonary embolus. The patient had a past medical history of blood hypertension and diabetes. The cause of the swelling was IV contrast medium extravasation from a mal positioned vein catheter on the dorsal surface of her left hand. About 110 ml of Iopromide were diffused in the soft tissue of the hand. The vein catheter was removed by the consultant radiologist as soon as the swelling was noticed.
The patient was evaluated 3 h post-CT scan and she was found to be in severe pain and significant swelling with skin blistering (Fig. ). Initially, the hand was elevated and ice was applied. No medical antidote, such as hyalouronidase was given to the patient, because it was not available. Needle drainage was not possible, because of diffuse swelling. Two hours later no improvement was identified. On the opposite, the pain was nonresponsive to painkillers, the hand was sitting in an intrinsic minus position (Fig. ), soft tissue edema was increased and paresthesias were developed. The hand looked pale and there was severe pain on stretching the interrosseoi muscles, as well as delayed capillary refill. All these signs were considered to be compatible with the diagnosis of compartment syndrome and an urgent fasciotomy was decided. There was no need to measure the intracompartmental pressures as clinical examination was typical.
Operation was performed using an axillary block, as the patient suffered from a chest infection and a general anesthesia was considered to be of a high risk. In theater, all hand compartments were opened. Two dorsal incisions were performed, one over the second metacarpal (to open the adductor, the first and second dorsal interosseous and the first palmar

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


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

[User]
RADIOLOGY NOTE:
A 62-year-old man was admitted for evaluation of a progressive abdominal distension noticed initially 4 months earlier in the left upper quadrant. Physical examination revealed a grossly distended and tender abdomen. The top margin of the swelling was at the level of the left upper quadrant and the lower margin was in the suprapubic region. Urinalysis showed seven to ten red blood cells per high-power field.
Abdominal ultrasonography demonstrated a huge, relatively well-demarcated tumor that consisted of an intermediate echogenic background stroma with variable, slightly hyperechoic, periphery nodules measuring up to 12 cm in diameter. The largest component of the tumor located at the upper margin had multiple, small hypoechoic areas thought to be corresponding to necrosis (). No vascular thrombosis was observed in main abdominal veins. The contralateral kidney was also normal.
A subsequent contrast-enhanced CT examination of the whole abdomen confirmed the sonographic findings. The tumor was heterogeneous and solid with a large, central low-density area. It has an extension into the pelvic inlet and a focal compression of the main vascular structures (). Approximate tumor dimensions were 35.0 cm (superior-inferior) by 24.0 cm (transverse) by 22.0 cm (anterior-posterior). No evidence of hepatic metastasis or regional lymphadenopathy was found. Neither imaging techniques could identify separate normal renal parenchyma or collecting system of the left kidney. Additionally, both sonography and CT scans of the lesser pelvis showed a second separate mass in 1.0 cm-diameter arising from the left postero-lateral bladder wall.
Based on the clinical and radiological findings, our diagnosis was initially a malignant tumor of the kidney such as a transitional carcinoma or renal cell carcinoma. A left radical nephrectomy with partial cystectomy was performed to remove the tumors. Pathological specimen showed that the entire left kidney was completely replaced by the tumor. The

