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

[User]
RADIOLOGY NOTE:
A 40 years old man, was injured in a car accident as a front passenger, occurred during a frontal collision with another vehicle passing illegally in continuous white line down the center of a national road, the impact speed was 100 km per hour. Unfortunately, the patient was not restrained by seatbelt and sustained lower extremity and head impacts without loss of consciousness, he experienced a severe pain in his hips. On presentation to the emergency department, patient was hemodynamically stable and conscious, examination of the chest and abdomen was normal. However, both hips were deformed in flexion, internal rotation and adduction (), without neurovascular deficit or skin lesions of the lower limbs. Radiographs displayed bilateral posterior hip dislocation combined with right femoral head fracture, and small posterior wall fracture of the left acetabulum. () Prompt hips reduction was performed within one hour of presentation through closed manipulation below general anesthesia, curarisation and controlled by fluoroscopy, patient was maintained in supine position on the ground and the aide applied a hand pression on the iliac wings of the pelvis, while the operator exerted a traction on the leg then flexed the hip with adduction and external rotation, the same technique was applied successfully to the second hip. The Left hip was stable up to 100° flexion and 45° internal and external rotation after reduction. However, the right hip was unstable, for this reason, we have positioned a posterior knee splint for temporary stabilization. Reduction of each hip was checked by antero-posterior pelvic radiograph () and CT-scan (). X-ray showed an irreducible right femoral head fracture, but in the other side it showed a concentric reduction of the left hip joint. CT scan showed in the right side a one-third of femoral head suprafoveal fracture Pipkin type II that was anterior, rotated and incarcerated associated with two small fragments; one was superior and the second

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


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

[User]
RADIOLOGY NOTE:
A 20-year-old woman presented to the emergency department with complaints of severe abdominal pain, multiple episodes of vomiting and obstipation for one day. She was a known case of abdominal tuberculosis and had received anti-tubercular treatment for two months. Vital signs showed a blood pressure of 100/64 mm Hg, heart rate of 110 per minute, respiratory rate of 18 per minute, oxygen saturation of 96% on room air and a temperature of 100.5°F. She was cachectic with a weight of 28 kg which was less than 5th percentile for gender and age matched normal population. Physical examination revealed diffuse abdominal tenderness and rigidity. Her erect abdominal radiography showed gas under right dome of the diaphragm. Clinical diagnosis of perforation peritonitis was made and the patient was wheeled to the operating room for emergent laparotomy. Intraoperatively, a 3 cm x 2 cm single ileal perforation was found 1 foot proximal to the ileocecal junction, with unhealthy bowel margins and multiple mesenteric lymphadenopathy. Resection of perforated bowel segment with proximal ileostomy and mucus fistula of distal ileum was performed. Later, histopathology report confirmed tubercular etiology showing caseous necrosis in mesenteric lymph nodes and epithelioid granuloma in ulcer edge biopsy. Two days after the surgery, the patient was started on oral feeds and was accepting meals orally subsequently. Ten days following surgery, the patient had multiple episodes of bilious vomiting with stoma output decreasing to less than 100 mL per day. Her abdomen remained flat with no increase in bowel sounds. Abdominal radiography showed dilated stomach with no air fluid levels. Oral feeds were stopped and a nasogastric tube was placed for drainage of gastric contents. A contrast enhanced computed tomography (CECT) abdomen was done to determine the cause of obstruction which revealed a decreased aortomesenteric angle of 15° (Figure ).
As a result of this decreased angle, an abrupt collapse

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


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

[User]
RADIOLOGY NOTE:
A 31 yr-old woman with complaints of massive abdominal distention and respiratory distress was referred to the gynecology and oncology department of an academic hospital, Mashhad University of Medical Sciences in Aug 2017. In past medical history, she mentioned a secondary infertility for four yrs and had one child aged eight yrs. The patient was candidate for In Vitro Fertilization (IVF) protocol due to tubal factors. In the first cycle of ovarian stimulation, metformin and Gonal-f 75 IU for six days were prescribed () and then continued for two days. The cycle was cancelled due to poor response after the second month from this protocol. She suffered from gradual abdominal distention.
Despite the failure of IVF, she was under the outpatient care and supportive treatment with possible diagnosis of hyperstimulation syndrome. Therefore, antagonist GnRH was prescribed for two days. At the next delayed month visit, because of persistent symptoms with the probability of hyperthyroidism, she received gonadotropin hormone agonist (Decapeptyl). She was re-evaluated due to unresponsive to treatment within this period.
Trans-abdominal and transvaginal ultrasonography were performed that showed multiple multiloculated cystic masses with predominantly solid components in both adnexa. The results of cross-sectional CT-scan and magnetic resonance imaging suggested the ovarian neoplasm. Also, massive peritoneal and pleural effusion was detected (). In this time, 4 months after management of hyperstimulation syndrome, due to persistent large ovarian mass and increased tumor marker inhibin more than 3000 pg/mL, she was referred to our oncology department. Physical examination demonstrated enlarged masses extended up to hypogastric region which resembled 36 wks of pregnancy.
Exploratory laparotomy was performed that showed massive ascites fluid and multi solid cystic masses in both ovaries extended up to the Xiphoid. Complete resection of the tumor was done. Pathology report of froze

[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 43-year-old female who developed end stage renal disease following an ANCA positive rapid progressive glomerulonephritis, for which she received a living donor renal transplant six years ago. The donor tissue was negative for Epstein Barr Virus (EBV serologies, while the recipient was positive for EBV IgG Antibodies only. She was managed on chronic immunosuppression with a combination of azathioprine and prednisone.
The patient presented initially after an exacerbation of chronic lower back pain following a non-traumatic injury while dancing. Radiographs and MRI of the lumbar spine were performed as part of the initial work-up. Radiographs were negative for acute injury. MRI of her L-spine incompletely captured irregular marrow signal at her left ischium and right sacral ala. This raised the concern for a primary or metastatic marrow replacing process and prompted further imaging work-up. MRI of the pelvis and sacrum performed at this time demonstrated multiple T
2-hyperintense and enhancing osseous lesions involving the lumbar spine, sacrum, pelvis, and proximal left femur. Several lesions demonstrated aggressive features, including periosteal reaction and large extra osseous soft tissue components (). The multifocal nature of the bone involvement and the presence of lytic and aggressive features raised concern for osseous metastatic disease from a distant primary.
CT of the chest, abdomen, and pelvis was performed at this time in attempt to locate a primary site of disease. The CT scan again demonstrated multiple bone lesions with areas of marked cortical destruction (). Numerous round pulmonary nodules measuring up to 1.8 cm, as well as a few enlarged axillary lymph nodes, the largest measuring 2.1 cm in the short axis, were also noted. However, there was no conclusive primary site of malignancy. Fluo-D-glucose positron emission tomography revealed markedly fludeoxyglucose (FDG) avid bone lesions with maximum standardized uptake value up to 35.8

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

[User]
RADIOLOGY NOTE:
A 46-year-old Chinese woman from a low-income family, living with her mother and two sons in the suburb of Taichung City, had a history of recurrent abdominal pain. Within two years, she visited the gastroenterology clinic many times with the same complaint. There was no remarkable family history. Likewise, results of her abdominal ultrasound, endoscopy, and colonoscopy were within normal limits. The patient reported intermittent episodes of anxiety and general weakness that became progressively worse over time. Blood tests from previous visits revealed slightly abnormal liver and renal function. Chronic hepatitis C infection was diagnosed on the basis of these findings. One month before this admission, the patient presented with acute abdominal pain and progressive bilateral weakness and pain in the limbs. She also experienced significant muscle atrophy and decreased strength. During admission, the patient reported moderate, sharp pain (pain score: 5) in extremities, back, chest, and neck. She also experienced episodes of sinus tachycardia and acute urinary retention, suggesting autonomic neuropathy. The patient also reported an unusual “floating sensation” in the trunk and extremities, which was suggestive of a proprioceptive defect. In addition to anxiety, minor behavioral changes, including confusion and signs of depression, were observed. Results of a nerve conduction potential study revealed motor-sensory polyneuropathy. A motor conduction study revealed a reduced compound muscle action potential amplitude, slowed nerve conduction velocity, delayed distal latency, and prolonged F latency over the median, ulnar, tibial, and peroneal nerves.
A sensory conduction study of the median, ulnar, and sural nerves revealed reduced sensory nerve action potential amplitude and delayed onset latency. Computed tomography of the brain was normal, and examination of cerebrospinal fluid showed no remarkable findings. Initial differential diagnoses included acute porphyria, lea