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


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

[User]
RADIOLOGY NOTE:
A 12-year-old male child patient visited the Department of Pediatric Dentistry with the presenting complaint of swelling and pain on the right side of the mandible for 6 months. The patient presented with a history of extraction of a carious tooth from the region 4 months back. On extraoral examination, it was found that a diffuse non-tender swelling was present on the right side of the mandible. The swelling was hard on palpation and was associated with right submandibular lymphadenopathy. The overlying skin color was normal. On intraoral examination, a hard bony swelling was found on the buccal aspect of the edentulous space of the first premolar region obliterating the vestibular depth (A) and was extending till the first permanent molar region.
Based upon these preliminary findings, it was provisionally diagnosed to be a case of chronic alveolar abscess with respect to deciduous molar, with a suspicion of some underlying bony pathology. To differentially diagnose the case, the patient had been advised a series of blood investigations and radiographic investigations (orthopantomogram, cone-beam CT). Complete blood count, bone biochemistry blood tests including levels of calcium, phosphate, electrolytes, etc., all were well within the normal range. Increased values of erythrocyte sedimentation rate (32 mm/hour) and alkaline phosphatase (280 U/L) were present.
Orthopantomogram showed developing tooth buds of mandibular right canine, premolars, and molars (B). A radiolucency was seen in the periapical area of the developing right second premolar area and there was also seen the localized thinning of the lower border of the mandible.
Cone-beam computed tomography examinations showed bony laminations parallel to each other and the underlying cortical bone in the axial and sagittal images and these were present both buccally and lingually (A and B). The lamellae were more prominent in the posterior sections of the mandible. However, the buccal cortex was destroyed in 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:
GSA, male, 55 years old, white, forklift operator, natural and from the state of São Paulo, was referred to the office reporting dyspnea on efforts with progressive worsening in the last two months, asthenia, inappetence and weight loss. He reported periods of night sweats but denied a fever. He referred to hypothyroidism and dyslipidemia on treatment with levothyroxine sodium and simvastatin. Physical examination was afebrile, eupneic and with mild jugular stasis. In the chest examination no adventitious noises were observed in the pulmonary auscultation and, in cardiac auscultation, the rhythm was irregular, without murmurs and the sounds were normal. No paradoxical pulse was observed. In the examination of the abdomen there was discrete hepatomegaly without other changes. Biochemical tests were normal, serology for human immunodeficiency virus (HIV) was negative, and the search for alcohol-acid-resistant bacilli in the sputum was negative. On the electrocardiogram, atrial fibrillation was evidenced. In the simple chest radiographs, there was extensive pericardial calcification involving right ventricular chamber and right atrial chamber (). In the color doppler echocardiogram it was observed the presence of echogenic image prior to the right atrium and ventricle, mainly restricting the mobility and contractility of the basal mean portion of the ventricular chamber; asynchronous movement of the whole right ventricle and interventricular septum compromising the systolic-diastolic function of this chamber; dilated hepatic veins and inferior vena cava with variation of expandability reduced to the maneuvers and impairment of left ventricular systolic function. Magnetic resonance of the thorax revealed signs of pericardial thickening with surrounding calcifications, with the largest thickness, about 3 cm, in the anterior and lower anterior pericardial walls (). The hemodynamic study showed significant diffuse pericardial calcification and absence of obstructive corona

[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 40-year-old female who presented to the emergency department with a complaint of left knee pain and swelling from falling down the stairs. She had no significant past medical or surgical history, nor a history of similar trauma. Clinical examination showed swelling of the knee and tenderness over the lateral aspect of the proximal tibia. Knee ligaments were stable and neurovascular status was intact. X-ray images showed a Schatzker Type III tibial plateau fracture. Computed tomography and magnetic resonance imaging better defined the fracture pattern and were used to rule out any concomitant knee pathologies (Figure ). Surgery was performed after signed consent. The patient was informed that data concerning her case would be submitted for publication. Her consent was obtained.
Surgical technique
Following a careful evaluation of the pre-operative CT scan, we planned to achieve a combined intraoperative arthroscopic- and fluoroscopic-guided reduction of the articular depression through a lateral cortical window. The fracture was fixed using a minimally invasive fixation technique. The patient was supine on a Jackson table under general anesthesia. She received 2 g of intravenous cefazolin for infection prophylaxis. Non-sterile tourniquet was applied. The right knee was prepared, draped, and flexed to 90 degrees using foot support and a lateral thigh kidney shape support. A standard lateral and medial anterior arthroscopic portals were made. Diagnostic knee arthroscopy was conducted and the fracture was assessed. No other knee pathologies were identified. The inflow pressure was kept to a minimum throughout the case to decrease the risk of fluid extravasation and reduce the subsequent potential for increased compartment pressure. An anterior cruciate ligament (ACL) guide was used to place a drill-tipped guide pin in the center of the depressed fragment through a small incision in the proximal anterolateral aspect of the tibia (Figure ).
Intraoperative

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


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

[User]
RADIOLOGY NOTE:
A 41-year-old, otherwise healthy male patient, pig farmer by profession from Ciego de Avila was admitted to a local hospital on 21 February 2010 because of burning ocular pain, blurred vision and redness of the left eye. He could not recall any ocular trauma. Empirical topical antibacterial treatment with ceftazidim (3 %) and vancomycin (3 %) was instituted (one eye drop every hour). The reaction to therapy was poor with increasing infiltration and ulcer extension. Corneal scraping grew methicillin-resistant Staphylococcus aureus (susceptible to amikacin, ciprofloxacin and gentamicin) and treatment was changed to amikacin (3 %) and ceftriaxone (3 %) eye drops every 30 min. The first few days the patient experienced a slight improvement but after a week clinical manifestations worsened, so he was referred to the Ophthalmological Institute 'Ramón Pando Ferrer' in Havana. At arrival the patient had slight oedema of the upper and lower lids of his left eye, scanty yellow secretions, intense cilium-conjunctival injection and a dense corneal yellowish infiltrate leaving only 1 mm of the peripheral limbo clear. Slit lamp examination showed central extensive epithelial defects with irregular and thick borders involving all corneal layers. There were no satellite lesions or evidence. No defects were observed in the anterior segment and his right eye was normal. Ocular ultrasound examination on 10 March 2010 showed a vitreous cavity without opacities and normal retina. Ten days later a filamentous fungus from corneal scrapings was reported and the patient started treatment with miconazole (1 %) one eye drop every hour, ketoconazole (1 %) one eye drop three times per day, and oral ketoconazole (200 mg daily for 7 days). On 22 March, he underwent penetrating keratoplasty and miconazole was replaced by natamycin (5 %) eye drops every 30 min. Eight days later topical ketoconazole was stopped and empirical oral moxifloxacin (400 mg daily for 7 days) was added. Natamycine was conti

[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 ten-year-old boy presented for a second opinion to the pediatric outpatient clinic with complaints of periodic swelling and pain in the right jaw region. Since two years, periodic swelling occurred every other month and remained present for several days to weeks. Consumption of acid fluids was painful. No fever was noted. During earlier acute phases, antibiotics had been administered twice, with a positive effect on the duration of the symptoms. Earlier ultrasound examination, dynamic magnetic resonance imaging (MRI) and sialography at the time of the swelling did not reveal any abnormalities, although his parents reported that he remained without symptoms for three months after the sialography, which was longer than normal. Medical and family history revealed no relevant facts, especially no history of autoimmune disease. The boy was vaccinated according to the Dutch vaccination program.
Because of the frequent and recurrent character of the symptoms, the parents were seeking a second opinion after an earlier diagnosis of chronic recurrent parotitis. When he presented at the outpatient clinic, swelling and pain of the right jaw region had been present for one month ().
Physical examination did not reveal abnormalities in the mouth and ears, except for the fact that he was not able to fully open his mouth (trismus). There were no signs of infection, periodontitis, caries or purulent saliva discharge in the mouth. Blood analysis showed an elevated erythrocyte sedimentation rate (ESR), and a normal amylase. The first echography performed during complaints showed lymphadenitis, without parotitis, while a second echography, also during complaints, showed a parotitis. The results of the examinations are listed in . As not all examinations were compatible with parotitis, and as there was no explanation for the fact that the boy was unable to fully open his mouth, a new MRI of the jaw was performed. This showed a diffusely broadened mandible, several areas of interruptio