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


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

[User]
RADIOLOGY NOTE:
A 47-year-old female presented to the emergency department after developing loss of consciousness with amnesia following several days of right loin pain and fevers. She awoke with left sided facial pain and a dull headache. She could not recall the prior events of the past day but was aware of blood stains on her bathroom floor. She did not report any eye pain or visual loss.
She had a previous ischaemic stroke and was being managed for hypertension and type 1 diabetes with secondary nephropathy requiring line dialysis. She has bilateral proliferative diabetic retinopathy and is registered as blind. Her left eye had undergone panretinal photocoagulation, delamination, and vitrectomy with internal air tamponade. Her right eye had undergone delamination and segmentation with silicone oil tamponade. All procedures occurred within the previous two years.
She was taking insulin and dual antiplatelet therapy. She lived alone and was independent with her activities of daily living.
On examination, there was bilateral periorbital bruising but no ophthalmoplegia. Blood pressure was 159/102 mmHg. Ophthalmology examination showed bilateral conjunctival haemorrhages in fundoscopy with no ophthalmoplegia. Gross examination of colour and visual fields was normal.
A CT brain without contrast was performed revealing a right-sided hyperdense orbital mass of 2.2 x 1.9 cm (Figure 1 ). A fracture of the medial wall of the left orbit with opacification of the adjacent ethmoid air cells, subcutaneous emphysema and an air-fluid level in the left maxillary sinus were also present. These findings were not present on a previous CT brain two years ago. Her blood tests showed a raised CRP and a mid-stream urine culture showed a pyuria with no growth. Given the uncertain source, a CT abdomen/pelvis was performed which revealed a small pleural effusion and anterior abdominal wall fat stranding secondary to trauma but no focal signs of infection.
The patient was reviewed in the clinic where direc

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


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

[User]
RADIOLOGY NOTE:
In March 2017, a 65-year-old Japanese man, a ship designer, had mild epigastric discomfort and general malaise. An attending doctor thought that he had a digestive tract disease; in upper gastrointestinal endoscopy, however, there was no abnormality. He continued to complain of epigastric comfort and general malaise; he was misdiagnosed as having functional dyspepsia and depressive state, and he started taking medicine for them. He continued the same treatment for approximately 6 months, but the symptoms did not disappear. In September, 2017, he had nausea and vomiting, and finally he could not take any meal. He was then hospitalized in our institution so that we could supply him with nutrition.
His height and body weight were 169 cm and 52.9 kg. Systolic and diastolic blood pressure and heart rate were 119/87 mmHg and 87 beats/minute. Body temperature was increased up to 38.5 °C. In physical examination, there was no special abnormality in his heart, lungs, and abdomen. Table shows the clinical characteristics on admission. His C-reactive protein (CRP) was increased up to 13.36 mg/dL, suggesting the presence of inflammation. An increase of blood urea nitrogen (BUN) and uric acid was observed which we think was probably due to dehydration. Although he had high fever and high CRP, all the infection markers that we examined were negative. In addition, several antibodies which we examined were all negative. Taking into account these data, we thought it unlikely that he had some inflammatory disease and/or autoimmune disorder such as collagen disease. Since his blood glucose level was relatively low and the number of eosinophils was relatively high, we examined the possibility of adrenal deficiency. As shown in Table , ACTH and cortisol levels were low and urinary cortisol level was also low, suggesting the presence of ACTH deficiency and adrenal insufficiency. An increased prolactin level was also observed which we assumed was induced by the side effect of dopamine blo

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


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

[User]
RADIOLOGY NOTE:
A 43-year-old male from Guatemala presented as a direct admission for untreated HIV complicated by cytomegalovirus (CMV) ileitis, 40 lb weight loss over one year, worsening abdominal pain, and odynophagia. His medical history was notable for untreated HIV diagnosed six years prior to admission and a remote history of methamphetamine abuse.
Two months prior to his hospitalization, the patient was hospitalized at an outside hospital in California for abdominal pain and a 40 lb weight loss. The initial CT abdomen showed an SBO and thickening in the terminal ileum, concerning inflammatory bowel disease (IBD). An esophagogastroduodenoscopy (EGD) at that time was unremarkable though biopsies were obtained. A colonoscopy demonstrated ulcers in the terminal ileum, and the patient was ultimately discharged on a two-week course of prednisone 40 mg with concern for new onset of Crohn’s disease. The biopsy pathologies subsequently returned with intraepithelial lymphocytosis on the duodenal tissue biopsy, scattered CMV inclusions by immunochemistry on the terminal ileum tissue biopsy, and negative for IBD, but these pathology reports, unfortunately, resulted after the patient had been discharged and he was unable to be reached to initiate therapy. There were no stains performed for histoplasmosis specifically, although the reasons are unclear.
Two months later, he was again admitted to the hospital for worsening abdominal pain. Upon admission, the patient stated that he had been having diffuse abdominal pain and intermittent non-bloody diarrhea for two months, as well as weight loss of 40 lbs over the past year. He had also experienced persistent throat pain with swallowing for the past month and had been eating significantly less due to the odynophagia. He denied dysphagia to solids and liquids, acid reflux, fever, chills, headache, joint pains, and new rashes. He stated that he had not taken any anti-HIV medications since diagnosis six years ago.
On initial physical examinatio

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


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

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

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

[User]
RADIOLOGY NOTE:
An 87-year-old Caucasian male with a past medical history of benign prostatic hyperplasia and irritable bowel syndrome presented to the hospital with urinary incontinence, diarrhea, abdominal pain, hypotension and altered mental status. A diagnosis of septic shock secondary to urinary tract infection was made on arrival based on symptomology and initial investigation. The patient had a history of lower abdominal pain for last two weeks. He visited his primary care physician and underwent a computed tomography (CT) scan of the abdomen and pelvis which showed hypertrophy of the prostate and bilateral hydronephrosis. The patient had progression of symptoms leading to hospitalization. On arrival to the hospital, the patient was hemodynamically stable but quickly decompensated. Vitals showed a blood pressure of 88/55 mmHg, heart rate of 143 beats per minute, respiratory rate of 20 breaths per minute, and temperature of 96.3°F. Initial pertinent laboratory findings included acute kidney injury with serum creatinine of 12 mg/dL (from a baseline of 1.2 mg/dL) and blood urea nitrogen (BUN) of 161 mg/dL. Labs demonstrated an anion gap metabolic acidosis secondary to lactic acidosis. Urinalysis showed evidence of infection, and blood and urine samples sent for cultures. Physical exam at arrival was significant for a minor distress, diaphoresis, enlarged and tender prostate, abdominal distension without tenderness to palpation, guarding, rebound tenderness, or abnormal dermatological findings. The white blood cell values from the day of surgery until discharge are detailed in Table .
The patient received empiric intravenous antibiotics and fluid resuscitation in the emergency department along with placement of a urinary catheter to relieve urinary obstruction. Urinary catheter placement revealed gross hematuria, but hematuria resolved by the next day. Blood and urine cultures were positive for E. coli and initial antibiotics were deescalated to ceftriaxone, to which the organis

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

[User]
RADIOLOGY NOTE:
A 74-year-old Chinese man presented with a one-month history of recurrent headaches, vomiting and left limb atony. He had undergone a successful clipping operation through the pterional approach for an anterior communicating artery aneurysm five years previously. One month before presentation, he developed a headache without apparent cause that was especially severe in the right frontal region. He also had a small tumor on the right side of his forehead at the original incision site; the tumor had gradually increased from soybean size to egg size in one month. This was accompanied by nausea, projectile vomiting of gastric contents and left limb atony. Computed tomography demonstrated a subcutaneous tumor on the right side of his forehead, a scalp lesion complicated with right frontal lobe hemorrhage, and a right ventricular hematocele. We gave our patient oxiracetam (5.0g in 250mL of normal saline (0.9% weight to volume of sodium chloride)) for treatment of neurotrophy. On the third day after admission, he suddenly lost consciousness. Urgent head computed tomography showed an intracranial hemorrhage, the volume of which had increased from 40mL to 90mL as well as persistent bleeding and a midline shift of over 1.5cm (Figure ).
Our patient then underwent surgery to resect the subcutaneous tumor and evacuate the intracranial hematoma under general anesthesia. An incision was made along the one from the original surgery. During the operation, it became apparent that the main part of the tumor was located in the subcutaneous tissue of his right frontal region. The tumor was approximately 7cm×6cm×4cm (Figure ), fully enveloped, and characterized by abundant revascularization. The cyst of the tumor was intact, and his temporal muscle tissue was thin. His cranial periosteum and cerebral dura mater were invaded by the tumor, resulting in a thin, brittle skull (Figure ). His dura mater was also thin and light yellow in color. The tumorous hemorrhage extended into his intracra