[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 10-year-old girl presented with osteosarcoma of her right distal femur, identified after a pathological fracture. Contrast-enhanced magnetic resonance imaging showed a large tumor arising from the distal femur and infiltrating the wall of the superficial femoral artery (Fig. ). She was otherwise healthy. She underwent neoadjuvant chemotherapy with adriamycin, cisplatin, and methotrexate. Then, intercalary wide resection of the femur, including the femoral artery and vein, was performed. The bony defect was 15 cm long and the vascular defect was 10 cm long. The sciatic nerve and the saphenous nerve were preserved.
The ipsilateral great saphenous vein (GSV) was harvested, and the superficial femoral artery and vein were reconstructed with interpositional vein grafts (Fig. ). The bony defect was bridged with an intramedullary nail, and bilateral fibular grafts were transferred. Both fibular grafts were harvested with a monitoring flap; however, circulation of the left monitoring flap was found to be poor and the flap was sacrificed. The left fibula was hooked up to the superficial femoral artery and vein with an end-to-side anastomosis. The right fibula was hooked up to the descending branch of the lateral circumflex femoral artery and its comitant vein (Fig. ). The monitoring flap of the right fibula was externalized for postoperative monitoring. We did not perform tibiofibular metaphyseal synostosis for either leg.
The wounds healed uneventfully. The circulation of the left fibula was confirmed using color doppler ultrasonography. The rehabilitation started from the fifth postoperative day. The patient underwent adjuvant chemotherapy with the same drugs from the 15th postoperative day for 3 months. At 7 months after the operation, the patient was allowed to walk with full weight bearing. Contrast-enhanced computed tomography obtained 14 months after the operation showed patency of the femoral artery and vein. At 20 months after the operation, the patient was able 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 38-year-old woman with no relevant medical history was brought into our emergency department for urgent neurological evaluation. Her relatives described a sudden language disturbance which had started less than three hours earlier. They also explained that throughout the previous day she had complained of gradually worsening holocranial headache and had suffered vomiting. There was no prior history of migraine or toxic abuse. On examination, the patient was slightly agitated and showed global aphasia without any other neurological deficit. The National Institutes of Health Stroke Scale (NIHSS) scored 6 points, all of them from the area of language.
A non-contrast cerebral CT scan, performed 185 minutes after the aphasia onset, was normal, revealing no signs of brain ischemia or hemorrhage. A transcranial Doppler study (TCD), immediately carried out after CT scan, showed velocity asymmetry between both middle cerebral arteries (MCA) compatible with a left MCA TIBI 3 pattern. An embolic stroke was suspected and intravenous thrombolysis was proposed. As the time elapsed since the aphasia onset was now over 3 hours, a multimodal brain MR study was made following our centerÂ´s protocol. Although the images revealed extensive delayed perfusion in the whole left hemisphere, including the territory of anterior (ACA), MCA and posterior (PCA) cerebral arteries, there were no altered diffusion-weighted images (Figure ). In the MR-angiography the diameter of left MCA and its main branches was reduced with respect to the contralateral artery (Figure ). There was no fetal origin of left PCA or flow alteration in terminal internal carotid artery. The existence of a complete hemispheric perfusion/diffusion mismatch, together with the clinical picture including the presence of headache, led to a presumed diagnosis of HaNDL (ICHD-II 7.8). A lumbar puncture was performed with a CSF opening pressure of 18 cmH20, 80 cells/mm3 (95% lymphocytes), 0.50 g/L proteins and 82 mg/dL glucose.

[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 male had been aware of a right parotid mass for about 10 years; however, he did not seek treatment as the mass was painless. On experiencing serious right parotid pain, he visited our affiliated hospital. Physical examination revealed a painful mass in his right parotid gland of approximately 30 mm in diameter and ipsilateral facial nerve palsy of House–Brackmann (HB) grade III. Laboratory findings showed a leukocyte count of 12,190/μL and C-reactive protein (CRP) of 0.18 mg/dL. Computed tomography (CT) revealed an enhanced irregularly shaped mass in the right parotid gland (). T1-weighted SE MR imaging of the mass showed lower intensity than that of the native parotid tissue (). T2-weighted SE MR imaging also showed intermediate signal intensity and partial hyperintensity (). At this stage, a malignant neoplasm of the parotid gland was suspected.
Nine days after the appearance of symptoms, he was referred to our hospital. On physical examination, the mass was found to be still present but the pain had eased. In addition, the facial nerve palsy showed some improvement to HB grade II. Ultrasound examination revealed an inhomogeneous, lobulated mass (approximately 30 × 25 mm) in the right parotid gland. CT showed that the tumor had become smaller than at the time of the previous scan in our affiliated hospital (). We tried ultrasound-guided fine needle aspiration cytology (FNAC) twice, with an initial finding of necrotic material and a subsequent finding of a large number of histiocytes and acinar cells and a small number of eosinophilic cells with no atypical findings observed. However, no definitive diagnosis was provided.
We suspected a malignant tumor because of the associated facial nerve paralysis and parotid pain. On the contrary, we considered the possibility of a benign tumor with inflammation due to the reduction in tumor size and pain. We planned a total parotidectomy including exeresis and reconstruction of the facial nerve. However, we also

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


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

[User]
RADIOLOGY NOTE:
A 56-years old man with complaint of dyspepsia has evaluated by gastroenterologist. He has suffered from pulmonary disease due to exposing to chemical warfare during Iran-Iraq war and he had right-sided heart failure following chronic obstructive pulmonary disease (cor pulmonale). He had no positive familial history of cancer.
He has initially evaluated by barium-meal study, and then has detected an ulcer-niche lesion on body and lesser curvature of stomach.
The patient has undergone upper GI endoscopy and there was a massive lesion of fundus and body of gastric mucosa that biopsy has performed. Histopathologic examination of the biopsy specimens has shown: adenocarcinoma, well differentiated, intestinal type. He has completely evaluated for metastatic disease. All of blood tests including liver-kidney function tests were normal. CT scan of neck, thorax and abdomino- pelvic cavity was normal except thickening of proximal gastric wall and several lymphadenopathy at celiac chain.
At echocardiography, he had normal LV systolic function and LVEF was 86% but right atrium and ventricle were enlarged. He has undergone total gastrectomy in November 2012 and histopathologic examination of surgical specimens has shown: adenocarcinoma, intestinal type, grade II with extension to subserosa. 11 of 11 lymphnodes metastatic, proximal and distal margins were without tumoral involvement. Staging: T3 N3. Post-operative CEA was 6.2. He has referred to Oncology department five weeks after surgery for adjuvant therapy. The patient has planned for concurrent chemoradiation with capecitabin 1000 mg twice daily continuously during radiation by 180 cGy in one daily fraction for five days in week and for total dose of 5040 cGy.
He was good and general condition was satisfactory and ultrasonography of abdominopelvic cavity at week 5 of treatment was normal. The patient has affected by headache and mild confusion at the end of adjuvant chemo radiation. Therefore, he has admitted in hospital fo

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


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

[User]
RADIOLOGY NOTE:
The patient was a 65-year-old man with a prior history of repeated plastic surgery for scar contracture of the hands and fingers, ablation surgery for idiopathic ventricular tachycardia, and diabetes. There was no family history of no consanguineous marriage or EB.
He had experienced recurrent blistering of the skin that was readily caused by an external force since the time shortly after birth, which had been treated symptomatically. He was diagnosed with EB during a genetic consultation that he had received before getting married at the age of 28 years. Subsequently, he was diagnosed with RDEB at the age of 38 years. Application of a strong external force to the skin results in blister formation as early as 15 min. In June 2012, he presented to a nearby hospital with epigastric pain, where he was diagnosed with cholelithiasis and cancer in the transverse colon and was referred to our hospital. In September 2012, transverse colectomy and cholecystectomy were performed via laparotomy, followed by an uneventful postoperative course. In April 2013, a liver metastasis (S2) was detected. The lesion was a solitary tumor measuring ≤2 cm and was treated by radiofrequency ablation (RFA) in June 2013, again followed by an uneventful postoperative course. In September 2015, a recurrent tumor was detected at the site of RFA, with suspected invasion into the diaphragm. He was then admitted to our hospital for curative open surgery. On admission, although no active blistering was noted, pigmentation and scars due to recurrent blistering were noted especially in the extremities and back. Most fingers in both hands were club-shaped, with a few intact fingers. Blood test showed a mild increase in glucose to 123 mg/dl and increases in tumor markers, including mean levels of CEA and CA19-9 of 25.0 (0–5) ng/ml and 62.1 (0–37) U/ml, respectively.
Abdominal CT/MRI revealed a 3.5 cm metastatic liver carcinoma with diaphragmatic invasion in the lateral segment