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

[User]
RADIOLOGY NOTE:
A 3-year-old boy was brought to the emergency room around 3 h after sustaining an injury while playing in the fields. His right upper limb accidentally got caught in the belt of a thresher machine and was avulsed from the chest wall. The child was taken to a nearby hospital with the amputated part [Figures and ] from where he was referred to our hospital.
On arrival, the child was stable and the amputated limb was well preserved. The patient was evaluated to rule out other injuries and prepared for surgery while an X-ray was done for the amputated part [Figures and ]. The amputated part was then shifted to the operation theatre for bench dissection.
On examination, the skin disruption was found to be at axillary level while the upper limb had avulsed from the chest wall along with the scapula and its attached muscles (scapulothoracic dissociation).
The deltoid muscle was disrupted from its origin and found in the amputated stump with the skin retracted distally over it. The cut ends of brachial artery and its accompanying vein were found retracted under the biceps muscle. The brachial plexus was disrupted at cord level with distal cut ends of medial, lateral and posterior cords found alongside the transected vessels. The posterior cord was found to be of longest length suggesting higher level of avulsion.
After thorough cleaning of the amputated limb, the brachial artery and its accompanying vein were dissected out and tagged. The brachial artery was cannulated, and infusion of cold heparinised saline (5000 units in 500 ml) started. The cut ends of medial, lateral and posterior cords were also tagged.
A fasciotomy was done on bench with diathermy. Meanwhile, the patient was shifted to the operating room and anaesthetised. On exploration of the amputation stump, the axillary artery was found to be transected after the branch to the latissimus dorsi muscle. 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 53-year-old male presented to the surgical department with lower abdominal pain. An ultrasound revealed a well-defined 5.6 × 4.6 cm isoechoic lesion superior to the urinary bladder and connecting with the umbilicus via a duct, suggesting an urachal remnant lesion or an infected urachal cyst. Subsequently, he was referred to our urology department for further management.
He was diabetic and had undergone a laparoscopic inguinal hernia mesh repair 2 years previously. Physical examination revealed some abdominal tenderness. Urine sediment and culture showed no abnormalities, laboratory findings were normal and abdominal computed tomography (CT) scan confirmed a urachal cyst []. Preoperative cystoscopy showed normal bladder mucosa. The patient deferred intervention for 9 months for personal reasons. On laparotomy, a 10-12 cm fibrous nodular mass was seen arising from the dome of the urinary bladder, fixed to the right posterior surface of the rectus muscles. Because the procedure was performed late at night, no pathologist was available so frozen section could not be done. Because of its malignant appearance, we considered the risk of invasion and metastasis very likely, what resulted in discontinuation of the procedure. Incisional biopsy was taken and procedure was deferred until histopathological examination was done. Because the preoperative CT scan had become dated, we repeated an abdominal CT scan postoperative, which showed a lesion with heterogeneous solid components and thickening of anterior bladder wall []. Histopathological examination revealed fibroinflammatory tissue.
Ruled out malignant disease, 6 days after the initial procedure relaparotomy with frozen section was planned. During dissection, the tumor was identified infiltrating the posterior wall of the right rectus sheath. Frozen section was done to exclude a sampling error and to rule out an inadequate first sample. Further dissection revealed presence of the previously placed inguinal mesh []. Exci

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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:
In May 2005, a 77-year-old man visited our emergency department (ED) complaining of chest pain. He had intermittently experienced exertional chest pain since 1996. In 1998, he visited a regional university hospital with recurrent chest pain and was diagnosed with cardiac syndrome X. His symptoms improved with medical treatment, but intermittent chest pain continued to recur.
In July 2002, he was admitted to our hospital for surgical treatment of benign prostate hypertrophy. The treadmill test was performed because of his history of angina and the result was positive. Thus, coronary angiography (CAG) and echocardiography were also performed, which showed no significant abnormalities. Medical treatment for syndrome X was continued.
In May 2005, the patient visited our ED due to chest pain that was aggravated in both intensity and duration. He did not have an acute ill-looking appearance because the angina had subsided. Physical examination did not reveal any specific abnormalities. Vital signs were stable. Complete blood cell counts, blood chemistries, electrolyte and cardiac enzymes were all within the normal range. CAG and echocardiography, which were performed with the suspicion of unstable angina, did not show any significant abnormalities. Chest computerized tomography showed no explicable findings. Thereafter, his hospital course worsened rapidly. On the seventh hospital day, he complained of dyspnea with chest pain in a resting state. Cardiogenic shock developed. Plain chest radiography showed pulmonary edema with bilateral pleural effusion. Echocardiography showed that the LV cavity in diastole was increased (59 mm) with severe global hypokinesia. LV ejection fraction was 29% by the Simpson's method, but LV wall thickness was normal. These findings were compatible with DCM except for the normal LV wall thickness (). Therefore, we inserted an intra-aortic balloon pump (IABP) for hemodynamic support. It was necessary to maintain the IABP, due to weaning failure

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

[User]
RADIOLOGY NOTE:
A 37-year-old man was referred to the department of oral and of maxillofacial radiology of dentistry school of Isfahan medical science university. The patient had a chief compliant of pain and swelling in the right maxilla and asymmetry in it []. The patient mentioned that the mass had first appeared 3 months ago and became slightly larger since then. Furthermore, the patient mentioned that he experienced pain in the right side of his face with referral to the right eye and also episodes of blur vision.
The intraoral examination demonstrated an enlargement of the buccal maxillary right region, extending to the area of the canine and first premolar. In addition, the patient had a slight swelling at the palatal region []. The swelling was bony hard, non-tender with no fluctuation on manual palpation. The covering mucosa and gingiva had normal color and smooth in texture. The first premolar appeared to have been displaced by the lesion. The first premolar and canine at the right side were positive to thermal testing; percussion and palpation tests were within the normal limits. The needle biopsy did not revealed any sign.
Radiographic evaluation showed the presence of a lesion extending throughout the maxillary right toberousity and right canine. The margins of the lesion appeared to be well-defined. Bone pattern is radiolucent with a few wispy trabeculae [Figures and ]. The tumor caused displacement of first right premolar with disappearing of its lamina dura. The mass caused expansion in all direction, but the cortical plate of the bone remained intact. The lesion occupied maxillary sinus and expanded its walls outward. Meanwhile a bony partition existed between the walls of the remaining sinus and the mass.
The CBCT showed a multi locular mass with wispy trabeculaes (similar to the pattern seen on Central Giant Cell Granuloma), occupying and expanding the right maxillary sinus [Figures -].
The expansion of Central Ossifying Fibroma into the antrum of the

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


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

[User]
RADIOLOGY NOTE:
This was a 13 days old baby boy, who was born via spontaneous vaginal delivery at term in our tertiary care hospital without any postnatal complications. He was discharged 24 hours after delivery. He was brought back to our ER with left eye purulent discharge, which was noticed since birth, and swelling of his left upper eyelid of 2 days duration.
There was no associated fever or history of decreased level of activity or feeding. There was no history of rashes or seizures.
The pregnancy course was remarkable only for gestational diabetes and the fact that the mother had a history of vaginal discharges, which was treated as vaginal candidiasis during the last trimester. Group B streprococcus screening on the 37th week of gestation was negative. Similarly, HIV and hepatitis B serology were negative one day prior to delivery. There was no maternal history of genital lesions, vesicles, or ulcers.
Examination was normal apart from the purulent eye discharge & swelling of the left eye upper eyelid. The eye secretions were yellowish sticky, copious, and profound. Fontanelles were soft & primitive reflexes were present and normal.
Due to suspicion of gonococcal ophthalmia neonatorum, a full septic workup was obtained including CBC, blood culture, urine analysis and culture, CSF analysis and culture, and left eye swab for culture and Chlamydia antigen (). He was subsequently started on meningitis dose of Cefotaxime, in addition to Gentamycin ophthalmic drops while waiting for the previous cultures' results. Azithromycin was added as well to cover the possibility of an associated chlamydial infection.
The eye swab culture revealed Neisseria gonorrhea, which was sensitive to Cefotaxime, so the antibiotic was continued while waiting for the results of the CSF culture.
Blood and urine cultures were negative. The CSF culture revealed Gram-negative rods after one day, which was identified as S. maltophilia on day 5 of admission. The organism was sensitive to Trimethoprim-Sulfameth

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

[User]
RADIOLOGY NOTE:
A 55-year-old man presented to the emergency department of a private hospital with complaints of acute onset of chest pain and shortness of breath. There was no significant past medical or surgical history. Taking the age and symptoms into account, he was immediately subjected to an electrocardiogram, which was normal except for right axis deviation. The cardiac enzymes were within normal limits. This was followed by a chest X-ray which was reported as left-sided tension pneumothorax for which intercostal chest drainage (ICD) was done. As the patient continued to be symptomatic, he was referred to our institute for further management 6 h later.
He presented to our casualty with breathlessness and chest pain along with a nonfunctioning ICD in situ. He was tachypneic with a respiratory rate of 25/min, a heart rate of 120/min, and his blood pressure was normal around 110/70 mm Hg. However, his oxygen saturation was well maintained in room air. Examination revealed a tracheal shift to the right and a tympanic note on percussion of the left hemithorax. He had characteristic findings on auscultation of the chest, with absent breath sounds in the left hemithorax, and the heart sounds being better heard on the right side. We also noticed gurgling bowel sounds in the left side. The abdomen was scaphoid, and there was no tenderness or organomegaly. On suspicion of herniation of abdominal contents into the chest, a nasogastric tube was inserted, and around 2 L of gastric contents were drained. This led to a dramatic improvement in his symptoms. A chest X-ray was followed which revealed marked mediastinal shift to the right along with massively dilated bowel loops in the left hemithorax [].
An emergency contrast-enhanced computed tomography of thorax and abdomen was done. This revealed a defect in the diaphragm with herniation of the stomach, spleen, and small bowel into the left hemithorax and mediastinal shift to the right []. Thus,

[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 healthy 5-year-old boy was referred to the pediatrics department of Shahid Beheshti School of Dental Medicine, Tehran, Iran, with the chief complaint of a painful swelling located in the mandibular left buccal region ().
The patient’s dental history indicated that the first primary molar had received conventional pulpotomy treatment one year before and the left second primary molar had a defective Class II amalgam filling with recurrent caries. Clinical examination revealed marked grade I mobility of the mandibular left first primary molar and a palpable expansion of the buccal plate with crepitus on the mandibular left primary molar region extending 2×2 cm. The panoramic radiograph showed a round radiolucent unilocular lesion with smooth and well defined borders, extending 22×23 mm in the periapical area of the mandibular left primary first molar. The expansion of the lesion had pushed the permanent first bicuspid very close to the lower border of the mandible (). Based on the patient’s history and clinical and radiographic examinations, the differential diagnosis of the lesion was radicular cyst or dentigerous cyst and the treatment plan was surgical enucleation of the lesion. Other treatments required for the patient consisted of pulpotomy and restoration of teeth number A, B, I, J, K and T, extraction of tooth number S and band and loop space maintainer to maintain the E space in the mandible.
Consent form was signed by the patient’s parents and the patient was scheduled for the surgery. At the day of surgery, standard disinfection protocols were followed and the area was anesthetized by block and infiltration injection of Lidocaine HCl with 1:100000 epinephrine. Initially, a needle biopsy was taken from the lesion and the result of aspiration was a light-yellow odorless liquid that was immediately sent to lab for cytopathologic evaluation. The results approved the cystic nature of the lesion. An incision was made from the left canine to the left second primar

[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 man presented with dysarthria lasting for about one hour, two days after returning from holidays from the island of Corfu, where he had spent several days exposed to strong sunshine. The day after the presentation, the symptoms of dysarthria recurred and lasted about two hours before completely resolving. There were no other neurological symptoms such as headache, dizziness, confusion, or weakness (except from the baseline weakness due to the polyneuropathy). During his holidays, he was exposed to the sun for more hours than usual, but he did not report excessive use of alcohol or other substances.
The patient was examined on the second day of symptom appearance when he was found to be afebrile with no other signs of infection. His dysarthria had resolved, and the rest of his neurological examination was normal with the exception of the baseline weakness of the lower extremities due to his polyneuropathy.
Blood tests including inflammatory parameters as well as an immunological screen were normal and so was urine analysis and cerebrospinal fluid (CSF) analysis. CSF oligoclonal bands were absent.
Magnetic resonance imaging (MRI) of his brain was obtained () which showed a diffuse symmetric deep white matter involvement of the centrum semiovale posterior frontal and parietal, with T2/FLAIR hyperintensity and restricted diffusion an ADC map images (first row of images).
The findings extended continuously to the splenium of the corpus callosum (second row of images). No major mass effect was recognized. No hemorrhagic changes on T2/GRE images and no postcontrast enhancement on enhanced T1 images were seen (not shown here).
Due to the transient recurrence of the symptoms on the second day of presentation, the patient was treated empirically with corticosteroids (1 gram of intravenous methylprednisone per day for 3 consecutive days). His neurological examination returned to baseline.
Repeat MRI examination performed one month later showed significant symmetr

[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 81-year-old woman was found to have an abnormal shadow in the right lower lung field on chest radiography for a routine health check-up (Figure ). Her past medical history was unremarkable. Her smoking history was 1 pack/day × 50 years, and she had quit smoking at age 70. Chest computed tomography (CT) showed a tumor with an irregular border centered in the hilar region extending from segment 6 (S6) to the middle lobe of the right lung (Figure ). Based on stenotic and occlusive findings of the pulmonary artery on CT scan, the tumor was considered to have directly invaded the pulmonary trunk (Figure ). Although positron emission tomography showed fluorodeoxyglucose uptake with a maximum standard uptake value of 4.7 in the tumor region (Figure ), there was no fluorodeoxyglucose uptake in mediastinal lymph nodes or other organs. To closely examine the extent of proximal intravascular tumor invasion, angiography was performed, which revealed complete occlusion of the pulmonary trunk at the periphery proximal to the bifurcation of the posterior ascending branch, and a filling defect at the root of this branch (Figure ). Although bronchoscopy showed no mass lesion in the visible range, adenocarcinoma was diagnosed by bronchoscopic biopsy of the tumor. The level of carcinoembryonic antigen was elevated, at 5.7 ng/mL (institutional cutoff value, 5.0 ng/ml); however, no abnormalities were detected in other blood chemistry or tumor marker levels. The patient was otherwise healthy and asymptomatic. Her vital capacity was 1.92 liters, and her forced expiratory volume in 1 second was 1.40 liters. Because right pneumonectomy would be difficult given her pulmonary function and age, preservation of the right upper lobe was chosen as the surgical strategy.
Intraoperatively, the tumor was found to be located on the interlobar surface of S6-middle lobe, tending to invade proximally and distally along the pulmonary trunk. Massive induration was felt inside the pulmonary

[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 eighteen-year-old female reported with the chief complaint of missing teeth in the lower front jaw region. She gave a history of trauma 1 year ago in which she lost her front teeth. No other significant history in terms of medications or family was obtained. She gives a history of a surgical attempt of separating the joined fingers, during which half of her ring finger of the left hand was lost due to postsurgical infection. The prenatal, natal, and post natal history was also nonsignificant. She also had mild to moderate mental retardation. On general examination, she was seen to have an abnormally short stature with a height of 4 feet 6 inches and weight of 30 kgs. She also had a loss of vision in the left eye and was wearing eye prosthesis (). She was also seen to have syndactyly in relation to middle, ring, and little fingers of both hands (). On intraoral examination, she had good oral hygiene and missing right and left mandibular central incisors ().
Relative microdontia with respect the crown root length was shorter than normal measurements (as measured on a radiovisuography), by approximately 8 mm, in mandibular right and left first molars and first premolars () and also in maxillary first molars () bilaterally. The soft tissue and other oral mucosal structures did not reveal any abnormality. Various investigations like orthopantomogram, lateral, and posteroanterior (PA) view of skull and hand wrist X-rays were taken to confirm the findings. The PA view () of skull was found to be normal. The orthopantomogram revealed the congenital absence of all the third molars and a generalised horizontal bone loss (). In addition to the aforesaid, enlarged pulp chambers with respect to the maxillary right and left second molars () were also observed. Hand wrist X-ray revealed bony union of the middle, ring, and little fingers of both hands ().