[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 76-year-old female taking warfarin due to a past pulmonary embolism presented to the emergency department jaundiced with a 3-day history of diffuse atraumatic myalgia and macroscopic hematuria. Laboratory evaluation revealed an international normalized ratio (INR) of 14.04. She was consequently administered Vitamin K. Initial neurovascular examination was normal, though within 10 minutes, the patient deteriorated with an acute onset of flaccid quadriplegia, graded as an American Spinal Injury Association (ASIA) score of A. This was accompanied by severe neck pain and respiratory distress with an O2 saturation of 73%. She was intubated, administered Beriplex, and continued to receive Vitamin K. Within 2 hours, her INR normalized to 1.60 with motor functioning limited to flickers in her toes and right fingers. An MRI performed 4 hours after symptom onset demonstrated an SSEH from C2 to S5, causing significant posterior spinal cord displacement, central canal stenosis, spinal and cauda equina nerve root compressions, seen in Fig. . The patient was transferred to the orthopedic spine team for assessment of a possible intervention, where she began to demonstrate recovery of neural functions. By 11 hours after the onset of her symptoms, the patient had improved to an ASIA score of D, with a Medical Research Council (MRC) grading of 4+ in her upper limbs and 4 in her lower limbs. The ensuing sustained motor improvement motivated the team's preference for close neurologic monitoring and continued medical therapy over surgery. She continued to improve and was extubated 13 hours after symptom onset. By 20 hours, the patient had regained full motor and sensory functions, returning to her initial neurological baseline at an ASIA score of E. Dilated intrahepatic and common bile ducts were incidentally detected on MRI, prompting an endoscopic retrograde cholangiopancreatography (ERCP). The ERCP demonstrated obstructions in the biliary tree consistent with choledocholithiasis, 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:
This participant is a 68-year-old retired male with a diagnosis of FXTAS (94 CGG repeats) in addition to mild cognitive impairment. His medical history includes a normal childhood and he was in good health until his 50s when he was diagnosed with gastroesophageal reflux disease, hypertension, and type 2 diabetes mellitus. His only health related complaint from early adulthood was recurrent headaches presenting multiple times per week that were associated with sensitivity to light. At age 60, he underwent prostatectomy to treat prostate cancer. He was put under prolonged general anesthesia due to complications during the procedure. After this surgery, he experienced a faster progression of neurological symptoms and he became intolerant to temperature changes. At age 63, he developed a shuffling gait and balance problems, and this led to the use of a cane at age 65 and then a walker at age 66; due to frequent falls he had been using a wheelchair for the past 6 months. He had cancer recurrence at age 65 and was treated with radiation therapy in the prostate area. Subsequently, he developed bladder incontinence and on occasion bowel incontinence. He also reported an onset of handwriting problems at age 65, and a very minor tremor at age 67. He has experienced tinnitus since age 50 and hearing loss in the last 5 years. Swallowing difficulties and choking on food started at age 66, leading to an episode of aspiration pneumonia.
His current daily medications include omeprazole (20 mg), aspirin (81 mg), lisinopril (40 mg), amlodipine (5 mg), metformin ER extended-release (1000 mg), and glimepiride (20 mg). He takes acetaminophen for recurrent headaches and chronic back pain. He was prescribed a 2-month trial of carbidopa/levodopa for his parkinsonian symptoms without beneficial effects. He does not drink alcohol. He denies cardiac and immunological problems. He is married and has an unaffected son, who has been diagnosed with attention deficit disorder (ADD),

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


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

[User]
RADIOLOGY NOTE:
In June 2006, a 13-year-old girl was referred to Kyoto University Hospital with dyspnea on exertion and wheezing. There was a history of pneumonia in infancy and asthma during early childhood, which had remitted after she started primary school. She did not have atopy or allergies. Both the chest X-ray and the chest computed tomography showed a giant bulla in the right upper lobe and hyperlucency of the right lower lobe because of diminished vasculature due to a hypoplastic right pulmonary artery. There was no evidence of bronchiectasis. The X-ray taken before referral to our hospital was not available. She was admitted to Kyoto University Hospital in March 2007 for further evaluation.
The exhaled nitric oxide level (27.9 ppb) was elevated compared with that of normal children (<20 ppb). The sputum eosinophil count was increased to 2.5%. Respiratory function tests (performed in July 2006) showed a severe obstructive pattern (Table ).
A methacholine challenge test was not performed because of severe airflow limitation, but peak expiratory flow (PEF) monitoring showed diurnal variation of 19% from 210 l/min in the morning to 250 l/min in the evening. A pulmonary perfusion scan demonstrated that arterial flow was decreased on the right side (right: left ratio = 1:3).
Based on the detection of unilateral pulmonary hyperlucency and the absence of other possible causes, including congenital cysts, congenital pulmonary artery abnormalities, and embolization of the main pulmonary artery, she was diagnosed as having Swyer-James syndrome with a giant bulla. In addition, her response to an inhaled bronchodilator, the diurnal variation of PEF, and the detection of eosinophilic airway inflammation suggested the recurrence of her asthma. Although surgical resection of the giant bulla was considered, medical treatment of the patient's asthma was given precedence to maximize her respiratory function. After treatment with an inhaled corticosteroid preparation and tulobuterol patch,