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


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

[User]
RADIOLOGY NOTE:
A 60-year-old man presented with sudden severe right shoulder and flank pain and numbness of the right hand. The patient had a history of working in his home garden every day. He had no subjective symptoms prior to the day of admission, and no past medical history other than hypertension, which was managed with medication. The patient called an ambulance 3 h after the onset of symptoms and was able to get into the ambulance unassisted. He was transported to a nearby hospital. At the hospital, he developed hemoptysis and hypoxemia with severe forced breathing and tachypnea. He was tracheally intubated and transferred to our emergency department by air ambulance helicopter 6 h after the onset of symptoms.
On examination in our emergency department, a coarse crackle with right lateral dominance was audible. A small volume of blood was continuously suctioned through the tracheal tube, although bronchoscopic examination did not reveal any source of bleeding. The patient’s blood pressure was 132/87 mmHg, pulse was 109 beats per minute and body temperature was 36.7 °C. He was mechanically ventilated with spontaneous breathing at a rate of 14 breaths per minute under sedation. No skin eruptions or lesions were observed.
Upon examination of chest computed tomography (CT), we saw infiltration predominant in the right upper lobe and spreading to the right middle and lower lobe and left hilar area (Fig. ). Peripheral blood was collected for laboratory examination. Arterial blood gas analysis showed a pH of 7.174, with a partial pressure of carbon dioxide of 62.4 mmHg, a partial pressure of oxygen of 94.3 mmHg, a base deficit of − 7.4. under the condition of end-expiratory pressure at 10 cm H2O, and a fraction of inspired oxygen of 0.5, indicating acute respiratory failure. Other laboratory data were normal, including blood cell count, coagulation, and biochemistry, including inflammatory biomarkers, other than a slight elevation in serum creatinine level

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


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

[User]
RADIOLOGY NOTE:
An 87-year-old Japanese man complaining of abdominal distention was referred to our hospital. He had been surgically treated for early colon cancer and abdominal aortic aneurysm and nonsurgically for sigmoid colon volvulus. After being aware of insidiously presenting abdominal distention, the patient had failed to defecate for 12 h due to lack of intestinal peristalsis. He had no fever and complained of neither chills nor abdominal pain. Blood tests showed a mild inflammatory response and normal CPK level: white blood cells 10,200/μL, C-reactive protein 0.183 mg/dL, and CPK 89 U/L. Plain abdominal radiograph and enhanced CT showed a markedly dilated colon in the fashion of the so-called coffee bean sign (Fig. ). Blood test and enhanced CT findings (Fig. ) led to the diagnosis of sigmoid volvulus without colon necrosis. The patient underwent initial and careful endoscopic reduction (Fig. ), leading to the successful reduction of the sigmoid volvulus followed by the improvement of abdominal distention. Although pretreatment assessment was sigmoid volvulus without colon necrosis, postreduction endoscopy showed widespread presumed mucosal ischemia (Fig. ). Considerable spread of the affected mucosa made it difficult for us to rule out the presence of transmural ischemia, which could lead to the necrosis of the sigmoid colon followed by peritonitis. However, we judged that the patient lacked the definitive evidence of necrosis of the detorsed sigmoid colon and decided to follow the patient with infusion, nil per os, and antibiotics administration under careful observation. Due both to no relapse of the abdominal symptoms and to the lack of increasing inflammatory response judged by laboratory tests, the patient started to take a meal on the 5th day and was discharged on the 9th day after endoscopic reduction of the sigmoid volvulus. Two months later, i.e., after full recovery of his physical condition, the patient received endoscopic surgery with a 20-cm resection of 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 26-year-old male patient with a history of spastic cerebral palsy, shunted hydrocephalus, and epilepsy was referred for his baclofen pump refill as well as increasing discomfort from spasticity. He was being treated with baclofen administered via an intrathecal baclofen pump that had been originally placed in subfascial position more than 20 years ago. His pump had been replaced twice previously. Specifically, he had undergone one previous end-of-service pump replacement and one revision to replace a fractured catheter, and the patient had not experienced any complications with any of his prior pump refills.
Because the patient’s baclofen pump could not be palpated in the created pocket and he continued to have signs of spasticity, an X-ray was performed, during his referral appointment at the clinic. The X-ray demonstrated a subcostal location of his baclofen pump, but it wasn’t clear from the X-ray whether the pump had migrated into the peritoneal cavity or not ().
The patient was subsequently admitted and taken to the operating room for revision of his baclofen pump. Upon opening the subfascial pump pocket, we saw the pump catheter, but unexpectedly noticed that the pump had migrated. The dissection was extended along the catheter until the peritoneal cavity was entered where the 40-mL baclofen pump was found ().
We removed his pump and inspected the bowel to ensure that no perforation had occurred. On further examination, we identified a fascial tear through which the baclofen pump had migrated. This defect in the fascia was in the right lower abdominal quadrant, on the posterior aspect of the subfascial pump pocket. For this reason, a smaller (20 mL) baclofen pump was filled and inserted instead subcutaneously.
Following the removal of his migrated baclofen pump and its replacement with a subcutaneous one, the patient was discharged home on postoperative day 7 only to return on postoperative day 9 with constipation and abdominal pain. Subsequently, he was rea

[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 50-year-old man with Child-Pugh class A alcoholic cirrhosis and recent increased ibuprofen use was brought to our Emergency Department after a syncopal episode at work. Shortly after arriving, he developed brisk hematemesis and hematochezia and had a full cardiac arrest. His hemoglobin dropped from 13.1 g / dL (on presentation) to 4 g / dL. The patient was intubated, and approximately four minutes of cardiopulmonary resuscitation (CPR) were required. He was resuscitated with six units of packed red blood cells and two units of fresh frozen plasma. During his resuscitation, he continued to pass a large amount of blood by mouth and per rectum. Once he was stabilized, a CT scan of the abdomen and pelvis was obtained, which showed mildly distended loops of the jejunum and ileum, with no free intra-abdominal air or fluid. No other pathological findings were identified. During the ongoing resuscitation, the patient's abdomen became distended. His peak airway pressures quickly increased (exceeding 40 mmHg). Consequently, pressure-controlled mechanical ventilation was required. His bladder pressures were 25 mmHg. Based on these findings, the patient was diagnosed with an abdominal compartment syndrome and was taken emergently to the Operating Room for a decompressive laparotomy and further assessment of his gastrointestinal hemorrhage.
Immediately after opening the patient's abdomen in the operating room, his peak airway pressures returned to normal. His stomach and small bowel were distended with blood, but otherwise appeared normal. Intraoperative upper gastrointestinal endoscopy was performed. There were no esophageal varices. The stomach was full of clotted blood and had no other abnormalities. An ulcer with an adherent clot on the posterior wall of the duodenal bulb was noted, although there was no active bleeding. Based on these findings, it was felt that the source of his hemorrhage was a duodenal ulcer that had eroded into the proximal gastroduodenal artery (GDA).

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


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

[User]
RADIOLOGY NOTE:
A 49-year-old previously healthy female presented with a 1-week posterior-region knee pain post direct fall from a standing position on her left knee. This was directly followed by knee joint blockage with a limited range of motion of only 30 to 60 degrees of flexion. The patient started taking NSAID and had minimal pain relief. She reported increased pain upon standing from a sitting position and vice versa with associated tingling and numbness at the level of the calf region especially upon standing.
On examination, she showed good lower-limb alignment, no pain was provoked on meniscal and ligament testing, and there was an absence of muscular atrophy. Her range of motion was limited to only 30 to 60 degrees of flexion, and the patient had pain on the active range of motion. She also had pain upon active and passive extension of the knee joint with tingling and numbness over the calf region extending from the knee posteriorly. She was found to have a nonpitting edema posteriorly with moderate anterior joint effusion. On patellar examination, she felt pain originating from the posterior region of her left knee joint. To note, the patient has never had any symptoms related to her knee up until the direct fall from the standing position.
MRI revealed a multiloculated structure arising from the synovium around the cruciate ligaments within the femoral notch extending beyond the joint capsule posteriorly with significant displacement of the popliteal vessels (Figures and ).
It showed evidence of synovial thickening, and on gradient echography, it showed spotty and irregular hyposignals compatible with the presence of hemosiderin. There also was associated soft tissue edema around the above-described lesion. The patient underwent arthroscopic intervention in the left knee under spinal anesthesia. The posterior compartment of the knee was reached arthroscopically through the triangular space formed by the ACL laterally, PCL medially, and the femoral notch superiorly. Tot

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


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

[User]
RADIOLOGY NOTE:
A 32-year-old woman (gravida 2, para 2) at a gestational age of 13 weeks and two days was referred to our hospital after her first trimester ultrasound scan at another institution had revealed a huge ovarian mass. The patient was asymptomatic, denying weight loss and abdominal pain.
On presentation to our institution, an ultrasonography showed that the fetus had a biparietal diameter of 37 mm, indicating appropriate growth for a 13-week singleton pregnancy and an adnexal mass, measuring approximately 17×12 cm, with a homogenous and unilocular cystic component, arising from the right ovary. Magnetic resonance imaging of the abdomen revealed a homogeneous unilocular parovarian cyst, measuring 17×12×10 cm, located close to the ipsilateral ovary (). Preoperative investigations (cell blood test, biochemistry, electrocardiogram, chest X-ray, and CA-125) were normal.
A laparoscopy was performed under general anesthesia at 14 weeks of gestation. No ascites were detected. A right parovarian cystic mass, which was the same size as an infant's head and which had an intact capsule, was detected posterior to the uterus. The uterus and the left ovary were normal. A right parovarian cystectomy was performed, and the tumor capsule was not ruptured. A permanent pathological examination demonstrated a borderline serous tumor. A microscopic evaluation revealed papillary epithelial proliferation, which refers to multiple papillary structures lined by serous epithelium showing stratification in some places without nuclear atypia. No stromal invasion was recognized ().
After the available treatment methods and their possible risks were thoroughly explained and consent was obtained, the pregnancy was allowed to continue under close observation on an outpatient basis.
The remaining weeks of the pregnancy progressed normally and a cesarean section was performed at 38 weeks of gestation and a normal infant weighing 3.2 kg was delivered. After delivering the baby, subsequent restaging surgery

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


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

[User]
RADIOLOGY NOTE:
A 19-year-old female visited our hospital with a 2 wk history of progressive pitting edema in both lower legs associated with a 2 kg weight gain. Symptom onset began shortly after intense physical exertion (dance practice). Her medical history included allergic rhinitis with sensitization to house dust mite and pollen, and she had visited the pediatric allergy clinic for about 10 years. None of her family members had a history of similar symptoms or specific diseases. Additionally, she noted mild pain in both knees and ankles, but tenderness was not remarkable on physical examination. She denied fever, dyspnea, chest pain, and urinary difficulty. She was not taking any medications. Physical examination revealed moderate bilateral pretibial pitting edema. No redness, induration, or thickened skin was observed. No contractures of joints were found, and muscle strength was normal in the upper and lower extremities.
At first, she visited the cardiovascular surgery clinic and was admitted for evaluation and treatment of deep vein thrombosis. However, computed tomography (CT) angiography of her lower extremities revealed no evidence of venous disturbance. Treatment with heparin and application of compression stockings did not alleviate her symptoms. Initial laboratory findings included a white blood cell count of 8,090 cells/µL with 28.9% eosinophils. Her eosinophil count was 2,340 cells/µL. Her hemoglobin level and platelet count were normal and her serum total IgE level was 786 kIU/L, but no remarkable change was observed compared to the previous year. The erythrocyte sedimentation rate and C-reactive protein level were not elevated. Serum urea nitrogen and creatinine were normal and urinalysis revealed no proteinuria or hematuria. Serum albumin was unremarkable at 4.2 g/dL. Serum protein electrophoresis results were within the normal range. Other laboratory data, including serum aminotransferase, alkaline phosphatase, cholesterol, and electrolyte levels, were normal. F

[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 male who presented with a swelling of the posterior surface of the proximal third of his left leg. His prior history included a prolonged stay in hospital for treatment of bacterial endocarditis, when two mitral valve replacement operations were performed. He had also previously undergone two abdominal operations to treat an intestinal tumor and one varicose veins surgery.
Physical examination revealed a pulsating mass in the posterior region of the proximal third of the left leg. Femoral, popliteal, and dorsal pedal pulses were palpable and normal in both lower limbs. The posterior tibial artery pulse was absent, whereas the posterior tibial artery pulse was palpable in the right lower limb.
Magnetic resonance angiography showed a saccular dilatation in the tibioperoneal trunk with a 4.4 cm diameter, at the level of the origin of the posterior tibial artery. The posterior tibial artery was also occluded ( ). Investigation was supplemented with laboratory tests (inflammatory activity tests, coagulation tests, and complete blood cell count), which all returned normal results, in addition to blood cultures, which were negative.
Having ruled out other probable etiologies and active infections, in view of the history of bacterial endocarditis, it was decided to perform a less invasive treatment, considering the inflammatory/infectious pathophysiology and the size and site of the pseudoaneurysm. A covered, self-expanding stent (Gore VIABAHN 6.0 × 50 mm) was therefore placed in the tibioperoneal trunk, preserving fibular artery patency and excluding the aneurysm. The transition between the tibioperoneal trunk and the fibular artery was ectatic, because of the pseudoaneurysm, which minimized difficulties caused by reduction of the distal diameter. A control magnetic resonance angiography showed that the aneurysm sac was no longer perfused and the fibular artery was patent ( ).
The patient was followed up for 10 years after treatment and during

[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:
Mr. S, a 23-year-old African American male with the diagnosis of paranoid schizophrenia, was hospitalized in our inpatient psychiatric hospital approximately 15 months ago. The patient had failed trials of several typical and atypical antipsychotics. Leading up to the admission, he was having religious delusions, ideas of reference, and thoughts of cutting his arm (he had lacerated his arm prior to that admission). He was displaying thought blocking and poverty of speech. His laboratory data, including complete blood count, basal metabolic profile, and thyroid function tests, were within normal limits. His urine drug screen was negative except for cannabinoids and blood alcohol level was less than 5 milligram per deciliter. Based on that, he was started on clozapine. He was discharged with a dosage of 200 mg of clozapine daily and was instructed to return to outpatient psychiatry clinic in a week. During that appointment, the patient continued to exhibit psychotic symptoms and also had gained considerable weight (345.7 pounds, body mass index of 42.7 kg/m2). Subsequently, clozapine was increased to 250 mg per day for one week and to 300 mg per day thereafter. In addition, topiramate was initiated at 25 mg per day for one week and 50 mg per day for the following two weeks and then finally increased to 100 mg per day until the following appointment. Mr. S continued clozapine 300 mg daily and topiramate 100 mg daily for the following eight months, during which his WBC and ANC were within the normal range. After eight months on this regimen, his weight continued to increase (370.2 pounds, body mass index of 48.28 kg/m2) but clinically he was doing well and he denied symptoms of psychosis and reported euthymic mood. In lieu of this, topiramate was increased to 200 mg per day, with no change in clozapine dosage. After 13 days, it caused a temporary spike in WBC to 7,000/μ

[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 27-year-old Thai female presented with a rapidly growing mass over her right thigh for 3 months. She had no underlying or previous surgery. She had pain when she walked. She had slightly limited her right hip function on flexion and abduction. Physical examination revealed a firm nonpulsatile mass over the right thigh measuring ~8 × 6 cm. in diameter (). No notable grossly skin involvement and the mass appears not fixed to bony structure. No sensory deficit was identified. Inguinal lymph node cannot be palpated.
The magnetic resonance imaging (MRI) scan demonstrated a 7.8 × 5.8 × 5.7 cm, in vertical × transverse × AP diameter of well-defined, thin rim, enhancing simple cyst with vascularity at the right anterior intermuscular fascia of the upper thigh, just inferior to the right inguinal region. The cyst was located between the pectineus muscle and sartorius muscle, accompanied with anterior bulging to subcutaneous fat. The right common femoral artery and vein and superficial artery and vein were displaced posteriorly ().
Percutaneous aspiration of cyst revealed clear yellowish fluid about 60 ml., and the cytological examination showed hypocellularity consisting of few small lymphocytes and foamy macrophages in background of few erythrocytes and concluded cystic fluid. The cyst disappeared for a few days and presented in the same size within one week.
The operation was performed on supine position under general anesthesia. Vertical incision was performed; the cyst was identified and found dense adherance to femoral artery. Carefully, dissection was done. Complete cystic removal with femoral artery preservation was successful with minimal leakage of cyst wall (). Cystic content had shown the clear, yellow fluid ().
Microscopic examination was demonstrated as . Hematoxylin-eosin staining (H&E staining) indicated that the wall of the cyst consisted of a single flattened cell lining. The cell lining was histologically supposed to be derived from endothelium or mesothe

[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 woman presented with abdominal pains and hematuria in the year 2000. Imaging showed a left perinephric retroperitoneal mass. She underwent resection with left nephrectomy, left oophorectomy and partial colectomy for a well-differentiated liposarcoma. Clear margins were attained. In 2003 recurrence in multiple sites was seen within the abdomen. She underwent total abdominal hysterectomy and right oophorectomy, cholecystectomy and resection of retroperitoneal metastases with clear margins. In 2005 a second recurrence was noted in the region of the left flank requiring removal of recurrent liposarcoma from the left psoas and resection of small bowel with anastomosis and removal of retroperitoneal and peritoneal lesions. A third recurrence in 2011 necessitated resection of the right ureter, distal pancreatectomy, splenectomy and pelvic and retroperitoneal resections of tumor. Pathology review at this time showed both well-differentiated and de-differentiated liposarcoma. The patient experienced a partial small bowel obstruction as a consequence of her surgeries necessitating surgery for lysis of adhesions in 2014. In the subsequent year, she again had multifocal disease recurrence. Imaging showed a 4.7 cm mass at anterior abdominal cavity, a 2.6 cm mass at right lower quadrant inferior to the kidney, a 2.4 cm mid-abdominal wall lesion and other smaller lesions near the common bile duct, within mesentery and at left hemidiaphragm. The latter posed concern for herniation across the diaphragm. Three surgical opinions were sought and all recommended against resection with concern for margins, adjacent structures and short disease recurrence. She began systemic gemcitabine with a local oncologist. She tolerated three cycles but had disease progression. She was interested in second-line systemic therapy with trabectedin on a clinical trial prior to US FDA approval. At this time her computed tomographies (CTs) showed predominately a 2 cm left lung base mass at cr