[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 seventy-six-year-old lady with a history of hypertension and previous sclera buckle for left eye retinal detachment presented to Singapore National Eye Centre with acute loss of vision of the right eye. There was no prior history of trauma or pain. On examination, visual acuity of the right eye was hand motions in the temporal region and perception of light in all four quadrants with a right grade 2 relative afferent pupillary defect. Intraocular pressure measured by Goldmann Applanation Tonometry was sixteen bilaterally. Anterior segment examination was unremarkable. Fundal examination of the right eye showed a pale optic disc and pale edematous macula with an evolving cherry red spot (). There was a very weak retinal venous flow which could be occluded on gentle pressure, indicating that the occlusion was likely incomplete. There were no plaques noted. Fundal examination of her left eye showed an epiretinal membrane and a flat retina with buckle indentation (). She underwent immediate ocular massage, anterior chamber paracentesis and intravenous acetazolamide 500 mg was administered. Optical coherence imaging using Heidelberg Spectralis was performed immediately after the above treatments and images showed opacification of inner retina with mild thickening and diffuse edema in the outer retina (Figures and ). Visual acuity subsequently improved slightly, and she was able to count fingers closely. She was admitted for complete work up to determine the cause of the event, and grave prognosis was conveyed to the patient. Carotid ultrasound showed an immobile 3 mm calcified plaque in the proximal segment of the right internal carotid artery, while 2D echocardiogram did not reveal any vegetations and fasting lipids and glucose were normal. Neurology consult was sought, and she was advised to start on aspirin 100 mg once a day, while no surgical intervention is required for the calcified plaque. Her vision remained stable and did not improve beyond counting fingers du

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


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

[User]
RADIOLOGY NOTE:
A 42-year-old male presented with pain in the epigastrium, radiating to the back and feeling of fullness of the abdomen for a duration of six months. He gave history of loss of appetite and weight loss of 5 kg over a period of six months. He complained of progressive breathlessness on exertion for a period of one month. He gave no history of cough, expectoration, fever, wheeze or hemoptysis. He did not give any history of trauma.
He was working as a casual laborer in the agriculture sector. He consumed alcohol on at least five days in a week and smoked at least two packets of beedis in a week.
Nine months back he was admitted to a hospital for treatment of acute abdominal pain. A diagnosis of acute on chronic calcified pancreatitis was made. The most probable cause for the chronic pancreatitis was due to excessive alcohol intake by the patient. A pancreatoduodenostomy was performed on him. He remained asymptomatic for a period of three months. A follow-up ultrasound done after three months showed multiple calcification of the head of the pancreas with bulky tail, and minimal ascites and one old calcified granuloma in the right lobe of the liver. He was put on a low-fat diet, small frequent feeds and received pancreatic enzyme supplements from the time he was operated upon.
On examination he was thin built and emaciated and was systemically well. There were no palpable lymphadenopathies. He had bilateral pitting pedal edema. On chest examination there was diminished movement of the right lower hemithorax when compared to the left. Percussion of the right hemithorax yielded a dull note in the right infraaxillary and infrascapular areas which persisted on deep inspiration. On auscultation diminished breath sounds in the right basal regions were apparent. On palpation his abdomen was distended, epigastric tenderness was present and bowel sounds were heard. Examinations of other systems were unremarkable

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


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

[User]
RADIOLOGY NOTE:
A 54-year-old male was admitted to our hospital with complaints of severe dyspnea, inability to lie in supine position, decrease in effort capacity, and pain in the left arm. Physical examination revealed tachycardia and 3/6 apical systolic murmur; bilateral rales in lower lung zones. Brachial, axillary, and radial pulses of the left arm were not palpable but were clearly palpated over the right arm. Lower extremity pulses were palpable. Past medical history revealed that he underwent coronary bypass graft operation five years prior to presentation.
He was assessed to have New York Heart Association Functional Classification Class III-IV, with a clinical diagnosis of ischemic cardiomyopathy (CMP), decompensated heart failure. An echoacradiogram was performed which showed increased left ventricular diameter and left ventricular ejection fraction of 18% by the modified Simpson method. He was started on diuretic and vasodilator treatment with regression of failure symptoms. However, he continued to have symptoms of angina and left arm pain responsive to isosorbide dinitrate. A differential diagnosis of CSSS was considered and patient underwent coronary angiography. It was observed on coronary angiography that point of origin of the left subclavian artery in the aorta was totally congested beginning from approximately 1 cm proximal []. A vertebral artery angiography was showed subclavian in bridge collaterals and flow to LIMA were observed in late period.
Using a ringed polytetrafluoroethylene (PTFE) graft (Vascutek, Germany) with a diameter of 6 mm, a left carotid-subclavian bypass was performed on the patient in elective conditions. Carotid shunt was not used while systemic heparin (5000 units) was administered during the operation. Postoperatively, a good graft pulse was felt in addition to easily palpable left upper extremity pulses. There were no complications. Following the operation and in the postoperative period, the complaints of the patient related to chest p

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