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


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

[User]
RADIOLOGY NOTE:
A 55 year old man was diagnosed with anemia by his family physician towards the end of 2017. In February of 2018, an upper GI endoscopy and colonoscopy were performed which showed a right colon cancer. CEA was 40.4. CT of the chest, abdomen, and pelvis was obtained in February of 2018. This showed a mass 7 cm in greatest diameter that was immediately adjacent to the undersurface of the right liver and contiguous with numerous loops small bowel and the lowest part of the second portion of the duodenum (). There were mildly prominent mesenteric lymph nodes but no evidence of distant metastatic disease.
In February of 2018, the patient underwent a single port laparoscopic right colon resection. The surgeon described the tumor as stuck to the undersurface of the liver with adhesions taken down without difficulty. On histopathologic examination, the tumor was PT3N0M0 with 0/16 positive nodes. Perineural invasion was identified. The cancer was moderately to poorly differentiated. Systemic chemotherapy was not recommended.
In June of 2018, the patient began noting problems with digestion and pain after eating. CEA had increased to 940 ng/ml. Repeat CT scan showed multiple nodules within the greater omentum compatible with peritoneal metastases. The liver, kidneys, and ureters were normal. There was marked stranding within the right colon resection site (). Bowel loops proximal to the prior ileocolic anastomotic site were moderately dilated and fluid-filled. A mass was noted in the abdominal wall at the laparoscopic port site. There was also a mass in the rectovesical space immediately adjacent or invading the right and left seminal vesicles.
In July of 2018, the patient underwent exploratory laparotomy. The posterior surface of the liver was layered by cancer. The undersurface of the right hemidiaphragm was covered by tumor nodules. The pelvis contained a 4 cm tumor mass invading into the seminal vesicles. The old ileocolic anastomosis was involved and needed to be resecte

[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 70-year-old male who was found in a chair at home by emergency medical services after a call from a friend who did not have his usual contact with the patient for several days. When paramedics arrived, it appeared he had been in that position for some time, as he had been incontinent of both bowel and bladder. He was found to be non-verbal, responsive only to painful stimuli, and was able to move all extremities, giving him a Glasgow Coma Scale (GCS) of eight. Medical history obtained from the friend who called emergency services was largely incomplete but was positive for diabetes mellitus. The patient had no reported history of stroke. Upon arrival to the emergency department, the patient began to seize with right gaze deviation. Lorazepam was administered to control the seizure and an emergent intubation was performed to protect his airway. The patient was afebrile, and vital signs were within normal limits throughout the course of presentation and treatment. On physical exam, there was a mild left facial droop with 3 mm pupils that were equal and reactive to light. The rest of his exam was non-focal. Laboratory results demonstrated a leukocytosis of 20,720 per cubic millimeter of blood and mild electrolyte disturbances.
A computed tomography (CT) scan performed in the emergency department showed a crescent-shaped hemorrhage with midline shift consistent with a subdural hemorrhage (Figure ). The CT was read by the radiologist as, “Subacute left subdural hematoma, 1.4 cm in width with midline shift from left to right of 0.7 cm. Left frontal encephalomalacia versus involving Q skin nick event.” The most likely differential diagnosis now included subdural hematoma vs. empyema. It was felt that the symptomatology did not overlap completely with subdural hemorrhage so magnetic resonance imaging (MRI) was performed. It showed a complex left-sided acute subdural fluid collection of moderate size with mass effect upon the left cerebral hemisphere and a 6

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


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

[User]
RADIOLOGY NOTE:
A 69-year-old man was admitted to our hospital because of bilateral ataxia and dizziness. He had not been taking any medications and had been smoking 40 cigarettes per day for 49 years. Laboratory tests revealed mild dyslipidemia and impaired glucose tolerance. Blood pressure on admission was 188/92 mmHg. Magnetic resonance imaging (MRI) showed acute brain infarction at the bilateral cerebellar hemispheres and the right thalamus. The lesions in the cerebellum were not perfectly consistent with vessel-dominant regions supplied by the anterior inferior cerebellar artery or posterior inferior cerebellar artery. Head magnetic resonance angiography (MRA) showed bilateral VAs but posterior communicating arteries were not observed bilaterally. Neck MRA indicated right VA but did not show left VA []. Contrast-enhanced three-dimensional computed tomographic angiography (3D-CTA) showed right VA severe stenosis at the origin and did not show the left VA from the ostia to the lower edge of the second cervical vertebra [, left]. Relatively thick OA was also shown. Cerebral angiography revealed right VA severe stenosis similar to 3D-CTA, but showed near-occlusion of the ostia of the left VA and markedly delayed poststenotic blood flow in the left VA. Stenosis was detected only at the ostia, in contrast to 3D-CTA. Argatroban, antiplatelet medication (aspirin 100 mg and clopidogrel 75 mg daily), rosuvastatin, and omarigliptin were started. After the acute phase, amlodipine and olmesartan treatment were also begun. The patient was discharged home with mild bilateral ataxia.
We planned surgical reconstruction of posterior circulation in order to avoid fatal brain infarction due to posterior circulatory insufficiency, which is related to high morbidity and mortality. In terms of preoperative neurological symptoms, the muscle tones of extremities were intact. The gait on a flat surface was normal without assistance, but the tandem gait was unsteady when attempting to touch the heel of

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


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

[User]
RADIOLOGY NOTE:
A 42-year-old woman from India (Asian by ethnicity) without any known comorbidities developed gait and stance unsteadiness around 1 month prior to presenting to us. It was rapidly followed by development of tremulousness in both hands, particularly while reaching for a target. Her first medical contact was through an orthopedic surgeon when she suffered a fall at around 2 weeks after the onset of her illness. At that time, she was diagnosed was having a fracture of her right tibia and received plaster casting of her right leg. However, her neurological illness continued to go downhill as she developed intermittent abnormal twisted posturing of her right hand, suggestive of focal dystonia. Subsequently, she developed progressive deterioration of her cognitive function for around 2 weeks before coming to our care. Reduced attention span, impairment of short-term memory, behavioral abnormality, and language problems in the form of comprehension difficulty as well as irrelevant talking were the major features at the onset of her cognitive disturbance. On detailed questioning, her family members admitted to the presence of intermittent brief rapid involuntary jerks involving one limb at a time, suggestive of myoclonic jerks, which used to persist during sleep as well. Over the course of 3–4 days prior to admission, her higher mental function deteriorated severely enough amounting to akinetic mute state. There was no family history of similar illness. On neurological examination, she was found to have akinetic mute state, paratonia in both upper limbs and left lower limb, intermittent focal myoclonic jerks, and bilateral extensor plantar response. Keeping all these in mind, differential diagnoses were formulated: encephalopathy which might have been due to metabolic factors or an autoimmune process, or an infective pathology such as prion disease. She was investigated thoroughly; her blood count and metabolic parameters were within normal limits. Anti-thyroperoxidase (TPO

[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 forty-year-old male welder with no past history of knee injury presented to another institution with left knee pain in September 2000. He underwent an arthroscopic partial menisectomy of the medial meniscus. In December 2004, 4 years after the primary surgery, he had a second arthroscopic partial menisectomy of the medial meniscus. However his left knee pain was not reduced. The radiographs of his left knee revealed a narrow medial joint space, femorotibial angle of 178 degrees, and posterior tibial slope [] of 9 degrees. In January 2005, when he was 44 years old, he received an opening-wedge HTO using a Puddu plate with a 15-mm opening block and osteochondral transplantation of the medial femoral condyle. The femorotibial angle was corrected to 170 degrees after the osteotomy, while the posterior tibial slope increased to 20 degrees. The Puddu plate was removed at 18 months after the osteotomy; however, he still had severe knee pain.
In January 2007, the patient first visited our institution for a second opinion, because he was recommended for another revision surgery to convert to total knee arthroplasty by the former hospital. He was unable to walk without a cane due to the left anteromedial knee pain. Physical examinations revealed quadriceps atrophy and no ligamentous laxity of the left knee. The range of motion was 140 degrees of flexion and -20 degrees of extension in the left knee, and 150 degrees of flexion and 0 degree of extension in the right knee. Severe left knee pain was observed with extension. The radiographs demonstrated complete bony union at the osteotomy site, a femorotibial angle of 169 degrees and posterior tibial slope of 20 degrees on the left side (Fig. ), and 178 degrees and 8 degrees on the right side. The mechanical axis of the left leg passed through the middle of the lateral femorotibial compartment. We concluded that the increased posterior tibial slope limited his knee extension, and that was the cause of the pain

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


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

[User]
RADIOLOGY NOTE:
A 75-year-old woman with a 60-year history of tobacco use was noted to have a right hilar mass on a routine chest X-ray. Computed tomography (CT) scan and magnetic resonance imaging (MRI) demonstrated a 4.5 cm well defined mass with slightly lobulated margins present between the upper and lower lobes of the right lung posterior to the right hilum (Figure ). The mass abutted the right main bronchus, the bronchus intermedius and the medial pleural surface. Although the visual impression of the mass radiologically suggested a solid mass, attenuation within the mass (approximately 24 Hounsfield Units (HU)) was less than in the aorta containing blood (approximately 35 HU) and skeletal muscle (approximately 46 HU) indicative of a cystic rather than a solid lesion (Figure ). There was no associated adenopathy or obvious compression of the airway or other structures. Positron emission tomography (PET) scan showed increased uptake in the thyroid gland which on follow-up ultrasound and fine-needle aspiration was diagnosed as multinodular colloid goiter and thyroiditis. Additional work-up was negative for metastatic disease. The patient was minimally symptomatic with a mild cough productive of yellow sputum, but with no shortness of breath or evidence of hemoptysis. The pulmonary mass was felt to represent a primary tumor and the patient underwent subsequent thoracotomy with right upper lobectomy and segmentectomy of the right lower lobe. At follow-up 2 years later, she had no evidence of recurrence or metastatic disease.
On pathological examination, the specimen consisted of resected right upper lobe of lung with attached superior segment of right lower lobe. The pleural surface showed a retracted, indurated area 4.5 × 3 cm close to the bronchus intermedius of the upper lobe. On sectioning, a 5.5 cm nodular cystic mass with a distinctly mucoid appearance (Figure and ) was seen.
Microscopically, the tumor, although situated adjacent, did not have any relationship with the bron

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


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

[User]
RADIOLOGY NOTE:
A 55-year-old man with a history of extensive alcohol and tobacco use presented with a 2-month history of a progressively enlarging, 5-cm ulcerative, and painful midline tongue lesion extending to the floor of mouth resulting in an anterior tongue cleft. This lesion was associated with unintentional weight loss, left otalgia, and submandibular swelling. Bilateral nontender palpable lymphadenopathy in levels I, II, and III were present.
Prior biopsies by an otolaryngologist in private practice did not demonstrate carcinoma but were otherwise inconclusive with reactive inflammatory changes. However, a positron emission tomography scan revealed hypermetabolic lesions of the anterior tongue as well as lymph nodes bilaterally in levels I, II, and III suggestive of malignancy (). The assessment was a likely T3/4N2cM0 tongue squamous cell carcinoma. He underwent a panendoscopy with biopsies and a physical examination under anesthesia for surgical planning. Biopsy results again did not yield carcinoma but showed granulomatous inflammation without organisms present.
A multidisciplinary tumor board recommended a rheumatologic workup and an excisional lymph node biopsy. Lymph node biopsy results demonstrated noncaseating granulomatous inflammation with no malignancy (), while laboratory results demonstrated markedly elevated ACE (angiotensin converting enzyme) levels. These findings suggested an atypical case of sarcoidosis, and the patient was referred for pulmonary consultation. The patient had developed scattered erythematous macules involving the extremities, palms, soles, and trunk. Laboratory evaluation demonstrated T pallidum immunoglobulin G antibodies present with a reflex RPR (rapid plasma reagin) titer of 1:512. The lymph node biopsy sample was then analyzed with immunohistochemistry (IHC) revealing spirochetes (). The patient was diagnosed with tertiary syphilis and started on doxycycline 100 mg twice daily for 30 days because of a severe penicillin allergy. After

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


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

[User]
RADIOLOGY NOTE:
An 84-year-old female patient had been visiting our urologic clinic due to her painless intermittent gross hematuria for a year. Evaluations revealed multiple enhancing masses in the urinary bladder, measuring 3.5 × 3.0 cm and 3.3 × 3.4 cm in the left lateral wall, 2.0 × 1.3 cm in the anterior wall, and 1.2 × 1.7 cm in the right lateral wall (Figure ). Invasion of tumor into the regional lymph node or distant organ was not seen. Under the impression of urothelial cancer of the bladder, so called “radical TURBT” was attempted to remove the deeply invasive tumors since the patient was deemed to be an unsuitable candidate for conventional radical cystectomy. Microscopic examination of the resected specimen confirmed the muscle invasive urothelial carcinoma, partly invading into the perivesical fat tissue. Cystogram conducted after the procedure revealed no extravasation of dye. The patient and her family refused major operation or any other adjuvant treatment due to her old age and comorbid physical status. The patient was urinating well and gave no specific complaint except intermittent gross hematuria during her follow up at 3 months after the operation.
The patient visited our clinic again 6 months later after the operation complaining abdominal distension and change in her mental status. Computed tomography revealed a large amount of ascites with enhancing peritoneal thickening and peripheral nodular enhancement of the right adnexa, indicating peritoneal seeding and metastasis (Figure a). The urinary bladder showed enhancing wall thickening with perivesical fat infiltration and a defect in the anterior wall, suggestive of perforation (Figure b). Analysis of ascitic fluid demonstrated high level of creatinine (indicating urinary ascites) and was positive for metastatic carcinoma. The patient expired 7 days after admission with conservative care.
The objective of TURBT is to eradicate all visible disease while attaining an accurate histological diagnosis. To achieve

[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 previously healthy male patient complained of sudden onset of a severe right-sided occipital headache for one day. Although he had dizziness and nausea, findings on his neurological examination were normal. He had no history of trauma or remarkable medical or familial history. Findings on a computed tomographic (CT) scan performed on admission showed no evidence of intracranial hemorrhage. In addition, no abnormality was observed on magnetic resonance imaging (MRI). However, a high signal intensity representing an intramural hematoma was distinguished from a flow-related enhancement of the VA on the source image of time-of-flight (TOF) - magnetic resonance angiography (MRA) (). The MRA showed tapered narrowing of the right VA at the junction of the right VA and PICA, and fusiform dilatation of the anterior medullary segment of the left PICA (). On the lumbar tapping, there was no evidence of SAH. Cerebral angiography performed the next day showed a "pearl and string" sign and a double lumen sign in the right distal V4 segment of the VA involving the origin of the right PICA, indicating a spontaneous dissecting aneurysm (), and focal stenosis with a post-stenotic fusiform aneurysmal dilatation of the left proximal PICA, suggesting a dissection with an aneurysm formation (). Endovascular treatment of the right VA dissection was performed immediately after cerebral angiography: a Prowler Selector Plus microcatheter (Cordis Neurovascular, Miami, FL) was placed through the dissection segment in the right VA; then, two Enterprise stents (Cordis Neurovascular, Miami, FL) were deployed to the right VA dissection site in order to dilate it to cover the dissection (). Several possible treatment options were considered for the suggestive dissecting aneurysm on the left proximal PICA. Finding clues of a dissection in this small vessel was difficult; thus, we could not rule out the likelihood of an originally existing fusiform aneurysm. In addition, the left PI

[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 79-year-old male was admitted to the hospital unit with the chief complaint of worsening cough and abdominal pain. He was seen in the emergency room three days before the admission with the chief complaint of wheezing and non-productive cough where he was diagnosed with bronchitis and sent home with levofloxacin 500 mg by mouth daily for seven days and albuterol hydrofluoroalkane (HFA) inhaler as needed. The patient had a significant past medical history of dementia, seizures, cerebral vascular accident, pulmonary fibrosis, and chronic kidney disease with a creatinine clearance (CrCL) of 36 mL/min on day 1 of their hospital admission. The patient’s family reports no tobacco and alcohol use. The patient returns to the emergency room due to a lack of symptomatic improvement as well as a new complaint of abdominal pain, fever, and altered mental status per family members. Upon admission, the patient appeared jaundiced with right upper quadrant pain, and all hepatic enzymes were elevated with total bilirubin three times more than the ULN, alkaline phosphatase two times more than the ULN, AST 14 times more than the ULN, and ALT six times more than the ULN (Table ).
An ultrasound of the abdomen was performed and showed a distended gallbladder with no gallstones and a common bile duct diameter of 5 mm. Upon admission, the patient presented with acute chronic kidney injury, with slightly elevated blood urea nitrogen (BUN), and mild tachycardia of 106 beats per minute (all other vitals normal). Of note, medications before admission that may have potentially led to the abnormalities in the hepatic laboratory work are levofloxacin and rosuvastatin (Table ). The patient was diagnosed with drug-induced cholestatic hepatitis due to levofloxacin after performing a hepatobiliary iminodiacetic acid (HIDA) scan and autoimmune hepatitis panel to rule out other causes. All hepatic enzymes peaked between day 8 and day 9 of hospital stay and improved thereafter in the remainder of 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.